Treatment of social anxiety disorder, generalized, in individuals without a substance use disorder

CBT: cognitive-behavioral therapy; MAOI: monoamine oxidase inhibitor; SNRI: serotonin-norepinephrine reuptake inhibitor; SSRI: selective serotonin reuptake inhibitor.

* Patient preference is a primary factor in determining whether to pursue treatment and in choice of treatment modality. We generally reserve treatment with combined modality for those who prefer combination or for select individuals with suboptimal response to one modality. Additionally, psychotherapy can be added to pharmacologic management at any point along the algorithm.

¶ Individual or group CBT provided for 12 to 15 weeks is the preferred form of psychotherapy for social anxiety disorder. Patient preference and availability are also factors. Refer to UpToDate content for discussion of psychotherapy treatment including components and length of treatment.

Δ We monitor symptoms using therapeutic scales on a regular basis. Patient preference determines whether to continue treatment. Refer to UpToDate content for further discussion of monitoring and decision to treat.

◊ We consider a therapeutic trial to include 10 to 12 weeks of treatment with 6 weeks at the highest tolerated dose within the therapeutic range. Refer to UpToDate for further discussion of choosing medication, titration, and length of trial.

§ For all individuals, for no response to first SSRI or SNRI, we try a second trial of a different SSRI or SNRI. Refer to UpToDate content for choice of SSRI or SNRI.

¥ Refer to UpToDate content for discussion of subsequent treatment and monitoring of individuals with a good response to treatment.

‡ Refer to UpToDate content for discussion of starting, titrating, and issues related to dependence when using benzodiazepines.

† Minimal data support these agents as monotherapy or augmentation for social anxiety disorder. Refer to UpToDate content for discussion on choosing between and using buspirone, gabapentin, or pregabalin.

** Refer to UpToDate content for other medication options (with limited support) and other psychotherapy options.

¶¶ Dietary restrictions must be followed when using MAOI. A washout period is needed after discontinuing SSRI or SNRI and prior to beginning an MAOI. Refer to UpToDate for further discussion of using MAOI including, dose, titration, and dietary restrictions.