Social Anxiety Disorder

This guideline talks about recognising and managing social anxiety disorder in adults and children. The median age of onset is 13.
Social Anxiety Disorder is common (12% lifetime prevalence), often coexists with other mental health disorders and substance misuse and can have a big impact on schooling, relationships and social functioning.
Many people never seek help and for those that do, they will often wait years before coming forward, so we need to be proactive about looking for it. We also need to provide an environment that allows people to talk to us. Phone calls, or writing could help, or separate waiting areas, for example.
As so often is the case, there's nothing earth shattering here, but I will summarise the main points.

Identification in adults
Consider using the 2 following screening questions:
• Do you find yourself avoiding social situations or activities?
• Are you fearful or embarrassed in social situations?
If they answer 'yes' to either, do a fuller assessment. Consider using a validated tool, such as:
• Social Phobia Inventory (SPIN)
• Leibowitz Social Anxiety Scale (LSAS)
Also ask about avoidance, distress, fear, triggers, view of self, safety seeking measures and functional impairment. Ask about pre and post event processing.

Identification in children
Kids may present differently. They may cry, freeze or throw tantrums in social situations. You may need to explain more when trying to identify the anxiety. NICE gives suggested wording, but it is basically giving typical triggers and symptoms in simple language.
Kids may find it hard to talk to you, so suggest talking through their parent, or writing or drawing.
There are paediatric versions of the SPIN and LSAS tools available.

Treatment
First-line in both adults and kids should be referral for CBT.
• If they refuse, explore why. Offer supported self-led CBT (they don't explain how to access this or specific resources, though advise that 'a CBT based self-help book' should be used.
• If they still refuse, offer medication. Start with an SSRI (they advise escitalopram or sertraline, then fluoxetine or paroxetine), then SNRI (venlafaxine), then a MAOI.
• If one intervention doesn't work, combine pharmacological and psychological treatments.
• Do not use medication in kids.

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton.

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