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Shyness Versus Social Phobia in US Youth
WHAT’S KNOWN ON THIS SUBJECT: Psychiatry and the
pharmaceutical industry have been criticized for publicizing
social phobia to increase pharmaceutical sales, particularly
among youth. Moreover, there has been open debate regarding
whether the diagnostic entity of social phobia “medicalizes”
normal human shyness.
WHAT THIS STUDY ADDS: This is the first general population
study of youth to demonstrate that social phobia is a disabling
psychiatric disorder beyond normal human shyness. In addition,
this study provides novel information concerning the plausibility
of the medicalization hypothesis for social phobia.
abstract
OBJECTIVES: Scholars and the popular press have suggested that the
diagnostic entity of social phobia “medicalizes” normal human shy-
ness. In this study we examined the plausibility of this hypothesis by (1)
determining the frequency of shyness and its overlap with social pho-
bia in a nationally representative adolescent sample, (2) investigating
the degree to which shyness and social phobia differ with regard to
sociodemographic characteristics, functional impairment, and psychi-
atric comorbidity, and (3) examining differences in rates of prescribed
medication use among youth with shyness and/or social phobia.
METHODS: The National Comorbidity Survey-Adolescent Supplement is
a nationally representative, face-to-face survey of 10 123 adolescents,
aged 13 to 18 years, in the continental United States. Lifetime social
phobia was assessed by using a modified version of the fully structured
World Health Organization Composite International Diagnostic Inter-
view. Adolescents and parents also provided information on youth shy-
ness and prescribed medication use.
RESULTS: Only 12% of the youth who identified themselves as shy also
met the criteria for lifetime social phobia. Relative to adolescents who
were characterized as shy, adolescents affected with social phobia
displayed significantly greater role impairment and were more likely
to experience a multitude of psychiatric disorders, including disorders
of anxiety, mood, behavior, and substance use. However, those adoles-
cents were no more likely than their same-age counterparts to be
taking prescribed medications.
CONCLUSIONS: The results of this study provide evidence that social
phobia is an impairing psychiatric disorder, beyond normal human
shyness. Such findings raise questions concerning the “medicaliza-
tion” hypothesis of social phobia. Pediatrics 2011;128:917–925
AUTHORS: Marcy Burstein, PhD, Leila Ameli-Grillon, BA,
and Kathleen R. Merikangas, PhD
Genetic Epidemiology Research Branch, National Institute of
Mental Health, Bethesda, Maryland
KEY WORDS
social phobia, shyness, adolescents, epidemiology, National
Comorbidity Survey-Adolescent Supplement
ABBREVIATIONS
DSM-IV—Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition
ODD—oppositional defiant disorder
SSRI—selective serotonin-reuptake inhibitor
OR—odds ratio
CI—confidence interval
ADHD—attention-deficit/hyperactivity disorder
The views and opinions expressed in this article are those of the
authors and should not be construed as representing the views
of any of the sponsoring organizations or agencies or the US
government.
www.pediatrics.org/cgi/doi/10.1542/peds.2011-1434
doi:10.1542/peds.2011-1434
Accepted for publication Jul 25, 2011
Address correspondence to Kathleen R. Merikangas, PhD,
National Institute of Mental Health, Genetic Epidemiology
Research Branch, Building 35, Room 1A201, 35 Convent Dr, MSC
3720, Bethesda, MD 20892. E-mail: kathleen.merikangas@nih.gov
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2011 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
Funded by the National Institutes of Health (NIH).
ARTICLES
PEDIATRICS Volume 128, Number 5, November 2011 917
. . . through bashfulness, suspicion, and
timorousness, will not be seen abroad;
loves darkness as life.... He dare not
come in company for fear of being mis-
used, disgraced, overshoot himself in
gestures or speech....He thinks every
man observed him...
Hippocrates1
In the past decade, the field of psychi-
atry has received increasing criticism
for pathologizing normal variations in
human emotions and behavior.2–4 Al-
though public skepticism has been
present for a variety of psychiatric dis-
orders, this criticism has been highly
evident for the condition of social pho-
bia,5–7 particularly among children and
adolescents.4–6,8 Moreover, both schol-
ars2,5,9 and the popular press10,11 have
equated this diagnostic entity to the
benign human trait of shyness. Specif-
ically, authors have suggested that the
pharmaceutical industry and scientific
experts jointly sought to publicize social
phobia in pursuit of particular pharma-
ceutical sales.5–10,12,13 Those within the
scientific community, however, con-
tend that social phobia and shyness
are not synonymous; rather, investiga-
tors have maintained that social pho-
bia is a persistent, disabling, psychiat-
ric condition.14–26
To date, only a minority of studies have
examined the characteristics and as-
sociated impairment of social phobia
in general population samples of
youth,23–25 and none has investigated
the degree to which shyness and social
phobia differ with regard to these fea-
tures. The few studies that have inves-
tigated the relationship between shy-
ness and social phobia have relied on
clinical27 and/or college student28,29
samples and therefore might overesti-
mate or underestimate differences be-
tween these conditions. In addition, al-
though the notion of medicalization
suggests a high rate of prescribed
medication use among adolescents
with social phobia or shyness, no stud-
ies to date have investigated rates of
medication use among these youth.
Therefore, the purpose of the present
study was threefold: (1) to examine the
frequency of shyness and its overlap
with social phobia in a nationally rep-
resentative adolescent sample, (2) to
investigate potential differences be-
tween shyness and social phobia with
respect to sociodemographic corre-
lates, indices of impairment, and psy-
chiatric comorbidity, and (3) to exam-
ine rates of prescribed medication use
among adolescents with shyness
and/or social phobia.
METHODS
Sample and Procedures
The National Comorbidity Survey
Replication-Adolescent Supplement is
a nationally representative, face-to-
face survey of 10 123 adolescents, 13
to 18 years of age, in the continental
United States.30–32 Information con-
cerning the sampling strategy, partici-
pation rates, and instruments in the Na-
tional Comorbidity Survey-Adolescent
Supplement can be found in greater de-
tail elsewhere.31,33 The survey was con-
ducted with a dual-frame sample that in-
cluded a household subsample (n⫽
879) and a school subsample (n⫽
9244).33 The adolescent response rate
for the combined subsamples was
82.9%. Minor differences in sample and
population distributions of sociodemo-
graphic and school characteristics
were corrected with poststratification
weighting.33
One parent/parent surrogate of each
participating adolescent was mailed a
self-administered questionnaire to col-
lect information on adolescent mental/
physical health and other family- and
community-level factors. The full self-
administered questionnaire was com-
pleted by 6483 parents. All recruitment
and consent procedures were approved
by the human subjects committees of
Harvard Medical School and the Univer-
sity of Michigan.
Diagnostic Assessments
Adolescents were administered a
modified World Health Organization
Composite International Diagnostic In-
terview 3.0, a fully structured interview
of Diagnostic and Statistical Manual of
Mental Disorders,Fourth Edition
(DSM-IV), diagnoses.34 Lifetime disor-
ders assessed include social phobia
and other anxiety disorders (separa-
tion anxiety disorder, specific phobia,
agoraphobia, panic disorder, and gen-
eralized anxiety disorder), mood disor-
ders (major depressive disorder and
dysthymic disorder), behavior disor-
ders (oppositional defiant disorder
[ODD], conduct disorder, and attention-
deficit/hyperactivity disorder [ADHD]),
alcohol use disorders (alcohol abuse/
dependence), and drug use disorders
(drug abuse/dependence). Parents
who completed the self-administered
questionnaire provided diagnostic in-
formation about major depressive dis-
order, dysthymic disorder, separation
anxiety disorder, ADHD, ODD, and con-
duct disorder. Because previous re-
search has indicated that adolescents
may be the most accurate informants
concerning their emotional symp-
toms,35 only adolescent reports were
used to assess diagnostic criteria for
mood and anxiety disorders. However,
findings from both the parent and the
adolescent were combined and classi-
fied as positive if either informant en-
dorsed the diagnostic criteria for ODD or
conduct disorder, and only parent re-
ports were used for diagnoses of
ADHD.35,36 Definitions of all psychiatric
disorders adhered to DSM-IV criteria.
Social Phobia and Shyness
Measures
Social Phobia
Twelve social fears, representing in-
teractional, observational, and perfor-
918 BURSTEIN et al
mance situations, were assessed
among adolescents. Adolescents met
DSM-IV lifetime criteria for social pho-
bia if they endorsed all DSM-IV social
phobia criteria, including ⱖ1 social
fear.37
Shyness
Ratings of adolescent shyness were
obtained from adolescents and par-
ents. Adolescents were asked to rate
their “shyness around people [their]
own age who [they] didn’t know very
well” by using a 4-point scale (4 ⫽very,
3⫽somewhat, 2 ⫽not very, and 1 ⫽
not at all). Parents responded to a par-
allel 4-point item. For the purposes of
the present study, the highest 2 rat-
ings (3 ⫽somewhat and 4 ⫽very)
were combined and the lowest 2 rat-
ings (2 ⫽not very and 1 ⫽not at all)
were combined, to create a dichoto-
mous variable reflecting the presence
versus absence of shyness.
Clinical Features
Past-Year Impairment and Days Out
of Role
Adolescents who endorsed any social
fear in the past 12 months were asked
to rate their impairment and disability
during the worst month of the past
year, in the areas of household chores,
school/work ability, family relation-
ships, and social life (Sheehan Disabil-
ity Scale).38 The response scale ranged
from 0 to 10. An additional item re-
quired respondents to estimate the to-
tal number of days in the previous year
that they were totally unable to carry
out their normal activities because of
social fear.
Lifetime Treatment Contact for
Anxiety Disorders
For each anxiety disorder, respon-
dents were asked whether they had
ever discussed their anxiety with a
professional (eg, “Did you ever talk to a
medical doctor or other professional
about your [anxiety]?”). Types of pro-
fessionals included psychologists,
counselors, and other healing profes-
sionals. A dichotomous index of anxiety
treatment contact was generated by
positively scoring cases who endorsed
seeking treatment for any anxiety dis-
order in their lifetimes.39
Prescribed Medication Use
Adolescents were asked to identify any
prescription medication they had used
because of psychiatric symptoms in
the previous year, from a list provided.
If adolescents showed difficulty re-
sponding, then interviewers asked
them to consult medication bottles
and/or information was obtained from
parents. Medications assessed included
antipsychotic agents, antidepressants,
anxiolytic agents, stimulants, mood sta-
bilizers/anticonvulsants, and other pre-
scribed medications. Four dichotomous
variables of prescribed medication use
were created: (1) Any medication in-
cluded use of ⱖ1 medication from the
6 broad medication categories as-
sessed. (2) Any antidepressant in-
cluded use of ⱖ1 of 52 antidepres-
sants, including selective serotonin-
reuptake inhibitors (SSRIs),
monoamine oxidase inhibitors, tricy-
clic antidepressants, tetracyclic anti-
depressants, and atypical antidepres-
sants. (3) Paroxetine included use of
the SSRI medication paroxetine. (4)
Any other SSRI included use of any of 4
SSRI medications with the exception of
paroxetine (ie, citalopram, fluoxetine,
fluvoxamine, or sertraline).
Statistical Analyses
Three mutually exclusive groups were
created to allow statistical compari-
sons across levels of shyness and so-
cial phobia: (1) no shyness included
adolescents who neither endorsed
shyness nor met criteria for lifetime
social phobia; (2) shyness included ad-
olescents who endorsed shyness but
did not meet criteria for lifetime social
phobia; and (3) social phobia included
adolescents who met criteria for life-
time social phobia (with or without
shyness). Because diagnoses of social
phobia were derived solely from ado-
lescent informants, adolescent re-
ports of shyness also were used, to
maintain methodologic consistency
across the 3 comparison groups. Sta-
tistical analyses were completed with
SPSS 17.0 (SPSS Inc, Chicago, IL) and
accounted for the complex survey de-
sign. General linear models and multi-
variate logistic regression analyses
were used to examine comorbidity,
clinical impairment, and rates of med-
ication use for each group; all models
controlled for gender, age, and other
psychiatric disorders simultaneously.
Confidence intervals (CIs) and SEs of
adjusted odds ratios (ORs)/contrast
estimates were calculated on the basis
of design-adjusted variances. The
design-adjusted Wald
2
test or F test
was used to examine differences
across groups, and statistical signifi-
cance was based on 2-sided tests (P⬍
.05).
RESULTS
Frequency of Shyness and
Prevalence of Social Phobia
The lifetime frequency of shyness and
the lifetime prevalence of social pho-
bia are presented overall and accord-
ing to sociodemographic characteris-
tics in Table 1. As shown, 62.4% of
parents reported that their adoles-
cents were shy, whereas a more-
moderate 46.7% of adolescents
thought that they were shy. In contrast,
only 8.6% of adolescents met DSM-IV
criteria for social phobia at some point
in their lifetime. The proportion of life-
time social phobia among youth with and
without shyness are presented in Fig 1.
As shown, among all youth who en-
dorsed shyness, only 12.4% met crite-
ria for lifetime social phobia. Similarly,
10.6% of adolescents who were consid-
ered shy by their parents met criteria
ARTICLES
PEDIATRICS Volume 128, Number 5, November 2011 919
for social phobia (results not shown).
Among the youth who were not consid-
ered shy by their own reports or their
parents’ reports, 5.2% and 5.5%, re-
spectively, met criteria for social pho-
bia (parent-reported shyness results
not shown).
Also as displayed, gender and age ef-
fects seemed to vary for shyness ver-
sus social phobia. According to both
parent and adolescent reports, shy-
ness was more common among fe-
male adolescents than among male
adolescents (parent report: 65.3% vs
59.7%; Wald F
1
⫽14.80; P⬍.05; ado-
lescent report: 50.1% vs 43.4%; Wald F
1
⫽24.07; P⬍.05). However, adolescent
gender had no significant effect on the
prevalence of social phobia. Similarly,
whereas shyness was more common
in the youngest age group, relative to
the oldest adolescent age group (par-
ent report: 66.2% vs 54.8%; Wald F
2
⫽
13.16; P⬍.05), or remained consistent
across age groups (adolescent re-
port), the prevalence of social phobia
increased with age (10.4% [17–18
years] and 9.6% [15–16 years] vs 6.3%
[13–14 years]; Wald F
2
⫽10.45; P⬍
.05).
Psychiatric Comorbidity According
to Adolescent Group
The weighted rates, ORs, and CIs of ad-
olescent psychiatric disorders are
presented for each of the 3 mutually
exclusive subgroups in Table 2. As
shown, adolescents with social phobia
were consistently more likely to expe-
rience a variety of psychiatric disor-
ders, relative to the other adolescent
groups. Relative to adolescents with
shyness, adolescents with social pho-
TABLE 1 Frequency of Shyness and Prevalence of Social Phobia According to Adolescent Gender and Age
Shyness/Social Phobia Rate, Estimate ⫾SE, %
Male Female 13–14 y 15–16 y 17–18 y Total
Any shyness, parent report 59.7 ⫾1.4 65.3 ⫾1.1
a
66.2 ⫾1.5
b
63.3 ⫾1.5 54.8 ⫾2.0 62.4 ⫾1.1
Any shyness, adolescent report 43.4 ⫾1.0 50.1 ⫾1.0
a
46.3 ⫾1.4 47.0 ⫾1.3 46.6 ⫾2.0 46.7 ⫾0.7
Lifetime social phobia, adolescent report 7.9 ⫾0.6 9.2 ⫾0.7 6.3 ⫾0.7 9.6 ⫾0.9
c
10.4 ⫾1.0
c
8.6 ⫾0.5
a
Significantly greater frequency than male subjects (P⬍.05).
b
Significantly greater frequency than 17- to 18-year-old subjects (P⬍.05).
c
Significantly greater prevalence than 13- to 14-year-old subjects (P⬍.05).
87.6
12.4
Any shyness
Social phobia
94.8
5.2
No shyness
Social phobia
FIGURE 1
Proportion of adolescents with lifetime social phobia among those with (n⫽4749) and without (n⫽
5374) shyness according to adolescent reports.
TABLE 2 Rates of Lifetime Psychiatric Disorders Among Adolescents According to Presence of Shyness or Social Phobia
Disorder Rate, Estimate ⫾SD, % OR (95% CI)
a
No
Shyness
Shyness Social
Phobia
Shyness vs No
Shyness
Social Phobia vs
No Shyness
Social Phobia vs
Shyness
Anxiety disorders 19.5 ⫾1.0 25.2 ⫾1.1 57.9 ⫾2.2 1.35 (1.02–1.79)* 3.77 (2.51–5.66)* 2.79 (1.94–4.00)*
Specific phobia 11.4 ⫾0.7 14.9 ⫾1.0 37.9 ⫾2.4 1.33 (0.92–1.92) 2.62 (1.97–3.47)* 1.97 (1.31–2.96)*
Agoraphobia 0.8 ⫾0.3 3.3 ⫾0.5 10.9 ⫾2.0 5.01 (2.30–10.91)* 12.92 (4.82–34.60)* 2.58 (1.38–4.83)*
Panic disorder 1.6 ⫾0.2 2.1 ⫾0.3 7.4 ⫾1.5 1.41 (0.71–5.13) 2.45 (1.17–5.13) 1.74 (0.85–3.57)
Posttraumatic stress disorder 3.6 ⫾0.5 3.0 ⫾0.5 11.4 ⫾1.4 0.60 (0.31–1.16) 1.17 (0.65–2.10) 1.96 (1.03–3.74)
Generalized anxiety disorder 2.9⫾0.5 3.0 ⫾0.5 10.3 ⫾1.5 0.65 (0.38–1.14) 1.47 (0.74–2.91) 2.24 (1.22–4.12)*
Separation anxiety disorder 4.8 ⫾0.5 6.2 ⫾0.5 21.9 ⫾2.3 1.18 (0.81–1.72) 3.32 (2.07–5.31)* 2.82 (1.78–4.47)*
Mood disorders 9.8 ⫾0.6 10.2 ⫾0.8 24.2 ⫾2.1 1.14 (0.86–1.51) 1.81 (1.18–2.79)* 1.59 (0.86–2.89)
Major depression 11.3 ⫾0.7 11.0 ⫾0.8 31.4 ⫾1.8 1.13 (0.85–1.50) 2.32 (1.44–3.75)* 2.06 (1.16–3.65)*
Dysthymia 3.5 ⫾0.4 2.1 ⫾0.3 8.7 ⫾1.0 0.55 (0.34–0.88) 0.61 (0.30–1.23) 1.12 (0.58–2.16)
Behavior disorders 21.4 ⫾1.5 16.4 ⫾1.2 35.5 ⫾4.2 0.72 (0.57–0.90)* 1.62 (1.08–2.45)* 2.26 (1.46–3.51)*
ODD 10.2 ⫾1.0 7.1 ⫾0.7 20.4 ⫾3.7 0.74 (0.54–1.01) 1.46 (0.95–2.26) 1.99 (1.23–3.22)*
Conduct disorder 11.9 ⫾1.2 8.2 ⫾0.8 21.8 ⫾4.5 0.76 (0.54–1.07) 1.35 (0.79–2.29) 1.77 (1.00–3.16)
ADHD 9.9 ⫾0.9 8.4 ⫾0.8 12.7 ⫾2.2 1.01 (0.76–1.34) 1.01 (0.54–1.89) 1.01 (0.57–1.78)
Substance use disorders 12.3 ⫾0.8 8.0 ⫾0.9 23.4 ⫾3.0 0.55 (0.41–0.74)* 1.27 (0.69–2.32) 2.30 (1.29–4.11)*
Alcohol use disorders 7.1 ⫾0.5 4.4 ⫾0.5 13.3 ⫾1.9 0.57 (0.37–0.87)* 0.71 (0.44–1.14) 1.24 (0.77–1.99)
Drug use disorders 9.3 ⫾0.8 6.0 ⫾0.7 21.0 ⫾3.1 0.53 (0.37–0.75)* 1.73 (0.86–3.47) 3.27 (1.72–6.21)*
a
Models were adjusted for adolescent gender, age, and comorbid anxiety, emotional, and behavior disorders (except the disorder of interest).
*
Statistically significant at P⬍.05.
920 BURSTEIN et al
bia were more likely to be affected by
anxiety disorders (OR: 2.79 [95% CI:
1.94 – 4.00]), major depressive disor-
der (OR: 2.06 [95% CI: 1.16 –3.65]), ODD
(OR: 1.99 [95% CI: 1.23–3.22]), and drug
use disorders (OR: 3.27 [95% CI: 1.72–
6.21]). Comparisons of adolescents
with social phobia with adolescents
with no shyness generated a similar
pattern of results.
Statistical comparisons of the social
phobia and shyness groups with the
no-shyness group generated results
that varied in direction as a function of
the disorder of interest. Similar to ad-
olescents with social phobia, adoles-
cents with shyness were more likely to
evidence agoraphobia (OR: 5.01 [95%
CI: 2.30 –10.91]), relative to adoles-
cents in the no-shyness group. Unlike
adolescents with social phobia, how-
ever, who showed positive associa-
tions with behavior and substance use
disorders, adolescents with shyness
were less likely to be affected with
these disorders (behavior disorders:
OR: 0.72 [95% CI: 0.57– 0.90]; substance
use disorders: OR: 0.55 [95% CI:
0.41– 0.74]).
Clinical Impairment, Professional
Treatment, and Medication Use
According to Adolescent Group
Mean ⫾SE values and weighted rates
of indicators of impairment are shown
for each adolescent group in Table 3.
As displayed, comparisons of clinical
indicators according to group showed
that adolescents with social phobia
demonstrated higher levels of impair-
ment, compared with adolescents in
both the no-shyness and shyness
groups. Relative to adolescents with
shyness, adolescents with social pho-
bia had greater impairment in the ar-
eas of school/work (mean: 4.32 ⫾0.24
vs 2.68 ⫾0.15; P⬎.05), family rela-
tionships (mean: 2.23 ⫾0.27 vs 1.22 ⫾
0.12; P⬍.05), and social life (mean:
TABLE 3 Clinical Impairment and Medication Use Among Adolescents According to Presence of Shyness or Social Phobia
Outcome Value, Mean ⫾SE
a
Days Proportion, Estimate ⫾SE, % Contrast Estimate ⫾SE OR (95% CI)
b
No Shyness Shyness Social
Phobia
No
Shyness
Shyness Social
Phobia
Shyness vs
No Shyness
Social
Phobia vs
No Shyness
Social
Phobia vs
Shyness
Shyness vs No
Shyness
Social Phobia
vs No Shyness
Social Phobia
vs Shyness
Past-year impairment
(adolescent
report)
Chores 0.88 ⫾0.12 0.98 ⫾0.12 1.45 ⫾0.25 — — — 0.10 ⫾0.18 0.57 ⫾0.26 0.47 ⫾0.27 — — —
School/work ability 2.42 ⫾0.16 2.68 ⫾0.15 4.32 ⫾0.24 — — — 0.26 ⫾0.20 1.91 ⫾0.32* 1.65 ⫾0.31* — — —
Family
relationships
1.20 ⫾0.15 1.22 ⫾0.12 2.23 ⫾0.27 — — — 0.01 ⫾0.20 1.03 ⫾0.28* 1.01 ⫾0.28* — — —
Social life 1.92 ⫾0.17 2.80 ⫾0.14 4.41 ⫾0.29 — — — 0.88 ⫾0.24* 2.48 ⫾0.36* 1.61 ⫾0.32* — — —
Days out of role 0.91 ⫾0.45 1.34 ⫾0.33 3.86 ⫾1.49 — — — 0.43 ⫾0.54 2.95 ⫾1.64 2.52 ⫾1.51 — — —
Lifetime treatment — — — — — — — — — — — —
Anxiety treatment — — — 6.6 ⫾0.6 7.2 ⫾0.8 22.7 ⫾2.4 — — — 1.70 (0.75–3.86) 2.07 (1.03–4.19) 1.22 (0.64–2.34)
Any medication — — — 6.4 ⫾0.8 6.4 ⫾0.6 12.1 ⫾1.4 — — — 1.01 (0.70–1.48) 1.14 (0.67–1.96) 1.13 (0.66–1.94)
Any antidepressant — — — 3.5 ⫾0.5 3.7 ⫾0.4 7.5 ⫾1.2 — — — 1.14 (0.73–1.79) 1.22 (0.67–2.20) 1.06 (0.58–1.95)
Paroxetine — — — 0.6 ⫾0.1 0.9 ⫾0.2 2.3 ⫾0.9 — — — 1.96(0.79–4.90) 1.42 (0.36–5.56) 0.72 (0.18–2.92)
Any other SSRI — — — 2.0 ⫾0.4 2.0 ⫾0.3 4.9 ⫾1.0 — — — 0.95 (0.54–1.68) 1.41 (0.64–3.10) 1.48 (0.70–3.12)
a
Impairment ratings were limited to adolescents who endorsed ⱖ1 fear of social situations in the past year (N⫽2487); impairment scores ranged from 0 to 10.
b
Models were adjusted for adolescent gender, age, and comorbid anxiety, emotional, and behavior disorders.
c
Statistically significant at P⬍.05.
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PEDIATRICS Volume 128, Number 5, November 2011 921
4.41 ⫾0.29 vs 2.80 ⫾0.14; P⬍.05).
Parallel results were observed when
adolescents with social phobia were
compared with adolescents with no
shyness.
Table 3 also presents estimates of
rates of professional treatment and
prescribed medication use across so-
cial phobia and shyness groups. Al-
though adolescents with social phobia
showed significantly higher levels of
impairment than did adolescents with
shyness, they were no more likely to
obtain professional treatment. Nota-
bly, nearly 80% of adolescents with so-
cial phobia failed to seek or to obtain
professional treatment for their anxi-
ety. Also as shown, rates of prescribed
medication use were systematically
low across groups; 2.3% of adoles-
cents with social phobia and 0.9% of
adolescents with shyness used parox-
etine. Statistical comparisons also in-
dicated that adolescents with social
phobia were no more likely to be using
any prescribed medication, any antide-
pressant, paroxetine, or any other
SSRI, relative to both other adolescent
groups. In the same manner, adoles-
cents with shyness were no more likely
to be using prescribed medications,
compared with adolescents with no
shyness.
DISCUSSION
On the basis of both descriptive and
analytic examination, the results of the
present study provide convergent evi-
dence that social phobia is not simply
shyness. In contrast to the high fre-
quency of shyness observed among US
adolescents, social phobia affected a
minority of youth in this sample and
only a fraction of those who identified
themselves as shy. Perhaps most im-
portant, adolescents who met criteria
for social phobia displayed signifi-
cantly greater role impairment and
were more likely to experience a broad
array of psychiatric disorders, includ-
ing disorders of anxiety, mood, behav-
ior, and substance use, relative to ad-
olescents who were characterized as
shy. However, these adolescents were
no more likely than their same-age
counterparts to be taking prescribed
medications.
Our results show that nearly one-half
(ie, 46.7%– 62.4%) of adolescents in
the US population may be considered
shy, according to their own reports or
their caregivers’ reports. Consistent
with these findings, other investiga-
tors have found that ⬎40% of high
school–aged and/or college-aged stu-
dents rate themselves as shy.29,31–42 In
contrast, and in accord with previous
work,26,32,37 rates of social phobia were
considerably lower; the condition af-
fected 8.6% of youth in their lifetime.
Moreover, only 10% to 12% of shy ado-
lescents also fulfilled diagnostic crite-
ria for social phobia. Such findings
strongly replicate previous investiga-
tions involving college students, which
found fairly low rates of social phobia
among individuals who are shy.28,29 In
addition, a nontrivial proportion of
youth who met the criteria for social
phobia were not considered shy by ei-
ther informant. Such results contest a
direct linear relationship between shy-
ness and social phobia and suggest
that, for some adolescents, the pres-
ence of social phobia might be inde-
pendent of shyness.
Observed differences in functional
impairment and rates of psychiatric
disorders among adolescent groups
provide further support for conceptu-
alizing shyness and social phobia as
distinct constructs. Relative to adoles-
cents with either shyness alone or no
shyness, adolescents with social pho-
bia displayed significantly higher lev-
els of impairment in multiple domains,
including school/work ability, social
life, and family relationships. In con-
trast, adolescents with shyness alone
were no more likely than youth who
were not shy to exhibit impairment in
the majority of these domains. Simi-
larly, consistent with previous studies
involving college students and/or clin-
ically referred young adults,27,28,43 ado-
lescents with social phobia were sig-
nificantly more likely to experience a
multitude of psychiatric disorders, rel-
ative to each of the other adolescent
groups. Further highlighting their dif-
ferences, comparisons with adoles-
cents in the no-shyness group yielded
some results that varied in direction
for the shyness and social phobia
groups. For instance, relative to ado-
lescents who failed to endorse shy-
ness, adolescents with social phobia
were more frequently affected by be-
havior and substance use disorders,
whereas adolescents with shyness
were less likely to present with these
disorders. In agreement with these re-
sults, a number of studies have re-
vealed strong associations between
social phobia and behavior and/or
substance use disorders,44–48 whereas
shyness in early childhood has been
found to reduce the risk of subsequent
behavior and substance use
problems.49–53
Shyness and social phobia also
showed unique sociodemographic pat-
terns, which supports the value of dis-
criminating between these phenom-
ena. In line with some previous studies
of youth,54,55 more female adolescents
than male adolescents displayed shy-
ness across informant reports. In con-
trast, no gender effects were observed
for social phobia, which was equally
distributed across male and female
youth. Although our failure to detect
gender differences in the prevalence
of social phobia counters some previ-
ous studies of youth,23,25 other investi-
gations have suggested that the fe-
male preponderance of social phobia
may be evident only for more pervasive
forms of the disorder.37,45,56 Similarly,
whereas shyness was most common
922 BURSTEIN et al
among adolescents in the youngest
age group (by parent reports) or
showed no variations with age (by ad-
olescent reports), social phobia was
significantly more prevalent among
older adolescents. The lack of nation-
ally representative studies examining
shyness and social phobia in this age
cohort makes comparisons with previ-
ous research difficult; however, a
study involving college student and
clinically referred participants also
observed varying sociodemographic
characteristics for individuals with
shyness versus social phobia.27
In addition, the estimates of pre-
scribed medication use in this study
counter ideas concerning the medical-
ization of shyness that have been pro-
posed.5–10,12 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.
Only 2.3% of youth with social phobia
and 0.9% of youth with shyness re-
ported using any paroxetine, rates that
are no different from the rate ob-
served among adolescents without
these characterizations. It also is im-
portant to note that the results of
this study represent prescription
medication use patterns before Food
and Drug Administration directives
that might have reduced SSRI pre-
scriptions for youth.57 Therefore, the
suggested efforts of pharmaceutical
companies (and the medical profes-
sion) to enhance prescription sales
among youth with shyness or social
phobia5–10,12 appear to have had a neg-
ligible effect.
Several study limitations are notable.
First, it was necessary to use a number
of abbreviated measures in the Na-
tional Comorbidity Survey-Adolescent
Supplement, to reduce assessment
burden and to ensure that costs were
not prohibitive. For example, the mea-
sure of shyness used in the present
study was limited to an index of the
presence versus absence (rather than
the severity) of shyness. Consequently,
because no continuous measure of
shyness severity was available, it was
not possible to examine the degree to
which social phobia approximates a
form of extreme shyness. Despite this
limitation, the rates of shyness re-
vealed among adolescents were fairly
consistent across multiple informants
and were strikingly similar to the rates
observed in other studies,29,40–42,58
which provides support for the reli-
ability of this index. Furthermore, the
magnitude and direction of relation-
ships between shyness and other key
constructs were comparable to the re-
sults of several previous stud-
ies,49,50,53–55 indicating robust nomo-
logic validity. Second, data on several
indices of impairment used in the
present study were available only for
youth who reported social fears in the
past year, and findings might not re-
flect impairment among youth who
failed to report recent social fears. Ad-
ditional research involving more-
comprehensive instruments and as-
sessment periods should provide
further support for the current
results.
CONCLUSIONS
Importantly, this study is the first to
examine the rate of shyness and its
overlap with social phobia in a nation-
ally representative sample of US ado-
lescents. In addition, it is the first to
investigate the degree to which fea-
tures of these constructs differ in a
general population sample of youth.
Taken together, the results of the pres-
ent study emphasize social phobia as
an impairing psychiatric disorder, be-
yond normal human shyness. Such
findings raise critical questions con-
cerning the plausibility of the medical-
ization hypothesis. Although many
adolescents with social phobia demon-
strate marked impairment, results
suggest that few ever seek or obtain
professional help. Persistent claims
that dispute the severity of this condi-
tion among youth likely will do little to
alter their course.
ACKNOWLEDGMENTS
This work was supported by the Intra-
mural Research Program of the Na-
tional Institute of Mental Health (grant
Z01 MH002808-08). The National Co-
morbidity Survey-Adolescent Supple-
ment and the larger program of re-
lated National Comorbidity Surveys
are supported by the National Institute
of Mental Health (grant U01-MH60220).
We gratefully acknowledge the assis-
tance of Brandon Nichter in acquiring
the references for this article.
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GETTING TO AUSTRALIA: One of the enduring mysteries of our species is how
and when we populated the continents. The traditional model is that ancestors
of modern humans migrated out of Africa in a single wave. Once in Arabia, one
group headed north toward Europe to become the ancestors of all Europeans. A
separate group headed east to become the ancestors of East Asians. The an-
cestors of the Australian aborigines split off from this group and settled in
Australia. However, as reported in The Wall Street Journal (World: September
23, 2011), recent genetic evidence suggests otherwise. Researchers compared
the genomes of two West Africans, three Han Chinese, and two Europeans with
the genes found in a 100 year old lock of hair from an Aborigine man who had
lived in a remote part of Australia and therefore unlikely to have any European
genes. Their surprising find suggests that Aborigine ancestors were part of an
early modern human exodus from Africa but split off from this group approxi-
mately 70,000 years ago. The ancestors of modern Europeans and Asians split
from each other approximately 30,000 years ago. Once the Aborigine ancestors
settled in Australia around 50,000 years ago, no other populations arrived. If
this is correct, Aborigines would represent one of the oldest continuous popu-
lations outside Africa. Another conclusion is that the Aborigine ancestors were
remarkably resourceful. To reach Australia, not only would they have had to
make use of boats but would have had to use the boats without being able to see
their destination. Water levels were lower then. Explorers would not have been
able to see the Australian landmass before embarking on their journey. While
provocative, this study is unlikely to be the final answer to how and when
modern humans left Africa. As gene-sequencing technology continues to prog-
ress, more studies such as this will help us learn more about who we are and
where we came from.
Noted by WVR, MD
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PEDIATRICS Volume 128, Number 5, November 2011 925
