research paper about social phobia

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The etiology of social anxiety disorder: An evidence-based model

Affiliations.

• 1 School of Applied Psychology and Australian Institute for Suicide Prevention and Research, Griffith University, Brisbane, QLD 4121, Australia. Electronic address: [email protected].
• 2 Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW 2109, Australia.
• PMID: 27406470
• DOI: 10.1016/j.brat.2016.06.007

The current paper presents an update to the model of social anxiety disorder (social phobia) published by Rapee and Spence (2004). It evaluates the research over the intervening 11 years and advances the original model in response to the empirical evidence. We review the recent literature regarding the impact of genetic and biological influences, temperament, cognitive factors, peer relationships, parenting, adverse life events and cultural variables upon the development of SAD. The paper draws together recent literature demonstrating the complex interplay between these variables, and highlights the many etiological pathways. While acknowledging the considerable progress in the empirical literature, the significant gaps in knowledge are noted, particularly the need for further longitudinal research to clarify causal pathways, and moderating and mediating effects. The resulting model will be valuable in informing the design of more effective treatment and preventive interventions for SAD and will provide a useful platform to guide future research directions.

Copyright © 2016 Elsevier Ltd. All rights reserved.

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Social context and the real-world consequences of social anxiety

1 Department of Psychology, University of Maryland, College Park, MD 20742 USA

Kathryn A. DeYoung

2 Department of Family Science, University of Maryland, College Park, MD 20742 USA

4 Department of Center for Healthy Families, University of Maryland, College Park, MD 20742 USA

Samiha Islam

Allegra s. anderson.

7 Department of Psychological Sciences, Vanderbilt University, Nashville, TN 37240 USA

Matthew G. Barstead

3 Department of Human Development and Quantitative Methodology, University of Maryland, College Park, MD 20742 USA

Alexander J. Shackman

5 Department of Neuroscience and Cognitive Science Program, University of Maryland, College Park, MD 20742 USA

6 Department of Maryland Neuroimaging Center, University of Maryland, College Park, MD 20742 USA

AUTHOR CONTRIBUTIONS

Associated Data

Social anxiety lies on a continuum, and young adults with elevated symptoms are at risk for developing a range of debilitating psychiatric disorders. Yet, relatively little is known about the factors that govern the hour-by-hour experience and expression of social anxiety in daily life.

Here, we used smartphone-based ecological momentary assessment (EMA) to intensively sample emotional experience across different social contexts in the daily lives of 228 young adults selectively recruited to represent a broad spectrum of social anxiety symptoms.

Leveraging data from over 11,000 real-world assessments, results highlight the central role of close friends, family members, and romantic partners. The presence of close companions is associated with enhanced mood, yet socially anxious individuals have smaller confidant networks and spend less time with their close companions. Although higher levels of social anxiety are associated with a general worsening of mood, socially anxious individuals appear to derive larger benefits—lower levels of negative affect, anxiety, and depression—from the presence of their closest companions. In contrast, variation in social anxiety was unrelated to the amount of time spent with strangers, co-workers, and acquaintances; and we uncovered no evidence of emotional hypersensitivity to less-familiar individuals.

Conclusions

Collectively, these findings provide a framework for understanding the deleterious consequences of social anxiety in emerging adulthood and set the stage for developing improved intervention strategies.

INTRODUCTION

Socially anxious individuals are prone to heightened fear, anxiety, and avoidance of social interactions and situations associated with potential social scrutiny ( Alden and Taylor 2004 , Heimberg et al. 2014 ). In addition to heightened negative affect (NA), socially anxious individuals tend to report lower levels of positive affect (PA) ( Kashdan and Collins 2010 , Anderson and Hope 2008 , Kashdan et al. 2011 , Geyer et al. 2018 ). Social anxiety symptoms lie on a continuum and, when extreme, can become debilitating ( Rapee and Spence 2004 , Craske et al. 2017 , Kessler 2003 , Lipsitz and Schneier 2000 , Katzelnick et al. 2001 , Stein et al. 2017 , Conway et al. 2019 , Krueger et al. 2018 , Ruscio 2019 ). Social anxiety disorder is among the most prevalent mental illnesses; contributes to the development of other psychiatric disorders, such as depression; and is challenging to treat ( Mathew et al. 2011 , Schneier et al. 1992 , Stein et al. 2017 , Craske et al. 2017 , Acarturk et al. 2009 , Rodebaugh et al. 2004 , Neubauer et al. 2013 ). Relapse and recurrence are common, and pharmaceutical treatments are associated with significant adverse effects ( Gordon and Redish 2016 , Batelaan et al. 2017 , Spinhoven et al. 2016 , Scholten et al. 2013 , Scholten et al. 2016 , Bruce et al. 2005 , Rhebergen et al. 2011 ). Yet the situational factors that govern the momentary experience and expression of social anxiety in the real world remain incompletely understood. To date, most of what it known is based on either retrospective report or acute laboratory challenges ( Afram and Kashdan 2015 , Alden and Wallace 1995 , Beck et al. 2006 , Buote et al. 2007 , Crişan et al. 2016 ).

As part of an on-going prospective-longitudinal study focused on individuals at risk for the development of mood and anxiety disorders, we used smartphone-based ecological momentary assessment (EMA) to intensively sample momentary levels of negative and positive affect in the daily lives of 228 young adults. Subjects were selectively recruited from a pool of 6,594 individuals screened for individual differences in dispositional negativity (i.e., negative emotionality), the tendency to experience more intense, frequent, or persistent levels of depression, worry, fear and anxiety—including social anxiety ( Shackman et al. 2016 , Hur et al. in press ). This ‘enrichment’ strategy enabled us to examine a broader spectrum of social anxiety symptoms than alternate approaches, such as convenience sampling. Because EMA data are captured in real time (e.g., Who are you with? ), they circumvent the biases that can distort retrospective reports, providing insights into how emotional experience dynamically responds to moment-by-moment changes in social context ( Lay et al. 2017 , Barrett 1997 , Csikszentmihalyi et al. 2013 , Shiffman et al. 2008 ). We focused on young adulthood because it is a time of profound, often stressful developmental transitions (e.g., moving away from home, forging new social relationships; Hays and Oxley 1986 , Alloy and Abramson 1999 , Arnett 2000 , Pancer et al. 2000 ). In fact, more than half of undergraduate students report overwhelming anxiety, with many experiencing the first onset or a recurrence of anxiety and mood disorders during this period ( Stein et al. 2017 , Global Burden of Disease Collaborators 2016 , Auerbach et al. 2016 , Auerbach et al. in press, Lipson et al. in press, American College Health Association 2016 ). In particular, those with elevated levels of social anxiety tend to experience substantial distress and impairment and are more likely to develop psychopathology ( Merikangas et al. 2002 ).

We were particularly interested in understanding how the momentary emotional experience of socially anxious individuals varies as a function of social context. Emotion is often profoundly social ( Fox and Shackman 2018 ). For instance, emotional experiences are routinely shared and dissected with friends, family, and romantic partners ( Rime 2009 ). Humans and other primates routinely seek the company of close companions in response to stressors, and increased social engagement promotes positive affect ( Shackman et al. 2018 , Cottrell and Epley 1977 ). Indeed, there is abundant evidence that close companions play a critical role in coping with stress and regulating negative affect ( Bolger and Eckenrode 1991 , Buote et al. 2007 , Coan and Sbarra 2015 , Marroquin 2011 , Myers 1999 , Zaki and Williams 2013 , Wade and Kendler 2000 , Kendler and Gardner 2014 , Ramsey and Gentzler 2015 , Reeck et al. 2016 ). Yet, many of these beneficial effects appear to be disrupted in socially anxious individuals ( Alden and Taylor 2004 ).

We began by testing whether social anxiety is associated with the amount of time allocated to different social contexts (e.g., with close companions) and whether this reflects the number of self-reported confidants. Social avoidance is diagnostic of social anxiety disorder, is a key component of dimensional measures of social anxiety, and contributes to functional impairment and reduced quality of life ( Liebowitz 1987 , APA 2013 , Beidel et al. 1999 , Strahan and Conger 1999 , Turner et al. 1986 ). Among community samples, adults with elevated levels of social anxiety are less likely to have a close friend and more likely to be unmarried by mid-life ( Davidson et al. 1994 ). They are also more likely to be lonely ( Lim et al. 2016 ). Recent work using unobtrusive, smartphone-based global positioning system (GPS) data provides additional evidence suggestive of social inhibition and avoidance ( Boukhechba et al. 2018 ), demonstrating that socially anxious university students spend significantly less time at ‘leisure’ (e.g., gymnasiums, pubs, cinemas, and coffee shops) and ‘food’ (e.g., restaurants, food courts, and dining halls) locations during peak hours in the evening. Socially anxious students also spent more time at home or off-campus (e.g., parents’ home), particularly on weekends, and visited fewer locations overall, suggesting a more restricted range of activities (see also Chow et al. 2017 ). Whether this pattern reflects generalized avoidance, specific avoidance of socially ‘distant’ individuals (e.g., strangers, acquaintances), or a lack of confidants remains unknown.

Next, we used a series of multilevel models (MLMs) to understand the interactive effects of social anxiety and the social environment on momentary affect. This enabled us to test whether socially anxious individuals experience heightened NA and attenuated PA in the presence of distant others, as one would expect based on laboratory studies of semi-structured and unstructured interactions with unfamiliar peers and researchers ( Kashdan et al. 2013b , Kashdan and Roberts 2004 , Kashdan and Roberts 2006 , Kashdan and Roberts 2007 , Heerey and Kring 2007 , Crişan et al. 2016 , Coles et al. 2002 , Creed and Funder 1998 , Meleshko and Alden 1993 ). Likewise, EMA research indicates that children with social anxiety disorder experience diminished PA in the presence of distant others ( Morgan et al. 2017 ). Whether this pattern is evident in adults is, as yet, unknown.

Using a MLM approach, we also tested two competing predictions about the consequences of close companions. One possibility is that socially anxious individuals derive increased emotional benefits (e.g., lower levels of NA) from close companions. Consistent with this view, the presence of a friend has been shown to normalize behavioral signs of anxiety and reduce negative self-thoughts in socially anxious adults exposed to an experimental speech challenge ( Pontari 2009 ). Likewise, diary studies suggest that spousal support plays a key role in dampening negative affect among patients with social anxiety disorder ( Zaider et al. 2010 ) and EMA studies suggests that the presence of close companions is associated with disproportionately enhanced PA in children with social anxiety disorder ( Morgan et al. 2017 ) and adults with elevated levels of dispositional negativity ( Shackman et al. 2018 ). More broadly, a variety of work suggests that individuals with low levels of psychological well-being and patients with depression reap larger emotional benefits from positive daily events ( Rottenberg 2017 , Lamers et al. 2018 , Grosse Rueschkamp et al. in press ). Although socially anxious adults often show symptoms of depression and anhedonia, it is unclear whether similar benefits extend to this population.

A competing possibility is that socially anxious individuals fail to capitalize on available socio-emotional support. Indeed, socially anxious individuals tend to be less emotionally expressive, disclosing, and intimate with companions ( Cuming and Rapee 2010 , Meleshko and Alden 1993 , Sparrevohn and Rapee 2009 , Vernberg et al. 1992 , Williams et al. 2018 ). They perceive themselves as receiving less social support ( Torgrud et al. 2004 , Cuming and Rapee 2010 , La Greca and Lopez 1998 ); perceive their friendships to be of a lower quality ( Rodebaugh 2009 , Rodebaugh et al. 2015 ); are less satisfied with friends, family, and romantic partners ( Stein and Kean 2000 , Wong et al. 2012 , Starr and Davila 2008 ); and are prone to emotional neediness and overreliance ( Davila and Beck 2002 , Darcy et al. 2005 ). Perhaps as a consequence, socially anxious individuals report elevated levels of interpersonal conflict ( Cuming and Rapee 2010 ) and, among patients, marked impairment of interpersonal relationships ( Wittchen et al. 2000 , Rapaport et al. 2005 , Olatunji et al. 2007 , Stein et al. 2017 ). Collectively, these observations motivate the prediction that socially anxious individuals derive smaller emotional benefits or even costs (e.g., higher levels of NA) from close companions.

Discovering the situational factors associated with the real-world experience of social anxiety is important. The identification of potentially modifiable targets, such as social context, has the potential to guide the development of improved intervention strategies.

As part of an on-going prospective-longitudinal study focused on individuals at risk for the development of internalizing disorders, we used well-established measures of dispositional negativity (often termed neuroticism or negative emotionality; Shackman et al. 2016 , Shackman et al. 2018 ) to screen 6,594 young adults (57.1% female; 59.0% White, 19.0% Asian, 9.9% African American, 6.3% Hispanic, 5.8% Multiracial/Other; M = 19.2 years, SD = 1.1 years). Screening data were stratified into quartiles (top quartile, middle quartiles, bottom quartile) separately for males and females. Individuals who met preliminary inclusion criteria were independently recruited from each of the resulting six strata. Approximately half the subjects were recruited from the top quartile, with the remainder split between the middle and bottom quartiles (i.e., 50% high, 25% medium, and 25% low). Given the typically robust relations between measures of dispositional negativity and social anxiety— R 2 = .25 in the present sample—this ‘enrichment’ strategy allowed us to examine a relatively wide range of social anxiety symptoms without gaps or discontinuities. All subjects were first-year university students in good physical health and access to a smartphone. All reported the absence of a lifetime psychotic, bipolar, neurological, or developmental disorder. Given the focus of the larger prospective-longitudinal study on risk for the development of mental illness, all subjects reported the absence of current alcohol/substance abuse, suicidal ideation, internalizing disorder (past 2 months), and psychiatric treatment. To maximize the range of psychiatric risk, subjects with a lifetime history of anxiety and mood disorders were not excluded, consistent with prior work (Alloy, Abramson et al. 2000). At the baseline laboratory session, subjects provided informed written consent, were familiarized with the EMA protocol (see below), and completed the social anxiety and social network assessments. Beginning the next day, subjects completed up to 8 EMA surveys/day for 7 days. All procedures were approved by the University of Maryland Institutional Review Board and the sample does not overlap with that detailed in prior work by our group ( Shackman et al. 2018 ).

Two-hundred and forty-two subjects completed the baseline assessment and EMA protocol. Fourteen subjects were excluded from analyses: 2 withdrew and 12 (~5%) failed to complete >39 survey prompts (70% compliance). The final sample included 228 subjects (51.3% female; 62.7% White, 17.5% Asian, 8.3% African American, 4.9% Hispanic, 6.6% Multiracial/Other; M = 18.76 years, SD = 0.35 years).

Power Analysis

Sample size was determined a priori as part of the application for the award that supported this research (R01-MH107444). The target sample size ( N ≈ 240) was chosen to afford acceptable power and precision given available resources (Schönbrodt & Perugini, 2013). At the time of study design, G-power 3.1.9.2 ( http://www.gpower.hhu.de ) indicated >99% power to detect a benchmark medium-sized effect ( r = .30) with up to 20% planned attrition ( N = 192 usable datasets) using α = .05 (two-tailed).

Social Anxiety

At baseline, the self-report version of the Liebowitz Social Anxiety Scale (LSAS) was used to quantify social anxiety ( Liebowitz 1987 ). Subjects used a 0 ( none ) to 3 ( severe ) scale to rate the amount of fear and anxiety they typically experience in response to 24 everyday situations (e.g., going to a party , meeting strangers , returning goods to a store , speaking up at meeting ). They used a 0 ( never ) to 3 ( usually ) rating scale to rate frequency of avoiding the 24 situations. Social anxiety was quantified by summing the 48 responses. As shown in Figure 1 , LSAS scores were approximately normally distributed ( M = 41.7, SD = 22.0, Range = 1–121, α = .95) and somewhat higher than that previously reported in large university convenience samples (N = 856, M = 34.7, SD = 20.4; Russell and Shaw 2009 ) 1 , 2 .

Social anxiety was assessed at baseline using the self-report version of the Liebowitz Social Anxiety Scale (LSAS). The two highest cases were not excluded because they are sensible—given the nature of the scale and the sample—and because they did not exert undue statistical leverage ( Hoaglin and Iglewicz, 1987 , Hoaglin et al., 1986 ). Exploratory analyses indicated that the exclusion of these cases did not meaningfully alter the results (not reported).

Social Network Size

At baseline, the number of close companions was measured using an item ( How many people do you know where you have a close, confiding relationship and can share your most private feelings? ) from the modified Kendler Social Support Inventory (MKSSI; Spoozak et al. 2009 ). Single-item measures of social network size are routinely used in epidemiology research (e.g., Kendler et al. 2005 , Kocalevent et al. 2018 , Van Lente et al. 2012 ). The resulting descriptive statistics ( M = 5.6, SD = 4.1, Range = 0 – 30) are broadly consistent with the results of past work focused on confidant networks in university students ( Sarason et al. 1983 , Freberg et al. 2010 ) and friendship networks in community-dwelling adults ( Wang and Wellman 2010 ).

EMA Procedures

SurveySignal ( Hofmann and Patel 2015 ) was used to automatically deliver 8 text messages/day to each subject’s smartphone. On weekdays, messages were delivered every 1.5 to 3 hours ( M = 115 minutes, SD = 25) between 8:30 AM and 10:30 PM. As in prior work by our group ( Shackman et al. 2018 ), weekday messages were delivered during the ‘passing periods’ between regularly scheduled university courses to maximize compliance. On weekends, messages were delivered every 1.5 to 2.5 hours ( M = 99 minutes, SD = 17) between 11:00 AM and 11:00 PM. Messages were delivered according to a fixed schedule that varied across days (e.g., the third message was delivered at 12:52 PM on Mondays and 12:16 PM on Tuesdays). Messages contained a link to a secure on-line survey. Subjects were instructed to respond within 30 minutes (Latency: Median = 2 min, SD = 7 min, Interquartile Range = 9 min) and to refrain from responding at unsafe or inconvenient moments (e.g., while driving). A reminder was sent when subjects failed to respond within 15 minutes. During the baseline laboratory session, several well-established procedures were used to maximize compliance ( Palmier‐Claus et al. 2011 ), including: (1) delivering a test message in the laboratory and confirming that the subject was able to successfully complete the on-line EMA survey, (2) 24/7 technical support, and (3) monetary bonuses. Base compensation was $10, with $20 bonuses for ≥70% and ≥80% compliance, respectively ( Total = $10-$50). In the final sample, EMA compliance was acceptable ( M = 87.9%, SD = 6.2%, Minimum = 71.4%, Total = 11,224) and unrelated to social anxiety, p = .77.

Current NA ( afraid, nervous, worried, hopeless, sad ) and PA ( calm, cheerful, content, enthusiastic, joy, relaxed ) at the time of the survey prompt was rated using a 0 ( not at all ) to 4 ( extremely ) scale. Subjects also indicated their current social context ( “At the time of ping, who was around?” ): alone, close friend(s), family, friend(s), romantic partner, acquaintance(s), co-worker(s), and/or stranger(s). Composite measures of NA and PA were computed by averaging the relevant items ( α s > .92). To enable follow-up assessments of generality, composite anxiety ( afraid, nervous, worried ) and depression ( hopeless, sad ) facet scales were computed ( α s > .88). Building on prior work by our group and others ( Shackman et al. 2018 , Diener and Seligman 2002 ), friends, close friends, family, and romantic partners were re-coded as ‘Close’ companions. Acquaintances, co-workers, and strangers were re-coded as ‘Distant’ companions. This approach is conceptually similar to the distinction between ‘strong’ and ‘weak’ social connections ( Granovetter 1973 ). Analyses indicated that assessments completed in the presence of a mixture of Close and Distant companions (8%) showed intermediate effects and are omitted from the report.

Analytic Strategy

The overarching aim of the present study was to understand the joint explanatory influence of Social Anxiety (LSAS) and Social Context (EMA) on real-world Affect (EMA-derived NA, PA). In all cases, hypothesis testing employed a continuous measure of Social Anxiety.

We began by testing whether variation in Social Anxiety prospectively predicts the aggregate amount of time allocated to different social contexts. A standard multivariate mediation framework was then used to test whether relations between Social Anxiety and Social Context were statistically attributable, in part, to variation in Social Network Size (e.g., elevated social anxiety → fewer confidants → less time with close companions ) ( Hayes 2017 ), where Size was indexed using the MKSSI. As in prior work by our group ( Stout et al. 2017 ), the significance of the indirect effect (‘mediation’) was assessed using non-parametric bootstrapping (5,000 samples). Although the mediation framework provides useful information, it rests on strong assumptions and positive results do not license causal inferences ( Green et al. 2010 , Bullock et al. 2010 ). Pirateplots were created using the yaRrr package for R ( Phillips 2017 ). Hotelling’s test for dependent correlations was computed using FZT ( https://psych.unl.edu/psycrs/statpage/comp.html ).

Next, a series of MLMs was implemented in SPSS (version 24.0.0.0) with momentary assessments of Affect and Social Context nested within subjects and intercepts free to vary across subjects. Separate MLMs were computed for NA and PA. Level 2 variables (i.e., Social Anxiety) were mean centered.

The equations defined below outline the basic structure of our final MLMs in standard notation ( Raudenbush and Bryk 2002 ). At the first level, Affect during EMA t for individual i was modeled as a function of Social Context:

Alone served as the dummy-coded reference category for primary analyses (as in Equation 1 ). Distant companions served as the reference category for follow-up analyses 3 .

At the second level, the association between Social Context and Affect was modeled as a function of individual differences in Social Anxiety:

Conceptually, this enabled us to test prospective relations between Social Anxiety and Affect, cross-sectional relations between EMA-derived measures of Social Context and Affect, and the potentially interactive effects of Social Anxiety and Social Context. We also explored the impact of incorporating variation in the amount of time allocated to different contexts as a nuisance variable. For significant effects, we examined generality across NA facets (i.e., anxious and depressed mood). As an additional validity check, we confirmed that similar results were obtained when two authors independently analyzed the data using SPSS (J.H.) and R (M.G.B.), respectively.

Momentary Emotional Experience Covaries with Social Context

Consistent with other work in young adults ( Shackman et al. 2018 , Reed W Larson 1990 , Berry and Hansen 1996 ), our sample spent slightly more than half their time with others (Close = 44.1%, Distant = 13.4%, Alone = 42.5%), although there were marked individual differences in the amount of time devoted to each social environment ( Figure 2 ). Individuals who spent more time with close others reported lower average levels of NA ( r = −.14, p = .03) and higher average levels of PA ( r = .31, p < .000). Conversely, those who spent more time alone reported higher average levels of NA ( r = .14, p = .03) and lower average levels of PA ( r = −.28, p < .001), replicating past work (e.g., Diener and Seligman 2002 , Shackman et al. 2018 , Oishi et al. 2007 , Diener et al. 2018 , Rogers et al. 2018 ). The average amount of time spent with distant others was unrelated to average mood ( p s > .20). In sum, individuals who spend more time with close companions report modestly enhanced mood, whereas those who are prone to seclusion show the opposite effect.

Figure depicts the data ( jittered gray points; individual participants ), density distribution ( colored bean plots ), Bayesian 95% highest density interval (HDI; white bands ), and mean ( black bars ) for each social context. HDIs permit population-generalizable visual inferences about mean differences and were estimated using 1,000 samples from a posterior Gaussian distribution

Socially Anxious Individuals Spend Less Time with Close Companions and Have Smaller Confidant Networks

On average, individuals with higher levels of social anxiety spent significantly less time in the company of close companions ( r = −.16, p = .01) and showed a trend to spend more time alone ( r = .13, p = .06), as in prior work ( Afram and Kashdan 2015 , Alden and Taylor 2004 ). A mediation analysis suggested that this reflects reduced access to close companions. As shown in Figure 3 , individuals with higher levels of social anxiety report fewer confidants ( a = −.19, p = .005), consistent with prior work ( Davidson et al. 1994 , Montgomery et al. 1991 , La Greca and Lopez 1998 ). Individuals with fewer confidants were, in turn, less likely to be in the presence of close companions ( b = .31, p < .001) at the time of momentary assessment 4 . Bootstrapped 95% confidence intervals for the indirect effect excluded zero, indicating significant mediation. Likewise, the direct effect of social anxiety on the amount of time spent with close companions was no longer significant after accounting for variation in the number of confidants ( c ’ path in Figure 3 ; p > .10). 5 Notably, social anxiety was not significantly related to the amount of time spent with distant companions ( p = .20), contraindicating a general bias to avoid others. The association between social anxiety and the amount of time allocated to close companions was significantly stronger than that with distant companions, t Hotelling = 2.18, p = .03.

Figure depicts significant mediation models for the amount of time allocated to close companions. Path labels indicate standardized regression coefficients, with c’ indicating the coefficient while controlling for variation in the self-reported number of confidants. Socially anxious individuals report fewer confidants, and individuals with fewer confidants were, in turn, less likely to be in the presence of close companions at the time of momentary assessment.

Social Anxiety is Associated with Diminished Real-World Emotional Experience

MLM analyses demonstrated that social anxiety is associated with reduced quality of real-world emotional experience. Individuals with higher levels of social anxiety report significantly increased NA ( t = 25.2, b = .12, SE = .005, p < .001) and reduced PA ( t = −24.1, b = −.19, SE = .008, p < .001), consistent with past research ( Kashdan 2004 , Kashdan et al. 2013a , Kashdan et al. 2013b , Kashdan and Steger 2006 ) 6 .

The Quality of Momentary Emotional Experience Covaries with the Presence of Close Companions

Relative to seclusion or the presence of distant others, MLM results showed that close companions are associated with lower levels of NA (Alone: t = −.7.51, b = −.09, SE = .012, p < .001; Distant: t = −6.71, b = −.10, SE = .015, p < .001) and higher levels of PA (Alone: t = 15.79, b = .31, SE = .019, p < .001; Distant: t = 15.03, b = .37, SE = .025, p <.001). Relative to seclusion, distant companions are associated with lower levels of PA (PA: t = −2.59, b = −.06, SE = .024, p = .01; NA: p > .30). Results were similar when controlling for variation in the amount of time allocated to different social contexts ( Supplementary Table S1 ). These findings reinforce the conclusion that the quality of momentary emotional experience is positively associated with the presence of close friends, family, and romantic partners.

Socially Anxious Individuals Derive Larger Emotional Benefits from Close Companions

We next considered the joint impact of social anxiety and social context on momentary mood ( Table 1 ). As shown in Figure 4 , the results of this more comprehensive MLM revealed that socially anxious individuals derive larger emotional benefits—indexed by significantly lower levels of NA—from close companions relative to seclusion (Social Anxiety × Close-Alone, t = −2.27, b = −.03, SE = .012, p = .02). In short, individuals with higher levels of social anxiety tend to experience the least intense, most normative levels of NA in the company of friends, family, and romantic partners. This effect remained significant after controlling for the amount of time allocated to different social contexts ( Supplementary Table S2 ) 7 . Other interactions were not significant for NA or PA ( p > .80). That is, social anxiety was not associated with an exaggerated emotional response in the presence of co-workers, strangers, and other distant companions ( Figure 4 and Table 1 ). The same general pattern of results was evident for analyses focused on the anxious and depressed facets of momentary NA ( Supplementary Tables S3 – S4 ).

The deleterious impact of social anxiety on momentary emotional experience critically depends on social context. Individuals with higher levels of social anxiety derive larger emotional benefits—larger decrements in negative affect (NA)—from close companions relative to being alone ( left side of display ). Hypothesis testing relied on a continuous measure of social anxiety. For illustrative purposes, predicted values derived from multilevel modeling are depicted for extreme levels (±1 SD) of social anxiety. Abbreviation—SA: Social anxiety.

The Impact of Social Anxiety and Social Context on Momentary Emotional Experience

Social anxiety lies on a continuum, from mild to debilitating, and young adults with elevated symptoms of social anxiety are more likely to show significant impairment and develop frank psychopathology. The present study provides new insights into the ways in which real-world emotional experience varies as a function of social anxiety and the social environment. Our results demonstrate that the presence of close companions is associated with lower levels of momentary NA ( Figure 4 ), including anxiety and depression. Importantly, individuals with higher levels of social anxiety were found to spend significantly less time with close companions and a mediation analysis suggested that this association is partially explained by smaller confidant networks ( Figure 3 ). Social anxiety was unrelated to the number of assessments completed in the presence of co-workers, strangers, and other distant companions, contraindicating a general social avoidance bias. Although social anxiety was prospectively associated with a diminished quality of momentary emotional experience (i.e., increased NA and reduced PA), MLM analyses demonstrated that individuals with higher levels of social anxiety derive significantly larger benefits—manifesting as lower levels of NA, anxiety, and depression—from the company of close companions ( Figure 4 ). In contrast, socially anxious individuals were not disproportionately sensitive to the presence of distant companions ( Table 1 and Figure 4 ). Indeed, they showed similarly high levels of NA when they were alone. Although social anxiety research and treatment has predominantly focused on responses to novelty and potential threat, our results underscore the centrality of friends, family, and romantic partners. These findings provide a framework for understanding the deleterious consequences of extreme social anxiety and guiding the development of improved intervention strategies.

The present findings extend developmental and laboratory research highlighting the importance of social and interpersonal processes for emotion regulation and mental wellbeing ( Coan and Sbarra 2015 , Zaki and Williams 2013 , Reeck et al. 2016 , Maresh et al. 2013 , Rubin et al. 2018 ). Our observations motivate the hypothesis that the pervasive NA characteristic of socially anxious young adults partially reflects difficulties forming or maintaining close relationships, consistent with work focused on children and adolescents at risk for developing social anxiety disorder ( Shackman et al. 2016 , Markovic and Bowker 2017 , Rubin et al. 2018 , Frenkel et al. 2015 , Ladd et al. 2011 ). With fewer confidants, socially anxious individuals spend significantly less time with close companions and are less frequent beneficiaries of their mood-enhancing effects ( Figures 3 – 4 ). Socially anxious individuals appear to have an intact capacity for social mood enhancement. Indeed, they show lower levels of NA in the company of close companions, in broad accord with work focused on depressed samples ( Rottenberg 2017 ). This model is well aligned with evidence from prospective longitudinal studies which indicate that close friendships and other kinds of social support and intimacy reduce the risk of developing anxiety symptoms in adolescence and early adulthood ( Narr et al. 2019 , Frenkel et al. 2015 , Tillfors et al. 2012 , Teachman and Allen 2007 , Rodebaugh 2009 ). Likewise, among patients undergoing treatment for social anxiety, higher levels of perceived social support are associated with a more favorable prognosis ( Rapee et al. 2015 ).

Naturally, our results do not license causal inferences. We cannot rule out the possibility that reduced access to confidants begets higher levels of social anxiety or, more likely, that these two constructs exert bi-directional effects ( Rubin et al. 2018 ). Likewise, it could be that socially anxious individuals actively seek out the company of close companions when they are experiencing lower levels of NA. Nevertheless, randomized laboratory studies reinforce the conclusion that close companions play a key role in mitigating NA. For example, the presence of a close companion has been shown to normalize negative affect and catastrophic cognitions ( ‘I’m going to die’ ) in anxiety patients exposed to a panic-inducing CO 2 challenge ( Carter et al. 1995 ) and to normalize behavioral signs of anxiety in socially anxious young adults during a videotaped speech challenge ( Pontari 2009 ). Taken with the present results, these observations motivate the hypothesis that friends, romantic partners, and family members serve as a regulatory ‘prosthesis’ for socially anxious individuals.

Relying on close companions is risky. This is particularly true for socially anxious individuals, who tend to experience elevated levels of interpersonal conflict ( Cuming and Rapee 2010 ) and, among patients, profound impairment of interpersonal relationships ( Wittchen et al. 2000 , Rapaport et al. 2005 , Olatunji et al. 2007 , Stein et al. 2017 ). Relationship distress and dissolution reduces or eliminates the possibility of interpersonal emotion regulation and, ultimately, can contribute to the development, maintenance, and recurrence of psychopathology ( Baucom et al. 2014 , Whisman and Baucom 2012 , Rehman et al. 2008 , Marroquin 2011 ). Even in the absence of relationship problems, as young adults transition to full-time employment, marriage, and parenting, social network size begins to decline and more time is spent with distant companions or alone ( Wrzus et al. 2016 , Wrzus et al. 2013 , R. W. Larson 1990 , Sander et al. 2017 , Lansford et al. 1998 )—effects that may be amplified in more recent cohorts, which tend to allocate less time to face-to-face social interaction and experience elevated levels of loneliness ( Twenge et al. 2019 ). Many middle-aged and older adults report that they have no confidant ( McPherson and Smith-Lovin 2006 ), depriving them of the emotional benefits of close companions. This is likely to be exacerbated among individuals with elevated levels of social anxiety, who are less likely to have close friends and more likely to be unmarried by mid-life ( Davidson et al. 1994 , Montgomery et al. 1991 , La Greca and Lopez 1998 ). Extending the present approach to earlier and later developmental periods is an important challenge for future research, and prospective-longitudinal studies are likely to be especially fruitful.

Social anxiety is often cast as an increased sensitivity to scrutiny from others, especially unfamiliar others, which manifests as heightened avoidance, fear (‘phobia’), and anxiety ( American Psychiatric Association 2013 ). The present results underscore the need to broaden this perspective. As indexed by EMA, social anxiety was unrelated to the amount of time spent with distant companions. Moreover, socially anxious individuals did not experience heightened NA in the presence of distant companions ( Table 1 and Figure 4 ). This suggests that, in the absence of clear signs of rejection, scrutiny, or threat, socially anxious individuals tend to show normative emotional responses to distant companions. Another possibility is that hyper-reactivity to strangers is specific to pathological levels of social anxiety or is only evident in a subset of socially anxious individuals. Adjudicating between these accounts represents another important avenue for future research.

From a clinical perspective, these observations suggest that naturally occurring social relationships are a potentially important target for intervention. Existing treatments for social anxiety typically focus on the individual, but our results highlight the value of simultaneously considering the role of close companions and developing supplementary interventions to enhance social connection, acceptance, and support. This could take the form of nurturing social-cognitive skills (e.g., emotional disclosure), cultivating stronger and more frequent ties with existing companions and social networks (e.g., via behavioral activation approaches), or reducing maladaptive thoughts and behaviors (e.g., neediness, overreliance) that promote conflict and rejection ( Masi et al. 2011 , Cacioppo et al. 2015 , Kok and Singer 2017 ). The development of smartphone-based interventions would provide a scalable and cost-effective alternative to more traditional modalities—already, 77% of U.S. adults, and 94% of U.S. adults aged 18–29 own a smartphone ( Pew Research Center 2018 ). Mobile applications may be especially effective for individuals who are unable or unwilling to use traditional care delivery systems and for subclinical presentations of social anxiety that do not warrant resource-intensive treatments ( Ruscio 2019 ). Regardless of delivery method, intervention research would also provide a crucial opportunity for testing the causal contribution of close companions to the everyday experience of social anxiety.

Our results highlight some additional avenues for future research. To understand the generalizability of our inferences, it will be useful to extend the present approach to larger and more representative samples and to populations with more severe symptoms, distress, and impairment. Future EMA studies may benefit from using larger sampling windows or selectively targeting periods of increased stress or disrupted social intimacy (e.g., transition from high school or university, or from university to full-time work) in order to capture a wider range of social interactions and their association with momentary affect. It will also be helpful to examine the nature and quality of naturalistic social interactions—including momentary perceptions of social connection, emotional support, and conflict—in more detail using either EMA (e.g., context- or event-triggered) or behavioral observations. Developing a clearer understanding of the processes that promote heightened levels of NA during periods of solitude—when both social support and social threat are absent ( Figure 4 )—is also likely to be fruitful ( Shackman et al. 2016 ).

In sum, the present study suggests that close companions play an important role in the momentary experience of socially anxious young adults. The use of well-established techniques for intensive EMA and a relatively large sample selectively recruited from a pool of more than 6,000 young adults increases our confidence in the reproducibility and translational relevance of these findings. These results set the stage for developing improved strategies for treating or preventing the sequelae of extreme social anxiety.

Supplementary Material

Acknowledgements.

The authors acknowledge the assistance of C. Garbin, L. Friedman, R. Tillman, and members of the Affective and Translational Neuroscience laboratory and constructive feedback from four anonymous reviewers and K. Rubin. This work was supported by the National Institutes of Health (DA040717, MH107444) and University of Maryland. Authors declare no conflicts of interest.

ETHICAL STANDARDS

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

DATA SHARING

Raw data have been or will be made available via the National Institute of Mental Health’s RDoC Database ( https://data-archive.nimh.nih.gov/rdocdb ).

1. The mean and dispersion of the present sample is similar to that of unselected individuals drawn from the same university population. For example, exploratory analyses of data collected as part of the University of Maryland Department of Psychology’s on-line survey during the 2015–2018 academic years ( N = 1,596) revealed that among the subset of respondents 18–19 years old, women reported significantly greater social anxiety ( N = 601, M = 46.8, SD = 23.2) than men ( N = 229, M = 40.3, SD = 22.7), t = 3.67, p = .001. When the on-line survey data were adjusted to reflect the percentage of women in the EMA study (51.3%), the resulting weighted distribution ( M = 43.6, Range = 2–122) was similar to the present EMA sample ( M = 41.7, Range = 1–121).

2. For descriptive purposes, depression was assessed using the General Depression subscale of the revised Inventory of Depression and Anxiety Symptoms (IDAS-II) Watson, D., O’Hara, M. W., Naragon-Gainey, K., Koffel, E., Chmielewski, M., Kotov, R., Stasik, S. M. and Ruggero, C. J. (2012) ‘Development and validation of new anxiety and bipolar symptom scales for an expanded version of the IDAS (the IDAS-II)’, Assessment, 19, 399–420.. As expected, levels of depression were somewhat elevated in the present sample ( M = 39.9, SD = 12.8), which corresponds to the 60 th percentile in U.S. normative data Nelson, G. H., O’Hara, M. W. and Watson, D. (2018) ‘National norms for the expanded version of the inventory of depression and anxiety symptoms (IDAS-II)’, J Clin Psychol, 74, 953–968..

3. Similar results were obtained for the model using the log-transformed NA scores as a DV (not reported).

4. The zero-order correlation between self-reported social network size and the proportion of momentary assessments completed in the presence of close companions was r = .29, p < .001.

5. Although the complementary pattern ( elevated social anxiety → fewer confidants → greater solitude ) was evident for a model focused on time spent alone, we refrain from reporting or interpreting it, given the strong dependency between time allocated to close companions vs. solitude. That is, social contexts were mutually exclusive ( Figure 2 ), and most assessments were completed either in the presence of close companions or alone. From this perspective, the results of the ‘alone’ model are almost entirely predictable knowing the results of the ‘close companions’ model.

6. Momentary NA and PA were negatively correlated within momentary assessments ( t = −18.7, b = −.26, SE = .014, p < .001).

7. It also remained significant when controlling for variation in depressive symptoms, indexed using the General Depression subscale of the IDAS-II (Social Anxiety × Close-Alone, t = −2.28, b = −.03, SE = .012, p = .02).

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Research Article

Social anxiety in young people: A prevalence study in seven countries

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Resilience Research Centre, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada

Roles Conceptualization, Methodology, Writing – review & editing

• Philip Jefferies, 
• Michael Ungar

• Published: September 17, 2020
• https://doi.org/10.1371/journal.pone.0239133
• Peer Review
• Reader Comments

Social anxiety is a fast-growing phenomenon which is thought to disproportionately affect young people. In this study, we explore the prevalence of social anxiety around the world using a self-report survey of 6,825 individuals (male = 3,342, female = 3,428, other = 55), aged 16–29 years (M = 22.84, SD = 3.97), from seven countries selected for their cultural and economic diversity: Brazil, China, Indonesia, Russia, Thailand, US, and Vietnam. The respondents completed the Social Interaction Anxiety Scale (SIAS). The global prevalence of social anxiety was found to be significantly higher than previously reported, with more than 1 in 3 (36%) respondents meeting the threshold criteria for having Social Anxiety Disorder (SAD). Prevalence and severity of social anxiety symptoms did not differ between sexes but varied as a function of age, country, work status, level of education, and whether an individual lived in an urban or rural location. Additionally, 1 in 6 (18%) perceived themselves as not having social anxiety, yet still met or exceeded the threshold for SAD. The data indicate that social anxiety is a concern for young adults around the world, many of whom do not recognise the difficulties they may experience. A large number of young people may be experiencing substantial disruptions in functioning and well-being which may be ameliorable with appropriate education and intervention.

Citation: Jefferies P, Ungar M (2020) Social anxiety in young people: A prevalence study in seven countries. PLoS ONE 15(9): e0239133. https://doi.org/10.1371/journal.pone.0239133

Editor: Sarah Hope Lincoln, Harvard University, UNITED STATES

Received: March 11, 2020; Accepted: August 31, 2020; Published: September 17, 2020

Copyright: © 2020 Jefferies, Ungar. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data files are available from the Open Science Framework repository (DOI: 10.17605/OSF.IO/VCNF7 ).

Funding: The author(s) received no specific funding for this work.

Competing interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: Unilever funds the lead author's research fellowship at Dalhousie University's Resilience Research Centre, though in no way have they directed this research, its analysis or the reporting or results.

Introduction

Social anxiety occurs when individuals fear social situations in which they anticipate negative evaluations by others or perceive that their presence will make others feel uncomfortable [ 1 ]. From an evolutionary perspective, at appropriate levels social anxiety is adaptive, prompting greater attention to our presentation and reflection on our behaviours. This sensitivity ensures we adjust to those around us to maintain or improve social desirability and avoid ostracism [ 2 ]. However, when out of proportion to threats posed by a normative social situation (e.g., interactions with a peer group at school or in the workplace) and when impairing functioning to a significant degree, it may be classified as a disorder (SAD; formerly ‘social phobia’; [ 3 ]). The hallmark of social anxiety in western contexts is an extreme and persistent fear of embarrassment and humiliation [ 1 , 4 , 5 ]. Elsewhere, notably in Asian cultures, social anxiety may also manifest as embarrassment of others, such as Taijin kyofusho in Japan and Korea [ 6 ]. Common concerns involved in social anxiety include fears of shaking, blushing, sweating, appearing anxious, boring, or incompetent [ 7 ]. Individuals experiencing social anxiety visibly struggle with social situations. They show fewer facial expressions, avert their gaze more often, and express greater difficulty initiating and maintaining conversations, compared to individuals without social anxiety [ 8 ]. Recognising difficulties can lead to dread of everyday activities such as meeting new people or speaking on the phone. In turn, this can lead to individuals reducing their interactions or shying away from engaging with others altogether.

The impact of social anxiety is widespread, affecting functioning in various domains of life and lowering general mood and wellbeing [ 9 ]. For instance, individuals experiencing social anxiety are more likely to be victims of bullying [ 10 , 11 ] and are at greater risk of leaving school early and with poorer qualifications [ 11 , 12 ]. They also tend to have fewer friends [ 13 ], are less likely to marry, more likely to divorce, and less likely to have children [ 14 ]. In the workplace, they report more days absent from work and poorer performance [ 15 ].

A lifetime prevalence of SAD of up to 12% has been reported in the US [ 16 ], and 12-month prevalence rates of .8% have been reported across Europe [ 17 ] and .2% in China [ 18 ]. However, there is an increasing trend to consider a spectrum of social anxiety which takes account of those experiencing subthreshold or subclinical social anxiety, as those experiencing more moderate levels of social anxiety also experience significant impairment across different domains of functioning [ 19 – 21 ]. Therefore, the proportion of individuals significantly affected by social anxiety, which include a substantial proportion of individuals with undiagnosed SAD [ 8 ], may be higher than current estimates suggest.

Studies also indicate younger individuals are disproportionately affected by social anxiety, with prevalence rates at around 10% by the end of adolescence [ 22 – 24 ], with 90% of cases occurring by age 23 [ 16 ]. Higher rates of social anxiety have also been observed in females and are associated with being unemployed [ 25 , 26 ], having lower educational status [ 27 ], and living in rural areas [ 28 , 29 ]. Leigh and Clark [ 30 ] have explored the higher incidence of social anxiety in younger individuals, suggesting that moving from a reliance on the family unit to peer interactions and the development of neurocognitive abilities including public self-consciousness may present a period of greater vulnerability to social anxiety. While most going through this developmentally sensitive period are expected to experience a brief increase in social fears [ 31 ], Leigh and Clark suggest that some who may be more behaviourally inhibited by temperament are at greater risk of developing and maintaining social anxiety.

Recent accounts suggest that levels of social anxiety may be rising. Studies have indicated that greater social media usage, increased digital connectivity and visibility, and more options for non-face-to-face communication are associated with higher levels of social anxiety [ 32 – 35 ]. The mechanism underpinning these associations remains unclear, though studies have suggested individuals with social anxiety favour the relative ‘safety’ of online interactions [ 32 , 36 ]. However, some have suggested that such distanced interactions such as via social media may displace some face to face relationships, as individuals experience greater control and enjoyment online, in turn disrupting social cohesion and leading to social isolation [ 37 , 38 ]. For young people, at a time when the development of social relations is critical, the perceived safety of social interactions that take place at a distance may lead some to a spiral of withdrawal, where the prospect of normal social interactions becomes ever more challenging.

Therefore, in this study, we sought to determine the current prevalence of social anxiety in young people from different countries around the world, in order to clarify whether rates of social anxiety are increasing. Specifically, we used self-report measures (rather than medical records) to discover both the frequency of the disorder, severity of symptoms, and to examine whether differences exist between sexes and other demographic factors associated with differences in social anxiety.

Materials and methods

This study is a secondary analysis of a dataset that was created by Edelman Intelligence for a market research campaign exploring lifestyles and the use of hair care products that was commissioned by Clear and Unilever. The original project to collect the data took place in November 2019, where participants were invited to complete a 20-minute online questionnaire containing measures of social anxiety, resilience, social media usage, and questions related to functioning across various life domains. Participants were randomly recruited through the market research companies Dynata, Online Market Intelligence (OMI), and GMO Research, who hold nationally representative research panels. All three companies are affiliated with market research bodies that set standards for ethical practice. Dynata adheres to the Market Research Society code of conduct; OMI and GMO adhere to the ESOMAR market research code of conduct. The secondary analyses of the dataset were approved by Dalhousie University’s Research Ethics Board.

Participants

There were 6,825 participants involved in the study (male = 3,342, female = 3,428, other = 55), aged 16–29 years (M = 22.84, SD = 3.97), from seven countries selected for their social and economic diversity (Brazil, China, Indonesia, Russia, Thailand, US, and Vietnam) (see Table 1 for full sample characteristics). Participant ages were collected in years, but some individuals aged 16–17 were recruited through their parents and their exact age was not given. They were assigned an age of 16.5 years in order to derive the mean age and standard deviation for the full sample.

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https://doi.org/10.1371/journal.pone.0239133.t001

Email invitations to participate were sent to 23,346 young people aged 16–29, of whom 76% (n = 17,817) were recruited to take the survey. These were panel members who had previously registered and given their consent to participate in surveys. Sixty-five percent of respondents were ineligible, with 10,816 excluded because they or their close friends worked in advertising, market research, public relations, journalism or the media, or for a manufacturer or retailer of haircare products. A further 176 respondents were excluded for straight-lining (selecting the same response to every item of the social anxiety measure, indicating they were not properly engaged with the survey; [ 39 ]). The final sample comprised 6,825 participants and matched quotas for sex, region, and age, to achieve a sample with demographics representative of each country.

Participants were compensated for their time using a points-based incentive system, where points earned at the end of the survey could be redeemed for gift cards, vouchers, donations to charities, and other products or services.

The survey included the 20-item self-report Social Interaction Anxiety Scale (SIAS; [ 40 ]). Based on the DSM, the SIAS was originally developed in conjunction with the Social Phobia Scale to determine individuals’ levels of social anxiety and how those with SAD respond to treatment. Both the SIAS and Social Phobia Scale correlate strongly with each other [ 40 – 43 ], but while the latter was developed to assess fears of being observed or scrutinised by others, the SIAS was developed more specifically to assess fears and anxiety related to social interactions with others (e.g., meeting with others, initiating and maintaining conversations). The SIAS discriminates between clinical and non-clinical populations [ 40 , 44 , 45 ] and has also been found to differentiate between those with social anxiety and those with general anxiety [ 46 ], making it a useful clinical screening tool. Although originally developed in Australia, it has been tested and found to work well in diverse cultures worldwide [ 47 – 50 ], and has strong psychometric properties in clinical and non-clinical samples [ 40 , 42 , 43 , 45 – 47 ].

For the current study, all 20 items of the SIAS were included in the survey, though we omitted the three positively-worded items from analyses, as studies have demonstrated that including them results in weaker than expected relationships between the SIAS and other measures, that they hamper the psychometric properties of the measure, and that the SIAS performs better without them [e.g., 51 – 53 ] (the omitted items were ‘I find it easy to make friends my own age’ , ‘I am at ease meeting people at parties , etc’ , and ‘I find it easy to think of things to talk about’ .). One item of the SIAS was also modified prior to use: ‘ I have difficulty talking to attractive persons of the opposite sex’ was altered to ‘ I have difficulty talking to people I am attracted to’ , to make it more applicable to individuals who do not identify as heterosexual, given that the original item was meant to measure difficulty talking to an attractive potential partner [ 54 ].

The questionnaire also included measures of resilience, in addition to other questions concerning functioning in daily life. These were included as part of a corporate social responsibility strategy to investigate the rates of social anxiety and resilience in each target market. A translation agency (Language Connect) translated the full survey into the national languages of the participants.

We analysed social anxiety scores for the overall sample, as well as by country, sex, and age (for sex, given the limited number and heterogeneity of individuals grouped into the ‘other’ category, we only compared males and females). As social anxiety is linked to work status [ 25 ], we also examined differences in SIAS scores between those working and those who were unemployed. Urban/rural differences were also investigated as previous research has suggested anxiety disorders may differ depending on where an individual lives [ 28 ]. Education level [ 27 ], too, was included using completion of secondary education (ISCED level 3) in a subgroup of participants aged 20 years and above to ensure all were above mandatory ages for completing high school. Descriptive statistics are reported for each group with significant differences explored using ANOVA (with Tukey post-hoc tests) or t-tests.

The SIAS is said to be unidimensional when using just the 17 straightforwardly-worded items [ 52 ], with item scores summed to give general social anxiety scores. Higher scores indicate greater levels of social anxiety. Heimberg and colleagues [ 42 ] have suggested a cut-off of 34 on the 20-item SIAS to denote a clinical level of social anxiety (SAD). This level has been adopted in other studies [e.g., 45 ] and found to accurately discriminate between clinical and non-clinical participants [ 53 ]. This threshold for SAD scales to 28.9 when just the 17 items are used, and this is slightly more conservative than others who have used 28 as an adjusted 17-item threshold [ 53 , 55 ]. Therefore, in addition to analyses of raw scores to gauge the severity of social anxiety (and reflect consideration of social anxiety as a spectrum), we also report the proportion of individuals meeting or exceeding this threshold for SAD (≥29) and analyse differences between groups using chi-square tests.

Additionally, despite the unidimensionality of the SIAS, the individual items can be interpreted as examples of contexts where social anxiety may be more or less acutely experienced (e.g., social situations with authority: ‘ I get nervous if I have to speak with someone in authority ’, social situations with strangers: ‘ I am nervous mixing with people I don’t know well ’). Therefore, as social anxiety may be experienced differently depending on culture [ 6 ], we also sorted the items in the measure to understand the top and least concerning contexts for each country.

Finally, we also sought to understand whether individuals perceived themselves as having social anxiety. After completing the SIAS, participants were presented with a definition of social anxiety and asked to reflect on whether they thought this was what they experienced. We contrasted responses with a SIAS threshold analysis to determine discrepancies, including assessment of the proportion of false positives (those who thought they had social anxiety but did not exceed the threshold) and false negatives (those who thought they did not have social anxiety but exceeded the threshold).

All analyses were conducted using SPSS v25 [ 56 ].

As the survey required a response for each item, there were no missing data. The internal reliability of the SIAS was found to be strong (α = .94), with the removal of any item resulting in a reduction in consistency.

Social anxiety by sex, age, and country

In the overall sample, the distribution of social anxiety scores formed an approximately normal distribution with a slightly positive skew, indicating that most respondents scored lower than the midpoint on the measure ( Fig 1 ). However, more than one in three (36%) were found to score above the threshold for SAD. There were no significant differences in social anxiety scores between male and female participants ( t (6768) = -1.37, n.s.) and the proportion of males and females scoring above the SAD threshold did not significantly differ either ( χ 2 (1,6770) = .54, n.s.).

https://doi.org/10.1371/journal.pone.0239133.g001

Social anxiety scores significantly differed between countries ( F (6,6818) = 74.85, p < .001, η p 2 = .062). Indonesia had the lowest average scores ( M = 18.94, SD = 13.21) and the US had the highest ( M = 30.35, SD = 15.44). Post-hoc tests revealed significant differences ( p s≤.001) between each of the countries, except between Brazil and Thailand, between China and Vietnam, between Russia and China, and between Russia and Indonesia (see Table 2 ). The proportion of individuals exceeding the threshold for SAD was also found to significantly differ between the seven countries (χ 2 (6,6825) = 347.57, p < .001). Like symptom severity, the US had the highest prevalence with more than half of participants surveyed exceeding the threshold (57.6%), while Indonesia had the lowest, with fewer than one in four (22.9%).

https://doi.org/10.1371/journal.pone.0239133.t002

A significant age difference was also observed ( F (2,6822) = 39.74, p < .001, η p 2 = .012), where 18-24-year-olds scored significantly higher ( M = 25.33, SD = 13.98) than both 16-17-year-olds ( M = 21.92, SD = 14.24) and 25-29-year-olds ( M = 22.44, SD = 14.22). Also, 25-29-year-olds scored significantly higher than 18-24-year-olds ( p s < .001). The proportion of individuals scoring above the threshold for SAD also significantly differed between age groups (χ 2 (2,6825) = 48.62, p < .001) ( Fig 2 ).

https://doi.org/10.1371/journal.pone.0239133.g002

A three-way ANOVA confirmed significant main effect differences in social anxiety scores between age groups ( F (2,6728) = 38.93, p < .001, η p 2 = .011) and countries ( F (6,6728) = 45.37, p < .001, η p 2 = .039), as well as the non-significant difference between males and females ( F (1,6728) = .493, n.s.). However, of the interactions between sex, age, and country, the two-way country*age interaction was significant ( F (12,6728) = 1.89, p = .031, η p 2 = .003), where 16-17-year-olds in Indonesia were found to have the lowest scores ( M = 15.70, SD = 13.46) and 25-29-year-olds in the US had the highest ( M = 30.47, SD = 16.17) ( Fig 3 ). There was also a significant country*sex interaction ( F (6,6728) = 2.25, p = .036, η p 2 = .002), where female participants in Indonesia had the lowest scores ( M = 18.07, SD = 13.18) and female participants in the US had the highest ( M = 30.37, SD = 15.11) ( Fig 4 ).

https://doi.org/10.1371/journal.pone.0239133.g003

https://doi.org/10.1371/journal.pone.0239133.g004

Work status

Social anxiety scores were also found to significantly differ in terms of work status (employed/studying/unemployed; F (2,6030) = 9.48, p < .001, η p 2 = .003), with those in employment having the lowest scores ( M = 23.28, SD = 14.32), followed by individuals who were studying ( M = 23.96, SD = 13.50). Those who were unemployed had the highest scores ( M = 26.27, SD = 14.54). Post-hoc tests indicated there were significant differences between those who were employed and unemployed ( p < .001), between those studying and unemployed ( p = .006), but not between those employed and those who were studying. The difference between those exceeding the SAD threshold between groups was also significant (χ 2 (2,6033) = 7.55, p = .023).

Urban/Rural

Social anxiety scores also significantly varied depending on an individual’s place of residence ( F (4,6820) = 9.95, p < .001, η p 2 = .006). However, this was not a linear relationship from urban to rural extremes ( Fig 5 ); instead, those living in suburban areas had the highest scores ( M = 25.64, SD = 14.08) and those in central urban areas had the lowest ( M = 22.70, SD = 14.67). This pattern was reflected in the proportions of individuals exceeding the SAD threshold (χ 2 (4,6825) = 35.84, p < .001).

https://doi.org/10.1371/journal.pone.0239133.g005

Education level

In the subsample of individuals aged 20 or above, level of education also resulted in a significant differences in social anxiety scores ( t (5071) = 5.51, p < .001), with individuals who completed secondary education presenting lower scores ( M = 23.40, SD = 14.15) than those who had not completed secondary education ( M = 27.94, SD = 15.07). Those exceeding the threshold for SAD also significantly differed (χ 2 (1,5073) = 38.75, p < .001), with half of those who had not finished secondary education exceeding the cut-off (52%), compared to just over a third of those who had (35%).

Concerns by context

Table 3 illustrates the items of the SIAS sorted by severity for each country. For East-Asian countries, speaking with someone in authority was a top concern, but less so for Brazil, Russia, and the US. Patterns became less discernible between countries beyond this top concern, indicating heterogeneity in the specific situations related to social anxiety, although individuals in most countries appeared to be least challenged by mixing with co-workers and chance encounters with acquaintances.

https://doi.org/10.1371/journal.pone.0239133.t003

Self-perceptions of social anxiety

Just over a third of the sample perceived themselves to experience social anxiety (34%). Although this was similar to the proportion of individuals who exceeded the threshold for SAD (36%), perceptions significantly differed from threshold results (χ 2 (1,6825) = 468.80, p < .001). Just fewer than half of the sample (48%) perceived themselves as not being socially anxious and were also below the threshold, and a fifth (18%) perceived themselves as being socially anxious and exceeded the threshold ( Fig 6 ). However, 16% perceived themselves to be socially anxious yet did not exceed the threshold (false positives) and 18% perceived themselves not to be socially anxious yet exceeded the threshold (false negatives). This suggests a large proportion of individuals do not properly recognise their level of social anxiety (over a third of the sample), and perhaps most importantly, that more than 1 in 6 may experience SAD yet not recognise it ( Table 4 ).

https://doi.org/10.1371/journal.pone.0239133.g006

https://doi.org/10.1371/journal.pone.0239133.t004

This study provides an estimate of the prevalence of social anxiety among young people from seven countries around the world. We found that levels of social anxiety were significantly higher than those previously reported, including studies using the 17-item version of the SIAS [e.g., 55 , 57 , 58 ]. Furthermore, our findings show that over a third of participants met the threshold for SAD (23–58% across the different countries). This far exceeds the highest of figures previously reported, such as Kessler and colleague’s [ 16 ] lifetime prevalence rate of 12% in the US.

As this study specifically focuses on social anxiety in young people, it may be that the inclusion of older participants in other studies leads to lower average levels of social anxiety [ 27 , 59 ]. In contrast, our findings show significantly higher rates of SAD than anticipated, and particularly so for individuals aged 18–24. It also extends the argument of authors such as Lecrubier and colleagues [ 60 ] and Leigh and Clark [ 30 ] that developmental challenges during adolescence may provoke social anxiety, especially the crucial later period when leaving school and becoming more independent.

We also found strong variations in levels of social anxiety between countries. Previous explorations of national prevalence rates have been less equivocal, with some reporting differences [ 6 ] while others have not [ 61 ]. Our findings concur with those of Hofmann and colleagues’ [ 6 ] who note that the US has typically high rates of social anxiety, which we also found (in contrast to other countries). However, the authors suggest Russia also has a high prevalence and that Asian cultures typically show lower rates. In contrast, we found samples from Asian countries such as Thailand and Vietnam had higher rates than in the sample from Russia, and that there were significant differences between Asian countries themselves ( Table 2 ). As our study used the SIAS, which determines how socially anxious an individual is based on their ratings of difficulty in specific social situation, one way of accounting for differences may be to consider the kinds of feared social situations that are covered in the measure. For instance, our breakdown of concerns by country ( Table 3 ) indicates that in Asian countries, speaking with individuals in authority is a strongly feared situation, but this is less challenging in other cultures. For non-Asian countries, one of the strongest concerns was talking about oneself or one’s feelings. In Asian countries, where there is typically less of an emphasis on individualism, talking about oneself may be less stressful if there is less perceived pressure to demonstrate one’s uniqueness or importance. Future investigations could further explore cultural differences in social anxiety across different types of social situations or could confirm cross-cultural social anxiety heterogeneity by using approaches that are less heavily tied to determining social anxiety within given contexts (e.g., a diagnostic interview), as many of the commonly used measures appear to be [ 62 , 63 ].

Our findings also provide mixed support for investigations of other demographic differences in social anxiety. First, previous studies have tended to indicate that female participants score higher than males on measures of social anxiety [ 27 , 64 ]. Although the samples from Brazil and China reflected this, we found no difference between males and females in the overall sample, nor in samples from Indonesia, Russia, Thailand, US, or Vietnam. Sex-related differences in social anxiety have been attributed to gender differences, such as suggestions that girls ruminate more, particularly about relationships with others [ 65 , 66 ]. It is possible that as gender roles and norms vary between countries, and in some instances start to decline, so may differences in social anxiety, which younger generations are likely to reflect first. However, given the unexpected finding that males in Vietnam scored significantly higher than their female counterparts, further investigation is needed to account for the potentially culturally nuanced relationship between sex and social anxiety.

We also confirmed previous findings that higher levels of social anxiety are associated with lower levels of education and being unemployed. Although these findings are in-line with previous research [ 27 , 64 ], our study cannot shed light on causal mechanisms; longitudinal research is required to establish whether social anxiety leads individuals to struggle with school and work, whether struggling in these areas provokes social anxiety, or whether there is a more dynamic relationship.

Finally, we found that 18% of the sample could be classified as “false negatives”. This sizeable group felt they did not have social anxiety, yet their scores on the SIAS considerably exceeded the threshold for SAD. It has been said that SAD often remains undiagnosed [ 67 ], that individuals who seek treatment only do so after 15–20 years of symptoms [ 68 ], and that SAD is often identified when a related condition warrants attention (e.g., depression or alcohol abuse; Schneier [ 5 ]). It has also been reported that many individuals do not recognise social anxiety as a disorder and believe it is just part of their personality and cannot be changed [ 3 ]. Living with an undiagnosed or untreated condition can result in substantial economic consequences for both individuals and society, including a reduced ability to work and a loss of productivity [ 69 ], which may have a greater impact over time compared to those who receive successful treatment. Furthermore, the variety of avoidant (or “safety”) behaviours commonly associated with social anxiety [ 70 , 71 ] mean that affected individuals may struggle or be less able to function socially, and for young people at a time in their lives when relationships with others are particularly crucial [ 72 , 73 ], the consequences may be significant and lasting. Greater awareness of social anxiety and its impact across different domains of functioning may help more young people to recognise the difficulties they experience. This should be accompanied by developing and raising awareness of appropriate services and supports that young people feel comfortable using during these important developmental stages [see 30 , 74 ].

Study limitations

Our ability to infer reasons for the prevalence of SAD is hindered by the present data being cross-sectional, and therefore only allowing for associations to be drawn. We are also unable to confirm the number of clinical cases in the sample, as we did not screen for those who may have received a professional diagnosis of SAD, nor those who are receiving treatment for SAD. Additionally, the use of an online survey incorporating self-report measures incurs the risk of inaccurate responses. Further research could build on this investigation by surveying those in middle and older age to discover whether rates of social anxiety have also risen across other ages, or whether this increase is a youth-related phenomenon. Future investigations could also use diagnostic interviews and track individuals over time to determine the onset and progression of symptoms, including whether those who are subclinical later reach clinical levels, or vice versa, and what might account for such change.

On a global level, we report higher rates of social anxiety symptoms and the prevalence of those meeting the threshold for SAD than have been reported previously. Our findings suggest that levels of social anxiety may be rising among young people, and that those aged 18–24 may be most at risk. Public health initiatives are needed to raise awareness of social anxiety, the challenges associated with it, and the means to combat it.

Acknowledgments

The authors would like to acknowledge the role of Edelman Intelligence for collecting the original data on behalf of Unilever and CLEAR as part of their mission to support the resilience of young people.

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ORIGINAL RESEARCH article

Prevalence and associated factors of social phobia among high school adolescents in northwest ethiopia, 2021.

• Department of Psychiatry, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia

Background: Social phobia is the third most common mental illness in the world. It harms educational achievement by increasing school absentees and prevents students to participate in class, and this leads to a significant impairment of the emotional, psychological, social, and physical wellbeing of students. The research done regarding social phobia and associated factors among high school students in low- and middle-income countries is limited. Therefore, this study aims to assess the prevalence and associated factors of social phobia among adolescents and have a pivotal role in further investigation.

Objectives: To assess the prevalence and associated factors of social phobia among high school adolescents in Northwest Ethiopia, 2021.

Materials and methods: An institutional-based cross-sectional study was conducted from 15 April to 14 May 2021, by using a simple random sampling technique to select a sample of 936 participants after proportional allocation to the six high schools. Social phobia was assessed by using the social phobia inventory (SPIN), independent variables like social support were assessed by Oslo social support scale, substance-related factors by ASSIST, and the rest of the other factors were assessed by structured questionnaires. Binary and multivariate analyses were done to identify factors associated with social phobia. Statistical significance was declared at a 95% confidence interval (CI) of p -value less than or equal to 0.05.

Result: The prevalence of social phobia among adolescents was found to be 40.2% (95% CI 37.0 to 43.4%). In the multivariable analysis, female sex (AOR = 1.374, 95% CI = 1.016, 1.858), poor social support (AOR = 2.408, 95% CI = 1.660, 3.493), having known chronic medical illness (AOR = 2.131, 95% CI = 1.173, 3.870), having a history of mental illness in the family (AOR = 1.723, 95% CI = 1.071, 2.773), and is highly risky alcohol user (AOR = 1.992 95% CI 1.034, 3.838) were factors significantly associated with social phobia symptoms.

Conclusion: The overall prevalence of SP among adolescents was high. Therefore, early detection and adequate intervention are crucial to reducing the overall burden of social phobia among adolescents.

Introduction

According to DSM-V, social phobia (also referred to as social anxiety disorder) is defined as intense, persistent fear, or anxiety of social situations in which the individual may be scrutinized by others and this situation interferes significantly with routines, academic functioning, and social activities ( 1 ).

In turn, social phobia in a school is the response pattern of the high level of arousal, avoidance, and escape behavior that is elicited by stressful school environment like speaking to the class, being rejected by peers, and answering questions of the teacher that the student perceives as negatively evaluated ( 1 , 2 ).

Social phobia is the third most common mental illness in the general population, and even the most illness of adult social phobia onset was during adolescence ( 3 , 4 ). Research conducted in seven countries showed that the lifetime prevalence of social phobia varies across the world from a range of 22.9–57.6% ( 5 ). In an international community survey across different 13 countries, the magnitude of SP was 4% and it was highly prevalent among females and young age groups ( 6 ). In a different study conducted in Africa, the prevalence of social phobia ranges from 10.3 to 76.4% ( 7 – 9 ), and in Ethiopia was 27.5% ( 10 ).

Different factors affect SP. These include low educational status, substance use, poor daily functioning, and unstable life, ( 6 , 11 – 13 ) which lead to a remarkable impairment of emotional, psychological, and social wellbeing ( 7 – 9 , 14 ). The risk of SP also among high school students is higher than among those who have poor academic performance, alcoholic drinkers, female gender, being living in rural, have young ages, victimization, comorbid chronic medical illness, and have a past and family history of mental illness ( 10 , 15 – 20 ).

Therefore, students with SP tend to have faced different problems. Such impaired social interactions like a risk to have fewer friends, feeling lonely, disappointed over missed opportunities for friendship, and hiding from others, might prevent students from discussing with friends in the classroom, going to a party, and joining different enjoying activities, and these problems extend through adulthood ( 13 , 21 ).

In a study conducted in Sweden and Poland, SP negatively affects students’ educational performance, might keep a person from volunteering to answer in class, reading aloud, giving a presentation, and avoiding oral questions, and all of this leads to poor academic performance ( 22 , 23 ). Students with social phobia were also consistently more likely to experience a variety of psychological problems, concurrent medical, and mental illness always occurs following social phobia, and this comorbidity may lead to poor prognosis and tends to impaired family relationships and commit suicide ( 13 , 17 , 24 ). A cross-sectional study conducted in developing countries including Ethiopia suggests that the risk for substance abuse like misuse of alcohol and other substance dependence is high in socially anxious students ( 24 – 26 ).

While SP among high school students has been relatively researched in developed countries, very few studies are available in developing countries including Ethiopia. In Africa, though SP was researched among university students, according to our research engine, there was only one published research in Ethiopia, but not included grade nine and ten students. Therefore, this study was conducted to assess the prevalence of SP and various factors that might be led to early interventions for further obstacles among high school adolescents. For instance, this study will give important recommendations to reduce the risk factors of social phobia and may contribute students to improving the status of their academic performance. Furthermore, the result of this study will provide information for health professionals to design appropriate solutions for the problem.

Materials and methods

An institutional-based cross-sectional study design was conducted from 15 April to 14 May 2021, among high school adolescents in Northwest Ethiopia. The study was conducted among six areas of high schools in Northwest Ethiopia and covered 1,018.11 km 2 . There were six governmental high schools that offered a total of 12,977 students, of these 6,587 are males and the rest are females, one primary hospital, and six health centers in the district, but no private schools. All high school adolescents who have been learning in Northwest Ethiopia were the source population. Thus, all high school students who were presented in class during data collection time were study populations. All high school students who attended a class during data collection time were included in the study, whereas students who were unable to communicate due to acute illness during data collection time at schools were excluded.

Sample size determination and procedure

The sample size was determined by assuming single population formula with the assumptions: The prevalence of social phobia was 27.5% ( 10 ), 95% confidence interval (CI), margin error of 3%, and 10% non-response rate. Accordingly, the final sample size of 936 students was used.

High school students in the area of the study were stratified based on their grades as grade nine, grade ten, grade eleven, and grade twelve. As data obtained from the Education office indicated that the total number of high school students during data collection was 12,977 (grade nine = 3,598, grade ten = 4,037, grade eleven = 2,940, and grade twelve = 2,402). Then, proportional allocation of study subjects for each stratum (grades) was calculated, and 260, 291, 212, and 173 high school students were drawn from grade nine, grade ten, grade eleven, and grade twelve, respectively. Finally, a computer-generated lottery method was used to select study participants from each given strata.

Operational definitions

Social phobia: From the social phobia inventory (SPIN) tool assessment, students who scored 20 and above considered to be social phobia ( 10 ).

Social support: From Oslo three-item scales, students who scored 3–8 on poor social support, 9–11 on moderate social support, and 12–14 on strong social support ( 27 ).

Current substance use: Measured by the ASSIST scale for the past 3 months. Therefore for alcohol, students who scored 0–10 were low risky, 11–26 moderate users, and 27 and more highly risky drinkers, whereas for current khat and cigarette use participants scored 0–3 low risky, 4–26 moderate risky, and 27 and more highly risky users ( 28 ).

Performance (average academic score): First-semester average results of students who scored 49% and below are considered to be poor, 50–74% sufficient, 75–84% good, and 85% and above very good academic performances ( 29 ).

Age: From WHO age classification, declared that adolescents aged 10–19 years and adults aged 20 years old and above ( 30 ).

Data collection tools

Data were collected using a structured self-administered questionnaire that has five parts: In part one, socio-demographic characteristics such as age, sex, grade, and the like were collected by using structured socio-demographic questionnaires. In the second part, an outcome variable prevalence of social phobia was assessed by using the social phobia inventory (SPIN). The sensitivity and specificity of the SPIN were 82.2 and 77.6%, respectively, as it was validated in Nigeria. The positive and negative predictive values were 80% each ( 31 ). It was used among colleges and high school students in different countries including Ethiopia ( 10 , 14 , 20 , 31 ). Part three clinical factors like family history of mental illness and history of other mental illness, suicide ideation and attempt, and chronic medical illness were assessed by structured yes/no questions. The fourth part substance-related factors, which comprise substance use for its assessment of which is currently used and ever used, were adapted from the ASSIST (Alcohol, Smoking, and Substance Involvement Screening Test). It is a well-validated instrument developed by the World Health Organization ( 28 , 32 ). Finally, in part five, psychosocial factors were assessed by both standardized tools and structured questionnaires: Therefore for social support, the OSLO three-item social support scale was used ( 27 ), whereas for both social media and mass media usage was assessed by structured yes/no questions.

To control the quality of data, the questionnaire was initially prepared in English, then translated into the Amharic language, and finally back to in English by two language experts and psychiatrists appropriately. The training was given to data collectors and supervisors, and each completed questionnaire was checked and the necessary feedback was also offered to interviewers the following morning. The questionnaire was pretested 1 week before the actual data collection time on 5% ( n = 47) of the study who were not included in the main survey. Therefore, the dependent variable tool assessment (SPIN) Cronbach alpha was 0.899. Based on the feedback obtained from the pre-test, an appropriate modification was made to the questionnaire.

The collected data were coded, edited, entered, and checked into the computer using EPI data version 4.6.02 and imported to SPSS version 25 to generate descriptive statistics: means, standard deviation, frequency, and percentages. To determine an association between dependent and independent variables, adjusted odds ratios were used using logistic regression and the significance level was determined using a confidence interval of 95%. Bivariate and multivariate logistic regression was used to identify the independent predictors of social phobia. Each independent variable was separately entered in the bivariate analysis. The variables with a p -value of less than 0.25 on bivariate analysis were entered into multivariate analysis. The variables that showed statistically significant association with a p -value of less or equal to 0.05 on logistic regression were considered to be predictors of social phobia.

Socio-demographic characteristics of participants

Data were obtained from 876 high school adolescents with a response rate of 93.6%. The mean age of the participants was 18.49 ± 1.706, ranging from 15 to 25 years old, and 618 (70.5%) of them were within 15–19 years old. More than half (55.4%) and 709 (80.9%) of the students were females and originally from rural areas, respectively. The majority of the students were single 815 (93.0%) and living with their two parents 682 (77.9%) ( Table 1 ).

Table 1. Socio-demographic characteristics of participants among high school adolescents in Northwest Ethiopia ( n = 876), 2021 Gorgonian Calendar (GC).

Clinical characteristics of the respondents

Out of the total participants, 63 (7.2%) have a history of mental illness, 90 (10.3%) have lifetime suicidal ideation, and 55 (6.3%) students had known chronic medical illnesses. Therefore from 55 chronic medical illnesses, the highest was epilepsy ( 32 ), the second was hypertension ( 8 ), and the list observed was asthmatics ( 2 ), and five students had cardiac problems, four students had HIV, and three students had diabetes mellitus ( Table 2 ).

Table 2. Clinical characteristics of participants among high school adolescents in Northwest Ethiopia ( n = 876), 2021 Gorgonian Calendar (GC).

Substance-related characteristics

Regarding substance use, out of the students, 404 (46.1%) were drinking alcohol at least once in their lifetime, whereas khat and cigarette lifetime users were 78 (8.9%) and 57 (6.5%), respectively. About four in five of the students (80.3%) were low risky alcoholic drinkers, whereas moderate and highly risky alcoholic drinkers were 129 (14.7%) and 44 (5.0%), respectively, ( Table 3 ).

Table 3. Substance-related description for participants among high school adolescents in Northwest Ethiopia ( n = 876), 2021 Gorgonian Calendar (GC).

Psychosocial characteristics of participants

Of the participants, about one-third of students have strong social support 293 (33.4%), whereas students who had moderate and poor social support were 339 (38.7%) and 244 (27.9%), respectively. Regarding media usage, 172 (19.6%) of the participants were using social media, and 633 (72.3%) were using mass media.

Prevalence and associated factors of social phobia

In this study, the overall prevalence of social phobia among high school adolescents was shown that 352 (40.2%) with a 95% CI of 37.0 to 43.4%.

Female sex, age less than or equal to nineteen, place of the upbringing of students, father’s educational status, marital status, grade, living arrangements, academic performance, absence from class, history of known chronic medical illness, history of mental illness, family history of mental illness, current alcohol drinking, current khat chewing, and social support were factors associated with SP at p -value less than 0.25 in binary logistic regression. Finally, multivariate analysis revealed that female sex, having a history of known chronic medical illness, family history of mental illness, highly risky current alcohol drinkers, and poor social support were found to be significantly associated with a social phobia with 95% of CI and at p -value less than or equal to 0.05.

Female adolescents were 1.4 times more likely to develop SP as compared with male adolescents (AOR = 1.374, 95% CI = 1.016–1.858), and adolescents who had a history of known chronic medical illness were about 2 (AOR = 2.131, 95% CI = 1.173–3.870) times to develop SP when compared with those who had no medical illness. Another associated factor with SP was having family history of mental illness (AOR = 1.723, 95% CI = 1.071–2.773) which is 1.7 times more odds to have SP than those who had not. Current alcohol drinking is also associated with social phobia (AOR = 1.992, 95% CI = 1.034–3.838). The odds of having social phobia were two times more prevalent in highly risky current alcohol drinkers as compared to low risky alcohol drinkers, and adolescents who had poor social support were about 2.4 times to develop SP when compared to those who had strong social support (AOR = 2.408, 95% CI = 1.660–3.493) ( Table 4 ).

Table 4. Bivariate and multivariate analyses of factors associated with social phobia (SP) among high school adolescents in Northwest Ethiopia ( n = 876), 2021 Gorgonian Calendar (GC).

Social phobia harms educational achievement by increasing school absentees and preventing students to participate in class, and this leads to a significant impairment of the emotional, psychological, social, and physical wellbeing of students. In this study, the prevalence of social phobia and its possible association with different factors were assessed. The result revealed that a remarkable proportion of students had a social phobia.

The finding of the current study showed that the prevalence of social phobia among high school adolescents in Northwest Ethiopia was 40.2% with (95%, CI: 37.0, 43.4%), which was consistent with the findings of other studies done in two areas of India; Sonitpur Assam and Karnataka, India, reported to be 38.3 and 39.7%, respectively, ( 33 , 34 ). The reason for the agreement could be the similar screening tool used in both the previous and the current study called Social Phobia Inventory (SPIN) and the other reason could be the similar type of population; both the current and the Karnataka district were conducted in a rural type of populations ( 35 , 36 ).

However, the prevalence of social phobia in this study was higher than in previous research findings done in Northeastern Ethiopia, high school students (27.5%) ( 10 ). The variation could be the difference in several female participants between the current and previous studies. In the previous study, only 39.6% and, in the current study, more than half (55.4%) were female students. Therefore, traits like submissive behaviors, avoidant personality, and shyness are more likely to be common in female students than males, the latter leading to the development of phobic symptoms ( 20 ). The current social phobia prevalence was also higher in studies done outside Ethiopia among high school adolescents in a comparative study between Arabian countries; Suhag Egypt, Abu Dhabi (UAE), and Abha (Saudi Arabia) were 13, 7.8, and 9.8%, respectively, ( 37 ). Similarly, the current study on social phobia prevalence is also higher than a study done in Abha Saudi Arabia in 2013 (11.7%), Ahmedabad India (12.8), Puducherry India (22.9), Swedish (10.6), Iran (6.2%), and Erbil, Kurdistan Region, Iraq high school students (31.25%) ( 15 , 17 , 20 , 24 , 38 , 39 ). The possible reason for the variation may be due to differences in sociocultural, socioeconomic, measurement tools, type of study populations, and availability of health facilities between those countries and Ethiopia. In Ethiopia, the perceptions of adolescents toward shyness as a measure of politeness are a predominant cultural norm, skills of social interaction might not be well developed, and later adolescents could be easily distressed in social gatherings ( 10 ). People living in low socioeconomic countries like Ethiopia could have poor healthcare infrastructure and a shortage of trained health staff that delivers inadequate healthcare services; in turn, social phobia might not be early identified and treated ( 40 ). The tool assessments used in Abha Saudi Arabia, Sweden, and Iran were different from the tool used in the current study. Leibowitz Social Anxiety Scale test (LSAS), Social Phobia Screening Questionnaire (SPSQ), and DSM four diagnostic tool was used in Saudi Arabia and Sweden, respectively, while the current study was using Social Phobia Inventory (SPIN), which is a non-diagnostic self-administered screening tool, and this might overestimate the prevalence of social phobia among adolescents ( 41 , 42 ).

On the contrary, the current study finding is lower than the previous study done among Abha Saudi Arabia in 2020 (45%) and Scotland UK high school students (53.8%) ( 16 , 43 ). The discrepancy could be the difference in age of participants between the current study and Abha Saudi Arabia and the UK. In the current study, the mean age of participants was 18.49 ± 1.706 and only 54.6% of the students were less than 18 years old, whereas all of the participants in the UK and 93.3% in Saudi Arabia were less than 18 years old, in which social phobia is more likely common as youngers could have lack of social skills, attention, and learning problems ( 16 , 17 ).

Regarding factors affecting social phobia, the female sex was significantly associated with higher rates of a social phobia than males. SP was nearly one and a half times more prevalent among females than males. These findings, supported by other studies in Ethiopia, Puducherry India, Sweden, and Iran, also reported that SP was more frequent in females than in males ( 10 , 15 , 20 , 38 ). The reason could be females are not equally participated in all activities, and especially in Ethiopia their activity is limited at home only because of cultural influence when compared to males; in our culture, males dominated and received special care from their parents and as a result, females have felt uncomfortable in social gatherings ( 10 , 44 ); in all developing countries, the perception of the community toward shyness and politeness as a measure of predominant cultural norm might have influenced the higher prevalence of social phobia among female students ( 20 ).

The present study also showed that social phobia was significantly associated with the presence of known chronic medical illnesses in high school adolescents. The odds of having social phobia were two times more common among students having a history of known chronic medical illness as compared with encounter parts. Similar findings were reported in Southeastern Ethiopia and Abha Saudi Arabia ( 14 , 16 ). There are several possible reasons why students with known chronic medical illnesses may be experienced high levels of social phobia. First, parents of students with known chronic medical illnesses may show overprotective behavior that may risk the development of phobic symptoms ( 45 , 46 ). Second, students with chronic medical illnesses may become socially anxious, because of an increased risk of being rejected by peers ( 47 ). Third, students with known chronic medical illnesses are also faced with dangerous stimuli, such as threatening symptoms of illness, for example, in case seizures may cause phobic symptoms ( 48 ).

Adolescents with a positive family history of mental illness had about 1.7 times more odds to have social phobia as compared with students who had no family history of mental illness. This finding is consistent with other findings done in a comparative study conducted between Egypt, Saudi Arabia, and the United Arab Emirates high school students and also among adolescent populations in South India ( 37 , 49 ). This may be due to genetic factors and the influence of similar cultural and social practices. As highly anxious families have less social interaction with others, the adolescents’ exposure to various social gatherings might also be limited. In turn, this might have negatively affected the development of their social skills and thus made them susceptible to social phobia. In the process, students could not have learned that social situations are harmless ( 49 ).

When compared to low risky alcoholic drinkers, the odds of social phobia were two times more common among highly risky alcoholic drinkers. This was supported by a previous study conducted in Woldia Ethiopia and Nigeria ( 10 , 26 ). The possible reason could be that highly risky current alcoholic drinkers may use alcohol frequently to self-medicate to relieve their fear, anxious feelings, and concerns of negative evaluation by others ( 26 , 50 ).

Finally, students with poor social support had more than two times more likely to have SP as compared with students who had strong social support. This finding was supported by the previous study done in Ethiopia and Iran ( 10 , 51 ). Social connectedness is useful for the development of self-confidence and good social skills. Therefore, if a student loses these skills later, they could be faced difficulties to cope with the situation when exposed to social gatherings ( 10 , 52 ).

Limitations of the study

There might be social desirability bias due to sensitive questions related to substance use. The other limitation is that as a cross-sectional study design was used, the current study design cannot show the direction of the association.

In this study, the overall prevalence of social phobia was high. The distribution of SP among high school adolescents showed that it was higher in the female gender, students who have a history of y known chronic medical illness and family history of y mental illness, highly risky alcoholic drinkers, and poor social support. Therefore, early detection and adequate introversion are crucial to reducing the overall burden of social phobia among high school students. Extending mental health services and strengthening the existing counseling services in all high schools are recommended. The authors also recommended conducting longitudinal research to identify the cause-and-effect relationship of SP with different factors.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving human participants were reviewed and approved by University of Gondar Institutional Review Bored. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.

Author contributions

GN conceptualized the study and involved in design, analysis, interpretation, report, and manuscript writing. MM, GD, and TZ made substantial contribution to conception, analysis, and interpretation of data, drafting the manuscript, and critical revision for important intellectual content. All the authors read and approved the final manuscript.

Acknowledgments

We thank to the University of Gondar for giving us the chance to conduct this research. The author’s appreciation also goes to the study participants, data collectors, and supervisors.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Abbreviations

AOR, adjusted odds ratio; ASSIST, Alcohol, Smoking, and Substance Involvement Screening Test; CI, confidence interval; COR, crude odds ratio; DSM, Diagnostic and Statically Manual; EB, Ethiopian Birr; GC, Gorgonian Calendar; km, kilometer; OR, odds ratio; SP, social phobia; SPIN, Social Phobia Inventory; UAE, United Arab Emirates; UK, United Kingdom; USA, the United States of America; WHO, World Health Organization.

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Keywords : prevalence, social phobia, adolescents, Ethiopia, associated factors

Citation: Nakie G, Melkam M, Desalegn GT and Zeleke TA (2022) Prevalence and associated factors of social phobia among high school adolescents in Northwest Ethiopia, 2021. Front. Psychiatry 13:949124. doi: 10.3389/fpsyt.2022.949124

Received: 20 May 2022; Accepted: 06 October 2022; Published: 25 October 2022.

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Copyright © 2022 Nakie, Melkam, Desalegn and Zeleke. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Girum Nakie, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.