Diagnostic framework #
Strong fear of scrutiny in social situations, avoidance or intense discomfort, persistence for at least 6 months and impairment support a DSM-oriented assessment. Distinguish the disorder from shyness without impairment and document whether the pattern is performance-limited or broader.
Targeted clinical assessment #
Ask about feared predictions, visible blushing/tremor, rehearsing, concealment, alcohol use before events and post-event rumination. Assess actual social participation, depression, suicidality, bullying and developmental communication differences. Include the patient’s own desired activities when setting goals.
Differential diagnosis #
| Alternative | Discriminator |
|---|---|
| Autism | Lifelong social-communication and sensory differences rather than scrutiny fear alone. |
| Depression | Withdrawal associated with low interest/energy may coexist. |
| Psychosis | Fixed conviction and broader psychotic symptoms differ from fear of negative evaluation. |
| Body dysmorphic concerns | Assess whether perceived appearance defects dominate the fear. |
Indicated investigations #
| Clinical question | Assessment |
|---|---|
| Tremor or physical symptoms | Examine and investigate suspected neurological/endocrine contributors. |
| Medicine selection | Review interactions, hepatic impairment, sodium susceptibility and mood-switch history. |
| Using alcohol to cope | Assess consumption, dependence and withdrawal separately. |
Treatment sequence #
View treatment map
- Initial evidence-based treatment
Individual CBT developed specifically for social anxiety, including attention training, behavioral experiments and exposure.
- Medicine preferred
Discuss sertraline or a guideline-supported alternative.
- Partial SSRI response
Add individual CBT after an adequate course.
- Ongoing impairment
Review safety behaviors, treatment participation, comorbidity and alternatives with specialist input.
| Situation | Treatment |
|---|---|
| Initial evidence-based treatment | Individual CBT developed specifically for social anxiety, including attention training, behavioral experiments and exposure. |
| Medicine preferred | Discuss sertraline or a guideline-supported alternative. |
| Partial SSRI response | Add individual CBT after an adequate course. |
| Ongoing impairment | Review safety behaviors, treatment participation, comorbidity and alternatives with specialist input. |
Doses & prescribing #
Each prescribing record identifies its population and source jurisdiction; international labeling does not establish Indian approval. The clinician selects treatment after assessment.
Sertraline
Social anxiety disorder
Adults · Immediate-release tablets · Oral · United States product labeling
- Starting dose
- 25 mg once daily for the first week; then 50 mg once daily.
- Titration
- Subsequent increases of 25–50 mg/day no more often than weekly, according to response and tolerability.
- Treatment range / target
- 50–200 mg/day.
- Maximum / limits
- 200 mg/day.
- Trial & duration
- Condition-specific trial and continuation guidance below.
- Monitoring
- Activation, mood switch, suicidality, gastrointestinal/sexual effects; sodium when indicated.
- Population & organ-function adjustments
- Mild hepatic impairment: half starting and maximum doses; moderate/severe hepatic impairment: not recommended.
- Important cautions
- Avoid MAOIs and pimozide; reconcile serotonergic and bleeding-related interactions.
Nonresponse & escalation #
For partial response after 10–12 weeks of an SSRI, NICE recommends adding individual CBT. With no response or intolerance, reassess adherence and the formulation before an alternative SSRI/SNRI. Judge benefit through real participation and reduced safety behaviors, not tolerance of an isolated social task.
Maintenance & discontinuation #
NICE advises continuing an effective medicine for at least a further 6 months after a good response in the first 3 months. Agree staged withdrawal and continue behavioral practice; distinguish withdrawal from recurrent avoidance.
Special populations & comorbidity #
Adapt therapy to language, communication and learning needs. Comorbid depression, autism and alcohol misuse may alter sequencing and support. Older age and hepatic impairment affect SSRI dosing; pregnancy and lactation require separate exposure discussions.
Follow-up #
NICE recommends review every 2–4 weeks during the first 3 months of pharmacological treatment, then monthly. Increase contact for suicidality or activation concerns. Record chosen activities, anticipatory worry, safety behavior and adverse effects.
Clinical pitfalls #
Avoid generic social-skills advice when the maintaining problem is fear and self-monitoring. Apparent comfort achieved through alcohol, avoidance or repeated rehearsal may preserve disability. Exposure goals should test predictions rather than demand flawless performance.
Assessment tools #
Choose the instrument for its intended purpose; interpretation accompanies the linked tool.
Patient discussion #
Open a plain-language explanation
Treatment helps test feared predictions and shift attention away from constant self-monitoring, with practice at an agreed pace.
References · 3
- NICE CG159: Social anxiety treatment · United Kingdom · Checked 2026-10-26 · Supports: Differential diagnosis; Treatment sequence; Nonresponse & escalation; Maintenance & discontinuation; Follow-up
- NIMH: Social anxiety disorder · United States · Checked 2026-10-26 · Supports: Diagnostic framework; Targeted clinical assessment; Indicated investigations; Special populations & comorbidity; Clinical pitfalls
- Sertraline tablets: indication-specific product dosing · United States label · Checked 2026-10-26 · Supports: Indicated investigations; Special populations & comorbidity; Sertraline — Social anxiety disorder (Immediate-release tablets)