Treatment of Social Phobia (Social Anxiety Disorder)

First-Line Treatments

• The American College of Neuropsychopharmacology recommends starting with either an SSRI (sertraline or escitalopram preferred) or individual cognitive behavioral therapy (CBT) specifically designed for social anxiety disorder, as both are first-line treatments with comparable efficacy 1, 2
• Selective Serotonin Reuptake Inhibitors (SSRIs) are the recommended first-line medications for social phobia, with a low evidence quality and weak recommendation strength (GRADE 2C) 1, 2

Pharmacotherapy

• Sertraline is a preferred SSRI option, starting at 25-50 mg daily, titrating by 25-50 mg every 1-2 weeks as tolerated, with a target dose of 50-200 mg/day 3
• Escitalopram is another preferred SSRI option, starting at 5-10 mg daily, titrating by 5-10 mg increments every 1-2 weeks, with a target dose of 10-20 mg/day 3
• Venlafaxine extended-release is suggested as an alternative first-line option, at a dose of 75-225 mg/day, requiring blood pressure monitoring due to the risk of sustained hypertension 1, 2

Psychotherapy

• Individual Cognitive Behavioral Therapy (CBT) specifically developed for social anxiety disorder is the recommended psychotherapy approach, using protocols based on the Clark and Wells model or Heimberg model 1, 2
• CBT should include education on anxiety mechanisms, cognitive restructuring, gradual exposure to feared social situations, and relaxation techniques 3

Treatment Duration and Monitoring

• Statistically significant improvement may begin by week 2, with clinically meaningful improvement by week 6, and maximal benefit by week 12 or later 3
• Monitoring should be done using standardized scales, such as the Liebowitz Social Anxiety Scale or Social Phobia Inventory, at every session 4

Combination Therapy

• There is no formal recommendation for combining pharmacotherapy and psychotherapy due to insufficient evidence, although each combination studied involved different drug-therapy pairings with very low certainty of evidence 1, 2, 4

Medications to Avoid or Use Cautiously

• Beta-blockers, such as atenolol and propranolol, are not recommended based on negative evidence 3
• Benzodiazepines should be reserved for short-term use only due to dependence, tolerance, and withdrawal risks 3
• Tricyclic antidepressants should be avoided due to an unfavorable risk-benefit profile, particularly cardiac toxicity 3