What is the recommended treatment for social phobia?

Treatment of Social Phobia (Social Anxiety Disorder)

Start with either an SSRI (sertraline or escitalopram preferred) or individual cognitive behavioral therapy (CBT) specifically designed for social anxiety disorder—both are first-line treatments with comparable efficacy. 1

First-Line Pharmacotherapy

Selective Serotonin Reuptake Inhibitors (SSRIs) are the recommended first-line medications for social phobia, though the evidence quality is low and the recommendation strength is weak (GRADE 2C). 1

Preferred SSRI Options:

• Sertraline: Start at 25-50 mg daily, titrate by 25-50 mg every 1-2 weeks as tolerated, target dose 50-200 mg/day 2, 3

  • FDA-approved for social anxiety disorder with demonstrated efficacy in multiple 12-20 week trials 3
  • Preferred due to favorable side effect profile and lower discontinuation symptoms 2

• Escitalopram: Start at 5-10 mg daily, titrate by 5-10 mg increments every 1-2 weeks, target dose 10-20 mg/day 2

  • Top-tier first-line agent with established efficacy and favorable tolerability 2

Alternative SSRI:

• Paroxetine: FDA-approved for social anxiety disorder with efficacy established in three 12-week trials 4
  • Critical caveat: Reserve for cases where first-tier SSRIs fail due to higher risk of discontinuation symptoms and potentially increased suicidal thinking 2

SNRI Alternative:

• Venlafaxine extended-release: 75-225 mg/day is suggested as an alternative first-line option (GRADE 2C) 1
  • Important monitoring: Requires blood pressure monitoring due to risk of sustained hypertension 2

Expected Timeline and Monitoring:

• Statistically significant improvement may begin by week 2, clinically meaningful improvement by week 6, maximal benefit by week 12 or later 2
• Monitor using standardized scales (Liebowitz Social Anxiety Scale or Social Phobia Inventory) at every session 1
• Common side effects include nausea, sexual dysfunction, headache, insomnia, which typically emerge within first few weeks 2
• Critical warning: Monitor closely for suicidal thinking, especially in first months and after dose adjustments 2

First-Line Psychotherapy

Individual Cognitive Behavioral Therapy (CBT) specifically developed for social anxiety disorder is the recommended psychotherapy approach. 1

CBT Specifications:

• Use protocols based on the Clark and Wells model or Heimberg model 1
• Individual sessions are prioritized over group therapy due to superior clinical and health-economic effectiveness 1
• Typical duration: 12-20 structured sessions 2
• Must be delivered by a skilled therapist with regular quality supervision 1

CBT Components Should Include:

• Education on anxiety mechanisms 2
• Cognitive restructuring to challenge distorted thoughts 2
• Gradual exposure to feared social situations 2
• Relaxation techniques 2

Alternative Psychotherapy Option:

• Self-help CBT with professional support is suggested if patient does not want face-to-face CBT 1

Combination Therapy Considerations

There is no formal recommendation for combining pharmacotherapy and psychotherapy due to insufficient evidence, though each combination studied involved different drug-therapy pairings with very low certainty of evidence. 1

• The balance between benefits and harms of combination therapy could not be determined 1
• Combination therapy may create additional burdens (side effects, costs, travel for CBT) without clear evidence of superiority 1
• Some older research suggests combination approaches may be beneficial, but this is not reflected in current guideline recommendations 5, 6

Treatment Duration

• Continue effective treatment for at least 12 months after symptom remission for first episode 7, 8
• For recurrent social phobia, longer-term or indefinite treatment may be beneficial 7
• Social phobia is typically chronic and unremitting if left untreated, with onset usually in childhood or adolescence 8
• Relapse rates are high after short-term therapy, supporting extended treatment duration 8

If First Treatment Fails

• After 8-12 weeks at therapeutic doses with inadequate response, switch to a different SSRI or SNRI 2
• Consider adding CBT if not already implemented 2
• Ensure CBT is being delivered by a skilled therapist following specific protocols 1

Medications to Avoid or Use Cautiously

• Beta-blockers (atenolol, propranolol) are not recommended based on negative evidence 2
• Benzodiazepines should be reserved for short-term use only due to dependence, tolerance, and withdrawal risks 2
• Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity 2

Common Pitfalls

• Do not escalate SSRI doses too quickly—allow 1-2 weeks between increases to assess tolerability 2
• Do not abandon treatment prematurely—full response may take 12+ weeks 2
• Do not use group CBT when individual CBT is available—individual therapy is superior 1
• Do not discontinue medications abruptly—taper gradually to avoid withdrawal symptoms, particularly with shorter half-life SSRIs 2