What is the recommended treatment for a patient with social anxiety disorder?

Treatment for Social Anxiety Disorder

For adults with social anxiety disorder, start with either an SSRI (escitalopram, paroxetine, or sertraline) or individual cognitive behavioral therapy (CBT) based on patient preference and availability, as both are first-line treatments with comparable efficacy. 1

First-Line Pharmacotherapy

Recommended SSRIs

• Escitalopram, paroxetine, or sertraline are the preferred first-choice medications for social anxiety disorder, with all SSRIs demonstrating similar efficacy (NNT = 4.70, meaning approximately 1 in 5 patients will respond who would not have responded to placebo). 1, 2
• Start with escitalopram 5-10 mg daily or sertraline 25-50 mg daily to minimize initial anxiety or agitation that can occur with SSRIs. 2
• Titrate escitalopram by 5-10 mg increments every 1-2 weeks to a target of 10-20 mg/day, or sertraline by 25-50 mg increments to a target of 50-200 mg/day. 2
• Paroxetine 20-50 mg/day is FDA-approved for social anxiety disorder and has demonstrated that 45-66% of patients achieve response (much or very much improved), though it carries higher risk of discontinuation symptoms compared to escitalopram or sertraline. 3, 4, 5

Alternative First-Line: SNRI

• Venlafaxine extended-release 75-225 mg/day is suggested as an alternative to SSRIs with comparable efficacy (NNT = 4.94), but requires blood pressure monitoring due to risk of sustained hypertension. 1, 6

First-Line Psychotherapy

Cognitive Behavioral Therapy

• Individual CBT specifically designed for social anxiety disorder (based on Clark and Wells model or Heimberg model) is recommended and prioritized over group therapy due to superior clinical and cost-effectiveness. 1, 2
• A structured duration of 12-20 CBT sessions is recommended to achieve significant symptomatic and functional improvement. 2
• If the patient refuses face-to-face CBT, self-help with support based on CBT principles is suggested as an alternative. 1

Expected Timeline and Monitoring

Response Timeline

• Statistically significant improvement may begin by week 2, with clinically significant improvement expected by week 6, and maximal therapeutic benefit achieved by week 12 or later. 2
• An optimal medication trial should continue beyond 8 weeks, as 27.7% of paroxetine nonresponders at week 8 became responders by week 12. 7
• Assess treatment response at 4 weeks and 8 weeks using standardized anxiety rating scales such as the Liebowitz Social Anxiety Scale (LSAS). 6

Common Side Effects to Monitor

• Nausea, sexual dysfunction, headache, insomnia, dry mouth, diarrhea, somnolence, and dizziness typically emerge within the first few weeks and often resolve with continued treatment. 2
• Monitor closely for suicidal thinking and behavior, especially in the first months and following dose adjustments, with a pooled risk difference of 0.7% versus placebo. 2

Treatment Algorithm for Inadequate Response

If First SSRI Fails After 8-12 Weeks

• Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa) using a gradual cross-taper: reduce the first SSRI by 25-50 mg every 1-2 weeks while simultaneously starting the new SSRI at a low dose. 2
• Consider adding individual CBT if not already implemented, as combination treatment provides superior outcomes compared to either treatment alone. 1, 2

Second-Line Options

• Duloxetine 60-120 mg/day or venlafaxine XR 75-225 mg/day can be considered if SSRIs are ineffective or not tolerated. 2, 6
• Pregabalin or gabapentin may be considered when first-line treatments fail, particularly for patients with comorbid pain conditions. 2

Combination Therapy

• There is no formal recommendation for combined pharmacotherapy and psychotherapy based on current evidence, though combination treatment may provide superior outcomes for patients with moderate to severe anxiety. 1, 2

Long-Term Management

• Continue effective medication for a minimum of 9-12 months after achieving remission to prevent relapse. 2
• Reassess monthly until symptoms stabilize, then every 3 months. 2
• Taper medication gradually over at least 10-14 days when discontinuing to avoid withdrawal symptoms, particularly with shorter half-life SSRIs like paroxetine and sertraline. 2, 6

Critical Pitfalls to Avoid

• Do not use benzodiazepines as first-line treatment due to risks of dependence, tolerance, and withdrawal; reserve only for short-term use. 2
• Beta-blockers (propranolol, atenolol) are explicitly deprecated for chronic social anxiety disorder treatment based on negative evidence, though they may be used off-label for acute performance anxiety situations. 2, 6, 8
• Do not escalate doses too quickly—allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window. 2, 6
• Do not abandon treatment prematurely, as full response may take 12+ weeks. 2, 7

Special Populations and Comorbidities

• Approximately one-third of patients with social anxiety disorder have comorbid psychiatric disorders including depression, other anxiety disorders, bipolar disorder, or substance use disorders, which should be screened for and may influence treatment selection. 1
• SSRIs and SNRIs have the additional benefit of treating comorbid depression and other anxiety disorders. 8