Social anxiety disorder

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

The primary goals of treatment are:

To reduce the anxiety experienced in social situations
To improve tolerance of discomfort in social situations
To reduce avoidance and safety behaviours
To improve functional capacity
To reduce anticipatory anxiety
To treat comorbid conditions.

Initial management should incorporate psychoeducation and advice on lifestyle factors (e.g., healthy eating, good sleep, regular exercise, minimising caffeine, tobacco, and alcohol use). The majority of patients with social anxiety disorder will require specific treatment in addition to this.[59]

Guidance from the National Institute for Health and Care Excellence (NICE) in the UK recommends individual cognitive behavioural therapy (CBT) as the first-line treatment option for social anxiety disorder.[60] The NICE guideline recommends pharmacotherapy as a second-line option due to variable adherence, treatment attrition, adverse effects, and the potential for discontinuation symptoms. Guidance varies internationally. Other international guideline bodies recommend an individualised approach to treatment with either CBT or a selective serotonin-reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI) (or a combination treatment with both CBT and medication) recommended as equal first-line options.[6][59]

When discussing treatment options, consider symptom severity, past treatment history, patient preference, concurrent disorders, cost-effectiveness, treatment safety, and accessibility.[59] A substantial body of evidence supports serotonergic antidepressants (SSRIs or SNRIs) or CBT as the first-line treatment options for social anxiety disorder.[8][59][61] While some evidence suggests relapse rates may be attenuated in groups who receive some degree of CBT combined with pharmacotherapy, the superiority of this combination therapy over monotherapy has not been established.[62][63][64]

For children and adolescents, CBT and family based interventions are preferred as the first-line intervention over pharmacotherapy alone.[60][65] One 2020 Cochrane review found that for childhood anxiety disorders in general, CBT is probably more effective in the short term than waiting lists/no treatment, although it found little to no evidence that CBT is superior to usual care or alternative treatments. However, confidence in these findings is limited due to concerns about the amount and quality of available evidence.[66] If younger populations have a sub-optimal response to behavioural interventions, then SSRI combination therapy with CBT can be considered by a specialist. Evidence suggests that combination CBT and sertraline may be superior to CBT or sertraline alone in children and adolescents with anxiety disorders.[67][68][69] One large systematic review looking at the safety of psychotropic medications in children and adolescents found that fluoxetine emerged as a relatively safe option in these age groups.[70]

Comorbidity with other anxiety, mood, or substance-use disorders is common in social anxiety and can complicate response to standard interventions.

Psychological treatment

Patient preference and motivation are extremely important when choosing a treatment modality. For those patients who choose psychological treatment, CBT has been shown to be an effective treatment for social anxiety disorder in children, adolescents, and adults.[71][72][73][74][75][76][77] CBT is considered the first-line intervention for children and adolescents with social anxiety disorder.[59][60][65] A referral to a mental health professional with expertise in CBT is recommended regardless of the severity of symptoms.

Treatment should typically last for at least 12 weeks, although different CBT programmes may vary.[62] In general, group psychotherapy studies vary between 6-12 weekly sessions, with each session lasting 60-120 minutes.[78] The gains seen with individual and group CBT appear to be maintained during 6-12 months or more of follow-up after completion of the treatment.[75][79]

Components of CBT

CBT is a skills-based approach designed to modify dysfunctional thoughts, avoidance behaviours, and environmental contingencies that are maintaining symptoms and impairments. Additional training in relaxation to regulate physical symptoms may be indicated, although the primary components of therapy should involve systematic exposure and cognitive restructuring.[72]
Exposure therapy involves gradually increasing the patient's tolerance to previously avoided situations (e.g., initiating conversations, presenting at work). The goal is to have the patient stay in the feared situation long enough to allow fear reduction to occur without engaging in escape or avoidance behaviour, or relying on safety cues (e.g., alcohol). Repeated, frequent, controllable, and predictable exposures are associated with optimal outcomes. Exposure also provides the opportunity to challenge negative beliefs and practise social skills. In some cases, gradual exposure to relevant uncomfortable physical sensations (e.g., tachycardia, sweating, flushing) in a repeated, controlled manner can reduce fearful beliefs and increase tolerance for these sensations across time.
Cognitive restructuring involves systematically learning how to challenge negative beliefs that maintain functional impairments and patterns of avoidance. Some evidence suggests that cognitive restructuring may be an even more important component of treatment for social anxiety than exposure.[80]
Social skills training is not regarded as an effective standalone intervention for social anxiety disorder. Rather, elements of this approach (e.g., eye contact, initiating small talk, public speaking, assertiveness) are typically embedded within a CBT programme.[72] However, social skills training and involvement of the parents in the treatment may be particularly important in younger children.[81][82] Social skills training often involves education, modelling by the clinician, practice, feedback, and using these skills in a variety of situations to help generalise their effects.

Mode of delivery

Treatment can be delivered in individual or group settings, including their combination. Group interventions may be a more cost-effective and efficient way of delivering care, and the built-in exposure opportunities and social support of group modalities can also be advantageous.[78][81] While some evidence suggests that individual interventions yield larger effect sizes than group modalities, other meta-analyses have found no statistically significant differences between individual and group formats.[77][83]
Internet-delivered CBT (known as internet CBT or digital CBT [dCBT]) accessed by computer, tablet, or smartphone is equally effective as face-to-face CBT for the treatment of social anxiety disorder, which has positive implications regarding increasing access to effective psychological treatment.[84][85][86][87] Outcome studies suggest that dCBT can produce positive treatment responses at a rate comparable to in-person, individual, and CBT group interventions.[88][89] An investigation with socially anxious individuals noted that large effects were maintained on the Liebowitz Social Anxiety Scale 5 years after completing dCBT.[90] One systematic review suggested that unguided dCBT may yield comparable findings to therapist-supported dCBT.[91] [ ] In the UK, NICE suggests a number of guided self-help dCBT technologies may be used for adults with anxiety and as an initial option for children and adolescents with mild to moderate symptoms of anxiety, subject to appropriate approvals and the development of further evidence.[86][87]
Virtual reality exposure therapy (VRET) utilises advanced computer technology to assist in the creation of phobic cues and situations, such as public speaking scenarios. Meta-analyses indicate comparable findings at post-intervention between VRET and standard exposure therapy, but standard exposure therapy appears superior at longer-term follow-up.[92][93]
Self-help manuals based on CBT principles may be a preferred and cost-effective treatment option for some patients.[62] Treatment strategies may also need to involve family members to help maximise the patient's consistency with recommended interventions.

Alternative psychological treatment

Mindfulness-based stress reduction (MBSR) may be considered as a second-line alternative to CBT for adults.
MBSR is a structured programme of meditation and mindfulness exercises.[94] One randomised clinical trial compared an 8-week trial of MBSR with escitalopram (an SSRI) among a mixed group of adult anxiety patients, including patients diagnosed with social anxiety.[95] Results yielded comparable findings between MBSR and pharmacotherapy, noting non-inferiority between these interventions. Dropout and adverse event rates were much lower in the MBSR group in comparison to those randomised to escitalopram, reinforcing the potential benefits of psychological over pharmacological interventions.[95]
According to one meta-analysis, MBSR significantly improved patient-rated anxiety compared with treatment as usual after 2 months, but it may not be as effective as CBT.[96]
Evidence on MBSR for children and adolescents with social anxiety disorder is insufficient.

Population-based approach

The Coordinated Anxiety Learning and Management (CALM) study is a large-scale, multicentre randomised controlled trial assessing the efficacy and effectiveness of evidence-based interventions (CBT and/or pharmacotherapy) for multiple anxiety disorders in primary care. Relative to usual care, patients involved in the collaborative care CALM model had significantly fewer anxiety symptoms, reduced functional impairments, and improved quality of care.[97] [ ] CALM has proved to be superior to usual care for social anxiety disorder at the 6-month follow-up interval.[98]

The Improving Access to Psychological Therapies (IAPT) programme is designed to increase the availability of evidence-based behavioural approaches to managing mental health conditions, including anxiety, in coordination with the NHS.[99][100][101] A similar programme, NewAccess, has been established in Australia.[102] A secondary analysis of Prompt Mental Health Care (PMHC), the Norwegian adaptation of IAPT, looked specifically at the effects on social anxiety and found small to moderate improvements in symptoms with PMHC compared with treatment as usual.[103]

Pharmacological therapy

For those patients who choose pharmacological treatment, interventions that have demonstrated efficacy in treating social anxiety disorder include: SSRIs, SNRIs, monoamine oxidase inhibitors (MAOIs), some anticonvulsants (gabapentin, pregabalin), and benzodiazepines.[61][64][104][105] Practice guidelines also suggest that patients being prescribed pharmacotherapy for anxiety should be instructed in the principles of exposure therapy to gradually face their fears.[59][62]

Serotonergic antidepressants

First-line pharmacotherapy because of their robust evidence base, preferable adverse-effect profile, efficacy in comorbid depression, and lack of misuse liability.[61][106][107]
More than 20 randomised controlled trials support the efficacy of SSRIs, with sertraline, paroxetine, and escitalopram having the most robust data.[61][104][108]
Fluoxetine has less consistent evidence but is also an effective option.[8][109]
The SNRI venlafaxine is also efficacious and recommended as a first-line option, although some authors suggest that noradrenergic reuptake blockade may not be required for a response.[8][64][107]
Patience is recommended, as 25% of individuals who have not responded to an SSRI by week 8 will have responded by week 12; UK-based treatment guidelines recommend offering a 12-week trial of medication for social anxiety disorder, given that a drug-placebo difference is most likely to be seen at this point.[110][111]
Most adverse effects are time-limited during dose titration, and should be discussed in advance with patients and monitored closely to ensure optimal treatment adherence.
In children and adolescents with a sub-optimal response to behavioural interventions, SSRI combination therapy with CBT can be considered by a specialist. Evidence suggests that combination CBT and sertraline may be superior to CBT or sertraline alone in a mixed sample of anxious patients aged between 7 to 17 years.[67][68][69] Carefully monitor patients treated with SSRIs for emotional or behavioural changes that may indicate potential for harm, including suicidal thoughts and the onset or worsening of agitation-type adverse events.

Benzodiazepines

The treatment of social anxiety disorder is complicated by the high rate of comorbid substance-use disorders, which may increase the risk of benzodiazepine misuse or dependence.[2][108][112] However, selected patients with a history of intolerance or poor response to several trials of first-line treatment (CBT, SSRIs, and SNRIs) may be considered for benzodiazepine monotherapy providing they do not have a history of substance misuse.[64]
The high-potency benzodiazepine clonazepam has shown efficacy in the treatment of social anxiety disorder over 10 weeks.[77][113][114] Alprazolam has demonstrated efficacy in open-label trials only.[108][115]
Potential adverse effects include sedation, cognitive impairment, falls in older people, tolerance, and dependence; in practice, it may be difficult to identify patients at risk of developing long-term problems.[59][111][112] However, benzodiazepines may still represent a valuable option for patients with persistent, severe, distressing, and impairing anxiety symptoms when other treatments have been ineffective.[111]
Specialist guidance (e.g., from a psychiatrist or addiction specialist) is recommended before prescribing a benzodiazepine for social anxiety disorder.[59][116]
Patients should be closely monitored, as physiological dependence can occur in as short a period as 2 to 4 weeks. Abrupt discontinuation or rapid tapering schedules can increase risk for withdrawal symptoms (e.g., dizziness, irritability, nausea, sweating, tremors, rebound anxiety, and seizure). Longer-acting agents (e.g., clonazepam) may be preferable to minimise inter-dose rebound anxiety.
May be used in conjunction with antidepressants for more intense anxiety presentations, but their use must be monitored closely and be short term because of their potential for misuse.[117][118]
Benzodiazepines are not usually recommended for children and adolescents.[119]

Monoamine oxidase inhibitors (MAOIs)

Phenelzine has demonstrated efficacy in randomised controlled trials.[77] However, significant adverse effects and risk of hypertensive crisis necessitating strict dietary restrictions (e.g., tyramine-free) complicate its use.[108]
Reversible MAOIs such as moclobemide have improved adverse-effect and safety profiles, but evidence of their efficacy is inconsistent and they are not readily available in some countries.[120][121][122][123] They are therefore considered to be a third-line treatment.
A washout period is necessary if switching from an SSRI/SNRI to a MAOI.[59] Consultant advice is recommended.
A treatment period of up to 12 weeks may be needed to assess efficacy.[59][111]

Anticonvulsants

Both gabapentin and pregabalin have demonstrated efficacy as monotherapy for social anxiety disorder.[108][124][125][126][127][128]
Given the lower misuse potential, these gamma-aminobutyric acid-ergic agents may be useful alternatives as third-line treatment when benzodiazepines are contraindicated.[106]
A treatment period of up to 12 weeks may be needed to assess efficacy.[59][111]

Other antidepressants

There are no controlled trials of tricyclic antidepressants in social anxiety disorder.[108] Clomipramine has demonstrated efficacy in an open-label study.[129] However, imipramine has been shown to be both ineffective and poorly tolerated.[130]
Mirtazapine has been found to be effective for social anxiety in some controlled studies, although one systematic review and meta-analysis concluded that it was not superior to waiting lists.[61][77][107][131][132]

Propranolol

The beta-blocker propranolol has shown efficacy in single-dose use for focused social anxiety situations, such as performance anxiety, but routine use is not supported in clinical trials.[34][35]
It is not recommended in generalised social anxiety disorder, as repeated controlled trials have demonstrated no advantage over placebo.[34][36][37][38][39]

Treatment duration and discontinuation

Following response, treatment for up to 12 months or longer is recommended to prevent relapse based on the available evidence.[59][133] After this time, the patient and prescriber can discuss whether or not to continue treatment, based on adverse effects and other considerations.[133][134]
However, benzodiazepines are typically only recommended for short-term use (e.g., 2-4 weeks) due to the risks of tolerance, dependence, and misuse.[59][111][116] Occasionally they may be used on a long-term basis to treat refractory anxiety, but this should only be done with caution under consultant guidance, and patients should be regularly offered the opportunity to gradually withdraw from long-term use.[64][116] In one study, patients were treated with clonazepam for 6 months and then assigned to either start a gradual taper, or to continue clonazepam for an additional 5 months (11 months total on clonazepam) and then taper. While the continuation group had slightly better clinical outcomes, both groups did well, and the rate of withdrawal symptoms was low in both groups.[135]
For all pharmacotherapy, if there is agreement to reduce and stop the drug, do so slowly and carefully monitor for the recurrence of symptoms. This may take several months at a rate that is tolerable to the patient. Withdrawal symptoms can vary from mild and transient to longer-lasting and more severe, and some patients may require a more gradual taper.[136][137] Consider reviewing additional treatment options, especially CBT, to help prevent relapse following discontinuation of drug therapy.[138]

Adults with comorbidities

With depression

All patients with social anxiety should be screened for depression, as this may be present in >45% cases.[139][140] Patients with comorbid depression should be treated with pharmacotherapy plus psychotherapy.
SSRIs and the SNRI venlafaxine are recommended as first-line treatments for both disorders.[105][106][141]
CBT is also an effective treatment for depression, and depressive symptoms often improve during the course of CBT for social anxiety disorder.[141][142] Individual and/or group CBT are effective.
MBSR may be considered as a second-line alternative to CBT. MBSR may reduce symptoms of anxiety and depression, but it may not be as effective as CBT for anxiety.[94][96]
MAOIs (e.g., phenelzine) can be used as a second-line treatment option.
A referral to a mental health professional with expertise in managing anxiety and depression may be indicated.

With another anxiety condition

Up to 60% of patients with social anxiety disorder will also present with another comorbid anxiety condition, such as panic disorder or generalised anxiety disorder.[139][140] Patients with comorbid anxiety should be treated with pharmacotherapy plus psychotherapy.
SSRIs and the SNRI venlafaxine are recommended as first-line treatments for anxiety disorders, including social anxiety.[105][106][108]
Patients with social anxiety disorder who have a history of intolerance or poor response to antidepressants, or significant comorbid panic symptoms, may be considered for benzodiazepine monotherapy if they do not have a history of substance-use disorders.[108]
CBT is also an effective treatment for the range of anxiety disorders, with exposure and cognitive restructuring being common principles for fear reduction.[111] Individual and/or group CBT are effective.
MBSR may be considered as a second-line alternative to CBT. Studies suggest MBSR may be effective for adults with a range of anxiety conditions.[95][96]
MAOIs (e.g., phenelzine) can be used as a second-line treatment option.
A referral to a mental health professional with expertise in managing anxiety disorders is recommended.

With bipolar disorder

The management of comorbid bipolar disorder and social anxiety is complex as bipolar symptoms may be more severe and there is an increased risk of substance-use disorders and suicide.[143]

In general, initiation of a mood-stabilising medication is indicated.
Caution must be exercised in starting an antidepressant in a person with bipolar disorder because it may precipitate mania.
A referral to a psychiatrist for further evaluation and management is recommended.
For further details, see Bipolar disorder in adults (Management approach).

History of substance misuse or dependence

Among patients with social anxiety disorder, 40% may have a history of substance misuse or dependence.[139][140] Substance misuse may function to regulate social anxiety symptoms and skills deficits.
If suspected, patients should be screened for substance misuse at the time of diagnosis. A motivational interviewing approach, which is similar to CBT, is recommended as an opportunity to frame the rationale for substance misuse in a non-judgemental manner and explore the patient's desire and readiness for change.[144] A referral to a mental health professional with expertise in CBT is recommended, regardless of the severity of symptoms. MBSR may be considered as a second-line alternative to CBT.[95][96]
For patients initiating measures to decrease substance misuse, the use of concurrent treatment with an SSRI or venlafaxine may be reasonable. Benzodiazepines should be avoided due to misuse liability.
A referral for formal substance misuse treatment is recommended.

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