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Adult Social Anxiety Disorder
Adult Social Anxiety Disorder
Diagnosis
Medication
Recommendation
Anxiety associated only with performances?
Yes
No
X
Severe
anxiety
Yes
Adequate response
(≥ 50% decrease in
symptoms)
Inadequate response
(< 50% improvement)
No
No
Inadequate
response
Inadequate
response
Consider TCA prior
to chronic benzodiazepines
Yes
Partial Response
On SSRI/SNRI?
On Buspirone
monotherapy?
No
Yes
No
Combination
Yes
Adequate response
(≥ 50% decrease in
symptoms)
Inadequate
response
Yes
Partial response
Social Anxiety Disorder
Consider
adjunctive prn
Benzodiazepine:
Clonazepam or
Lorazepam, ideally
<4 weeks SOR A
Performance only?
prn beta blocker
(i.e., Propranolol)
Psychotherapy:
1. Cognitive behavioral therapy (SOR A)
2. Acceptance and commitment therapy (SOR C)
SSRI or SNRI
SOR A
Follow up and titrate dose
as appropriate q 1-2 weeks for active
medication management
Maintain effective
pharmacotherapy
for minimum of 12
months; if
asymptomatic for
4-6 months,
consider slow
taper
Max dose achieved
with inadequate
response (<50%
improvement)
Buspirone
monotherapy?
First time failing an
SSRI or SNRI?
Discontinue
current
medication
Trial Mirtazapine
SOR B
Discontinue Mirtazapine;
trial Gabapentin/Pregabalin
SOR A
Discontinue Gabapentin/Pregabalin
agent and start either:
TCA
Imipramine most studied,
other TCAs reasonable
Benzodiazepine
Lorazepam
Clonazepam
Switch to
SSRI/SNRI
Partial response
Continue SSRI/SNRI;
augment with Buspirone
Follow up and titrate dose
as appropriate q 1-2 weeks for active
medication management
Discontinue both
SSRI/SNRI and Buspirone
Trial different SSRI/SNRI
Discontinue ineffective augmentation
therapy
Prior to trialing other augmentation options
ensure minimum two SSRI/SNRI trials
Further Augmentation therapy options:
First Choice: Mirtazapine
Second Choice: Pregabalin/Gabapentin
Third Choice: TCA (avoid if taking SSRI/SNRI)
Discontinue prior
augmentation therapy
Continue Buspirone Trial
different SSRI/SNRI
Continue Buspirone;
add SSRI/SNRI
SSRI/SNRI
SOR A
Buspirone
SOR C
Max dose NOT
achieved due to
side effects
Trial of different
medication
Comorbid
Depression?
