One of the debates that has been ongoing over the past several years is whether social anxiety disorder (SAD) diagnoses are on the increase because shyness is being medicalized. In other words, pharmaceutical companies are convincing shy people that what they suffer from is a disorder that requires medication.

A recent study by Kathleen Merikangas of the National Institute of Mental Health (NIMH) in Bethesda, Maryland offers some evidence that contradicts the medicalization hypothesis. The study examined data from the National Comorbidity Survey (Adolescent); a nationally representative face-to-face survey of over 10,000 13 to 18-year-olds in the United States.

The goals of the study were to determine the frequency of shyness and SAD, as well as how the two differed in terms of sociodemographic characteristics, impairment in functioning, comorbidity, and prescription medication use.

Rates of lifetime SAD were assessed using the World Health Organization Composite International Diagnostic Interview. Parents and teenagers also provided information about shyness and medication use.

Results of the study showed that about half of the teenagers surveyed were shy, while 9% had suffered with SAD at some point in their life. One in eight self-described shy teenagers also met criteria for SAD, whereas 1 in 20 teenagers who did not describe themselves as shy met criteria for SAD.

Teenagers who met criteria for lifetime SAD had greater impairment in functioning and were more likely to suffer with other anxiety, mood, behavioral or substance use disorders. However, they were no more likely to be taking prescription medications; in fact, less than 8% of teens with SAD had been treated with antidepressants.

The study author concludes that results question the validity of the medicalization of shyness. Social anxiety disorder is clearly more impairing and separate from simple shyness. In other words, SAD was not created by pharmaceutical companies to sell medications.

At the same time, critics of the study, such as Glend Spielmans, a psychologist at Metropolitan State University in Saint Paul Minnesota argues that the study estimates should be regarded cautiously.

In an interview with Reuters, Spielman commented that the interviews were conducted in 2001 and 2002, at a time when medication use was less prevalent. He also voiced concern over whether interviewers were mental health professionals and competent at diagnosis. Finally, Spielmans pointed out that the study does little to dispel concern that shyness is being pathologized in adults.

Personally, I found a few of the other study details interesting.

First was the fact that only 8% of teenagers with SAD had taken prescription medication for the disorder. Based on those results, SAD is not being overdiagnosed or over-medicated in teenagers.

Second, I found it interesting to note that although the rates of SAD in non-shy teenagers were less than in those who self-identified as shy, they were not zero. As a quick example, half of the teenagers did not identify themselves as shy, so roughly 5000 kids. Of those 5000 teenagers, roughly 5%, or 250 kids, would have met criteria for SAD.

I think this is an idea that is sometimes swept under the rug. Social anxiety disorder and shyness are not only not the same thing, but they don’t always have to co-exist. This also emphasizes the dividing line between a personality style and a disorder. It is possible for SAD to appear in the absence of a shy personality style. Outgoing and extroverted children can become socially fearful teenagers; and the pain of social fears might be doubly impairing.

What do you make of these study results?

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