Social Anxiety Disorder: A Care Staff Guide to NICE CG159

Some people are not simply shy. They avoid meetings, meals, phone calls and appointments because the fear of being judged or embarrassed feels overwhelming. Left unrecognised, social anxiety disorder can quietly limit a person's life, and it can lead people to miss the very services that could help them. NICE guideline CG159 sets out how it should be recognised, assessed and treated, and it includes advice that matters to any staff member who meets people at the front line.

What is social anxiety disorder?

Social anxiety disorder is an intense and persistent fear of social situations, often linked with avoiding them. The NICE identification questions capture the core: does the person avoid social situations or activities, and are they fearful or embarrassed in social situations? It is different from general worry. Our guide to generalised anxiety and panic disorder explains related conditions that can occur alongside it, and our guide to specific phobias covers fears of particular objects and situations.

How NICE recommends it is identified

NICE advises that, where social anxiety disorder is suspected, practitioners can use the three-item Mini-SPIN or the two questions above. A person should be offered a comprehensive assessment if the Mini-SPIN score is 6 or more, or if they answer yes to either question. Staff who are not clinicians do not diagnose, but they can notice patterns such as repeatedly cancelled appointments, avoidance of group activities, or a person who becomes distressed when asked to speak in front of others, and pass those observations to a clinician or the GP.

What does NICE recommend as treatment?

• First choice for adults: individual cognitive behavioural therapy (CBT) designed specifically for social anxiety disorder, based on the Clark and Wells or Heimberg model.
• If the person declines this but wants another psychological approach: CBT-based supported self-help.
• If the person declines cognitive behavioural options and prefers medicine: clinicians should explore why, address concerns, and may offer an SSRI such as escitalopram or sertraline, with close monitoring for adverse reactions.
• Children and young people: individual or group CBT focused on social anxiety, with parents or carers involved to support delivery, particularly for younger children.

NICE also stresses that treatment should be delivered by competent practitioners following a treatment manual, with regular supervision and routine outcome measures such as the Social Phobia Inventory or the Liebowitz Social Anxiety Scale, reviewed with the person.

Making services less frightening

One of the most practical parts of CG159 is aimed at the way services are organised. NICE recommends that, when first offering an appointment, particularly in specialist services, a letter should explain where to go on arrival, where to wait, including a private area or a place outside the premises, key facilities such as parking and toilets, and what will and will not happen during assessment and treatment. On arrival, services should offer to meet the person or alert them, for example by text, when the appointment is about to start. These small adjustments reduce the anticipatory fear that so often leads to non-attendance.

What this means in everyday care

• Explain in advance. Tell people what will happen, who will be there and how long it will take.
• Offer choices. Let people decide whether to join group activities, sit near the edge of a room or have meals in a quieter space.
• Do not force exposure. Encouragement is helpful, but pushing a person into the situation they fear can increase distress. Therapy works in planned, supported steps.
• Be mindful of how you speak. Avoid putting someone on the spot in front of others. Give them time to answer and a way to opt out.
• Notice the knock-on effects. Isolation, low mood, and the use of alcohol or other substances to cope can follow, so share concerns with the clinical team.

Everyone in a service benefits from mental health awareness, and our guide to mental health first aid shows how to start a supportive conversation.

Recording and care planning

Record what the person has told you triggers their anxiety, which adjustments help, and any therapy they are receiving, so that every member of the team responds consistently. If someone is engaged in CBT, ask them how you can support their between-session tasks without taking over. Review whether appointments, activities and communication methods still suit them, and involve them in setting goals such as attending a family event or joining a meal.

Supporting staff learning

Understanding anxiety conditions improves the experience of the people we support. Learnsignal's CPD courses for care and healthcare staff can help teams build confidence in mental health practice.

Frequently asked questions

Is social anxiety just shyness? No. NICE describes a disorder involving fear, embarrassment and avoidance that is significant enough to warrant assessment and treatment.

Who can diagnose it? A clinician following a comprehensive assessment. Staff can notice signs and refer on.

What is the main treatment? NICE recommends individual CBT designed for social anxiety disorder as the first choice for adults, with supported self-help or an SSRI as alternatives where the person prefers.