Social phobia is an impairing psychiatric disorder that transcends typical human shyness, according to findings from the National Comorbidity Survey-Adolescent Supplement, which examined the rate of shyness and its overlap with social phobia in a nationally representative sample of adolescents. Yet, no significant differences were seen between adolescents characterized as shy and those who met the diagnostic criteria for social phobia in the use of prescribed medications.

Compared with adolescents with shyness, those with social phobia were more likely to be affected by anxiety disorders, major depressive disorder, oppositional defiant disorder, and drug use disorders.

The findings of the study, which involved face-to-face interviews with 10,123 adolescents aged 13-18 years, suggest there is little overlap between shyness and social phobia. The absence of differences in the use of prescribed medications between the two groups raises questions about the "medicalization hypothesis" of social phobia, which is a prevalent belief that the entity of social phobia is little more than medicalization of normal shyness, Marcy Burstein, Ph.D., and her colleagues from the National Institute of Mental Health in Bethesda, Md., argue in the November issue of Pediatrics (2011;128:917-25).

In fact, only 12.4% of 4,749 youth who described themselves as shy, and 10.6% whose parents considered them shy, also met the DSM-IV lifetime diagnostic criteria for social phobia. Furthermore, 5.2% and 5.5% of those who were not considered shy by their own or their parents’ reports, respectively, met the diagnostic criteria for social phobia, the investigators said.

Compared with adolescents with shyness, those with social phobia had significantly greater impairment in school and/or work (mean impairment score of 4.32 vs. 2.68 on a 10-point scale), family relationships (mean scores of 2.23 vs. 1.22), and social life (mean scores of 4.41 vs. 2.80). They also were more likely to be affected by anxiety disorders (odds ratio, 2.79), major depressive disorder (OR, 2.06), oppositional defiant disorder (OR, 1.99), and drug use disorders (OR, 3.27).

Despite these findings, the use of prescribed medications was low in both groups. For example, 0.9% and 2.3% of those who were shy and those with social phobia, respectively, used paroxetine, they noted.

"Statistical comparisons also indicated that adolescents with social phobia were no more likely to be using any prescribed medication, any antidepressant, paroxetine, or any other SSRI (selective serotonin reuptake inhibitor) relative to both other adolescent groups (shy and non-shy adolescents). In the same manner, adolescents with shyness were no more likely to be using prescribed medications, compared with adolescents with no shyness," Dr. Burstein and her associates said.

Differences between shyness and social phobia were seen in this study as well. For example, based on both parent and adolescent reports, shyness was significantly more common in girls than boys, occurring in 65.3% of girls and 59.7% of boys (based on parent reports), and in 50.1% of girls and 43.4% of boys (based on adolescent reports). However, no gender differences were seen for social phobia.

Also, shyness was more common in the youngest age group, compared with the oldest, occurring in 66.2% and 54.8% of the groups, respectively (based on parent reports), or consistent across age groups (based on adolescent reports), while the prevalence of social phobia increased with age, occurring in 6.3% of 13- to 14-year-olds, 9.6% of 15- to 16-year-olds, and 10.4% of 17- to 18-year-olds.

Although limited by numerous factors, such as the inability to examine the degree to which social phobia approximates a form of extreme shyness, the findings in this study were fairly consistent across multiple informants and were similar to those seen in other studies, according to the investigators.

The findings provide "convergent evidence that social phobia is not simply shyness," they said, noting that adolescents who met criteria for social phobia displayed "significantly greater role impairment and were more likely to experience a broad array of psychiatric disorders ... relative to adolescents who were characterized as shy."

These differences in impairment and psychiatric disorders, as well as the unique sociodemographic patterns seen in shyness vs. social phobia in this study, support the conceptualization of shyness and social phobia as distinct constructs, they said.

Furthermore, the estimates of prescribed medication use in this study counter claims that the concept of social phobia is merely the medicalization of shyness, they argued, stating that "contrary to the notion of medicalization, which would predict higher rates of prescribed medication use (in particular, paroxetine use) among adolescents with social phobia or shyness, we found no differences in the rates of prescription medication use across adolescent subgroups."

Of note, nearly 80% of adolescents with social phobia failed to seek or to obtain professional treatment for their anxiety, the investigators said.

"Persistent claims that dispute the severity of this condition among youth likely will do little to alter their course," they concluded.

This study was funded by the NIMH. The authors had no relevant financial disclosures.

Social Phobia in Youth: More Than Just Shyness