Social Anxiety Disorder: full guideline

271 Pages·2012·2.66 MB·English

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SOCIAL ANXIETY
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DISORDER:
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RECOGNITION, ASSESSMENT
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AND TREATMENT
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National Clinical Guideline Number X
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National Collaborating Centre for Mental Health
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commissioned by the
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National Institute for Health and Clinical Excellence
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20 published by
21 The British Psychological Society and The Royal College of
22 Psychiatrists

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CONTENTS
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2 1 Preface ............................................................................................................................... 7
3 1.1 National guideline ..................................................................................................... 7
4 1.2 The National Social Anxiety Disorder Guideline .................................................... 10
5 2 Social Anxiety Disorder............................................................................................... 13
6 2.1 The Disorder ............................................................................................................ 13
7 2.2 Aetiology .................................................................................................................. 18
8 2.3 Treatment And Management In The NHS ............................................................. 19
9 2.4 The economic cost of social anxiety disorder ............................................................ 27
10 3 Methods used to develop this guideline .................................................................. 29
11 3.1 Overview .................................................................................................................. 29
12 3.2 The scope .................................................................................................................. 30
13 3.3 The Guideline Development Group ......................................................................... 31
14 3.4 Review questions ...................................................................................................... 32
15 3.5 Systematic clinical literature review........................................................................ 33
16 3.6 Health economics methods ....................................................................................... 54
17 3.7 The incorporation and adaptation of existing NICE guideline recommendations .. 59
18 3.8 From evidence to recommendations ......................................................................... 61
19 3.9 Stakeholder contributions ........................................................................................ 62
20 3.10 Validation of the guideline ....................................................................................... 63
21 4 Improving Access to Services and The Experience of Care .................................. 64
22 4.1 Introduction ............................................................................................................. 64
23 4.2 Methods ................................................................................................................... 65
24 4.3 Aims of the evidence review ..................................................................................... 66
25 4.4 Review of the literature for access to services and experience of care ...................... 68
26 4.5 Developing principles of care specifically for people with social anxiety disorder ... 73
27 4.6 From evidence to recommendations ......................................................................... 74
28 4.7 Recommendations .................................................................................................... 76
29 5 Case identification and assessment........................................................................... 80
30 5.1 Introduction ............................................................................................................. 80
31 5.2 Case identification .................................................................................................... 83
32 5.3 Recommendations for case identification ................................................................. 92
33 5.4 Assessment ............................................................................................................... 94
34 5.5 Recommendations for assessment .......................................................................... 100

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1 6 Interventions for Adults ............................................................................................ 104
2 6.1 Introduction ........................................................................................................... 104
3 6.2 Current practice ..................................................................................................... 104
4 6.3 Definitions and aims of interventions ................................................................... 105
5 6.4 Clinical review protocol ......................................................................................... 110
6 6.5 Overview of studies considered and clinical evidence ........................................... 113
7 6.6 Pharmacological interventions .............................................................................. 125
8 6.7 Psychological interventions ................................................................................... 140
9 6.8 Combined psychological and pharmacological interventions ................................ 147
10 6.9 Specific subgroups ................................................................................................. 149
11 6.10 Health economic evidence ...................................................................................... 151
12 6.11 Overall clinical summary ...................................................................................... 189
13 6.12 From evidence to recommendations ....................................................................... 191
14 6.13 Recommendations .................................................................................................. 196
15 7 Interventions for Children and Young People ...................................................... 203
16 7.1 Introduction ........................................................................................................... 203
17 7.2 Clinical review protocol ......................................................................................... 206
18 7.3 Overview of Clinical evidence ................................................................................ 209
19 7.4 Pharmacological interventions .............................................................................. 214
20 7.5 Psychological interventions ................................................................................... 215
21 7.6 Health economic evidence ...................................................................................... 221
22 7.1 Evidence summary ................................................................................................. 221
23 7.2 From evidence to recommendations ....................................................................... 222
24 7.3 Recommendations .................................................................................................. 223
25 8 Computerised cognitive behavioural therapy (ccbt) for specific phobias in adults
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27 8.1 Introduction ........................................................................................................... 226
28 8.2 Review protocol ...................................................................................................... 227
29 8.3 Clinical evidence .................................................................................................... 230
30 8.4 Clinical summary .................................................................................................. 241
31 8.5 From Evidence to recommendations ...................................................................... 241
32 8.6 Recommendations .................................................................................................. 241
33 9 References .................................................................................................................... 242
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GUIDELINE DEVELOPMENT GROUP MEMBERS
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5 Professor David Clark (Chair, Guideline Development Group)
6 Professor of Psychology, University of Oxford
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8 Professor Stephen Pilling (Facilitator, Guideline Development Group)
9 Director, National Collaborating Centre for Mental Health
10 Professor of Clinical Psychology and Clinical Effectiveness
11 Director, Centre for Outcomes Research and Effectiveness, University College
12 London
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14 Dr Evan Mayo-Wilson
15 Systematic Reviewer, National Collaborating Centre for Mental Health
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17 Dr Safi Afghan
18 Consultant Psychiatrist, Dorothy Pattison Hospital, Dudley & Walsall Mental
19 Health Partnership NHS Trust, Walsall
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21 Mr Benedict Anigbogu
22 Health Economist, National Collaborating Centre for Mental Health (until
23 September 2012)
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25 Mr Peter Armstrong
26 Director of Training, Newcastle Cognitive & Behavioural Therapies Centre,
27 Northumberland, Tyne & Wear NHS Foundation Trust
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29 Dr Madeleine Bennett
30 GP and NSPCR Fellow, University College London
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32 Dr Sam Cartwright-Hatton
33 Clinical Psychologist, NIHR Career Development Fellow, University of Sussex
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35 Dr Cathy Creswell
36 Principal Research Fellow, School of Psychology & Clinical Language Sciences,
37 University of Reading
38 Honorary Consultant Clinical Psychologist, Berkshire Child Anxiety Clinic,
39 Berkshire Healthcare NHS Foundation Trust
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41 Dr Melanie Dix
42 Consultant Child and Adolescent Psychiatrist, Cumbria Partnership Foundation
43 Trust
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45 Mr Nick Hanlon
46 Service User Representative and Chairman, Social Anxiety West, Bristol

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2 Ms Kayleigh Kew
3 Research Assistant, National Collaborating Centre for Mental Health (until
4 November 2012)
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6 Dr Andrea Malizia
7 Consultant Psychiatrist and Clinical Psychopharmacologist, Clinical Partners and
8 North Bristol NHS Trust
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10 Dr Ifigeneia Mavranezouli
11 Senior Health Economist, National Collaborating Centre for Mental Health
12 Dr Jane Roberts
13 Clinical Senior Lecturer and General Practitioner, University of Sunderland and
14 GP
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16 Mrs Kate Satrettin
17 Project Manager, National Collaborating Centre for Mental Health (until
18 September 2012)
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20 Ms Melinda Smith
21 Research Assistant, National Collaborating Centre for Mental Health
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23 Mr Gareth Stephens
24 Service User Representative
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26 Dr Lusia Stopa
27 Director of CBT programmes and Senior Lecturer, School of Psychology,
28 University of Southampton and Honorary Consultant Clinical Psychologist,
29 Hampshire Partnership Foundation Trust
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31 Ms Sarah Stockton
32 Senior Information Scientist, National Collaborating Centre for Mental Health
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34 Dr Clare Taylor
35 Senior Editor, National Collaborating Centre for Mental Health
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37 Dr Craig Whittington
38 Senior Systematic Reviewer, National Collaborating Centre for Mental Health
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ACKNOWLEDGEMENTS
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3 The Guideline Development Group (GDG) and the National Collaborating Centre
4 for Mental Health (NCCMH) review team would like to thank Clinical Guidelines
5 Technical Support Unit and specifically the following people:
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7 Professor Tony Ades (PhD)
8 Professor of Public Health Science
9 University of Bristol
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11 Dr Sofia Dias (PhD)
12 Research Fellow (Statistician)
13 University of Bristol
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15 Editorial assistance
16 Ms Nuala Ernest
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1 PREFACE
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2 This guideline is concerned with the recognition, management and treatment of
3 social anxiety disorder in adults (aged 18 years or older) and children and young
4 people (from school age to 17 years) in primary and secondary care, and
5 educational and other settings where healthcare or related interventions may be
6 delivered. This guideline updates and replaces the section of NICE technology
7 appraisal 97 (NICE, 2006) that deals with phobia.
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9 The guideline recommendations have been developed by a multidisciplinary
10 team of healthcare professionals, people with social anxiety disorder and
11 guideline methodologists after careful consideration of the best available
12 evidence. It is intended that the guideline will be useful to clinicians and service
13 commissioners in providing and planning high-quality care for people with social
14 anxiety disorder while also emphasising the importance of the experience of care
15 for people with social anxiety disorder and their carers (see Appendix 1 for more
16 details on the scope of the guideline).
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18 Although the evidence base is rapidly expanding, there are major gaps, and
19 future revisions of this guideline will incorporate new scientific evidence as it
20 develops. The guideline makes a number of research recommendations
21 specifically to address gaps in the evidence base. In the meantime, it is hoped that
22 the guideline will assist clinicians, people with social anxiety disorder and their
23 carers by identifying the merits of particular treatments and treatment
24 approaches where the evidence from research and clinical experience exists.
1.1 NATIONAL GUIDELINE
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26 1.1.1 What are clinical guidelines?
27 Clinical practice guidelines are ‘systematically developed statements that assist
28 clinicians and patients in making decisions about appropriate treatment for
29 specific conditions’ (Mann, 1996). They are derived from the best available
30 research evidence, using predetermined and systematic methods to identify and
31 evaluate the evidence relating to the specific condition in question. Where
32 evidence is lacking, the guidelines incorporate statements and recommendations
33 based upon the consensus statements developed by the Guideline Development
34 Group (GDG).
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36 Clinical guidelines are intended to improve the process and outcomes of
37 healthcare in a number of different ways. They can:
38 provide up-to-date evidence-based recommendations for the
39 management of conditions and disorders by healthcare
40 professionals
41 be used as the basis to set standards to assess the practice of
42 healthcare professionals

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1 form the basis for education and training of healthcare professionals
2 assist service users and their carers in making informed decisions
3 about their treatment and care
4 improve communication between healthcare professionals, service
5 users and their carers
6 help identify priority areas for further research.
7 1.1.2 Uses and limitation of clinical guidelines
8 Guidelines are not a substitute for professional knowledge and clinical
9 judgement. They can be limited in their usefulness and applicability by a number
10 of different factors: the availability of high-quality research evidence, the quality
11 of the methodology used in the development of the guideline, the generalisability
12 of research findings and the uniqueness of individuals.
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14 Although the quality of research in this field is variable, the methodology used
15 here reflects current international understanding on the appropriate practice for
16 guideline development (AGREE Collaboration, 2003), ensuring the collection and
17 selection of the best research evidence available and the systematic generation of
18 treatment recommendations applicable to the majority of people with social
19 anxiety disorder. However, there will always be some people for whom and
20 situations for which clinical guideline recommendations are not readily
21 applicable. This guideline does not, therefore, override the individual
22 responsibility of healthcare professionals to make appropriate decisions in the
23 circumstances of the individual, in consultation with the person with social
24 anxiety disorder or their carer.
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26 In addition to the clinical evidence, cost-effectiveness information, where
27 available, is taken into account in the generation of statements and
28 recommendations of the clinical guidelines. While national guidelines are
29 concerned with clinical and cost effectiveness, issues of affordability and
30 implementation costs are to be determined by the National Health Service (NHS).
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32 In using guidelines, it is important to remember that the absence of empirical
33 evidence for the effectiveness of a particular intervention is not the same as
34 evidence for ineffectiveness. In addition, and of particular relevance in mental
35 health, evidence-based treatments are often delivered within the context of an
36 overall treatment programme including a range of activities, the purpose of
37 which may be to help engage the child, young person or adult and provide an
38 appropriate context for the delivery of specific interventions. It is important to
39 maintain and enhance the service context in which these interventions are
40 delivered, otherwise the specific benefits of effective interventions will be lost.
41 Indeed, the importance of organising care in order to support and encourage a
42 good therapeutic relationship is at times as important as the specific treatments
43 offered.

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1 1.1.3 Why develop national guidelines?
2 The National Institute for Health and Clinical Excellence (NICE) was established
3 as a Special Health Authority for England and Wales in 1999, with a remit to
4 provide a single source of authoritative and reliable guidance for service users,
5 professionals and the public. NICE guidance aims to improve standards of care,
6 diminish unacceptable variations in the provision and quality of care across the
7 NHS, and ensure that the health service is person-centred. All guidance is
8 developed in a transparent and collaborative manner, using the best available
9 evidence and involving all relevant stakeholders.
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11 NICE generates guidance in a number of different ways, three of which are
12 relevant here. First, national guidance is produced by the Technology Appraisal
13 Committee to give robust advice about a particular treatment, intervention,
14 procedure or other health technology. Second, NICE commissions public health
15 intervention guidance focused on types of activity (interventions) that help to
16 reduce people’s risk of developing a disease or condition, or help to promote or
17 maintain a healthy lifestyle. Third, NICE commissions the production of national
18 clinical guidelines focused upon the overall treatment and management of a
19 specific condition. To enable this latter development, NICE has established four
20 National Collaborating Centres in conjunction with a range of professional
21 organisations involved in healthcare.
22 1.1.4 From national clinical guidelines to local protocols
23 Once a national guideline has been published and disseminated, local healthcare
24 groups will be expected to produce a plan and identify resources for
25 implementation, along with appropriate timetables. Subsequently, a
26 multidisciplinary group involving commissioners of healthcare, primary care and
27 specialist mental health professionals, service users and carers should undertake
28 the translation of the implementation plan into local protocols, taking into
29 account both the recommendations set out in this guideline and the priorities set
30 in the National Service Framework for Mental Health (Department of Health,
31 1999) and related documentation. The nature and pace of the local plan will
32 reflect local healthcare needs and the nature of existing services; full
33 implementation may take considerable time, especially where substantial training
34 needs are identified.
35 1.1.5 Auditing the implementation of clinical guidelines
36 This guideline identifies key areas of clinical practice and service delivery for
37 local and national audit. Although the generation of audit standards is an
38 important and necessary step in the implementation of this guidance, a more
39 broadly-based implementation strategy will be developed. Nevertheless, it
40 should be noted that the Care Quality Commission in England, and the
41 Healthcare Inspectorate Wales, will monitor the extent to which commissioners
42 and providers of health and social care have implemented these guidelines.

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1.2 THE NATIONAL SOCIAL ANXIETY DISORDER
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GUIDELINE
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3 1.2.1 Who has developed this guideline?
4 This guideline has been commissioned by NICE and developed within the
5 National Collaborating Centre for Mental Health (NCCMH). The NCCMH is a
6 collaboration of the professional organisations involved in the field of mental
7 health, national service-user and carer organisations, a number of academic
8 institutions and NICE. The NCCMH is funded by NICE and is led by a
9 partnership between the Royal College of Psychiatrists and the British
10 Psychological Society’s Centre for Outcomes Research and Effectiveness, based at
11 University College London.
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13 The GDG was convened by the NCCMH and supported by funding from NICE.
14 The GDG included people with social anxiety and carers, and professionals
15 psychiatry, clinical psychology, general practice, nursing, and psychiatric
16 pharmacy.
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18 Staff from the NCCMH provided leadership and support throughout the process
19 of guideline development, undertaking systematic searches, information
20 retrieval, appraisal and systematic review of the evidence. Members of the GDG
21 received training in the process of guideline development from NCCMH staff,
22 and the service users and carers received training and support from the NICE
23 Patient and Public Involvement Programme. The NICE Guidelines Technical
24 Adviser provided advice and assistance regarding aspects of the guideline
25 development process.
26
27 All GDG members made formal declarations of interest at the outset, which were
28 updated at every GDG meeting. The GDG met a total of 12 times throughout the
29 process of guideline development. It met as a whole, but key topics were led by a
30 national expert in the relevant topic. The GDG was supported by the NCCMH
31 technical team, with additional expert advice from special advisers where
32 needed. The group oversaw the production and synthesis of research evidence
33 before presentation. All statements and recommendations in this guideline have
34 been generated and agreed by the whole GDG.
35 1.2.2 For whom is this guideline intended?
36 This guideline will be relevant for children, young people and adults with social
37 anxiety disorder and covers the care provided by primary, community,
38 secondary, tertiary and other healthcare professionals who have direct contact
39 with, and make decisions concerning the care of, children, young people and
40 adults with social anxiety disorder.
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42 The guideline will also be relevant to the work, but will not cover the practice, of
43 those in:

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