Core features

• Marked fear or anxiety about one or more social situations involving possible scrutiny (e.g., meeting new people, public speaking, eating in public).
• Fear of acting in a way that will be humiliating or lead to negative evaluation.
• Social situations provoke anxiety and are avoided or endured with intense distress.
• Symptoms persistent (typically ≥6 months) and cause clinically significant impairment.

Types & specifiers

• Performance‑only specifier: anxiety limited to public speaking or performance situations.
• Generalised SAD: fear across many social situations leading to broader impairment.
• Comorbidity is common: depressive disorders, other anxiety disorders, substance misuse (self‑medication), and avoidant personality traits.

Assessment checklist

1. Detailed history: onset, course, feared situations, avoidance, safety behaviours, impact on work/education/relationships and alcohol or drug use for social facilitation.
2. Use validated measures: Liebowitz Social Anxiety Scale (LSAS), Social Phobia Inventory (SPIN), and screening for depression (PHQ‑9).
3. Assess for performance‑only fears vs widespread social fears and screen for comorbid conditions and suicidality.
4. Functional analysis: identify safety behaviours (avoiding eye contact, rehearsing, using alcohol) that maintain anxiety.

Evidence‑based psychological treatments

• Cognitive‑Behavioural Therapy (CBT): first‑line—includes cognitive restructuring, behavioural experiments, and graduated exposure to feared situations.
• Exposure therapy: in‑vivo, imaginal, or video‑feedback exposures; role‑plays and public‑speaking practice are effective.
• Social skills training: helpful for clients with deficits in social competence; include assertiveness and conversation skills.
• Group CBT: offers naturalistic exposure and peer feedback—efficient and often effective for SAD.

Pharmacotherapy

• SSRIs & SNRIs: first‑line medications (sertraline, paroxetine, escitalopram, venlafaxine) — use therapeutic doses and allow 8–12 weeks to assess response.
• Performance anxieties: short‑acting beta‑blockers (propranolol) or benzodiazepines before performance situations may reduce autonomic symptoms; benzodiazepines carry dependence risk and may impair exposure learning.
• Other options: pregabalin, gabapentin or MAOIs in specialist settings for treatment‑resistant SAD—consult psychiatry for complex cases.

Treatment planning & sequencing

• Offer CBT‑based therapy as first‑line; consider combined SSRI + CBT for severe or persistent cases.
• Use group CBT for natural exposure opportunities when available; consider digital CBT for stepped care models.
• Monitor progress with LSAS/SPIN and set measurable behavioural goals (e.g., attend a social event, deliver a 5‑minute talk).

Practical tips for clinicians

• Start with clear psychoeducation: normalise anxiety, explain exposure rationale and set collaborative, measurable goals.
• Use video feedback to correct negative self‑perceptions—patients often rate their performance more negatively than observers do.
• Address safety behaviours explicitly—design exposures that prevent their use to maximise learning.
• Encourage behavioural experiments that test catastrophic predictions in real life and review outcomes together.

Key takeaways

• Social Anxiety Disorder is common and treatable—CBT with exposure is first‑line; SSRIs are effective for many cases.
• Address safety behaviours, use measurable goals and consider group formats for efficient exposure opportunities.
• Consider developmental, cultural and comorbidity factors when planning treatment and escalate to specialist care for treatment resistance.