When Does Shyness Become a Disorder?

Over 2,000 years ago, Hippocrates described a patient with social phobia, which is also known as social anxiety disorder (SAD): "He dare not come in company for fear he should be misused, disgraced, overshoot himself in gesture or speech or be sick; he thinks every man observes him."

The lifetime and 12-month prevalences of SAD are 13.3% and 7.9%, respectively, making SAD the third most common psychiatric disorder following major depression and alcohol(Drug information on alcohol) dependence/abuse (Kessler et al., 1994). Despite this high prevalence rate, SAD remains woefully underdiagnosed.

There are two subtypes of SAD. Non-generalized SAD is the less severe subtype and includes those individuals who experience anxiety in only one or two types of social situations (primarily public speaking and/or performance anxiety experienced by entertainers). Individuals with non-generalized SAD usually have adequate social skills and function normally outside these specific performance situations.

The majority (about 75%) of those who suffer from the generalized subtype of SAD experience distress in nearly all interpersonal situations. Generalized SAD affects females twice as frequently as males, typically appears in the mid-teens, and rarely occurs after age 25. When fears interfere with social, occupational or family life, the affected individual is not suffering from normal shyness, but rather a treatable anxiety disorder.

Recovery from generalized SAD without treatment is rare. Generalized SAD, which often appears early in prepubertal children, can effectively cause a developmental psychosocial arrest by preventing normal peer interactions, assertiveness and optimal school performance due to extreme fear of negativity from peers or authority figures. It should be kept in mind that months, or even years, may be needed for the individual to achieve social competence even after treatment attenuates pathological social fear and avoidance to a manageable level.

Individuals with generalized SAD are more likely to have comorbid psychiatric disorders (e.g., depression, other anxiety disorders, alcohol/drug abuse) than those with the more circumscribed performance subtype (Magee et al., 1996). Generalized SAD confers functional impairment to roughly the same degree as major depression (Wittchen and Beloch, 1996). Kessler et al. (1994) suggested a model for comorbidity in which both severity of illness and risk for developing additional psychiatric disorders increase progressively. Theoretically, early detection and treatment of SAD may prevent the development of other psychiatric disorders that frequently co-occur with untreated SAD.

Even clinicians familiar with SAD find it difficult to tease it apart from other co-existing conditions. Many of the symptoms of SAD overlap with those of depression and other anxiety disorders. Individuals who present with anxiety, depression, or alcohol- or substance-related disorders should be considered at high risk for undetected SAD. Table 1 shows a differential diagnostic schema for detecting SAD, which commonly co-occurs with other anxiety disorders, depression or alcohol dependence/abuse. Social anxiety disorder is present in 30% to 50% of individuals with panic disorder (Magee et al., 1996; Montejo and Liebowitz, 1994). The fear and avoidance in SAD is invariably linked to feared social situations. Likewise, major depression frequently co-exists with SAD, presenting clinicians with the diagnostic challenge of distinguishing social withdrawal due to depression from fearful social avoidance.

Alcohol-related disorders occur twice as often in those affected by SAD than in those without (Schneier et al., 1992). Social anxiety disorder usually precedes alcohol abuse and about 20% of those treated for alcohol-related disorders have SAD (Randall et al., 2001). If undetected, the risk of rapid relapse is high, since psychosocial treatments that are often a central aspect of treating alcohol abuse may be difficult or impossible to attend. Importantly, when SAD is treated in alcohol abusers, both social anxiety and alcohol use appear to improve.

Childhood sexual and/or physical abuse histories are associated with SAD in adults (especially women) (Stein et al., 1996). Individuals surviving events perceived as life-threatening are at greater risk for developing secondary SAD than individuals who experience less severe trauma (Boudreaux et al., 1998). It is not known if secondary SAD in trauma victims is different in character or response to treatment.

Finally, certain medical conditions such as stuttering, benign essential tremor, Parkinson's disease, irritable bowel syndrome, disfiguring burn injuries and so on, can cause symptoms resembling SAD (George and Lydiard, 1994). Limited literature and clinical experience suggest that symptoms secondary to certain medical conditions may respond to treatment. Clearly, more research is needed in this area.