Social anxiety disorder: recognition, assessment and treatment

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.

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