Social anxiety in young people: A prevalence study in seven countries.

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.

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

Design

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.

Table 1

Sample characteristics.

	Male	Female	Other a	Total
Brazil	479	491	7	977
China	486	500	6	992
Indonesia	494	457	8	959
Russia	475	500	8	983
Thailand	469	487	12	968
US	452	500	10	962
Vietnam	487	493	4	984
Total	3,342	3,428	55	6,825

a “Other” includes individuals who selected non-binary (n = 17), prefer to self-describe (n = 7), and prefer not to say (n = 31).

Procedure

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.

Measures

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.

Analyses

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].

Results

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(1,6770) = .54, n.s.).

Fig 1

Frequency of social anxiety scores (full sample).

Social anxiety scores significantly differed between countries (F(6,6818) = 74.85, p < .001, η = .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 (ps≤.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 (χ2(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%).

Table 2

Social anxiety scores.

	SCORES		SCORE DIFFERENCE BETWEEN GROUPS (T / F, P)	PROPORTION WITH SAD (SIAS≥29) (%)	PROPORTION DIFFERENCE BETWEEN GROUPS (Χ2, P)
	M	SD
Overall sample	23.82	14.18		36.2
Sex			-1.37, n.s.		.54, n.s.
Male	23.53	14.12		35.6
Female	24.00	14.18		36.5
Country			74.85, < .001		347.57, < .001
Brazil	26.18	15.23		42.4
China	22.30	13.52		32.1
Indonesia	18.94	13.21		22.9
Russia	20.78	12.79		27.0
Thailand	25.57	13.92		41.4
US	30.35	15.44		57.6
Vietnam	22.68	11.77		30.7
Age			39.74, < .001		48.62, < .001
16–17	21.92	14.24		30.8
18–24	25.33	13.98		40.3
25–29	22.44	14.22		32.8
Work			9.48, < .001		7.55, .023
Employed	23.28	14.32		35.3
Studying	23.96	13.50		36.5
Unemployed	26.27	14.54		41.7
Urban/rural			9.95, < .001		35.84, < .001
Central urban	22.70	14.67		33.0
Urban area	23.62	13.77		35.3
Suburban	25.64	14.08		42.4
Semi-rural	24.53	13.74		37.9
Rural	25.37	13.91		41.9
Education			5.51, < .001		38.75, < .001
L3 unfinished	27.94	15.07		52.0
L3 finished	23.40	14.15		34.8

M = mean, SD = standard deviation, t = t-test, F = ANOVA, χ2 = chi-square, p = significance, L3 = ISCED level 3 (secondary education), SAD = Social Anxiety Disorder.

A significant age difference was also observed (F(2,6822) = 39.74, p < .001, η = .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 (ps < .001). The proportion of individuals scoring above the threshold for SAD also significantly differed between age groups (χ2(2,6825) = 48.62, p < .001) (Fig 2).

Fig 2

Proportion of individuals meeting the threshold for Social Anxiety Disorder by age group and country.

A three-way ANOVA confirmed significant main effect differences in social anxiety scores between age groups (F(2,6728) = 38.93, p < .001, η = .011) and countries (F(6,6728) = 45.37, p < .001, η = .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 = .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 = .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).

Fig 3

Levels of social anxiety by country and age.

Fig 4

Levels of social anxiety by country and sex.

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 = .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 (χ2(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 = .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 (χ2(4,6825) = 35.84, p < .001).

Fig 5

Level of social anxiety by place of living.

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 (χ2(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.

Table 3

Concerns by country.

Item		BR	CN	ID	RU	TH	US	VN	Overall
1	I get nervous if I have to speak with someone in authority (teacher, boss, etc.)	5	1	1	4	1	5	3	1
2	I have difficulty making eye contact with others	11	11	10	9	14	12	12	12
3	I become tense if I have to talk about myself or my feelings	1	8	5	1	8	2	5	4
4	I find it difficult to mix comfortably with the people I work with	16	17	15	17	13	16	16	16
5	I tense up if I meet an acquaintance in the street	17	15	13	16	17	15	17	17
6	When mixing socially, I am uncomfortable	13	10	16	12	10	8	15	14
7	I feel tense if I am alone with just one other person	12	9	9	15	5	14	9	11
8	I have difficulty talking with other people	14	16	17	14	16	13	14	15
9	I worry about expressing myself in case I appear awkward	6	4	2	2	6	3	1	3
10	I find it difficult to disagree with another’s point of view	15	12	11	13	7	17	6	13
11	I have difficulty talking to people I am attracted to	3	13	4	8	4	6	8	7
12	I find myself worrying that I won’t know what to say in social situations	4	3	8	7	3	4	4	5
13	I am nervous mixing with people I don’t know well	2	5	3	6	2	1	2	2
14	I feel I’ll say something embarrassing when talking	7	14	14	3	15	7	7	10
15	When mixing in a group, I find myself worrying I will be ignored	8	7	7	10	11	11	11	8
16	I am tense mixing in a group	10	6	12	11	12	9	13	9
17	I am unsure whether to greet someone I know only slightly	9	2	6	5	9	10	10	6

Dark shaded cells indicate the top three concerns (1–3); lightly shaded cells indicate the least three concerns (15–17); BR = Brazil; CN = China; ID = Indonesia; RU = Russia; TH = Thailand; US = United States; VN = Vietnam.

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 (χ2(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).

Fig 6

Perceptions of social anxiety vs. classification.

Table 4

Classification of social anxiety scores.

	Self-perceived as non-SA						Self-perceived as SA
	SIAS <28a			SAD: SIAS ≥28 b			SIAS <28 b			SAD: SIAS ≥28 a
	M	SD	% of group	M	SD	% of group	M	SD	% of group	M	SD	% of group
Overall sample	13.92	7.80	47.8	38.53	8.38	17.8	18.34	6.79	15.9	40.02	8.60	18.4
Sex
Male	13.96	7.82	50.1	37.56	8.42	20.5	18.26	7.02	14.3	39.87	8.39	15.1
Female	13.92	7.77	46.0	38.42	8.29	15.1	18.42	6.60	17.6	40.09	8.73	21.4
Country
Brazil	14.10	8.15	39.4	39.36	8.37	16.2	17.88	6.99	18.2	41.96	9.19	26.2
China	13.18	7.60	46.4	38.73	8.08	15.4	17.78	6.40	21.6	38.36	7.56	16.6
Indonesia	12.49	8.03	65.0	37.42	8.45	15.3	17.62	7.32	12.1	38.89	8.47	7.6
Russia	13.51	7.61	57.1	36.09	6.28	13.9	18.24	6.49	16.0	39.37	7.64	13.0
Thailand	15.15	7.60	46.7	38.76	8.79	21.8	19.48	6.26	11.9	39.38	8.64	19.6
US	13.79	8.70	27.4	40.95	9.32	25.7	19.09	6.70	14.8	41.35	9.15	31.5
Vietnam	15.58	6.82	52.7	36.55	6.88	16.4	18.74	6.49	16.6	37.57	7.01	14.3

M = Mean, SD = Standard Deviation.

a Congruence: self-perceptions align with measure.

b Conflict in classification (false positive or negative).

Discussion

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.

Conclusion

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.

1 Jul 2020

PONE-D-20-06197

Social anxiety in young people: A prevalence study in seven countries

PLOS ONE

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Academic Editor

PLOS ONE

Additional Editor Comments:

Thank you for your submission. The reviewers felt like this paper is important for the field, but they have some reservations about various aspects of the manuscript. We invite you to revise and resubmit.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This study provides valuable information for both researchers and clinicians specializing in anxiety as it offers an examination of cross-cultural and worldly prevalence rates of SAD. In addition to examining prevalence rates between seven countries, the authors examine SAD rates through contributing factors such as gender, age, and SES. The strengths of this paper include the evolutionary perspective of social anxiety and making the distinction between subclinical social anxiety and symptoms that reach the clinical threshold of SAD. The authors also present multiple graphs of their findings that are visually appealing and easy to understand. There are a number of suggested changes that would strengthen this manuscript, which are presented below.

Major:

1. The authors can improve the quality of this manuscript by expanding on many ideas and theories that are only briefly mentioned. This can be accomplished both by incorporating more background literature as well as the authors’ own interpretations and hypotheses. These include:

Introduction:

-Speak more to the distinction between subthreshold social anxiety and clinical levels of SAD. For example, are there any predisposing factors for some to reach clinical levels of social anxiety compared to others? Are there any current theories (potentially physiological in nature) that explain the differences between subclinical and clinical social anxiety?

-When discussing current prevalence rates of SAD, the authors should consider also including rates of undiagnosed SAD and implications on treatment. The authors first include this information in the discussion starting on line 331 but it should be first presented in the introduction.

-It may be helpful to include a developmental theory of SAD in the introduction, especially as the authors repeatedly reference social media and technology contributing to the development of SAD in young adults.

-Likewise, given the focus on worldly prevalence of SAD, further detail on cross-cultural perspectives is likely merited. The authors briefly social anxiety in Asian cultures but should offer more information regarding other cultures. Additionally, the authors could provide hypotheses from the existing literature as to why there are differing rates of social anxiety in different parts of the world rather than simply stating the statistics in the introduction (i.e., the differences in social anxiety expression that the authors note in the discussion). For example, the authors find that speaking with authority figures to be a top concern for Asian countries compared to other countries, which may potentially be linked with cultural values of respect to authority and status that could discussed in the introduction.

-It would be helpful for readers to have some explanation (either hypothesized by the existing literature or the authors’ own speculation) as to why social anxiety rates are increased by social media/technology and why this rate is hypothesized to increase for only young adults. This may be achieved through the Lecrubier et al. and Leigh and Clark’s theories that are referenced in the discussion.

-The authors introduce contributing factors of status, location, and education in the findings but do not discuss these factors in the introduction (i.e., line 315-316 females scoring higher on SAD measures than males). Consider presenting these factors and their associated literature earlier on in the manuscript given they are major areas of the study’s focus.

-The authors do not provide a reason or explanation for their study. Consider clarifying the importance of this particular study and reasoning behind specific aims (Why young adults with SAD? Why assess cross-cultural prevalence?). Was there any reasoning behind choosing the seven countries that were included in this study?

Discussion:

-Before line 299, it is suggested that the authors first reiterate and elaborate on their findings regarding age and social anxiety before their discussion of these particular findings. The authors may want to further elaborate on their findings of age and social anxiety. Do these findings predict an increase in the rates of SAD in the future? What are the clinical implications of this potential high-risk age range?

-Expand on findings related to cross-cultural differences in prevalence (paragraph starting line 307). Why might these discrepancies exist? What are the implications of this finding? Additionally, the two sentences starting at line 309 (Our findings concur…) ending at line 313 are confusing to the reader. Consider rephrasing or possibly listing countries with the highest to lowest rates of endorsement for social anxiety.

-Explain potential reasoning behind the differences seen in male/female prevalence rates (paragraph starting line 314). Are these findings in line with the existing literature on gender differences in prevalence rates in these respective countries? Why might these differences exist in this particular sample?

-The authors should consider including additional implications of incorrectly perceived social anxiety in the paragraph starting on 329.

-There are additional study limitations that the authors do not address in the manuscript. The most notable limitation is the use of an online survey to gather responses. The authors cannot be confident that participants are accurate in their reports of demographics and social anxiety symptoms. Additionally, the authors were only able to utilize one questionnaire of social anxiety rather a diagnostic interview and are unable to gather important information such as previous/current treatment or medication management of symptoms. Relatedly, the authors were unable to include additional measures beyond social anxiety symptoms that could have contributed to their findings, such as social media usage questionnaires.

-Consider including a section on the clinical implications of these findings or include these implications throughout the discussion.

Minor:

2. To improve the flow of the article, it is suggested that the authors move lines 32-34 (starting with “individuals experiencing social anxiety visibly struggle…” to after line 29 “boring or incompetent.” This allows for line 35 to continue with the authors’ discussion on impairment.

3. Consider adding race/ethnicity and SES to Table 1’s demographics.

4. On line 116, please provide which three items from the scales were not included in analyses.

5. The paragraph starting on line 314 continually indicates scores are “worse” or “poorly.” Consider rephrasing to clarify if authors mean score higher/lower.

Reviewer #2: This is a well-written manuscript addressing an important topic. Strengths include the large sample, and cross-national comparisons.

The most significant limitation of the current manuscript is not carefully distinguishing between heightened social anxiety vs social anxiety disorder. Relying on cutoff scores on the SIAS greatly overestimates the prevalence of social anxiety disorder. Given that the authors report that they collected data on functioning (see page 7), I would have liked to see the authors incorporate impairment in functioning in their determination of "disorder".

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Reviewer #1: No

Reviewer #2: No

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14 Jul 2020

Please see the Response to Reviewers file for comments and details of specific changes made to address each issue.

Submitted filename: Response to Reviewers file.docx

Click here for additional data file.

1 Sep 2020

Social anxiety in young people: A prevalence study in seven countries

PONE-D-20-06197R1

Dear Dr. Jefferies,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Sarah Hope Lincoln

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

3 Sep 2020

PONE-D-20-06197R1

Social anxiety in young people: A prevalence study in seven countries

Dear Dr. Jefferies:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

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Academic Editor

PLOS ONE