Anxiety blushing, trembling, fear of rejection, nausea, and

Anxiety disorders are conceptualised as a
nomenclature of mental disorders, characterised by substantial feelings of
anxiety and fear. Fear occurs as a
result of the perceived imminent threat, whereas anxiety is a state of
anticipation about anticipated future threats (Craske et al., 2009). They
diverge from developmentally normative or stress-induced ephemeral anxiety by persisting
out of proportion to the actual threat posed, and by impairing daily
functioning (e.g., for at least six months; American Psychiatric Association,
2013). Social anxiety disorder (SAD), also known as social phobia, is a
perpetual and pernicious disorder that falls into the categorical
classification of anxiety disorders in the Diagnostic and Statistical Manual of
Mental Disorders, 5th Edition (DSM-5; American Psychiatric Association, 2013).
According to the DSM-5, individuals diagnosed with SAD typically avoid numerous social environments that manifest the
perception of humiliation or embarrassment. The visible anxiety symptoms may be
manifested by profuse sweating, blushing, trembling, fear of rejection, nausea,
and social inhibitions (American
Psychiatric Association, 2013). SAD affects various facets of the
individual’s life by initiating a conspicuous fear of social situations. This
fear and anxiety instigates
detrimental inhibitions associated with academic, occupational and social
functioning – including relationships, careers and other areas where social
interactions are involved due to the repeated tendency of avoiding stressors
and social exposure (McCarthy & Bates, 2016).

Social anxiety disorder is estimated to be the
second most prevalent anxiety disorder, with a lifetime prevalence of 10.7% in
the US (Kessler et al., 2012), and 6.7% in Europe (range 3.9-13.7%; Fehm, Pélissolo,
Furmark, & Wittchen, 2005). Furthermore, it is the fourth most prevalent of
all mental disorders, exceeded only by major depressive disorder, alcohol
misuse, and specific phobia (Kessler et al., 2005). SAD has an early onset,
which is estimated to commence around 13 years in high-income countries (Stein
et al., 2017), and 95% of patients reporting onset before the age of 35 (Kessler
et al., 2012). According to a recent study by Stein and colleagues (2017),
individuals with a primary diagnosis of SAD, also experienced impulse control
disorders (19%), substance use disorders (28%), mood disorders (47%), and other
anxiety disorders (60%). Moreover, men are more likely to experience comorbid
externalising disorders (e.g., alcohol and drug misuse, and conduct disorder),
while women are more likely to experience comorbid internalising disorders
(e.g., other anxiety disorders, and mood disorders aside from bipolar disorder;
Xu et al., 2012). Despite this, and the fact that effective treatments exist,
less than half of the people with this condition seek treatment (Stein et al.,
2017), many after waiting 10-15 years (Grant et al., 2005).


Cognitive Behavioural Therapy

therapy (CBT) has been consistently considered a highly efficacious intervention
for SAD (Arch & Craske, 2009; Norton & Price, 2007: (Nathan
& Gorman, 2015). In a current
meta-analysis, Mayo-Wilson et al. (2014) found that compared to various types
of psychological and pharmacology interventions, the Clark-Wells model of CBT (referred
to as cognitive therapy; Clark & Wells, 1995) yielded the highest effect
sizes in randomized controlled trials (Clark et al., 2006). This approach
includes several components, such as establishing a personal version of the
model, role-play-based behavioural experiments, practicing external focus of
attention, and restructuring distorted self-image by video feedback or behavioural
experiments. These procedures are assumed to reverse the maintaining factors
identified in the Clark and Wells model of SAD, especially safety behaviours
and self-focused attention. Safety behaviours are a form of avoidance behaviour
where a person attempts to reduce anxiety in social situations. Furthermore,
there is evidence that CT is significantly more effective than standard
pharmacological treatment (Clark et al., 2003), interpersonal therapy
(Stangier, Schramm, Heidenreich, Berger, & Clark, 2011), manualized
short-term psychodynamic therapy (Leichsenring et al., 2013), and also yielded
the highest effect sizes compared to other forms of CBT (Mayo-Wilson et al.,

Social anxiety disorder
can be a detrimental and debilitating impairment that takes a toll on all socio-economical
levels. Therefore, it is imperative to consider not only the effectiveness of
interventions, but also the cost (Pilling et al., 2013). In a recent
study examining the cost-effectiveness of psychological and pharmacological
interventions, using a model-based economic analysis, Mavranenzouli and
colleagues (2015) found that individual cognitive therapy, adapted from the
Clark and Wells model (1995) was the most cost-effective intervention for adults
with SAD. The probability of recovery for the Clark and Wells model of CBT was
62%, followed by generic individual cognitive behavioural therapy (47%), Phenelzine
(51%) and book-based self-help without support (34%). Individualised-CBT
remained the most cost-effective intervention following 5-years after the end
of treatment, but the probability of recovery outcomes was still relatively low
(50% after 5-years). CBT general followed as the second ranked intervention
with 41% after 5-years, with Phenelzine at 35%. These findings are supported by
the NICE guidelines for treating SAD, which suggest using the Clark and Wells
model of individualised-CBT as the first line of treatment. The guidelines also
encouraged the avoidance of offering group CBT, in preference to individualised-CBT
because while it is an effective treatment (Wersebe, Sijbrandij, &
Cuijpers, 2013), it is less clinically and cost-effective. The second line of
treatments are self-help interventions with support, for those who wish to
still use a psychological treatment, or SSRI’s, for those that do not (Pilling
et al., 2013).

Cognitive behavioural therapy has held up against
numerous comparative investigations, and continues to demonstrate high rates of
efficacy (Clark et al., 2006) – Results from the trial demonstrated that
cognitive therapy was superior to individual exposure plus relaxation on all
social anxiety measures at post-treatment and at 3-month follow up. 1-year
follow up outperformed individual exposure therapy plus relaxation, but was not
as marked. Clark’s cognitive therapy was later compared with two randomised
trials using interpersonal psychotherapy (Stangier et al., 2011) and
psychodynamic therapy (Leichsenring et al., 2013). Cognitive therapy
demonstrated a superior response rate to both interpersonal psychotherapy (66%
vs. 42%) and psychodynamic therapy (60% vs. 52%) at posttreatment. These
studies suggest that cognitive therapy may have stronger outcomes in comparison
to a waitlist and alternative psychotherapies. Moreover, it is important for researchers to continue investigating
interventions which may ultimately reduce the economic costs of the disorder.


Virtual and Internet-Based Interventions

In recent literature,
there has been an increase in the examination of internet-based cognitive
behavioural therapy and virtual reality exposure therapy (VRET) as alternatives
to generic-use CBT. Exposure therapy (ET) is an effective
CBT component, that is accomplished through in vivo and imaginal exposure, which
includes contesting feared, but objectively safe stimuli, situations, or
memories (Peris et al., 2017). The use of multi-sensory virtual reality (VR)
has been proposed as a cost-effective and logistically convenient clinical tool
for ET, relative to traditional in vivo exposure procedures (Rothbaum et al.,
2006). VR incorporates computer graphics, visual displays, and sensory inputs
to create an immersive virtual environment that facilitates the psychological
sense of participating in the computer world. Given that VR permits the
creation of customised virtual environments, this modality lends itself well to

Three meta-analyses conducted on VRET for anxiety
disorders have concluded that VRET is superior to waitlist control, no relative
differences to active treatments, has good stability over time, and has little
difference between drop-out rates of other evidence-based treatments (Opri? et
al., 2012; Parsons & Rizzo, 2008; Powers & Emmelkamp, 2008). Similarly,
Meyerbröker and Emmelkamp (2010) concluded in a narrative review that VRET is a
promising treatment for anxiety disorders; however, the authors noted that the
literature base for this treatment would benefit from studies with stronger methodologies.
Additional considerations about the quality of the current VRET literature have
been discussed due to the use of small sample sizes, lack of breadth, lack of
comparison groups, and uniformity in the reporting of data (Maples-Keller, Bunnell,
Kim, & Rothbaum, 2016; Parsons & Rizzo, 2008).

Internet-based cognitive behavioural therapy has
also been indicated as an efficacious treatment for SAD. In a recent
meta-analysis, Kampmann, Emmelkamp, and Morina (2016) examined the efficacy of
technology-assisted interventions for individuals with SAD. In total, 37 RCTs were
separated into groups of internet-based cognitive behaviour therapy, virtual
reality exposure therapy, and cognitive bias modification. Overall, both
internet-based CBT and virtual reality exposure therapy were more effective at
reducing symptoms following treatment, compared to the control conditions. The efficacy
of CBM was minor, and did not differ considerably from passive control
conditions. While the potential for technology-based interventions are innumerable,
conducting further RCTs with larger sample sizes is a categorical necessity to
better understood and recognize them as adequate treatments.


Pharmacological Treatments

Pharmacotherapy is typified as a prevalent treatment
option for SAD, but there still remains a considerable amount of deliberation
regarding its comparability to psychological treatments (Curtiss, Andrews, Davis,
Smits, & Hofmann, 2017). Many pharmacological treatments including, SSRIs,
SSNRIs, and MAOIs have been shown to effectively reduce anxiety symptoms, and
improve quality of life (Baldwin, 2016; Mayo-Wilson et al., 2014). These
findings have substantiated pharmacotherapy as an efficacious intervention for

While in some cases, pharmacological treatments
have been seen as more effective than psychological interventions (Bandelow et
al., 2015), it is important to consider the side effects, interactions, and
contraindications. Pharmacological interventions such as SSRIs and
SNRIs were associated with a short half-life and were most likely for the
greatest risk of discontinuation, on top of side-effects during treatment (e.g.,
agitation) which may be particularly daunting for those with SAD (Mayo-Wilson
et al., 2014). Furthermore, many pharmacological treatments have a lower
cost-effectiveness compared to their psychological treatment counterparts (Pilling et al., 2013).



Treatment approaches for social anxiety disorder
has made considerable progression, but there remains a need for a greater focus on the dissemination
of empirically-based treatments into conventional practice, which has been
indicated as a significant provocation within mental health care delivery
(Gillihan, Conklin, & Foa, 2014; Gunter & Whittal, 2010; McHugh &
Barlow, 2010). Our comprehension of the mechanisms of many interventions have
certainly grown, but patients do not regularly receive empirically supported
psychological treatments (Shafran et al., 2009). One unfortunate deterrent in
the dissemination of evidence-based interventions involves general beliefs
among clinicians about the limited relevance and appropriateness of findings
from RCTs in clinical practice. There is also a paucity of comprehension and
training about evidence-based treatments, and their application withi a
clinical setting (Shafran et al., 2009; Weisz, Ng,
& Bearman, 2014). Gunter & Whittal, 2010; Weisz et al., 2014). Based on previously elucidated studies, and under NICE
guidelines, individualised CBT was the most efficacious treatment, followed by
SSRIs. One of the more exciting areas is the implication of VR and
internet-based cognitive behavioural therapy, especially as a potential
cost-effective treatment. Though with small sample sizes, lack of breadth, lack
of comparison groups, and uniformity in the reporting of data (Maples-Keller et
al., 2016; Parsons & Rizzo, 2008), further research is needed.

According to the DSM-5, women are more likely to
have SAD, whereas men with the disorder are more likely to seek treatment
(American Psychiatric Association, 2013). Therefore, another important
consideration is to understand gender differences in SAD, which can have
implications for clinical assessment and diagnosis, as well as for treatment delivery
(Asher, Asnaani, & Aderka, 2017). For instance, information regarding
gender differences in types of feared situations can guide and inform clinical
assessment, as well as the choice of exposure exercises for men and women.

In response to the difficulties with dissemination,
the National Health Service (NHS) announced the development of the Improving
Access to Psychological Therapies (IAPT) in 2008. The purpose of IAPT was to
increase the amount of positions for psychological therapists, and to increase
the amount of evidence-based psychological treatments in stepped-care services
designed for depression and anxiety disorders (Clark, 2011). The initial outcomes
have demonstrated an elevation in patients receiving the appropriate treatments
recommended by the National Institute of Health and Care Excellence (NICE) treatment
guidelines, increased recovery rates at 40.3%, and improvement rates at 63.7%
(Gyani, Shafran, Layard, & Clark, 2013). The challenge now lies in optimum
integration and dissemination of these treatments, and learning how to help the
30–40% of patients for whom treatment does not work.