22nd February 2024

Management

CBT

First line management is CBT which has been developed specifically for social anxiety disorder. It is based on the Clark and Wells model or Heimberg model. 

• The Clarks and Wells model: 14 sessions lasting over 90 mins each for approx. 4 months. It focuses on the following concepts:
  • Providing education about social anxiety
  • Exercises to show patients the downsides of SAD related safety seeking / avoidance behaviours and self-focus.
  • Video feedback so patients can see how they come across, which challenges a negative self-image
  • Dealing with any memories of social trauma 
  • Identifying and modifying negative core beliefs
  • Prevention of relapse
  • Training in externally focused attention 
• The Heimberg model. It focuses on the following concepts:
  • Providing education about social anxiety 
  • Cognitive restricting 
  • Gradual / graded exposure to situations the individual fears
  • Identifying and modifying negative core beliefs

Supported CBT

If CBT is declined or another option is sought, supported (self-help) CBT should be offered. Supported self-help consists of 9 sessions over approx. 4 months where patients are guided through a CBT based self-help book. 

Pharmacological management 

Pharmacological management should be started if CBT has been ineffective.

• 1st line – Selective Serotonin Reuptake Inhibitors (SSRIs) e.g., Sertraline or Escitalopram. If these aren’t tolerated, alternative SSRIs can be given, e.g., Paroxetine. 
• 2nd line – Serotonin Noradrenaline Reuptake Inhibitor (SNRIs) e.g., Venlafaxine. If symptoms don’t improve after 10-12 weeks, consider individual CBT.
• 3rd line – Monoamine oxidase inhibitor e.g., Moclobemide

Psychodynamic psychotherapy 

Patients who decline CBT or pharmacological treatment can be offered psychodynamic psychotherapy aimed at SAD. However, this has limited effectiveness and is not cost effective, so is used as the last line of management. 

It involves up to 30 sessions, each lasting up to 50 minutes for 6-8 months, and focuses on the following concepts:

• Providing education about social anxiety 
• Focusing on shame
• Encouraging patients to face social scenarios that they fear outside of sessions.
• Promoting self-affirmation
• Improving social skills.