What is the treatment for social anxiety disorder?

Treatment for Social Anxiety Disorder

Start with either an SSRI (selective serotonin reuptake inhibitor) or individual cognitive behavioral therapy (CBT) specifically designed for social anxiety disorder—both are equally effective first-line options, and the choice depends primarily on patient preference and availability of trained therapists. 1

First-Line Pharmacotherapy

SSRIs are the recommended first-line medications with the following specific agents showing efficacy: 1

• Sertraline: Start at 25 mg daily for the first week, then increase to 50 mg daily. Titrate by 25-50 mg increments every 1-2 weeks as tolerated, with a target dose of 50-200 mg/day. 2
• Escitalopram: Start at 5-10 mg daily, increase by 5-10 mg increments every 1-2 weeks, targeting 10-20 mg/day. 3, 4
• Paroxetine, fluvoxamine, and fluoxetine are also effective but carry higher risks of discontinuation symptoms and should be reserved for when first-tier SSRIs fail. 1, 5

Venlafaxine (SNRI) is an equally effective alternative to SSRIs, dosed at 75-225 mg/day, but requires blood pressure monitoring due to risk of sustained hypertension. 1

Expected Timeline and Monitoring

• Statistically significant improvement may begin by week 2, with clinically significant improvement expected by week 6, and maximal benefit achieved by week 12 or later. 4
• Most adverse effects (nausea, sexual dysfunction, headache, insomnia) emerge within the first few weeks and typically resolve with continued treatment. 4
• Critical warning: Monitor closely for suicidal thinking, especially in the first months and following dose adjustments (pooled risk 1% vs 0.2% placebo). 4

First-Line Psychotherapy

Individual CBT specifically developed for social anxiety disorder is strongly recommended, using either: 1

• Clark and Wells model or Heimberg model
• Structure: Approximately 14 individual sessions of 60-90 minutes each over 4 months 1
• Components include: psychoeducation, cognitive restructuring, gradual exposure to feared social situations (in-session and homework), review of core beliefs, and relapse prevention 1

Individual therapy is prioritized over group therapy due to superior clinical and cost-effectiveness, despite both being effective. 1

If face-to-face CBT is unavailable or unwanted, self-help materials based on CBT with professional support (approximately 9 sessions over 3-4 months via face-to-face or telephone) is an acceptable alternative. 1

Combination Therapy

There is no formal recommendation for combining pharmacotherapy with psychotherapy based on current evidence, though some research suggests potential benefit. 1 The guideline explicitly states no recommendation exists for combination therapy, leaving this decision to clinical judgment on a case-by-case basis. 1

Treatment Duration and Maintenance

• Continue medication for at least 6-12 months after symptom remission for a first episode. 3, 6
• For recurrent or chronic social anxiety disorder, longer-term or indefinite treatment may be necessary. 3
• Sertraline has demonstrated maintained efficacy for up to 24 weeks following initial 20-week treatment, with significantly lower relapse rates compared to placebo. 2
• Periodically reassess patients to determine ongoing need for treatment and adjust to the lowest effective dose. 2

Second-Line and Alternative Options

If first-line SSRIs or SNRIs fail after 8-12 weeks at therapeutic doses: 4, 5

• Switch to a different SSRI or SNRI before considering other medication classes
• Benzodiazepines (clonazepam, alprazolam, bromazepam) can be considered but should be reserved for short-term use due to dependence, tolerance, and withdrawal risks 5, 6
• Pregabalin or gabapentin (alpha-2-delta calcium channel blockers) are alternatives 1, 5
• Phenelzine (irreversible MAOI) may be more potent than SSRIs but should be restricted to treatment-resistant cases due to food and drug interaction liabilities 1, 7

Medications to Avoid

Beta-blockers (atenolol, propranolol) are not recommended for generalized social anxiety disorder based on negative evidence, though they may have limited benefit for performance anxiety only. 1, 5

Common Pitfalls

• Do not escalate SSRI doses too quickly—allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window. 4
• Do not abandon treatment prematurely—full response may take 12+ weeks. 4
• Do not use benzodiazepines as first-line therapy despite their rapid onset, due to long-term risks. 6
• Ensure CBT is specifically designed for social anxiety disorder—generic anxiety-focused CBT is less effective than disorder-specific protocols. 1