Social anxiety disorder — structured clinical viva

This is generalised social anxiety disorder (interactional and performance situations) with alcohol as a safety behaviour and inadequate prior antidepressant trials (stopped within 10 days — not therapeutic dose/duration). The belief "I already know I am awkward" is a treatment target (distorted self-image / certainty without behavioural experiments), not a reason to abandon CBT. Do not escalate long-term benzodiazepines as the primary plan.^[1][4][5]

Formulation. Vulnerability (possible behavioural inhibition/temperament), maintaining factors (self-focused attention, safety behaviours including alcohol, post-event processing, avoidance of meetings), precipitants (workplace demands), and iatrogenic history of aborted SSRI trials without activation management.^[1]

SSRI re-challenge strategy. Explain early activation; start low (e.g. sertraline 25 mg), frequent early review, short-term non-escalating support, parallel CBT engagement work. Prior "failure" at 10 days is not pharmacological non-response.^[3][5]

CBT sales pitch without collusion. Validate distress; introduce experiments testing whether others notice blushing as much as feared; attention training; video feedback; drop alcohol-as-safety-behaviour experiments with medical support if dependence risk high.^[1][4]

Specialist ladder. If true non-response after adequate SSRI/SNRI and quality CBT: switch class, combination, refractory pathway; phenelzine has landmark comparative efficacy versus CBGT but requires specialist MAOI counselling (diet, interactions, washout).^[2][5]

Maintenance. After response, continue medication for a substantial period — sertraline continuation reduces relapse versus placebo substitution in responders.^[6]