Almost everyone has felt some jitters before speaking in public or walking into a party. For some people, however, that everyday shyness can become so crippling that they’re unable to give a presentation at work or muster up the courage to ask someone out on a date.
Mental-health experts have a term for this extreme shyness: social phobia. According to the official manual psychiatrists use to diagnose patients, social phobia — also known as social anxiety disorder — occurs when the anxiety people feel before (or during) social situations becomes so persistent and overwhelming that it interferes with their daily lives or causes them to avoid those situations altogether.
Not everyone agrees with this definition. For years, some doctors and journalists have held up social phobia as an example of the “medicalization” of a normal personality trait. These critics say pharmaceutical companies, in order to broaden the market for their anti-anxiety drugs, have encouraged doctors and consumers to label garden-variety shyness as a mental disorder, especially in children and teens.
A team of researchers at the National Institute of Mental Health (NIMH) is now disputing the charge that social phobia is simply medicalized shyness. In a new government-funded study of teenagers, published this week in the journal Pediatrics, they conclude that social phobia is an “impairing psychiatric disorder” distinct from “normal human shyness” that increases the risk of other health problems and requires treatment.
The study included a nationally representative sample of more than 10,000 teenagers between the ages of 13 and 18, who were surveyed about shyness and a range of other psychological characteristics in face-to-face interviews (along with their parents, in some cases). Half of the girls and 43% of the boys said they were “somewhat” or “very” shy.
Of those teens, 12.4% met the criteria for social phobia outlined in the Diagnostic and Statistical Manual of Mental Disorders, which doctors and insurance companies use to classify patients. The teens with social phobia reported more difficulty in their social lives, family relationships, and performance at school or work compared to those who were merely shy, the study found.
“What you realize, when you’re on the treatment side of this and you see how much these kids are suffering, [is that] there’s just no way this is some kind of conspiracy to medicalize something,” says Kathleen R. Merikangas, the lead author of the study and a senior investigator at the NIMH.
Ronald Kessler, a professor of health care policy at Harvard Medical School, in Boston, says that although drawing a line between shyness and social phobia is tricky, it does make sense to distinguish — and treat — people who fall into the latter category. “These are people who are in pain,” he says, “and there is some evidence that psychotherapy is helpful for people and can get them a normal life again.”
At the same time, Kessler says, the attention paid to conditions such as social phobia partly reflects the influence of drug companies. “There is a whole lot more talk about things that pharmaceutical companies just happen to have a medication for,” says Kessler, who was not involved in the study. “Awareness of this stuff is a lot higher than it would be otherwise.”
In the study, however, Merikangas and her colleagues found that teens with social phobia were no more likely than their shy peers to be taking antidepressants or anti-anxiety drugs such as paroxetine (Paxil). What’s more, Merikangas says, the standard treatment for social anxiety disorder doesn’t involve drugs specifically marketed for the disorder.
“Behavioral therapy and exposure therapy really work for these kinds of fears,” she says, adding that even some non-psychiatric drugs, such as beta-blockers — a heart drug that happens to dampen the fight-or-flight stress response — can be helpful as well.
People with social phobia “respond dramatically” to treatment, Merikangas says. “You don’t have to put them on lifelong [antidepressants].”
The study does suggest that some form of treatment is necessary, since teens do not appear to grow out of social phobia. Although the rate of ordinary shyness stayed roughly the same across age groups, social phobia — which typically appears during puberty or later, Merikangas says — was more common among older teenagers: 10% of 17-to-18-year-olds met the criteria for the disorder, compared to just 6% of 13-to-14-year-olds.
Social phobia was associated with various other health problems. Anxiety, depression and drug abuse were all more common among the study participants with social phobia than among the shy ones, although there’s no way of determining from this data whether social phobia directly caused or worsened these problems, rather than vice versa.
Christopher Lane, the author of the 2007 book Shyness: How Normal Behavior Became a Sickness, says he’s unconvinced by the study findings. Lane, a research professor of literature at Northwestern University, in Evanston, Ill., stresses that the diagnostic criteria that separate social phobia from ordinary shyness are largely arbitrary and may overestimate the true rate of social phobia.
“The prevalence of social phobia depends heavily on where the diagnostic threshold is set,” he says, adding that “diagnostic overreach” among mental health professionals continues to be a worry. “There is ample grounds for concern about the expansion of these criteria and the role that the drug companies are playing in promoting them.”