Social Anxiety Disorder

RESEARCH ARTICLE

Social anxiety in young people: A prevalence

study in seven countries

Philip JefferiesID*, Michael Ungar

Resilience Research Centre, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada

* [email protected]

Abstract

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 Disor-

der (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 indi-

vidual 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 embar-

rassment 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,

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OPEN ACCESS

Citation: Jefferies P, Ungar M (2020) Social

anxiety in young people: A prevalence study in

seven countries. PLoS ONE 15(9): e0239133.

https://doi.org/10.1371/journal.pone.0239133

Editor: Sarah Hope Lincoln, Harvard University,

UNITED STATES

Received: March 11, 2020

Accepted: August 31, 2020

Published: September 17, 2020

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https://doi.org/10.1371/journal.pone.0239133

Copyright: © 2020 Jefferies, Ungar. This is an open
access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All data files are

available from the Open Science Framework

repository (DOI: 10.17605/OSF.IO/VCNF7).

Funding: The author(s) received no specific

funding for this work.

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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 individu-

als 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]. How-

ever, 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 anxi-

ety 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-conscious-

ness 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 tempera-

ment 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 with-

drawal, 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 differ-

ences in social anxiety.

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Competing interests: I have read the journal’s

policy and the authors of this manuscript have the

following competing interests: Unilever funds the

lead author’s research fellowship at Dalhousie

University’s Resilience Research Centre, though in

no way have they directed this research, its

analysis or the reporting or results.

https://doi.org/10.1371/journal.pone.0239133

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 question-

naire 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.

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

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).

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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 interac-

tions 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 omit-

ted the three positively-worded items from analyses, as studies have demonstrated that includ-

ing 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 bet-

ter 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 attrac-
tive 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 con-

cerning functioning in daily life. These were included as part of a corporate social responsibil-

ity 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’ cate-

gory, 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 unem-

ployed. Urban/rural differences were also investigated as previous research has suggested anxi-

ety 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 par-

ticipants 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.

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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 indi-

cate 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 sever-

ity 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 inter-

preted 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 reli-

ability 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

(χ2(1,6770) = .54, n.s.).
Social anxiety scores significantly differed between countries (F(6,6818) = 74.85, p < .001, ηp 2 = .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 Viet- nam, between Russia and China, and between Russia and Indonesia (see Table 2). The propor- tion 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 thresh- old (57.6%), while Indonesia had the lowest, with fewer than one in four (22.9%). PLOS ONE Social anxiety in young people: A prevalence study in seven countries PLOS ONE | https://doi.org/10.1371/journal.pone.0239133 September 17, 2020 5 / 18 https://doi.org/10.1371/journal.pone.0239133 A significant age difference was also observed (F(2,6822) = 39.74, p < .001, ηp 2 = .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). A three-way ANOVA confirmed significant main effect differences in social anxiety scores between age groups (F(2,6728) = 38.93, p < .001, ηp 2 = .011) and countries (F(6,6728) = 45.37, p < .001, ηp 2 = .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, ηp 2 = .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 sig- nificant country�sex interaction (F(6,6728) = 2.25, p = .036, ηp 2 = .002), where female partici- pants 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 1. Frequency of social anxiety scores (full sample). https://doi.org/10.1371/journal.pone.0239133.g001 PLOS ONE Social anxiety in young people: A prevalence study in seven countries PLOS ONE | https://doi.org/10.1371/journal.pone.0239133 September 17, 2020 6 / 18 https://doi.org/10.1371/journal.pone.0239133.g001 https://doi.org/10.1371/journal.pone.0239133 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, ηp 2 = .003), with those in employment hav- ing 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). 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. https://doi.org/10.1371/journal.pone.0239133.t002 PLOS ONE Social anxiety in young people: A prevalence study in seven countries PLOS ONE | https://doi.org/10.1371/journal.pone.0239133 September 17, 2020 7 / 18 https://doi.org/10.1371/journal.pone.0239133.t002 https://doi.org/10.1371/journal.pone.0239133 Urban/Rural Social anxiety scores also significantly varied depending on an individual’s place of residence (F(4,6820) = 9.95, p < .001, ηp 2 = .006). However, this was not a linear relationship from urban Fig 2. Proportion of individuals meeting the threshold for Social Anxiety Disorder by age group and country. https://doi.org/10.1371/journal.pone.0239133.g002 PLOS ONE Social anxiety in young people: A prevalence study in seven countries PLOS ONE | https://doi.org/10.1371/journal.pone.0239133 September 17, 2020 8 / 18 https://doi.org/10.1371/journal.pone.0239133.g002 https://doi.org/10.1371/journal.pone.0239133 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). Education level In the subsample of individuals aged 20 or above, level of education also resulted in a signifi- cant differences in social anxiety scores (t(5071) = 5.51, p < .001), with individuals who com- pleted 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 thresh- old 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, indi- cating 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 encoun- ters with acquaintances. 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 Fig 3. Levels of social anxiety by country and age. https://doi.org/10.1371/journal.pone.0239133.g003 PLOS ONE Social anxiety in young people: A prevalence study in seven countries PLOS ONE | https://doi.org/10.1371/journal.pone.0239133 September 17, 2020 9 / 18 https://doi.org/10.1371/journal.pone.0239133.g003 https://doi.org/10.1371/journal.pone.0239133 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 anx- ious 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 propor- tion 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). 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 fig- ures 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 inclu- sion of older participants in other …