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.