Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

adults: no comorbidity

1st line – psychotherapy

Back
ONGOING
|
adults: no comorbidity
1st line – 

psychotherapy

A referral to a mental health professional with expertise in cognitive behavioural therapy (CBT) is recommended as first-line treatment.[61] Guidance varies internationally on whether CBT and pharmacotherapy are equal first-line options. While the UK National Institute for Health and Care Excellence (NICE) recommends pharmacotherapy second line (due to variable adherence, treatment attrition, adverse effects, and the potential for discontinuation symptoms), others recommend both first line and suggest an individualised approach.[6][59][60] When discussing treatment options, consider symptom severity, past treatment history, patient preference, concurrent disorders, cost-effectiveness, treatment safety, and accessibility.[59]

Individual and/or group CBT are effective.[77][83] 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]

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] Meta-analyses indicate comparable findings at post-intervention between virtual reality exposure therapy (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 need to involve family members to help maximise the patient's consistency with recommended interventions.

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 to 12 months or more of follow-up after completion of the treatment.[75][79]

Mindfulness-based stress reduction (MBSR) may be considered as a second-line alternative to CBT. One randomised clinical trial compared an 8-week trial of MBSR with escitalopram (a selective serotonin-reuptake inhibitor [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]

1st line – selective serotonin-reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI)

Back
ONGOING
|
adults: no comorbidity
1st line – 

selective serotonin-reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI)

Guidance varies internationally on whether CBT and pharmacotherapy are equal first-line options. While the UK NICE recommends pharmacotherapy second line (due to variable adherence, treatment attrition, adverse effects, and the potential for discontinuation symptoms), others recommend both first line and suggest an individualised approach.[6][59][60] When discussing treatment options, consider symptom severity, past treatment history, patient preference, concurrent disorders, cost-effectiveness, treatment safety, and accessibility.[59]

For those patients who prefer pharmacological therapy, SSRIs or SNRIs are first-line therapies.[61][105] Practice guidelines suggest that patients being prescribed pharmacotherapy for anxiety should also be instructed in the principles of exposure therapy to gradually face their fears.[59][62]

More than 20 randomised controlled trials support the efficacy of SSRIs, with sertraline, paroxetine, and escitalopram having the most robust data.[61][104][108]

The SNRI venlafaxine is also efficacious and recommended as a first-line option.[64][107][145]

Fluoxetine, an SSRI, is also an effective option, although the evidence is less consistent.[8][109]

A treatment period of up to 12 weeks may be needed to assess efficacy.[59][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.

Following response, treatment for up to 12 months or longer is recommended to prevent relapse.[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] If there is agreement to reduce and stop the antidepressant, 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]

Primary options

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

OR

paroxetine: 5-10 mg orally (immediate-release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

OR

escitalopram: 10 mg orally once daily initially, increase by 10 mg/day increments every 4 weeks according to response, maximum 20 mg/day

OR

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase by 37.5 to 75 mg/day increments every 7 days according to response, maximum 225 mg/day

Secondary options

fluoxetine: 10 mg orally (immediate-release) once daily initially, increase by 10-20 mg/day increments every 2-4 weeks according to response, maximum 80 mg/day

OR

citalopram: 10 mg orally once daily initially, increase by 20 mg/day increments every 7 days according to response, maximum 40 mg/day

OR

duloxetine: 30 mg orally once daily initially, increase by 30 mg/day increments every 2-4 weeks according to response, maximum 60 mg/day

Consider – benzodiazepine

Back
ONGOING
|
adults: no comorbidity
Consider – 

benzodiazepine

Additional treatment recommended for SOME patients in selected patient group

May be used in conjunction with serotonergic agents for more intense or treatment-resistant anxiety presentations, but their use must be monitored closely because of their potential for misuse.[117][118]

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]

Physiological dependence can occur in as short a period as 2 to 4 weeks.

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 for longer 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] If there is agreement to reduce and stop the benzodiazepine, 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]

Abrupt discontinuation or rapid tapering schedules can increase risk for withdrawal symptoms.

Longer-acting agents (e.g., clonazepam) may be preferable to minimise inter-dose rebound anxiety.

Primary options

clonazepam: 0.25 mg orally twice daily initially, increase by 0.25 to 0.5 mg/day increments every 3 days according to response, maximum 4 mg/day

Secondary options

alprazolam: 0.25 to 0.5 mg orally (immediate-release) three times daily initially, increase by 1 mg/day increments every 3-4 days according to response, maximum 6 mg/day

2nd line – benzodiazepine

Back
ONGOING
|
adults: no comorbidity
2nd line – 

benzodiazepine

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]

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]

Consultant guidance (e.g., from a psychiatrist or addiction consultant) is recommended before prescribing a benzodiazepine for social anxiety disorder.[59][116]

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]

Patients should be closely monitored as physiological dependence can occur in as little as 2 to 4 weeks.

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] If there is agreement to reduce and stop the benzodiazepine, 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]

Abrupt discontinuation or rapid tapering schedules can increase risk for withdrawal symptoms.

Longer-acting agents (e.g., clonazepam) may be preferable to minimise inter-dose rebound anxiety.

Practice guidelines suggest that patients being prescribed pharmacotherapy for anxiety should also be instructed in the principles of exposure therapy to gradually face their fears.[59][62]

Primary options

clonazepam: 0.25 mg orally twice daily initially, increase by 0.25 to 0.5 mg/day increments every 3 days according to response, maximum 4 mg/day

Secondary options

alprazolam: 0.25 to 0.5 mg orally (immediate-release) three times daily initially, increase by 1 mg/day increments every 3-4 days according to response, maximum 6 mg/day

3rd line – monoamine oxidase inhibitor (MAOI)

Back
ONGOING
|
adults: no comorbidity
3rd line – 

monoamine oxidase inhibitor (MAOI)

Phenelzine has demonstrated efficacy in randomised controlled trials.[77]

Significant adverse effects and risk of hypertensive crisis necessitating strict dietary restrictions (e.g., tyramine-free) complicate its use.[108] A washout period is necessary if switching from an SSRI/SNRI to a MAOI.[59] Consultant advice is recommended.

Reversible MAOIs such as moclobemide have improved adverse-effect and safety profiles, and are efficacious, but are not readily available in some countries.[121][122][123][146][147][148]

A treatment period of up to 12 weeks may be needed to assess efficacy.[59][111]

Following response, treatment for up to 12 months or longer is recommended to prevent relapse.[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] If there is agreement to reduce and stop the antidepressant, 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]

Practice guidelines suggest that patients being prescribed pharmacotherapy for anxiety should also be instructed in the principles of exposure therapy to gradually face their fears.[59][62]

Primary options

phenelzine: 15 mg orally three times a day initially, adjust dose according to response, maximum 90 mg/day

OR

moclobemide: 300 mg orally once daily for three days, followed by 300 mg twice daily on the fourth day and thereafter

3rd line – gabapentin or pregabalin

Back
ONGOING
|
adults: no comorbidity
3rd line – 

gabapentin or pregabalin

Both gabapentin and pregabalin have demonstrated efficacy as monotherapy for social anxiety disorder.[108][124][125][126][127]

Given the lower misuse potential, these 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]

Following response, treatment for up to 12 months or longer is recommended to prevent relapse.[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] If there is agreement to reduce and stop the gabapentinoid, 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]

Practice guidelines suggest that patients being prescribed pharmacotherapy for anxiety should also be instructed in the principles of exposure therapy to gradually face their fears.[59][62]

Primary options

gabapentin: 300 mg orally three times a day initially, increase by 300 mg/day increments every 2-3 days according to response, maximum 3600 mg/day

OR

pregabalin: 150 mg/day orally given in 2-3 divided doses initially, increase by 150 mg/day increments at weekly intervals according to response, maximum 600 mg/day

4th line – alternative antidepressant

Back
ONGOING
|
adults: no comorbidity
4th line – 

alternative antidepressant

Clomipramine has demonstrated efficacy in an open-label study.[129]

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]

A treatment period of up to 12 weeks may be needed to assess efficacy.[59]

Following response, treatment for up to 12 months or longer is recommended to prevent relapse.[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] If there is agreement to reduce and stop the antidepressant, 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]

Practice guidelines suggest that patients being prescribed pharmacotherapy for anxiety should also be instructed in the principles of exposure therapy to gradually face their fears.[59][62]

Primary options

clomipramine: 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 250 mg/day

OR

mirtazapine: 15 mg orally once daily at bedtime initially, increase by 15 mg/day increments every 1-2 weeks according to response, maximum 45 mg/day

adults: comorbidities

1st line – selective serotonin-reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI)

Back
ONGOING
|
adults: comorbidities
|
with depression
1st line – 

selective serotonin-reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI)

All patients with social anxiety should be screened for depression, as this may be present in >45% cases.[139][140]

SSRIs and the SNRI venlafaxine are recommended as first-line treatments for both disorders.[105][106][141]

A treatment period of up to 12 weeks may be needed to assess efficacy.[59][111]

A referral to a mental health professional with expertise in managing anxiety and depression may be indicated.

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.

Following response, treatment for up to 12 months or longer is recommended to prevent relapse.[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] If there is agreement to reduce and stop the antidepressant, 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 cognitive behavioural therapy (CBT), to help prevent relapse following discontinuation of drug therapy.[138]

Primary options

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

OR

paroxetine: 5-10 mg orally (immediate-release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

OR

escitalopram: 10 mg orally once daily initially, increase by 10 mg/day increments every 4 weeks according to response, maximum 20 mg/day

OR

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase by 37.5 to 75 mg/day increments every 7 days according to response, maximum 225 mg/day

Secondary options

fluoxetine: 10 mg orally (immediate-release) once daily initially, increase by 10-20 mg/day increments every 2-4 weeks according to response, maximum 80 mg/day

OR

citalopram: 10 mg orally once daily initially, increase by 20 mg/day increments every 7 days according to response, maximum 40 mg/day

OR

duloxetine: 30 mg orally once daily initially, increase by 30 mg/day increments every 2-4 weeks according to response, maximum 60 mg/day

Plus – psychotherapy

Back
ONGOING
|
adults: comorbidities
|
with depression
Plus – 

psychotherapy

Treatment recommended for ALL patients in selected patient group

CBT is an effective treatment for depression, and depressive symptoms often improve over the course of CBT for social anxiety disorder.[141][142] A referral to a mental health professional with expertise in CBT is recommended.

Individual and/or group CBT are effective.[77][83] 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]

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]

Meta-analyses indicate comparable findings at post-intervention between virtual reality exposure therapy (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 need to involve family members to help maximise the patient's consistency with recommended interventions.

Treatment should typically last for at least 12 weeks, although several CBT programmes may vary.[62] In general, group psychotherapy studies vary between 6-12 weekly sessions, with each section lasting 60-120 minutes.[78]

The gains seen with individual and group CBT appear to be maintained during 6 to 12 months or more of follow-up after completion of the treatment.[75][79]

Mindfulness-based stress reduction (MBSR) may be considered as a second-line alternative to CBT. 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] MBSR may also be effective for reducing depression symptom severity.[94]

2nd line – monoamine oxidase inhibitor (MAOI)

Back
ONGOING
|
adults: comorbidities
|
with depression
2nd line – 

monoamine oxidase inhibitor (MAOI)

May be used as a second-line treatment option.

Phenelzine has demonstrated efficacy in randomised controlled trials.[77]

Significant adverse effects and risk of hypertensive crisis necessitating strict dietary restrictions (e.g., tyramine-free) complicate its use.[108] A washout period is necessary if switching from an SSRI/SNRI to a MAOI.[59] Consultant advice is recommended.

Reversible MAOIs such as moclobemide have improved adverse-effect and safety profiles, and are efficacious, but are not readily available in some countries.[121][122][123][146][147][148]

A treatment period of up to 12 weeks may be needed to assess efficacy.[59][111]

Following response, treatment for up to 12 months or longer is recommended to prevent relapse.[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] If there is agreement to reduce and stop the antidepressant, 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]

Primary options

phenelzine: 15 mg orally three times a day initially, adjust dose according to response, maximum 90 mg/day

OR

moclobemide: 300 mg orally once daily for three days, followed by 300 mg twice daily on the fourth day and thereafter

Plus – psychotherapy

Back
ONGOING
|
adults: comorbidities
|
with depression
Plus – 

psychotherapy

Treatment recommended for ALL patients in selected patient group

CBT is an effective treatment for depression, and depressive symptoms often improve over the course of CBT for social anxiety disorder.[141][142] A referral to a mental health professional with expertise in CBT is recommended.

Individual and/or group CBT are effective.[77][83] 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]

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] In the UK, the National Institute for Health and Care Excellence (NICE) suggests a number of guided self-help dCBT technologies may be used for adults with anxiety, subject to appropriate approvals and the development of further evidence.[86]

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 need to involve family members to help maximise the patient's consistency with recommended interventions.

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 to 12 months or more of follow-up after completion of the treatment.[75][79]

MBSR may be considered as a second-line alternative to CBT. 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] MBSR may also be effective for reducing depression symptom severity.[94]

1st line – selective serotonin-reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI)

Back
ONGOING
|
adults: comorbidities
|
with another anxiety condition
1st line – 

selective serotonin-reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI)

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]

SSRIs and the SNRI venlafaxine are recommended as first-line treatments for anxiety disorders, including social anxiety.[105][106][108]

A treatment period of up to 12 weeks may be needed to assess efficacy.[59][111]

A referral to a mental health professional with expertise in managing anxiety disorders is recommended.

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.

Following response, treatment for up to 12 months or longer is recommended to prevent relapse.[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] If there is agreement to reduce and stop the antidepressant, 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]

Primary options

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

OR

paroxetine: 5-10 mg orally (immediate-release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

OR

escitalopram: 10 mg orally once daily initially, increase by 10 mg/day increments every 4 weeks according to response, maximum 20 mg/day

OR

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase by 37.5 to 75 mg/day increments every 7 days according to response, maximum 225 mg/day

Secondary options

fluoxetine: 10 mg orally (immediate-release) once daily initially, increase by 10-20 mg/day increments every 2-4 weeks according to response, maximum 80 mg/day

OR

citalopram: 10 mg orally once daily initially, increase by 20 mg/day increments every 7 days according to response, maximum 40 mg/day

OR

duloxetine: 30 mg orally once daily initially, increase by 30 mg/day increments every 2-4 weeks according to response, maximum 60 mg/day

Plus – psychotherapy

Back
ONGOING
|
adults: comorbidities
|
with another anxiety condition
Plus – 

psychotherapy

Treatment recommended for ALL patients in selected patient group

CBT is an effective treatment for the range of anxiety disorders, with exposure and cognitive restructuring being common principles for fear reduction.[111]

A referral to a mental health professional with expertise in CBT is recommended.

Individual and/or group CBT are effective. 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] 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] In the UK, NICE suggests a number of guided self-help dCBT technologies may be used for adults with anxiety, subject to appropriate approvals and the development of further evidence.[86]

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 need to involve family members to help maximise the patient's consistency with recommended interventions.

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 to 12 months or more of follow-up after completion of the treatment.[75][79]

MBSR may be considered as a second-line alternative to CBT. 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]

2nd line – benzodiazepine

Back
ONGOING
|
adults: comorbidities
|
with another anxiety condition
2nd line – 

benzodiazepine

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 misuse.[108][118]

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]

Consultant guidance (e.g., from a psychiatrist or addiction consultant) is recommended before prescribing a benzodiazepine for social anxiety disorder.[59][116]

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]

Patients should be closely monitored as physiological dependence can occur in as little as 2 to 4 weeks.

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] If there is agreement to reduce and stop the benzodiazepine, 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]

Abrupt discontinuation or rapid tapering schedules can increase risk for withdrawal symptoms.

Longer-acting agents (e.g., clonazepam) may be preferable to minimise inter-dose rebound anxiety.

Primary options

clonazepam: 0.25 mg orally twice daily initially, increase by 0.25 to 0.5 mg/day increments every 3 days according to response, maximum 4 mg/day

Secondary options

alprazolam: 0.25 to 0.5 mg orally (immediate-release) three times daily initially, increase by 1 mg/day increments every 3-4 days according to response, maximum 6 mg/day

Plus – psychotherapy

Back
ONGOING
|
adults: comorbidities
|
with another anxiety condition
Plus – 

psychotherapy

Treatment recommended for ALL patients in selected patient group

CBT is an effective treatment for the range of anxiety disorders, with exposure and cognitive restructuring being common principles for fear reduction.[111]

A referral to a mental health professional with expertise in CBT is recommended.

Individual and/or group CBT are effective. 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] 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] In the UK, NICE suggests a number of guided self-help dCBT technologies may be used for adults with anxiety, subject to appropriate approvals and the development of further evidence.[86]

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 need to involve family members to help maximise the patient's consistency with recommended interventions.

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 to 12 months or more of follow-up after completion of the treatment.[75][79]

MBSR may be considered as a second-line alternative to CBT. 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]

2nd line – monoamine oxidase inhibitor (MAOI)

Back
ONGOING
|
adults: comorbidities
|
with another anxiety condition
2nd line – 

monoamine oxidase inhibitor (MAOI)

May be used as a second-line treatment option.

Phenelzine has demonstrated efficacy in randomised controlled trials.[77]

Significant adverse effects and risk of hypertensive crisis necessitating strict dietary restrictions (e.g., tyramine-free) complicate its use.[108] A washout period is necessary if switching from an SSRI/SNRI to a MAOI.[59] Consultant advice is recommended.

Reversible MAOIs such as moclobemide have improved adverse-effect and safety profiles, and are efficacious, but are not readily available in some countries.[121][122][123][146][147][148]

A treatment period of up to 12 weeks may be needed to assess efficacy.[59][111]

Following response, treatment for up to 12 months or longer is recommended to prevent relapse.[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] If there is agreement to reduce and stop the antidepressant, 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]

Primary options

phenelzine: 15 mg orally three times a day initially, adjust dose according to response, maximum 90 mg/day

OR

moclobemide: 300 mg orally once daily for three days, followed by 300 mg twice daily on the fourth day and thereafter

Plus – psychotherapy

Back
ONGOING
|
adults: comorbidities
|
with another anxiety condition
Plus – 

psychotherapy

Treatment recommended for ALL patients in selected patient group

CBT is an effective treatment for the range of anxiety disorders, with exposure and cognitive restructuring being common principles for fear reduction.[111]

A referral to a mental health professional with expertise in CBT is recommended.

Individual and/or group CBT are effective. 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] 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] In the UK, NICE suggests a number of guided self-help dCBT technologies may be used for adults with anxiety, subject to appropriate approvals and the development of further evidence.[86]

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 need to involve family members to help maximise the patient's consistency with recommended interventions.

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 to 12 months or more of follow-up after completion of the treatment.[75][79]

MBSR may be considered as a second-line alternative to CBT. 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]

1st line – referral to psychiatrist

Back
ONGOING
|
adults: comorbidities
|
with bipolar disorder
1st line – 

referral to psychiatrist

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, and 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).

1st line – detoxification or chemical dependency treatment

Back
ONGOING
|
adults: comorbidities
|
with a history of substance misuse or dependence
1st line – 

detoxification or chemical dependency treatment

Among patients with social anxiety disorder, 40% may have a history of substance misuse or dependence.[139][140]

A referral for formal substance misuse treatment is recommended.

Plus – psychotherapy

Back
ONGOING
|
adults: comorbidities
|
with a history of substance misuse or dependence
Plus – 

psychotherapy

Treatment recommended for ALL patients in selected patient group

A motivational interviewing approach, which shares many common features with 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.

Treatment should typically last for at least 12 weeks, although different CBT programmes may vary.[62]

The gains seen with individual and group CBT appear to be maintained during 6 to 12 months or more of follow-up after completion of the treatment.[75][79]

MBSR may be considered as a second-line alternative to CBT. 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]

Consider – selective serotonin-reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI)

Back
ONGOING
|
adults: comorbidities
|
with a history of substance misuse or dependence
Consider – 

selective serotonin-reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI)

Additional treatment recommended for SOME patients in selected patient group

For patients initiating measures to decrease substance misuse, the use of concurrent treatment with an SSRI or the SNRI venlafaxine may be reasonable.

The treatment period needs to be at least 12 weeks.[110]

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.

Following response, treatment for up to 12 months or longer is recommended to prevent relapse.[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] If there is agreement to reduce and stop the antidepressant, 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]

A referral for formal substance misuse treatment is recommended.

Primary options

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

OR

paroxetine: 5-10 mg orally (immediate-release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

OR

escitalopram: 10 mg orally once daily initially, increase by 10 mg/day increments every 4 weeks according to response, maximum 20 mg/day

OR

venlafaxine: 37.5 mg orally (extended-release) once daily initially, increase by 37.5 to 75 mg/day increments every 7 days according to response, maximum 225 mg/day

Secondary options

fluoxetine: 10 mg orally (immediate-release) once daily initially, increase by 10-20 mg/day increments every 2-4 weeks according to response, maximum 80 mg/day

OR

citalopram: 10 mg orally once daily initially, increase by 20 mg/day increments every 7 days according to response, maximum 40 mg/day

OR

duloxetine: 30 mg orally once daily initially, increase by 30 mg/day increments every 2-4 weeks according to response, maximum 60 mg/day

children and adolescents

1st line – cognitive behavioural therapy (CBT)

Back
ONGOING
|
children and adolescents
1st line – 

cognitive behavioural therapy (CBT)

For children and adolescents, CBT and family based interventions are preferred as the first-line intervention over pharmacotherapy alone.[60][65]

A referral to a mental health professional with expertise in CBT is recommended.

CBT may be delivered individually, in groups, face-to-face, virtually, and with or without parents.[81] ​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]​ In the UK, the National Institute for Health and Care Excellence (NICE) suggests a number of guided self-help digital CBT technologies may be used 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.​[87]

Social skills training and involvement of parents 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. Elements of this approach (e.g., eye contact, initiating small talk, public speaking, assertiveness) are typically embedded within a CBT programme.[72]

Treatment should typically last for at least 12 weeks, although different CBT programmes may vary.[62]

The gains seen with individual and group CBT appear to be maintained during 6 to 12 months or more of follow-up after completion of the treatment.[75][79]

2nd line – selective serotonin-reuptake inhibitor (SSRI) plus cognitive behavioural therapy (CBT)

Back
ONGOING
|
children and adolescents
2nd line – 

selective serotonin-reuptake inhibitor (SSRI) plus cognitive behavioural therapy (CBT)

If patients have a sub-optimal response to behavioural interventions, then SSRI combination therapy with CBT can be considered by a specialist (e.g., child and adolescent psychiatrist).

Evidence suggests that combination CBT and sertraline may be superior to CBT or sertraline alone in a mixed sample of 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]

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.

A referral to a mental health professional with expertise in CBT is recommended. CBT may be delivered individually, in groups, face-to-face, virtually, and with or without parents.[81] 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]

Social skills training and involvement of parents 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. Elements of this approach (e.g., eye contact, initiating small talk, public speaking, assertiveness) are typically embedded within a CBT programme.[72]

CBT treatment should typically last for at least 12 weeks, although different CBT programmes may vary.[62]

The gains seen with CBT appear to be maintained during 6 to 12 months or more of follow-up after completion of the treatment.[75][79]

Primary options

sertraline: consult specialist for guidance on dose

OR

fluoxetine: consult specialist for guidance on dose

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