New NICE guidance on the recognition, assessment and treatment of social anxiety disorder (2nd post)
Last updated on 14th June 2013
I wrote an initial blog post yesterday on this month's new NICE guideline on "Social anxiety disorder: recognition, assessment and treatment". In today's post I would like to focus more on the guideline's very interesting treatment recommendations.
Fascinatingly this NICE guidance comes down fair & square on the side of one-to-one cognitive therapy as the first line treatment for social anxiety disorder. So the authors write:
1.3.2 Offer adults with social anxiety disorder individual cognitive behavioural therapy (CBT) that has been specifically developed to treat social anxiety disorder (based on the Clark and Wells model or the Heimberg model; see recommendations 1.3.13 and 1.3.14).
1.3.3 Do not routinely offer group CBT in preference to individual CBT. Although there is evidence that group CBT is more effective than most other interventions, it is less clinically and cost effective than individual CBT.
1.3.4 For adults who decline CBT and wish to consider another psychological intervention, offer CBT-based supported self-help (see recommendation 1.3.15).
1.3.5 For adults who decline cognitive behavioural interventions and express a preference for a pharmacological intervention, discuss their reasons for declining cognitive behavioural interventions and address any concerns.
1.3.6 If the person wishes to proceed with a pharmacological intervention, offer a selective serotonin reuptake inhibitor (SSRI) (escitalopram or sertraline). Monitor the person carefully for adverse reactions (see recommendations 1.3.17-1.3.23).
1.3.7 For adults who decline cognitive behavioural and pharmacological interventions, consider short-term psychodynamic psychotherapy that has been specifically developed to treat social anxiety disorder (see recommendation 1.3.16). Be aware of the more limited clinical effectiveness and lower cost effectiveness of this intervention compared with CBT, self-help and pharmacological interventions.
Options for adults with no or a partial response to initial treatment
1.3.8 For adults whose symptoms of social anxiety disorder have only partially responded to individual CBT after an adequate course of treatment, consider a pharmacological intervention (see recommendation 1.3.6) in combination with individual CBT.
1.3.9 For adults whose symptoms have only partially responded to an SSRI (escitalopram or sertraline) after 10 to 12 weeks of treatment, offer individual CBT in addition to the SSRI.
1.3.10 For adults whose symptoms have not responded to an SSRI (escitalopram or sertraline) or who cannot tolerate the side effects, offer an alternative SSRI (fluvoxamine  or paroxetine) or a serotonin noradrenaline reuptake inhibitor (SNRI) (venlafaxine), taking into account: the tendency of paroxetine and venlafaxine to produce a discontinuation syndrome (which may be reduced by extended-release preparations) the risk of suicide and likelihood of toxicity in overdose.
1.3.11 For adults whose symptoms have not responded to an alternative SSRI or an SNRI, offer a monoamine oxidase inhibitor (phenelzine  or moclobemide).
1.3.12 Discuss the option of individual CBT with adults whose symptoms have not responded to pharmacological interventions.
Delivering psychological interventions for adults
1.3.13 Individual CBT (the Clark and Wells model) for social anxiety disorder should consist of up to 14 sessions of 90 minutes' duration over approximately 4 months and include the following: education about social anxiety experiential exercises to demonstrate the adverse effects of self-focused attention and safety-seeking behaviours; video feedback to correct distorted negative self-imagery; systematic training in externally focused attention; within-session behavioural experiments to test negative beliefs with linked homework assignments; discrimination training or rescripting to deal with problematic memories of social trauma; examination and modification of core beliefs: modification of problematic pre- and post-event processing; relapse prevention.
Fascinating, but this all sounds a bit of a pipe dream just now. How many well-trained cognitive therapists are there with specific skills in treating social anxiety disorder? Not only this but there apparently needs to be expert supervision provided as well, so the guideline states:
1.3.1 All interventions for adults with social anxiety disorder should be delivered by competent practitioners. Psychological interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Practitioners should consider using competence frameworks developed from the relevant treatment manual(s) and for all interventions should: receive regular, high-quality outcome-informed supervision; use routine sessional outcome measures (for example, the SPIN or LSAS) and ensure that the person with social anxiety is involved in reviewing the efficacy of the treatment; engage in monitoring and evaluation of treatment adherence and practitioner competence - for example, by using video and audio tapes, and external audit and scrutiny if appropriate.
I personally have already had training in cognitive therapy for social anxiety disorder and I'm off down to London in July for a one day update on this treatment. A bit of a drop in the ocean though. If you're a cognitive therapist based in the UK maybe see you there!