Social anxiety disorder is one of the most common anxiety disorders, with around one in ten people affected. NICE has today published a clinical guideline to help healthcare professionals recognise the disorder and provide effective treatments.

Social anxiety disorder involves a persistent fear of one or more social situations, such as meeting new people, 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, and public speaking. Although anxiety about these situations is common in the general population, people with social anxiety disorder worry excessively about them, avoid them and this has major consequences for their personal lives, education and in the workplace.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: “Social anxiety disorder isn't about being shy at parties or feeling anxious about a job interview, it's about experiencing a level of anxiety that can disrupt normal life, interfering with social relationships and affecting performance at work or school. In these cases, it is really important that the individual is able to get the right help.

“This guideline includes a number of recommendations to support healthcare professionals to accurately diagnose and manage social anxiety disorder. We hope that the development of NICE guidance in this area will help ensure that those affected by this disorder receive the best possible support.”

Recommendations include:

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

• where to go on arrival and where they can wait (offer the use of a private waiting area or the option to wait elsewhere, for example outside the service's premises)
• location of facilities available at the service (for example, the car park and toilets)
• what will happen and what will not happen during assessment and treatment.

Identification of adults with possible social anxiety disorder: Ask the identification questions for anxiety disorders in line with the NICE clinical guideline on Common mental health disorders, and if social anxiety disorder is suspected:

• use the 3-item Mini-Social Phobia Inventory (Mini-SPIN) or
• consider asking the following 2 questions: Do you find yourself avoiding social situations or activities? Are you fearful or embarrassed in social situations?
• If the person scores 6 or more on the Mini-SPIN, or answers yes to either of the 2 questions above, refer for or conduct a comprehensive assessment for social anxiety disorder

Initial treatment options for adults with social anxiety disorder:

• Offer adults with social anxiety disorder individual cognitive behavioural therapy (CBT) that has been specifically developed to treat social anxiety disorder
• For adults who decline CBT and wish to consider another psychological intervention, offer CBT-based supported self-help
• For adults who decline cognitive behavioural interventions and express a preference for a pharmacological intervention, discuss their reasons for declining cognitive behavioural interventions and address any concerns
• If the person wishes to proceed with a pharmacological intervention, offer a selective serotonin reuptake inhibitor (SSRI) (escitalopram or sertraline). Monitor the person carefully for adverse reactions.

Treatment for children and young people with social anxiety disorder: Offer individual or group CBT focused on social anxiety to children and young people with social anxiety disorder. Consider involving parents or carers to ensure the effective delivery of the intervention, particularly in young children.

Professor David M. Clark, Professor of Experimental Psychology, University of Oxford and Chair of the group that developed the guideline, said: “Social anxiety disorder is a common but under-recognised condition that causes considerable hardship and prevents people from achieving their full potential. It typically starts in childhood or adolescence and for a substantial proportion of people can be life-long in the absence of treatment. Thankfully, effective treatments exist but they are currently under-used. It is hoped that the new NICE guideline will help overcome this problem by providing clear guidance on how to detect and effectively treat social anxiety disorder.”

Professor Stephen Pilling, Director, National Collaborating Centre for Mental Health; Professor of Clinical Psychology and Clinical Effectiveness, UCL and facilitator of the Guideline Development Group (GDG), said: “Despite the existence of effective treatments, recognition of social anxiety disorder can be difficult and it is often overlooked or misdiagnosed as another condition, such as depression. Also individuals may not access treatment due to perceived stigma and the avoidance behaviour associated with the condition. Despite the extent of distress and impairment, only about half of those with the disorder ever seek treatment. Instead they may become withdrawn, avoiding social situations and in some cases turn to alcohol or other drugs to try to reduce their anxiety, which can in turn potentially lead to substance abuse.

“The guideline can help more patients receive effective treatment to relieve the incessant uncontrollable worry and anxiety that is the core characteristic of this condition.”

Gareth Stephens, member of the group that developed the guideline, with personal experience of social anxiety disorder, said:"Social anxiety disorder can be crippling, making the world seem to the sufferer like a place devoid of happiness and full of threat. Simple things that most people take for granted, such as going into a shop, or even walking down the street, can seem like insurmountable tasks. Because of the very nature of the condition sufferers often feel unable to report their anxiety to their GP and others, and therefore treatment is not received, the condition becoming even more deeply ingrained, and the sufferer more hopeless and isolated. This guideline is essential as it will increase recognition and help to remove some of the barriers to access, thereby giving people the opportunity to break free from the prison of their anxiety.”

Nick Hanlon, Chairman of Social Anxiety West, Bristol and member of the group that developed the guideline with personal experience of social anxiety disorder, said: "As well as the situations we might typically associate with social anxiety, such as dating, public speaking and social gatherings, many people with social anxiety disorder find everyday tasks such as making a phone call, visiting a shop or cooking a meal in shared accommodation highly stressful. Without the right help, most will suffer daily and struggle with relationships, education and work for years or decades despite very much wanting to progress in these areas. This guideline recommends effective treatments that can provide them with the opportunity to reduce their distress, move their life forward and engage in society. It also importantly includes recommendations that aim to make accessing treatment easier for them, as they can find seeking help difficult due to their fears."

Nicky Lidbetter, CEO of Anxiety UK, said: “We welcome the development of these guidelines for social anxiety and the recognition that the condition of social anxiety can be extremely disabling for those who experience it. The recommendations for the treatment of social anxiety disorder will provide GP and other health professionals with a clear pathway to provide the help and support needed.”

Ends

Notes to Editors

Explanation of terms

1. It is estimated that 6-7% of people experience social anxiety disorder in any given year and around 12% are affected sometime in their life, compared to lifetime estimates of around 6% for generalised anxiety disorder (GAD). Social anxiety disorder often coexists with other mental health disorders, most commonly one in five people also experiencing depression.

2. Cognitive-behaviour therapy (CBT) is a short-term psychological treatment that helps people examine the way they think, what they attend to, and how they behave in social situations. It mainly focuses on people's present concerns but can also address earlier traumatic memories that may contribute to those concerns. It involves practical exercises as well as discussions with a therapist.

About the guideline

3. The guideline will be available on the NICE website from 22 May 2013. Embargoed copies are available on request from the NICE press office.

4. A podcast with Gareth Stephens discussing the signs and symptoms of social anxiety and his personal experience of the disorder will also be available on the website from 22 May 2013.

About NICE

The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.

Formerly the National Institute for Health and Clinical Excellence, our name changed on 1 April 2013 to reflect our new and additional responsibility to develop guidance and set quality standards for social care, as outlined in the Health and Social Care Act (2012).

Our aim is to help practitioners deliver the best possible care and give people the most effective treatments, which are based on the most up-to-date evidence and provide value for money, in order to reduce inequalities and variation.

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