How shy is too shy?

Years ago, when parents came to him worried because their kids seemed abnormally shy, Murray Stein, a psychiatrist at UC San Diego, would tell them not to worry -- that most children outgrow periods of intense shyness. “Now we’re not so quick to dismiss their concern,” he says.

Although most very shy kids do emerge from their shells, as many as one in three become more and more troubled, according to Stein, one of the country’s leading experts in childhood anxiety disorders. They go on to develop social phobia, also called social anxiety disorder -- shyness so extreme that it causes physical symptoms, such as racing heartbeats and shortness of breath, and interferes with a normal life.

As their dread of meeting people or being in the spotlight intensifies, they withdraw more and more from the world.

“These are kids who eventually drop out of college because they’re so terrified of being called on in class,” says epidemiologist Ronald Kessler, a professor of healthcare policy at Harvard Medical School who studies anxiety disorders. “They miss out on jobs they’re qualified for because they’re too afraid to go to interviews.”

There are other dangers. Recent nationwide surveys that Kessler has directed show that people with social phobia are at greater risk of developing severe depression, panic attacks and substance abuse problems. They are also more likely to commit suicide.

Given those risks, a growing number of childhood psychiatrists and psychologists say it’s important to be alert to early signs of problem shyness. “Social phobia has the earliest onset of almost any mental disorder,” says Stein. “People with the earliest onset generally fare the worse. So if we can intervene and treat children or adolescents early, we may be able to help prevent more serious problems later.”

Fortunately, the disorder has turned out to be among the most treatable of all mental conditions.

Several classes of prescription drugs that were first developed to treat depression or anxiety have been shown to relieve the symptoms of social phobia in many sufferers. The newest and most widely used are selective serotonin reuptake inhibitors, or SSRIs, which were first developed to treat depression. To date, the U.S. Food and Drug Administration has approved three SSRIs specifically for social phobia: paroxetine (Paxil), sertraline (Zoloft) and venlafaxine (Effexor).

The drugs appear to work in both children and adults. A 2004 University of Texas study of 319 children and adolescents with social phobia found that 48% were “very much” improved after taking Paxil, compared with 15% of those on a placebo.

Another approach is psychosocial therapy, which uses counseling to encourage people to face their fears, overcome them and then develop social skills to feel more comfortable in the company of others.

One widely used approach is cognitive behavioral therapy. Although individual programs vary, most involve helping patients recognize negative thoughts that feed their fears -- for example, “If I say something, everyone will laugh at me” -- and replace them with more realistic expectations. The next step is to disarm anxieties by being gradually exposed to the social situations that trigger them. The treatment usually involves 12 to 16 weekly sessions.

“Exposure is a powerful tool,” says Thomas Rodebaugh, associate director of the Adult Anxiety Clinic at Temple University in Philadelphia. “When the worst thing people fear doesn’t happen, they begin to lose that fear.”

In one experiment, 67 children ages 8 through 12 who were diagnosed with social anxiety disorder were randomly divided into two groups. One received behavioral therapy aimed at easing fears and increasing social skills. The control group received counseling to improve test-taking skills. At the end of 12 weeks, 67% of the children in the behavioral group no longer met the criteria for social disorder, compared with 5% in the test-taking group.

Both medication and psychotherapy are remarkably similar in effectiveness, according to Rodebaugh. But there are important differences. Studies suggest that medication works faster and may be more effective in the short term. Psychotherapy has longer-lasting benefits and appears to be more effective than medication at preventing relapses.

In practice, many mental health experts use both medication and counseling to treat social phobia.

The toughest challenge, experts say, is getting help to the people who need it most. Only about 15% of people with serious social phobia seek medical help, surveys suggest, making it one of the most under-treated of all psychiatric disorders.

“Most extremely shy people are just too shy to ask for help until their problems become so severe that they feel they have no other choice,” Kessler says. The very nature of the disorder prevents many people from getting treatment.

At the other end of the spectrum, some people with garden-variety shyness are being inappropriately diagnosed and treated for social phobia, some experts acknowledge.

Part of the problem lies in the definition of social phobia. Ever since social phobia was added to the list of anxiety disorders in the 1986 revision of the official classification of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), critics have complained that there is no objective way to distinguish between normal shyness and social phobia.

“We don’t have a laboratory test for social phobia, the way we do for blood pressure or cholesterol or cancer,” says Paul Chodoff, a psychiatrist at George Washington University. “Even the term ‘disorder’ is deliberately vague.” As a result, he worries, people whose shyness falls well within the range of a normal personality trait may be told that they have a mental problem that needs to be treated.

Critics say drug companies have helped blur the line between normal shyness and social phobia -- a charge echoed by the FDA, which recently objected to a television commercial for the drug Paxil. In the commercial, people are depicted in everyday situations -- walking into the cafeteria at work, sitting on a sofa at a party, putting on lipstick in the mirror -- wearing nametags that supposedly describe their emotions, including “self-conscious” and “nervous.”

In a letter last year to Glaxo- SmithKline, which markets Paxil, the FDA charged that the ad fails to distinguish between social anxiety disorder and “lesser degrees of performance anxiety or shyness that do not generally require psychopharmacological treatment.” The ad has since been pulled.

Roughly half the adult population describe themselves as shy, recent surveys have found, and medications offer a quick fix. That’s a vast market for drugs.

What’s more, recent surveys have shown that more and more adults are troubled by shyness. The reason, experts suspect, is that current society places a high premium on being outgoing and vivacious.

“There used to be many more opportunities for people who were socially shy and reticent to live in small communities, work at home and limit their social interactions,” says Stein. “Now, particularly as women have entered the workplace, people have to interact more. If you want to get ahead, you have to be out there in people’s faces.”

The percentage of people who have true social phobia is much smaller -- only 3% to 4% of the population, according to Stein. Moreover, the distress that they experience is much more extreme than simply feeling uncomfortable at a cocktail party.

According to the official definition, the disorder is a “marked and persistent fear” of certain social or performance situations. People with social phobia experience anxiety that can approach the intensity of a panic attack. To qualify as a disorder, extreme shyness also has to interfere with people’s ability to function at work, in school, or in personal relationships.

The definition has been a work in progress, however. In 1994, the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Assn., dropped two categories -- avoidant disorder and overanxious disorder -- and merged their symptoms into social phobia. It acknowledged that social phobia may be expressed differently in children than adults -- with crying, tantrums or withdrawal, for example. And it added another crucial distinction: While adults with social phobia know they aren’t behaving normally, children typically don’t realize that their fears are unreasonable or abnormal.

That children are often unaware that they have a problem is just one of several factors that make diagnosing and treating young patients tricky. Another is knowing whom to treat. “We know that some very shy children will outgrow it,” says Stein. “Some will go on to have serious problems. Unfortunately, we’re still not very good yet at knowing who we should worry about.”

One clue is family history. Social phobia tends to be inherited, researchers have found. Another is how long the symptoms persist. If children remain shy and withdrawn for more than two years, there’s a good chance they will develop severe social phobia.

In his practice at UC San Diego, Stein usually starts with psychosocial approaches -- strategies as simple as boosting children’s confidence, improving their social skills and gradually exposing them to fearful situations in manageable doses.

When children don’t respond adequately, he may recommend medication.

The idea of putting children or adolescents on mind-altering drugs of any kind -- whether for depression, attention deficit disorder, or social phobia -- has long been controversial. The controversy intensified when recent studies showed an increased risk of suicidal thoughts among kids on antidepressants.

Even so, the number of children using antidepressants continues to increase, rising from 1.6% to 2.4% from 1998 to 2002, according to a report published in the journal Psychiatric Services in April 2004. How many of the drugs are prescribed specifically for social phobia isn’t known.

In practice, most psychiatrists and parents are extremely reluctant to put children on prescription drugs, according to Stein. “Believe me, I don’t have parents coming into my office asking me to put their kids on medication,” he says. “It’s almost always a last resort.”

At the same time, he’s seen medication work wonders, helping kids who were overwhelmed with fear begin to lead normal lives -- making friends, participating in school, living free of fear. “When we’re successful, we can really change these kids’ lives forever.”