Synopsis
Separate fear of scrutiny from fear of a circumscribed object or situation, assess avoidance and functional impact, and select disorder-specific CBT and exposure while using medication appropriately and safely.
- Social anxiety disorder is persistent fear of social situations where scrutiny and negative evaluation are possible, with avoidance or intense endurance and meaningful impairment.
- Specific phobia is disproportionate fear and avoidance tied to a particular object or situation, such as animals, heights, blood-injection-injury or flying.
- Ask what outcome is feared: humiliation suggests social anxiety, inability to escape suggests agoraphobia, and harm intrinsic to a circumscribed cue suggests specific phobia.
- For adult social anxiety, offer individual disorder-specific CBT based on the Clark and Wells or Heimberg model; do not routinely prefer group CBT over individual treatment.
- For specific phobia, graded in-vivo exposure within CBT is central; build a hierarchy and repeat safe contact while reducing escape and safety behaviours.
- If an adult with social anxiety declines CBT and chooses medicine, NICE recommends an SSRI, either escitalopram or sertraline, with early activation and suicide monitoring.
- Medication is not the core treatment for a specific phobia and a sedative taken before every exposure can block learning and create dependence.
Key red flags
Suicidal thinking linked to humiliation, isolation, bullying or chronic restriction requires direct assessment of intent, means, recent actions and protective supports.
Fainting with injury, exertional symptoms, objective allergy, hypoxia or neurological change during a feared situation warrants physical assessment rather than automatic attribution to phobia.
Refusal of essential food, healthcare, education or safe housing because of fear can create immediate physical and safeguarding risk.
Marked suspiciousness, fixed beliefs about persecution, developmental communication differences or body-image preoccupation may require a different or additional formulation.
Investigation priorities
Identify triggers, predictions, bodily sensations, attention, safety behaviours, avoidance and consequences.
Management branches
An adult chooses the recommended individual psychological treatment for social anxiety.
- Develop a disorder-specific formulation covering self-image, self-focused attention, anticipatory worry, safety behaviours and post-event rumination.
- Use attention training, behavioural experiments, objective feedback and graduated exposure while dropping strategies that conceal or prevent disconfirmation.
- Consolidate learning across meaningful settings, address residual shame and plan independent practice and relapse responses over the structured course.