Anxiety disorders

Welcome to our Anxiety Disorders Guide. Use the headings below to reveal the sections of the Guide, or scroll down for latest ACAMH events, blogs, journal articles, videos and podcasts in anxiety disorders.

  • Anxiety disorders in children and young people are common and can have a significant impact on mental health and well-being. Anxiety disorders can affect family, school and social life, leisure activities and educational achievement and they often occur alongside other mental health problems. They are particularly prevalent in children with autism spectrum disorder and ADHD.
  • There are seven main anxiety disorders, including phobias, panic disorder, separation anxiety disorder and generalised anxiety disorder.
  • Children and young people with an anxiety disorder may be tired and irritable, have problems sleeping and find it hard to concentrate. Anxiety may also show itself as physical symptoms such as headache and muscle tension, or as dysregulated behaviour including tantrums, crying and ‘freezing’ with fear.
  • There is no single cause of anxiety disorders, but instead multifactorial risk factors, such as family history, adverse life events and parenting behaviours.
  • The main treatment for anxiety disorders is cognitive behavioural therapy (CBT), which is effective in children and young people. It can be delivered in various ways, including as parent-guided therapy, computer based programmes and face to face sessions. Medication can also be used, but is not routinely prescribed.
  • Introduction

    Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat. Obviously, these two states overlap, but they also differ, with fear more often associated with surges of autonomic arousal necessary for fight or flight, thoughts of immediate danger, and escape behaviors, and anxiety more often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviors. (APA 2013)

    Anxiety disorders in children and young people are very common, and are often associated with long-term mental health problems which persist into adulthood (Creswell et al, 2014). Anxiety is a part of life for everyone and some anxiety is essential because it helps us to act to protect ourselves and ensure our safety. However, anxiety can become overwhelming, and the symptoms that arise as a result can persist long after the anxiety provoking situation has ended. When this happens, it can cause distress and have a significant impact on the mental health of children and young people.

    Anxiety disorders are characterised by excessive fear, anxiety and worry about events or activities and this happens more often than not for a child and continues for at least six months (APA 2013). The anxiety or worry, or physical symptoms that arise as a result, can cause significant distress to a child or young person and affect their quality of life and ability to function day to day (APA 2013).

    Children and young people with a generalised anxiety disorder can feel restless and on edge much of the time. They may be tired and irritable, have problems sleeping, find it hard to concentrate and be unable to control of deal effectively with their worries (APA 2013). In young children the anxiety may be more likely to show itself as physical symptoms, such as muscle tension, headache or stomach ache (James 2015).  Angry outbursts, tantrums, crying and ‘freezing’ with fear are also common symptoms in children.

    The Diagnostic and Statistical Manual of Mental Disorders lists seven anxiety disorders (APA, 2013):

    • Separation anxiety disorder. This is an inappropriate and extreme anxiety about being separated from home or from a major attachment figure (such as a parent), which causes significant distress to a child (Evans 2012). Children can become reluctant to take part in activities that mean they must be separated from a key attachment figure and this can affect their attendance at school (Evans 2012).
    • Selective mutism. This is when a child consistently fails to speak in situations in which they are expected to speak, such as at school (APA 2013). Selective mutism isn’t a communication disorder and it’s also not the child being uncomfortable with speaking in those situations, or not knowing what to say (APA 2013).
    • Specific phobia. This is an extreme or unreasonable feeling of fear or anxiety linked to a specific animal, object, activity, or situation (Evans 2012). This fear causes extreme distress and can stop children taking part in normal day to day activities (Evans 2012).
    • Social phobia. This is a persistent fear of social or performance situations with unfamiliar people, where a child or young person feels like they are being scrutinised (APA 2013). Children can worry that they will act in a way that is embarrassing and humiliating, and this can lead to a panic attack (APA 2013). Children will either avoid the situations that cause this distress, or will take part in them but with intense anxiety and distress (APA 2013).
    • Panic disorder. This often starts in older children and young adults (Evans 2012). It’s the repeated fear of impending doom or danger which develops after unprovoked physical symptoms, such as rapid heart rate, shortness of breath, choking sensations, and sweating (Evans 2012).
    • This is fear or severe anxiety about multiple situations in which escape might be difficult or panic-like symptoms might develop (Cornacchio et al, 2015). If it’s not treated, agoraphobia can lead to more serious mental health problems such as depression, substance misuse, and lead to suicide (Cornacchio et al, 2015).
    • Generalized anxiety disorder. This is excessive anxiety and worry (apprehensive expectation) about several events or activities (such as work or school performance) (APA, 2013).

    Anxiety disorders are among the most common psychiatric conditions in children and young people. Just over two percent of five to 10 year olds have a diagnosable anxiety-related disorder, and this doubles to five percent in 11-15 year olds (Green et al, 2005).

    Anxiety disorders usually have an adverse impact on many aspects of a child’s day to day life, including family, school and social life, leisure activities and educational achievement (Creswell et al, 2014). They often occur alongside other anxiety disorders, depression, behavioural disorders and substance misuse. (APA, 2013).

    Anxiety disorders are particularly common among children with autism spectrum disorders (ASD) and attention deficit hyperactive disorder (ADHD). Around forty percent of young people with ASD have at least one other anxiety disorder, such as specific phobia and social anxiety disorder (van Steensel et al, 2011). At least one quarter of children and young people with ADHD are thought to have a co-existing anxiety disorder (Michelini et al, 2015).

  • What we know already

    Causes

    There is no single cause of anxiety disorders. Instead, a combination of factors, including biological, familial and environmental factors are thought to be the cause. The risk factors for developing an anxiety disorder include:

    • Genetics – anxiety disorders tend to run in families (Hill et al, 2016). Children of parents with an anxiety disorder are seven times more likely to have an anxiety disorder, compared to children of parents with no disorder.
    • A child’s temperament – for example, an inhibited temperament in early childhood is a risk factor for anxiety disorders in middle childhood and mid-adolescence (Hill et al, 2016). Information processing biases may also be a factor- for example if a child interprets ambiguous situations as threatening.
    • Emotional neglect in childhood, such as rejection, criticism and a negative relationship with their main attachment figure (usually a parent) (Schimmenti & Bifulco, 2015)
    • Stressful life events (Hill et al, 2016).

    There is evidence that how parents act and behave will affect a child’s risk of developing an anxiety disorder (Yap et al, 2013). These include showing less warmth towards a child, increased inter-parental conflict, over-involvement in a child’s activities and aversiveness (making a child avoid doing something by using a punishing behaviour) (Yap et al, 2013).

    The 2011 NICE guidance on generalised anxiety disorder in adults contains a useful chapter on aetiology (page 17 of this PDF), which is good background reading for those wishing to know more.

    Diagnosis

    There is no one ‘test’ to confirm anxiety disorders and it can be difficult to detect. The challenge is to distinguish between anxiety disorders and what may be ‘normal’ and age appropriate fears and worries for a child or young person (Creswell et al, 2014). Anxiety disorders are an extreme version of a normal behaviour, so a diagnosis of anxiety disorder is based on how severe and long standing the symptoms are, as well as the impact they have on a child or young person’s ability to function in day to day life (Creswell et al, 2014).

    The 2013 NICE Guidelines on society anxiety disorder contain guidance about identifying anxiety disorders in general. The guidelines state that primary care health professionals, youth and community workers and teachers have a role to play in recognising possible anxiety, particularly in children and young people who:

    • avoid school, social or group activities
    • avoid talking in social situations
    • are irritable, excessively shy or overly reliant on parents or carers.

    If there are general concerns that a child or young person may have an anxiety disorder, then an appropriate health professional should talk to both the child or young person and their parents or carers. Because of the likelihood that other conditions may exist alongside an anxiety disorder, it’s also important to check for other mental health problems, neurodevelopmental conditions, drug and alcohol misuse and speech and language problems (Creswell et al, 2014).

    There is a wide range of tools available to diagnose anxiety, as well as measuring symptoms. The NICE guidelines on society anxiety disorder recommend the use formal instruments such as the Multidimensional Anxiety Scale for Children (MASC), the Revised Child Anxiety and Depression Scale (RCADS) for children and young people, the Spence Children’s Anxiety Scale (SCAS) and the Screen for Child Anxiety Related Emotional Disorders (SCARED) for children. If anxiety may be affecting a child’s academic progress then it’s important to have cognitive ability formally measured as well.

    Treatment

    There is evidence that most young people with anxiety disorders don’t access clinical services, and therefore don’t receive treatment (Merikangas, 2011). There are several reasons why this may be the case, including long waiting lists, lack of awareness, inappropriate services and lack of trained professionals (Creswell et al, 2014).

    Cognitive behavioural therapy (CBT)

    CBT is a well-established, highly researched evidence-based treatment, that is now considered to be an effective treatment for anxiety in children and young people (James et al, 2015). However, there is no clear evidence to show which way of providing CBT is the most effective (e.g. in a group, individually, with parents). Self-help books and other active therapies may be as effective for anxiety as CBT (James et al, 2015).

    Two computerised treatment programmes for childhood anxiety disorders have been developed and evaluated: BRAVE for Children-Online and Camp-Cope-A-Lot: The Coping Cat (Creswell et al, 2014). For both programmes the child completes 10–12 computerised CBT sessions, with parents taking part in some additional sessions. BRAVE was shown to bring about small but significant improvements in anxiety (March et al, 2009) and Camp-Cope-A-Lot was as effective as face-to-face CBT (Khanna & Kendall, 2010).  Three computerised treatments designed specifically for anxious adolescents have been evaluated: BRAVE for Teenagers-Online, Cool Teens and Think, Feel Do (Creswell et al, 2014). These also show that computerised CBT is a promising treatment for young people (Creswell et al, 2014).

    There is also some evidence that low intensity CBT delivered by parents is effective at treating anxiety. Several studies have explored the use of a self-help book for parents with or without support from a therapist as a way of delivering CBT. This type of support shows some promise, particularly when parents are supported by a therapist (Brown, 2014). For example, in one UK study, half of the children no longer had anxiety immediately following the intervention and this increased to over 70% after six months (Thirlwall et al, 2013).

    Mindfulness

    There is not as much mindfulness research with children and young people as there is for adults, and some of the studies include small numbers and have other limitations, so conclusions are tentative (Weare 2012). However, mindfulness may be effective at:

    • reducing stress (Weare 2012)
    • improving sleep, self-esteem and the ability to manage behaviour and emotions (Weare 2012)
    • reducing anxiety (Crowley, 2017)

    School based intervention

    Group psychoeducational programmes for children and adolescents aimed at preventing the development of anxiety disorder have shown small, but significant effects (Teubert et al, 2011). Several studies have shown that anxiety prevention programmes, provided as universal or targeted interventions, can be effective in the short term (Stallard et al, 2013).

    Medication

    There is some evidence that medication is an effective treatment for anxiety disorders, however, routine prescription is not recommended for children and young people because of the potential harms (Creswell et al, 2014).

    Medication may help to reduce the overall severity of anxiety symptoms across all disorders (Ipser et al, 2009). Most clinical trials showing an effect have used selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine and sertraline (Ipser et al, 2009). There is no good evidence to show that benzodiazepines work in children and young people (Ipser et al, 2009).

  • Areas of uncertainty

    Cognitive Behavioural Therapy (CBT) is successfully used as a treatment in anxiety, but we don’t know whether it is any more effective than treatment with medication, or usual treatment. We also don’t know whether the improvements made in the symptoms of anxiety immediately after CBT are maintained in the long-term (James 2015).

    Most clinical trials to evaluate CBT for anxiety disorders in young people have included children over the age of seven (Creswell et al, 2014). Whether CBT works in younger children remains a subject of debate, as it’s not clear whether they have the cognitive abilities to get the most out of the treatment (Creswell et al, 2014). A small number of parent and child programmes for children from the age of four have shown promise. However, more research is needed (Creswell et al, 2014).

    Many of the research studies in children and young people have included those with a range of anxiety disorders, a kind of ‘one size fits all’ approach. We don’t know however, whether a more specific approach could be more effective, i.e. targeted treatments specifically developed for distinct disorders (Creswell et al, 2014). For example, recent research has shown that children and young people with social anxiety disorder don’t get the same benefits from generic treatment as those with other anxiety disorders (Kerns et al, 2013).

    We don’t really understand why CBT as a treatment doesn’t work for some children (Hudson et al, 2013). For example, we don’t know whether a child’s gender, ethnicity or culture, genetics or the severity of their anxiety have an impact on treatment success, though research is beginning to explore this area (Hudson et al, 2013).

    As yet, the evidence isn’t clear on what works better for children and young people; psychological therapy, medication or a combination of both (Isper et al, 2009). It’s also unclear what the best dose of medication is in different age groups and how well medication works and is tolerated in the long-term (Isper et al, 2009).

  • What's in the pipeline?

    People who are anxious pay more attention to things that are frightening or threatening; this is called an attentional bias (Bar-Haim, 2010). Attentional bias modification is a computer based programme that is designed to train attention away from images that might provoke anxiety and more towards neutral images. This way, people learn to focus their attention away from negative images.  Up until now, much of the research in attentional bias has been done in adults and, as yet, there is little high-quality evidence in children and young people. However, emerging evidence suggests that generally attentional bias modification works as a treatment for anxiety in children and young people (Lowther 2014).

    In the last few years, virtual reality been explored for use in the field of mental health; in particular as a treatment for social and specific phobias. For example, in one recent study, people with social anxiety disorder were randomly assigned to have CBT plus either Virtual Reality exposure therapy or real human exposure, or placed on a waiting list (Bouchard et al, 2016). Results reported a highly significant drop in scores on all clinical measures between the active treatments and the waiting list (Bouchard et al, 2016). As well as being effective, virtual reality was found to be more practical and less effort to deliver (Bouchard et al, 2016). As technology develops further, it’s highly likely this kind of treatment for anxiety will be rolled out to young adults and children too.

  • Useful organisations and resources

    National Institute for Health and Care Excellence (NICE)

    Social anxiety disorder: recognition, assessment and treatment. https://www.nice.org.uk/guidance/cg159/chapter/1-Recommendations#identification-and-assessment-of-children-and-young-people

    Sources

    Public Health England (PHE). (2016) The mental health of children and young people in England. London Public Health England. Available at: https://www.gov.uk/government/publications/improving-the-mental-health-of-children-and-young-people [Accessed 10 July 2017]

    Creswell C, Waite P, Cooper PJ. (2014) Assessment and management of anxiety disorders in children and adolescents Archives of Disease in Childhood; 99:674-678. Available at: http://adc.bmj.com/content/99/7/674 [Accessed 10 July 2017]

    Van Steensel, F. J. A., Bögels, S. M., & Perrin, S. (2011). Anxiety Disorders in Children and Adolescents with Autistic Spectrum Disorders: A Meta-Analysis. Clinical Child and Family Psychology Review, 14(3), 302–317. http://doi.org/10.1007/s10567-011-0097-0 Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3162631/ [Accessed 10 July 2017]

    Khan L. (2015) Missed Opportunities: A review of recent evidence into children and young people’s mental health. London. Centre for Mental Health. Available at:  http://www.centreformentalhealth.org.uk/Handlers/Download.ashx?IDMF=37cccf4c-c86b-4e64-ba8c-e7774cac66c7 [Accessed 10 July 2017]

    American Psychiatric Association (APA) (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-V). APA Press, Arlington, VA. Available at:  http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596 [accessed 8 June 2017]

    Costello EJ, Egger HL, Angold A. Developmental epidemiology of anxiety disorders. In: Ollendick TH, March JS editor(s). Phobic and Anxiety Disorders in Children and Adolescents: A Clinician’s Guide to Effective Psychosocial and Pharmacological Interventions. New York: Oxford University Press, 2004:61-91.

    James AC, James G, Cowdrey FA, Soler A, Choke A. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD004690. DOI: 10.1002/14651858.CD004690.pub4. Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004690.pub4/full [Accessed 10 July 2017]
    Mental elf link: https://www.nationalelfservice.net/mental-health/anxiety/cochrane-review-finds-solid-evidence-for-cbt-for-anxiety-in-young-people-but-lacks-evidence-for-long-term-benefits

    Evans, D.L., Foa, E.B., Gur, R.E. et al (2012) Treating and preventing adolescent mental health disorders: What We Know and What We Don’t Know. A Research Agenda for Improving the Mental Health of Our Youth. Oxford. Oxford University Press. Available at: http://oxfordmedicine.com/view/10.1093/9780195173642.001.0001/med-9780195173642-chapter-10?rskey=DRkzHY&result=1 [Accessed 14 July 2017]

    Cornacchio, D., Chou, T., Sacks, H., et al. (2015). Clinical consequences of the revised DSM-5 definition of agoraphobia in treatment-seeking anxious youth. Depression and Anxiety, 32(7), 502–508. http://doi.org/10.1002/da.22361 Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340313/ [Accessed 14 July 2017]

    Green, H., McGinnity, A.,Meltzer, H. et al. (2005) Mental health of children and young people in Great Britain, 2004. Office for National Statistics. Newport. HMSO.  Available at: http://content.digital.nhs.uk/catalogue/PUB06116/ment-heal-chil-youn-peop-gb-2004-rep2.pdf    [Accessed 14 July 2017]

    Michelini, G., Eley, T. C., Gregory, A. M. and McAdams, T. A. (2015), Aetiological overlap between anxiety and attention deficit hyperactivity symptom dimensions in adolescence. J Child Psychol Psychiatr, 56: 423–431. doi:10.1111/jcpp.12318 Available at: http://onlinelibrary.wiley.com/doi/10.1111/jcpp.12318/full [Accessed 14 July 2017]

    Yap, M.B.H., Pilkington, P.D., Ryan, S. M., & Jorm, A.F. (2013). Parental factors associated with depression and anxiety in young people: A systematic review and meta-analysis. Journal of Affective Disorders. Available at: http://reseauconceptuel.umontreal.ca/rid=1NJ3Z7NPQ-VXMFJP-179V0/GERVAIS_Alexandra_Vignette7_Article.pdf [Accessed 14 July 2017]

    Mental elf link: https://www.nationalelfservice.net/mental-health/anxiety/systematic-review-identifies-key-parenting-factors-associated-with-adolescent-depression-and-anxiety/

    National Institute for Health and Care Excellence (NICE) (2013) Social anxiety disorder: recognition, assessment and treatment. Available at: https://www.nice.org.uk/guidance/cg159/chapter/1-Recommendations#identification-and-assessment-of-children-and-young-people [Accessed 14 July 2017]

    Merikangas, K. R., He, J., Burstein, M. E., Swendsen, J. et al. (2011). Service Utilization for Lifetime Mental Disorders in U.S. Adolescents: Results of the National Comorbidity Survey Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 50(1), 32–45. http://doi.org/10.1016/j.jaac.2010.10.006 Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408275/  [Accessed 14 July 2017]

    Schimmenti, A. and Bifulco, A. (2015), Linking lack of care in childhood to anxiety disorders in emerging adulthood: the role of attachment styles. Child Adolesc Ment Health, 20: 41–48. doi:10.1111/camh.12051 Available at: http://onlinelibrary.wiley.com/doi/10.1111/camh.12051/full [Accessed 17 July 2017]

    Weare K (2012) Evidence for the Impact of Mindfulness on Children and Young People. Mindfulness in schools project. University of Exeter. https://mindfulnessinschools.org/wp-content/uploads/2013/02/MiSP-Research-Summary-2012.pdf [accessed 17 July 2017]

    Crowley, M. J., Nicholls, S. S., McCarthy, D et al. (2017), Innovations in practice: group mindfulness for adolescent anxiety – results of an open trial. Child Adolesc Ment Health. doi:10.1111/camh.12214 Available at: http://onlinelibrary.wiley.com/doi/10.1111/camh.12214/full [accessed 17 July 2017]

    Bar-Haim, Y. (2010) Research Review: attention bias modification (ABM): a novel treatment for anxiety disorders. Journal of Child Psychology and Psychiatry, 51: 859–870. doi: 10.1111/j.1469-7610.2010.02251.x Available at: http://onlinelibrary.wiley.com/wol1/doi/10.1111/j.1469-7610.2010.02251.x/full [accessed 17 July 2017]

    Lowther H, Newman E. (2014) Attention bias modification (ABM) as a treatment for child and adolescent anxiety: a systematic review. J Affect Disord. Oct;168:125-35. doi: 10.1016/j.jad.2014.06.051. Epub 2014 Jul 5. Available at: http://www.jad-journal.com/article/S0165-0327(14)00419-4/fulltext, [accessed 17 July 2017]

    March S, Spence SH, Donovan CL. (2009) The efficacy of an internet-based cognitive-behavioral therapy intervention for child anxiety disorders. J Pediatr Psychol; 34:474–87. Available at: https://academic.oup.com/jpepsy/article-pdf/34/5/474/6313867/jsn099.pdf [accessed 17 July 2017]

    Khanna M, Kendall P. (2010) Computer-assisted cognitive behavioral therapy for child anxiety: Results of a randomized clinical trial. J Consult Clin Psychol; 78:737–45. Available at: https://pdfs.semanticscholar.org/f547/b2ed93fd4962c11aa79b0ab932590ad3f772.pdf [accessed 17 July 2017]

    Stallard, P. (2013) School-based interventions for depression and anxiety in children and adolescents. Evidence-Based Mental Health, 16 (3). pp. 60-61. ISSN 1362-0347 Available at: http://opus.bath.ac.uk/35734/1/Stallard_EBMH_2013.pdf [accessed 25 June 2017]

    Teubert,D., & Pinquart,M. (2011). A meta-analytic review on the prevention of symptoms of anxiety in children and adolescents. Journal of Anxiety Disorders, 25(8), 1046-1059. Available at: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0052967/ [accessed 17 July 2017]

    Ipser JC, Stein DJ, Hawkridge S, Hoppe L. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD005170. DOI: 10.1002/14651858.CD005170.pub2. Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005170.pub2/abstract [accessed 17 July 2017]

    Kerns C.M., Read K.L., Klugman, J. et al. (2013) Cognitive behavioral therapy for youth with social anxiety: Differential short and long-term treatment outcomes. Journal of Anxiety Disorders. 27(2): 210-215. https://doi.org/10.1016/j.janxdis.2013.01.009 Available at: http://www.sciencedirect.com/science/article/pii/S0887618513000212 [accessed 17 July 2017]

    Brown A. (2014) Predictors of change in treatment outcome for parent-delivered guided CBT bibliotherapy for children with anxiety: Effects of age, severity and comorbidity at long term follow-up. Doctoral thesis, UCL (University College London). Available at:  http://discovery.ucl.ac.uk/1449265/ [accessed 5 Oct 2017]

    Thirlwall,K., Cooper, P.J., Karalus, J. et al. (2013) Treatment of child anxiety disorders via guided parent-delivered cognitive-behavioural therapy: randomised controlled trial. The British Journal of Psychiatry 203 (6) 436-444; DOI: 10.1192/bjp.bp.113.126698 Available at: http://bjp.rcpsych.org/content/203/6/436?ijkey=0e8813e2cce88e26dbad57e40934091ed5f5d868&keytype2=tf_ipsecsha [accessed 17 July 2017]

    Hudson, J. L., Lester, K. J., Lewis, C. M., et al. (2013), Predicting outcomes following cognitive behaviour therapy in child anxiety disorders: the influence of genetic, demographic and clinical information. J Child Psychol Psychiatr, 54: 1086–1094. doi:10.1111/jcpp.12092 Available at: http://onlinelibrary.wiley.com/doi/10.1111/jcpp.12092/full  [accessed 17 July 2017]

    Bouchard S, Dumoulin S, Robillard G, et al. (2016) Virtual reality compared with in vivo exposure in the treatment of social anxiety disorder: a three-arm randomised controlled trial. The British Journal of Psychiatry, bjp.bp.116.184234; DOI: 10.1192/bjp.bp.116.184234 Available at: http://bjp.rcpsych.org/content/early/2016/12/01/bjp.bp.116.184234 [accessed 17 July 2017]
    Mental elf link: https://www.nationalelfservice.net/mental-health/anxiety/virtual-reality-for-social-anxiety-disorder/

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