Most of us are shy to some degree, but acute shyness is one of the most under-recognised mental health problems of the modern age, say some. So when is being shy an illness?

Walking down a busy high street with your cheeks painted like a clown isn't normal behaviour for most people. But it's precisely what is being prescribed for one group of people who desperately want to feel more normal.

People suffering from acute social embarrassment are encouraged to wear ridiculous amounts of blusher in public as part of their treatment at one hospital.

It's an unlikely cure for a condition called social phobia.

The problem was first recognised as a mental health condition in 1980 and some professionals believe it's one of the most under-recognised and under-treated mental health problems of the modern age.

Others are uneasy about such statements, saying shyness is behaviour that falls within the normal part of human experience.

[Photo: the press dubbed the demure Princess Diana "Shy Di."]

So when does shyness become a mental health problem?

Social phobia is basically a fear, says the Royal College of Psychiatrists. The fear of social situations can be all-consuming and can even include contact with a person's immediate family. Sufferers describe the condition as "soul destroying".

Symptoms can sound less alarming than other mental health problems and are often perceived as less serious. But at its most serious social phobia can be debilitating and distressing, leaving people unable to carry out even the most normal daily activities.

Tragedy

Even something as simple as buying a newspaper can entirely obsess sufferer James. He gets anxious about what to say to the person serving him and then agonises afterwards about what he did or didn't say.

"People with social phobia tend to think that everyone can see they're anxious and embarrassed which in turn makes them feel even more anxious and embarrassed, but this is a rather exaggerated belief," says psychologist Professor David Clark.

A big problem with the condition is that it often goes undiagnosed.

"Social phobia is tragic and the tragedy is that it's relatively easily treated but most people don't get treatment," says Professor Ronald Kessler from Harvard Medical School.

"As a humane society we really should be thinking a lot more about it than we do."

Only 5% to 10% of people with social phobia in the UK currently get treatment for it, says Prof Clark.

"It's shocking when you consider the long lasting and devastating impact it can have on people and their families."

On top of this, it isn't likely to go away on its own. People are less likely to recover from it naturally than other mental health problems, says Prof Clark.

Studies over the last 12 years show only a third of people with social phobia recover without intervention, compared to a 95% natural recovery rate for depression and an 80% rate for panic disorders.

'Freaked out'

The condition can impact on every area of a sufferer's life.

"It's heartbreaking, it's so lonely," says sufferer Jayne. "Just being around people is horrible and when that includes your own family it's soul destroying."

It can influence people's decisions from an early age and sufferers often choose jobs which minimise their social contact, even if they would rather do something else.

SOCIAL PHOBIA FACTS

It can be general or specific

Physical symptoms include heart palpations and shaking

Women are more likely to suffer it than men

     Source: Royal College of Psychiatrists

"People with social phobia are much more likely to drop out of school early, because as soon as they can escape the crowded classroom they do," says Prof Kessler. "They're also much less likely to get promoted at work."

The condition often results in alcohol and drug addiction later in life, as sufferers use excessive amounts of both to control their fears. They can also end up acutely depressed by their sense of isolation.

But while some health care professionals argue the condition is under-recognised, others worry the problem is psychiatry itself - labelling people who are just plain shy as having a mental illness.

"Social phobia is yet another example of normal behaviour being re-branded as an illness," says English professor Christopher Lane, author of Shyness: How Normal Behaviour Became a Sickness.

Embarrassing

Professionals are also often at odds over how many people have it. The Royal College of Psychiatrists puts it at up to 2% of men and 3% of women in the UK.

Some studies say 7% to 15% of people will be affected at some stage of their lifetime, but this includes those at the mildest end of the spectrum.

Prof Kessler estimates that 4% to 8% of people in the UK will suffer chronic anxiety at some time, while Prof Lane puts it at 1% to 2%.

Another battle is over how social phobia is described and treated. Pharmaceutical companies with big advertising budgets are keen to raise awareness of the condition and supply anti-depressants as a solution.

But some remain unconvinced that powerful drugs should be used to treat shyness.

"For as long as social phobia is seen as medical problem people will favour a pharmaceutical treatment," says Prof Lane.

The drug companies argue that playing down the disease and its impact does a huge disservice to patients and their families.

Randomised control trials show that while both anti-depressants and cognitive behavioural therapy (CBT) can help people with social phobia, therapy is more effective than medication in the longer term.

Which is why treatments such as going out looking like a clown have been developed. This method is part of a CBT programme specifically designed at Maudsley Hospital in London for people with social phobia.

Proving to these people they are not constantly being watched, no matter how ridiculous they look, is a powerful way of helping them to feel less self-conscious.

For them such methods may be embarrassing but it's a small price to pay if it helps them to overcome a phobia which, to date, has made their life a misery.

Some names have been changed in this article.

Source: BBC News 4 March 2008.

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