social anxiety research proposal

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Peer-reviewed

Research Article

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

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

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

Roles Conceptualization, Methodology, Writing – review & editing

• Philip Jefferies, 
• Michael Ungar

• Published: September 17, 2020
• https://doi.org/10.1371/journal.pone.0239133
• Peer Review
• Reader Comments

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.

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

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: 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.

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.

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

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.

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https://doi.org/10.1371/journal.pone.0239133.t001

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.

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.

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 ].

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 2 (1,6770) = .54, n.s.).

https://doi.org/10.1371/journal.pone.0239133.g001

Social anxiety scores significantly differed between countries ( F (6,6818) = 74.85, p < .001, η p 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 ( p s≤.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 (χ 2 (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%).

https://doi.org/10.1371/journal.pone.0239133.t002

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

https://doi.org/10.1371/journal.pone.0239133.g002

A three-way ANOVA confirmed significant main effect differences in social anxiety scores between age groups ( F (2,6728) = 38.93, p < .001, η p 2 = .011) and countries ( F (6,6728) = 45.37, p < .001, η p 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, η p 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 significant country*sex interaction ( F (6,6728) = 2.25, p = .036, η p 2 = .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 ).

https://doi.org/10.1371/journal.pone.0239133.g003

https://doi.org/10.1371/journal.pone.0239133.g004

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 p 2 = .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 (χ 2 (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 p 2 = .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 (χ 2 (4,6825) = 35.84, p < .001).

https://doi.org/10.1371/journal.pone.0239133.g005

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 (χ 2 (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.

https://doi.org/10.1371/journal.pone.0239133.t003

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 (χ 2 (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 ).

https://doi.org/10.1371/journal.pone.0239133.g006

https://doi.org/10.1371/journal.pone.0239133.t004

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.

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.

Acknowledgments

The authors would like to acknowledge the role of Edelman Intelligence for collecting the original data on behalf of Unilever and CLEAR as part of their mission to support the resilience of young people.

• View Article
• PubMed/NCBI
• Google Scholar
• 3. National Collaborating Centre for Mental Health (UK). Social Anxiety Disorder: Recognition, assessment and treatment. Leicester, UK: British Psychological Society; 2013. Report No.: NICE Clinical Guidelines, No. 159. https://www.ncbi.nlm.nih.gov/books/NBK327674/
• 4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: Author; 2013.
• 29. McNeil DW. Evolution of terminology and constructs in social anxiety and its disorders. Social anxiety: Clinical, developmental, and social perspectives, 2nd ed. San Diego, CA, US: Elsevier Academic Press; 2010. pp. 3–21. https://doi.org/10.1016/B978-0-12-375096-9.00001-8
• 33. Dobrean A, Păsărelu C-R. Impact of social media on social anxiety: a systematic review. New Developments in Anxiety Disorders. London, UK: IntechOpen; 2016. https://www.intechopen.com/books/new-developments-in-anxiety-disorders/impact-of-social-media-on-social-anxiety-a-systematic-review
• 44. Blanc ALL, Bruce LC, Heimberg RG, Hope DA, Blanco C, Schneier FR, et al. Evaluation of the psychometric properties of two short forms of the Social Interaction Anxiety Scale and the Social Phobia Scale. Assessment. 2014 [cited 31 Jan 2020].
• 56. IBM Corp. IBM SPSS Statistics. Armonk, NY: IBM Corp; 2017.
• 63. Liebowitz MR, Pharmacopsychiatry MP. Social phobia. 1987.
• 72. Brown BB, Larson J. Peer relationships in adolescence. Handbook of adolescent psychology: Contextual influences on adolescent development, Vol 2, 3rd ed. Hoboken, NJ, US: John Wiley & Sons Inc; 2009. pp. 74–103.
• 73. Collins WA, Steinberg L. Adolescent development in interpersonal context. 6th ed. Handbook of child psychology. 6th ed. New York, NY: John Wiley & Sons, Inc; 2007. pp. 1003–1067. https://doi.org/10.1002/9780470147658.chpsy0316

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Social anxiety in adolescents and young adults from the general population: an epidemiological characterization of fear and avoidance in different social situations

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• Volume 42 , pages 28130–28145, ( 2023 )

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• Julia Ernst   ORCID: orcid.org/0000-0002-4532-4418 1 ,
• Theresa Magdalena Ollmann 1 ,
• Elisa König 1 ,
• Lars Pieper 1 ,
• Catharina Voss 1 ,
• Jana Hoyer 1 ,
• Frank Rückert 1 ,
• Susanne Knappe 1 , 2 &
• Katja Beesdo-Baum   ORCID: orcid.org/0000-0002-9687-5527 1  

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Social Anxiety Disorder (SAD) and, more generally, social fears are common in young people. Although avoidance behaviors are known to be an important maintaining factor of social anxiety, little is known about the severity and occurrence of avoidance behaviors in young people from the general population, hampering approaches for early identification and intervention. Symptoms, syndromes, and diagnoses of DSM-5 mental disorders including SAD were assessed in a random population-based sample of 14-21-year-olds (n = 1,180) from Dresden, Germany, in 2015/2016 using a standardized diagnostic interview (DIA-X-5/D-CIDI). An adapted version of the Liebowitz Social Anxiety Scale was used to ascertain the extent of social fears and avoidance. Diagnostic criteria for lifetime SAD were met by n = 82 participants, resulting in a weighted lifetime prevalence of 6.6%. Social anxiety was predominantly reported for test situations and when speaking or performing in front of others. Avoidance was most prevalent in the latter situations. On average, anxiety and avoidance first occurred at ages 11 and 12, respectively, with avoidance occurring in most cases either at about the same age as anxiety or slightly later. In the total sample, lifetime prevalence for most DSM-5 disorders increased with the severity of social anxiety and avoidance. Results underline the need for preventive or early intervention efforts especially regarding test anxiety and fear and avoidance of speaking in front of others. These situations are particularly relevant in youth. Avoidance behaviors may also be discussed as diagnostic marker for early case identification.

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Introduction

Social fears are very common in young people (Fehm et al., 2008 ) and are associated with considerable suffering and severe impairments in psychosocial functioning as well as negative outcomes including suicidality and a range of mental disorders (Asselmann et al., 2018 ; Miché et al., 2018 ; Solano et al., 2016 ; Wong et al., 2012 ). Lifetime prevalence of social anxiety disorder (SAD) is estimated at around 7% with high incidence rates in childhood and early adolescence (Beesdo-Baum et al., 2012 ; Merikangas et al., 2010 ). In addition, a substantial proportion of young people does not meet the diagnostic criteria of threshold SAD, but nevertheless reports ever having had a strong fear of a social situation and/or the desire to avoid it (Knappe et al., 2015 ). According to the results from a large community sample of 14-to 24-year-olds, which was followed up for 10 years, almost half of the participants reported having fear of at least one social situation (Knappe et al., 2011 ).

Regarding the prevalence of anxiety in different social situations in the general population, anxiety about speaking in front of others (6.2 − 24.8%) and taking tests (14.0 − 28.1%) seem to be the most widespread, whereas other social fears like eating/drinking in public (1.9 − 8.3%) or entering an occupied room (3.0 − 11.9%) are less frequently reported (Gren-Landell et al., 2009 ; Knappe et al., 2011 ; Ruscio et al., 2008 ; Tillfors & Furmark, 2007 ). The ranking order of reported social fears among people with SAD are similar to those without SAD, but prevalence estimations are usually considerably higher (Gren-Landell et al., 2009 ; Knappe et al., 2011 ; Ruscio et al., 2008 ; Tillfors & Furmark, 2007 ).

Strong fear of social situations is often accompanied by avoidance behavior, which in turn contributes to the maintenance of these fears (Wong & Rapee, 2016 ) and possibly the development of full blown SAD. Yet, there seems to be a lack of epidemiological studies providing data on the proportion and extent of avoidance behavior in social situations among youth from the general population, that is, that are not limited to adolescents diagnosed with SAD. Across clinical (Kodal et al., 2017 ), treatment-seeking (Beidel et al., 2007 ) or student samples (Heiser et al., 2009 ) with SAD, the most often avoided situations were initiation of or participation in a conversation, or reporting in front of others. Higher levels of anxiety were found to be associated with higher levels of avoidance (Heimberg et al., 1999 ), albeit anxiety and avoidance can also have different developmental trajectories (Sumter et al., 2009 ). Whether a social situation is avoided depends on the extent of the fear, as well as on the consequences and on how easily the situation or consequences can be avoided (Sunderland et al., 2016 ). Overall, however, there is little information on the extent to which avoidance behaviors occur in the general population of young people, its onset, the transition from anxiety to avoidance behaviors, and how this relates to SAD (Sumter et al., 2009 ; Sunderland et al., 2016 ).

Looking at the most often feared and avoided social situations, it is noticeable that these are mostly performance-related situations (Beidel et al., 2007 ; Dell’Osso et al., 2015 ; Heiser et al., 2009 ; Kodal et al., 2017 ). According to the DSM-5 (American Psychiatric Association, 2013), it can be specified whether social anxiety does only occur in performance-related situations, as it seems that people who exclusively suffer from performance fears form a distinct group within SAD that is less impaired and less comorbid (Fuentes-Rodriguez et al., 2018 ; Heimberg et al., 2014 ; Knappe et al., 2011 ). The prevalence of performance-only social anxiety among people with diagnosed SAD varies between 0% and 26% in adolescents (Burstein et al., 2011 ; Fuentes-Rodriguez et al., 2018 ; Garcia-Lopez et al., 2018 ; Kerns et al., 2013 ) and 0.3% in adult samples (Crome et al., 2015 ). Given this high variance in findings among adolescents, further investigation of prevalence is warranted.

At last, it needs to be emphasized that SAD often co-occurs with other mental disorders (Knappe et al., 2015 ; Wittchen & Fehm, 2003 ), in adolescents especially with other anxiety disorders, predominantly generalized anxiety disorder and specific phobia, depressive disorders and substance use disorder (Garcia-Lopez et al., 2016 ; Wittchen et al., 1999 ). In adults, comorbidity rates typically range from 69 to 99% (Fehm et al., 2005 ; Knappe et al., 2015 ; Steinert et al., 2013 ), in adolescents and young adults the proportions seem to be lower (33-72%) (Garcia-Lopez et al., 2016 ; Wittchen et al., 1999 ). Moreover a dose-response pattern is observed in adults in which comorbidity increases with severity of social anxiety (Fehm et al., 2008 ) or number of feared situations (Ruscio et al., 2008 ). In adolescents and young adults, there was likewise an increase in comorbidity when comparing non-generalized vs. generalized social phobia based on DSM-IV (Wittchen et al., 1999 ), however current data in this age group are missing.

The current study aims to extent basic epidemiologic knowledge on DSM-5 SAD and social fears as well as avoidance behavior of adolescents and young adults from the general population. In addition to prevalence estimates based on current (DSM-5) criteria, it will be reported how often SAD is limited to performance-related situations, i.e. the prevalence of the DSM-5 performance-only specifier, as previous findings on the specifier in this age group are inconclusive (Burstein et al., 2011 ; Fuentes-Rodriguez et al., 2018 ; Garcia-Lopez et al., 2018 ; Kerns et al., 2013 ). Further, the level of fear and avoidance of a wide spectrum of typical social situations will be presented separately as well as the age of onset of anxiety and avoidance. In accordance with previous findings (Gren-Landell et al., 2009 ; Knappe et al., 2011 ; Kodal et al., 2017 ; Sunderland et al., 2016 ), we expect performance-related situations, especially speaking in front of others, to be most often feared and avoided, and that avoidance will mostly occur after fear. Last, comorbidity rates in SAD and the prevalence of social fears and avoidance behaviors in other mental disorders, based on DSM-5 criteria, will be examined. Here we expect to find a similar dose-response pattern as in other studies (Ruscio et al., 2008 ), i.e., comorbidity rates increase with higher levels of social anxiety. This allows for a broader description of basic epidemiological data which are currently missing, particularly regarding avoidance behavior.

Sample and procedures

The Behavior and Mind Health (BeMIND) study is a prospective-longitudinal cohort study of a general population sample of adolescents and young adults from Dresden, Germany, to investigate developmental trajectories of mental and behavioral disorders. The present study uses data from the BeMIND baseline investigation (n = 1,180), thus comprising a cross-sectional epidemiological study design. The study protocol as well as its amendments were approved by the ethics committee of the Technische Universität Dresden (TUD: EK381102014). Details on sampling and methods of the BeMIND study are provided in detail elsewhere (Beesdo-Baum et al., 2020 ).

Briefly, an age- and sex-stratified random sample of 14-21-year-olds was drawn from the population registry of the city of Dresden in 2015. Exclusion criteria were not living in a household in Dresden during the field period, institutionalization, and insufficient German language skills. Written informed consent/assent after complete study information was required to participate in the study; in minors, all legal guardians also provided written informed consent.

A total of n = 6,321 subjects were invited by written information letter to participate in the study with a maximum of two reminder letters, n = 893 were found to be ineligible and of n = 2,708 the eligibility remained unknown. Of the remaining n = 5,428 individuals, n = 1,180 participated in the study assessments which were conducted between 11/2015 and 12/2016 at the study center at the Technische Universität Dresden (response rate: 21.7%, cooperation rate: 43.4%; ( The American Association for Public Opinion Research , 2016)). Most common reported reasons for non-participation were no interest and lack of time.

At baseline, subjects participated in a standardized clinical-diagnostic assessment, in an experimental assessment approximately one week later, and in an Ecological Momentary Assessment (EMA) as well as an online questionnaire assessment in between these two personal appointments.

Assessments

Self-reported sociodemographic information containing age, sex, nationality, education, social class, financial and living situation were assessed during the standardized computer-assisted personal interview.

Diagnostic status of the participants was assessed with an updated version (DIA-X-5/D-CIDI; Hoyer et al., 2020 ) of the Munich Composite International Diagnostic Interview (DIA-X/M-CIDI; Wittchen & Pfister, 1997) providing lifetime and 12-month diagnoses of a range of mental disorders including SAD according to DSM-5 (APA, 2013). The fully standardized computer-assisted personal interviews were conducted face-to-face by trained clinical (psychology/medical) interviewers. Via tablet computers, supporting lists and dimensional symptom scales were applied.

SAD was assessed within the anxiety disorders (D)-Section of the DIA-X-5, starting with the stem question phrase: “In the list you will find some typical situations that some people have a strong fear of or avoid. Have you ever had a strong fear or avoidance of doing things in front of others or of being in the center of attention? Please read all situations carefully and tell me if you ever had a strong fear of such situations or avoided them.” The presented list included eight typically feared social situations (e.g., writing while being watched, taking an exam or test, speaking in front of others). If the participant affirmed the stem question, they were prompted to rate the degree of fear and avoidance related to each of the situations endorsed on the tablet (see details below), followed by more detailed interview questions to assess whether the criteria for SAD were met. The performance-only specifier was given to participants who indicated only performance-related situations in the stem question, i.e., taking an exam or test, speaking in front of others, or performing in front of an audience. Participants who positively affirmed the CIDI stem question for social anxiety but did not meet the criteria for lifetime SAD comprise the group lifetime symptomatic social anxiety (SA) only. Participants who negated the CIDI stem question for social anxiety comprise the group no lifetime social anxiety.

Regarding the age of onset, participants first indicated the approximate age at which they began to fear or avoid each of the positively affirmed social situations and then reported the situations which they feared or avoided first. If the participant reported that the situation was always feared or avoided, the age of onset was set at 2 years. If the participant had difficulties to remember the age, the age was set at 4 years if it was before school, 12 years if it was before adolescence, 19 years if it was before adulthood and 20 years otherwise. N = 1 participant did not fill the SAD section and was conservatively counted as having no SAD diagnosis. Regarding the diagnostic test-retest reliability of the DIA-X-5, agreement and kappa for SAD diagnosis were estimated at 80.0% and 0.29, and for the SAD stem item at 91.7% and 0.83 (Hoyer et al., 2020 ). The intraclass coefficient for SAD age of onset was 0.73 (Hoyer et al., 2020 ). The validity evaluation of the DIA-X-5 is still pending, yet the validity of the DSM-IV social phobia diagnosis assessed with the DIA-X/M-CIDI was estimated with a kappa of 0.80 (Reed et al., 1998 ).

Feared and avoided social situations were assessed via an adapted version of the Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987) presented on a tablet screen. It comprises 8 upper categories and 27 subcategories of social situations and the extent of anxiety and avoidance in these situations. The upper categories, which corresponded to the categories of the list mentioned above, and the subcategories were only presented when the corresponding social situation was affirmed in the stem question of the DIA-X-5. Respondents reported the extent of anxiety on a scale ranging from 0 (no) to 100 (high) as well as the avoidance from 0 (never) to 100 (usually) by using a slider.

Data preparation and statistical analyses

To improve representativeness regarding sex and age, sample weights were applied to make sure that the sample distribution of sex and age is equal to the one of the target population of the 14-21-year-old people living in Dresden; n are reported unweighted. Descriptive statistics (weighted percent, %w; mean values, M ; standard deviation, SD , median, Mdn ) are provided regarding sociodemographic characteristics, both for the total sample as well as separately for those with lifetime SAD and with symptomatic social anxiety (SA) only and no lifetime social anxiety. Logistic regressions adjusted for age and sex were calculated for each sociodemographic characteristic and comorbid diagnoses to examine associations (odds ratios, OR) with 95% confidence intervals (95%CI) for SAD vs. symptomatic SA only and no SA, respectively, and symptomatic SA only vs. no SA. The alpha level was set to α = 0.05.

To report the extent of fear and avoidance of social situations, the parts of the LSAS that were not filled were set to 0, since the presentation of the categories depended on the answers to the stem question in the DIA-X-5. If the category was not selected in the stem question, it was assumed that there was no fear or avoidance in its subcategories either. The raw values for anxiety and avoidance were then divided into 4 categories, respectively: no/never (0–10), low/occasionally (11–40), moderate/often (41–70), high/usually (71–100). Weighted relative frequencies were graphically presented for each situation and category for anxiety and avoidance in the total sample as well as in the lifetime SAD and symptomatic SA group.

To report social anxiety and avoidance behavior in the context of other DSM-5 lifetime diagnoses, DIA-X-5/CIDI lifetime diagnoses and LSAS data categorized in the manner described above were combined. The highest rating of all situations was used to classify severity, regardless of how many situations were rated at that level, e.g., moderate anxiety includes all individuals who reported moderate anxiety in at least one situation. As for SAD, individuals with missing sections within the DIA-X-5 were assumed to not meet the criteria for the respective diagnosis. Depending on the diagnosis, this applied to between n = 0 and n = 16 cases.

Wald-tests with α = 0.05 were calculated to compare the onset of anxiety and onset of avoidance between and within the groups with SAD and symptomatic SA only. To report the sequence of onset, i.e., whether a person first feared or first avoided situations, the difference of both onset data was calculated. No consideration was given to whether the first feared situation and the first avoided situation were identical. N = 9 of those with SAD and n = 121 of those with symptomatic SA only reported never avoiding a feared social situation, so no age of onset of avoidance was available in these cases. In addition, onset of anxiety was missing in n = 3 and onset of avoidance in n = 30 of those with symptomatic SA only. There were no missing values in those with SAD. Missing values were not included in the analyses. For the graphical illustration of onset of anxiety respective avoidance, the weighted proportions were calculated for the age of first occurrence for each situation and then cumulated. All observed cases including the multiple answers were considered, respectively.

Demographic sample characteristics

Table  1 presents the descriptive characteristics of the total sample, participants with lifetime SAD, lifetime symptomatic SA only and no lifetime social anxiety. Higher age (SAD vs. symptomatic SA only: OR = 1.15; 95%CI: 1.03–1.28; p  = .012; SAD vs. no SA: OR = 1.12; 95%CI: 1.01–1.25; p  = .031) and female sex (SAD vs. symptomatic SA only: OR = 2.37; 95%CI: 1.35–4.16; p  = .003; SAD vs. no SA: OR = 3.52; 95%CI: 2.01–6.17; p  < .001) were associated with lifetime SAD compared to lifetime symptomatic SA only and no lifetime SA. Female sex was also associated with lifetime symptomatic SA only compared with no lifetime SA (OR = 1.54; 95%CI: 1.21–1.96; p  < .001).

Prevalence of SAD and social anxiety

The DSM-5 criteria for lifetime SAD were fulfilled by 6.6% (n = 82) of all participants (9.9% of girls, n = 65, and 3.6% of boys, n = 17) and 4.8% (n = 63) for 12-months SAD (7.9% of girls, n = 54 and 2.0% of boys, n = 9). Lifetime SAD restricted only to performance-related situations applied to 0.9% (n = 10) of the total sample, thereof n = 6 girls and n = 4 boys. Of those with lifetime SAD, 13.2% met the criteria of the performance-only specifier. In the total sample, 17.4% (n = 209, thereof 53.4% female, n = 134) reported ever having strongly feared or avoided exclusively performance-related social situations, and 34.3% (n = 415, thereof 53.9% female, n = 266) feared or avoided social situations from other domains exclusively or additionally. In the total sample, 45.0% (n = 542, thereof 51.2% female, n = 335) reported lifetime symptomatic social anxiety only, i.e., lifetime social anxiety but never meeting criteria for a DSM-5 lifetime SAD diagnosis, and 48.4% (n = 556, thereof 42.3% female, n = 285) reported no lifetime social fears.

Types of feared or avoided social situations

Relative frequencies of different intensities of fear and avoidance behavior in different social situations are illustrated in Figs.  1 and 2 , respectively.

Relative frequencies of different anxiety intensities in various social situations in the total sample, the subsample of those fulfilling the criteria for lifetime social anxiety disorder (SAD) and those with lifetime symptomatic social anxiety only (affirmed the CIDI stem question for lifetime social anxiety but did not meet the criteria of lifetime SAD). The presented relative frequencies are weighted percent, %w, adjusted for sex and age. Data were obtained from the adapted version of the Liebowitz Social Anxiety Scale (LSAS). The extent of anxiety was measured on a scale ranging from 0 (no) to 100 (high) and divided in four categories: no (0 – 10), low (11 – 40), moderate (41 – 70), high (71 – 100). Participants only filled the categories that were affirmed in the stem question of the standardized diagnostic interview (DIA-X-5/D-CIDI). Not filled categories were set to 0

Relative frequencies of different intensities of avoiding various social situations in the total sample, the subsample of those fulfilling the criteria for lifetime social anxiety disorder (SAD) and those with lifetime symptomatic social anxiety only (affirmed the CIDI stem question for lifetime social anxiety but did not meet the criteria of lifetime SAD). The presented relative frequencies are weighted percent, %w, adjusted for sex and age. Data were obtained from the adapted version of the Liebowitz Social Anxiety Scale (LSAS). The extent of avoidance was measured on a scale ranging from 0 (never) to 100 (usually) and divided in four categories: never (0 – 10), occasionally (11 – 40), often (41 – 70), usually (71 – 100). Participants only filled the categories that were affirmed in the stem question of the standardized diagnostic interview (DIA-X-5/D-CIDI). Not filled categories were set to 0

Regarding the total sample, there are two situational clusters, where social anxiety predominantly occurs: taking tests and speaking in front of others, whereby oral exams (high anxiety reported by 13.2%), giving a speech (high anxiety reported by 12.9%) and speaking without preparation (high anxiety reported by 15.4%) are most often highly feared. With regard to avoidance behavior, the pattern is slightly different, so that the cluster of speaking in front of others, especially speaking without preparation (usual avoidance reported by 14.1%), continues to be the most pronounced, but avoidance of exams hardly occurs (usual avoidance reported by 1.5%). The least feared and avoided social situations in the total sample were eating (high anxiety reported by 1.7%, usual avoidance reported by 3.5%) or drinking in public (high anxiety reported by 0.5%, usual avoidance reported by 0.3%), writing while being observed (high anxiety reported by 0.9%, usual avoidance reported by 1.2%), and using a public restroom (high anxiety reported by 0.9%, usual avoidance reported by 2.9%).

When comparing lifetime SAD and symptomatic SA only, it is notable that the patterns are overall very similar, albeit more pronounced in SAD. Again, the situations speaking without preparation (SAD: high anxiety reported by 60.2%, usual avoidance reported by 56.7%; symptomatic SA: high anxiety reported by 25.4% usual avoidance reported by 23.1%) and giving a speech (SAD: high anxiety reported by 49.7%, usual avoidance reported by 48.5%; symptomatic SA: high anxiety reported by 21.5%, usual avoidance reported by 13.5%) were most often highly feared and avoided. As well, oral exams were highly feared but rather rarely avoided (SAD: high anxiety reported by 43.5%, usual avoidance reported by 12.3%; symptomatic SA: high anxiety reported by 22.9%, usual avoidance reported by 1.5%), although the avoidance tendency in SAD is nevertheless striking in comparison. Other situations that are notable for severe anxiety and avoidance, especially in SAD, include performing in front of an audience, flirting, and throwing a party.

Situations that are least likely to evoke fear and avoidance are drinking in public (SAD: high anxiety reported by 1.2%, usual avoidance reported by 1.9%; symptomatic SA: high anxiety reported by 1.0%, usual avoidance reported by 0.3%), writing while being observed (SAD: high anxiety reported by 8.2%, usual avoidance reported by 8.5%; symptomatic SA: high anxiety reported by 0.8%, usual avoidance reported by 1.5%) and using a public restroom (SAD: high anxiety reported by 7.2%, usual avoidance reported by 12.5%; symptomatic SA: high anxiety reported by 0.7%, usual avoidance reported by 4.6%).

Onset of social anxiety and avoidance behavior

The mean age of onset of social anxiety was M  = 10.9 ( SD  = 3.4; Mdn  = 11; Range : 2–21) for those with lifetime SAD and M  = 11.3 ( SD  = 3.7; Mdn  = 11; Range : 2–21) for those with symptomatic SA only, differing not significantly ( F (1, 620) = 0.96; p  = .328). About 90.1% (n = 73) of those with SAD and 77.8% (n = 421) of those with symptomatic SA only reported having avoided social situations at least rarely. When avoidance behaviors were reported, the onset of avoidance was M  = 12.1 ( SD  = 2.9; Mdn  = 12; Range : 2–17) for those with lifetime SAD and M  = 12.3 ( SD  = 3.4; Mdn  = 12; Range : 2–21) for those with symptomatic SA only, differing not significantly from each other ( F (1, 463) = 0.47; p  = .495). Avoidance behavior occurred significantly later than anxiety in both groups (SAD: F (1, 72) = 18.55; p  < .001; symptomatic SA only: F (1, 388) = 67.20; p  < .001). Looking more closely at the sequence of onset, also considering those who reported the onset of anxiety but not avoidance, the following pattern was observed:

Most participants reported the same age of first onset of anxiety and avoidance (lifetime SAD: n = 39, 50.7%; symptomatic SA only: n = 195, 37.7%). The onset of anxiety before avoidance of at least one year was reported by 34.6% (n = 31) of those with lifetime SAD and by 34.0% (n = 170) of those with symptomatic SA only. The onset of avoidance before anxiety of at least one year was reported by 4.8% (n = 3) of those with lifetime SAD and by 4.4% (n = 24) of those with symptomatic SA. Anxiety but no onset of avoidance was reported by 9.9% (n = 9) of those with SAD and by 23.8% (n = 121) of those with symptomatic SA.

Figure  3 shows the cumulated proportions of the ages of onset of anxiety and avoidance. In Part A and B, the onset is shown across all situations separately for those with lifetime SAD and symptomatic SA only. Part C and D display the onset curves for each situation, but for both groups together. In all curves, a slight delay is observable for avoidance compared to anxiety. The onset of anxiety increases moderately between the ages of 5 and 9 years and more markedly between the ages of 10 and 16 years, with the slope decreasing earlier among those with symptomatic SA only compared with lifetime SAD. Regarding the onset of avoidance, there is a slight increase from the age of 6 years that becomes steeper from the ages of 11 to 16 years with a small delay from the age of 12 years of symptomatic SA only versus lifetime SAD. Referring to the different situations, the primary observation is that the curves for fear and avoidance of talking to others rise earlier in childhood than the curves for other situations. In contrast, onset curves for fear and avoidance of eating or drinking in public and participating an event, meeting, or party increase most during early adolescence. Regarding the first occurrence of anxiety and avoidance of exams or tests, a sharp increase in onset can be observed at the age of 9 years.

Cumulative proportions of the ages of onset of fear (parts A and C) and avoidance behavior (parts B and D). Part A and B show the cumulative proportions across all social situations separately for those with lifetime social anxiety disorder (SAD) and lifetime symptomatic social anxiety (SA) only. In parts C and D, the cumulative proportions are presented for different social situations, but without distinguishing the groups mentioned. The plotted data show all observed cases, including multiple answers. Age of onset was set at 2 years if the participant indicated that the situation has always been feared respectively avoided. In parts C and D, the number of cases (n; anx: anxiety; av: avoidance) differs strongly between the situations since situations were differently often feared or avoided first

Social anxiety and other mental disorders

Data on comorbidity are shown in Table  2 . About 90% of those with lifetime SAD met the criteria of at least one other lifetime DSM-5 disorder which is significantly more than the 58% of those reporting symptomatic SA only (OR = 6.67; 95%CI: 3.13–14.21; p  < .001) and, than the 42% of those reporting no social anxiety (OR = 13.82; 95%CI: 6.42–29.72; p  < .001). Comparing lifetime SAD to symptomatic SA only, significantly elevated odds ratios were found for other anxiety, obsessive-compulsive, trauma-related, depressive, bipolar, eating and attention deficit hyperactivity disorders with the highest odds for the last two. When comparing lifetime SAD to no lifetime SA, there were significantly increased odds for all disorders studied except disruptive, impulse-control or conduct disorder. Lifetime symptomatic SA only compared to no lifetime SA showed elevated odd ratios for any anxiety, depressive, psychotic, and substance use disorder.

The proportion of any other lifetime mental disorder increases the more at least one social situation is feared or avoided (Table  3 ). This dose-response pattern is predominantly evident for anxiety disorders but when comparing severe and less severe social anxiety/avoidance behavior a marked increase in lifetime prevalence is also found for other disorders except for disruptive, impulse-control or conduct disorder and, concerning only social avoidance behavior, substance use disorder.

Furthermore, when looking separately at performance-only SAD compared to SAD, it is noticeable that performance-only SAD is less often associated with severe anxiety and avoidance behavior.

This cross-sectional epidemiologic study confirms a high prevalence for SAD according to DSM-5 criteria in adolescents and young adults and provides data on the occurrence and onset of social fears and avoidance behaviors as well as on comorbidity rates in youth in the general population, thus adding current basic epidemiological data to the literature.

The weighted lifetime prevalence of DSM-5 SAD in this sample was 6.6% with almost three quarters being female (72.1%). These rates are in line with previous findings (Avenevoli, 2012 ; Beesdo-Baum et al., 2012 ; Fehm et al., 2005 ; Kessler et al., 2005 ; Knappe et al., 2015 ; Merikangas et al., 2010 ; Ruscio et al., 2008 ) and corroborate that especially girls and young women are affected. Furthermore, 45% of the sample reported ever having had social anxiety or avoidance behaviors, yet not fulfilling diagnostic criteria for a full blown / threshold SAD diagnosis. This emphasizes the extent of subclinical social anxiety among adolescents and young adults in the general population. Regarding the performance-only subtype of social anxiety specified in DSM-5, a minority of 13.2% of those with lifetime SAD apply to the criteria, which lies in the middle of the relatively wide range of previous findings (Boyers et al., 2017 ; Burstein et al., 2011 ; Crome et al., 2015 ; Fuentes-Rodriguez et al., 2018 ; Garcia-Lopez et al., 2018 ; Kerns et al., 2013 ). Our findings suggest that the vast majority of youth with DSM-5 SAD, and also independent of SAD diagnosis, are not or not only affected by fear and avoidance of performance situations. Furthermore, with regard to severity, individuals with performance-only SAD more often reported milder forms of anxiety and, in particular, less avoidance behavior compared to SAD, which is consistent with previous findings (Fuentes-Rodriguez et al., 2018 ; Peyre et al., 2016 ). Overall, it can be assumed that this specifier may be rarely applied in clinical practice and therefore be of limited use for treatment planning purposes.

Concerning the prevalence and severity of anxiety and avoidance of social situations in a general population sample of adolescents and young adults, there are predominantly two situational clusters where anxiety occurs most frequently: test situations, especially oral exams, and speaking and performing in front of others. As expected, these are performance-related situations. That is, almost a quarter of adolescents and young adults seem to perceive at least moderate fear in these areas, which corresponds to the results of other large-scale studies with adults (Ruscio et al., 2008 ; Stein et al., 2010 ; Tillfors & Furmark, 2007 ) and adolescents (Gren-Landell et al., 2009 ; Knappe et al., 2011 ). As might be expected, overt avoidance behavior is less prevalent than anxiety (Kodal et al., 2017 ; Wong & Rapee, 2016 ), yet about one-sixth of participants reported at least often avoiding situations involving speaking in front of others, especially without preparation. Exams, however, seem to be endured despite fear, as the negative consequences of avoiding would likely be too serious (Sunderland et al., 2016 ). Similar patterns are found in young people who met DSM-5 criteria for lifetime SAD, albeit these are much more pronounced, also compared with individuals who reported symptomatic social anxiety only. Some situations, however, seem to be strongly feared and avoided especially by those with SAD. So, apart from the aforementioned situational clusters, the largest discrepancies between individuals with SAD and symptomatic anxiety only were found for flirting and throwing a party and, in terms of avoidance behaviors, talking to a person who is barely known. These situations should therefore receive particular attention in the clinical context. Overall, these findings are not unexpected and correspond to the existing literature (Beidel et al., 2007 ; Heiser et al., 2009 ; Knappe et al., 2011 ; Kodal et al., 2017 ; Ruscio et al., 2008 ). Nonetheless, to our knowledge, there is not yet such a detailed overview that specifically presents avoidance behaviors separately from reported anxiety in a general population sample of adolescents and young adults. High levels of social anxiety and avoidance of social situations can have detrimental consequences for affected youth, particularly in the school context, starting with presentations, that might be perceived as very stressful, over difficulties to find friends up to bullying (Blöte et al., 2015 ). In view of the quite frequent occurrence of social fears and avoidance behavior among adolescents and young adults found in this study and usually waxing and waning course of SAD (Beesdo-Baum et al., 2012 ), it is therefore very important to raise awareness of this topic at an early stage, ideally in the school context, and to offer preventive, low-threshold support. Avoidance behaviors may thus serve as an additional diagnostic marker for social anxiety, when physical or cognitive symptoms of SAD are not prominent.

On average, social anxiety and avoidance behavior first occur in early adolescence, that is, at ages 11 and 12, respectively, in our sample of 14-21-year-olds. As expected, avoidance of social situations occurs in most cases either at about the same age as anxiety or slightly later. The transition from anxiety to avoidance seems thus to take place very quickly and often within the first year (Sunderland et al., 2016 ). In some cases, especially in milder forms of social anxiety, no overt avoidance behavior was reported, suggesting that situations might be endured despite fear or that covert avoidance or safety behaviors might be used. In few cases, avoidance was reported to occur before anxiety. Looking at the onset curves, it is also noticeable that there is an initial increase in anxiety between ages 5 and 10, which is much smaller for avoidance behavior. Then, from the age of 11, there is a marked increase in both anxiety and avoidance, making the period before, i.e., elementary school age, favorable for preventive measures. Avoidance behaviors may present an early behavioral symptom, timely close to SAD incidence. From a clinical perspective, however, it could be argued that children aged 5 to 10 years already have a concept of fear, but not of avoidance. Even when children exhibit avoidance behavior from an adult perspective, they may not yet reliably associate it with fear. However, this reasoning and whether it can explain the delayed onset of avoidance behavior needs to be examined elsewhere.

A slight delay in the onset of fear and avoidance in symptomatic SA compared to SAD is observable, yet not clinically relevant due to the small difference. The comparison of the different situations revealed varying patterns of onset. Fear and avoidance of talking to or addressing other people seems to be often already prevalent at younger ages, while eating or drinking in public and participating or giving an event, meeting or party seems to be first feared and avoided only in early adolescence. Further, fear and avoidance of exams seems to occur rather seldom at primary school age, but increases rapidly at secondary schools, i.e., from about 10 years of age. This might be explained by an increased exam load and higher demands in educational and social life. Also, with increasing age, children learn better to judge their own performance and comparisons with peers become more important, which in turn might increase pressure and test anxiety (McDonald, 2001 ). Overall, it appears that social fears increasingly first occur in late childhood and early adolescence and that avoidance behavior often follows within a short time. It would therefore be very useful to implement preventive measures in this period to counteract avoidance behavior, the consolidation and generalization of social fears and the development of SAD at an early stage. For example, the Anxiety and Avoidance Scale for Children (AVAC) was developed to identify the most anxiety-eliciting situations in children aged 8 to 16 years and their parents, by taking into account ratings on both levels of fear and avoidance (Lippert et al., 2021 ).

At last, social anxiety has been shown to play an important role in other mental disorders. The observed lifetime comorbidity rate of 90% in all SAD cases is within the range of findings from other studies (69-99%) (Knappe et al., 2015 ; Leichsenring et al., 2003 ; Wittchen et al., 1999 ), albeit they mostly involved adult samples. Data on comorbidities in adolescents are rare, yet Jystad and colleagues ( 2021 ) reported a rate of 72.8% and Garcia-Lopez and colleagues ( 2016 ) a rate of 33%, although the latter is lower than expected given the clinical sample. Trying to explain this difference, it is conspicuous that no comorbidity with substance use disorder was reported in the study by Garcia-Lopez and colleagues ( 2016 ), although high comorbidity was found in other literature (Knappe et al., 2015 ) and our study (33%). On the other hand, in the study by Jystad and colleagues ( 2021 ), comorbidity with substance abuse was rather low. Otherwise, it might be possible that comorbid disorders predominantly occur in early adulthood (rather than in late childhood). Although it has been shown that SAD is a risk factor for other disorders, e.g., depressive (Beesdo et al., 2007 ) or substance use disorders (Buckner et al., 2008 ), literature on the age of onset of comorbid disorders in SAD is scarce (Beesdo et al., 2007 ). Corroborating previous findings (Beesdo-Baum et al., 2012 ; Fehm et al., 2008 ; Wittchen et al., 1999 ), highest comorbidity rates were found for other anxiety (56%), depressive (48%) and substance use disorders (33%). A dose-response pattern is generally observed in adults, with prevalence rates higher the more severe the social anxiety (Fehm et al., 2008 ; Ruscio et al., 2008 ), which is supported and extended by our data. Hence, this pattern seems to be also evident in adolescents and young adults for most mental disorders, not only in the level of social anxiety, but also in the level of avoidance of social situations. Exceptions to this appear to be disruptive, impulse-control or conduct disorder, and partly substance use disorder (Ruscio et al., 2008 ). Overall, prospective studies are needed to further investigate the sequence and onset of comorbid disorders in SAD, especially with regard to the dose-response-pattern.

There are some limitations to be mentioned. First, since the data were retrospective, they might be biased, especially concerning the age of onset. Some situations were only rarely reported to be the first feared or avoided social situation (e.g., writing), thus the graphs in Fig.  3 need to be interpreted with caution. Moreover, the onset of anxiety and avoidance was assessed only in years, so the exact temporal order of both is not clear when the same age of onset was reported for anxiety and avoidance. However, it is plausible to assume that in most cases anxiety occurred before avoidance, arguing for avoidance to contribute to SAD persistence, but not or rarely to SAD onset. Further, the sample was restricted to adolescents and young adults aged 14–21 years living in the city of Dresden, Germany, which limits the generalization of the results to other regions or ages. The overall response rate of the study (21.7%) was relatively low, which does not necessarily impair the validity of the findings but needs to be kept in mind when interpreting the results. Prevalence estimates and the extent of fear and avoidance of social situations might be underestimated in the current study since the in person participation in the BeMIND study itself is a social situation, which might have been avoided by particularly socially anxious young people. Last, the low kappa (0.29) of the SAD diagnosis found by Hoyer and colleagues ( 2020 ) needs to be discussed. A closer look showed that 9 of 12 discordant cases were due to discordance on only one criterion, predominantly on the avoidance or duration criterion (Hoyer et al., 2020 ). It can therefore be assumed that the DIA-X-5/D-CIDI might have difficulties with regard to these criteria to clearly separate subthreshold from suprathreshold SAD, yet the validity of the severity and situation data should be at an acceptable level. In addition, it must be noted that the study sample size in this retest-reliability study was limited to 60 participants and included as well older adults, so that a further examination of the reliability and validity of the SAD diagnosis, especially for young adults, seems reasonable.

In comparison, there are also strengths to be highlighted. The study is based on a general population sample of adolescents and young adults, in which the diagnostic status was assessed in each case by means of a fully standardized computer-assisted personal interview. The diagnoses were based on current diagnostic criteria (DSM-5), giving the opportunity of reporting recent prevalence and comorbidity estimates of SAD and its performance-only specifier among adolescents and young adults. It was further used an adapted version of the Liebowitz Social Anxiety Scale, which was extended by 27 subcategories, so that the extent of fear and avoidance could be examined in a very detailed way and acknowledging social situations particularly salient in early adolescence. A particular strength here is the separate focus on avoidance behavior, which to our knowledge has not yet been reported in this detail in an epidemiologic context.

With those limitations and strengths in mind, the findings demonstrate that social anxiety disorder and social fears and avoidance of social situations are very prevalent in adolescence and young adulthood. When looking at different social situations, it was found that, in addition to oral exams, situations where to speak or perform in front of others were particularly considered very frightening. Feared situations of young people fulfilling the criteria of SAD were largely no different from those reporting symptomatic social anxiety only, although prevalence estimates were considerably higher. With regard to the onset, it seems that avoidance behavior often occurs within a short period of time after the onset of strong fear emphasizing the need for early prevention measures. Lastly, in terms of comorbidity in SAD, a dose-response-pattern similar to findings in adult samples was observed (Fehm et al., 2008 ; Ruscio et al., 2008 ). The prevalence of most mental disorders seems to increase with severity of social anxiety and avoidance behavior also independent of a SAD diagnosis. Overall, this leads to the conclusion that social anxiety and avoidance behavior should be identified at an early stage particularly because of the widespread prevalence and high comorbidity even at this young age. It could be helpful to sensitize not only parents and guardians but also teachers to this topic. Targeted prevention measures in early adolescence, e.g., in schools, could help to ameliorate the burden of social fears and avoidance and interrupt progression to SAD and comorbid conditions.

Data Availability

The data that support the findings of this study are available from the senior author upon reasonable request.

American Psychiatric Association (Hrsg.). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed).American Psychiatric Association.

Asselmann, E., Wittchen, H. U., Lieb, R., & Beesdo-Baum, K. (2018). Sociodemographic, clinical, and functional long-term outcomes in adolescents and young adults with mental disorders. Acta Psychiatrica Scandinavica , 137 (1), 6–17. https://doi.org/10.1111/acps.12792

Article   PubMed   Google Scholar  

Avenevoli, S. (2012). Prevalence, Persistence, and Sociodemographic Correlates of DSM-IV Disorders in the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry , 69 (4), 372. https://doi.org/10.1001/archgenpsychiatry.2011.160

Beesdo, K., Bittner, A., Pine, D. S., Stein, M. B., Höfler, M., Lieb, R., & Wittchen, H. U. (2007). Incidence of Social Anxiety Disorder and the Consistent Risk for Secondary Depression in the First Three Decades of Life. Archives of General Psychiatry , 64 (8), 903. https://doi.org/10.1001/archpsyc.64.8.903

Beesdo-Baum, K., Knappe, S., Fehm, L., Höfler, M., Lieb, R., Hofmann, S. G., & Wittchen, H. U. (2012). The natural course of social anxiety disorder among adolescents and young adults: Natural course of social anxiety disorder. Acta Psychiatrica Scandinavica , 126 (6), 411–425. https://doi.org/10.1111/j.1600-0447.2012.01886.x

Beesdo-Baum, K., Voss, C., Venz, J., Hoyer, J., Berwanger, J., Kische, H., Ollmann, T. M., & Pieper, L. (2020). The Behavior and Mind Health (BeMIND) study: Methods, design and baseline sample characteristics of a cohort study among adolescents and young adults. International Journal of Methods in Psychiatric Research , 29 (1), https://doi.org/10.1002/mpr.1804

Beidel, D. C., Turner, S. M., Young, B. J., Ammerman, R. T., Sallee, F. R., & Crosby, L. (2007). Psychopathology of Adolescent Social Phobia. Journal of Psychopathology and Behavioral Assessment , 29 (1), 46–53. https://doi.org/10.1007/s10862-006-9021-1

Article   Google Scholar  

Blöte, A. W., Miers, A. C., Heyne, D. A., & Westenberg, P. M. (2015). Social Anxiety and the School Environment of Adolescents. In K. Ranta, A. M. La Greca, L.-J. Garcia-Lopez, & M. Marttunen (Hrsg.), Social Anxiety and Phobia in Adolescents (S. 151–181). Springer International Publishing. https://doi.org/10.1007/978-3-319-16703-9_7

Boyers, G. B., Broman-Fulks, J. J., Valentiner, D. P., McCraw, K., Curtin, L., & Michael, K. D. (2017). The latent structure of social anxiety disorder and the performance only specifier: A taxometric analysis. Cognitive Behaviour Therapy , 46 (6), 507–521. https://doi.org/10.1080/16506073.2017.1338310

Buckner, J. D., Schmidt, N. B., Lang, A. R., Small, J. W., Schlauch, R. C., & Lewinsohn, P. M. (2008). Specificity of social anxiety disorder as a risk factor for alcohol and cannabis dependence. Journal of Psychiatric Research , 42 (3), 230–239. https://doi.org/10.1016/j.jpsychires.2007.01.002

Burstein, M., He, J. P., Kattan, G., Albano, A. M., Avenevoli, S., & Merikangas, K. R. (2011). Social Phobia and Subtypes in the National Comorbidity Survey–Adolescent Supplement: Prevalence, Correlates, and Comorbidity. Journal of the American Academy of Child & Adolescent Psychiatry , 50 (9), 870–880. https://doi.org/10.1016/j.jaac.2011.06.005

Crome, E., Grove, R., Baillie, A. J., Sunderland, M., Teesson, M., & Slade, T. (2015). DSM-IV and DSM-5 social anxiety disorder in the Australian community. Australian & New Zealand Journal of Psychiatry , 49 (3), 227–235. https://doi.org/10.1177/0004867414546699

Dell’Osso, L., Abelli, M., Pini, S., Carpita, B., Carlini, Mengali, F., Tognetti, R., Rivetti, F., & Massimetti, G. (2015). The influence of gender on social anxiety spectrum symptoms in a sample of university students. Rivista di Psichiatria , 2015Novembre-Dicembre . https://doi.org/10.1708/2098.22688

Fehm, L., Beesdo, K., Jacobi, F., & Fiedler, A. (2008). Social anxiety disorder above and below the diagnostic threshold: Prevalence, comorbidity and impairment in the general population. Social Psychiatry and Psychiatric Epidemiology , 43 (4), 257–265. https://doi.org/10.1007/s00127-007-0299-4

Fehm, L., Pelissolo, A., Furmark, T., & Wittchen, H. U. (2005). Size and burden of social phobia in Europe. European Neuropsychopharmacology , 15 (4), 453–462. https://doi.org/10.1016/j.euroneuro.2005.04.002

Fuentes-Rodriguez, G., Garcia-Lopez, L. J., & Garcia-Trujillo, V. (2018). Exploring the role of the DSM-5 performance-only specifier in adolescents with social anxiety disorder. Psychiatry Research , 270 , 1033–1038. https://doi.org/10.1016/j.psychres.2018.03.052

Garcia-Lopez, L. J., Beidel, D., Muela-Martinez, J. A., & Espinosa-Fernandez, L. (2018). Optimal Cut-Off Score of Social Phobia and Anxiety Inventory-Brief Form: Detecting DSM-5 Social Anxiety Disorder and Performance-Only Specifier. European Journal of Psychological Assessment , 34 (4), 278–282. https://doi.org/10.1027/1015-5759/a000324

Garcia-Lopez, L. J., Bonilla, N., & Muela-Martinez, J. A. (2016). Considering Comorbidity in Adolescents with Social Anxiety Disorder. Psychiatry Investigation , 13 (5), 574. https://doi.org/10.4306/pi.2016.13.5.574

Article   PubMed   PubMed Central   Google Scholar  

Gren-Landell, M., Tillfors, M., Furmark, T., Bohlin, G., Andersson, G., & Svedin, C. G. (2009). Social phobia in Swedish adolescents: Prevalence and gender differences. Social Psychiatry and Psychiatric Epidemiology , 44 (1), 1–7. https://doi.org/10.1007/s00127-008-0400-7

Heimberg, R. G., Hofmann, S. G., Liebowitz, M. R., Schneier, F. R., Smits, J. A. J., Stein, M. B., Hinton, D. E., & Craske, M. G. (2014). Social Anxiety Disorder in DSM-5: Review: Social Anxiety Disorder in DSM-5. Depression and Anxiety , 31 (6), 472–479. https://doi.org/10.1002/da.22231

Heimberg, R. G., Horner, K. J., Juster, H. R., Safren, S. A., Brown, E. J., Schneier, F. R., & Liebowitz, M. R. (1999). Psychometric properties of the Liebowitz Social Anxiety Scale. Psychological Medicine , 29 (1), 199–212. https://doi.org/10.1017/S0033291798007879

Heiser, N. A., Turner, S. M., Beidel, D. C., & Roberson-Nay, R. (2009). Differentiating social phobia from shyness. Journal of Anxiety Disorders , 23 (4), 469–476. https://doi.org/10.1016/j.janxdis.2008.10.002

Hoyer, J., Voss, C., Strehle, J., Venz, J., Pieper, L., Wittchen, H. U., Ehrlich, S., & Beesdo-Baum, K. (2020). Test-retest reliability of the computer-assisted DIA-X-5 interview for mental disorders. Bmc Psychiatry , 20 (1), 280. https://doi.org/10.1186/s12888-020-02653-6

Jystad, I., Bjerkeset, O., Haugan, T., Sund, E. R., & Vaag, J. (2021). Sociodemographic Correlates and Mental Health Comorbidities in Adolescents With Social Anxiety: The Young-HUNT3 Study, Norway. Frontiers in Psychology , 12 , 663161. https://doi.org/10.3389/fpsyg.2021.663161

Kerns, C. E., Comer, J. S., Pincus, D. B., & Hofmann, S. G. (2013). Evaluation of the proposed social anxiety disorder specifier change for DSM-5 in a treatment-seeking sample of anxious youth. Depression and Anxiety , 30 (8), 709–715. https://doi.org/10.1002/da.22067

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry , 62 (6), 593. https://doi.org/10.1001/archpsyc.62.6.593

Knappe, S., Beesdo-Baum, K., Fehm, L., Stein, M. B., Lieb, R., & Wittchen, H. U. (2011). Social fear and social phobia types among community youth: Differential clinical features and vulnerability factors. Journal of Psychiatric Research , 45 (1), 111–120. https://doi.org/10.1016/j.jpsychires.2010.05.002

Knappe, S., Sasagawa, S., & Creswell, C. (2015). Developmental Epidemiology of Social Anxiety and Social Phobia in Adolescents. In K. Ranta, A. M. La Greca, L.-J. Garcia-Lopez, & M. Marttunen (Hrsg.), Social Anxiety and Phobia in Adolescents (S. 39–70). Springer International Publishing. https://doi.org/10.1007/978-3-319-16703-9_3

Kodal, A., Bjelland, I., Gjestad, R., Wergeland, G. J., Havik, O. E., Heiervang, E. R., & Fjermestad, K. (2017). Subtyping social anxiety in youth. Journal of Anxiety Disorders , 49 , 40–47. https://doi.org/10.1016/j.janxdis.2017.03.009

Leichsenring, F., Jaeger, U., Rabung, S., & Streeck, U. (2003). Soziale Ängste und psychische Krankheiten: Daten zu Komorbidität, Häufigkeit und Schwere der Störung. PiD - Psychotherapie im Dialog , 4 (1), 68–74. https://doi.org/10.1055/s-2003-37604

Lippert, M. W., Sommer, K., Flasinski, T., Pflug, V., Rölver, A., Christiansen, H., In-Albon, T., Knappe, S., Romanos, M., Tuschen-Caffier, B., & Schneider, S. (2021). Personalized Assessment of Anxiety and Avoidance in Children and Their Parents—Development and Evaluation of the Anxiety and Avoidance Scale for Children. Frontiers in Psychology , 12 , 703784. https://doi.org/10.3389/fpsyg.2021.703784

McDonald, A. S. (2001). The Prevalence and Effects of Test Anxiety in School Children. Educational Psychology , 21 (1), 89–101. https://doi.org/10.1080/01443410020019867

Merikangas, K. R., He, J., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., Benjet, C., Georgiades, K., & Swendsen, J. (2010). Lifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry , 49 (10), 980–989. https://doi.org/10.1016/j.jaac.2010.05.017

Miché, M., Hofer, P. D., Voss, C., Meyer, A. H., Gloster, A. T., Beesdo-Baum, K., & Lieb, R. (2018). Mental disorders and the risk for the subsequent first suicide attempt: Results of a community study on adolescents and young adults. European Child & Adolescent Psychiatry , 27 (7), 839–848. https://doi.org/10.1007/s00787-017-1060-5

Peyre, H., Hoertel, N., Rivollier, F., Landman, B., McMahon, K., Chevance, A., Lemogne, C., Delorme, R., Blanco, C., & Limosin, F. (2016). Latent class analysis of the feared situations of social anxiety disorder: A population-based study: Peyre et al. Depression and Anxiety , 33 (12), 1178–1187. https://doi.org/10.1002/da.22547

Reed, V., Gander, F., Pfister, H., Steiger, A., Sonntag, H., Trenkwalder, C., Sonntag, A., Hundt, W., & Wittchen, H. U. (1998). To what degree does the Composite International Diagnostic Interview (CIDI) correctly identify DSM-IV disorders? Testing validity issues in a clinical sample. International Journal of Methods in Psychiatric Research , 7 (3), 142–155. https://doi.org/10.1002/mpr.44

Ruscio, A. M., Brown, T. A., Chiu, W. T., Sareen, J., Stein, M. B., & Kessler, R. C. (2008). Social fears and social phobia in the USA: Results from the National Comorbidity Survey Replication. Psychological Medicine , 38 (1), 15–28. https://doi.org/10.1017/S0033291707001699

Solano, P., Ustulin, M., Pizzorno, E., Vichi, M., Pompili, M., Serafini, G., & Amore, M. (2016). A Google-based approach for monitoring suicide risk. Psychiatry Research , 246 , 581–586. https://doi.org/10.1016/j.psychres.2016.10.030

Stein, D. J., Ruscio, A. M., Lee, S., Petukhova, M., Alonso, J., Andrade, L. H. S. G., Benjet, C., Bromet, E., Demyttenaere, K., Florescu, S., de Girolamo, G., de Graaf, R., Gureje, O., He, Y., Hinkov, H., Hu, C., Iwata, N., Karam, E. G., Lepine, J. P., & Kessler, R. C. (2010). Subtyping social anxiety disorder in developed and developing countries. Depression and Anxiety , 27 (4), 390–403. https://doi.org/10.1002/da.20639

Steinert, C., Hofmann, M., Leichsenring, F., & Kruse, J. (2013). What do we know today about the prospective long-term course of social anxiety disorder? A systematic literature review. Journal of Anxiety Disorders , 27 (7), 692–702. https://doi.org/10.1016/j.janxdis.2013.08.002

Sumter, S. R., Bokhorst, C. L., & Westenberg, P. M. (2009). Social fears during adolescence: Is there an increase in distress and avoidance? Journal of Anxiety Disorders , 23 (7), 897–903. https://doi.org/10.1016/j.janxdis.2009.05.004

Sunderland, M., Crome, E., Stapinski, L., Baillie, A. J., & Rapee, R. M. (2016). From Fear to Avoidance: Factors Associated with the Onset of Avoidance in People who Fear Social Situations. Journal of Experimental Psychopathology , 7 (4), 534–548. https://doi.org/10.5127/jep.055216

The American Association for Public Opinion Research. Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. 9th edition.

Tillfors, M., & Furmark, T. (2007). Social phobia in Swedish university students: Prevalence, subgroups and avoidant behavior. Social Psychiatry and Psychiatric Epidemiology , 42 (1), 79–86. https://doi.org/10.1007/s00127-006-0143-2

Wittchen, H. U., & Fehm, L. (2003). Epidemiology and natural course of social fears and social phobia: Epidemiology and course of SP. Acta Psychiatrica Scandinavica , 108 , 4–18. https://doi.org/10.1034/j.1600-0447.108.s417.1.x

Wittchen, H. U., Stein, M. B., & Kessler, R. C. (1999). Social fears and social phobia in a community sample of adolescents and young adults: Prevalence, risk factors and co-morbidity. Psychological Medicine , 29 (2), 309–323. https://doi.org/10.1017/S0033291798008174

Wong, N., Sarver, D. E., & Beidel, D. C. (2012). Quality of life impairments among adults with social phobia: The impact of subtype. Journal of Anxiety Disorders , 26 (1), 50–57. https://doi.org/10.1016/j.janxdis.2011.08.012

Wong, Q. J. J., & Rapee, R. M. (2016). The aetiology and maintenance of social anxiety disorder: A synthesis of complementary theoretical models and formulation of a new integrated model. Journal of Affective Disorders , 203 , 84–100. https://doi.org/10.1016/j.jad.2016.05.069

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Ernst, J., Ollmann, T.M., König, E. et al. Social anxiety in adolescents and young adults from the general population: an epidemiological characterization of fear and avoidance in different social situations. Curr Psychol 42 , 28130–28145 (2023). https://doi.org/10.1007/s12144-022-03755-y

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Review these short summaries of recent research on social anxiety and its evidence-based treatment.

HOMEWORK ENGAGEMENT IN COGNITIVE BEHAVIORAL GROUP THERAPY FOR SOCIAL ANXIETY

4-day intensive treatment for social anxiety, social anxiety and suicidality in youth, recent advances in social anxiety research, the cringe factor: social closeness modulates vicarious embarrassment, safety behavior subtypes across distinct social contexts in social anxiety & depression, the efficacy of internet-delivered cognitive behavioral therapy for adolescent social anxiety disorder, long-term outcomes in cbt for social anxiety: patients continue improving after treatment, the effect of depression on treatment outcome in social anxiety disorder, adolescent safety behaviors, psychosocial impairment and social anxiety, impact of social restrictions on social anxiety, loneliness & depression, social skills impairment in co-occurring social anxiety and adhd, the impact of intolerance of uncertainty in social anxiety on the perception of positive social events, inhibitory learning in exposure therapy for social anxiety and other anxiety- related disorders, mediums of communication in social anxiety disorder, envy in social anxiety, telehealth group cbt for social anxiety is effective and acceptable, use of cbd oil in treating social anxiety, cbt vs. mindfulness-based stress reduction for social anxiety, virtual reality treatment for public speaking anxiety, barriers to treatment for socially anxious persons, problematic social networking use and social anxiety, visual avoidance of faces in socially anxious individuals, impact of negative self-images for socially anxious adolescents, social anxiety, attractiveness and conformity, imagery rescripting for social anxiety improves positive memory and core beliefs, social skills training when treating social anxiety, decrease in post-event processing as social anxiety improves through cbt, visible symptoms vs. performance in social anxiety, fading positive memories in social anxiety, traditional cbt vs. acceptance & commitment therapy (act) for social anxiety, pre- and post-event rumination important factors in social anxiety, “hangxiety”: socially anxious persons experience increased anxiety the day after drinking, cognitive-behavioral therapy with relational focus (cbt-r) more effective for social anxiety than exposure therapy and relaxation, negative self-bias among the socially anxious; positive self-bias among others, perfectionism increasing over generations, verbal suggestions enhance social anxiety treatment, internet-delivered cbt for social anxiety, the interaction of distress tolerance and intolerance of uncertainty in cbt for social anxiety, video feedback for social anxiety, genetic links to social anxiety disorder, cbt alone more effective for social anxiety than medication, or medication + cbt —and— cbt for social anxiety changes the brain, virtual reality exposure therapy for social anxiety, is behavior therapy more efficient than cbt for anxiety disorders.

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Imaging the socially-anxious brain: recent advances and future prospects

Janna marie bas-hoogendam.

1 Developmental and Educational Psychology, Institute of Psychology, Leiden University, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands

2 Leiden Institute for Brain and Cognition, c/o LUMC, postzone C2-S, P.O.Box 9600, 2300 RC Leiden, The Netherlands

3 Department of Psychiatry, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands

P. Michiel Westenberg

Social anxiety disorder (SAD) is serious psychiatric condition with a genetic background. Insight into the neurobiological alterations underlying the disorder is essential to develop effective interventions that could relieve SAD-related suffering. In this expert review, we consider recent neuroimaging work on SAD. First, we focus on new results from magnetic resonance imaging studies dedicated to outlining biomarkers of SAD, including encouraging findings with respect to structural and functional brain alterations associated with the disorder. Furthermore, we highlight innovative studies in the field of neuroprediction and studies that established the effects of treatment on brain characteristics. Next, we describe novel work aimed to delineate endophenotypes of SAD, providing insight into the genetic susceptibility to develop the disorder. Finally, we outline outstanding questions and point out directions for future research.

Introduction

Social anxiety disorder (SAD) is a serious psychiatric condition with a genetic background and typically evolves during late childhood and early adolescence 1 – 5 . Patients are afraid of a negative evaluation by others and avoid social situations as much as possible, leading to significant adverse effects on important areas of functioning 6 – 9 . SAD is characterized by a chronic course, has severe consequences for patients 10 – 14 and high costs for society 15 , and is often suboptimally treated 16 , 17 . In order to develop effective interventions, which could relieve individual suffering and reduce the serious societal consequences of SAD, insight into the neurobiological alterations underlying the disorder is essential 18 . We are pleased to note that SAD is increasingly considered an interesting topic worthy of investigation 19 . In this review, we highlight recent advances with respect to neuroimaging work on SAD while focusing on data from magnetic resonance imaging (MRI) studies. First, we review work on biomarkers for SAD, being any measurable indicator of disease; second, we summarize recent work on profiling SAD endophenotypes, which are heritable and measurable characteristics associated with a certain disorder 20 . It is essential to distinguish biomarkers from endophenotypes, as they provide different types of information. For example, biomarker research is valuable for identifying treatment targets, whereas endophenotypes may be important for disentangling genetic underpinnings and identifying genetic mediators. Subsequently, we outline several outstanding questions and provide suggestions for future studies.

Biomarker research on social anxiety disorder

As recently outlined by Etkin 21 , neuroimaging research in psychiatry often uses a case-control design, in which a selected group of patients, based mostly on meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for a specific disorder, is compared with a sample of healthy control participants. Such a design is especially suitable to identify biomarkers, as these are features associated with a particular condition. In 2014, Brühl et al . published an extensive overview of the neuroimaging biomarker literature on SAD 22 . They summarized findings with respect to the structure and function of the brain in patients with SAD, reviewed data on brain connectivity in SAD, and performed a meta-analysis of functional MRI (fMRI) studies regarding brain responsiveness in SAD. Their overview resulted in a neurofunctional model of the socially anxious brain, characterized by hyperactivation of the fear circuit—consisting of the amygdala, insula, prefrontal cortex (PFC) and anterior cingulate cortex (ACC)—and hyper-responsive parietal and occipital regions, in reaction to SAD-relevant stimuli. Furthermore, Brühl et al . described SAD-related hypoconnectivity of these parieto-occipital brain areas, which are located in the medial part of the brain and are part of the default mode network and dorsal attention network; thereby, the authors suggest that these changes in network structure are reflective of the increased emotional arousal and enhanced focus on potentially threatening stimuli that characterize patients with SAD 22 .

Since the publication of that review 22 , new findings have added to our knowledge of the neurobiological basis of SAD. Several recent structural MRI studies have pointed to a role of the striatum in SAD and in related constructs such as “intolerance of uncertainty” 23 ; these studies, which concern (respectively) an international mega-analysis in the largest MRI sample of 174 patients with SAD and 213 healthy controls to date 24 , a study in women with a varying range of social anxiety levels 25 , and a correlational study in a sample of 61 healthy volunteers 26 , 27 , all implied increased striatal volume in (social) anxiety. Interestingly, a treatment study on SAD revealed that 8-weeks of paroxetine treatment led to significant reductions in gray matter in the bilateral caudate and putamen, both part of the striatum 28 . However, another study reported decreased gray matter in the putamen in SAD 29 . Furthermore, the increase in striatum volume was not replicated by a recent meta-analysis on brain structure in SAD 30 ; see also the commentary belonging to this work 31 . These inconsistent findings underscore the need for replication studies on large datasets (for example, by pooling data from different research centers, which use preferably similar protocols for data acquisition and analysis) (compare the recommendation by 21 ). In recent years, interest in data sharing has grown, and initiatives such as Enhancing Neuro Imaging by Meta-Analysis (ENIGMA) 32 have increasingly received attention (see a summary of a decade of ENIGMA studies in 33 ); analyses on brain structure in SAD are currently being performed within the ENIGMA-Anxiety Working Group 34 .

In addition to these structural MRI studies, recent fMRI studies explored the relationship between social anxiety and brain responses, aiming to identify functional biomarkers. Several research directions deserve to be highlighted. An intriguing line of research focuses on amygdala activation in social anxiety. This is not surprising, as the amygdala, a small structure located deep in the brain, plays a critical role in detecting and evaluating environmental cues that might be reflective of potential threat 35 , 36 , and amygdala hyperreactivity in SAD has been frequently reported 37 . Interestingly, recent work aims to determine in more detail which functional alterations in amygdala responses are associated with social anxiety. We will mention several lines of research.

First of all, an influential article published around 20 years ago provided evidence that amygdala activation, in response to stimuli presented multiple times without a meaningful consequence, decreased over time (that is, higher amygdala activation was present for novel faces when compared with already presented faces, a process called habituation) 38 ; subsequently, a landmark article indicated that adult participants who were characterized at age 2 as “behavioral inhibited” (a temperamental trait associated with an increased risk for developing SAD later in life 39 – 42 ) showed increased amygdala responses to novel faces 43 , providing an initial explanation for their anxious feelings in social situations. Building upon these findings, work from 2011 showed that individuals with an extreme inhibited temperament were characterized by a sustained increase in amygdala activation to faces 44 , and a follow-up article confirmed that the amygdala response failed to habituate in participants with an inhibited temperament 45 . In 2016, Avery and Blackford demonstrated that habituation rate differed across the continuum of social fearfulness, and slower rates of habituation in participants were associated with higher levels of social fearfulness 46 ; furthermore, these differences were not limited to the amygdala but were present in multiple regions of the social brain, and connectivity analyses revealed that slower habituation was accompanied by increased connectivity between the amygdala and visual brain areas 46 , 47 . Although these findings need to be replicated in patients with SAD, this series of experiments increases our insight into the failed habituation response in socially anxious participants and provides a neurobiological basis for their experience of feeling uncomfortable in social settings.

Other lines of amygdala research are devoted to determining the specificity of SAD-related amygdala hyperactivation 48 , the time course of amygdala activation 49 , 50 , and the specific roles of amygdala sub-regions during aversive processing 51 . In addition, studies on task-related connectivity of the amygdala—for example, during emotion discrimination 52 , related to performing an affective counting Stroop task with emotional faces 53 , and during the perception of fearful faces 54 or disorder-related complex visual scenes 55 —revealed that SAD is not characterized just by aberrant local amygdala activation; instead, the whole functional amygdala network displays alterations, and the direction of these changes depends on the specific task on hand.

Furthermore, the role of the bed nucleus of stria terminalis (BNST), as part of the extended amygdala network, has increasingly received attention in research on threat processing and in studies on (social) anxiety 56 – 66 . The role of the BNST in threat and anxiety (in comparison with the function of the amygdala) is still a topic of debate; whereas some researchers attributed a specific and unique functional role to the BNST when compared with the amygdala 63 , 67 , others indicate that the BNST and amygdala have similar functional profiles 68 . When we specifically consider BNST research in SAD, evidence for both viewpoints is provided. On the one hand, Blackford et al . (2019) demonstrated that social anxiety was associated with a BNST versus amygdala difference in response to unpredictable images 65 . On the other hand, a recent study on the temporal profile of amygdala and BNST activation during the anticipation of temporally unpredictable aversive cues revealed similar activation patterns in the central amygdala and BNST: the investigators reported increased phasic activation in both the amygdala and BNST in patients with SAD compared with healthy controls, possibly reflective of hypervigilance in the SAD group; no group differences were present when sustained brain activation (in both amygdala and BNST) was considered 69 . We argue that, in line with the comments of Gungor and Pare included in the article by Shackman and Fox 68 , future research on fear and anxiety should not ignore the BNST but needs to acknowledge this structure as part of the integral anxiety network.

Next, we want to acknowledge recent studies on alterations in functional connectivity (FC) of the brain during rest 70 – 75 ; cf. the review by MacNamara et al . 76 . It should be mentioned that these studies often differ in their analytical approaches and investigate various networks of interest. A meta-analysis of their findings is beyond the scope of this expert review, but most studies report changes in the default mode network, a network involved in social referencing and the cognitive ability to understand other people’s mental state (theory of mind) 77 . Interestingly, a study using multivariate pattern analysis demonstrated that patients with SAD could be reliably classified (versus healthy controls) on the basis of FC measures 78 . Furthermore, recent studies using graph theory models provided insight into the topological organization of functional networks in SAD 79 – 82 .

A new line of biomarker research in SAD focuses on determining reliable biomarkers for treatment choice. (For a review on neuroprediction in anxiety disorders, we recommend 83 ; a review dedicated to SAD was recently provided by Klumpp and Fitzgerald 84 .) For example, Frick et al . 85 investigated a sample of 48 patients with SAD and acquired fMRI scans before the start of a 9-week treatment with internet-based cognitive behavioral therapy (CBT), CBT plus the serotonin reuptake inhibitor escitalopram, or a placebo. The investigators explored how pre-treatment brain responses related to treatment outcome, and they demonstrated that pre-treatment brain activation in the dorsal ACC predicted the response to CBT 85 , 86 . Other recent examples of work on neuroprediction in SAD report that the outcome of CBT could be predicted from pre-treatment activation in the dorsolateral PFC 87 , frontoparietal regions (including the dorsal ACC and insula) 88 , and the rostral ACC 89 . In addition, several research groups explored the use of brain connectomics as predictive biomarkers for treatment response to CBT. One group used the amygdala as a seed region and demonstrated that resting-state connectivity and integrity of a specific white matter tract (the right inferior longitudinal fasciculus) predicted clinical improvement in patients with SAD 90 ; another group recently showed that stronger inverse FC between the amygdala and the ventrolateral PFC, as measured during an implicit emotion regulation task, was related to better treatment response 91 . Furthermore, activation in the ventromedial PFC during early extinction learning predicted the reduction of public speaking anxiety and social anxiety symptoms after exposure 92 . Although these studies show the potential clinical relevance of neuroimaging in deciding on appropriate treatment options for patients with SAD, the results should be considered preliminary given the small sample sizes and heterogeneous findings (cf. 83 , 84 ).

Related to research on neuroprediction are recent studies focusing on the effect of treatment on the brain. Using a longitudinal design and multiple MRI techniques, Steiger et al . demonstrated changes in several structural brain characteristics following group CBT 93 . Another multimodal longitudinal study reported decreases in amygdala volume and amygdala activation levels after CBT and showed that the reduction in amygdala volume mediated the relationship between the diminished amygdala response and clinical improvement 94 . Notably, in a one-year follow-up study on the same participants, the investigators still found reduced amygdala volume in CBT responders; this finding suggests that effective psychological interventions can induce long-lasting changes in human brain structure 95 . However, given the small sample size (n = 13 patients with SAD) in the latter study, more longitudinal studies are essential to further substantiate this finding and to explore the long-term effects of treatment on brain function. Other studies demonstrated effects of treatment on FC between the amygdala and ventromedial PFC 96 and on network parameters of the precuneus 97 .

Importantly, the majority of studies summarized above were performed in adult patients with SAD. However, given the early onset of the disorder, typically during late childhood and early adolescence 98 , neuroimaging studies in socially anxious youth can provide valuable information about the neurobiology of the disorder, as the results of these studies are less likely to be confounded by the experience of recurrent SAD episodes. On the other hand, most neuroimaging studies on adolescents include comorbid anxiety disorders (for example, interesting work on attentional processing of social threat and responses to social evaluation 99 – 104 ; a review of neuroimaging in pediatric anxiety is available here 105 ), which makes it difficult to establish specific SAD-related neurobiological alterations (see the work of McElroy et al . demonstrating strong associations between symptoms of depression and anxiety in childhood and early to mid-adolescence 106 ). Nevertheless, several studies provided insight into the neural substrates of SAD across developmental phases. Blair et al . (2011) 107 , for example, revealed increased brain responses in the amygdala and rostral ACC in both adult and adolescent participants with SAD, suggesting that the neurobiological characteristics of adults with SAD are not the result of adaptive responses or developmental changes over time; rather, these alterations are stable characteristics related to the disorder. On the other hand, work of Britton et al . (2013) in anxious adolescents and adults distinguished shared and age-specific neurobiological correlates of fear conditioning 108 , and Jarcho et al . reported on heightened striatal activity in adolescents with SAD but not in socially anxious adults 109 . In addition, there is work on adolescents who are at risk for developing SAD, based on the fact that they are characterized as “behavioral inhibited”; such studies demonstrated, for example, increased amygdala response 110 and altered striatal activation 111 , 112 in children and adolescents temperamentally at risk for anxiety. (An extensive review of literature on this topic is provided elsewhere 113 ; for a more complete overview of neuroimaging work in adolescent SAD, we recommend 1 , 114 .) Longitudinal studies (cf. 115 ), preferably following children into adulthood, are essential to shed light on this important topic 116 .

Endophenotype research on social anxiety disorder

In addition to highlighting these biomarker studies, we want to mention recent work on SAD endophenotypes. Endophenotypes are measurable and heritable characteristics on the pathway from genotype to phenotype; as defined in literature on this topic 117 , 118 , endophenotypes are supposed to be (1) associated with a particular disorder, (2) stable trait characteristics, and (3) heritable. Furthermore, endophenotypes should co-segregate with the disorder of interest within families, and non-affected family members show altered levels of the endophenotype in comparison with the general population (fourth criterion). Thereby, endophenotypes are reflective of the genetic vulnerability to develop psychopathology and this important characteristic distinguishes endophenotypes from biomarkers. Biomarkers do not necessarily have a genetic basis; endophenotypes, on the other hand, are by definition heritable and supposed to be reflective of genetically based disease mechanisms 20 . So, as stated by Lenzenweger, “all endophenotypes are biomarkers, but not all biomarkers are endophenotypes” 20 . Given their genetic background, endophenotypes can be used to unravel the genetic vulnerability to psychopathology. In addition, endophenotypes provide insight into the pathways leading to complex psychiatric disorders 119 , 120 . Furthermore, endophenotypes can increase our understanding of the transdiagnostic characteristics of mental disorders 120 , 121 .

In the past decade, the endophenotype approach has been applied to psychiatric disorders such as depression 122 , 123 , obsessive–compulsive disorder 124 – 126 , and schizophrenia 127 – 130 , revealing alterations in brain structure and function in patients and their unaffected relatives. Thereby, these studies provide initial insight into the genetic vulnerability to these disorders, as they show that the changes are not just a manifestation of the disease state (as the alterations were present in unaffected family members as well) and are likely heritable because the characteristics were present in both patients and relatives (cf. 131 ). However, endophenotype research in SAD is new; nevertheless, given the results of family and twin studies showing genetic influences in the development of SAD 132 – 135 , such work is of importance in order to gain insight into the genetic susceptibility to SAD.

In the Leiden Family Lab study on Social Anxiety Disorder 136 , we investigated candidate endophenotypes of SAD 137 by using a multiplex, multigenerational family design (MRI sample: eight families, n = 110). Within the sample, we explored evidence for two endophenotype criteria: the co-segregation of the endophenotypes with social anxiety, within families genetically enriched for SAD, and the heritability of the endophenotypes. This study revealed multiple promising neurobiological endophenotypes of SAD 138 . To start, several structural brain characteristics, derived from cortical and subcortical brain regions, co-segregated with social anxiety within families and were at least moderately heritable 139 ; see accompanying commentary 140 . Furthermore, we employed two fMRI paradigms to explore the potential of brain responses as SAD endophenotypes. Using the first paradigm, the Social Norm Processing Task (revised version 141 ; based on work by 142 , 143 ), we found evidence for hyperreactivity of the medial PFC and frontal pole in response to unintentional social norm violations as a neurobiological endophenotype of social anxiety 144 . Second, we investigated responses to neutral faces. Data revealed that impaired neural habituation in the hippocampus met the two endophenotype criteria of interest 145 ; in addition, amygdala engagement in response to conditioned faces with a social-evaluative meaning qualified as a neurobiological candidate endophenotype of social anxiety 146 , 147 . Although future studies are required to examine the stability of these candidate endophenotypes over time (endophenotype criterion 2) and to discover genetic variants underlying the abovementioned candidate endophenotypes, these promising findings offer a starting point for follow-up studies on the genetic susceptibility to SAD.

Outstanding questions and future research

The studies summarized above suggest that multiple brain regions are functionally or anatomically altered in patients with SAD (biomarkers) or involved in the genetic vulnerability to develop the disorder (endophenotypes). However, several important considerations remain and most of them are not specific for research on SAD but apply to the broader field of neuroimaging research in psychiatry 21 . First of all, as recently outlined by Etkin in his thought-provoking review 21 , meta-analyses of brain structure and function across psychiatry have shown that brain alterations are often non-specific 148 , 149 ; that is, similar brain changes are apparent in distinct psychiatric disorders (based on DSM criteria); interestingly, recent studies implicate that the same non-specificity is present in the field of psychiatry genomics 150 , 151 . Therefore, it needs to be investigated whether a dimensional approach as described in the Research Domain Criteria (RDoC) framework 152 , which focuses on symptom levels, could yield more reliable neurobiological biomarkers of specific clinical presentations.

A second important question concerns the issue of causality. Although studies with larger sample sizes could lead to more reliable results with respect to brain alterations related to psychopathology, their findings still concern associations and do not necessarily imply causal mechanisms 21 , 153 . For a more elaborate illustration of the risk of “just-so” stories (being “internally consistent explanations that have no basis in fact”), we recommend a recent viewpoint article 153 . To increase our understanding of the functional implications of brain alterations in psychopathology, future research should combine neuroimaging with neurostimulation tools, which are able to intervene with normal brain functioning. Such tools (for example, non-invasive brain stimulation) enable causal relationships to be discerned and could reveal target points for interventions 154 – 156 .

This issue strongly relates to the final open questions that we wish to highlight, namely whether the SAD-related brain characteristics described above can be influenced in order to prevent the development of SAD or to alleviate its symptoms. It would be interesting to investigate whether a cutting-edge technique such as real-time fMRI-based neurofeedback 157 – 160 could be successfully used in the prevention and treatment of SAD. In addition, a focus on individual level biomarkers, using new “precision MRI” approaches, offers promising prospects for optimizing diagnosis and treatment 161 – 163 . It is our hope that the insights from neuroimaging research will eventually lead to promising effective interventions that increase the quality of life of patients with SAD.

Abbreviations

ACC, anterior cingulate cortex; BNST, bed nucleus of stria terminalis; CBT, cognitive behavioral therapy; DSM, Diagnostic and Statistical Manual of Mental Disorders ; ENIGMA, Enhancing Neuro Imaging by Meta-Analysis; FC, functional connectivity; fMRI, functional magnetic resonance imaging; MRI, magnetic resonance imaging; PFC, prefrontal cortex; SAD, social anxiety disorder

[version 1; peer review: 2 approved]

Funding Statement

The author(s) declared that no grants were involved in supporting this work.

Editorial Note on the Review Process

F1000 Faculty Reviews are commissioned from members of the prestigious F1000 Faculty and are edited as a service to readers. In order to make these reviews as comprehensive and accessible as possible, the referees provide input before publication and only the final, revised version is published. The referees who approved the final version are listed with their names and affiliations but without their reports on earlier versions (any comments will already have been addressed in the published version).

The referees who approved this article are:

• Su Lui , Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University, Chengdu, PR, China Competing interests: Su Lui is part of the ENIGMA-ANXIETY working group, of which Janna Marie Bas-Hoogendam is one of the coordinators.
• Jennifer Lau , Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK No competing interests were disclosed.

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Group Proposal-Social Anxiety

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ORIGINAL RESEARCH article

Exploring the association between social support and anxiety during major public emergencies: a meta-analysis of the covid-19 pandemic.

• 1 School of Public Policy and Management, China University of Mining and Technology, Xuzhou, China
• 2 School of Education Science, Jiangsu Normal University, Xuzhou, China

Objective: The COVID-19 pandemic has prompted a surge in research focusing on mental health issues faced by society, with particular emphasis on the interplay between social support and anxiety. However, the results of these studies have often been controversial.

Methods: To address this, we conducted a meta-analysis of 104 studies ( N  = 107,660) to investigate the relationship between anxiety and social support and the potential moderate variables.

Results: Our meta-analysis revealed a negative correlation between social support and anxiety ( r  = −0.233). The study also demonstrated the variation in the relationship between social support and anxiety was moderated by cultural area ( Q  = 14.120, p  < 0.05) and phrase of the pandemic ( Q  = 13.678, p  < 0.05).

Conclusion: The relationship between social support and anxiety can differ across different cultural areas and throughout the phrase of the pandemic. Consequently, we advocate for a nuanced assessment of the role of social support in mitigating public anxiety, taking into account the mediating effects of these factors in the context of major public emergencies.

Introduction

The outbreak of the Coronavirus Disease 2019 (COVID-19) has had a profound and far-reaching impact on a global scale. The health implications of the virus have been severe, with millions of confirmed cases and over three million deaths reported globally as of now. The social and psychological impacts of the pandemic have also been significant. Social distancing measures and lockdowns have led to increased loneliness and isolation, particularly for vulnerable populations such as the older adult and those with pre-existing mental health conditions ( 1 – 3 ). The uncertainty and fear surrounding the virus have also led to a rise in anxiety and depression levels among the general public ( 4 – 6 ). According to the World Health Organization (WHO), the ongoing pandemic could trigger a significant increase in anxiety disorders by more than 25%, and the annual economic burden associated with anxiety and depressive disorders is projected to approximate $1 trillion ( 7 ). The widespread anxiety experienced during the pandemic underscores the urgency for empirical research to investigate effective strategies for managing anxiety during the major public emergencies.

The role of social support on anxiety

Social support serves as a pivotal social resource that individuals leverage, stemming from networks such as friends, family, and significant others ( 8 ). Extensive empirical investigations have consistently evidenced that social support is effective in alleviating negative emotional states, including depression, anxiety, and stress ( 9 – 12 ). Moreover, social support has been shown to positively predict emotional well-being, a sense of belonging, and overall individual flourishing ( 13 , 14 ). Researchers have further examined the intricate relationship between social support and psychological resilience ( 13 , 15 ). It is plausible that social support can enhance an individual’s psychological resilience, thereby promoting positive mental health outcomes.

Recently, researchers have been interested in how the relationship between social support and mental health is particularly during the COVID-19 pandemic ( 16 – 19 ). For example, a recently study showed that perceived social support has a positive impact on resilience and academic self-efficacy. Additionally, social support, resilience, and academic self-efficacy collectively have a negative influence on the uncertainty associated with COVID-19 ( 18 ). Though numerous investigations consistently highlight the protective role of social support in helping individuals manage anxiety ( 20 , 21 ), critical questions regarding the strength of the association between social support and anxiety, as well as the moderating factors influencing this relationship, remain unanswered.

Role of moderator variables

In this study, we proposed that the relationship between social support and anxiety is potentially moderated by a constellation of variables, including but not limited to the demographic characteristics of the individuals (such as age and gender), the population involved in the study (identifying the target audience), the phrase of the pandemic under examination, and the encompassing cultural milieu within which the support is exchanged. The goal was to elucidate the nuanced and context-dependent nature of the relationship between social support and anxiety, acknowledging the diverse ways in which these constructs interact in different populations and at varying stages of the major public emergencies.

Cultural area

The Inglehart-Welzel cultural map, an instrument extracted from the World Values Survey, is a widely recognized tool that categorizes nations into eight distinct clusters based on their underlying social and cultural value orientations. This map provides a comprehensive framework for understanding the variations in social and cultural values across different nations ( 22 , 23 ). The clusters identified by the Inglehart-Welzel cultural map represent diverse regions with distinct cultural identities and value systems. For example, cultures in the English-speaking cluster tend to highly value personal independence, individualism, and personal freedom ( 24 ). On the other hand, Confucian Cultural Areas prioritize interdependence, collectivism, and social harmony ( 25 ). These fundamental value differences have significant implications for how social support is understood and utilized within different cultural contexts. Research has consistently shown that social support plays a critical role in buffering the negative effects of stress and anxiety ( 9 – 12 ). However, the perception and effectiveness of social support can be deeply influenced by cultural norms and expectations. In collectivist cultures, such as those found in Confucian Cultural Areas, social support may be more about maintaining group harmony and less about individual distress ( 26 ). In contrast, individualistic cultures may emphasize the importance of personal autonomy and emotional self-regulation when dealing with anxiety. Therefore, this study incorporates cultural area as a moderating variable to examine how the link between social support and anxiety may vary across different cultural contexts.

Pandemic phase

Psychological health and social support services have been affected in different ways by different phases of the COVID-19 pandemic ( 27 – 29 ). There has been variation in anxiety symptoms in other stages of lockdown activities. For example, the initial phase of strict lockdowns may have led to a perceived decrease in available social support, resulting in increased anxiety due to the isolation and uncertainty ( 30 ). Therefore, we examined whether the connection between anxiety and social support changes throughout the phrase of the pandemic.

Target audience

It has been found that the different population face varying mental health challenges and experience different levels of social support, based on their unique attributes and exposure to the pandemic ( 20 , 21 ). For example, during the COVID-19 pandemic, the healthcare workers, especially the environmental services workers, may face greater psychological stress. This stress stems from the high-risk work environment, the intense nature of the work itself, and the multifaceted pressures of interpersonal relationships ( 31 , 32 ). Given their increased risks and demands, it is likely that the relationship between anxiety and social support among this group is different from that in other populations. Thus, this study considers the target audience as a moderating variable to explore its influence on the relationship between anxiety and social support.

Age and gender

Previous studies showed that perceptions of support and mental health outcomes based on age during the COVID-19 pandemic ( 33 – 35 ). Choi et al. ( 36 ) found that enhanced social support, including emotional/informational support and positive social interactions, was associated with a lower risk of depression, with age served as significant modifiers of this association. Therefore, age is used as a moderator to examine its role in explaining the relationship between social support and anxiety. In addition, it suggested that the COVID-19 pandemic may exacerbate gender disparities in mental health outcomes ( 37 – 39 ). Some studies have reported more pronounced mental health issues among females, including higher levels of anxiety, depression, and stress ( 37 , 38 ). However, not all studies have found statistical differences between genders in terms of mental health responses to the pandemic ( 39 ). These inconsistent results may be attributed to the complexity of gender as a social construct and the multifaceted nature of mental health outcomes. Thus, this study takes into account the potential moderating effect of gender on the relationship between social support and anxiety.

The current study

To address the issue of heterogeneity in previous research findings, we employed the meta-analysis method to comprehensively examine the relationship between social support and anxiety during the COVID-19 pandemic. This study used the meta-analytic method and incorporated a substantial sample size ( N  = 107,660), which allows for the identification of patterns and trends across various studies, enhancing the robustness and generalizability of the findings. Furthermore, the analysis incorporates moderating variables, enabling a discussion on the underlying mechanisms governing the relationship between social support and anxiety. By exploring these moderating factors, this study provides valuable insights into the heterogeneity of the social support-anxiety linkage, allowing for a more nuanced understanding of the pathways through which social support can mitigate anxiety.

Ethical Statement

This study, given its non-involvement of human participants, negated the need for informed consent. Ethical approval was, however, diligently obtained from the ethnic committee at Jiangsu Normal University.

Preregistration statement

No preregistration was conducted in this study.

Search procedures

A thorough synthesis of existing literature was meticulously conducted to gather all pertinent evidence related to the research topic. The study adopted a systematic exploration of diverse English databases, including Google Scholar, Web of Science, PubMed, PsycINFO, JSTOR, Science Direct, Springer Link, Wiley, Ebscohost, ProQuest, and the Chinese database CNKI. In addition, we have access to three primary types of gray literature through academic libraries, which include theses/dissertations, annual reports, and catalogues.

The search was confined to articles published up to June 30, 2023. Article titles, keywords, and abstracts were retrieved using a combination of search terms such as ‘COVID-19,’ ‘Coronavirus,’ ‘2019-ncov,’ alongside ‘stress,’ ‘anxiety,’ and ‘social support.’ Additionally, a comprehensive manual reference search was performed on the reference lists of eligible studies, including review studies and meta-analyses identified during the initial search. This approach ensured the inclusion of a diverse array of both published and unpublished works, mitigating the risk of inadvertent oversights in the search process. Figure 1 visually outlines the steps involved in the literature screening process.

Figure 1 . Flowchart of the search and screening process.

Inclusion criteria

The criteria for selecting literature encompassed the following elements: (1) studies considered for inclusion must have been conducted within the framework of the COVID-19 pandemic; (2) the studies had to employ questionnaires as the designated measurement method; (3) the reported findings needed to include bivariate correlation coefficients between anxiety and social support variables, accompanied by information on the total sample size of participants; (4) literature composed in either English or Chinese was eligible for inclusion.

Exclusion criteria

The criteria for excluding literature covered several aspects: (1) literature written in languages other than English and Chinese was excluded; (2) meta-analytic or review-type studies were not considered for inclusion; (3) studies that provided separate data for distinct subgroups (e.g., males and females, physicians and non-physicians) instead of reporting correlation coefficients for variables in the overall sample were excluded; (4) studies lacking reported sample sizes were also excluded.

Literature quality assessment

In this study, we conducted an assessment of the literature’s quality utilizing the JBI Critical Appraisal Tools ( 40 ) across eight distinct dimensions: inclusion criteria, sample description, measurement, metrics, identification of confounders, response to confounders, outcome measures, and statistical analyses. Through this rigorous evaluation process, we derived comprehensive quality scores for each literature item (detailed results in Appendix 1). For the purpose of our analysis, we excluded studies that received a quality score of less than 4 (a total of 6 studies) and also disregarded articles published in non-peer-reviewed journals (a total of 23 articles). As a result, our final dataset comprised a total of 104 articles ( N  = 107,660) that met the criteria for inclusion in the analysis.

The literature included in the meta-analysis was coded for characteristics, and during the coding process, each article was coded by two researchers for the following information in the literature according to a fixed coding pattern: (a) descriptive information (e.g., title of the literature, year of publication, and information about the authors); (b) sample information (e.g., sample size, number of males, number of females, age, country, cultural area, and target audience); (c) correlation coefficients; and (d) phrase of pandemic. To ensure consistency, one researcher carried out the coding for all the literature, while the other researcher randomly selected two-thirds of the literature for coding, resulting in a concordance rate of 90% or higher. A partial coding list of the literature information is displayed in Table 1 .

Table 1 . Literature information coding table (partial).

The process of study coding adhered to the following principles: (1) Effect values were extracted based on independent samples, ensuring that each independent sample contributed only one effect value; (2) In the process of coding the cultural areas, we referred to the most recent edition of the Inglehart-Welzel cultural map of the world (2020 edition). This classification system grouped the diverse countries into eight distinct clusters, denoted as the English-speaking Cultural Area, Latin American Cultural Area, Orthodox Europe Cultural Area, Catholic Europe Cultural Area, Protestant Europe Cultural Area, African-Islamic Cultural Area, West and South Asia Cultural Area, and Confucian Cultural Area ( 22 ); (3) In situations where multiple dimensions of one or more variables were involved, if the overall correlation coefficient between the variables was not reported in the literature, a formula was employed to combine the correlation coefficients, following the approach proposed by Raudenbush ( 41 ). The specific formula employed was as follows.

Analysis of publication bias

Given the potential impact of publication bias on the integrity of study findings ( 41 ), it was imperative to evaluate the presence of such bias within the included literature as a prerequisite for ensuring the reliability of the study outcomes. The assessment of publication bias in this investigation primarily relied on the outcomes of funnel plots ( 42 ), along with the fail-safe-N ( 43 ) and Egger’s regression tests ( 44 ). The meta-analysis encompassed studies that were meticulously examined for any signs of publication bias via the funnel plots depicted in Figure 2 . Upon reviewing Figure 2 , it is evident that the effect sizes are predominantly clustered above the funnel plot, and they are uniformly distributed on either side of the graph around the aggregate effect size, suggesting a symmetrical pattern.

Figure 2 . Publication bias funnel plot.

In order to ensure the absence of publication bias, Rosenthal’s fail-safe number (FSN) value was calculated. The results are provided in Table 2 . As seen in Table 2 , the FSN was calculated as N  = 7,704. According to Rosenthal, a high N number will increase the validity of the results obtained with the meta-analysis ( 45 ). Moreover, this value is well above the N/5 k + 10 (N: Number of Error Protection; k: Number of studies included in the meta-analysis) limit and is too high to reach ( 46 ). This information was accepted as another indication that there was no publication bias and that the results of the meta-analysis were reliable ( 57 ). Additionally, the results obtained from the Egger linear regression analysis indicate non-significance, with an intercept of 1.603, 95% CI [−2.800, 3.559]. Consequently, these findings provide substantial evidence to conclude that there is no observable presence of publication bias.

Table 2 . Rosenthal’s Fail-safe number calculations.

Testing for heterogeneity and selection of models

In this study, the Q significance test and I2 index values were utilized to evaluate heterogeneity. If substantial heterogeneity was observed, the random effects model was employed. Otherwise, the fixed effects model was applied ( 58 ). The heterogeneity test results indicated a significant level of heterogeneity, with Q-significance values below 0.001 and I2 values exceeding 75% (refer to Table 3 ). Consequently, considering these findings, the weighted correlations were calculated using the random effects model for this study.

Table 3 . Results of heterogeneity test and publication bias.

The relationship between social support and anxiety

The outcomes derived from the random effects model revealed a significant correlation of −0.233 ( K  = 104, 95% CI [−0.275, −0.191]) between social support and anxiety, indicating the presence of a weak negative association between these variables. Figure 3 presents the detailed forest plot illustrating these results.

Figure 3 . Forest plot of the relationship between social support and anxiety correlation.

Subgroup analysis

The potential moderating effects of various factors on the association between social support and anxiety were thoroughly examined. The results from the moderating effect analysis revealed that age ( Q  = 4.080, p  = 0.395), sex ratio (Coefficient = 0.0012, Z  = −0.57, p  = 0.567), and target audience ( Q  = 12.856, p  = 0.169) did not exhibit any significant moderating effects on the relationship between social support and anxiety. However, cultural area, and pandemic phase demonstrated a notable moderating effect on the relationship between social support and anxiety (refer to Table 4 ).

Table 4 . Analysis of the effects of relevant moderator variables.

In the Confucian Cultural Area, the correlation between social support and anxiety displayed the strongest association with a coefficient of −0.295, significantly higher than correlations observed in other cultural areas. Following closely was the African-Islamic Cultural Area, showing the second-strongest correlation at −0.230. In contrast, the Protestant Europe Cultural Area exhibited a notably weak positive association with a correlation of 0.029, significantly lower than correlations in other cultural areas. Subgroup analysis results indicated a significant difference in group effect sizes ( Q  = 14.120, p  < 0.05), suggesting varying strengths of the correlation between social support and anxiety across different cultural areas.

The correlation analysis revealed that the association between social support and anxiety manifested most robustly during the first half of 2022, yielding a weighted correlation coefficient of −0.316. The second-strongest correlation occurred in the first half of 2021, with a coefficient of −0.275. Notably, the weakest correlation was observed in the first half of 2020, with a coefficient of −0.220. Subgroup analysis results indicated a significant difference in group effect sizes ( Q  = 13.678, p  < 0.05), suggesting varying strengths of the correlation between social support and anxiety across different phrase of the pandemic. Table 4 analysis of the effects of relevant moderator variables area African-Islamic Cultural Area 19–0.230 -0.321 -0.134 14.120* Confucian Cultural.

Numerous researchers have investigated the correlation between social support and public mental health since the onset of the COVID-19 pandemic. Our findings indicate a negative correlation between social support and anxiety, aligning with the outcomes of most previous studies ( 59 , 60 ). The current meta-analysis presented here provided a comprehensive summary of the existing literature on the relationship between social support and mental health during the COVID-19 pandemic. By analyzing a substantial sample size, our findings contribute to the robustness of the evidence base regarding the role of social support in mitigating the mental health consequences of the COVID-19 pandemic.

We believe that social support has likely played a role in reducing anxiety during the COVID-19 pandemic in at least two aspects. Firstly, anxiety during the pandemic often stems from profound uncertainty [(e.g., 61 )]. Given the virus’s ongoing novelty and propensity for mutation, individuals are frequently enveloped in a climate of unpredictability, which unequivocally heightens levels of anxiety among the public. However, a recently study indicated that social support can significantly reduce individuals’ uncertainty of COVID-19 [(e.g., 18 )]. Therefore, amidst the pandemic, the availability of social support has the potential to offer individuals the psychological comfort they require by mitigating uncertainty, thereby resulting in a notable reduction of their anxiety levels. Secondly, the existing research has pointed out that resilience can effectively reduce individuals’ anxiety levels during the COVID-19 pandemic ( 62 ). The relationship between social support and resilience is intricately intertwined ( 63 , 64 ). Social support, in its various forms, serves as a buffer against stress and anxiety, providing individuals with the emotional, informational, and instrumental resources necessary to cope effectively. This support fosters a sense of belonging, self-esteem, and efficacy, which in turn bolsters resilience, enabling individuals to adapt to challenges and adversity with greater flexibility and strength.

The Secondary goal of this current study was to investigate which factors moderate the relationship between social support and the public’s negative mental outcomes, particularly anxiety, in the context of the COVID-19 pandemic. The results from the analysis of moderating effects revealed that cultural context significantly impacted the relationship between social support and anxiety. Notably, the Confucian cultural area exhibited the strongest correlation between social support and anxiety, while the Protestant European cultural area demonstrated the weakest correlation among participants. Collectivist cultural qualities, emphasizing group social cohesion, adherence to social norms, and emotional responsiveness, are typically prevalent in countries within the Confucian Cultural Area, such as, China ( 65 ). The collectivist culture can facilitate a more proactive approach to seeking social support, as individuals in such cultures may perceive support-seeking as a normative and necessary response to hardship. This proactive social support-seeking is fostered by a collectivist cultural norm, which in turn can lead to the development of a more extensive social network and a heightened sense of community, serving as crucial resources during major public emergencies. This cultural predisposition likely accounts for the stronger correlation between social support and anxiety observed in the Confucian cultural area. In contrast, the Protestant Europe cultural area, exhibited the weakest correlation among participants. This may be attributed to the cultural values of individualism, autonomy, and egalitarianism that are prevalent in these societies ( 66 ). The emphasis on personal freedom and self-determination may lead individuals to rely less on social support and feel more empowered to manage their own anxiety ( 67 ). This cultural inclination could explain the weaker correlation between social support and anxiety found in the Protestant European cultural area.

The pandemic phrase has been identified as a critical factor that moderated the relationship between social support and anxiety, with the strength of this association varying depending on the timeframe under consideration. A significant finding from the research is that the first half of 2022 exhibited the strongest correlation between social support and anxiety. It is possible because the phrase saw the benefits of vaccination preventive measures becoming more pronounced, as more individuals were vaccinated and experiencing a sense of security against the virus ( 68 ). The gradual relaxation of national lockdown regulations also played a role, as people adjusted to new social norms and experienced a sense of returning to a more normalized way of life, potentially increasing the reliance on social support to navigate these changes ( 69 ). In contrast, the first half of 2020, which encompassed the early stages of the pandemic when the situation was particularly dire and stringent lockdown restrictions were implemented, revealed a weaker relationship between social support and anxiety. This weakened correlation can be understood in the context of the immense challenges faced by individuals in accessing social support during this time. The restrictions not only limited physical interactions but also disrupted the normal social networks and support systems ( 70 ). The psychological impact of such restrictions, coupled with the fear and uncertainty surrounding the pandemic, likely mitigated the availability of social support, thus weakening the association between social support and anxiety.

In conclusion, social support is a powerful tool in reducing public anxiety during the COVID-19 pandemic. In the future major public emergencies, strategies to enhance social support should be tailored to the specific needs and contexts of different communities. For example, in areas with high levels of social isolation, initiatives to promote digital connectivity and virtual social gatherings can be implemented. In communities with vulnerable populations, such as the older adult or those with chronic illnesses, targeted social support programs, including home visits, telephone check-ins, and mental health counseling, can be provided. In addition, in leveraging social support to alleviate anxiety, it’s imperative to consider both cultural factors and the varying impacts of different pandemic phrase. For instance, in a collectivist culture during the first half of 2022, when vaccination measures were increasingly effective, promoting community-based support groups could be highly effective, as individuals felt safer engaging in group activities. However, in the same culture during the initial lockdown phase in 2020, the same approach may have been less effective due to the stringent restrictions on social gatherings. Conversely, in an individualistic culture, during the same periods, online counseling or one-on-one support sessions tailored to individual needs may be more appropriate. Understanding these nuances allows us to tailor social support strategies to be culturally sensitive and responsive to the changing pandemic landscape.

Limitation and future directions

In summary, the research presented here has endeavored to capture the multifaceted nature of social support and its relationship with anxiety amid the COVID-19 pandemic. The study underscores the function of social support in bolstering mental well-being within the individuals, acknowledging the nuanced ways in which this support can operate under various underlying conditions. However, it is essential to recognize the limitations of this review to appreciate the scope and implications of the findings. One key limitation is the restrictive inclusion criteria that focused primarily on literature published in Chinese and English. Such a constraint may have inadvertently introduced linguistic bias, potentially overlooking valuable insights from studies conducted in other languages. To address this, future research should strive for inclusivity by encompassing a broader range of linguistic and cultural contexts. Furthermore, it highlights the need to consider the influence of positive psychological attributes, such as resilience and hope, on mental health outcomes during the pandemic. These attributes can serve as protective factors against anxiety and other mental health challenges, thereby modulating the impact of social support. Future studies might explore the interplay between these attributes and the effectiveness of social support mechanisms in buffering against the stresses of pandemics. Finally, considering the ongoing developments of the pandemic and its psychological effects [(e.g., 71 )], longitudinal studies may yield valuable insights into how the connection between social support and anxiety evolves over time.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by the ethnical committee at Jiangsu Normal University. The studies were conducted in accordance with the local legislation and institutional requirements. The human samples used in this study were acquired from this is a meta-analysis article. The statistical values were acquired from previous published articles based on literature review. Written informed consent for participation was not required from the participants or the participants' legal guardians/next of kin in accordance with the national legislation and institutional requirements.

Author contributions

JL: Conceptualization, Formal analysis, Methodology, Writing – review & editing, Visualization. SC: Data curation, Formal analysis, Methodology, Visualization, Writing – original draft. ZW: Conceptualization, Writing – review & editing, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Supervision, Writing – original draft. FR: Conceptualization, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This study was supported by the National Social Science Foundation of China (Grant Number 20BSH096) to ZW.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

1. Chiesa, V, Antony, G, Wismar, M, and Rechel, B. COVID-19 pandemic: health impact of staying at home, social distancing and ‘lockdown’ measures—a systematic review of systematic reviews. J Public Health . (2021) 43:e462–81. doi: 10.1093/pubmed/fdab102

PubMed Abstract | Crossref Full Text | Google Scholar

2. Ganesan, B, Al-Jumaily, A, Fong, KN, Prasad, P, Meena, SK, and Tong, RKY. Impact of coronavirus disease 2019 (COVID-19) outbreak quarantine, isolation, and lockdown policies on mental health and suicide. Front Psych . (2021) 12:565190. doi: 10.3389/fpsyt.2021.565190

3. Murphy, L, Markey, K, O'Donnell, C, Moloney, M, and Doody, O. The impact of the COVID-19 pandemic and its related restrictions on people with pre-existent mental health conditions: a scoping review. Arch Psychiatr Nurs . (2021) 35:375–94. doi: 10.1016/j.apnu.2021.05.002

4. Gunnell, D, Appleby, L, Arensman, E, Hawton, K, John, A, Kapur, N, et al. Suicide risk and prevention during the COVID-19 pandemic. Lancet Psychiatry . (2020) 7:468–71. doi: 10.1016/S2215-0366(20)30171-1

5. Islam, MS, Sujan, MSH, Tasnim, R, Sikder, MT, Potenza, MN, and van Os, J. Psychological responses during the COVID-19 outbreak among university students in Bangladesh. PLoS One . (2020) 15:e0245083. doi: 10.1371/journal.pone.0245083

6. Lim, SR, Ng, QX, Xin, X, Lim, YL, Boon, ESK, and Liew, TM. Public discourse surrounding suicide during the COVID-19 pandemic: an unsupervised machine learning analysis of twitter posts over a one-year period. Int J Environ Res Public Health . (2022) 19:13834. doi: 10.3390/ijerph192113834

7. World Health Organization. (2023), WHO director-General's opening remarks at the mental health at work panel, world economic Forum-1 2023. Available at: https://www.who.int/zh/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-mental-health-at-work-panel--world-economic-forum---18-january-2023 (Accessed January 18, 2023).

Google Scholar

8. Zimet, GD, Dahlem, NW, Zimet, SG, and Farley, GK. The multidimensional scale of perceived social support. J Pers Assess . (1988) 52:30–41. doi: 10.1207/s15327752jpa5201_2

Crossref Full Text | Google Scholar

9. Alshehri, NA, Yıldırım, M, and Vostanis, P. Saudi adolescents’ reports of the relationship between parental factors, social support and mental health problems. Arab J Psychiatry . (2020) 31:130–43. doi: 10.12816/0056864

10. Cobb, N. Social support as a factor in the reduction of stress In: L Berkowitz, editor. Advances in experimental social psychology . New York, NY: Plenum Press (1976). 277–319.

11. Cohen, S, and Wills, TA. Stress, social support, and the buffering hypothesis. Psychol Bull . (1985) 98:310–57. doi: 10.1037/0033-2909.98.2.310

12. Fong, AJ, Scarapicchia, TMF, McDonough, MH, Wrosch, C, and Sabiston, CM. Changes in social support predict emotional well-being in breast cancer survivors. Psycho Oncol . (2017) 26:664–71. doi: 10.1002/pon.4064

13. Brailovskaia, J, Schönfeld, P, Kochetkov, Y, and Margraf, J. What does migration mean to us? USA and Russia: relationship between migration, resilience, social support, happiness, life satisfaction, depression, anxiety and stress. Curr Psychol . (2019) 38:421–31. doi: 10.1007/s12144-017-9627-3

14. Yıldırım, M, Aziz, IA, Vostanis, P, and Hassan, MN. Associations among resilience, hope, social support, feeling belongingness, satisfaction with life, and flourishing among Syrian minority refugees. J Ethn Subst Abus . (2024) 23:166–81. doi: 10.1080/15332640.2022.2078918

15. Yıldırım, M, and Green, ZA. Social support and resilience mediate the relationship of stress with satisfaction with life and flourishing of youth. Br J Guid Counsell . (2023):1–12. doi: 10.1080/03069885.2023.2172551

16. Cao, J. The role of social support in mitigating the psychological impact of the COVID-19 pandemic on college students. J Am Coll Heal . (2020) 68:577–86.

17. Chen, YH, Chen, YM, Chen, PY, and Hsu, HY. Social support and mental health during the COVID-19 pandemic: a cross-sectional study in Taiwan. Int J Environ Res Public Health . (2020) 17:6345.

18. Green, ZA, Çiçek, İ, and Yıldırım, M. The relationship between social support and uncertainty of COVID-19: the mediating roles of resilience and academic self-efficacy. Psihologija . (2024) 2. doi: 10.2298/PSI220903002G

19. Ma, H, and Miller, C. Trapped in a double bind: Chinese overseas student anxiety during the COVID-19 pandemic. Health Commun . (2021) 36:1598–605. doi: 10.1080/10410236.2020.1775439

20. Kandeğer, A, Aydın, M, Altınbaş, K, Cansız, A, Tan, Ö, Tomar Bozkurt, H, et al. Evaluation of the relationship between perceived social support, coping strategies, anxiety, and depression symptoms among hospitalized COVID-19 patients. Int J Psychiatry Med . (2021) 56:240–54. doi: 10.1177/0091217420982085

21. Wu, W, Zhang, Y, Wang, P, Zhang, L, Wang, G, Lei, G, et al. Psychological stress of medical staffs during outbreak of COVID-19 and adjustment strategy. J Med Virol . (2020) 92:1962–70. doi: 10.1002/jmv.25914

22. Inglehart, R, and Baker, WE. Modernization, cultural change, and the persistence of traditional values. Am Sociol Rev . (2000) 65:19–51. doi: 10.1177/000312240006500103

23. Park, J, Kitayama, S, Karasawa, M, Curhan, K, Markus, HR, Kawakami, N, et al. Clarifying the links between social support and health: culture, stress, and neuroticism matter. J Health Psychol . (2013) 18:226–35. doi: 10.1177/1359105312439731

24. Inglehart, R. Culture shift in advanced industrial societies . Princeton, NJ: Princeton University Press (1990).

25. Yum, JO. The impact of Confucianism on interpersonal relationships and communication patterns in East Asia. Commun Monogr . (1988) 55:374–88. doi: 10.1080/03637758809376178

26. Uchino, BN. Understanding the links between social support and physical health: a lifespan perspective with emphasis on the separability of perceived and received support. Perspect Psychol Sci . (2009) 4:236–55. doi: 10.1111/j.1745-6924.2009.01122.x

27. La Rosa, VL, and Commodari, E. University experience during the first two waves of COVID-19: students’ experiences and psychological wellbeing. Eur J Investig Health Psychol Educ . (2023) 13:1477–90. doi: 10.3390/ejihpe13080108

28. Murphy, J, Spikol, E, McBride, O, Shevlin, M, Bennett, KM, Hartman, TK, et al. The psychological wellbeing of frontline workers in the United Kingdom during the COVID-19 pandemic: first and second wave findings from the COVID-19 psychological research consortium (C19PRC) study In: New theory, research and policy . Ann Arbor: The University of Michigan Press (2020)

29. Paucsik, M, Leys, C, Marais, G, Baeyens, C, and Shankland, R. Self-compassion and savouring buffer the impact of the first year of the COVID-19 on PhD students’ mental health. Stress Health . (2022) 38:891–901. doi: 10.1002/smi.3142

30. Holt-Lunstad, J, Shaefer, D, and Streamer, A. Social isolation and loneliness: a systematic review of population-based mortality studies. Perspect Psychol Sci . (2020) 15:107–21.

31. Ng, QX, Koh, NYK, Xin, X, Zainal, H, Tan, JT, Thumboo, J, et al. Experiences of environmental services workers in a tertiary hospital in Asia during the COVID-19 pandemic: a qualitative study. Front Public Health . (2023) 11:1178054. doi: 10.3389/fpubh.2023.1178054

32. Razu, SR, Yasmin, T, Arif, TB, Islam, MS, Islam, SMS, Gesesew, HA, et al. Challenges faced by healthcare professionals during the COVID-19 pandemic: a qualitative inquiry from Bangladesh. Front Public Health . (2021) 9:647315. doi: 10.3389/fpubh.2021.647315

33. Bruine de Bruin, W. Age differences in COVID-19 risk perceptions and mental health: evidence from a national US survey conducted in march 2020. J Gerontol Series B . (2021) 76:e24–9. doi: 10.1093/geronb/gbaa074

34. Li, F, Luo, S, Mu, W, Li, Y, Ye, L, Zheng, X, et al. Effects of sources of social support and resilience on the mental health of different age groups during the COVID-19 pandemic. BMC Psychiatry . (2021) 21:1–14. doi: 10.1186/s12888-020-03012-1

35. Pieh, C, Budimir, S, and Probst, T. The effect of age, gender, income, work, and physical activity on mental health during coronavirus disease (COVID-19) lockdown in Austria. J Psychosom Res . (2020) 136:110186. doi: 10.1016/j.jpsychores.2020.110186

36. Choi, KW, Lee, YH, Liu, Z, Fatori, D, Bauermeister, JR, Luh, RA, et al. Social support and depression during a global crisis. Nat Mental Health . (2023) 1:428–35. doi: 10.1038/s44220-023-00078-0

37. Bigalke, JA, Greenlund, IM, and Carter, JR. Sex differences in self-report anxiety and sleep quality during COVID-19 stay-at-home orders. Biol Sex Differ . (2020) 11:1–11. doi: 10.1186/s13293-020-00333-4

38. Liu, CH, Zhang, E, Wong, GTF, and Hyun, S. Factors associated with depression, anxiety, and PTSD symptomatology during the COVID-19 pandemic: clinical implications for US young adult mental health. Psychiatry Res . (2020) 290:113172. doi: 10.1016/j.psychres.2020.113172

39. Tull, MT, Edmonds, KA, Scamaldo, KM, Richmond, JR, Rose, JP, and Gratz, KL. Psychological outcomes associated with stay-at-home orders and the perceived impact of COVID-19 on daily life. Psychiatry Res . (2020) 289:113098. doi: 10.1016/j.psychres.2020.113098

40. JBI. (2020). Checklist for analytical cross sectional studies. Available at: https://jbi.global/critical-appraisal-tools

41. Raudenbush, SW. Methods of Meta-analysis: correcting error and Bias in research findings. J Am Stat Assoc . (1991) 86:242–4. doi: 10.2307/2289738

42. Light, RJ, and Pillemer, DB. Summing up: The science of reviewing research . Cambridge, MA: Harvard University Press (1984).

43. Viechtbauer, W. Publication bias in meta-analysis: prevention, assessment and adjustments. Psychometrika . (2007) 72:269. doi: 10.1007/s11336-006-1450-y

44. Egger, M, Smith, GD, Schneider, M, and Minder, C. Bias in meta-analysis detected by a simple, graphical test. BMJ . (1997) 315:629–34. doi: 10.1136/bmj.315.7109.629

45. Borenstein, M, Cooper, H, Hedges, L, and Valentine, J. Effect sizes for continuous data. Handb Res Synthesis Meta Anal . (2009) 2:221–35.

46. Mullen, B, Muellerleile, P, and Bryant, B. Cumulative meta-analysis: a consideration of indicators of suefficiency and stability. Personal Soc Psychol Bull . (2001) 27:1450–62. doi: 10.1177/01461672012711006

47. Abdoli, N, Farnia, V, Jahangiri, S, Radmehr, F, Alikhani, M, Abdoli, P, et al. Sources of sleep disturbances and psychological strain for hospital staff working during the COVID-19 pandemic. International Journal of Environmental Research and Public Health . (2021) 18:6289.

48. Ao, Y, Zhu, H, Meng, F, Wang, Y, Ye, G, Yang, L, et al. The impact of social support on public anxiety amidst the COVID-19 pandemic in China. International Journal of Environmental Research and Public Health . (2020) 17:9097.

49. Barros, C, and Sacau-Fontenla, A. New Insights on the Mediating Role of Emotional Intelligence and Social Support on University Students’ Mental Health during COVID-19 Pandemic: Gender Matters. International Journal of Environmental Research and Public Health . (2021) 18:12935.

50. Chen, H, Zhao, X, Zeng, M, Li, J, Ren, X, Zhang, M, et al. Collective self-esteem and perceived stress among the non-infected general public in China during the 2019 coronavirus pandemic: A multiple mediation model. Personality and Individual Differences . (2021) 168:110308

51. Chinawa, A, Aronu, A, Ossai, E, and Chinawa, J. Promotive factors associated with internalising symptoms amongst college students during the COVID-19 lockdown in Enugu metropolis. Nigeria. South African Journal of Psychiatry . (2022) 28:1672.

52. Costa, S, Canale, N, Mioni, G, and Cellini, N. Maintaining social support while social distancing: The longitudinal benefit of basic psychological needs for symptoms of anxiety during the COVID‐19 outbreak. Journal of Applied Social Psychology . (2022) 52:439–48.

53. Ekmen, E, Koçak, O, Solmaz, U, Kopuz, K, Younis, MZ, and Orman, D. How Does the Social Support Affect Refugees’ Life Satisfaction in Turkey? Stress as a Mediator, Social Aids and Coronavirus Anxiety as Moderators. Sustainability . (2021) 13:12727.

54. Grumi, S, Provenzi, L, Accorsi, P, Biasucci, G, Cavallini, A, Decembrino, L, et al. Depression and anxiety in mothers who were pregnant during the COVID-19 outbreak in Northern Italy: the role of pandemic-related emotional stress and perceived social support. Frontiers in Psychiatry . (2021) 12:716488. doi: 10.3389/fpsyt.2021.716488

55. Hou, T, Yin, Q, Xu, Y, Gao, J, Bin, L, Li, H, et al. The mediating role of perceived social support between resilience and anxiety 1 year after the COVID-19 pandemic: disparity between high-risk and low-risk nurses in China. Frontiers in Psychiatry . (2021) 12:666789.

56. Muyor-Rodríguez, J, Caravaca-Sánchez, F, and Fernández-Prados, JS. COVID-19 fear, resilience, social support, anxiety, and suicide among college students in Spain. International Journal of Environmental Research and Public Health . (2021) 18:8156.

57. Rosenthal, R. Meta-analytic procedures for social research . Thousand Oaks, CA: Sage Publications (1991).

58. Huedo-Medina, TB, Sánchez-Meca, J, Marín-Martínez, F, and Botella, J. Assessing heterogeneity in meta-analysis: Q statistic or I 2 index? Psychol Methods . (2006) 11:193–206. doi: 10.1037/1082-989X.11.2.193

59. Erbil, N, Arar, MA, and Yıldırım, F. Determination of anxiety and perceived social support among mothers with infants from 0-1 years during the COVID-19 pandemic. Int J Caring Sci . (2022) 15:1493–504.

60. Li, X, Yang, P, Jiang, Y, and Gao, D. Influence of fear of COVID-19 on depression: the mediating effects of anxiety and the moderating effects of perceived social support and stress perception. Front Psychol . (2023) 13:1005909. doi: 10.3389/fpsyg.2022.1005909

61. Wu, D, Yang, T, Hall, DL, Jiao, G, Huang, L, and Jiao, C. COVID-19 uncertainty and sleep: the roles of perceived stress and intolerance of uncertainty during the early stage of the COVID-19 outbreak. BMC Psychiatry . (2021) 21:306. doi: 10.1186/s12888-021-03310-2

62. Barzilay, R, Moore, TM, Greenberg, DM, DiDomenico, GE, Brown, LA, White, LK, et al. Resilience, COVID-19-related stress, anxiety and depression during the pandemic in a large population enriched for healthcare providers. Transl Psychiatry . (2020) 10:291. doi: 10.1038/s41398-020-00982-4

63. Yıldırım, M, and Aziz, IA. Turkish validation of the Psy-flex scale and its association with resilience and social support. Environ Soc Psychol . (2023) 8:1513. doi: 10.18063/esp.v8.i1.1513

64. Yıldırım, M, Turan, ME, Albeladi, NS, Crescenzo, P, Rizzo, A, Nucera, G, et al. Resilience and perceived social support as predictors of emotional well-being. J Health Soc Sci . (2023) 8:59–75.

65. Sinha, JB, and Sinha, JB. Collectivism and individualism. Psycho Soc Anal Indian Mindset . (2014) 13:27–51. doi: 10.1007/978-81-322-1804-3_2

66. Berry, JW. Social and cultural patterns associated with stress and coping in modernization In: LA Ensure, editor. Social stress: Studies in the psychology of stress . New York, NY: Plenum Press (1980). 1–37.

67. Aslund, I, Persson, R, and Ringsmärck, H. The role of social support in the association between job strain and anxiety: a study of Swedish workers. Int J Stress Manag . (2012) 19:39–52.

68. Kim, YI, Lei, J, Park, J, and Patel, V. Mental health and well-being during the COVID-19 pandemic: a global perspective. Lancet Psychiatry . (2021) 8:567–76.

69. Fauci, AS, Hansen, JA, and Moderna, T. Opening up America again—the role of testing, tracing, and vaccines. N Engl J Med . (2020) 382:1509–10.

70. WHO (World Health Organization). (2020). Mental health and psychosocial support during the COVID-19 pandemic. Available at: https://www.who.int/mental_health/publications/covid19-mental-health/en/

71. Commodari, E, and La Rosa, VL. Adolescents in quarantine during COVID-19 pandemic in Italy: perceived health risk, beliefs, psychological experiences and expectations for the future. Front Psychol . (2020) 11:559951. doi: 10.3389/fpsyg.2020.559951

Keywords: COVID-19, social support, anxiety, culture, pandemic phrase, major public emergencies

Citation: Liu J, Chang S, Wang Z and Raja FZ (2024) Exploring the association between social support and anxiety during major public emergencies: a meta-analysis of the COVID-19 pandemic. Front. Public Health . 12:1344932. doi: 10.3389/fpubh.2024.1344932

Received: 27 November 2023; Accepted: 14 June 2024; Published: 09 July 2024.

Reviewed by:

Copyright © 2024 Liu, Chang, Wang and Raja. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Zhidan Wang, [email protected]

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