Social anxiety disorder — assessment and stepped management (MEQ)

(i) Assessment priorities. Structure as risk, substances, medical exclusion, differential social-anxiety formulation, MSE, collateral and function. Risk: expand passive burden/awkwardness thoughts into full assessment — ideation frequency, intent, plan, means, prior attempts, hopelessness, protective factors, alcohol-related impulsivity. Substances: quantify pre-event drinking and any other drugs; assess dependence/withdrawal. Medical: review for thyrotoxic features, tremor differentials, medications; baseline labs as indicated before pharmacotherapy (repeat TSH if clinically indicated, U&E/LFT, pregnancy test if relevant). Scales: SPIN for severity monitoring (not stand-alone diagnosis); LSAS if available; PHQ-9 14 indicates concurrent depressive symptoms needing full MDD criteria review. Bipolar screen before antidepressant. Developmental history (behavioural inhibition, bullying), ASD traits, BDD screen. Prior treatment adequacy. Collateral if available. Capacity for outpatient plan.^[1][4][5]

(ii) Working diagnosis and differentials. Working diagnosis: social anxiety disorder (marked fear of negative evaluation under scrutiny in interaction/performance situations for years, almost always provoked, avoidance/endurance with intense fear, impairment) with concurrent depressive symptoms and hazardous alcohol use as safety behaviour. Differentials with discriminators: normal shyness (impairment and avoidance of crucial academic tasks exceed shyness); panic disorder (no unexpected discrete attacks described); GAD (not multi-domain free-floating worry as primary); ASD (fear of evaluation dominant here — still screen communication/restricted patterns); avoidant personality traits (may coexist); BDD (not primarily appearance defect belief); substance-induced anxiety (alcohol contributes but symptoms extend beyond intoxication). Performance-only specifier does not apply if interactional situations (parties, tutorials) are also feared.^[1]

(iii) Stepped management. Psychoeducation using a cognitive model; alcohol reduction plan with motivational approach; sleep/caffeine advice. Offer high-intensity individual CBT for SAD: external attention training, drop safety behaviours (including alcohol), video feedback, behavioural experiments, graded exposure hierarchy (seminars → presentations), cognitive restructuring of cost/probability of negative evaluation, homework, roughly 12–16+ sessions depending on protocol; CBGT is an evidence alternative in some services.^[3][6] Named first-line drug example: sertraline 25–50 mg orally each morning, early review in 1–2 weeks for activation/suicidality and side-effects, titrate toward 100–150 mg if tolerated and incomplete response, plan about 8–12 weeks at therapeutic dose with serial SPIN/PHQ-9. Shared decision-making; crisis contacts; university disability liaison if appropriate. Continue effective treatment after response rather than stopping at first improvement.^[2][4]

(iv) Alcohol and benzodiazepines. Alcohol is a safety behaviour that prevents disconfirmation of social fears and risks dependence — not disease-modifying treatment; address in parallel with CBT and medical alcohol advice.^[1][4] Benzodiazepines: short-term bridge only if severe distress, with stop date — not indefinite monotherapy (dependence, cognitive harm, blocked exposure learning).^[4]

(v) Depression comorbidity. Concurrent depression elevates suicide risk and disability; treat both; SSRI strategy addresses both domains; more frequent early review after antidepressant initiation; safety plan; do not discharge to empty follow-up; escalate setting if risk rises.^[1][4]