Social Anxiety Disorder Treatment

Social anxiety disorder is intense fear of being watched or judged in social situations, strong enough that those situations are avoided or endured with dread, and lasting six months or more.

Also called: Social phobia, Social anxiety.

ICD-10 F40.1 · ICD-11 6B04

Test the fear. Drop the shield.

Avoiding what you fear makes perfect sense in the moment. It is also exactly what keeps social anxiety going. Getting through on safety behaviours does the same.

The treatment with the best evidence is a form of cognitive behavioural therapy, or CBT, built for social anxiety. It treats each fear as a prediction and then tests it. Attention is turned outward, and the safety behaviours are put down.

WHERE TREATMENT STARTS

Individual CBT first, medicine if that is not wanted or not enough

NICE, the National Institute for Health and Care Excellence, is the body that writes the UK guidelines. For adults, it recommends individual CBT designed for social anxiety as the first treatment. A large analysis of over a hundred trials found it the most effective option.

If someone does not want CBT, they are offered a selective serotonin reuptake inhibitor, or SSRI, such as escitalopram or sertraline. Guided self-help based on CBT is another option.

For children and young people, CBT adapted for their age comes first. Parents are often involved in it.

A BEHAVIOURAL EXPERIMENT

Test the fear.

In therapy, a fear is treated as a prediction that can be checked. The example below is speaking up in a small meeting at work.

The person runs the same conversation twice. The first time they use their usual safety behaviours. The second time they drop them. The conversation is filmed, so they can see how they really came across.

Three things get measured, and the gap between them is the whole point. How anxious it FELT to them. How anxious they LOOKED on the video. And how much the other person ENJOYED the conversation.

Pick a fear, say how sure you are, then run it both ways. Watch how far apart "felt" and "looked" turn out to be.

Pick the fear, rate how sure you are, then run the conversation both ways.

The prediction

They will see me shaking

I will go blank and look stupid

They will think I am boring

How sure are you?

And now, how sure are you?

Talk with safety behaviours

• Rehearse every sentence
• Grip the cup
• Look at the table
• Keep it short

0.55

0.8

0.82

0.8

0.52

0.34

Talk without them

• Say what comes to mind
• Put the cup down
• Look at them
• Ask a question back

0.62

0.85

0.6

0.42

0.3

0.74

How anxious it felt

How anxious you looked

How much they enjoyed it

5

Pick the fear first.

Now say how sure you are that it will happen.

Run the conversation. You can start either way round.

Rehearsing, gripping the cup, looking down. Attention stays on yourself.

Anxiety spikes at first. Then attention moves to them, and it starts to ease.

It felt bad all the way through, and it looked tense. They stayed polite and kept it short.

It felt worse at first, then better by the end. On the video it hardly showed at all.

Now look at your prediction again.

The prediction came down because you tested it. Not because somebody told you it would be fine.

Compare the two runs. Without the safety behaviours it felt harder at first. It looked far calmer than it felt. And the other person enjoyed it more. That is the core of CBT for social anxiety. Turn attention outward, put the shield down, and let real evidence change the prediction.

The person picks a fear, such as "they will see me shaking", and rates how sure they are about it.

They then have the same conversation twice. Once with safety behaviours, once without them.

Without them, anxiety rises at first and then falls. On video they look much calmer than they felt. And the other person enjoys the conversation more.

Then they rate the fear again. It is lower, because it was tested.

These numbers are invented to show the idea. Real CBT for social anxiety usually runs for about 14 weekly sessions with a trained therapist. The experiments are planned together, one step at a time.

THE OPTIONS

What else has evidence

Individual CBT is the core treatment. These are the other tools.

SSRIs

Escitalopram and sertraline are the usual ones. They help many people. They take several weeks to work, and symptoms are more likely to return if they are stopped too soon.

Internet CBT

Online CBT guided by a therapist has good evidence behind it. It can be an easier first step for people who dread sitting in a clinic.

Beta blockers

These are often used before a single performance, to calm shaking and slow the heart. They are not a treatment for social anxiety disorder itself.

Why reassurance is not enough

Saying "nobody is looking at you" is kind, and it rarely helps. A fear that has never been tested does not go away because somebody disagrees with it. It goes when the person finds out for themselves.

IF YOU START CBT

What actually happens, in order

It is structured and gradual. Every step is agreed together.

First you map your own version of the cycle. That means your fears, the picture you have of yourself, and your safety behaviours.

Then come experiments. They compare focusing on yourself with focusing outward, and using safety behaviours with dropping them.

Then comes video or audio feedback, so you can see how you really come across.

Then come real-world tests, planned together, moving from easier to harder.

Finally you work on dropping the replay, and build a plan to keep going after therapy ends.

OVER TIME

How well it works

Better than most people expect.

In trials, individual CBT for social anxiety produces large improvements. Those improvements tend to last after therapy ends.

SSRIs work for many people too. But symptoms are more likely to come back when the medicine stops.

Many people still feel nervous in some situations afterwards. The difference is that they no longer let it decide what they do.

COMING OFF

Slowly, with a plan

The medicine is usually continued for a while after things improve.

Guidelines suggest continuing an SSRI for at least six months after someone improves. Longer is advised if the symptoms have lasted a long time.

Stopping should be gradual, and done with a doctor, to avoid withdrawal symptoms.

The CBT skills keep working after therapy. When the old fear returns, the same rule applies. Test it, and put the shield down.