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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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• Research note
• Open access
• Published: 19 July 2019

The prevalence and correlates of social phobia among undergraduate health science students in Gondar, Gondar Ethiopia

• Getachew Tesfaw Desalegn 1 ,
• Wondale Getinet 1 &
• Getnet Tadie 1  

BMC Research Notes volume  12 , Article number:  438 ( 2019 ) Cite this article

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Social phobia is highly prevalent among university students. The lowest and highest point prevalence of social phobia among undergraduate university students was estimated at 7.8% and 80%, respectively. However, research into social phobia and associated factors among undergraduate university students in low and middle-income countries has been limited. Therefore, this study aimed to assess social phobia and associated factors among university students in Ethiopia to contribute an attempt to ensure optimal care for students.

A total of 503 participants were interviewed with a response rate of 100%. The mean age of the respondents was 22.17 (± 10) years. The prevalence of social phobia symptoms among students was found to be 31.2% with (95% CI 27.3 to 35.6%). In the multivariable analysis, poor social support (AOR = 2.8, 95% CI 1.40, 5.60), female sex (AOR = 2.3; 95% CI 1.50, 3.60), 1st-year students (AOR = 5.5; 95% CI 1.80, 17.20), and coming from a rural residence (AOR = 1.6; 95% CI 1.00, 2.40) were factors significantly associated with social phobia symptoms.

Introduction

Social phobia (SP) is the fear of social situations that involved interaction with others with its prevalence ranges from 3 to 13% in the general population [ 1 ]. Globally, the lifetime and current prevalence of social anxiety disorder was estimated at 4% and 1.3%, respectively [ 2 ]. Its onset started in late childhood and associated with new demands for social interaction, younger age, female sex, lower educational status, lower income, and performing in public [ 1 , 3 ].

Social anxiety disorder was fearful in social gatherings, fear of public speaking, meeting new people, and avoidance of social situations [ 1 , 2 , 3 ]. Social fearful persons made bad images of their performance in social situations [ 4 ].

Social phobia was associated with problems within the siblings and the family [ 5 ]. The most common prevalence of social fear among the people was public speaking, and associated with female gender, low educational performance, psychiatric medication use, and absence of social support which led to low self-esteem, more distorted body image, and difficulty to interact with a social environment [ 4 , 6 , 7 , 8 ].

Social phobia was a high prevalence among high school, college, and university students [ 9 , 10 , 11 , 12 ]. Two studies were done among undergraduate university students: the point prevalence of social phobia estimated at 7.8% and 80%, respectively [ 9 , 13 ]. Different studies revealed that the major source of SP among university students was; exam, presentation, language, parental anger, criticism in front of others, exaggerated protection, maltreatment, and family provocation [ 12 , 14 ]. Contributing factors for SP among students were a problem with the peers, roommates, feel that campus environment uncomfortable for study, racial diversity, and too many classmates were making study difficult [ 4 ].

Why students feared situations to diagnosis SP were giving talks in front of the audience and trying to make someone’s intimate romantic relationship [ 15 , 16 ] and different studies reported risk factors of social phobia were; female sex, poor academic performances, psychoactive medication use, poor social support, freshmen, and spending more time thinking about face book [ 9 , 17 , 18 ].

The impact of social phobia among students decreased educational performance, dependence to take alcohol, avoid oral presentations, weak performance at clinical examinations, and develop depressive symptoms [ 13 , 19 ].

Even though social anxiety disorder/social phobia has a high prevalence among university students globally including Ethiopia, little attention is given to its diagnosis and treatment. To the best of our knowledge, there has been no published study on social anxiety symptoms and associated factors among university students in Ethiopia. This study, therefore, aimed to investigate the prevalence and associated factors of social phobia symptoms among undergraduate students with a view to informing the development of interventions.

An institution based cross-sectional study was conducted at the University of Gondar from April to May 2018, Gondar Ethiopia.

Regular undergraduate students at the University of Gondar College of Medicine and Health Sciences were included in the sample and excluded critically ill students.

The sample size was determined by using the single population proportion formula involving the use of Epi-info version 7 with a 95% CI, a 4% margin of error, and a social phobia of 27.5% from previous study conducted among high school adolescents in Ethiopia [ 20 ]. Assuming a 5% non-response rate, 503 students were recruited randomly by using the simple random sampling technique. The total number of students in the college with their identification number taken from the UoG CMHS registrar office; then the required sample was selected through lottery method. The lists of dormitory students took from the UoG CMHS Student’s union dormitory affairs.

Data were collected using a pre-tested self-administered questionnaire, which contained socio-demographic factors, social support, clinical factors, and substance use factors. Social support was collected by the Oslo 3-item social support scale, which had a 3-item questionnaire commonly used to assess social support and used in several studies. The sum score scale ranges from 3 to 14, and had three broad categories: “Poor support” 3–8, “moderate support” 9–11, and “strong support” 12–14 [ 21 ]. Social phobia was measured by using 17 items social phobia inventory (SPI) scale with cut-off point’s ≥ 21. Its score ranges from 0 to 68, which was rated from 0 (not at all) to 4 (extremely) [ 22 ]. Social phobia inventory scale validated in different countries among adults and adolescents [ 23 , 24 ].

Data were entered into Epi-info 7 software after checking for completeness and imported to SPSS version 21 for analysis. Univariate analysis was done to see the association of each independent variable with the outcome variable. Those variables a P-value less than 0.2 were entered into the multivariate logistic regression model to identify the effect of each independent variable with the outcome variables. The strength of the association evaluated by the adjusted odds ratio with a 95% CI, and less than 0.05 P-values were considered statistically significant.

Socio-demographic characteristics

A total of 503 students was included in the study with a response rate of 100%. The mean age of the respondents was 22.17 (± 10) years. Out of the participants, 362 (72%) were male, 472 (93.8%) were single, 289 (57.5%) were coming from the rural residence, and over two-fifth (43.3%) were between the ages of 18 and 21 years. Among the respondents, 185 (36.8%) were 3rd-year students and their grade scored between a range of 2.75 and 3.5 (Table  1 ).

Clinical, social, and substance characteristics

A small number, 13 (2.6%) of the participants had history of mental illness, 84 (16.7%) had a chronic physical illness, and about 3.2% had family history of mental illness. Of the participants, almost two in five (43.3%) students had moderate social support and nearly two in five (41.4%) had poor social support. Regarding the current use of the substance: over two-thirds (43.7%) of the students were drinking alcohol and 56 (11.1%) were taking khat at the movement (Additional file 1 ).

Prevalence of social phobia

The 17-items of social phobia inventory were summed and the single variable was generated. The new variable ranges from 0 to 68 in absolute value. A total of 84 (16.7%) students had mild social phobia (scored about 21 to 30) and 47 (9.3%) of the students had a moderate social phobia (scored 31 to 40). A small number, 19 (3.8%) and 7 (1.39%) of the students had severe and very severe social phobia, respectively (Fig.  1 ). We further categorized social phobia into two levels (no social phobia and social phobia). This study showed that the prevalence of social phobia symptoms among participants was 31.2% with (95%, CI 27.3, 35.6%) (Additional file 2 ).

Bar chart showing that the distribution SPI score for students at the University of Gondar, Northwest Ethiopia in, 2018 (N = 503)

Factors associated with social phobia

Among all covariates, female sex, students studying in the 1st year, family history of mental illness, and poor social support had less than 0.2 a P-value in the univariate logistic regression and were considered as the multiple logistic regression models.

In the multivariable analysis suggested that the odds of social phobia, increased by 2.8 times (95% CI 1.40, 5.60) for students had poor social support compared to students had good social support. Female students were about 2.3 times (95%, CI 1.50, 3.60) more likely risk of social phobia compared to counterparts. Students studying in the 1st year were 5.5 times (95%, CI 1.80, 17.20) more likely to develop social phobia compared to counterparts. Similarly, the risk of social phobia for students whose residence from the rural areas increased by 1.6 times (95%, CI 1.00, 2.40) compared to students whose residence from the urban areas (Table  2 ).

In this study, the prevalence of social phobia and possible association with various factors was assessed. The results of the present study revealed that a remarkable proportion of students had social phobia. The prevalence of social phobia among students was found to be 31.2%.

Regarding prevalence, our result is consistent with those of other studies carried out in Ethiopia, Nigeria, India, and Australia the prevalence was estimated at 27.5%, 31.1%, 28.6%, and 30%, respectively [ 20 , 25 , 26 , 27 ].

On the other hand, the current study finding was higher than those of other studies done in two areas of Saudi Arabia, Canada, Iran, and India, the prevalence was estimated at 14.1%, 16.3%, 7.9%, 17.2%, and 7.8%, respectively [ 5 , 7 , 9 , 11 , 28 ]. The variations might be the distinctions in sample sizes, measurement tools, rating scales, gender differences, and the socio-cultural contrast between Ethiopia and the other countries. In two areas of Saudi Arabia, the sample size was higher than in our study, while the measurement tool was the same [ 5 , 28 ]. Besides the above differences, in two areas of Saudi Arabia took male and female students in their studies respectively [ 6 , 27 ]. In Canada, Iran, and India, the diagnostic interview schedule III, Leibowitz questionnaires, and social interaction anxiety scale tools were used to assess the social phobia among university students, respectively.

However, our result was lower than those of other studies conducted in Saudi, India, Iran, two areas of Iraq and reported 60%, 46%, 78.9%, 58.5%, 80%, and 55.7%, respectively [ 12 , 13 , 19 , 29 , 30 ]. The discrepancy might be the sample size alterations and assessment tool differences. In Saudi, the study conducted among medical students and tested by using social phobia scale which differed from our assessment tool [ 19 ], in India, the study participants were only medical students but in our study all health science students included [ 30 ], in two areas of Iraq, college students and nursing students included in their studies respectively [ 13 , 29 ].

Regarding associated factors, female sex was 2.3 times more likely at risk of increasing social phobia compared to male students. This study supported by those of other studies, females are not equally participated in all activities because of cultural influence when compared to male in Ethiopia [ 20 ], and in Iran, female students had highly prevalence of social anxiety disorder compared to male students [ 11 ]. The rate of specific phobias in women was double those of men [ 1 ]. The prevalence of social phobia near to double in female students compared to male students and the difference might be neglectful parenting styles and authoritarian difference between female and male students. Cultural and biological factors that may underlie sex differences in anxiety disorders [ 31 , 32 ]. Social phobia has been faced comparatively high in female students compared to male students in our culture; males dominated and received special care from their parents. This is the major factors which affect the psychology of females and led to social anxiety symptoms and as a result, females have felt uncomfortable in social gatherings.

Poor social support was 2.8 times more likely to develop social phobia compared to good support this is comparable with the study done in Ethiopia [ 20 ], in Saudi Arabia, female students who had low income were exposed to social anxiety disorder [ 27 ], in India, medical students came from low socioeconomic class were a high risk of social phobia during their education [ 16 ], and school-age adolescents from urban residence had insufficient income families were more risk of social phobia [ 33 ].

Students studying in the 1st year were 5.5 times had social phobia compared to 5th-year students. This study was supported by other study was done in Indian medical college students compared to 2nd-year students but in our study the reference took from 5th-year students because most of the studies had low prevalent of social phobia in the last years of their study [ 17 ]. The 1st and 2nd-year students were highly risky for social phobia, the reason might be the University settings where they forced to live for away from their parents for the first time and expose for new environmental stressors including social situation [ 1 , 34 ].

In Turkish, the 1st and 2nd-year university students had higher anxiety stress scores than other students [ 35 ]. Stress and environmental factors play a role in interpersonal stressors and thus can contribute to the development of social anxiety and differences in background, appearance, language, social and emotional development, all can affect whether or not a student fits in the university [ 36 ].

Finally, students coming from the rural areas were 1.6 times the risk of increasing social phobia compared to urban areas. Which was supported the studies done in India [ 14 ] and residence of students from the rural area in India medical college students developed social phobias which were consistency to our study [ 17 ]. Similar studies in Egypt, the prevalence of social phobia among male students were higher in urban areas but among female students were higher in rural areas [ 32 ] and the magnitude of social phobia was higher among rural areas’ students than urban and suburban students [ 37 ]. In Benin, the University of Parakou (UP) the impact of social phobia on academic performance among students living in rural areas were more risky to social phobia than those living in urban areas which means the prevalence of social phobia depends on the environment [ 34 ]. In Taiwan, rural adolescents were highly vulnerable to specific phobias compared to urban residences [ 38 ]. Another study conducted in India, risk factors of social anxiety in medical students were no significant difference between rural and urban residence [ 39 ]. The people living in rural areas were higher physical symptoms compared to those living in rural areas. The people belonging to urban areas had higher harm avoidance compared to those living in rural areas [ 36 ].

Conclusion and recommendations

In this study, the overall magnitude of social phobia was found to be 31.2%. Female sex, poor social support, students studying in the 1st year, and rural residence were explanatory variables significantly associated with social phobia. The ministry of education and the University of Gondar better to develop guidelines to solve the aforementioned factors. Further research on risk factors for social phobia should be conducted to strengthen and broaden these findings.

Limitations

A cross-sectional design cannot permit conclusions for some variables, for example, to decide whether social phobia symptoms are risks for or consequence. This finding is likely only to hint at the complex interactions between social phobia and explanatory variables (risk factors). The survey samples were a small number of students, the research work provided a summary of survey results. Another most important limitation of this study is the fact that the SPI scale was not validated in Ethiopia although it is widely used as a screening tool for social phobia in other countries. Further research should be considered on risk factors for social phobia to strengthen and broaden our results.

Availability of data and materials

No additional file is available for this study; all the data are included in the manuscript

Abbreviations

cognitive behavioral therapy

College of Medicine and Health Science

Diagnostic and Statistical Manual of Mental Disorders, 5th edition

National Co-morbidity Survey Revised

post traumatic stress disorder

social phobia inventory scale

social phobia scale

University of Gondar

World Health Organization

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Acknowledgements

The authors acknowledge the University of Gondar Department of Psychiatry for funding. The authors appreciate the study institution and the study participants for their cooperation in providing the necessary information.

The funding was funded by the University of Gondar and the funders only involved by giving the funding for the design of a study, data collection, analysis, and interpretation only.

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Getachew Tesfaw Desalegn, Wondale Getinet & Getnet Tadie

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GTD conceived the study and was involved in the study design, reviewed the article, analysis, report writing, and drafted the manuscript. WG and GT were involved in the study design, analysis, and drafted the manuscript. All authors read and approved the final manuscript.

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Ethical approval was obtained from the Institutional Review Board (IRB) of the University of Gondar Department of Psychiatry. The objectives and demand of the study were explained carefully. To ensure confidentiality, participants’ data were linked to a code number and registered. All participants were given information sheets and were included in the study only after providing written consent. Confidentiality was maintained by using anonymous copes and who had a severe social phobia were considered for link a psychiatrist for further investigation and treatment.

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Additional file 1..

Distribution of clinical, social, and substance characteristics of students at UoG, CMHS in, 2018 (n = 503).

Additional file 2.

Pie chart distribution of social phobia among students in the University of Gondar, Northwest Ethiopia in, 2018 (N = 503).

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Desalegn, G.T., Getinet, W. & Tadie, G. The prevalence and correlates of social phobia among undergraduate health science students in Gondar, Gondar Ethiopia. BMC Res Notes 12 , 438 (2019). https://doi.org/10.1186/s13104-019-4482-y

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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.

Reviewed by:

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.

• Open access
• Published: 27 July 2022

Social anxiety disorder and its associated factors: a cross-sectional study among medical students, Saudi Arabia

• Wejdan M. Al‑Johani   ORCID: orcid.org/0000-0003-4851-0934 1 ,
• Nouf A. AlShamlan   ORCID: orcid.org/0000-0002-8049-237X 1 ,
• Naheel A. AlAmer   ORCID: orcid.org/0000-0003-2700-5197 1 ,
• Rammas A. Shawkhan   ORCID: orcid.org/0000-0002-2623-0838 2 ,
• Ali H. Almayyad   ORCID: orcid.org/0000-0001-8633-9432 3 ,
• Layla M. Alghamdi   ORCID: orcid.org/0000-0002-5624-8625 1 ,
• Hatem A. Alqahtani   ORCID: orcid.org/0000-0002-0832-1357 1 ,
• Malak A. Al-Shammari   ORCID: orcid.org/0000-0002-7434-7432 1 ,
• Danya Mohammed Khalid Gari 1 &
• Reem S. AlOmar   ORCID: orcid.org/0000-0003-4899-7965 1  

BMC Psychiatry volume  22 , Article number:  505 ( 2022 ) Cite this article

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Social Anxiety disorder (SAD) is common worldwide. However, data from Saudi Arabia is deficient. This study aims to determine the prevalence of SAD across Saudi medical students and its associations with sociodemographic factors and their academic performance.

The main outcome was presence/absence of SAD and the secondary outcome was its level of severity. These were assessed from the Social Phobia Inventory. Associated factors included sociodemographic variables, as well as educational characteristics of students. Descriptive statistics were reported as counts and percentages, and unadjusted and adjusted odds ratios (OR) and their 95% confidence intervals (CIs) were computed through bivariate and multivariate logistic regression.

Of 5896 Saudi medical students who participated in the study ,  the prevalence of SAD was almost 51%. While 8.21% and 4.21% had reported severe and very severe SAD, respectively. Older age students were at lower risk of developing SAD (OR = 0.92, 95% CI = 0.89 – 0.96). In contrast, females (OR = 1.13, 95% CI = 1.01 – 1.26), students enrolled in private colleges and colleges implementing non-problem-based learning (OR = 1.29, 95% CI = 1.09 – 1.52 and OR = 1.29. 95% CI = 1.15 – 1.46 respectively) were at higher risk. A significant elevated risk of SAD was found among students who had previously failed, and had a low GPA.

SAD is prevalent among the sampled population, and different associated factors were identified. Current results could raise the awareness of faculty members and healthcare providers towards early detection and management of these cases.

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Social Anxiety Disorder (SAD) which was initially named social phobia, is defined according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as an extreme fear or anxiety about one or more social situations in which the individual is exposed to scrutiny by others, for instance, social interactions (e.g., meeting and talking to new people), being observed (e.g., eating or drinking), and performing in front of others (e.g., public speaking) [ 1 ]. The most common reported presentation of SAD was fear of speech-making [ 2 ]. SAD can occur in any public place where a person feels observed and judged by others [ 3 ]. Individuals will develop different cognitive and somatic anxiety symptoms characterized by autonomic stimulation, such as blushing, tremors, increased sweating, and tachycardia [ 4 ].

It is one of the most predominant anxiety disorders among adolescents and younger aged groups, impairing their functioning capabilities if left untreated [ 5 ]. In addition, its high prevalence would make it the third most common mental disorder after depression and alcohol abuse [ 6 ].

The lifetime prevalence of SAD has been reported in various studies, ranging between 3–13% [ 1 ]. The prevalence of SAD among university students has been assessed in multiple studies. In Jordan, Ghana, Nigeria, Brazil and Sweden Universities, the prevalence was around 9–16.1% [ 5 , 7 , 8 , 9 , 10 ]. A higher prevalence of SAD has been found among university students in Ethiopia and India (26%, 31.1%) respectively [ 11 , 12 ]. Moreover, it was associated with female gender, low educational attainment, positive personal or family history of mental disorders, psychiatric medication use, and lack of social support [ 2 , 13 ]. Studies have shown that SAD has led to low self-esteem and impaired body image, consequently negatively impacting on students' academic performance [ 14 , 15 ].

Furthermore, SAD is considered a significant risk factor for developing major depressive disorders and alcohol abuse disorder [ 16 ].

Although various studies worldwide have assessed the prevalence and impact of SAD among different populations, Saudi Arabia's data is scarce. After a thorough literature search, few data regarding SAD among medical students in small cities in Saudi Arabia have been obtained. Medical students are more exposed to academic challenges, including the lengthiest education and training period, the stress of multiple written and clinical examinations, oral presentations, interaction with patients and their families, and exposure to serious life and death issues. Consequently, medical students particularly require intact physical and mental well-being, strong personality structures, and a willingness to attain professional and communication skills to deal with academic challenges [ 17 ]. Therefore, this study aims to estimate the prevalence of SAD among medical students in the Kingdom of Saudi Arabia (KSA) and determine its association with students' sociodemographic factors and academic performance.

Study design and participants

This cross-sectional study included all medical students and medical interns both males and females attending any medical college in Saudi Arabia whether private or governmental. The number of medical colleges in Saudi Arabia is rising to 34 colleges, 27 of which are governmental. All Saudi medical colleges provide six-year undergraduate study, followed by one year of practical internship [ 18 , 19 ].

Sample size and sampling technique

The Saudi Commission for Health Specialties in its most recent published report stated that the total number of undergraduate students in medical colleges both private and governmental was 101,256 students [ 20 ]. The minimum required sample was calculated to be 2342 students using Epiinfo V.7.0. The 51.9% of presence of (SAD) was obtained from a Saudi study that examined social phobia among Saudi students in a single college, with an alpha level of 0.05 and a precision of 2% [ 21 ].

A non-probability sampling technique was used where students were invited to take part by answering an online-based questionnaire. The QuestionPro questionnaire software (Seattle, Washington, USA) was used.

Data collection tool and processes

Data were collected using a validated online self-administered questionnaire consisting of two parts. The first part included the socio-demographic information (age, gender, educational level, marital status, income, and Grade Point Average (GPA)). The second part included the validated Social Phobia Inventory (SPIN) questionnaire by K. M. Connor, a screening tool for SAD, consisting of 17 items. Each point is ranked with a five-degree Likert scale (0 = No, 1 = Low, 2 = Somewhat, 3 = High, 4 = Very Much). The total score ranges from 0 – 68; thus, an individual who scores more than 20 is considered to have SAD. The SPIN had good test–retest reliability, internal consistency, convergent and divergent validity, the Cronbach alpha is 0.85. Therefore, SPIN can be used as a measurement for the screening of SAD and monitoring the responses of treatment [ 22 , 23 ]

The online link of the survey was sent to the students' phone numbers through assigned data collectors from each college. The survey was customized to accept a single response from each number to avoid duplication of responses.

Statistical analysis

The primary outcome in this study was whether medical students had SAD or not according to the Social Phobia Inventory. A secondary outcome is the severity of SAD which may be computed from the inventory itself. After summing all 17 items of the inventory, participants who score less than or equal to 20 are assumed to not have SAD while those who score above 20 do have SAD. As for the severity as a secondary outcome, a participant scoring from 21 to 30 is considered to have mild SAD, 31 to 40 as moderate, 41 to 50 as severe and more than 51 as very severe. Descriptive statistics were obtained by counts and percentages, and potential associations were tested through the Pearson’s X 2 test and the T-test. Trends of proportions over GPA were tested for statistical significance. Unadjusted and adjusted Odds Ratios (ORs) and 95% Confidence Intervals (CIs) were drawn through binary logistic regression analyses where the outcome was for the presence/absence of SAD. Final variables in the regression model were decided based on a Directed Acyclic Graph of associations and were not entirely based on significance testing of bivariate associations. The model with the best fit was chosen based on model diagnostics. The Variance Inflation Factor measure was used to test for multicollinearity. All analyses were performed in Stata V.15.0.

Characteristics of the students

A total of 5896 students participated in this study (5.82% of the target population). It included 44.88% of males and 55.12% of females. The mean age of all students was 22.43 ± 1.68 years. Most students were single (85.72%). Overall, 24.87% had previously failed during their studies. However, the last known GPA was mostly A (43.49%) and only 35 students (0.59%) had a last known GPA of F. Most students belonged to a medical college that implemented a Problem-Based learning scheme (PBL) (65.84%), and only 16.50% of the total respondents were in private medical colleges. According to the Social Phobia Inventory severity score, 49.05% were not found to have SAD, while 20.22% were considered as mild, 18.32% as moderate, 8.21% severe and 4.21% as very severe (Table 1 ).

Figure  1 presents the five-level severity score of the Social Phobia Inventory across the different GPAs of the students. Among those with a GPA of A and B, a larger portion of the students are seen to not have (SAD). Whereas among those with a GPA of F, students were found to have a higher portion of (SAD) across all levels of severity, mild, moderate, severe, and very severe.

The five-level score of the Social Phobia Inventory and students’ GPA, Saudi Arabia, N  = 5896

Factors relating to the presence/absence of social anxiety disorder (SAD)

The presence of SAD was found to be associated with several factors at the bivariate analyses level (Table 2 ). For example, it was found to be associated with age ( P  < 0.01). It was also found to be statistically associated with sex ( P  = 0.02) where females were found to have more SAD compared to males. Previous academic failure and the last known GPA were highly statistically associated with SAD ( P  < 0.001). The data clearly shows that the lower the GPA the more the proportion of SAD (P for trend < 0.001). Neither family income nor the year of study were statistically associated with SAD in the study sample.

Factors associated with SAD according to multivariable analyses

Table 3 shows the results of the binary logistic regression both before and after adjustment. Age was a significant predictor whereby the risk of SAD decreased with increasing age both before and after adjustment (Unadjusted OR = 0.93, 95% CI = 0.90 – 0.96 and Adjusted OR = 0.92, 95% CI = 0.89 – 0.96 respectively). The model also showed that females were significantly more likely to have SAD when compared to males after adjustment (Adjusted OR = 1.46, 95% CI = 1.26 – 1.69). Having previously failed was also associated both before and after adjustment (Unadjusted OR = 1.64, 95% CI = 1.45 – 1.84 and Adjusted OR = 1.46, 95% CI = 1.26 – 1.69). An increase in risk was found with decreased GPA levels, for example the highest odds of 4.13 was found for students with a GPA of F (95% CI = 1.56 – 10.92) when compared to students with a GPA of A. Elevated risk was also observed for students who are enrolled in colleges that do not adopt a problem-based educational scheme and those who are in private colleges (Adjusted OR = 1.29, 95% CI = 1.15 – 1.46 and Adjusted OR = 1.29, 95% CI = 1.09 – 1.52).

The model was highly significant ( P  < 0.001) with a Pseudo R 2 value of 0.16. The Hosmer–Lemeshow value for this model was 11.25, with a p -value of 0.19 indicating good model fit.

The present study demonstrated that about half of the examined medical students in Saudi Arabia screened positive for SAD. Moreover, 8.21% and 4.21% of students had severe and very severe SAD symptoms, respectively. Other studies worldwide have also investigated the prevalence of SAD in undergraduate universities and medical students. Nevertheless, comparing our findings with these studies is difficult because of variations in the methodologies, study tools used, participants' backgrounds, social factors, and cultures. In agreement with the findings from the current study, Al-Hazmi et al., conducted a study among 504 medical students from Taibah university, Saudi Arabia, using the SPIN questionnaire and reported that 13.5% of the participating medical students had severe to very severe SAD [ 21 ]. Findings from the present study were higher than Desalegn et al.'s study which demonstrated that 31.2% (95% CI 27.3 to 35.6%) of undergraduate health science students in Ethiopia had SAD symptoms [ 24 ]. A study among 525 medical students in Germany revealed that 12.2% reported SAD symptoms [ 25 ]. In Iran, Afshari surveyed 400 medical sciences students using the SPIN tool and demonstrated that 41.5% and 13.2% of students had moderate and high SAD, respectively [ 26 ].

Furthermore, the findings of this study showed that SAD is less common among older aged students, which is consistent with Al-Hazmi et al. findings [ 21 ]. The decreased prevalence in older students may be attributed to their exposure to the clinical settings, as senior students tend to interact more with patients and are more experienced in interviewing skills. For instance, Alotaibi et al., found that older aged groups and higher-level students showed a higher score on the positive attitude scale towards learning communication skills [ 27 ]. Moreover, Davis et al.'s study showed that the final-year students had better communication skills than first-year students, indicating that they have a better vision and understanding of the importance of communication skills [ 28 ].

An expected and true finding of the current study is that social anxiety rates are higher among females compared to males. This finding is relevant to the (DSM-5) statement, which revealed that the prevalence of SAD is higher in females, and this difference is more pronounced among adolescents [ 4 ]. A similar finding was obtained by Xu et al.'s data survey from the National Epidemiologic Sample on Alcohol and Related Conditions among the United States adult population where the lifetime prevalence of SAD was higher in females than in males (5.7% and 4.2% respectively) [ 29 ]. Additionally, studies among the Canadian and European populations have shown similar results [ 30 , 31 , 32 , 33 , 34 ]. This outcome is contrary to Elhadad et al.'s study on only 380 medical students in Abha, Saudi Arabia, which found that SAD rates were higher among males. However, the Elhadad study population was obtained from a single institution and a relatively small sample size, hence, their results are less generalizable [ 35 ]. A possible explanation of why females are at higher risk of developing SAD can be best understood from a “vulnerability-stress perspective”. Exposure to variable psychosocial stressors and an increased biological and psychological vulnerability towards anxiety in females may explain the sex differences in anxiety disorders [ 36 ]. Interestingly, the current study found higher SAD rates among divorced, widowed, and singles than married ones. This finding supports the result of the systematic review conducted by Toe et al., which found that SAD was consistently associated with social isolation, such as being unmarried or living alone. Whether social isolation causes social anxiety or vice versa is still unclear [ 37 ].

Moreover, this study demonstrates that students who were enrolled in institutions implementing traditional teaching methods had an increased risk of having phobia compared to the students in PBL institutions, which indicates the effect of different learning styles on students’ mental well-being [ 38 ]. Furthermore, it draws attention to the nature of PBL, which revolves around the idea that a problem is of crucial importance in learning. It focuses on community problems, scientific problems, and real-life scenarios, motivating trainees and boosting their confidence. PBL promotes a deep learning approach rather than a superficial one by making trainees interact with information in a multilevel fashion. The absence of a teacher role in PBL increases the sense of responsibility towards self-learning and promotes personal development [ 39 ]. In other words, PBL is student-centered and encourages communication and teamwork through multiple tools of assessments, including presentations, small group discussions, seminars, assignments, and Objective Structured Clinical Examinations. The repeated exposure to social interactions and public speaking through PBL may increase students' confidence in social and clinical settings [ 40 ].

Many studies have reported high levels of stress and psychological comorbidities among Saudi medical students [ 41 ]. However, studies examining the differences between governmental and private medical schools in Saudi Arabia are limited. Moreover, we propose that the differences in teaching and learning approaches could explain finding a lower risk of SAD among governmental college students than those in private colleges. AlOmar et al. conducted a survey among 3767 students using the Approaches and Study Skills Inventory for Students (ASSIST), which showed that the deep and strategic approaches were predominant among Saudi medical students. In addition, private medical school students were more likely to adopt a strategic rather than a deep learning approach [ 42 ], which suggests that the difference in SAD levels between governmental and private medical college students may be explained by the differences in learning methods.

SAD was found to be associated with impairment in education and work productivity [ 43 , 44 ]. A large cohort, population-based study in Sweden showed an inverse association between SAD and academic performance at different levels [ 43 ]. In line with this finding, the current study revealed that a lower GPA was linked to a higher risk of SAD; hence it was more frequently reported among students with a previous failure in medical school. Furthermore, previous Saudi studies have also reported a similar inverse relationship [ 21 , 35 ]. This may be explained by the fact that medical school environments are highly competitive; students are working hard to achieve higher grades and GPA to look for opportunities in the postgraduate residency programs and jobs. These stressors make medical students vulnerable to mental health problems [ 45 ]. Moreover, the presence of students with low GPA or previous failure with their high achieving colleagues could be another burden on them. It might lead to social isolation, low self-esteem, being inactive in the group work, and consequently having social anxiety symptoms more frequently than their peers.

To the best of our knowledge, the current study is the first Saudi study investigating SAD among a large sample of medical students from all regions in the kingdom. However, some limitations exist. Firstly, the sample only included medical students and did not represent the general Saudi population. Secondly, since the design of the study was cross-sectional, temporality and causality between factors could not be assured. Additionally, despite of the high response rate the possibility of response bias could not be eliminated. Finally, the SPIN tool utilized in the study is a screening tool, and the high-risk cases need a further diagnostic step by a clinical interview.

The current study found that SAD was highly prevalent among the investigated medical students in Saudi Arabia. Older students had lower odds of SAD. On the other hand, being female, studying in private colleges or with non-problem-based learning methods, and having a history of a previous failure in the medical school or a lower GPA were identified as factors that had higher odds of SAD. These findings emphasize the positive role of the university faculty members, counselors, and mentors in supporting these students and encouraging them to participate in curricular and extracurricular activities. In addition, evaluation of the educational environment and the types of the teaching curriculum in Saudi Medical schools is necessary to optimize students learning experience and maintain their psychological wellbeing. Along with enhancing the primary care providers and mental health care experts to accomplish their role of early detection and management of these cases.

Availability of data and materials

The datasets generated and analysed for the current study are not publicly available for data protection reasons. However, the data that support the findings of this study may be available from the corresponding author on reasonable request.

Abbreviations

Social Anxiety Disorder

Diagnostic and Statistical Manual of Mental Disorders

• Kingdom of Saudi Arabia

Grade Point Average

Problem-Based Learning

Approaches and Study Skills Inventory for Students

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The authors would like to acknowledge the efforts of medical students who participated in the data collection. Also, we would like to thank all students who filled out the questionnaires.

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Wejdan M. Al‑Johani, Nouf A. AlShamlan, Naheel A. AlAmer, Layla M. Alghamdi, Hatem A. Alqahtani, Malak A. Al-Shammari, Danya Mohammed Khalid Gari & Reem S. AlOmar

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WMAJ, RSAO, and NAAS conceived the idea and developed the study design. AHA and RAS recruited participants and helped in data collection. Data preparation, statistical analyses, results interpretation, and creation of tables and figures were carried out by RSAO. The initial draft of the introduction, methods, and discussion were written by WMAJ, HAA, LMA, NAAS, AHA, RAS, MAAS, NAAA, and DMKG. The final manuscript was written by WMAJ, RSAO, and NAAS. All authors read and approved the final manuscript.

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Al‑Johani, W.M., AlShamlan, N.A., AlAmer, N.A. et al. Social anxiety disorder and its associated factors: a cross-sectional study among medical students, Saudi Arabia. BMC Psychiatry 22 , 505 (2022). https://doi.org/10.1186/s12888-022-04147-z

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• PMID: 11839136
• DOI: 10.1080/08039480152693327

Social phobia is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity, occurring in about 18% of the clinical population. Despite good results with cognitive-behavioural treatment, social phobia seems to be a chronic disorder with several complications. The author describes an analysis of a divorced woman who was exposed to an early premature sexual seduction by her father, abruptly terminated because of an accident. The loss of the father was repaired by a delusional system as defence against the re-emergence of a catastrophic situation. Her compulsion to repeat the traumatic situation was seen in symbolic attempts to reproduce the lost experience of forbidden pleasure with other men, ending in hopeless affairs. According to DSM-IV the patient had-besides social phobia-several personality disturbances, clinically manifested by weak ego boundaries, an unclear identity, and low self-esteem. Cognitive-behavioural therapy and psychopharmaca were without any effect. The childhood experiences were repeated in the context of the analysis and worked through, especially the pre-oedipal and oedipal conflicts. Important repeating themes were "crime", guilt, and punishment. After 3 years of analysis it was possible for the patient to expose herself to anxiety-producing situations with less symptoms. It was possible for her to withdraw the projections and take more responsibility for the unconscious sexual and aggressive impulses. At the 5-year follow-up her satisfactions had become more realistic and she became involved in a positive relationship.

• Anxiety / psychology
• Cognitive Behavioral Therapy*
• Follow-Up Studies
• Freudian Theory
• Phobic Disorders / therapy*
• Psychoanalysis
• Psychoanalytic Theory
• Transference, Psychology

• Systematic Review
• Open access
• Published: 12 May 2024

Association between problematic social networking use and anxiety symptoms: a systematic review and meta-analysis

• Mingxuan Du 1 ,
• Chengjia Zhao 2 ,
• Haiyan Hu 1 ,
• Ningning Ding 1 ,
• Jiankang He 1 ,
• Wenwen Tian 1 ,
• Wenqian Zhao 1 ,
• Xiujian Lin 1 ,
• Gaoyang Liu 1 ,
• Wendan Chen 1 ,
• ShuangLiu Wang 1 ,
• Pengcheng Wang 3 ,
• Dongwu Xu 1 ,
• Xinhua Shen 4 &
• Guohua Zhang 1  

BMC Psychology volume  12 , Article number:  263 ( 2024 ) Cite this article

Metrics details

A growing number of studies have reported that problematic social networking use (PSNU) is strongly associated with anxiety symptoms. However, due to the presence of multiple anxiety subtypes, existing research findings on the extent of this association vary widely, leading to a lack of consensus. The current meta-analysis aimed to summarize studies exploring the relationship between PSNU levels and anxiety symptoms, including generalized anxiety, social anxiety, attachment anxiety, and fear of missing out. 209 studies with a total of 172 articles were included in the meta-analysis, involving 252,337 participants from 28 countries. The results showed a moderately positive association between PSNU and generalized anxiety (GA), social anxiety (SA), attachment anxiety (AA), and fear of missing out (FoMO) respectively (GA: r  = 0.388, 95% CI [0.362, 0.413]; SA: r  = 0.437, 95% CI [0.395, 0.478]; AA: r  = 0.345, 95% CI [0.286, 0.402]; FoMO: r  = 0.496, 95% CI [0.461, 0.529]), and there were different regulatory factors between PSNU and different anxiety subtypes. This study provides the first comprehensive estimate of the association of PSNU with multiple anxiety subtypes, which vary by time of measurement, region, gender, and measurement tool.

Peer Review reports

Introduction

Social network refers to online platforms that allow users to create, share, and exchange information, encompassing text, images, audio, and video [ 1 ]. The use of social network, a term encompassing various activities on these platforms, has been measured from angles such as frequency, duration, intensity, and addictive behavior, all indicative of the extent of social networking usage [ 2 ]. As of April 2023, there are 4.8 billion social network users globally, representing 59.9% of the world’s population [ 3 ]. The usage of social network is considered a normal behavior and a part of everyday life [ 4 , 5 ]. Although social network offers convenience in daily life, excessive use can lead to PSNU [ 6 , 7 ], posing potential threats to mental health, particularly anxiety symptoms (Rasmussen et al., 2020). Empirical research has shown that anxiety symptoms, including generalized anxiety (GA), social anxiety (SA), attachment anxiety (AA), and fear of missing out (FoMO), are closely related to PSNU [ 8 , 9 , 10 , 11 , 12 ]. While some empirical studies have explored the relationship between PSNU and anxiety symptoms, their conclusions are not consistent. Some studies have found a significant positive correlation [ 13 , 14 , 15 ], while others have found no significant correlation [ 16 , 17 , 18 , 19 ]. Furthermore, the degree of correlation varies widely in existing research, with reported r-values ranging from 0.12 to 0.80 [ 20 , 21 ]. Therefore, a systematic meta-analysis is necessary to clarify the impact of PSNU on individual anxiety symptoms.

Previous research lacks a unified concept of PSNU, primarily due to differing theoretical interpretations by various authors, and the use of varied standards and diagnostic tools. Currently, this phenomenon is referred to by several terms, including compulsive social networking use, problematic social networking use, excessive social networking use, social networking dependency, and social networking addiction [ 22 , 23 , 24 , 25 , 26 ]. These conceptual differences hinder the development of a cohesive and systematic research framework, as it remains unclear whether these definitions and tools capture the same underlying construct [ 27 ]. To address this lack of uniformity, this paper will use the term “problematic use” to encompass all the aforementioned nomenclatures (i.e., compulsive, excessive, dependent, and addictive use).

Regarding the relationship between PSNU and anxiety symptoms, two main perspectives exist: the first suggests a positive correlation, while the second proposes a U-shaped relationship. The former perspective, advocating a positive correlation, aligns with the social cognitive theory of mass communication. It posits that PSNU can reinforce certain cognitions, emotions, attitudes, and behaviors [ 28 , 29 ], potentially elevating individuals’ anxiety levels [ 30 ]. Additionally, the cognitive-behavioral model of pathological use, a primary framework for explaining factors related to internet-based addictions, indicates that psychiatric symptoms like depression or anxiety may precede internet addiction, implying that individuals experiencing anxiety may turn to social networking platforms as a coping mechanism [ 31 ]. Empirical research also suggests that highly anxious individuals prefer computer-mediated communication due to the control and social liberation it offers and are more likely to have maladaptive emotional regulation, potentially leading to problematic social network service use [ 32 ]. Turning to the alternate perspective, it proposes a U-shaped relationship as per the digital Goldilocks hypothesis. In this view, moderate social networking usage is considered beneficial for psychosocial adaptation, providing individuals with opportunities for social connection and support. Conversely, both excessive use and abstinence can negatively impact psychosocial adaptation [ 33 ]. In summary, both perspectives offer plausible explanations.

Incorporating findings from previous meta-analyses, we identified seven systematic reviews and two meta-analyses that investigated the association between PSNU and anxiety. The results of these meta-analyses indicated a significant positive correlation between PSNU and anxiety (ranging from 0.33 to 0.38). However, it is evident that these previous meta-analyses had certain limitations. Firstly, they focused only on specific subtypes of anxiety; secondly, they were limited to adolescents and emerging adults in terms of age. In summary, this systematic review aims to ascertain which theoretical perspective more effectively explains the relationship between PSNU and anxiety, addressing the gaps in previous meta-analyses. Additionally, the association between PSNU and anxiety could be moderated by various factors. Drawing from a broad research perspective, any individual study is influenced by researcher-specific designs and associated sample estimates. These may lead to bias compared to the broader population. Considering the selection criteria for moderating variables in empirical studies and meta-analyses [ 34 , 35 ], the heterogeneity of findings on problematic social network usage and anxiety symptoms could be driven by divergence in sample characteristics (e.g., gender, age, region) and research characteristics (measurement instrument of study variables). Since the 2019 coronavirus pandemic, heightened public anxiety may be attributed to the fear of the virus or heightened real life stress. The increased use of electronic devices, particularly smartphones during the pandemic, also instigates the prevalence of problematic social networking. Thus, our analysis focuses on three moderators: sample characteristics (participants’ gender, age, region), measurement tools (for PSNU and anxiety symptoms) and the time of measurement (before COVID-19 vs. during COVID-19).

The present study was conducted in accordance with the 2020 statement on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 36 ]. To facilitate transparency and to avoid unnecessary duplication of research, this study was registered on PROSPERO, and the number is CRD42022350902.

Literature search

Studies on the relationship between the PSNU and anxiety symptoms from 2000 to 2023 were retrieved from seven databases. These databases included China National Knowledge Infrastructure (CNKI), Wanfang Data, Chongqing VIP Information Co. Ltd. (VIP), Web of Science, ScienceDirect, PubMed, and PsycARTICLES. The search strings consisted of (a) anxiety symptoms, (b) social network, and (c) Problematic use. As shown in Table  1 , the keywords for anxiety are as follows: anxiety, generalized anxiety, social anxiety, attachment anxiety, fear of missing out, and FoMO. The keywords for social network are as follows: social network, social media, social networking site, Instagram, and Facebook. The keywords for addiction are as follows: addiction, dependence, problem/problematic use, excessive use. The search deadline was March 19, 2023. A total of 2078 studies were initially retrieved and all were identified ultimately.

Inclusion and exclusion criteria

Retrieved studies were eligible for the present meta-analysis if they met the following inclusion criteria: (a) the study provided Pearson correlation coefficients used to measure the relationship between PSNU and anxiety symptoms; (b) the study reported the sample size and the measurement instruments for the variables; (c) the study was written in English and Chinese; (d) the study provided sufficient statistics to calculate the effect sizes; (e) effect sizes were extracted from independent samples. If multiple independent samples were investigated in the same study, they were coded separately; if the study was a longitudinal study, they were coded by the first measurement. In addition, studies were excluded if they: (a) examined non-problematic social network use; (b) had an abnormal sample population; (c) the results of the same sample were included in another study and (d) were case reports or review articles. Two evaluators with master’s degrees independently assessed the eligibility of the articles. A third evaluator with a PhD examined the results and resolved dissenting views.

Data extraction and quality assessment

Two evaluators independently coded the selected articles according to the following characteristics: literature information, time of measurement (before the COVID-19 vs. during the COVID-19), sample source (developed country vs. developing country), sample size, proportion of males, mean age, type of anxiety, and measurement instruments for PSNU and anxiety symptoms. The following principles needed to be adhered to in the coding process: (a) effect sizes were extracted from independent samples. If multiple independent samples were investigated in the same study, they were coded separately; if the study was a longitudinal study, it was coded by the first measurement; (b) if multiple studies used the same data, the one with the most complete information was selected; (c) If studies reported t or F values rather than r , the following formula \( r=\sqrt{\frac{{t}^{2}}{{t}^{2}+df}}\) ; \( r=\sqrt{\frac{F}{F+d{f}_{e}}}\) was used to convert them into r values [ 37 , 38 ]. Additionally, if some studies only reported the correlation matrix between each dimension of PSNU and anxiety symptoms, the following formula \( {r}_{xy}=\frac{\sum {r}_{xi}{r}_{yj}}{\sqrt{n+n(n-1){r}_{xixj}}\sqrt{m+m(m-1){r}_{yiyj}}}\) was used to synthesize the r values [ 39 ], where n or m is the number of dimensions of variable x or variable y, respectively, and \( {r}_{xixj} \) or \( {r}_{yiyj}\) represents the mean of the correlation coefficients between the dimensions of variable x or variable y, respectively.

Literature quality was determined according to the meta-analysis quality evaluation scale developed [ 40 ]. The quality of the post-screening studies was assessed by five dimensions: sampling method, efficiency of sample collection, level of publication, and reliability of PSNU and anxiety symptom measurement instruments. The total score of the scale ranged from 0 to 10; higher scores indicated better quality of the literature.

Data analysis

All data were performed using Comprehensive Meta Analysis 3.3 (CMA 3.3). Pearson’s product-moment coefficient r was selected as the effect size index in this meta-analysis. Firstly, \( {\text{F}\text{i}\text{s}\text{h}\text{e}\text{r}}^{{\prime }}\text{s} Z=\frac{1}{2}\times \text{ln}\left(\frac{1+r}{1-r}\right)\) was used to convert the correlation coefficient to Fisher Z . Then the formula \( SE=\sqrt{\frac{1}{n-3}}\) was used to calculate the standard error ( SE ). Finally, the summary of r was obtained from the formula \( r=\frac{{e}^{2z}-1}{{e}^{2z}+1}\) for a comprehensive measure of the relationship between PSNU and anxiety symptoms [ 37 , 41 ].

Although the effect sizes estimated by the included studies may be similar, considering the actual differences between studies (e.g., region and gender), the random effects model was a better choice for data analysis for the current meta-analysis. The heterogeneity of the included study effect sizes was measured for significance by Cochran’s Q test and estimated quantitatively by the I 2 statistic [ 42 ]. If the results indicate there is a significant heterogeneity (the Q test: p -value < 0.05, I 2  > 75) and the results of different studies are significantly different from the overall effect size. Conversely, it indicates there are no differences between the studies and the overall effect size. And significant heterogeneity tends to indicate the possible presence of potential moderating variables. Subgroup analysis and meta-regression analysis were used to examine the moderating effect of categorical and continuous variables, respectively.

Funnel plots, fail-safe number (Nfs) and Egger linear regression were utilized to evaluate the publication bias [ 43 , 44 , 45 ]. The likelihood of publication bias was considered low if the intercept obtained from Egger linear regression was not significant. A larger Nfs indicated a lower risk of publication bias, and if Nfs < 5k + 10 (k representing the original number of studies), publication bias should be a concern [ 46 ]. When Egger’s linear regression was significant, the Duval and Tweedie’s trim-and-fill was performed to correct the effect size. If there was no significant change in the effect size, it was assumed that there was no serious publication bias [ 47 ].

A significance level of P  < 0.05 was deemed applicable in this study.

Sample characteristics

The PRISMA search process is depicted in Fig.  1 . The database search yielded 2078 records. After removing duplicate records and screening the title and abstract, the full text was subject to further evaluation. Ultimately, 172 records fit the inclusion criteria, including 209 independent effect sizes. The present meta-analysis included 68 studies on generalized anxiety, 44 on social anxiety, 22 on attachment anxiety, and 75 on fear of missing out. The characteristics of the selected studies are summarized in Table  2 . The majority of the sample group were adults. Quality scores for selected studies ranged from 0 to 10, with only 34 effect sizes below the theoretical mean, indicating high quality for the included studies. The literature included utilized BSMAS as the primary tool to measure PSNU, DASS-21-A to measure GA, IAS to measure SA, ECR to measure AA, and FoMOS to measure FoMO.

Flow chart of the search and selection strategy

Overall analysis, homogeneity tests and publication bias

As shown in Table  3 , there was significant heterogeneity between PSNU and all four anxiety symptoms (GA: Q  = 1623.090, I 2  = 95.872%; SA: Q  = 1396.828, I 2  = 96.922%; AA: Q  = 264.899, I 2  = 92.072%; FoMO: Q  = 1847.110, I 2  = 95.994%), so a random effects model was chosen. The results of the random effects model indicate a moderate positive correlation between PSNU and anxiety symptoms (GA: r  = 0.350, 95% CI [0.323, 0.378]; SA: r  = 0.390, 95% CI [0.347, 0.431]; AA: r  = 0.345, 95% CI [0.286, 0.402]; FoMO: r  = 0.496, 95% CI [0.461, 0.529]).

Figure  2 shows the funnel plot of the relationship between PSNU and anxiety symptoms. No significant symmetry was seen in the funnel plot of the relationship between PSNU and GA and between PSNU and SA. And the Egger’s regression results also indicated that there might be publication bias ( t  = 3.775, p  < 0.001; t  = 2.309, p  < 0.05). Therefore, it was necessary to use fail-safe number (Nfs) and the trim and fill method for further examination and correction. The Nfs for PSNU and GA as well as PSNU and SA are 4591 and 7568, respectively. Both Nfs were much larger than the standard 5 k  + 10. After performing the trim and fill method, 14 effect sizes were added to the right side of the funnel plat (Fig.  2 .a), the correlation coefficient between PSNU and GA changed to ( r  = 0.388, 95% CI [0.362, 0.413]); 10 effect sizes were added to the right side of the funnel plat (Fig.  2 .b), the correlation coefficient between PSNU and SA changed to ( r  = 0.437, 95% CI [0.395, 0.478]). The correlation coefficients did not change significantly, indicating that there was no significant publication bias associated with the relationship between PSNU and these two anxiety symptoms (GA and SA).

Funnel plot of the relationship between PSNU and anxiety symptoms. Note: Black dots indicated additional studies after using trim and fill method; ( a ) = Funnel plot of the PSNU and GA; ( b ) = Funnel plot of the PSNU and SA; ( c ) = Funnel plot of the PSNU and AA; ( d ) = Funnel plot of the PSNU and FoMO

Sensitivity analyses

Initially, the findings obtained through the one-study-removed approach indicated that the heterogeneities in the relationship between PSNU and anxiety symptoms were not attributed to any individual study. Nevertheless, it is important to note that sensitivity analysis should be performed based on literature quality [ 223 ] since low-quality literature could potentially impact result stability. In the relationship between PSNU and GA, the 10 effect sizes below the theoretical mean scores were excluded from analysis, and the sensitivity analysis results were recalculated ( r  = 0.402, 95% CI [0.375, 0.428]); In the relationship between PSNU and SA, the 8 effect sizes below the theoretical mean scores were excluded from analysis, and the sensitivity analysis results were recalculated ( r  = 0.431, 95% CI [0.387, 0.472]); In the relationship between PSNU and AA, the 5 effect sizes below the theoretical mean scores were excluded from analysis, and the sensitivity analysis results were recalculated ( r  = 0.367, 95% CI [0.298, 0.433]); In the relationship between PSNU and FoMO, the 11 effect sizes below the theoretical mean scores were excluded from analysis, and the sensitivity analysis results were recalculated ( r  = 0.508, 95% CI [0.470, 0.544]). The revised estimates indicate that meta-analysis results were stable.

Moderator analysis

The impact of moderator variables on the relation between psnu and ga.

The results of subgroup analysis and meta-regression are shown in Table  4 , the time of measurement significantly moderated the correlation between PSNU and GA ( Q between = 19.268, df  = 2, p  < 0.001). The relation between the two variables was significantly higher during the COVID-19 ( r  = 0.392, 95% CI [0.357, 0.425]) than before the COVID-19 ( r  = 0.270, 95% CI [0.227, 0.313]) or measurement time uncertain ( r  = 0.352, 95% CI [0.285, 0.415]).

The moderating effect of the PSNU measurement was significant ( Q between = 6.852, df  = 1, p  = 0.009). The relation was significantly higher when PSNU was measured with the BSMAS ( r  = 0.373, 95% CI [0.341, 0.404]) compared to others ( r  = 0.301, 95% CI [0.256, 0.344]).

The moderating effect of the GA measurement was significant ( Q between = 60.061, df  = 5, p  < 0.001). Specifically, when GA measured by the GAD ( r  = 0.398, 95% CI [0.356, 0.438]) and the DASS-21-A ( r  = 0.433, 95% CI [0.389, 0.475]), a moderate positive correlation was observed. However, the correlation was less significant when measured using the STAI ( r  = 0.232, 95% CI [0.187, 0.276]).

For the relation between PSNU and GA, the moderating effect of region, gender and age were not significant.

The impact of moderator variables on the relation between PSNU and SA

The effects of the moderating variables in the relation between PSNU and SA were shown in Table  5 . The results revealed a gender-moderated variances between the two variables (b = 0.601, 95% CI [ 0.041, 1.161], Q model (1, k = 41) = 4.705, p  = 0.036).

For the relation between PSNU and SA, the moderating effects of time of measurement, region, measurement of PSNU and SA, and age were not significant.

The impact of moderator variables on the relation between PSNU and AA

The effects of the moderating variables in the relation between PSNU and AA were shown in Table  6 , region significantly moderated the correlation between PSNU and AA ( Q between = 6.410, df  = 2, p  = 0.041). The correlation between the two variables was significantly higher in developing country ( r  = 0.378, 95% CI [0.304, 0.448]) than in developed country ( r  = 0.242, 95% CI [0.162, 0.319]).

The moderating effect of the PSNU measurement was significant ( Q between = 6.852, df  = 1, p  = 0.009). Specifically, when AA was measured by the GPIUS-2 ( r  = 0.484, 95% CI [0.200, 0.692]) and the PMSMUAQ ( r  = 0.443, 95% CI [0.381, 0.501]), a moderate positive correlation was observed. However, the correlation was less significant when measured using the BSMAS ( r  = 0.248, 95% CI [0.161, 0.331]) and others ( r  = 0.313, 95% CI [0.250, 0.372]).

The moderating effect of the AA measurement was significant ( Q between = 17.283, df  = 2, p  < 0.001). The correlation was significantly higher when measured using the ECR ( r  = 0.386, 95% CI [0.338, 0.432]) compared to the RQ ( r  = 0.200, 95% CI [0.123, 0.275]).

For the relation between PSNU and AA, the moderating effects of time of measurement, region, gender, and age were not significant.

The impact of moderator variables on the relation between PSNU and FoMO

The effects of the moderating variables in the relation between PSNU and FoMO were shown in Table  7 , the moderating effect of the PSNU measurement was significant ( Q between = 8.170, df  = 2, p  = 0.017). Among the sub-dimensions, the others was excluded because there was only one sample. Specifically, when measured using the FoMOS-MSME ( r  = 0.630, 95% CI [0.513, 0.725]), a moderate positive correlation was observed. However, the correlation was less significant when measured using the FoMOS ( r  = 0.472, 95% CI [0.432, 0.509]) and the T-S FoMOS ( r  = 0.557, 95% CI [0.463, 0.639]).

For the relationship between PSNU and FoMO, the moderating effects of time of measurement, region, measurement of PSNU, gender and age were not significant.

Through systematic review and meta-analysis, this study established a positive correlation between PSNU and anxiety symptoms (i.e., generalized anxiety, social anxiety, attachment anxiety, and fear of missing out), confirming a linear relationship and partially supporting the Social Cognitive Theory of Mass Communication [ 28 ] and the Cognitive Behavioral Model of Pathological Use [ 31 ]. Specifically, a significant positive correlation between PSNU and GA was observed, implying that GA sufferers might resort to social network for validation or as an escape from reality, potentially alleviating their anxiety. Similarly, the meta-analysis demonstrated a strong positive correlation between PSNU and SA, suggesting a preference for computer-mediated communication among those with high social anxiety due to perceived control and liberation offered by social network. This preference is often accompanied by maladaptive emotional regulation, predisposing them to problematic use. In AA, a robust positive correlation was found with PSNU, indicating a higher propensity for such use among individuals with attachment anxiety. Notably, the study identified the strongest correlation in the context of FoMO. FoMO’s significant association with PSNU is multifaceted, stemming from the real-time nature of social networks that engenders a continuous concern about missing crucial updates or events. This drives frequent engagement with social network, thereby establishing a direct link to problematic usage patterns. Additionally, social network’s feedback loops amplify this effect, intensifying FoMO. The culture of social comparison on these platforms further exacerbates FoMO, as users frequently compare their lives with others’ selectively curated portrayals, enhancing both their social networking usage frequency and the pursuit for social validation. Furthermore, the integral role of social network in modern life broadens FoMO’s scope, encompassing anxieties about staying informed and connected.

The notable correlation between FoMO and PSNU can be comprehensively understood through various perspectives. FoMO is inherently linked to the real-time nature of social networks, which cultivates an ongoing concern about missing significant updates or events in one’s social circle [ 221 ]. This anxiety prompts frequent engagement with social network, leading to patterns of problematic use. Moreover, the feedback loops in social network algorithms, designed to enhance user engagement, further intensify this fear [ 224 ]. Additionally, social comparison, a common phenomenon on these platforms, exacerbates FoMO as users continuously compare their lives with the idealized representations of others, amplifying feelings of missing out on key social experiences [ 225 ]. This behavior not only increases social networking usage but also is closely linked to the quest for social validation and identity construction on these platforms. The extensive role of social network in modern life further amplifies FoMO, as these platforms are crucial for information exchange and maintaining social ties. FoMO thus encompasses more than social concerns, extending to anxieties about staying informed with trends and dynamics within social networks [ 226 ]. The multifaceted nature of FoMO in relation to social network underscores its pronounced correlation with problematic social networking usage. In essence, the combination of social network’s intrinsic characteristics, psychological drivers of user behavior, the culture of social comparison, and the pervasiveness of social network in everyday life collectively make FoMO the most pronouncedly correlated anxiety type with PSNU.

Additionally, we conducted subgroup analyses on the timing of measurement (before COVID-19 vs. during COVID-19), measurement tools (for PSNU and anxiety symptoms), sample characteristics (participants’ region), and performed a meta-regression analysis on gender and age in the context of PSNU and anxiety symptoms. It was found that the timing of measurement, tools used for assessing PSNU and anxiety, region, and gender had a moderating effect, whereas age did not show a significant moderating impact.

Firstly, the relationship between PSNU and anxiety symptoms was significantly higher during the COVID-19 period than before, especially between PSNU and GA. However, the moderating effect of measurement timing was not significant in the relationship between PSNU and other types of anxiety. This could be attributed to the increased uncertainty and stress during the pandemic, leading to heightened levels of general anxiety [ 227 ]. The overuse of social network for information seeking and anxiety alleviation might have paradoxically exacerbated anxiety symptoms, particularly among individuals with broad future-related worries [ 228 ]. While the COVID-19 pandemic altered the relationship between PSNU and GA, its impact on other types of anxiety (such as SA and AA) may not have been significant, likely due to these anxiety types being more influenced by other factors like social skills and attachment styles, which were minimally impacted by the epidemic.

Secondly, the observed variance in the relationship between PSNU and AA across different economic contexts, notably between developing and developed countries, underscores the multifaceted influence of socio-economic, cultural, and technological factors on this dynamic. The amplified connection in developing countries may be attributed to greater socio-economic challenges, distinct cultural norms regarding social support and interaction, rising social network penetration, especially among younger demographics, and technological disparities influencing accessibility and user experience [ 229 , 230 ]. Moreover, the role of social network as a coping mechanism for emotional distress, potentially fostering insecure attachment patterns, is more pronounced in these settings [ 231 ]. These findings highlight the necessity of considering contextual variations in assessing the psychological impacts of social network, advocating for a nuanced understanding of how socio-economic and cultural backgrounds mediate the relationship between PSNU and mental health outcomes [ 232 ]. Additionally, the relationship between PSNU and other types of anxiety (such as GA and SA) presents uniform characteristics across different economic contexts.

Thirdly, the significant moderating effects of measurement tools in the context of PSNU and its correlation with various forms of anxiety, including GA, and AA, are crucial in interpreting the research findings. Specifically, the study reveals that the Bergen Social Media Addiction Scale (BSMAS) demonstrates a stronger correlation between PSNU and GA, compared to other tools. Similarly, for AA, the Griffiths’ Problematic Internet Use Scale 2 (GPIUS2) and the Problematic Media Social Media Use Assessment Questionnaire (PMSMUAQ) show a more pronounced correlation with AA than the BSMAS or other instruments, but for SA and FoMO, the PSNU instrument doesn’t significantly moderate the correlation. The PSNU measurement tool typically contains an emotional change dimension. SA and FoMO, due to their specific conditional stimuli triggers and correlation with social networks [ 233 , 234 ], are likely to yield more consistent scores in this dimension, while GA and AA may be less reliable due to their lesser sensitivity to specific conditional stimuli. Consequently, the adjustment effects of PSNU measurements vary across anxiety symptoms. Regarding the measurement tools for anxiety, different scales exhibit varying degrees of sensitivity in detecting the relationship with PSNU. The Generalized Anxiety Disorder Scale (GAD) and the Depression Anxiety Stress Scales 21 (DASS-21) are more effective in illustrating a strong relationship between GA and PSNU than the State-Trait Anxiety Inventory (STAI). In the case of AA, the Experiences in Close Relationships-21 (ECR-21) provides a more substantial correlation than the Relationship Questionnaire (RQ). Furthermore, for FoMO, the Fear of Missing Out Scale - Multi-Social Media Environment (FoMOS-MSME) is more indicative of a strong relationship with PSNU compared to the standard FoMOS or the T-S FoMOS. These findings underscore the importance of the selection of appropriate measurement tools in research. Different tools, due to their unique design, focus, and sensitivity, can reveal varying degrees of correlation between PSNU and anxiety disorders. This highlights the need for careful consideration of tool characteristics and their potential impact on research outcomes. It also cautions against drawing direct comparisons between studies without acknowledging the possible variances introduced by the use of different measurement instruments.

Fourthly, the significant moderating role of gender in the relationship between PSNU and SA, particularly pronounced in samples with a higher proportion of females. Women tend to engage more actively and emotionally with social network, potentially leading to an increased dependency on these platforms when confronting social anxiety [ 235 ]. This intensified use might amplify the association between PSNU and SA. Societal and cultural pressures, especially those related to appearance and social status, are known to disproportionately affect women, possibly exacerbating their experience of social anxiety and prompting a greater reliance on social network for validation and support [ 236 ]. Furthermore, women’s propensity to seek emotional support and express themselves on social network platforms [ 237 ] could strengthen this link, particularly in the context of managing social anxiety. Consequently, the observed gender differences in the relationship between PSNU and SA underscore the importance of considering gender-specific dynamics and cultural influences in psychological research related to social network use. In addition, gender consistency was observed in the association between PSNU and other types of anxiety, indicating no significant gender disparities.

Fifthly, the absence of a significant moderating effect of age on the relationship between PSNU and various forms of anxiety suggests a pervasive influence of social network across different age groups. This finding indicates that the impact of PSNU on anxiety is relatively consistent, irrespective of age, highlighting the universal nature of social network’s psychological implications [ 238 ]. Furthermore, this uniformity suggests that other factors, such as individual psychological traits or socio-cultural influences, might play a more crucial role in the development of anxiety related to social networking usage than age [ 239 ]. The non-significant role of age also points towards a potential generational overlap in social networking usage patterns and their psychological effects, challenging the notion that younger individuals are uniquely susceptible to the adverse effects of social network on mental health [ 240 ]. Therefore, this insight necessitates a broader perspective in understanding the dynamics of social network and mental health, one that transcends age-based assumptions.

Limitations

There are some limitations in this research. First, most of the studies were cross-sectional surveys, resulting in difficulties in inferring causality of variables, longitudinal study data will be needed to evaluate causal interactions in the future. Second, considerable heterogeneity was found in the estimated results, although heterogeneity can be partially explained by differences in study design (e.g., Time of measurement, region, gender, and measurement tools), but this can introduce some uncertainty in the aggregation and generalization of the estimated results. Third, most studies were based on Asian samples, which limits the generality of the results. Fourth, to minimize potential sources of heterogeneity, some less frequently used measurement tools were not included in the classification of measurement tools, which may have some impact on the results of heterogeneity interpretation. Finally, since most of the included studies used self-reported scales, it is possible to get results that deviate from the actual situation to some extent.

This meta-analysis aims to quantifies the correlations between PSNU and four specific types of anxiety symptoms (i.e., generalized anxiety, social anxiety, attachment anxiety, and fear of missing out). The results revealed a significant moderate positive association between PSNU and each of these anxiety symptoms. Furthermore, Subgroup analysis and meta-regression analysis indicated that gender, region, time of measurement, and instrument of measurement significantly influenced the relationship between PSNU and specific anxiety symptoms. Specifically, the measurement time and GA measurement tools significantly influenced the relationship between PSNU and GA. Gender significantly influenced the relationship between PSNU and SA. Region, PSNU measurement tools, and AA measurement tools all significantly influenced the relationship between PSNU and AA. The FoMO measurement tool significantly influenced the relationship between PSNU and FoMO. Regarding these findings, prevention interventions for PSNU and anxiety symptoms are important.

Data availability

The datasets are available from the corresponding author on reasonable request.

Abbreviations

• Problematic social networking use
• Generalized anxiety
• Social anxiety
• Attachment anxiety

Fear of miss out

Bergen Social Media Addiction Scale

Facebook Addiction Scale

Facebook Intrusion Questionnaire

Generalized Problematic Internet Use Scale 2

Problematic Mobile Social Media Usage Assessment Questionnaire

Social Network Addiction Tendency Scale

Brief Symptom Inventory

The anxiety subscale of the Depression Anxiety Stress Scales

Generalized Anxiety Disorder

The anxiety subscale of the Hospital Anxiety and Depression Scale

State-Trait Anxiety Inventory

Interaction Anxiousness Scale

Liebowitz Social Anxiety Scale

Social Anxiety Scale for Social Media Users

Social Anxiety for Adolescents

Social Anxiety Subscale of the Self-Consciousness Scale

Social Interaction Anxiety Scale

Experiences in Close Relationship Scale

Relationship questionnaire

Fear of Missing Out Scale

FoMO Measurement Scale in the Mobile Social Media Environment

Trait-State Fear of missing Out Scale

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• Published: 07 November 2023

Social virtual reality helps to reduce feelings of loneliness and social anxiety during the Covid-19 pandemic

• Keith Kenyon   ORCID: orcid.org/0000-0002-5084-9024 1 ,
• Vitalia Kinakh 2 &
• Jacqui Harrison 1  

Scientific Reports volume  13 , Article number:  19282 ( 2023 ) Cite this article

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Evidence shows that the Covid-19 pandemic caused increased loneliness, anxiety and greater social isolation due to social distancing policies. Virtual reality (VR) provides users with an easy way to become engaged in social activities without leaving the house. This study focused on adults, who were socialising in Altspace VR, a social VR platform, during the Covid-19 pandemic and it explored whether social VR could alleviate feelings of loneliness and social anxiety. A mixed-methods research design was applied. Participants (n = 74), aged 18–75, completed a questionnaire inside the social VR platform to measure levels of loneliness (UCLA 20-item scale) and social anxiety (17-item SPIN scale) in the social VR platform (online condition) and real world (offline condition). Subsequently, a focus group (n = 9) was conducted to gather insights into how and why participants were using the social VR platform. Findings from the questionnaire revealed significantly lower levels of loneliness and social anxiety when in the social VR platform. Lower levels of loneliness and social anxiety were also associated with participants who socialised with a regular group of friends. In addition, findings from the focus group suggested that being part of an online group facilitates stronger feelings of belonging. Social VR can be used as a valuable intervention to reduce feelings of loneliness and social anxiety. Future studies should continue to establish whether social VR can help to encourage group formation and provide people with enhanced social opportunities beyond the COVID-19 pandemic.

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Introduction.

On the 11th March 2020 the World Health Organisation declared the rapidly spreading Corona virus outbreak a pandemic 1 and world governments began to impose enforced social isolation rules. Throughout 2020/2021 the majority of countries imposed lengthy periods of lockdown. The first UK lockdown lasted almost 4 months and during this time only essential travel was permitted and interaction with others from outside the direct household was forbidden 2 . The lock-down caused disruption to daily routines, social activities, education and work. Social distancing measures led to a collapse in social contact. When people experience a reduction in social contact or when the quality of interaction with others is diminished, they can suffer feelings of loneliness. Nearly 7.5 million adults experienced "lockdown loneliness," which is the equivalent to around 14% of the population. 3 Additionally, the percentage of the UK population reporting loneliness increased from 10% in March 2020 to 26% in February 2021 4 .

Social isolation and loneliness

Social isolation and loneliness are different. Social isolation is commonly defined as “the state in which the individual or group expresses a need or desire for contact with others but is unable to make that contact” 5 , p. 731 . Social isolation can occur due to quarantine or physical separation. Due to quarantine measures enforced during lockdown, people faced involuntary social isolation or at least a reduction in their social interactions to the point that their social network was quantitatively diminished 6 . Loneliness is a subjective experience that arises when a person feels that they are isolated and deprived of companionship, lack a sense of belonging, or that their social interactions with others are diminished in either quantity or quality 7 .

Social isolation, loneliness and detrimental implications for physical and mental health

The rise of loneliness during lockdown also increased the prevalence of anxiety 3 and such health problems as depressive symptoms and insomnia, reconfirming findings from earlier research 8 that explored the relationship between social isolation and loneliness and the effect it has on our physical and mental health. Loneliness can lead to stress and high blood pressure, a sedentary or less active lifestyle, and a reduction in cognitive function 9 , 10 , 11 . Loneliness can also lead to less healthy behaviours e.g. an increase in alcohol consumption and smoking 12 , a poor diet 13 and poor sleeping patterns 14 . Loneliness has been found to have an impact on a person’s social wellbeing leading to feelings of low self-esteem and worthlessness as well as increased anxiety and decreased levels of happiness, resulting in depression 11 , 15 , 16 , 17 .

Technology-based interventions to reduce social isolation and loneliness

Within the last decade several systematic reviews have focused on technology-based interventions for people who are experiencing or who are at risk of experiencing loneliness and social isolation 18 , 19 , 20 , 21 . Masi et al. 18 in their meta-analysis, explored the efficacy of technology-based vs non-technology-based interventions across all population groups, notably, the mean size effect for technology-based interventions was − 1.04 (N = 6; 95% CI  − 1.68, − 0.40; p  < 0.01), as opposed to − 0.21 (N = 12; 95% CI  − 0.43, 0.01; p = 0.05) for non-technology-based interventions. Choi et al. 19 reported a significant pooled reduction in loneliness in older adults after implementing technology-based interventions (Z = 2.085, p  = 0.037). Early technology-based interventions consisted of conference calls/video conferencing, text-based Inter Relay Chat and Emails 18 , 19 , 20 . Subsequent systematic reviews 21 , 22 found that video conferencing was able to reduce loneliness in older particpants, however, this technology only helped to facilitate communication between existing, rather than new contacts. These types of intervention are therefore less beneficial for individuals who are socially isolated and struggling to establish connections with others.

During the Covid-19 lockdowns there was no possibility to provide or continue providing face-to-face individual or group interventions for lonely people. Moreover, even non-lonely people found themselves in situations where they could not maintain their social relationships through face-to-face interactions. Thus, the Department of Primary Care and Public Health in England recommended that avenues for mitigating feelings of loneliness should look to include web- and smartphone-based interventions 23 .

Virtual reality (VR) using a head mounted display (HMD) is considered qualitatively different from other technologies in that it has the ability to provide a sensation of immersiveness or ‘being there’ 24 . VR technologies are becoming more accessible and comfortable with the creation of lighter more portable HMDs at a more affordable cost. This allows the technology to be used by a greater range of adults and members of vulnerable groups, e.g. adults with mobility impairments and older adults with age-related impairments. VR users, often represented as avatars, are able to meet and communicate in real-time with each other within a range of different scenarios. People are able to participate in social activities with new people, e.g. venturing off into new and exciting worlds (with nature scenes) 24 , travelling to different destinations around the world 25 , 26 without leaving their homes and escaping their confined realties or engaging in horticultural therapeutic interactions 27 . Older adults are able to engage in social networking activities, including playing games with other people and attending family events through VR, users spoke very positively and expressed visible signs of enjoyment about their experience 28 , 29 , 30 . Virtual gaming is very popular among younger users with 31 , 32 reporting that players experience significantly lower levels of loneliness and social anxiety when playing VR games compared within the real world.

Users taking part in VR interventions report being less socailly isolated, show less signs of depression, and demonstrate greater levels of overal well-being 24 , 25 , 26 , 27 , 33 , 34 . Widow(er)s in a VR support group showed a significant improvement during an 8-week intervention 35 . While both systematic reviews 33 , 34 reported useful insights regarding the positive impact of VR technology on loneliness, most studies on VR environments included a small number of participants from specific populations, thus the reported findings have limited generalisability.

When VR is used as an intervention to reduce social and public speaking anxiety, it is found to be most effective as a mode of delivery for alternative therapeutic interventions such as Acceptance and Commitment Therapy 36 . Furthermore, Kim et al. 37 found that patients with Social Anxiety Disorder (SAD) benefitted from the use of VR as an intervention, evidenced by short-term neuronal changes during exposure. They concluded that VR is useful as a first intervention for SAD patients who are unable to access formal treatment.

Various social VR platforms have emerged since 2013, e.g. VRChat, Altspace VR and RecRoom, however, the use of social VR as an intervention for reducing social isolation and loneliness is still a relatively new and unexplored field. Therefore, whilst there is research to support the effectiveness of VR as a tool to deliver therapeutic interventions and improve social well-being, there is limited research on the use of social VR as an online mechanism to decrease social isolation and improve group belonging.

Innovation and contributions of this study

The current study is a cross-sectional study of the general population, socially isolated during the Covid-19 pandemic and who were using social VR platforms to interact with each other. This study addresses the limitations of previous studies, which have focused exclusively on specific groups within the population, i.e. older adults or VR gamers, or explored general well-being rather that loneliness and social anxiety. In previous studies the HMDs were often provided by the research team, meaning that there was a time restrain (frequency or length) in relation to the use of the VR technology by participants. This study is novel as it explores the effects of loneliness and social anxiety on a wider demographic of people, who have unrestricted access to HMDs and have been socialising in Altspace VR during the Covid-19 pandemic. This study is of an international character and utilises a mixed methods approach to explore the benefits of social VR to help reduce feelings of loneliness and social anxiety and to provide additional means by which social contact can be enhanced for vulnerable populations who may remain isolated post-pandemic.

Research hypotheses

The following hypotheses were explored:

Lower levels of loneliness and social anxiety are experienced when participants are in the social VR platform (online) compared with in the real-world condition (offline).

Lower levels of loneliness and social anxiety are experienced by participants who are part of a group in social VR, i.e. members of a Virtual Social Group (VSG), than those who are not.

Lower levels of loneliness and social anxiety are experienced by participants who have a group of friends in the social VR in comparison with those who do not.

Lower levels of loneliness and social anxiety are experienced by participants who spend greater amounts of time in social VR.

The study used a convergent parallel mixed-methods research design 38 to collect both diverse quantitative and qualitative data (see Fig.  1 ). The study complied will relevant ethical regulations and was approved by the Research Ethics Committee of the University of Bolton, UK. Written informed consent was obtained from all participants.

A convergent parallel mixed-methods model of the current research.

Collection of quantitative data

Participants.

Participants were required to be English speaking, over the age of 18 and users of Altspace VR. A message of invitation was posted on different Discord community channels/message boards: Official Altspace VR; Educators In VR; Spatial Network; Humanism; Computer Science in VR; VR Church. 87 participants were recruited via an opportunity sampling method.

Materials and measures

A private research room was created inside Altspace VR to ensure that participants were able to complete the questionnaire undisturbed (see Fig.  5 ). The online questionnaire was created in Qualtrics XM and could be accessed across multiple devices: Oculus Quest, Oculus GO, Oculus Rift, HTC Vive and PC. The online questionnaire included sections about demographics, details of Altspace VR usage and sections assessing participant’s subjective feelings of loneliness and social anxiety. Measures of loneliness and social anxiety were collected for both conditions—real world (offline condition), followed by social VR (online condition).

The UCLA Loneliness Scale version 3 39 was used to measure the subjective level of loneliness. This 20-item self-reporting questionnaire uses a four-point Likert scale, with 0 = “Never”, 1 = “Rarely”, 2 = “Sometimes”, 3 = “Often”. The loneliness score for each participant (range from 0 to 60) was determined as the sum of responses to all 20 items—higher scores reflecting greater loneliness. The UCLA Loneliness scale was adapted to include the word Altspace in the online condition as it was felt that this would further help participants to focus specifically on the online experience. No further adaptations were made to this questionnaire. The Social Phobia Inventory (SPIN) scale 40 was used to measure the subjective level of social anxiety as it is effective in measuring the severity of social anxiety. This 17-item self-reporting questionnaire uses a five-point Likert scale, with 0 = “Not at all”, 1 = "A little”, 2 = “Somewhat”, 3 = “Very much”, 4 = “Extremely”. Adding the scores from each item produced a SPIN score for each participant. A higher SPIN score indicates more severe symptoms of social anxiety. No adaptations were made to the SPIN questionnaire.

Participants who were interested in taking part in the survey were taken to the research room inside Altspace VR where they were sent a message with a link to the online questionnaire. Participants who clicked on the link were then presented with a browser window inside the room that only they could see. Participants who opened the questionnaire were first presented with the participant information sheet giving full details of the study. Information regarding withdrawal from the study and a list of additional support services were also provided in line with the University of Bolton’s ethical guidelines. After reading the study information sheet, participants were presented with the consent form for which full consent was required before they were able to move onto the survey.

The strategy for dealing with incomplete cases was to remove any participants who did not answer all of the questions, thus analysis was conducted on 74 participants. Exported data from the Qualtrics system was imported into the Statistical Package for Social Sciences (IBM SPSS, version 25). A Kolmogorov–Smirnov test ( p  > 0.5) was carried out to test for a normal distribution and histograms, nominal Q-Q plots and box plots were used to identify any outliers. Two outliers were found in the data for Social Anxiety in the offline condition and these were replaced with the mean of 17.54 .

Characteristics of the sample

Of the total sample (n = 74), 46 were males and 28 females. The age range of respondents was 18–75 years (the split of valid participants is shown in Table 1 ). Participants were recruited globally (the geographical demographic is shown in Fig.  2 ). Out of these 74 participants, 31 participants (15 males, 16 females) were new to Altspace VR, having joined Altspace VR during the Covid-19 pandemic. 43 participants indicated that they had used Altspace VR before the outbreak of Covid-19.

Participant’s location.

Change in loneliness and social anxiety

Figure  3 shows the breakdown of social anxiety scores in both the online and offline conditions. The data shows that the severity of social anxiety is higher in the offline condition, whereas participant’s levels of anxiety reduce when they are online.

Participant’s SPIN Scores.

The UCLA loneliness scale uses continuous scoring and so it is not possible to provide a similar breakdown for participant’s levels of loneliness. The effect that social VR has on the participant will be discussed in greater detail later.

It was anticipated that during the Covid-19 pandemic and as a direct result of social distancing rules being imposed that general usage in Altspace VR would increase. Figure  4 shows that 76% of participants felt that their usage had increased and after calculating the average difference in usage (before and during Covid-19) an average increase per user of 11 h per week was reported.

Participants usage of Altspace VR since Covid-19.

Hypothesis 1

Hypothesis 1 predicted lower levels of loneliness and social anxiety are experienced when participants are in social VR (online) compared with in the real-world condition (offline) A paired-samples t-test was carried out to compare online (inside social VR) and offline (real-world) conditions for both loneliness and social anxiety. The results in Table 2 demonstrate a statistically significant decrease in the scores for loneliness from the offline condition (M = 20.53, SD = 14.80) to the online condition (M = 16.32, SD = 11.04), t  = − 2.573, p  < 0.05. A statistically significant decrease in social anxiety was found in the offline condition (M = 23.01, SD = 16.65) compared to the online condition (M = 16.34, SD = 13.09), t  = − 5.80, p  < 0.05. A small to moderate effect size 41 was found for both variables (i.e. d loneliness = 0.32 and d social anxiety = 0.45).

Hypotheses 2, 3 and 4

H2 predicted that lower levels of loneliness and social anxiety are experienced by participants who are part of a group in social VR than those who are not.

Being a member of a VSG means that the participant meets with a group or number of groups on a regular basis to take part in scheduled events, e.g. regular church services for members of VR Church; discussions around education each week for members of Educators in VR; mediation and relaxation sessions for members of the EvolVR group; and discussions on a whole range of matters relating to life in the Humanism group. 75.7% of participants (n = 56) indicated that they were a member of a VSG and 24.3% (n = 18) were not affiliated with any groups.

A one-way between participants ANOVA was carried out to compare the effect of being a member of a VSG separately for each of the dependent variables. No significant effect was found for loneliness in both the online condition F(1,72) = 0.17, p  = 0.68 and offline condition F(1,72) = 1.63, p  = 0.20. No significant effect was found for social anxiety in the online condition F(1,72) = 2.22, p  = 0.14, however, a significant effect was found for social anxiety in the offline condition F(1,72) = 4.23, p  < 0.05, η 2  = 0.06 (a medium effect size). This finding suggests that participants who are part of a VSG experience less social anxiety (M = 20.80, SD = 15.64) than those who are not (M = 29.89, SD = 18.26) when in the real world (offline) condition.

H3 predicted that lower levels of loneliness and social anxiety are experienced by participants who have a group of friends in social VR in comparison with those who do not. This differs from Hypothesis 2 in that having friends in Altspace VR is seen as a deeper connection than simply taking part in group events where connections may not have been formed. Participants were grouped on whether they have a circle of friends in social VR with whom they regularly socialise with (52.7%, n = 39) and not (47.3%, n = 35).

A one-way between participants ANOVA was carried out to compare the effect of having a circle of friends separately for each of the dependent variables. A significant effect was found for loneliness in the online condition F(1,72) = 6.75, p  < 0.05, η 2  = 0.08 (a medium effect size), whereas no significant effect was found for loneliness in the offline condition F(1,72) = 0.03, p  = 0.86. This suggests that participants who have a circle of online friends experience less loneliness (M = 13.28, SD = 11.02) than those who do not (M = 19.71, SD = 10.17). A significant effect was found for social anxiety in both the online condition F(1,72) = 6.82, p  < 0.05, η 2  = 0.09 (a medium effect size) and offline condition F(1,72) = 9.18, p  < 0.01, η 2  = 0.11 (a large effect size). This suggests that participants who have a circle of online friends experience less social anxiety (M = 12.72, SD = 12.64) than those who do not (M = 20.37, SD = 12.54) in both online and offline conditions.

H4 predicted that lower levels of loneliness and social anxiety are experienced by participants who spend greater amounts of time in social VR. There was a reasonable balance of participants who have been members of Altspace VR for more than 6 months prior to (n = 43) and who joined during (n = 31) the Covid-19 pandemic.

A one-way between participants ANOVA shows a significant effect for loneliness in the online condition F(1,72) = 4.68, p  < 0.05, η 2  = 0.06 (a medium effect size), whereas no significant effect was found for loneliness in the offline condition F(1,72) = 0.08, p  = 0.93. This suggests that participants who have been members of Altspace VR for more than 6 months experienced less loneliness (M = 14.02, SD = 11.63) than those who joined during the Covid-19 pandemic (M = 19.52, SD = 09.43). No significant effect was found for social anxiety in the online condition F(1,72) = 2.13, p  = 0.15, however, a significant effect was found for social anxiety in the offline condition F(1,72) = 4.77, p  < 0.05, η 2  = 0.06 (a medium effect size). This suggests that participants who have been members of Altspace VR for more than 6 months experienced less social anxiety (M = 19.51, SD = 16.82) than those who recently joined (M = 27.87, SD = 15.38).

Discussion of quantitative results

Research into the use of web-based technologies and virtual worlds has consistently demonstrated positive effects of such interventions on an individual’s subjective feelings of loneliness and social anxiety. Hypothesis 1 of this study is therefore supported and is consistent with the earlier findings 31 , 32 , 42 , 43 and a recent review 44 .

The results of this study in relation to hypothesis 2 were unable to support the assumption that being part of a VSG will reduce feelings of loneliness. The study was therefore unable to support findings from 32 which reported that VR gamers who played as part of a guild were less likely to experience feelings of loneliness. Social identity theory 45 provides a possible explanation for this. Teaming up with a specific VR gaming guild with the common purpose of defeating an enemy for example exerts a stronger sense of identity and group attachment compared to belonging to multiple virtual social groups, where an individual could have several social identities, thus group attachment is less salient. Furthermore, group attachment takes time to develop and within Altspace VR new VSGs are being created all the time. Future studies should look to explore the relationship between the membership duration and the strength of group attachment and the effect this has on subjective feelings of loneliness.

The results of this study support hypothesis 3 in that participants, who have a circle of friends with who they regularly socialise in social VR, experience lower levels of loneliness and social anxiety. This is consistent with the findings of 32 who found that playing with known people helps to reduce feelings of loneliness and social anxiety. This also further supports the findings of 46 who found that half of participants considered their gamer friends to be comparable to their real-life friends. As pointed out by 47 in the Need to Belong Theory, people need frequent and meaningful interactions to feel fulfilled. The ability to form positive social interactions with people with which we feel most connected, i.e. a circle of friends that share our goals or with which we have a common purpose, promotes greater levels of satisfaction and generates greater feelings of belonginess, which in turn reduces our feelings of loneliness and social anxiety 48 .

The results of this study in relation to hypothesis 4 support the assumption that the longer a person has been in social VR the lower will be their feelings of loneliness. There was a significant reduction in feelings of loneliness in the online condition, but not in the offline condition. The explanation for the divergence is that both new and existing Altspace VR users were experiencing similarly high levels of loneliness in the real-world condition, due to the sudden enforced period of lockdown that was imposed upon them, and that whilst being in social VR for a longer period of time showed a greater reduction in feelings of loneliness, in the real world the length of time they had been using social VR was not significant. A possible explanation for this is that when returning to the real world a person is again faced with the challenges of the imposed social isolation and will therefore continue to experience greater levels of loneliness. The reverse situation was found for social anxiety with a significant reduction in social anxiety being found in the offline condition for participants who had been using social VR for longer. This is a useful finding because it shows that using social VR for longer periods of time can help to reduce feelings of social anxiety in the real world. As is suggested by 42 social VR can be used to build up social capital and thereby help to improve a person’s social skills in the real world.

Focus group

Nine participants (6 male, 3 female) who took part in the online questionnaire were later recruited to take part in a focus group. The demographics of this group are shown in Table 3 . The focus group was made up of a wide mix of people from around the world. Participants were a mix of educators, students, developers and other professionals. Four of the participants were new to Altspace VR, having joined during the Covid-19 pandemic, whilst five had been in Altspace VR for more than 6 months. All the participants had previously attended at least one Educators in VR research event.

The focus group study took place in a private research room inside of Altspace VR (see Fig.  5 ), purposely created by the researcher. Only selected participants were able to join this room via a portal link provided by the researcher. The interview was recorded using OBS screen recording software on the researcher’s computer.

Virtual research room.

Prompts were kept to a minimum and questions were open-ended to elicit rich responses from participants. The focus group was later transcribed verbatim by the researcher. The transcript was analysed using a thematic data analysis approach as per the Braun and Clarke framework 49 . Thematic analysis is a suitable analytic approach to systematically establish patterns of meaning within qualitative data sets 50 . Microsoft Word was used to facilitate data management and the coding of themes. Participants’ responses were coded and themes identified.

Qualitative results

Four superordinate themes with several subordinate themes were identified (see Table 4 ).

Theme 1. Why the participant visits the social VR platform

Participants spoke freely about how they got involved in Altspace VR and what they believe to be the main reason they visit Altspace VR. Three sub-themes were discovered, although from the discussions it was clear that most, if not all, participants, valued the group interaction and attendance at events very highly.

Socialising in VR

What was interesting about the group of participants in the focus group was that they were all connected due to their involvement with the Educators in VR community and not through friendship ties. Some participants highlighted that they initially joined Altspace VR to meet new people and then started building a network of professional relationships.

Participant quotes from the transcripts are given within the results section for each subordinate theme. For confidentiality purposes quotes from participants will be referenced as: Participant (P), followed by a number 1–9 and the participant’s gender M (male), F (female) e.g. “P1M”.

“In VR I hang out with friends and of course the [Educators in VR] research team, but I don’t hang out around the campfire as much anymore” (31-33,P3F).

The campfire in Altspace VR is a meeting place for new users to mingle, chat and make friends. New users to Altspace VR tend to levitate towards the campfire until they establish friendship groups and events in which to take part in. This participant has already established a network of meaningful friendships and they are now spending less unstructured time in social zones.

All participants highlighted that they had seen an increase in their usage during the Covid-19 pandemic. The imposed restrictions on physical meetups led to several participants using social VR to meet with real-world friends to satisfy their social needs.

“During this pandemic I have probably come in an hour or two more per day. Part of that was to connect with some of my friends. I got some friends to start coming into Altspace VR so we were able actually hang out in Altspace” (52-55,P5F). “more recently, in the last month or so, because I work in the VR community and a lot of my personal friends have VR headsets, the people that I work with at the university, The people that are in my groups and in my sphere so to speak at the university are some of my best friends and so we have started having social meet-ups in VR for nothing other than social, like just for social meet-ups” (125-132,P1M)

Attending community events and learning new skills

All of the focus group participants recognised the value of taking part in regular events in social VR. In particular, participants were positive about the opportunities that exists within Altspace VR to collaborate with others to expand and learn new skills. Community involvement within Altspace VR generates a strong sense of belonging thus reducing feelings of loneliness and social anxiety.

“I got inspired by the Covid situation to host events, so it inspired me to bring people together. I think if the Covid situation did not happen I wouldn’t have organised these research meetings to be honest, so it was pretty much the catalyst to hosting events” (161-165,P3F) “One thing I love about the Altspace environment is the Educators forum because I have joined philosophy classes, I’ve done Psychology classes, I’ve really interacted. In fact, I started a talk show, [ ] my own event, and that’s one thing that I love about Altspace, so I do love this place” (72-78,P7M)

Sharing ideas with professionals and like-minded people

Altspace VR allows users to create their own events and to share knowledge with other users. There are a wide range of different interest groups within Altspace VR. Establishing common interests with others is a cornerstone to forming positive and meaningful relationships. Establishing a network of contacts is also beneficial by encouraging, giving advice and supporting each other in difficult times 51 . Several of the participants commented that social VR is a useful tool not least during periods of enforced social isolation, but also to those who find themselves unable to form such relationships within their existing real-world social networks.

“I entered Altspace mainly for the Educators in VR conference and after that, during the Covid crisis obviously I stayed because it is a perfect place to find people that have a similar interest with mine” (62-64,P6F). “It’s almost impossible where I live to find people with similar interests like mine, so this is probably the only way for me to find people with similar interests” (188-190,P6F) “I love coming here because there are so many truly brilliant people with so much to learn and so many interesting things to hear and see” (105-107,P9M)

Theme 2. How the participant sees their current situation

Although participants were not specifically asked, they took it upon themselves to reflect how they see the current situation and their specific circumstance in terms of being socially isolated. Participants felt that they were socially isolated and less social for several reasons. These have been broken down into the following sub-themes.

Introverted/anti-social

Several participants stated that they are socially inhibited and anxious individuals, who find socialising in the real world more challenging, whereas social VR offers a less intimidating way for them to meet and make friends.

“If you struggle with social interaction, VR is a little less intimidating, I would say. I really think these platforms are a great way to connect and less intimidating as well” (240-245,P3F) “Prior to Covid I was actually pretty like unsocial, I still kind of am unsocial, but it seems as though now society is kind of like bending towards introverts so in a sense it’s like the market’s benefiting my type so like in a sense I’m becoming increasingly more social” (18-22,P2M).

Socially isolated due to remote location and work/life balance

Some participants lamented that their geographic location or work/life balance in the real world made it very difficult for them to meet and to have frequent interactions with people with similar interests to theirs. This aspect makes them at a greater risk of loneliness to others. Social interaction within social VR is not restricted by geographic location and so these participants feel that this has helped to enhance their social interaction with others.

“I use VR to socialise because I live in a little village so for me it’s the only way to meet people, to communicate with people etc because normally I don’t meet people in the real life. With my friends and with my brother etc so I use the VR to socialise okay” (40-43,P4M) “I went on sabbatical in September this academic year I spent my entire summer, last year outside hiking and camping and all of that and then all of a sudden I was inside doing research and I was isolated from my community. I feel like my work community is my community, you know, and I felt like I lost my community and I felt like I found a new one in Altspace” (259-265,P1M)

Theme 3. How the participant sees the social VR platform

Several participants elaborated in detail on how they felt that social VR helped them to connect with people in ways that were better than alternative digital communication methods such as video conferencing, text chat or social media.

Greater immersion/presence

Immersion and presence are important characteristics within VR because the aim after all is to replicate, to some degree, the feelings of being within the real world. The more this is made possible the more useful VR will be in combating feelings of loneliness and social anxiety during periods of prolonged isolation in the real world.

“I’ve been in here with students for tutorials and […] students have said that they feel more presence with other students in this environment” (108-111,P9M) “I’m a perceptual psychologist so I even think about it from the view of like it feels like some of the spaces that I go into now in Altspace really regularly feel in my head like real spaces that I go to so when I feel like I go to a couple of events in the afternoon in Altspace and then I take the headset off it kind of feels like I left my house and I went out and did something and then came back, it doesn’t feel like I was in my house the whole time” (154-160,P1M)

More ways to connect

In addition to the greater immersion and presence that VR can create, Altspace VR also gives individuals the ability to control and create their own environments for social interaction. It is not possible within the real world for most of us to simply create our own hang-outs or to control our environments so easily. This allows people to therefore interact in ways that up until now have not been possible. Several participants linked the ability to create stimulating and exciting environments in the Altspace VR to something that they can feel proud of, and this gives them social capital over other users with less advanced skills in world creation. This in turn helps to improve their ability to socialise and build further friendships in social VR that they would not have been able to build in the real world.

“I made a beach environment, a beach world and there are other ones out there, but I made a custom private one for me and my friends to meet in and so we meet in there and other places and we bounce around and look at different places but we often find somewhere like a private room where we can actually have a nice private conversation and we don’t have to worry about anyone interfering and everyone said its fantastic it really allows us to connect in ways, you know like those personal chats you have with close friends that it’s hard to do in any other medium, it feels a little more natural in VR to do that and so it’s been fantastic, we’ve been really enjoying it” (132-142,P1M) “Since coming in here now [my friends] are like world building and have created some really awesome spaces in here and so we go in and check out the space that they just created and so I’m still kind of doing project oriented hang-outs as far as like we will be like oh that lighting needs to be a little different and stuff like that but it’s been a really fun way to hang out with people that I already may have been friends with before all this happened but now that this happened they are starting to come into this space so we can connect even more often” (214-222,P5F)

Theme 4. How social VR is helping during the Covid-19 pandemic

In the second part of the focus group, participants were asked to think about how they thought Altspace VR was helping them specifically during the Covid-19 pandemic and whether they thought that others could benefit from this experience too. The responses were very positive and provided a great deal of insight into how Altspace VR is helping them to deal with loneliness and social anxiety during Covid-19. A number of key sub-themes emerged from this category.

Helps people feel less lonely

Several participants said that social VR helps them to feel connected with a circle of friends and that this helps to reduce feelings of loneliness and depression.

“I feel it really does help me in social isolation. I have been on sabbatical this last year so my whole year has been about isolation even before Covid-19, I’ve been working a lot on my own and that sort of thing so yeah becoming part of the community in Altspace, collectively in the different ways that I have has had a huge impact on my mental health. I was getting a little depressed in the fall and having this community has really felt like that it brought me out of it a bit” (147-154,P1M) “By the second semester I only had like one course and we were like really concentrating on a specific project and everything and it was like really limiting me to go outside and do some other stuff. Even though I’m an introvert but I do feel like I really wanted to go outside and have some fun. I really like to see other stuff around me and doing all this stuff here in VR kept me really engaged with the communities” (191-197,P8M)

Helps to motivate and provide structure

Having a purpose and being occupied with an interesting project and subsequently conversing about its progress/issues with others in social VR were perceived as motivational factors, which helped them to deal with the imposed social isolation.

“Events really motivated me to keep busy also when I was in social isolation for two months. Yeah, two months is a long time you know to not get out of your house so that was great I created some sense of purpose and it was really heart-warming to see everybody come together and really interesting people as well. Everybody has something cool to share and was very helpful so that gave me some energy, you know to just keep on going and make the best out of the situation” (166-173,P3F) “I finally have a structure for a project that I have been thinking about for over a year now and having these interactions in here and talking to people allowed me to bring a clear picture of how I can start a project I have been thinking about and start building it inside Altspace, so that’s a big plus for me” (178-182,P6F)

Helps people to be less anti-social and reduced social anxiety

Several participants explained that social VR is “a great way to connect and less intimidating as well” for socially anxious, i.e. “unsocial” and “introverted” people, who as a result often feel lonely. In addition, social VR is a convenient tool for social interactions as it brings people closer “especially during these situations, but not only during like pandemics”. (240–243,P3F)

“In my case the Covid increased my social interaction with people because I’m a pretty anti-social person in real life so for me this has increased ten-fold my social interaction in general” (174-176,P6F). “Covid pushed people inside spaces like VR and made my social interactions far easier to have” (186-188,P6F). “I am in sort of a group, let’s say of people who have problems with connecting with people, this is awesome. This is definitely a big plus and I would like more of this” (322-324,P6F) “I was, I guess, somewhat socially isolated before coming in Altspace I tend to just like to work on projects and stay at home or be at work, but since coming in Altspace I’ve definitely started experiencing more of the social aspect of living like making connections with other people in ways that aren’t strictly like a project that I’m working on and so that’s been nice” (202-208,P5F). “I do think that VR can help us, those of us who are socially isolated or have social anxieties of some sort. It does make it more accessible for us to be able to go into a space and interact with people. For instance in real life, if you were to have social anxiety and you start feeling almost like a panic attack coming on, that would prevent you from going into a real life space, whereas in VR you […] can say, oh I have to go really easily and you’re back in your home and you can work through whatever may have come up with social anxiety. So I do think it makes social interactions more accessible in those cases” (307-316,P5F)

Helps to socialise with real life friends during lock-down

Another idea that surfaced among the participants is the potential to use social VR as a mode of interaction/engagement with real-life friends/family members who live afar. Participants expressed the view that the current restriction on face-to-face contact could to some extent be counterbalanced by inviting real-world friends into social VR to socialise.

“The fully social part of VR has happened because of the Covid-19 situation, because I used to go for dinners with people like every month, […] and we can’t do the real world social, so we are trying to do the VR social” (142-146,P1M) “Once everyone went into social isolation for Covid I actually started hanging out with a friend that lives 3 hours away from me more than before because before it would be a 3 hour drive, but then once all this happened, I actually convinced them to come into Altspace” (208-212,P5F) “It’s been a really fun way to hang out with people that I already may have been friends with before all this happened but now that this happened they are starting to come into this space so we can connect even more often. (218-222,P5F).

Discussion of qualitative findings

Overall, participants’ commentaries to Theme 1 reconfirm that their usage of social VR has increased during the period of imposed social isolation and restrictions on physical meetups due to the Covid-19 pandemic. They were using social VR to meet with real-world friends to satisfy their social needs and continue to receive support from people they are close to; or to mix socially with other users who they meet either at a “campfire” or whilst taking part in regular events inside of the social VR platform, thus expanding their social network of non-intimate contacts. As a result, they felt less lonely online (whilst being in Altspace VR) as they felt like they were in the same space together. Interestingly, participants noted that they also benefited emotionally from meeting like-minded people/professionals and sharing ideas with them, getting support and advice, and working together in real-time. This is a new explanation why people use VR technology, which did not surface in the earlier research studies. Nonetheless this reason ties with the Need to Belong Theory 47 . This is useful to help us to understand why users visit Altspace VR in general and during the enforced social isolation period.

In theme 2 participants’ responses reiterate what has already been explained in the literature that shy, socially inhibited and anxious individuals find online anonymity liberating and less inhibited than the real world 52 . Moreover, in Altspace VR it is also possible to make use of non-verbal communication such as emojis or emoticons (see Fig.  6 ).

Use of emojis to communicate in Altspace VR.

Some participants commented that their geographic location or work/life balance in the real world made it very difficult for them to meet people with similar interests. The social internet, e.g. Facebook 53 and video conferencing 54 have long been used to socialise with friends and family and have been found to be an affective intervention for reducing loneliness. Theme 3 considers that social VR could be regarded as the latest endeavour within this field as individuals are able to create their own exciting hangouts, e.g. a beach or a city from Ancient Greece. Furthermore users are able to easily control environments and restrict entry. This allows people to interact in ways that up until now have not been possible.

Findings in Theme 4 give a clear indication that social VR helps to reduce feelings of loneliness, and this further supports the findings of 32 . Social interactions in social VR are also particularly attractive to those who are lonely or shy/socially anxious/self-conscious or have poor social skills, etc. as they feel more in control of their online interactions and feel that they have a broader range of topics that they are able to discuss compared with in the real world 55 . Lonelier people also feel that they can be more themselves in online social interactions than in the real world 56 .

General discussion

People use social VR for many different reasons: to socialise with new and existing friends; to join social interest groups; to learn new skills and generally to be part of a larger community of people (including other professionals) than those that they are part of in the real world. Social VR attracts a wide range of people because of the ease in which people can meet people with similar interests to their own, although it could be argued that up until the recent Covid-19 pandemic social VR tended to attract a greater amount of people who found real-life social interaction difficult. The results of this study show a reduction in social anxiety in individuals with moderate, severe and very severe social anxiety in the online condition, i.e. when using social VR. The increase in availability of VR headsets in recent years has led to an expansion in usage of social VR and the recent Covid-19 pandemic and subsequent social distancing rules led to more people and organisations making a greater use of VR to communicate and carry out their daily business and routines during the prolonged period of social isolation. Social VR also enables people to collaborate in ways not possible within the real world, reducing geographic restrictions and breaking through communication barriers by using visually stimulating content creation tools to enhance the process of human interaction through world-building and event hosting.

The main objective of this study was to explore whether social VR could be used to help reduce feelings of loneliness and social anxiety amongst people confined to their homes and away from their regular friendship groups and social connections, i.e. when the quantity and quality of their social network is gravely affected. Overall, the synthesised results of the present study show that participants experience a statistically significant reduction in loneliness and social anxiety when in social VR than in the real world during prolonged periods of imposed social isolation. Qualitative findings support/validate the quantitative results for H1. Thus, the evidence shows that social VR can decrease the sense of loneliness and social anxiety with users and have an overall positive effect on their emotional and social wellbeing.

The qualitative data diverges from the quantitative results presented for H2 that addressed the effect of being part of a VSG separately for loneliness and social anxiety. The quantitative results showed no significant effect for loneliness in the online and the offline conditions, whereas participants’ views showed that being a member of a VSG created a sense of belongingness and helped them to feel less lonely and depressed. Quantitative data showed no significant effect for social anxiety when an individual is a member of a VSG or not; but revealed a medium effect for social anxiety in the offline condition indicating that users, who are part of a VSG and subsequently take part in regular group events, experience less social anxiety in real world (i.e. offline), than those who are not part of a VSG. Participants who are part of a VSG were positive about the possibilities of social VR and being part of a VSG, because this setup helped shy and socially inhibited individuals to observe conversations, use emojis to show emotions rather than speak, use the online anonymity to get over the discomfort of social interactions and gradually become more connected and accepted by other members of the VSG. This prepares socially anxious individuals to handle being out there (in online and the real world).

Qualitative findings are in line with the quantitative results for H3 in that the degree of loneliness and social anxiety is also further reduced by factors such as having a circle of online friends. Social VR allows people to meet others who share similar interests, this is more difficult within the real world for people who struggle with social anxiety or who live in remote locations for example, or as was the case with this study, people who were confined to their homes due to social distancing rules during a pandemic. The qualitative data helps to produce a better understanding in relation to ‘online friends’ as these include individuals who were met in social VR and real-life friends who currently live afar and were invited to join the social VR platform.

The qualitative findings somewhat converge with quantitative results for H4 in that online loneliness reduces with the length of time the participant has been using social VR, i.e. participants who had been using social VR for greater than 6 months experienced less loneliness than those who joined during the Covid-19 pandemic. The length of time the participant had been using social VR had no effect on their feelings of loneliness in the real world. Comments from participants who have been members of Altspace VR for more than 6 months revealed that finding a new (online) community that supports their need to belong and provides meaningful and positive social interactions acted as an antidote to the loneliness that they experience in the real world. Individuals who struggle to build meaningful relationships in the real world due to social anxiety and other social phobias turn to social VR as it provides a less confrontational way in which to form and maintain social relationships with others and therefore help to reduce feelings of loneliness and social anxiety.

Research limitations and implications

The heterogeneity of the sample for the quantitative survey enabled conclusions to be drawn regarding the participant experience in Altspace VR, their subjective feelings of loneliness and social during the Covid-19 pandemic. However, in interpreting the views of participants in the focus group it should be stressed that the sample of participants was solely recruited from the Educators in VR research event and that this may not represent the views of others who do not take part in such events. Although the reported themes were clearly identified, there remains a possibility that additional themes would be detected should the views of participants from a wider pool be collected.

It is the researcher’s understanding that this is the first study that has exclusively focused on participant’s feelings of loneliness and social anxiety during a period of enforced prolonged isolation whereby social VR has been utilized as an intervention to help reduce such feelings. The results offered here, should therefore be taken as a starting point upon which further empirical studies could be built. Longitudinal investigations could be carried out to further assess the suitability of social VR as an intervention to help reduce loneliness and social anxiety amongst specific communities, e.g. remote learners/workers, people living alone or in care, the less physically able, prisoners and other sub-groups of people facing loneliness and social anxiety whereby their ability to socialise with other is in some way restricted. Future research would also need to provide accurate estimates of the prevalence of loneliness and social anxiety in these sub-groups.

The COVID-19 pandemic forced people to change the way in which they connected with others during lockdown. Social VR helped to improve social connectedness during the COVID-19 pandemic and reduce “lockdown loneliness”. Post-pandemic it is necessary to recognise the additional needs that face society, especially vulnerable people and those struggling with mental health issues resulting from lockdown. Social VR can, therefore, be a way of further supporting people facing social isolation, loneliness and social anxiety. Social VR platforms may be virtual, but the relationships we build in them are very real.

Data availability

All data generated or analysed during this study are included in this published article or in the accompanying Supplementary Information file.

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Kenyon, K., Kinakh, V. & Harrison, J. Social virtual reality helps to reduce feelings of loneliness and social anxiety during the Covid-19 pandemic. Sci Rep 13 , 19282 (2023). https://doi.org/10.1038/s41598-023-46494-1

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Understanding the Different Types of Anxiety Disorders

• Generalized Anxiety Disorder

Panic Disorder

• Social Anxiety Disorder

Separation Anxiety Disorder

• OCD and PTSD Classification

Living With Anxiety Disorders

• Next in Anxiety Disorder Guide Causes and Risk Factors of Anxiety

An anxiety disorder is a mental health condition that involves intense feelings of fear or worry. Different types of anxiety disorders affect millions of Americans. For example, 15 million U.S. adults experience social anxiety disorder, and 6 million experience panic disorder.

Anxiety disorders can be challenging and may greatly impact daily life. Learn about the different types of anxiety disorders, their causes, treatment, coping, and more.

Kseniya Ovchinnikova / Getty Images

Generalized Anxiety Disorder (GAD)

People with GAD experience intense feelings of worry or fear that occur most days for six months or longer. This anxiety is related to a variety of different areas of life, such as relationships, careers, health, and safety. GAD affects nearly 6% of adults at some point in their lives.

In addition to worry and fear that is difficult to control, symptoms of GAD may include:

• Changes in sleep or difficulty sleeping
• Difficulty concentrating
• Digestive issues
• Feeling restless
• Irritability
• Tense muscles , often in the neck and shoulders

While some people may be genetically prone to GAD, this condition may run in families partially because of life circumstances and the home environment. The specific causes are not fully understood.

Diagnosis involves an evaluation with a healthcare provider or mental health professional (such as a psychiatrist, psychologist, or social worker) who will ask questions and assesses the condition.

Treatment can include the following, which may be combined:

• Psychotherapy : Cognitive behavioral therapy (CBT) teaches how to modify your thinking, behavior, and reaction to situations. Acceptance and commitment therapy teach strategies to address negative thoughts and reduce anxiety.
• Medication : Antidepressants or antianxiety medications may be prescribed.

Panic disorder is a condition in which a person experiences many panic attacks over a long period of time. The panic attacks come on suddenly, without any known danger, and involve intense feelings of fear or feelings of losing control. This condition is more than twice as common among females than males.

Symptoms of a panic attack include:

• Difficulty breathing
• Feeling weak
• Increased heart rate
• Light-headedness
• Pain in the chest
• Shaking or chills
• Sweating with our without feeling hot
• Upset stomach

A person with panic disorder is intensely fearful of experiencing another panic attack, and they often fear or avoid places where they have had a panic attack.

Like GAD, it is not entirely clear what causes panic disorder. People who experience traumatic events or loss are at an increased risk. A mental health professional such as a psychiatrist can diagnose this condition with an evaluation that involves asking questions.

Panic disorder can be treated with talk therapy (psychotherapy) techniques such as cognitive behavioral therapy (CBT), coping techniques, relaxation exercises , support groups, lifestyle changes, and medications (antidepressants, antianxiety drugs, beta-blockers ).

Social Anxiety Disorder (SAD)

SAD involves fear or worry related to social interactions. Women are more likely to experience SAD than men, especially among teens and young women. Additionally, their symptoms tend to be more severe.

Social anxiety disorder symptoms include:

• Avoiding social situations or interactions
• Extreme shyness or fear of talking to new people
• Feelings of nervousness , embarrassment, or being judged
• Overthinking conversations
• Ruminating about interactions with others

The specific causes of social anxiety disorder are unclear. It may run in families, and stress and environmental factors also may play a role.

Similar to other types of anxiety disorders, SAD can be diagnosed by talking with a mental health professional. Some providers offer virtual appointments, which tend to be easier for people experiencing symptoms of SAD. Treatment may involve talk therapy, medications, or both.

Separation anxiety disorder involves intense fear or reaction related to being apart from those to whom the individual is attached. These fears and reactions are normal for babies and young children but can become a concern if they do not grow out of it around school age. This condition may also affect teens and adults.

Symptoms of separation anxiety disorder include:

• Difficulty sleeping, leaving the house, or taking part in activities that involve being away from a primary caregiver
• Extreme reaction when separated from a primary caregiver
• Fear or worry related to danger for a primary caregiver or self
• Feeling physically ill when separated from a primary caregiver
• Intense desire to constantly be with a specific person

The causes of separation anxiety disorder are not fully known. Traumatic experiences, instability at home, and stressful situations can increase the risk of this condition. It can be diagnosed with an evaluation from a mental health professional.

This condition can be treated with talk therapy or play therapy for children and talk therapy or medications for adults.

A phobia is a continuous, irrational, and intense fear of something that poses little or no actual danger. Most people who have a specific phobia have more than one. For example, a person may have a phobia of both spiders and heights.

Phobia symptoms include:

• Avoiding something specific due to fear, such as needles or dogs

Phobias can be caused by a traumatic event involving the thing that is feared or someone repeatedly or intensely expressing the dangers of what is feared. However, sometimes the cause is unrelated to the specific phobia, or the cause is unknown.

Phobias can be evaluated and diagnosed by a mental health professional. Treatment options include talk therapy and exposure therapy.

New Classifications for OCD and PTSD

Obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) used to be considered anxiety disorders, but are now classified independently.

Obsessive-Compulsive Disorder

OCD involves repeated, unwanted thoughts or urges (obsessions) and feeling the need to do something repeatedly (compulsions). It affects up to 3 million American adults.

Symptoms of OCD include:

• Feeling fear of losing control of their behavior
• Feeling the need to clean excessively or an intense fear of germs
• Fear of forgetting or losing things
• Placing items in a specific order
• Repeatedly checking that things have been completed

OCD may be caused by genetics or traumatic experiences, especially in childhood, but the causes are not fully understood. This condition can be diagnosed with an evaluation from a mental health professional such as a psychiatrist. It is treated with talk therapy , medications, or both.

Post-Traumatic Stress Disorder

PTSD can result from experiencing a traumatic event. It involves a nervous system response after the event has ended and the person is no longer in danger.

PTSD affects about 6% of Americans at some point in their life. It affects about 8% of women compared to 4% of men due to trauma such as sexual assault being more commonly experienced by women.

PTSD symptoms include:

• Intrusive thoughts, which may include flashbacks
• Avoiding situations, places, and people that remind them of the traumatic event.
• Negative thoughts, guilt, shame, fear, distorted beliefs about themself or others
• Constant vigilance for potential danger
• Difficulty sleeping
• Jumpiness or being scared easily

PTSD is caused by a past experience of a traumatic event or events. Risk factors include abuse, accidents, and war. After an evaluation, this condition can be diagnosed by a mental health professional. It is treated with talk therapy such as cognitive behavioral therapy CBT, eye movement desensitization and reprocessing (EMDR) , and medications.

Anxiety disorders are challenging, and often severe enough to impact daily life. They are also treatable. Up to 85% of people who receive treatment for anxiety disorders find it to be effective. Additionally, there are many ways to cope with anxiety disorders long term.

Coping methods include:

• Relaxation exercises
• Breathing techniques
• Mindfulness and meditation
• Connecting with a trusted friend or family member
• Lifestyle behaviors such as prioritizing sleep, eating nutritious foods, and exercising regularly

Anxiety disorders involve intense feelings of fear or worry that recur for six months or longer. There are different types of anxiety disorders, such as social anxiety disorder, which is an intense fear of social interactions that may be severe enough to interfere with daily life.

Panic disorder involves sudden episodes of intense fear called panic attacks. Separation anxiety disorder is when an older child, teen, or adult experiences an extreme reaction to being away from a primary caregiver or another loved one.

Generalized anxiety disorder is when anxiety is related to a variety of different areas of life rather than a specific object or situation.

Obsessive-compulsive disorder and post-traumatic stress disorder were once considered anxiety disorders, but they are now considered separate conditions.

Anxiety disorders are treatable. It is important to seek help for these conditions to get relief and prevent further complications. If you or someone you know is experiencing symptoms of an anxiety disorder, reach out to a primary care provider or mental health professional for support.

A Note on Gender and Sex Terminology

Verywell Health acknowledges that  sex and gender  are related concepts, but they are not the same. To reflect our sources accurately, this article uses terms like “female,” “male,” “woman,” and “man” as the sources use them.

Anxiety and Depression Association of America. Anxiety disorders - facts and statistics .

National Institute of Mental Health. Generalized anxiety disorder .

National Institute of Mental Health. Anxiety disorders .

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By Ashley Olivine, Ph.D., MPH Dr. Olivine is a Texas-based psychologist with over a decade of experience serving clients in the clinical setting and private practice.

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The Loneliness Curve

New research suggests people tend to be lonelier in young adulthood and late life. But experts say it doesn’t have to be that way.

By Christina Caron

When Surgeon General Vivek Murthy went on a nationwide college tour last fall, he started to hear the same kind of question time and again: How are we supposed to connect with one another when nobody talks anymore?

In an age when participation in community organizations , clubs and religious groups has declined, and more social interaction is happening online instead of in person, some young people are reporting levels of loneliness that, in past decades, were typically associated with older adults.

It’s one of the many reasons loneliness has become a problem at both the beginning and end of our life span. In a study published last Tuesday in the journal Psychological Science, researchers found that loneliness follows a U-shaped curve: Starting from young adulthood, self-reported loneliness tends to decline as people approach midlife only to rise again after the age of 60, becoming especially pronounced by around age 80.

While anyone can experience loneliness, including middle-aged adults , people in midlife may feel more socially connected than other age groups because they are often interacting with co-workers, a spouse, children and others in their community — and these relationships may feel stable and satisfying, said Eileen K. Graham, an associate professor of medical social sciences at the Northwestern University Feinberg School of Medicine and the lead author of the study.

As people get older, those opportunities can “start to fall away,” she said. In the study, which looked at data waves spanning several decades, starting as early as the 1980s and ending as late as 2018, participants at either end of the age spectrum were more likely to agree with statements such as: “I miss having people around me” or “My social relationships are superficial.”

“We have social muscles just like we have physical muscles,” Dr. Murthy said. “And those social muscles weaken when we don’t use them.”

When loneliness goes unchecked, it can be dangerous to our physical and mental health, and has been linked to problems like heart disease, dementia and suicidal ideation.

Dr. Graham and other experts on social connection said there were small steps we could take at any age to cultivate a sense of belonging and social connection.

Do a relationship audit.

“Don’t wait until old age to discover that you lack a good-quality social network,” said Louise Hawkley, a research scientist who studies loneliness at NORC, a social research organization at the University of Chicago . “The longer you wait, the harder it gets to form new connections.”

Studies suggest that most people benefit from having a minimum of four to six close relationships, said Julianne Holt-Lunstad, a professor of psychology and neuroscience and the director of the Social Connection and Health Lab at Brigham Young University.

But it’s not just the quantity that matters, she added, it’s also the variety and the quality.

“Different relationships can fulfill different kinds of needs,” Dr. Holt-Lunstad said. “Just like you need a variety of foods to get a variety of nutrients, you need a variety of types of people in your life.”

Ask yourself: Are you able to rely on and support the people in your life? And are your relationships mostly positive rather than negative?

If so, it’s a sign that those relationships are beneficial to your mental and physical well-being, she said.

Join a group.

Research has shown that poor health, living alone and having fewer close family and friends account for the increase in loneliness after about age 75.

But isolation isn’t the only thing that contributes to loneliness — in people both young and old, loneliness stems from a disconnect between what you want or expect from your relationships and what those relationships are providing.

If your network is shrinking — or if you feel unsatisfied with your relationships — seek new connections by joining a community group, participating in a social sports league or volunteering , which can provide a sense of meaning and purpose, Dr. Hawkley said.

And if one type of volunteering is not satisfying, do not give up, she added. Instead try another type.

Participating in organizations that interest you can offer a sense of belonging and is one way to accelerate the process of connecting in person with like-minded people.

Cut back on social media.

Jean Twenge, a social psychologist and the author of “Generations,” found in her research that heavy social media use is linked to poor mental health — especially among girls — and that smartphone access and internet use “ increased in lock step with teenage loneliness .”

Instead of defaulting to an online conversation or merely a reaction to someone’s post, you can suggest bonding over a meal — no phones allowed.

And if a text or social media interaction is getting long or involved, move to real-time conversation by texting, “Can I give you a quick call?” Dr. Twenge said.

Finally, Dr. Holt-Lunstad suggested asking a friend or family member to go on a walk instead of corresponding online. Not only is taking a stroll free, it also has the added benefit of providing fresh air and exercise.

Take the initiative.

“Oftentimes when people feel lonely, they may be waiting for someone else to reach out to them,” Dr. Holt-Lunstad said. “It can feel really hard to ask for help or even just to initiate a social interaction. You feel very vulnerable. What if they say no?”

Some people might feel more comfortable contacting others with an offer to help, she added, because it helps you focus “outward instead of inward.”

Small acts of kindness will not only maintain but also solidify your relationships, the experts said.

For example, if you like to cook, offer to drop off food for a friend or family member, Dr. Twenge said.

“You’ll not only strengthen a social connection but get the mood boost that comes from helping,” she added.

Christina Caron is a Times reporter covering mental health. More about Christina Caron

Managing Anxiety and Stress

Stay balanced in the face of stress and anxiety with our collection of tools and advice..

How are you, really? This self-guided check-in will help you take stock of your emotional well-being — and learn how to make changes .

These simple and proven strategies will help you manage stress , support your mental health and find meaning in the new year.

First, bring calm and clarity into your life with these 10 tips . Next, identify what you are dealing with: Is it worry, anxiety or stress ?

Persistent depressive disorder is underdiagnosed, and many who suffer from it have never heard of it. Here is what to know .

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My parents gave me an unusual name. As a kid, it gave me social anxiety, but now I love it.

• My parents named me Eibhlis, pronounced "eyelish."
• They taught me how to spell my name with foam letters in the bathtub. 
• Having an uncommon name give me social anxiety. 

If you've got an unusual name , you know "the phase.'' The time when, as a gangly teen with acne and zero social skills, you absolutely dread explaining how to pronounce your name.

My dad's family is Irish , and my mom and dad were watching a documentary on Siamese twins — one called Katie and one called Eilish — while she was pregnant with me. They decided to nab the latter name, pronounced "eyelish," just slightly adapting the spelling.

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I always thought it was beautiful, but the difficult pronunciation left me crippled with anxiety for years.

It's hard to spell

To be fair to them, I wasn't totally in the deep end; I could spell my name at 4. My mom bought foam letters that I stuck on the side of the bath each evening. Perhaps in sympathy, she had helped me almost nail the spelling before school.

However, the first day at school had still been confusing. I'd come out asking my mom why the teachers couldn't say my name. It was a curveball among the Sophies and Matthews, and nobody else in my first primary school class had a non-English name. It felt isolating when teachers knew everyone else's names straight away.

It amplified my social anxiety in my school years

In high school there were others with unusual names, so I wasn't the only one having to explain pronunciations at registration. However, at around 12 years old, my social anxiety tripled. Public speaking , or basically speaking to anyone more than on a one-to-one basis, could bring uncontrollable shaking, dizzy spells, and stuttering words that refused to flow.

I dreaded speaking up and explaining my name to yet another supply teacher in front of a class of over 30 people. The start of the new school year was a nightmare, too, explaining my name to each teacher repeatedly until they cracked it or I finally accepted a slightly remixed version. Heaven forbid I ever got called on in assemblies when nearly 300 pupils crammed into a single hall.

Having that constant worry amplified my already lurking social anxiety . It also added to the usual teenage angst of struggling to find myself. You'd think having to explain pronunciation constantly would have helped me forge a more solid identity, but it actually did the opposite.

It worsened my people-pleasing tendencies when I'd just accept wrong pronunciations; I was called "Eeblis" for about two years by one science teacher. Instead of embracing my name, I found myself shrinking it to avoid the potential anxiety.

Some days, I wished the floor would swallow me up, most notably when my geography teacher somehow got "Elvis" from my name on the register, and everyone burst out laughing. It took me a long time to realize that my name was an identity, not a butt of a joke.

Now I love my name and its nod to my heritage

Gradually, though, something shifted. I learned my name's meaning — "God is my oath" and an Irish Gaelic adaptation of the name Elizabeth. I realized how endangered the Irish language was and how proud I was to carry that symbol of my heritage. I began to embrace the story it held — from the twins to my family history and, eventually, how it pushed me out of my comfort zone in those formative school years.

Most of all, my name never let me sit quietly in the back of a classroom, even when that's all I wanted to do. And for that, I'm very grateful.

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