Treatments for adults

Cognitive behavioural therapy

The first treatment you should be offered is a psychological therapy called cognitive behavioural therapy ('CBT' for short). It should be a type of CBT that has been specifically designed to treat social anxiety disorder, either 'Clark and Wells CBT' or 'Heimberg CBT', named after the people who designed them. You should usually be offered CBT on your own with a therapist rather than in a group. You should have up to 14–16 meetings with your therapist over 4 months, with each meeting lasting an hour to an hour and a half.

CBT-based supported self-help

If you decide not to have CBT and wish to try another psychological therapy you should be offered CBT-based supported self-help. You should usually have up to 9 sessions over 3 to 4 months. A healthcare professional should provide support and check your progress either face to face or by telephone, for a total of 3 hours during the treatment.

If you decide not to have CBT or CBT-based supported self-help and wish to try medication instead, your healthcare professional should talk to you about why you do not want to try these psychological therapies and discuss any concerns you have.

Medication

If you wish to proceed with medication you should be offered a selective serotonin reuptake inhibitor ('SSRI' for short), either escitalopram or sertraline. SSRIs are antidepressants, but they can also be helpful for anxiety – being offered an antidepressant does not necessarily mean that you have depression. Antidepressants are usually not as helpful as CBT for social anxiety disorder. See About taking medication for more information.

Short-term psychodynamic psychotherapy

If you decide not to have CBT, CBT-based supported self-help or medication, you may be offered a psychological therapy called short-term psychodynamic psychotherapy designed for social anxiety disorder. However this is usually not as helpful for social anxiety disorder as CBT, CBT-based supported self-help or antidepressants. If you decide to have short-term psychodynamic psychotherapy you should have 25–30 meetings with your therapist over 6 to 8 months, with each meeting lasting 50 minutes.

Treatments you should not be offered

You should not usually be offered any of the following:

You should not be offered either of the following:

If you don't feel better after your first treatment

If your first treatment was CBT and you don't feel better you may be offered medication with an SSRI (escitalopram or sertraline) together with another course of CBT.

If your first treatment was an SSRI and you don't feel better after 10 to 12 weeks, you should be offered CBT in addition to the SSRI. If you have had unpleasant side effects or have decided not to have CBT, you should be offered a different SSRI (either fluvoxamine or paroxetine) or venlafaxine.

If you are offered either paroxetine or venlafaxine your healthcare professional should take into account that both are dangerous if you take too much of them, that they can sometimes increase thoughts about harming yourself and that you may have unpleasant side effects when stopping them.

If you don't feel better after a different SSRI or venlafaxine, you may be offered a monoamine oxidase inhibitor (either phenelzine or moclobemide). You should be warned that this type of medication can interact with other medicines and with certain foods, such as cheese, and that sometimes these interactions can cause serious health problems.

If you don't feel better after you have tried all the medication offered, your healthcare professional should discuss with you again the possibility of having CBT, even if you refused CBT before.

About taking medication

Before you start medication

Your healthcare professional should discuss the different medication options and any concerns you have about taking medication. They should explain why medication has been offered and discuss and give you full written information, and should explain:

  • the way the medication might help you

  • that when you first start taking an SSRI or a medication called venlafaxine you may feel more anxious and agitated, and may have problems sleeping and eating, but that this usually passes after a short time

  • that the medication takes some time to work, sometimes over 2 weeks or more

  • the side effects you may experience, including when you stop taking the medication

  • whether taking an antidepressant will affect other medication you may be taking

  • the importance of carefully following the instructions about taking your medication so that it works properly, telling your healthcare professional about any side effects (however mild you consider them to be) and telling them if you are thinking of stopping taking it and any concerns you have about doing so

  • that you may need to continue taking medication even when you feel better because this can help you to stay well.

'Off-label' drug treatment

Drugs are approved for use (licensed) for particular conditions or for particular groups of people. At the time of publication, 2 of the drugs mentioned in this guideline, fluvoxamine, which is an SSRI, and phenelzine, which is a monoamine oxidase inhibitor, are being recommended for use 'off label'. This means they may not be prescribed exactly as set out in the license – some drugs licensed for one condition can help treat a different condition. You can find more information about licensing drugs at NHS Choices (www.nhs.uk).

If a healthcare professional offers a drug treatment 'off-label', they should explain the treatment and discuss the possible benefits and harms with the person (or their carer) so that they have enough information to decide whether or not to have the treatment. This is called giving informed consent.

While you are taking medication

If you are aged 30 or older and are not thought to be at risk of harming yourself, your healthcare professional should see you within 1 to 2 weeks of first starting an SSRI or venlafaxine to discuss any side effects and check whether you feel more restless or agitated. They should then arrange to see you every 2 to 4 weeks during the first 3 months of treatment and then every month.

If you are aged under 30 and you are taking an SSRI or venlafaxine, your healthcare professional should tell you that there is a small chance that you will have thoughts of harming yourself. They should see you in the first week after you have started the medication and then every week for the first month.

If there is a risk you may harm yourself, your healthcare professional should see you every week until the risk has subsided. They should continue to see you every 2 to 4 weeks during the first 3 months of treatment and then every month.

If you have side effects soon after starting medication, your healthcare professional should give you information about these. They may monitor you carefully, lower the dose of the medication or stop it and offer you a different medication or CBT.

While you are taking medication your healthcare professional should advise you to start to get involved in social situations that you fear or avoid and support you to gradually do so.

If you feel better after the first 3 months of taking medication, you should be advised to continue it for at least another 6 months. When stopping medication, the dose should be lowered gradually. If you start to feel anxious again when the dose is lowered or the medication is stopped, your healthcare professional may increase the dose, start the medication again or offer you CBT.

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