Social anxiety disorder: recognition, assessment and treatment

Be aware that people with social anxiety disorder may:

• not know that social anxiety disorder is a recognised condition and can be effectively treated

• perceive their social anxiety as a personal flaw or failing

• be vulnerable to stigma and embarrassment

• avoid contact with and find it difficult or distressing to interact with healthcare professionals, staff and other service users

• avoid disclosing information, asking and answering questions and making complaints

• have difficulty concentrating when information is explained to them.

Primary and secondary care clinicians, managers and commissioners should consider arranging services flexibly to promote access and avoid exacerbating social anxiety disorder symptoms by offering:

• appointments at times when the service is least crowded or busy

• appointments before or after normal hours, or at home initially

• self-check-in and other ways to reduce distress on arrival

• opportunities to complete forms or paperwork before or after an appointment in a private space

• support with concerns related to social anxiety (for example, using public transport)

• a choice of professional if possible.

When a person with social anxiety disorder is first offered an appointment, in particular in specialist services, provide clear information in a letter about:

• where to go on arrival and where they can wait (offer the use of a private waiting area or the option to wait elsewhere, for example outside the service's premises)

• location of facilities available at the service (for example, the car park and toilets)

• what will happen and what will not happen during assessment and treatment.
  
  When the person arrives for the appointment, offer to meet or alert them (for example, by text message) when their appointment is about to begin.

Be aware that changing healthcare professionals or services may be particularly stressful for people with social anxiety disorder. Minimise such disruptions, discuss concerns beforehand and provide detailed information about any changes, especially those that were not requested by the service user.

For people with social anxiety disorder using inpatient mental health or medical services, arrange meals, activities and accommodation by:

• regularly discussing how such provisions fit into their treatment plan and their preferences

• providing the opportunity for them to eat on their own if they find eating with others too distressing

• providing a choice of activities they can do on their own or with others.

Offer to provide treatment in settings where children and young people with social anxiety disorder and their parents or carers feel most comfortable, for example, at home or in schools or community centres.

Consider providing childcare (for example, for siblings) to support parent and carer involvement.

When assessing a person with social anxiety disorder, provide opportunities for them to make and change appointments by various means, including text, email or phone.

When communicating with children and young people and their parents or carers, be aware that children who are socially anxious may be reluctant to speak to an unfamiliar person, and that children with a potential diagnosis of selective mutism may be unable to speak at all during assessment or treatment; accept information from parents or carers, but ensure that the child or young person is given the opportunity to answer for themselves, through writing, drawing or speaking through a parent or carer if necessary.

Healthcare, social care and educational professionals working with children and young people should be trained and skilled in:

• negotiating and working with parents and carers, including helping parents with relationship difficulties find support

• referring children with possible social anxiety disorder to appropriate services.

Ensure that children and young people and their parents or carers understand the purpose of any meetings and the reasons for sharing information. Respect their rights to confidentiality throughout the process and adapt the content and duration of meetings to take into account the impact of the social anxiety disorder on the child or young person's participation.

If a parent or carer cannot attend meetings for assessment or treatment, ensure that written information is provided and shared with them.

Maintain links with adult mental health services so that referrals for any mental health needs of parents or carers can be made quickly and smoothly.

Ask the identification questions for anxiety disorders in line with recommendation 1.2.2 in the NICE guideline on generalised anxiety disorder and panic disorder, and if social anxiety disorder is suspected:

• use the 3-item Mini-Social Phobia Inventory (Mini-SPIN) or

• consider asking the following 2 questions:

  • Do you find yourself avoiding social situations or activities?

  • Are you fearful or embarrassed in social situations?
    
    If the person scores 6 or more on the Mini-SPIN, or answers yes to either of the 2 questions above, refer for or conduct a comprehensive assessment for social anxiety disorder (see recommendations 1.2.5 to 1.2.8).

If the identification questions (see recommendation 1.2.1) indicate possible social anxiety disorder, but the practitioner is not competent to perform a mental health assessment, refer the person to an appropriate healthcare professional. If this professional is not the person's GP, inform the GP of the referral.

If the identification questions (see recommendation 1.2.1) indicate possible social anxiety disorder, a practitioner who is competent to perform a mental health assessment should review the person's mental state and associated functional, interpersonal and social difficulties.

If an adult with possible social anxiety disorder finds it difficult or distressing to attend an initial appointment in person, consider making the first contact by phone or internet, but aim to see the person face to face for subsequent assessments and treatment.

When assessing an adult with possible social anxiety disorder:

• conduct an assessment that considers fear, avoidance, distress and functional impairment

• be aware of comorbid disorders, including avoidant personality disorder, alcohol and substance misuse, mood disorders, other anxiety disorders, psychosis and autism.

Consider using a validated measure for social anxiety to inform the assessment and support the evaluation of any intervention, for example, the Social Phobia Inventory (SPIN) or the Liebowitz Social Anxiety Scale (LSAS).

Obtain a detailed description of the person's current social anxiety and associated problems and circumstances including:

• feared and avoided social situations

• what they are afraid might happen in social situations (for example, looking anxious, blushing, sweating, trembling or appearing boring)

• anxiety symptoms

• view of self

• content of self-image

• safety-seeking behaviours

• focus of attention in social situations

• anticipatory and post-event processing

• occupational, educational, financial and social circumstances

• medication, alcohol and recreational drug use.

If a person with possible social anxiety disorder does not return after an initial assessment, contact them (using their preferred method of communication) to discuss the reason for not returning. Remove any obstacles to further assessment or treatment that the person identifies.

After diagnosis of social anxiety disorder in an adult, identify the goals for treatment and provide information about the disorder and its treatment including:

• the nature and course of the disorder and commonly occurring comorbidities

• the impact on social and personal functioning

• commonly held beliefs about the cause of the disorder

• beliefs about what can be changed or treated

• choice and nature of evidence-based treatments.

If the person also has symptoms of depression, assess their nature and extent and determine their functional link with the social anxiety disorder by asking them which existed first.

• If the person has only experienced significant social anxiety since the start of a depressive episode, treat the depression in line with recommendations in the NICE guideline on depression in adults.

• If the social anxiety disorder preceded the onset of depression, ask: "if I gave you a treatment that ensured you were no longer anxious in social situations, would you still be depressed?"

  • If the person answers 'no', treat the social anxiety (unless the severity of the depression prevents this, then offer initial treatment for the depression).

  • If the person answers 'yes', consider treating both the social anxiety disorder and the depression, taking into account their preference when deciding which to treat first.

• If the depression is treated first, treat the social anxiety disorder when improvement in the depression allows.

For people (including young people) with social anxiety disorder who misuse substances, be aware that alcohol or drug misuse is often an attempt to reduce anxiety in social situations and should not preclude treatment for social anxiety disorder. Assess the nature of the substance misuse to determine if it is primarily a consequence of social anxiety disorder and:

• offer a brief intervention for hazardous alcohol or drug misuse (see the NICE guideline on alcohol-use disorders or drug misuse in over 16s)

• for harmful or dependent alcohol or drug misuse consider referral to a specialist alcohol or drug misuse service.

All interventions for adults with social anxiety disorder should be delivered by competent practitioners. Psychological interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Practitioners should consider using competence frameworks developed from the relevant treatment manual(s) and for all interventions should:

• receive regular, high-quality outcome-informed supervision

• use routine sessional outcome measures (for example, the SPIN or LSAS) and ensure that the person with social anxiety is involved in reviewing the efficacy of the treatment

• engage in monitoring and evaluation of treatment adherence and practitioner competence – for example, by using video and audio tapes, and external audit and scrutiny if appropriate.

Offer adults with social anxiety disorder individual cognitive behavioural therapy (CBT) that has been specifically developed to treat social anxiety disorder (based on the Clark and Wells model or the Heimberg model; see recommendations 1.3.13 and 1.3.14 in the section on delivering psychological interventions for adults).

Do not routinely offer group CBT in preference to individual CBT. Although there is evidence that group CBT is more effective than most other interventions, it is less clinically and cost effective than individual CBT.

For adults who decline CBT and wish to consider another psychological intervention, offer CBT-based supported self-help (see recommendation 1.3.15 in the section on delivering psychological interventions for adults).

For adults who decline cognitive behavioural interventions and express a preference for a pharmacological intervention, discuss their reasons for declining cognitive behavioural interventions and address any concerns.

If the person wishes to proceed with a pharmacological intervention, offer a selective serotonin reuptake inhibitor (SSRI) (escitalopram or sertraline). Monitor the person carefully for adverse reactions (see recommendations 1.3.17 to 1.3.23 in the section on prescribing and monitoring pharmacological interventions in adults).

For adults who decline cognitive behavioural and pharmacological interventions, consider short-term psychodynamic psychotherapy that has been specifically developed to treat social anxiety disorder (see recommendation 1.3.16 in the section on delivering psychological interventions for adults). Be aware of the more limited clinical effectiveness and lower cost effectiveness of this intervention compared with CBT, self-help and pharmacological interventions.

For adults whose symptoms of social anxiety disorder have only partially responded to individual CBT after an adequate course of treatment, consider a pharmacological intervention (see recommendation 1.3.6 in the section on initial treatment options for adults with social anxiety disorder) in combination with individual CBT.

For adults whose symptoms have only partially responded to an SSRI (escitalopram or sertraline) after 10 to 12 weeks of treatment, offer individual CBT in addition to the SSRI.

For adults whose symptoms have not responded to an SSRI (escitalopram or sertraline) or who cannot tolerate the side effects, offer an alternative SSRI (fluvoxamine or paroxetine) or a serotonin noradrenaline reuptake inhibitor (SNRI) (venlafaxine), taking into account:

• the tendency of paroxetine and venlafaxine to produce a discontinuation syndrome (which may be reduced by extended-release preparations)

• the risk of suicide and likelihood of toxicity in overdose.
  
  At the time of publication (May 2013) fluvoxamine did not have a UK marketing authorisation for use in adults with social anxiety disorder. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

For adults whose symptoms have not responded to an alternative SSRI or an SNRI, offer a monoamine oxidase inhibitor (phenelzine or moclobemide).

At the time of publication (May 2013) phenelzine did not have a UK marketing authorisation for use in adults with social anxiety disorder. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

Discuss the option of individual CBT with adults whose symptoms have not responded to pharmacological interventions.

Individual CBT (the Clark and Wells model) for social anxiety disorder should consist of up to 14 sessions of 90 minutes' duration over approximately 4 months and include the following:

• education about social anxiety

• experiential exercises to demonstrate the adverse effects of self-focused attention and safety-seeking behaviours

• video feedback to correct distorted negative self-imagery

• systematic training in externally focused attention

• within-session behavioural experiments to test negative beliefs with linked homework assignments

• discrimination training or rescripting to deal with problematic memories of social trauma

• examination and modification of core beliefs

• modification of problematic pre- and post-event processing

• relapse prevention.

Individual CBT (the Heimberg model) for social anxiety disorder should consist of 15 sessions of 60 minutes' duration, and 1 session of 90 minutes for exposure, over approximately 4 months, and include the following:

• education about social anxiety

• cognitive restructuring

• graduated exposure to feared social situations, both within treatment sessions and as homework

• examination and modification of core beliefs

• relapse prevention.

Supported self-help for social anxiety disorder should consist of:

• typically up to 9 sessions of supported use of a CBT-based self-help book over 3 to 4 months

• support to use the materials, either face to face or by telephone, for a total of 3 hours over the course of the treatment.

Short-term psychodynamic psychotherapy for social anxiety disorder should consist of typically up to 25 to 30 sessions of 50 minutes' duration over 6 to 8 months and include the following:

• education about social anxiety disorder

• establishing a secure positive therapeutic alliance to modify insecure attachments

• a focus on a core conflictual relationship theme associated with social anxiety symptoms

• a focus on shame

• encouraging exposure to feared social situations outside therapy sessions

• support to establish a self-affirming inner dialogue

• help to improve social skills.

Before prescribing a pharmacological intervention for social anxiety disorder, discuss the treatment options and any concerns the person has about taking medication. Explain fully the reasons for prescribing and provide written and verbal information on:

• the likely benefits of different drugs

• the different propensities of each drug for side effects, discontinuation syndromes and drug interactions

• the risk of early activation symptoms with SSRIs and SNRIs, such as increased anxiety, agitation, jitteriness and problems sleeping

• the gradual development, over 2 weeks or more, of the full anxiolytic effect

• the importance of taking medication as prescribed, reporting side effects and discussing any concerns about stopping medication with the prescriber, and the need to continue treatment after remission to avoid relapse.

Arrange to see people aged 30 years and older who are not assessed to be at risk of suicide within 1 to 2 weeks of first prescribing SSRIs or SNRIs to:

• discuss any possible side effects and potential interaction with symptoms of social anxiety disorder (for example, increased restlessness or agitation)

• advise and support them to engage in graduated exposure to feared or avoided social situations.

After the initial meeting (see recommendation 1.3.18), arrange to see the person every 2 to 4 weeks during the first 3 months of treatment and every month thereafter. Continue to support them to engage in graduated exposure to feared or avoided social situations.

For people aged under 30 years who are offered an SSRI or SNRI:

• warn them that these drugs are associated with an increased risk of suicidal thinking and self-harm in a minority of people under 30 and

• see them within 1 week of first prescribing and

• monitor the risk of suicidal thinking and self-harm weekly for the first month. [This recommendation is from the NICE guideline on generalised anxiety disorder and panic disorder in adults].

Arrange to see people who are assessed to be at risk of suicide weekly until there is no indication of increased suicide risk, then every 2 to 4 weeks during the first 3 months of treatment and every month thereafter. Continue to support them to engage in graduated exposure to feared or avoided social situations.

Advise people taking a monoamine oxidase inhibitor of the dietary and pharmacological restrictions concerning the use of these drugs as set out in the British National Formulary.

For people who develop side effects soon after starting a pharmacological intervention, provide information and consider 1 of the following strategies:

• monitoring the person's symptoms closely (if the side effects are mild and acceptable to the person)

• reducing the dose of the drug

• stopping the drug and offering either an alternative drug or individual CBT, according to the person's preference.
  
  [This recommendation is adapted from the NICE guideline on generalised anxiety disorder and panic disorder in adults].

If the person's symptoms of social anxiety disorder have responded well to a pharmacological intervention in the first 3 months, continue it for at least a further 6 months.

When stopping a pharmacological intervention, reduce the dose of the drug gradually. If symptoms reappear after the dose is lowered or the drug is stopped, consider increasing the dose, reintroducing the drug or offering individual CBT.

Health and social care professionals in primary care and education and community settings should be alert to possible anxiety disorders in children and young people, particularly those who avoid school, social or group activities or talking in social situations, or are irritable, excessively shy or overly reliant on parents or carers. Consider asking the child or young person about their feelings of anxiety, fear, avoidance, distress and associated behaviours (or a parent or carer) to help establish if social anxiety disorder is present, using these questions:

• "Sometimes people get very scared when they have to do things with other people, especially people they don't know. They might worry about doing things with other people watching. They might get scared that they will do something silly or that people will make fun of them. They might not want to do these things or, if they have to do them, they might get very upset or cross."

  • "Do you/does your child get scared about doing things with other people, like talking, eating, going to parties, or other things at school or with friends?"

  • "Do you/does your child find it difficult to do things when other people are watching, like playing sport, being in plays or concerts, asking or answering questions, reading aloud, or giving talks in class?"

  • "Do you/does your child ever feel that you/your child can't do these things or try to get out of them?"

If the child or young person (or a parent or carer) answers 'yes' to one or more of the questions in recommendation 1.4.1 consider a comprehensive assessment for social anxiety disorder (see recommendations 1.4.5 to 1.4.11 in the section on assessment of children and young people with possible social anxiety disorder).

If the identification questions (see recommendation 1.4.1) indicate possible social anxiety disorder, but the practitioner is not competent to perform a mental health assessment, refer the child or young person to an appropriate healthcare professional. If this professional is not the child or young person's GP, inform the GP of the referral.

If the identification questions (see recommendation 1.4.1) indicate possible social anxiety disorder, a practitioner who is competent to perform a mental health assessment should review the child or young person's mental state and associated functional, interpersonal and social difficulties.

A comprehensive assessment of a child or young person with possible social anxiety disorder should:

• provide an opportunity for the child or young person to be interviewed alone at some point during the assessment

• if possible, involve a parent, carer or other adult known to the child or young person who can provide information about current and past behaviour

• if necessary, involve more than one professional to ensure a comprehensive assessment can be undertaken.

When assessing a child or young person obtain a detailed description of their current social anxiety and associated problems including:

• feared and avoided social situations

• what they are afraid might happen in social situations (for example, looking anxious, blushing, sweating, trembling or appearing boring)

• anxiety symptoms

• view of self

• content of self-image

• safety-seeking behaviours

• focus of attention in social situations

• anticipatory and post-event processing, particularly for older children

• family circumstances and support

• friendships and peer groups, educational and social circumstances

• medication, alcohol and recreational drug use.

As part of a comprehensive assessment, assess for causal and maintaining factors for social anxiety disorder in the child or young person's home, school and social environment, in particular:

• parenting behaviours that promote and support anxious behaviours or do not support positive behaviours

• peer victimisation in school or other settings.

As part of a comprehensive assessment, assess for possible coexisting conditions such as:

• other mental health problems (for example, other anxiety disorders and depression)

• neurodevelopmental conditions such as attention deficit hyperactivity disorder, autism and learning disabilities

• drug and alcohol misuse (see recommendation 1.2.11 in the section on planning treatment for adults diagnosed with social anxiety disorder)

• speech and language problems.

To aid the assessment of social anxiety disorder and other common mental health problems consider using formal instruments (both the child and parent versions if available and indicated), such as:

• the LSAS – child version or the Social Phobia and Anxiety Inventory for Children (SPAI-C) for children, or the SPIN or the LSAS for young people

• the Multidimensional Anxiety Scale for Children (MASC), the Revised Child Anxiety and Depression Scale (RCADS) for children and young people who may have comorbid depression or other anxiety disorders, the Spence Children's Anxiety Scale (SCAS) or the Screen for Child Anxiety Related Emotional Disorders (SCARED) for children.

Use formal assessment instruments to aid the diagnosis of other problems, such as:

• a validated measure of cognitive ability for a child or young person with a suspected learning disability

• the Strengths and Difficulties Questionnaire for all children and young people.

Assess the risks and harm faced by the child or young person and if needed develop a risk management plan for risk of self-neglect, familial abuse or neglect, exploitation by others, self-harm or harm to others.

Develop a profile of the child or young person to identify their needs and any further assessments that may be needed, including the extent and nature of:

• the social anxiety disorder and any associated difficulties (for example, selective mutism)

• any coexisting mental health problems

• neurodevelopmental conditions such as attention deficit hyperactivity disorder, autism and learning disabilities

• experience of bullying or social ostracism

• friendships with peers

• speech, language and communication skills

• physical health problems

• personal and social functioning to indicate any needs (personal, social, housing, educational and occupational)

• educational and occupational goals

• parent or carer needs, including mental health needs.

All interventions for children and young people with social anxiety disorder should be delivered by competent practitioners. Psychological interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Practitioners should consider using competence frameworks developed from the relevant treatment manual(s) and for all interventions should:

• receive regular high-quality supervision

• use routine sessional outcome measures, for example:

  • the LSAS – child version or the SPAI-C, and the SPIN or LSAS for young people

  • the MASC, RCADS, SCAS or SCARED for children

• engage in monitoring and evaluation of treatment adherence and practitioner competence – for example, by using video and audio tapes, and external audit and scrutiny if appropriate.

Be aware of the impact of the home, school and wider social environments on the maintenance and treatment of social anxiety disorder. Maintain a focus on the child or young person's emotional, educational and social needs and work with parents, teachers, other adults and the child or young person's peers to create an environment that supports the achievement of the agreed goals of treatment.

Offer individual or group CBT focused on social anxiety (see recommendations 1.5.4 and 1.5.5) to children and young people with social anxiety disorder. Consider involving parents or carers to ensure the effective delivery of the intervention, particularly in young children.

Individual CBT should consist of the following, taking into account the child or young person's cognitive and emotional maturity:

• 8 to 12 sessions of 45 minutes' duration

• psychoeducation, exposure to feared or avoided social situations, training in social skills and opportunities to rehearse skills in social situations

• psychoeducation and skills training for parents, particularly of young children, to promote and reinforce the child's exposure to feared or avoided social situations and development of skills.

Group CBT should consist of the following, taking into account the child or young person's cognitive and emotional maturity:

• 8 to 12 sessions of 90 minutes' duration with groups of children or young people of the same age range

• psychoeducation, exposure to feared or avoided social situations, training in social skills and opportunities to rehearse skills in social situations

• psychoeducation and skills training for parents, particularly of young children, to promote and reinforce the child's exposure to feared or avoided social situations and development of skills.

Consider psychological interventions that were developed for adults (see the section on interventions for adults with social anxiety disorder) for young people (typically aged 15 years and older) who have the cognitive and emotional capacity to undertake a treatment developed for adults.

Do not routinely offer computerised CBT to treat specific phobias in adults.