Date:
Patient:
Reason for Visit:
Initial evaluation for social anxiety disorder (SAD)
Follow-up for SAD
Assessment of treatment response or symptom progression
Management plan discussion
History:
Presenting Illness: (For initial evaluation)
Onset and duration of social anxiety symptoms (fear of public speaking, social interactions, scrutiny, negative evaluation)
Specific situations or triggers that provoke anxiety (e.g., parties, meetings, using public restrooms)
Impact of symptoms on daily life (work, school, social relationships)
Avoidance behaviors related to social anxiety
Comorbid conditions (e.g., depression, generalized anxiety disorder)
Past Medical History (PMH):
Any past diagnoses or treatments for mental health conditions
Medications (including over-the-counter)
Social History:
Educational and occupational background
Social support system (family, friends)
Substance use (alcohol, drugs)
Mental Status Exam (MSE):
Appearance: Note patient’s overall presentation (anxious, nervous, fidgeting).
Mood and Affect: Assess mood state (depressed, anxious) and emotional expression (restricted, worried).
Speech: Evaluate speech patterns (rapid, hesitant) and volume (soft, loud).
Thought Process: Explore for negative thoughts, catastrophizing, or rumination related to social situations.
Thought Content: Assess for suicidal ideation or other concerning thoughts.
Sensorium: Ensure patient is oriented to time, place, and person.
Insight and Judgment: Evaluate patient’s understanding of their condition and ability to make sound decisions.
Assessment:
Diagnosis: Based on DSM-5 criteria for social anxiety disorder, including symptom severity, duration, and impact on functioning.
Severity of symptoms: Mild, moderate, or severe based on clinician judgment and standardized rating scales (e.g., Social Anxiety Inventory – SAI).
Functional impairment: Evaluate how social anxiety affects daily life (work, school, social interactions).
Plan:
Treatment approach: Consider a combination of therapies based on individual needs and preferences.
Psychotherapy:
Cognitive-behavioral therapy (CBT) – the first-line treatment for SAD, focusing on identifying and modifying negative thoughts and behaviors related to social situations.
Exposure therapy – gradual exposure to feared social situations in a safe and controlled environment.
Social skills training – developing communication and social interaction skills.
Medications:
Selective serotonin reuptake inhibitors (SSRIs) – may be helpful in reducing anxiety symptoms.
Beta-blockers – may be used for short-term relief of physical symptoms of anxiety in specific social situations.
Self-management strategies:
Relaxation techniques (deep breathing, meditation).
Mindfulness practices.
Maintaining a healthy lifestyle (regular exercise, sleep hygiene).
Follow-up:
Schedule regular follow-up appointments to monitor symptom response, treatment adherence, and adjust the plan as needed.
Consider involving collateral sources of information (e.g., family members) to track progress.
Patient education: Provide information about social anxiety disorder, its causes, treatment options, and self-management strategies.
Normalize the experience of social anxiety and emphasize the effectiveness of treatment.
Encourage open communication about challenges and progress.
Disclaimer: This information is for educational purposes only and should not be interpreted as psychotherapy or treatment advice. Please consult with a qualified mental health professional for diagnosis and treatment of social anxiety disorder.