Social anxiety (or social phobia), which affects some 10 million people in the United States, is a condition almost as common as depression. However, the first study on it was only published in the late 1980s and only recently has the pharmaceutical industry marketed a drug to treat the disorder.

Social anxiety is severe pathological shyness, stemming from fear of rejection and humiliation. Socially anxious people tend to avoid situations such as talking to their boss, speaking up in meetings, asking directions or even writing a check in public. They believe they are the object of others' scrutiny or harsh judgement says Dr. Peter Roy-Byrne, professor of psychiatry and behavioural sciences at the University of Washington School of Medicine and chief of psychiatry at Harborview Medical Centre.

There are two types of social anxiety - discrete and generalised. The discrete type is linked to performance anxiety, such as a fear of speaking in front of others that is so intense a person may get physically ill just thinking about it and feel no relief after its over. For people with generalised social anxiety, forming relationships is difficult and about 75 percent of them remain single. They also tend to be underachievers, by not reaching a professional level that matches their skills or education. "For instance, you might find a Phi Beta Kappa graduate working as a file clerk," says Roy-Byrne. "They are uncomfortable with the competition often seen in the workplace."

Social anxiety stems from a combination of genetic vulnerability - it tends to run in families - and environmental circumstances. It usually begins in junior high, when social rules become more complicated, and is especially prevalent among women who are highly strung and have low economic status. However, it's also possible that social anxiety caused them to drift that way, says Roy-Byrne.

Although social anxiety ranks just behind depression and alcoholism among the nations most prevalent mental disorders, the three conditions often overlap - 80 percent to 85 percent of socially anxious people have clinical depression, while 25 percent to 35 percent of them have a drinking problem.

Most socially anxious people don't realise they have a medical disorder and believe it's just their personality type, says Roy-Byrne. However, he stresses, "This is a chronic condition. You can get substantial improvement with drugs and therapy but there is no cure." There are two effective treatments for the socially anxious, both likely to produce results within six to 12 weeks:

• Cognitive therapy, to learn social and assertiveness skills, particularly in a group. The drawback is that the socially anxious are the least likely to seek this kind of help, as it requires new social interaction both with an authoritarian figure and strangers. Also, such therapy may only be available in big cities. But once patients have joined the group, they tend to feel comfortable and results can be long lasting.

• Medication is an easier alternative. SSRI (selective serotonin reuptake inhibitor) drugs already used for panic disorders, depression and obsessive compulsive behaviour work for social anxiety by making patients less inhibited. About 30 percent to 40 percent of patients relapse when they stop medication for a year.

Health Beat, University of Washington

Date reviewed: 18 February 2000