Results of this nationally representative study of adolescents indicate that social phobia is a highly prevalent, persistent, and impairing mental disorder among adolescent youth, closely resembling the magnitude and severity of this condition among adults.3–5,33
In addition, findings suggest that while the performance only
subtype of social phobia appears to be quite rare among adolescents, generalized
social phobia is both a common and clinically relevant form of social phobia in this adolescent age range. Adolescents with the generalized
subtype not only evidenced higher levels of severity and disability relative to adolescents with non-generalized
social phobia, but they experienced this degree of clinical severity over longer periods.
As reported in our earlier work,22
we found that approximately 9% of youth in the U.S. experience social phobia at some point in their lifetime. Although the prevalence estimate of social phobia revealed in these data approximates previous studies of youth,1
this rate is slightly lower than the 12.1% rate observed among U.S. adults in the National Comorbidity Survey – Replication (NCS-R).34
Nevertheless, converging with findings from both adult3,5
and youth surveys,4,6,7
we found that social phobia in any form was associated with marked levels of impairment and persistence. Likewise, our results regarding the comorbidity of social phobia with other anxiety disorders closely parallel previous community studies of adults34,35
Our failure to find significant associations between social phobia and mood or alcohol use disorders after controlling for comorbid disorders, however, suggests that these relations may be due in part to other psychopathology. It is also possible that the secondary risk for these conditions among affected individuals is not yet evident during the adolescent years, instead emerging during adulthood.36,37
In line with previous investigations of adults34
more than half (55.8%) of adolescents with lifetime social phobia exhibited fear of most
social situations, consistent with the DSM-IV/DSM-V definition of generalized
social phobia. In addition to its common presentation, adolescents characterized with generalized
social phobia demonstrated greater morbidity and clinical severity relative to adolescents who failed to endorse a fear of most
social situations. These youth displayed an earlier age of onset, experienced a higher degree of disability and impairment, and were more likely to have a variety of other psychiatric disorders, relative to adolescents with non-generalized
social phobia. Such findings extend prior work with exclusively adult samples,34,38–41
and strongly replicate one previous study of German youth.4
While it is clear that individuals who fear a greater number of situations evidence greater clinical pathology, several previous studies have contested the presence of qualitative (as opposed to quantitative) distinctions between individuals with and without generalized
Moreover, the matter of whether generalized
social phobia is best defined by a particular number of fears or whether it should instead be conceptualized along a continuum of severity continues to be an outstanding empirical question.43,44
Although beyond the scope of this study, future work on this topic will examine how various thresholds may function to identify individuals with more severe and pervasive forms of the disorder.
Providing some support for retaining DSM-5 definitions of generalized
social phobia, patterns of sociodemographic correlates appeared to differ across recognized subtypes. Such variations in sociodemographic correlates by subtype may partly explain inconsistent findings of previous community and international studies of youth.4,6–9,12
In line with this notion, general population studies of adults have found a higher proportion of females to evidence generalized
social phobia and a greater number of males to evidence non-generalized
Further, while both subtypes of social phobia displayed associations with specific phobia, SAD, and drug use disorders, several psychiatric disorders showed unique associations with only one subtype. Similar to our findings, previous studies of youth have also found unique associations between generalized
social phobia and agoraphobia4
and between non-generalized
social phobia and PTSD.10
Taken together, these results highlight the heterogeneity of social phobia and the need to investigate psychiatric correlates of various presentations in the future.
In contrast to the large proportion of adolescents affected with the generalized
subtype, less than 1% of youth with social phobia displayed a fear profile consistent with the proposed DSM-5 performance only
subtype. Yet, higher proportions of performance only
social phobia have been observed in studies involving participants of older ages.11,39,45
These findings suggest that public speaking (and performance) fears may only become clinically significant with the greater opportunity for avoidance that characterizes adulthood. For instance, whereas youth are often required by caretakers and teachers to engage in public speaking activities, adults retain the ability to avoid such situations. The demand to participate in public speaking activities may provide youth more occasions for exposure, consequently resulting in performance anxiety habituation and lower prevalence rates. Alternatively, it is possible that adolescents who exhibit clinically significant public speaking and performance fears fail to do so in the absence of other clinical-level social fears. Prospective research will be useful in providing further information on variations in the nature and magnitude of social fears across development.
Several limitations of the current study deserve comment. First, given that clinical information on social phobia was acquired exclusively from adolescents via retrospective reports, interview data may be subject to both informant and recall biases. Yet, because the onset of social phobia closely coincides with the age of participants in the present study, respondents may be less vulnerable to such reporting errors.3,7
Further, the current study supplemented interview questions with additional probes that have been found to increase the recall accuracy of psychiatric disorder onset.29
In addition, the cross-sectional study design prohibits examination of longitudinal associations between social phobia and observed correlates, emphasizing the need for prospective general population studies of youth in the future.
Even with these limitations, the current study is the first to examine the lifetime prevalence and associated features of social phobia in a large, nationally representative sample of U.S. adolescents. In addition, this study provides novel information on the scale, impact, and potential utility of the proposed DSM-5 social phobia subtypes among U.S. adolescent youth. In consideration of the extremely low rate of performance only
social phobia among adolescents, additional work is necessary to evaluate the impact of modifications to this subtype. For example, some studies involving youth with social phobia have found that approximately one-quarter to one-third are affected primarily with performance fears when a broader definition is employed.11,46
Therefore, revisions to the proposed DSM-5 subtype may benefit from inclusion of a number of additional performance fears appropriate to this age range (e.g., speaking in class when a teacher calls on you, taking an important test or exam, etc.). Quite the opposite, the proposed generalized
subtype of social phobia appears to identify a large number of affected youth who experience a distinct illness course and level of clinical severity. Despite the degree of impairment associated with generalized
social phobia, it is notable that less than one-fifth of these youth had ever contacted a professional concerning their social fears. Such a substantial discrepancy calls critical attention to the importance of enhancing public awareness and access to evidence based interventions for social phobia in adolescents.47
The observed increase in generalized
social phobia as adolescents advance into adulthood further highlights this period as an opportune time for the prevention of future risk.