Diagnosis and Treatment Approach
This patient most likely has avoidant personality disorder (AvPD) with comorbid depression and anxiety, and should be started on an SSRI (sertraline 25-50 mg daily or escitalopram 5-10 mg daily) combined with individual cognitive behavioral therapy specifically targeting social avoidance patterns. 1, 2
Clinical Reasoning
The presentation reveals key features distinguishing this from simple social anxiety disorder:
- Pervasive pattern of social withdrawal extending beyond performance situations to all interpersonal relationships 3
- Ego-syntonic avoidance ("like staying at home") suggesting personality-level pathology rather than pure anxiety disorder 3
- Anhedonia and fatigue indicating comorbid depression 3
- Fear of disappointing others reflecting core AvPD feature of hypersensitivity to rejection 3
- Preserved occupational functioning ("people person at work") demonstrates capacity when structure is provided 1
Treatment Algorithm
Immediate Pharmacological Intervention
Start with first-line SSRI:
- Sertraline 25-50 mg daily OR escitalopram 5-10 mg daily to minimize initial activation symptoms 1, 2
- Titrate sertraline by 25-50 mg every 1-2 weeks to target 50-200 mg/day 2
- Titrate escitalopram by 5-10 mg increments to target 10-20 mg/day 2
- Expect statistically significant improvement by week 2, clinically significant improvement by week 6, maximal benefit by week 12 2, 4
Alternative if SSRI not tolerated:
Concurrent Psychological Treatment
Individual CBT is mandatory and superior to group therapy for this presentation 1, 2:
- Structure: 12-20 sessions over 4 months, 60-90 minutes each 1
- Target social avoidance patterns, not just anxiety symptoms 1
- Address fear of rejection and disappointment themes specific to AvPD 3
- CBT shows large effect size (Hedges g = 1.01) for anxiety disorders 2, 4
Monitoring and Adjustment
At 2-week intervals until symptom remission:
- Assess medication adherence and side effects (nausea, headache, insomnia, sexual dysfunction) 2
- Monitor for suicidal ideation (pooled risk 1% vs 0.2% placebo, NNH=143) 2
- Evaluate CBT engagement and attendance 3
If inadequate response at 8-12 weeks despite therapeutic dosing:
- Switch to different SSRI (sertraline ↔ escitalopram) 2
- Consider adding SNRI if not already tried 1, 2
- Intensify CBT if compliance poor 3
Critical Pitfalls to Avoid
Do not use benzodiazepines beyond short-term crisis management due to dependence risk and lack of efficacy for depression 2, 5
Do not undertreat the depression component - anhedonia and fatigue require full antidepressant dosing, not just anxiolytic doses 3, 4
Do not refer to group therapy - individual CBT is clinically and economically superior for social avoidance patterns 1, 2
Do not abandon treatment prematurely - full response requires 12+ weeks; most patients and providers give up too early 2
Do not ignore the personality disorder substrate - pure anxiety treatment will fail without addressing pervasive avoidance patterns and rejection sensitivity 3
Adjunctive Interventions
- Structured physical activity program provides moderate-to-large anxiety reduction 2
- Psychoeducation for patient about the chronic nature of personality-level patterns and realistic treatment timeline 3
- Breathing techniques, progressive muscle relaxation, grounding strategies as self-management tools 2
Expected Outcomes
With combined pharmacotherapy and individual CBT:
- SSRIs show SMD -0.55 to -0.67 vs placebo for anxiety disorders 4
- CBT demonstrates Hedges g = 0.41-1.01 depending on specific anxiety disorder 4
- Combination therapy superior to either alone for severe presentations 2
Continue medication for 6-12 months after remission before considering gradual taper to prevent relapse 5