Drs Clare Taylor (left) and Evan Mayo-Wilson, and Professors DavidMClark and Stephen Pilling explain how social anxiety disorder is under-recognised
Social anxiety disorder (formerly known as social phobia) is one of the most persistent and common of the anxiety disorders, with lifetime prevalence rates in Europe of 6.7% (range 3.9%–13.7%);1 however, public and healthcare professional awareness of the disorder is limited.
Individuals with social anxiety disorder have a persistent fear of, or anxiety about, one or more social or performance situations, out of proportion to the actual threat posed by the situation.
Typical anxiety-provoking situations include:
- meeting people, including strangers
- talking in meetings or in groups
- starting conversations
- talking to authority figures
- working, eating, or drinking while being observed
- going to school
- going shopping
- being seen in public
- using public toilets
- public performances, including speaking.
The onset of social anxiety disorder usually occurs in early to mid-adolescence, although it can also present in younger children.
Although a significant disorder in its own right, social anxiety disorder commonly coexists with a number of other disorders, for example:2
- substance-use disorder
- generalised anxiety disorder
- panic disorder
- post-traumatic stress disorder.
This co-presentation with other disorders can make social anxiety disorder difficult to identify, especially in brief primary care consultations. Problems identifying the disorder can be further exacerbated by the reluctance of many people with social anxiety disorder to seek help. This reluctance may be related to avoidance of social situations as characterised by the disorder itself, but also by the common belief that the problem is an intractable personal difficulty for which the person bears responsibility, and which is not amenable to treatment.
Social anxiety disorder can have a significant effect on a person’s daily functioning by impeding the formation of relationships, reducing quality of life, and negatively affecting performance at work or school.3 This can have lifelong implications and can explain the poor long-term social4 and occupational performance5 of people with social anxiety disorder. Some coping strategies (e.g. excessive drug or alcohol use) can exacerbate the problem.
Challenges to treatment
A number of effective treatments exist for social anxiety disorder, and these are described below. Limited access to psychological interventions may restrict treatment options for some, but under-recognition by professionals and family members, and the reluctance of affected individuals to seek help, are also major factors.6 As a consequence, only one-half of affected people seek treatment, and in many this can be 10 to 15 years or more after the onset of the disorder.7
Social anxiety disorder can therefore become chronic, and although about 40% of individuals who develop the condition in childhood or adolescence may recover before reaching the age of 18 years, for those in whom the disorder persists into adulthood, the likelihood of spontaneous recovery is more limited than for many other common mental health problems.8
Clinical Guideline 159
This article summarises the key recommendations from NICE Clinical Guideline (CG) 159, Social anxiety disorder: recognition, assessment and treatment (see www.nice.org.uk/guidance/CG159) that are relevant to GPs and other primary care professionals. The guideline was developed by a team led by the National Collaborating Centre for Mental Health (NCCMH) and offers best practice advice on the care of children and young people (from school age to 17 years) and adults (aged 18 years and older) with social anxiety disorder.6
Improving access to services
Aware that many people with social anxiety disorder would find it difficult and distressing to interact with healthcare professionals and other service users, the guideline development group (GDG) for NICE CG159 made several recommendations to improve access to services. It judged that some people with the disorder may not:
- present to services
- be willing to talk about their symptoms, because they think that their social anxiety is a personal flaw or failing
- be aware that social anxiety disorder is a recognised condition that can be effectively treated.6
Opportunities to engage a person with social anxiety disorder should be taken at the earliest opportunity. NICE CG159 recommends that when a person is first offered an appointment, they should be sent clear information in a letter regarding:6
- where to go on arrival and where to wait (with the option of using a private waiting area or waiting outside the service’s premises)
- the location of facilities, such as the car park and toilets
- what will happen and what will not happen during assessment and treatment.
NICE CG159 recommends that when the person arrives for the appointment, an offer should be made to meet them or alert them (for example, by text message) when their appointment is about to begin.6
The GDG recommended that primary and secondary care clinicians, managers, and commissioners should consider arranging services flexibly to promote access and to avoid exacerbating symptoms of social anxiety disorder. For instance, services could offer:6
- appointments before or after normal hours (or at home initially), or at times when the service is least crowded or busy
- self-check-in, to reduce the person’s stress on arrival
- an opportunity for the person to complete forms or paperwork in a private space
- support for the individual with concerns related to social anxiety (such as using public transport)
- a choice of professional if possible.
NICE CG159 emphasises that, if possible, appointments for children and young people should be organised so that they do not interfere with school and social activities; in addition, treatment for this age group should be provided where they and their parents or carers feel most comfortable (for example, at home, school, or a community centre). Childcare should be provided to support parent and carer involvement.6
Given that interaction and communication with other people can cause distress in individuals with social anxiety disorder, NICE CG159 makes recommendations to address this difficulty. For example, during assessment, the person should be able to communicate with professionals in the way they find most comfortable (e.g. by letter or questionnaire). Professionals, in turn, can offer to communicate with the person by phone, text, or email.
Communicating with children
Communicating with children may present particular challenges because children may be reluctant to speak to an unfamiliar person, and those whose social anxiety is expressed as selective mutism may be unable to speak at all. NICE CG159 advises that professionals should accept information from parents and carers, but ensure that the child has the opportunity to answer for themselves through writing, drawing, or speaking via a parent or carer if necessary.Professionals should use plain language and communication aids (e.g. pictures, symbols, large print, braille, different languages, or sign language) if needed, and check that the child or young person (and their parents or carers) understands what is being said.6
Identifying the disorder
The starting point for enquiring about social anxiety disorder in adults is NICE Clinical Guideline (CG) 123 on Common mental health disorders: identification and pathways to care (see www.nice.org.uk/guidance/CG123),9 which recommends using the two-item Generalized Anxiety Disorder Scale (GAD-2).10 If social anxiety disorder is suspected, NICE CG159 recommends using the 3-item Mini-Social Phobia Inventory (Mini-SPIN).6,11 However, the GDG was concerned that the Mini-SPIN might not be practical for some GPs, and therefore advised that they could ask two specific questions instead:6
- ‘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 two questions above about avoidance and fear, professionals should conduct (or refer the person for) a comprehensive assessment.6
For children and young people, NICE CG159 recommends that healthcare and social care professionals in primary care, education, and community settings should be alert to possible anxiety disorders, particularly in those who avoid:
- social or group activities
- talking in social situations
or who are:
- excessively shy
- overly reliant on parents or carers.
Professionals should consider asking the child or young person (or their parents or carers) about their feelings of anxiety, fear, avoidance, distress, and associated behaviours, using these questions:6
- ‘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 these questions, a comprehensive assessment should be considered.
Referral and assessment
If the identification questions (as discussed in the previous section) for adults, children, and young people indicate possible social anxiety disorder, professionals who are competent to perform a mental health assessment should review the person’s mental state and associated functional, interpersonal, and social difficulties. If the professional is not competent to conduct this assessment, they should refer the person to an appropriate healthcare professional. If this individual is not the child or young person’s GP, the GP should be informed of the referral.
If adults find it difficult or distressing to attend an initial appointment for assessment in person, professionals can make the first contact by phone or internet, but should aim to see the person face to face for subsequent assessments and treatment.
Assessment for all people with possible social anxiety disorder should involve obtaining a detailed description of the person’s current social anxiety (including feared and avoided situations, and what they are afraid might happen in social situations), and associated problems.6
Treatment options for adults
Cognitive behavioural interventions
NICE CG159 recommends a range of interventions for adults with social anxiety disorder, but stipulates that the first-line intervention should be individual cognitive behavioural therapy (CBT) that has been specifically developed to treat this condition (based on the Clark and Wells model12 or the Heimberg model13). NICE CG159 cautions against the use of group CBT in preference to individual CBT, because although there is evidence that group CBT is more effective than most other interventions for social anxiety disorder, it is less clinically and cost effective than individual CBT.
For those who decline CBT and wish to consider another psychological intervention, CBT-based supported self-help should be offered. The GDG emphasised that psychological interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention, and professionals should consider using competence frameworks developed from these manuals.14
Medication is recommended in NICE CG159 as a second-line treatment for social anxiety disorder in adults. This decision was taken because most service users have a strong preference for psychological interventions15 and because a number of the drugs that were considered to be potentially effective are rarely prescribed in primary care (where the vast majority of prescriptions for social anxiety disorder are issued15).
Therefore for adults who decline cognitive behavioural interventions, and express a preference for a pharmacological intervention, NICE CG159 recommends that professionals discuss the person’s reasons for declining psychological interventions and address any concerns. If the person wishes to proceed with a pharmacological intervention, a selective serotonin reuptake inhibitor (SSRI) should be offered. Given concerns about the side-effects of some antidepressants, the recommended first-line drug treatments are:6
Drugs recommended in NICE CG159 as second-line treatments are:6
Although the above-listed three second-line drug treatments are possibly as effective as the other SSRIs, they were considered to be second-line options because of concerns about side-effects and discontinuation symptoms (particularly with paroxetine and venlafaxine16). (At the time of publication of NICE CG159 [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.)
The monoamine oxidase inhibitors (phenelzine or moclobemide) were considered third-line pharmacological interventions because of interactions, dietary restrictions, and side-effects.6,16 (At the time of publication of NICE CG159 [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.)
NICE CG159 stresses that people taking medication should be monitored carefully for adverse reactions.6 Professionals should ask about side-effects regularly, particularly at the start of treatment, as people with social anxiety disorder may not report them spontaneously. Adults aged below 30 years who are taking an SSRI or serotonin noradrenaline reuptake inhibitor should be monitored closely for suicidal thinking and self-harm. Professionals should also advise and support people who are taking medication to engage in graduated exposure to feared or avoided social situations.6
Other treatment interventions
For those adults who decline both cognitive behavioural and pharmacological interventions, short-term psychodynamic psychotherapy specifically designed to treat social anxiety disorder may be considered, but professionals were advised of the more limited clinical effectiveness and lower cost effectiveness of this intervention compared with CBT, self-help, and pharmacological interventions.6
If there is no response to initial treatment (or only a partial response), NICE CG159 outlines a number of options, including changing intervention or referral to specialist mental health services.6
Interventions not recommended
NICE CG159 also recommends that the following should not be routinely used to treat social anxiety disorder:6
- tricyclic antidepressants
- antipsychotic medication
- mindfulness-based interventions
- supportive therapy
- St John’s wort or other over-the-counter medications and preparations for anxiety.
In addition, botulinum toxin should not be offered to treat hyperhidrosis (excessive sweating), and endoscopic thoracic sympathectomy should not be offered to treat hyperhidrosis or facial blushing in people with social anxiety disorder because there is no good-quality evidence showing benefit for either intervention, and both may be harmful.6
Treatment for children and young people
The evidence base was limited for interventions in children and young people (up to aged 17 years) with social anxiety disorder. No antidepressant is licensed for social anxiety disorder in children and young people, and because of the potential increased risk of harm in this population, NICE CG159 does not recommend pharmacological interventions for routine use in this age group.6
The GDG judged that CBT (either individual or group) focused on social anxiety should be offered to children and young people, with the involvement of parents or carers to ensure effective delivery of the intervention, particularly in young children.6 The GDG advised that psychological interventions developed for adults could be considered for young people (typically aged 15 years and older) who have the cognitive and emotional capacity to undergo this treatment.
As with treatments for adults, psychological interventions for children and young people should be based on relevant treatment manuals, with competence frameworks devised from these manuals.14 Additionally, NICE CG159 advises professionals to be aware of the impact of home, school, and social environments on the maintenance and treatment of social anxiety disorder, and to create an environment (with parents and carers) that supports the achievement of the agreed goals of treatment.
Implementing the NICE guideline on social anxiety disorder
The major barrier to effective implementation of NICE CG159 remains poor recognition of people with social anxiety disorder in healthcare and educational settings. The introduction of simple case identification tools (as set out in NICE CG159) is one way to address this, but a programme of wider professional and public education is needed, so that people with social anxiety disorder do not think that
social anxiety is part of their personality and cannot be changed (or, in the case of children, that they will grow out of it). This should also mean that a person’s fear of negative evaluation by healthcare professionals if they talk about their problem will be reduced. This has significant implications for the training of a range of professionals in primary care (and also staff working in the educational system) to support early identification and effective work with other healthcare providers. In turn, there needs to be increased provision of effective interventions for children, which are currently underdeveloped.
Social anxiety disorder is a common and disabling condition that responds well to effective treatments. Practitioners can recognise social anxiety by asking a few simple questions, so people who think they may have social anxiety disorder can be encouraged to seek help from a GP or other local service. Increased provision of CBT specifically developed for social anxiety will reduce the burden of this disorder for adults, children, and young people. Adults who do not want a psychological intervention should be offered supported self-help or medication, which may also be effective; medication is not, however, recommended for children because of the risks of side-effects.
NICE implementation tools
NICE has developed the following tools to support implementation of Clinical Guideline 159 (CG159) on Social anxiety disorder: recognition, assessment and treatment. The tools are now available to download from the NICE website:
NICE support for commissioners
Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline.
Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets.
NICE support for service improvement systems and audit
Baseline assessment tool
The baseline assessment tool is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.
Clinical audit tool
Clinical audit tools aim to assist organisations with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. They consist of audit criteria and data collection tool(s) and can be edited or adapted for local use.
NICE support for education and learning
Two podcasts are available, based on the personal experiences of a:
- service user
- service user representative from the guideline development group.
CBT competence framework and list of treatment manuals for cognitive behavioural therapy
The treatment recommendations in CG159, refer to treatment manuals. This competence framework is based on these treatment manuals. A list of the manuals and source materials are available from the weblink provided above.
Key to NICE implementation icons
NICE support for commissioners
- Support package for commissioners and others for quality standards
- NICE guide for commissioners
- NICE cost impact support for guidance (selection from national report/local template/costing statement, dependent on topic)
NICE support for service improvement systems and audit
- Forward planner
- 'How to' guides (generic advice on processes)
- Local government briefings (with Centre for Public Health Excellence)
- Baseline assessment tool for guidance
- Audit support including electronic data collection tools
- E-learning modules (commissioned)
NICE support for education and learning
- Clinical case scenarios
- Learning packages including slide sets
- Shared learning and other local best practice examples
- Social anxiety disorder is persistent and common, affecting almost 7% of the European population over its lifetime
- Only around 50% of people with social anxiety disorder seek treatment, sometimes up to 15 years after onset of the disorder
- If the disorder begins in childhood and persists into adolescence, the chance of spontaneous recovery is more limited than with many other mental health problems
- The use of a few brief questions can help detect social anxiety disorder in primary care
- The first-line treatment option for adults is CBT that is specifically developed to treat social anxiety disorder
- Medication is an effective second-line option for adults but should not be used in children and young people.
CBT=cognitive behavioural therapy
- Commissioners should review current provision of services against NICE Clinical Guideline 159 with specific reference to the interface between adult and childrenâ€™s services
- CCGs could, through Health and Wellbeing Boards, look to raise awareness of social anxiety disorder via educational services as many cases start in adolescence, and delayed or non presentation occurs in 50% of cases
- CCGs should review their provision of commissioned IAPT (Improving Access to Psychological Therapies) and ensure it allows sensitive access, including self-referral, to people with social anxiety disorder
- Some of the medications recommended for people who do not to respond to initial pharmacological treatment are recommended for use outside their marketing authorisation, and prescribers and CCGs will need to manage this appropriately.
- Fehm L, Pelissolo A, Furmark T, Wittchen H. Size and burden of social phobia in Europe. Eur Neuropsychopharmacol 2005; 15 (4): 453–462.
- Wittchen H, Fehm L. Epidemiology and natural course of social fears and social phobia. Acta Psychiatr Scan 2003; 417: 4–18.
- Van Ameringen M, Mancini C, Farvolden P. The impact of anxiety disorders on educational achievement. J Anxiety Disord 2003; 17 (5): 561–571.
- Whisman M, Sheldon C, Goering P. Psychiatric disorders and dissatisfaction with social relationships: does type of relationship matter? J Abnorm Psychol 2000; 109 (4): 803–808.
- Wittchen H, Fuetsch M, Sonntag H et al. Disability and quality of life in pure comorbid social phobia—findings from a controlled study. Eur Psychiatry 1999; 14 (3): 118–131.
- NICE. Social anxiety disorder: recognition, assessment and treatment. Clinical Guideline 159. NICE: London, 2013. Available at:
- Grant B, Hasin D, Blanco C et al. The epidemiology of social anxiety disorder in the United States: results from the National Epidemiologic Survey on alcohol and related conditions. J Clin Psychiatry 2005; 66 (11): 1351–1361.
- Beesdo-Baum K, Knappe S, Fehm L et al. The natural course of social anxiety disorder among adolescents and young adults. Acta Psychiatr Scand 2012; 126 (6): 411–425.
- NICE. Common mental health disorders: identification and pathways to care. Clinical Guideline 123. London: NICE, 2011. Available at: www.nice.org.uk/CG123
- Kroenke K, Spitzer R, Williams J et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007; 146 (5): 317–325.
- Connor K, Kobak K, Churchill L et al. Mini-SPIN: a brief screening assessment for generalized social anxiety disorder. Depress Anxiety 2001; 14 (2): 137–140.
- Clark D, Wells A. A cognitive model of social phobia. In: Heimberg R, Liebowitz M, Hope D, Schneier F, editors. Social phobia: diagnosis, assessment and treatment. New York: Guildford Press, 1995: 69–93.
- Heimberg R, Dodge C, Hope D et al. Cognitive behavioral group treatment for social phobia: comparison with a credible placebo control. Cognitive Ther Res 1990; 14: 1–23.
- University College London website. CBT competences framework for depression and anxiety disorders. www.ucl.ac.uk/clinical-psychology/CORE/CBT_Framework.htm#Description (accessed 5 August 2013).
- National Collaborating Centre for Mental Health. Social anxiety disorder: recognition, assessment and treatment. Leicester, London: British Psychological Society, Royal College of Psychiatrists, 2013. Available: at www.nice.org.uk/nicemedia/live/14168/63846/63846.pdf
- National Collaborating Centre for Mental Health. Depression: the treatment and management of depression in adults. Updated edition. Leicester, London: British Psychological Society, Royal College of Psychiatrists, 2010. Available at: www.nice.org.uk/guidance/CG90/Guidance G