The short answer
- NICE (England and Wales, 2013): individual CBT built for social anxiety first. Medication (an SSRI) only if the person declines CBT or does not fully respond. Not group CBT in preference to individual. No benzodiazepines, anticonvulsants or mindfulness routinely.
- Canada (2014): CBT is the “gold-standard” non-drug treatment, group or individual. Medication is graded in lines: SSRIs, venlafaxine and pregabalin first-line; benzodiazepines, gabapentin and phenelzine second-line. Atenolol and propranolol not recommended for SAD.
- BAP (UK psychopharmacology, 2014): therapy and medication have broadly similar efficacy at first, so let the person’s needs and preferences decide. SSRI first among drugs. Benzodiazepines only after other approaches have failed.
- WFSBP (international, 2023): SSRIs and SNRIs first-line medicines; CBT first-line psychotherapy for anxiety disorders, including social anxiety disorder.
Checked against the source
All three main guidelines were read in full text for this page on 9 November 2026: NICE on nice.org.uk (earlier researchers had been blocked; it was accessible this time), the Canadian guideline in its open-access version on Europe PMC, and the BAP guideline from the BAP website. For the WFSBP guideline only the abstract was read, so its social-anxiety-specific line assignments are not shown here.
Side by side
| Question | NICE CG159 | Canada 2014 | BAP 2014 |
|---|---|---|---|
| Scope | Adults, children and young people; psychological and drug treatment | Anxiety disorders, PTSD and OCD; medication and psychological treatment | Medication for anxiety disorders, PTSD and OCD, with notes on psychological treatment |
| First-line psychological | Individual CBT developed for SAD (Clark and Wells or Heimberg model) | CBT, the “gold-standard” non-drug treatment | CBT; cognitive therapy appears superior to exposure |
| Group CBT | Do not routinely offer it in preference to individual CBT: less clinically and cost effective | Group or individual; meta-analyses find no significant difference | Notes some evidence on cost-effectiveness of group CBT |
| Therapy or medication first? | Therapy first; medication if CBT is declined | Not ranked against each other; several studies found similar acute efficacy | Broadly similar acute efficacy; choose by features, preference and availability |
| Self-help | CBT-based supported self-help if individual CBT is declined | Internet CBT beat wait-list in RCTs; may widen access | Notes cost-effectiveness evidence for internet-delivered approaches |
| First-line medicines | SSRI: escitalopram or sertraline | Escitalopram, fluvoxamine (and CR), paroxetine (and CR), pregabalin, sertraline, venlafaxine XR | An SSRI |
| Next steps | Other SSRI (fluvoxamine, paroxetine) or venlafaxine; then an MAOI (phenelzine or moclobemide) | Second-line: alprazolam, bromazepam, citalopram, clonazepam, gabapentin, phenelzine. Third-line includes moclobemide | Raise dose, switch, or combine evidence-based treatments; consider adding buspirone after partial SSRI response |
| Benzodiazepines | Do not routinely offer | Second-line | Consider in patients who have not responded to other approaches |
| Pregabalin, gabapentin | Do not routinely offer anticonvulsants | Pregabalin first-line; gabapentin second-line | Listed among evidence-based acute options |
| Beta-blockers | Not part of the recommended pathway | Atenolol and propranolol not recommended; footnote says beta-blockers are used in practice for performance situations such as public speaking | Avoid atenolol in generalized SAD; small single-dose studies suggest benefit in performance anxiety |
| Psychodynamic therapy | Consider if both CBT and medication are declined; less effective and less cost-effective than CBT | Not stated | Not stated |
| Mindfulness, supportive therapy | Do not routinely offer | Not stated | Not stated |
| How long to continue medication | At least a further 6 months after response in the first 3 months; taper when stopping | Not stated | At least 6 months after response |
| Combining drug and therapy | Add CBT for partial SSRI response after 10 to 12 weeks; add medication for partial CBT response | Clonazepam added to paroxetine not recommended | Not routinely at the start; consider when initial treatments fail |
| Children and young people | Individual (8 to 12 × 45 min) or group (8 to 12 × 90 min) CBT; do not routinely offer medication | Not covered in the SAD section read here | Not stated |
| Things not to offer | Botulinum toxin for sweating, endoscopic thoracic sympathectomy, St John’s wort | Buspirone, imipramine, levetiracetam, quetiapine, beta-blockers | Atenolol, buspirone (generalized SAD) |
“Not stated” means the point was not found in the section of the guideline read for this page.
Where they disagree, and why
Benzodiazepines. NICE says no, routinely. Canada lists clonazepam, alprazolam and bromazepam second-line. BAP keeps them for people who have not responded. The trial base is thin: the later Cochrane review found a response risk ratio of 4.03, but from only 2 trials. Canada’s text gives lack of effect on common comorbidities as one reason for not making them first-line; dependence risk is the usual further reason for caution. Many people with social anxiety drink to cope, which adds a further reason for caution.
Pregabalin. Canada puts it first-line; NICE does not recommend anticonvulsants routinely. In a fixed-dose trial of 329 people, only 600 mg/day beat placebo. Misuse risk and the dose-dependence make the NICE position easier to defend. The Canadian ranking follows the existence of positive placebo-controlled trials.
Therapy first, or patient choice? NICE builds its pathway on its own network meta-analysis and economic model, which put individual cognitive therapy ahead on effect against placebo and on cost-effectiveness. BAP and Canada look mainly at acute efficacy, where drugs and therapy look similar. Both views are partly right. They use different outcomes (see why the rankings change).
Group CBT. NICE separates individual and group CBT because its analysis found a difference. Canada relied on older meta-analyses that did not.
Beta-blockers. All three agree they are not a treatment for generalized social anxiety disorder. For propranolol, a review found only one trial in social phobia, with 16 people; atenolol did not beat placebo in the trials Canada and BAP cite. Canada and BAP both acknowledge use for one-off performance situations.
How current are they?
- NICE CG159 was published in May 2013. NICE lists it as last reviewed on 21 May 2024. At that review NICE removed general recommendations covered by other NICE guidelines.
- The Canadian and BAP guidelines date from 2014 and predate internet cognitive therapy trials and the newer VR and digital evidence.
- Only Canada mentions VR: it notes that CBT with VR exposure beat wait-list and matched CBT with imaginal or in vivo exposure in two meta-analyses. None makes a recommendation on VR or app-based treatment. See VR in practice.
What could not be checked
- The SAD-specific recommendations and line assignments in the 2023 WFSBP guideline (full text not available to us; only the abstract was read).
- Whether any newer national guideline for social anxiety disorder exists in other countries (for example, in Germany or Australia). These were not searched for this page.
Sources
- National Institute for Health and Care Excellence (NICE) (2013). Social anxiety disorder: recognition, assessment and treatment (CG159).NICE clinical guideline.
- Katzman MA, Bleau P, Blier P, Chokka P, Kjernisted K, Van Ameringen M, et al. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders.BMC Psychiatry.
- Baldwin DS, Anderson IM, Nutt DJ, et al. (2014). Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology.Journal of Psychopharmacology.
- Bandelow B, Allgulander C, Baldwin DS, et al. (2023). World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders - Version 3. Part I: Anxiety disorders.World Journal of Biological Psychiatry 24(2):79-117.
- Mayo-Wilson E, Dias S, Mavranezouli I, Kew K, Clark DM, Ades AE, Pilling S (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis.Lancet Psychiatry.
- Mavranezouli I, Mayo-Wilson E, Dias S, Kew K, Clark DM, Ades AE, Pilling S (2015). The Cost Effectiveness of Psychological and Pharmacological Interventions for Social Anxiety Disorder: A Model-Based Economic Analysis.PLoS One.
- Williams T, Hattingh CJ, Kariuki CM, Tromp SA, van Balkom AJ, Ipser JC, Stein DJ (2017). Pharmacotherapy for social anxiety disorder (SAnD).Cochrane Database of Systematic Reviews.
- Steenen SA, van Wijk AJ, van der Heijden GJ, van Westrhenen R, de Lange J, de Jongh A (2016). Propranolol for the treatment of anxiety disorders: Systematic review and meta-analysis.Journal of Psychopharmacology.
- Feltner DE, Liu-Dumaw M, Schweizer E, Bielski R (2011). Efficacy of pregabalin in generalized social anxiety disorder: results of a double-blind, placebo-controlled, fixed-dose study.International Clinical Psychopharmacology.
- NICE CG159: Social anxiety disorder: recognition, assessment and treatment (overview, published 22 May 2013, last reviewed 21 May 2024)
- NICE CG159: full recommendations
- Canadian clinical practice guidelines (Katzman et al. 2014), open-access full text on Europe PMC
- BAP guidelines for anxiety disorders (Baldwin et al. 2014), PDF from the British Association for Psychopharmacology