Social Anxiety Disorder
Social anxiety disorder (SAD), previously social phobia, is a mental health condition characterised by fear of social situations. Social anxiety can be characterised by the excessive fear or anxiety regarding social interactions where one could be evaluated by others, for example meeting friends, holding a conversation, eating or drinking in the presence of others, job interviews and social occasions. Someone who displays characteristics of social anxiety disorder (SAD) will be anxious that they will act in a certain way or show anxiety symptoms which might be negatively perceived by others around them. Relevant social situations are consistently avoided or else endured with intense fear or anxiety. The three components in SAD are; 1) Cognitive, where negative thoughts and images about oneself takes place (e.g., low self-esteem, embarrassment, fear, unrealistic demands of self); 2) Behavioural, where one avoids situations and engages in behaviours intended to change or hide how one comes across (e.g. planning what to say, hiding one’s face) persisting for at least several months. This may result in significant distress or not achieving one’s potential in personal, family, social, educational, occupational, or other important areas of functioning; and 3) Physical, relating to anxiety symptoms such as dry mouth, feeling scared, hot or shaking, which are distressing, and people fear may be visible to others (1).
Developmental and systemic factors should be considered when identifying and treating Children and Young People (CYP) with SAD (see the Matrix information on GAD for further information). Accurate identification of SAD requires differentiation from the impact of developmental stage with the associated increased focus on social comparison and importance of peer relationships during adolescence (2). Within the younger age range, social anxiety may manifest through behaviours such as shrinking from interactions, crying, freezing or behavioural outbursts such as tantrums. Children may also be less likely to articulate the reasons for their anxiety or acknowledge that their fears are irrational when they are away from a social situation (3).. SAD in CYP is associated with loneliness, friendship problems and school refusal4 with significant impact upon functioning during key developmental stages across academic, social and family domains (4).
Limited knowledge and understanding of social anxiety disorder (SAD) in both people with SAD and professionals means that SAD is often unrecognised, and people are not signposted to appropriate treatment (3). Without access to effective treatment, SAD in CYP has a chronic course with poorer recovery rates as compared with other anxiety disorders (5), underscoring the need for early detection and effective intervention.
The National Institute for Care and Excellence (3) reports that social anxiety disorder is one of the most persistent and common anxiety disorders with a lifetime prevalence rate of 12% (USA) (6), 6.7% (range 3.9-13.7%) in Europe (7). Social anxiety disorder often coexists with depression, substance use disorder, generalised anxiety disorder, panic disorder, and post-traumatic stress disorder.
Within CYP, SAD prevalence rates escalate during early adolescence (range from 3.4% - 8.2%, 12-month prevalence, 11% cumulative incidence and 9.1% lifetime prevalence) (8-10). Younger children do also present with SAD (1.6% 4–11-year-olds) (10-12). Established comorbidities in CYP include depression, other anxiety disorders and substance misuse in older adolescents (13-15).
This information is for commissioners, managers, trainers and healthcare practitioners to consider the evidence base for the delivery of psychological interventions for people with SAD. This information is also for people diagnosed with SAD, their families and carers.
This topic introduction page covers evidence-based psychological interventions used to treat social anxiety disorder (SAD) in children, young people and adults. This topic area also includes the psychological practice/settings in which each intervention can be delivered. This topic does not cover pharmacological interventions or interventions which are not informed by psychological theory. There are a wider range of non-psychological interventions and supports that are beyond the scope of this topic and full guidance on best practice can be found in the NICE guidance and pathways (3).
Types of evidence included: There are a range of interventions that could be included in the treatment tables for SAD. However, in order to be consistent with a focus on interventions with the highest levels of efficacy and the strongest levels of evidence where these exist, psychological interventions for the treatment of SAD with low strength evidence and low levels of efficacy have not been included. For adult populations (where most research is available) the majority of the psychological interventions presented provide high to medium levels of evidence and medium to high levels of efficacy. The psychological treatments for adults and CYP with moderate strength evidence and moderate efficacy have also been included.
CYP Overview
Multiple studies, including randomised control trials (RCTs), systematic reviews and meta-analyses, have reported the effectiveness of psychological and psychosocial treatments for the management of social anxiety disorder in adults and children and young people (CYP).
Evidence shows that CBT (16-20) has been effective in treating CYP with social anxiety disorder, with high level evidence identified. This includes CBT delivered as individual CBT (16-18,20) and face-to-face group CBT (19). Where these interventions are offered, there should be consideration of parental or carer involvement, taking into account the CYP’s cognitive and emotional maturity. Where young people may have the cognitive and emotional capacity (typically aged 15 and over), consideration should be given to psychological interventions developed for adults (3). CYP with social anxiety disorder have commonly been treated with psychological interventions that cover a broad range of anxiety disorders; however, evidence suggests that CYP with social anxiety disorder are less likely to recover using a generic CBT model as compared with other primary anxiety disorders (19,21) . There is emerging evidence supporting the use of SAD specific CBT for adolescents (3), the use of VR augmented or internet delivered CBT (22-24).
Moderate level evidence supports the use of face-to-face psychodynamic therapy to treat social anxiety in CYP (17) It should be noted that mindfulness-based interventions (e.g. Mindfulness based stress reduction, mindfulness based cognitive therapy) or supportive therapy should not be routinely offered to treat social anxiety disorder in children and young people (3).
Overview of evidence for adults
There is high level evidence to support the effectiveness of Cognitive Behavioural Therapy (CBT) (25) in the management of social anxiety disorder in adults, with NICE recommending the use of Clark and Wells model (26) and Heimberg model (27), as the first line intervention. Evidence also suggests the effectiveness of adapted/modified CBT, including Internet-based cognitive behavioural therapy (I-CBT) (28) and therapist supported I-CBT (29). Therapist assisted I-CBT can improve the efficiency of outcomes in SAD (30). Group CBT (3) is an effective treatment for practitioners to consider, NICE suggests group formats are less effective and less cost effective than individual CBT, a more recent meta-analysis is suggestive of greater equivalence of outcomes (31). There is evidence for exposure therapy (3) and virtual reality exposure therapy (32,33) (less effective than in vivo). There is support for psychodynamic therapy in the treatment of social anxiety disorder/phobias in adults (25,34). NICE suggest that, where first line CBT interventions are not provided and psychodynamic therapy is used, short term psychodynamic therapy manualized for specifically for SAD is preferable. The evidence for internet-based psychodynamic psychotherapy is less rigorous, with moderate levels of efficacy reported. There is evidence for group psychotherapy, however, psychodynamic approaches were a small subset of the meta-analysis (31). In addition, there is evidence in the tables below which suggests that interventions such as CBT based Self-help with/without support (3) have been effective in adult populations.
Overview of evidence for Older People
In the absence of specific evidence for psychological therapies for older people with Social Anxiety the guidance for adults applies. Clinicians are advised that there are differences in presentation of psychological problems in later life and to consult Delivering Effective Psychological Therapies and Interventions to Older People for further information on factors relevant to practice.
| Recommendation* | Who for? | List of Interventions | Type of Psychological Practice | Evidence | Efficacy |
First line intervention |
Children and Young people | CBT focused on SAD (16-20) (consider family involvement based on developmental stage) | Specialist | A | Medium-High |
| First line intervention | Children and Young people | Group CBT focused on SAD (19) (consider family involvement based on developmental stage) | Specialist | A | High |
First line intervention |
Adolescents with SAD | Therapist- guided Internet-Delivered CBT (24, 24) | Specialist | A | Medium-High |
| Alternative (evidence less established) | Children and Young People | Psychodynamic Therapy (17) | Specialist | B | Medium |
| Alternative (evidence less established) | Children and Young People | VR/Virtual Environment augmented CBT (23) | Specialist | B | N/A |
| Recommendation* | Who for? | List of Interventions | Type of Psychological practice | Evidence | Efficacy |
| First line intervention | Adults |
CBT (25) - Clark and Wells model (26) - Heimberg model (27) |
Specialist | A | High |
| CBT may be delivered supported by an internet package specifically for SAD (28-30) | Specialist | A | Medium - High | ||
| Alternative if patient prefers format | Adults | Group CBT (25) | Specialist | A | Medium-High |
| Alternative, if available, and patient prefers format | Adults | Virtual reality exposure (32,33) | Enhanced/Specialist | A | Medium-High |
| Alternative (lower efficacy) if patient prefers format | Adults |
Self-help with support (25) Self-help without support (25) (includes practitioner supported internet delivered CBT)(28) |
Enhanced | A | Medium |
| Alternative (lower efficacy) if patient declines CBT based treatment | Adults | Short-term Psychodynamic psychotherapy specifically designed for SAD (25,34) | Specialist | A | Medium |
| Alternative (lower efficacy) if patient declines CBT based treatment | Adults | Group psychotherapy (31) | Specialist | B | Medium |
With thanks to Alice Loyal and Louise Waddington from NHS Wales who participated in the advisory and technical groups.
Advisory group: Audrey Espie, Fhionna Moore, Suzy O’Connor, Anne Joice, Sean Harper, Alex Doherty, Gemma Brown, Naomi Whyte, Alia Ul-hassan, Andrew Jahoda, Suzanne Roos, Regina Esiovwa.
Technical group: Marie Claire Shankland, Anne Joice, Leeanne Nicklas, Fhionna Moore, Gemma Brown, Suzy O’Connor, Naomi Harding, Regina Esiovwa.
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