ORIGINAL ARTICLE

Parental Psychopathology, Parenting Styles,

and the Risk of Social Phobia in Offspring
A Prospective-Longitudinal Community Study
Roselind Lieb, PhD; Hans-Ulrich Wittchen, PhD; Michael Hofler, DiplStat; Martina Fuetsch, Mag.rer.nat;
Murray B. Stein, MD; Kathleen R. Merikangas, PhD

Background: This article examines the associations be-

Results: There was a strong association between paren-

tween DSM-IV social phobia and parental psychopathology, parenting style, and characteristics of family functioning in a representative community sample of
adolescents.

tal social phobia and social phobia among offspring (odds

ratio [OR], 4.7; 95% confidence interval [CI], 1.6-13.5).
Other forms of parental psychopathology also were associated with social phobia in adolescents (depression:
OR, 3.6; 95% CI, 1.4-9.1; any anxiety disorder other than
social phobia: OR, 3.5; 95% CI, 1.4-8.8; and any alcohol
use disorder: OR, 3.0; 95% CI, 1.1-7.8). Parenting style,
specifically parental overprotection (OR, 1.4; 95% CI, 1.01.9) and rejection (OR, 1.4; 95% CI, 1.1-1.9), was found
to be associated with social phobia in respondents. Family functioning was not associated with respondents social phobia.

Methods: Findings are based on baseline and first

follow-up data of 1047 adolescents aged 14 to 17 years

at baseline (response rate, 74.3%), and independent
diagnostic interviews with one of their parents. Diagnostic assessments in parents and adolescents were
based on the DSM-IV algorithms of the Munich-Composite International Diagnostic Interview. Parenting
style (rejection, emotional warmth, and overprotection) was assessed by the Questionnaire of Recalled
Parental Rearing Behavior, and family functioning
(problem solving, communication, roles, affective
responsiveness, affective involvement, and behavioral
control) was assessed by the McMaster Family Assessment Device.

From the Department of

Clinical Psychology and
Epidemiology, Max Planck
Institute of Psychiatry, Munich,
Germany (Drs Lieb and
Wittchen, Mr Hofler and
Ms Fuetsch); Department of
Psychiatry, University of
California at San Diego,
La Jolla (Dr Stein); and the
Department of Epidemiology
and Public Health, Yale
University School of Medicine,
New Haven, Conn
(Dr Merikangas).

Conclusions: Data suggest that parental psychopathol-

ogy, particularly social phobia and depression, and perceived parenting style (overprotection and rejection) are
both associated with the development of social phobia
in youth.
Arch Gen Psychiatry. 2000;57:859-866

OCIAL PHOBIA has become rec-

ognized as a prevalent mental disorder that typically

starts in adolescence and is
associated with significant
impairment in work and social functioning.1-12 Despite the growing body of research on the risk factors, course, clinical
characteristics, and treatment, the key etiological or pathogenetic mechanisms of social phobia are largely unknown. Several
risk factors have been proposed, including biological, 1 3 - 1 6 familial, and genetic10,12,17-20; early temperament (eg, behavioral inhibition 21,22 ); socialization
patterns23,24; and psychological factors,
ranging from behavioral conditioning25,26
to cognitive variables.27-29 There is increasing evidence regarding the role of familial factors in the development of social
phobia. Studies using both the family study
and family history approach have found

(REPRINTED) ARCH GEN PSYCHIATRY/ VOL 57, SEP 2000

859

higher rates of social phobia in relatives

of social phobic patients compared with
relatives of controls.30-37 Two studies suggest that familial social phobia might be
particularly important in the development of the generalized subtype, a more
severe form of social phobia that is characterized by fears in a broad range of social situations.34,35 Since most family studies have focused primarily on the familial
aggregation of social phobia among adult
relatives, there is little research on specific links between social phobia in parents and offspring. High-risk studies of
anxiety 36 and social phobia 37 have revealed increased rates of social phobia in
offspring.
Although most studies indicate that
the family may play an important role in
the development of social phobia, there is
little empirical evidence regarding the nature of the familial link in terms of ge-

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SUBJECTS AND METHODS

summarizes the weighted and unweighted numbers and

percentages at baseline, first follow-up, and the parent
survey for the study sample.

DESIGN
DIAGNOSTIC ASSESSMENT
The data presented come from the Early Developmental
Stages of Psychopathology Study (EDSP). The EDSP is designed as a prospective-longitudinal survey to collect data
on the prevalence and incidence, familial and other risk factors, comorbidity, and course of mental disorders in a representative sample of 3021 subjects aged 14 to 24 years at
baseline. This article is restricted to adolescent respondents aged 14 to 17 years at baseline. Detailed descriptions of the EDSP design and field procedures are reported elsewhere.45,46
COMMUNITY RESPONDENTS AND PARENTS
The EDSP builds on a random population sample from the
1994 government population registers of residents in metropolitan Munich, including the surrounding counties. Details about the sampling and representativeness of the
sample, along with its sociodemographic characteristics,
have been reported elsewhere.45-48 The response rate for the
study sample of the 14- to 17-year-olds at baseline was
74.3%. These subjects, who will be referred to as the respondents in this article, were reinvestigated approximately 20 months later (mean, 19.7 months; range, 15.025.6 months) (N=1228), with a response rate of 88%. At
baseline, most of the respondents were attending school
(89%) and living with their parents (97.8%). About 10%
were in job training. The majority were classified as belonging to the middle class (61.4%). Noteworthy changes
in sociodemographic characteristics from baseline to follow-up were only found for school (follow-up: 71% attended school) and employment status (follow-up: 21% were
in job training).
Independent diagnostic interviews were conducted
with the parents of these repondents. Interested not only
in familial psychopathology but also in respondents early
development, we primarily interviewed the respondents
mothers. Fathers were interviewed only if the mother was
dead or not locatable. The parents of 1053 adolescents were
interviewed directly (response rate: 86%; in 1026 cases the
mother, in 27 cases the father). Nonresponse in parents was
predominantly because of refusal to participate (12.9%),
failure to contact parents (0.7%), and lack of time (0.5%).
Throughout the article, data were weighted by age,
sex, geographic location, noncontact and nonresponse to
match the distribution of the sampling frame.46 Table 1

netic influences (eg, heritable biological factors) and specific family environmental factors (eg, parenting styles).
With respect to the latter, several studies have demonstrated that adults with anxiety disorders, especially social phobia, retrospectively rate their parents as rejective and/or overprotective. Both parenting characteristics,
individually and in combination (described in the literature as affectionless control38), may result in offsprings development of subsequent difficulties in interpersonal interactions and social situations.39-44 It should
be noted that neither the role of parental social phobia
nor the relevance of parenting style as risk factors for the
(REPRINTED) ARCH GEN PSYCHIATRY/ VOL 57, SEP 2000
860

Assessment of Respondents
Diagnostic assessments in the baseline and first follow-up
investigation were based on the computer-assisted version
of the Munich-Composite International Diagnostic Interview (M-CIDI49), a modified version of the World Health Organization (WHO) CIDI, version 1.2, supplemented by questions to cover DSM-IV 50 and International Classification of
Diseases, 10th Revision (ICD-10)51 criteria. A detailed discussion of the M-CIDI, its social phobia module, and how
it differs from the WHO-CIDI and findings of its reliability
and validity have been presented elsewhere.12,46,52-54 The MCIDI allows for the assessment of symptoms, syndromes, and
diagnoses of 48 mental disorders, along with information
about onset, duration, and clinical and psychosocial severity. It includes a separate family-history module to evaluate
psychopathology in relatives of the respondents. In both assessments, interviews were administered by highly trained
clinical interviewers. Most interviews were carried out in the
homes of the respondents.
Assessment of Parents
Parents were independently assessed with the M-CIDI as
well, thus providing direct diagnostic information (MCIDI/DSM-IV criteria) for the interviewed parent. All interviews were conducted by clinical interviewers who were
blind to the diagnostic findings of the respective respondents, and most interviews took place in the parents homes.
The parent M-CIDI was supplemented with 2 additional
modules that provided detailed information about the respondents perinatal, psychological, and somatic conditions in infancy and early childhood, and family history data
for the noninterviewed parent and other family members
of the respondent.55
ASSIGNMENT OF DIAGNOSES
For respondents, diagnostic findings are based exclusively
on the M-CIDI/DSM-IV diagnostic algorithms.49 Diagnostic
estimates for parents were obtained using all available diagnostic information from the 2 sources: the family history data
obtained from the M-CIDI family-history module at baseline with the respondent as informant, and the M-CIDI of

development of social phobia has yet been tested prospectively in a community sample.
Using data from a representative population sample,
this article evaluates whether parental social phobia is associated with social phobia in offspring, examines whether
such an association is specific to parental social phobia or
whether the risk is also elevated among offspring with other
parental psychopathology, explores whether the parentoffspring association is higher in the generalized subtype
of social phobia, and evaluates whether specific parenting styles and family functioning dimensions increase the
risk for social phobia in adolescents.
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the parent investigation, which provided direct M-CIDI/

DSM-IV diagnostic information for the interviewed parent
and family-history data for the noninterviewed parent. Parental diagnostic estimates were derived by computer on the
basis of a priori established diagnostic algorithms with 3 levels of diagnostic certainty: definite, probable, or no diagnosis. Parents met criteria for a definite diagnosis whenever diagnostic information for the respective disorder was
reported by both sources of data (the respondent interview
and the parent investigation). A probable diagnosis was assigned whenever diagnostic information was reported by only
1 source (respondent or parent), with 1 notable exception:
if a directly interviewed parent met full M-CIDI/DSM-IV criteria for a disorder, a definite diagnosis was assigned irrespective of the adolescents report.
Because of the reliance on mothers reports, no sexspecific analyses were performed. Family history items in
both the baseline respondent interview and the parent survey were designed taking the the Family History Research
Diagnostic Criteria56 as a basic model. To obtain family history information about the same DSM-IV Axis I disorders
that are in the M-CIDI, we used the stem questions from
the full M-CIDI to assess the key symptoms for the DSM-IV
diagnoses. Questions were also asked to determine if the
index subject sought professional help because of the respective symptoms. The validity of the family history information has been investigated by comparing the family
history information gathered from the adolescents about
their mothers with the diagnostic information obtained by
the mothers themselves in the direct parent survey. Comparable with other studies,57-59 we found high specificity but
rather low sensitivity of the family history information.
ASSESSMENT OF PARENTING STYLE
AND FAMILY FUNCTIONING
Parenting style was assessed by the Questionnaire of Recalled Parental Rearing Behaviour (German version, FEE60),
which assesses the subjects (in our study, the adolescents)
perceived parental rearing behavior. It is composed of the
dimensions of rejection, emotional warmth, and overprotection. Each scale is answered by the subject separately for
mother and father. Reliability and validity findings have been
reported.60-62 To assess family functioning, interviewed parents completed the McMaster Family Assessment Device
(FAD63), which is based on the McMaster Model of Family
Functioning. The FAD assesses 6 dimensions of family functioning: problem solving, communication, roles, affective
responsiveness, affective involvement, and behavior control. The scale general functioning assesses the overall

RESULTS

SOCIAL PHOBIA IN RESPONDENTS AND PARENTS

Of the respondents, 5.6% fullfilled criteria for DSM-IV social phobia; 4.4% met criteria for the nongeneralized subtype; and generalized social phobia was present in 1.1%
(Table 2). Social phobia was slightly more frequent in
women than in men (6.9% vs 4.2%; independence test:
design-based F1,1052 = 3,40; P = .06). One hundred thirtyseven parents (unweighted numbers) fulfilled criteria for
either probable or definite social phobia. In 134 cases the
(REPRINTED) ARCH GEN PSYCHIATRY/ VOL 57, SEP 2000
861

health/psychopathology of the family. The subject rates her

or his agreement with how adequately the item decribes
her or his family. Psychometric properties of the FAD have
been reported.64
STATISTICAL ANALYSES
The aim of this study was to assess the association of parental social phobia, other parental psychopathology, parenting style, and family functioning with social phobia in adolescent respondents. Respondents social phobia status was
defined as the cumulative lifetime incidence of social phobia reported at baseline or first follow-up. For all family
history analyses, the occurence of a diagnosis in either
mother or father was taken as the unit of the analyses. Parental diagnoses were organized so that parents with social phobia could also have other diagnoses, but parents
with other psychopathology (other anxiety disorders, depression, alcohol use disorders) could not have social phobia. In the logistic regressions used to calculate odds ratios (ORs65), parental psychopathology, parenting styles,
and family functioning were the independent variables, while
respondents social phobia was the dependent variable. To
investigate separate associations with generalized and nongeneralized social phobia, multinomial logistic regressions were used.65 The resulting ORs describe the association between the covariate and the respective subtype
in the population in which the other subtype does not
occur. Mean scores of all family environment scales were
divided by their SDs to improve the comparability of
associations. Because of the positively skewed shape of
the distributions of these scores, differences between parental psychopathology groups were analyzed with gamma
regressions65,66 with multiplicative effects. To apply the
gamma distribution, scales were transformed so that the
minimum score was 0. For 1 of the scales (emotional
warmth), scores were negatively skewed; in this case, scores
(x) were replaced with (maximum x), so that gamma regressions could be applied. Calculations were made with
the LOGISTIC, SVYMLOG, XTGEE, SVYTAB, and ST procedures of the software package Stata.67 For the examination of age of onset data, survival analyses were performed. The Kaplan-Meier method was used to estimate
cumulative lifetime incidences; this method recognizes agecensoring for respondents younger than the maximum age
(19 years).68 Differences in terms of hazard rates were tested
with the Cox model for discrete time (year intervals of age)66
while testing the proportional hazards assumption (ie, hazard ratios [HR] independent of age).69 This assumption was
not violated, and no cohort effects were found.

mother was affected, and in 3 cases the father was affected.

In no case were both parents affected by social phobia. Diagnostic information about social phobia in 2 fathers and
5 mothers was reported solely from the respondent at baseline, whereas all other cases of parental social phobia were
obtained directly from the parental interviews.
PARENTAL PSYCHOPATHOLOGY AND
SOCIAL PHOBIA IN OFFSPRING
Offspring of parents with DSM-IV social phobia had higher
rates of social phobia than offspring of parents without
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Table 1. Response Rates and Demographic Distribution

of Adolescents Aged 14 to 17 Years at Baseline*
Total

Men

Table 2. Social Phobia in Respondents

and Their Parents (Weighted Data)*

Women

Total eligible baseline sample,

No. (% of the sample)
1877 (100.0) 963 (51.3) 914 (48.7)
Baseline (1995)
Subjects, No.
1395
714
681
Response rate, %
74.3
74.1
74.5
First follow-up (1996/1997)
1228 (1228) 637 (619) 591 (609)
Subjects, No. (Nw)
Response rate, %
88.0
89.2
86.8
Parent survey (1997)
1053 (1047) 541 (521) 512 (526)
Subjects, No. (Nw)
Response rate, %
85.7
84.9
86.6
*Nw indicates weighted N.
First follow-up investigation was conducted on average 19.7 months
after baseline (range, 15-25.6 months).
For 1026 adolescents, the mother was interviewed, and for 27
adolescents, the father was interviewed.
Weights of the follow-up study were used for adjusting the data of the
parent survey.

psychopathology (9.6% vs 2.1%) (Table 3). Rates of social phobia were also elevated in adolescents whose parents met criteria for other anxiety, depressive, or alcohol use disorders. Logistic regression analyses revealed
the highest sample OR when parents were affected by social phobia. There was no notable difference in whether
parental social phobia was diagnosed at the probable (OR,
5.2; 95% CI, 1.5-17.3; P = .008) or the definite (OR, 4.0,
95% CI, 1.0-14.8; P = .04) level. Slightly lower associations were found for the other mental disorders in parents. Respondents whose parents suffer from social phobia and multiple comorbid other disorders seem to have
a greater risk to meet criteria for DSM-IV social phobia.
No significant interactions between any form of parental psychopathology and sex of the respondent were found.
The same pattern of results emerged when all the
associations were adjusted for the effects of respondents
comorbidity. Controlling for the presence of other anxiety, depressive, and alcohol use disorders did not substantially alter the significance and strengths of the associations shown in Table 3. Subsetting the analyses to
only directly interviewed parents yielded qualitatively
the same associations, but all but one failed to reach
significance.
ASSOCIATIONS WITH SUBTYPES
When nongeneralized social phobia in respondents was
considered separately as the outcome, associations were
found for parental social phobia (OR, 3.3; 95% CI, 1.010.3; P=.04), for other parental anxiety disorders (OR,
2.9; 95% CI, 1.1-7.4; P=.02), and parental depression (OR,
3.0; 95% CI, 1.1-7.7; P=.02). Because of the fact that there
were no cases of generalized social phobia in offspring
without parental psychopathology, no separate ORs could
be calculated for the generalized subtype. However, it is
remarkable that 4 of the 13 adolescents with social phobia with parental social phobia met criteria for the generalized subtype. Lower percentages of generalized so(REPRINTED) ARCH GEN PSYCHIATRY/ VOL 57, SEP 2000
862

Frequency of Social Phobia

No. (Nw)
Respondents
DSM-IV social phobia
59 (58)
Generalized subtype
13 (12)
Nongeneralized subtype
46 (46)
Respondents Parents
Either probable or definite\
137 (134)
Probable diagnosis
78 (77)
Definite diagnosis
59 (57)

% (95% CI)
5.6 (4.2-7.3)
1.1 (0.6-2.1)
4.4 (3.2-6.0)
12.8 (10.8-15.2)
7.3 (5.8-9.2)
5.5 (4.2-7.2)

*CI indicates confidence interval; Nw, weighted N.

This column indicates weighted percentages.
There was a weighted total of 1047 subjects (521 males and 526
females).
Social phobia was present in either mother or father.
\In 134 cases, the mother was affected; in 3 cases, the father was
affected.

cial phobia were found among respondents whose parents

are affected by other mental disorders.
PARENTAL PSYCHOPATHOLOGY
AND AGE OF ONSET
For respondents with parental social phobia, the survival curve decreases most steeply, while the curve for
respondents without parental psychopathology decreases only slightly (Figure). Statistical analyses showed
that these 2 curves were significantly different (HR, 4.4;
95% CI, 1.5-12.2; P = .004), indicating a higher incidence rate of social phobia in nearly every year in respondents whose parents are affected by social phobia.
A comparison of the cumulative incidence age-of-onset
curves of nongeneralized and generalized social phobics with parental social phobia revealed an earlier onset of the generalized subtype (6 vs 11 years) in adolescents affected by parental social phobia.
PARENTING STYLE
AND FAMILY FUNCTIONING
Higher parental overprotection and higher parental
rejection were significantly associated with increased
rates of social phobia in offspring. Concerning emotional warmth, the negative association just failed to
reach significance. The analyses of the FAD family
functioning scales revealed no associations between any
specific scale and offsprings social phobia. Therefore,
only the overall general functioning scale score is
reported (Table 4).
With regard to associations between parenting
style and parental mental disorders, parental alcohol
use disorder was found to be slightly associated with
emotional warmth (mean ratio [MR], 1.1; 95% CI, 1.01.2; P=.048), and parental anxiety disorder other than
social phobia was found to be positively associated with
parental rejection (MR, 1.3; 95% CI, 1.0-1.6; P=.02).
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Table 3. Association Between Parental Psychopathology and DSM-IV Social Phobia in Adolescents*
Respondents Social Phobia Status
No DSM-IV Social Phobia
(Nw = 989)
Parental Diagnosis
Social phobia (Nw = 134)\
Any other anxiety disorder (Nw = 387)#**
Any depressive disorder (Nw = 381)
Any alcohol use disorder (Nw = 301)
No anxiety, depressive, or alcohol use
disorder (Nw = 259)
Comorbidity**
Social phobia only (Nw = 8)
Social phobia, 1 other diagnosis (Nw = 42)
Social phobia, 2 other diagnoses (Nw = 43)
Social phobia, 3 other diagnoses (Nw = 42)

DSM-IV Social Phobia

(Nw = 58)

Nw (%)

95% CI

Nw (%)

95% CI

Adjusted Odds
Ratios (95% CI)

121 (90.4)
358 (92.7)
352 (92.5)
282 (93.8)
254 (97.9)

82.7-94.9
89.4-95.1
88.9-95.0
89.9-96.2
95.3-99.1

13 (9.6)
28 (7.3)
29 (7.5)
19 (6.3)
5 (2.1)

5.1-17.3
4.9-10.6
5.0-11.1
3.8-10.1
0.9-4.7

4.7 (1.6-13.5)
3.5 (1.4-8.8)
3.6 (1.4-9.1)
3.0 (1.1-7.8)
1.0

8 (100)
38 (89.5)
41 (95.6)
35 (84.5)

...
73.4-96.3
78.6-99.2
66.9-93.6

...
3.7-26.6
0.8-21.4
6.4-33.1

...
5.5 (1.3-22.1)
2.1 (0.3-14.5)
7.6 (2.1-27.1)

...
4 (10.7)
2 (4.5)
7 (15.6)

*Nw indicates weighted N; CI, confidence interval.

Includes both probable and definite cases; the unit is either in mother or father.
This column indicates weighted percentages.
Adjusted for age and sex of respondent; no significant interaction effects were found for sex of respondent. Odds ratios for directly interviewed parents were
as follows: parental social phobia: OR, 2.0 (95% CI, 0.7-5.2; P = .15); parental anxiety disorder, excluding social phobia: OR, 2.0 (95% CI, 1.0-4.0; P = .04);
parental depressive disorder excluding social phobia: OR, 2.0 (95% CI, 0.9-4.2; P = .06); and parental alcohol use disorder excluding social phobia: OR, 1.3 (95%
CI, 0.4-3.8; P = .59).
\In 8 cases (6%), parental social phobia was pure. In 97 cases (72%), parental social phobia was comorbid with any other anxiety disorder; in 88 (66%), it was
comorbid with depression; and in 68 (50%), it was comorbid with any alcohol use disorder (comorbid diagnoses are not mutually exclusive).
P,.05 by Wald test.
#Includes panic, agoraphobia, generalized anxiety disorder, specific phobia, and obsessive-compulsive disorder. Parents with social phobia were excluded.
**Since the Nw values have been rounded to the nearest whole number, the sum of the individual Nw values does not equal the rounded total Nw.
Includes major depressive disorder and dysthymia. Parents with social phobia were excluded.
Includes alcohol abuse and dependence. Parents with social phobia were excluded.
Reference group for all comparisons.

COMMENT

The key finding that children of social phobic parents

are more likely to develop social phobia than children
of healthy parents suggests that parental social phobia
is a risk factor for social phobia in offspring. This find(REPRINTED) ARCH GEN PSYCHIATRY/ VOL 57, SEP 2000
863

1.00
0.98

1Cumulative Lifetime Incidencce

The examination of the interactions between parenting behavior and parental psychopathology with regard
to respondents social phobia status revealed that the association between parental rejection and adolescents social phobia is significantly greater when parents are affected by psychopathology, irrespective of the specific
parental disorders (association difference in comparison with no mental disorder: for social phobia [OR, 2.3;
95% CI, 1.1-4.6; P=.02]; any other anxiety disorder [OR,
1.8; 95% CI, 0.9-3.5; P=.09]; any depressive disorder [OR,
2.1; 95% CI, 1.0-4.1; P = .03]; any alcohol use disorder
[OR, 2.1; 95% CI, 1.0-4.3; P=.04]; comorbid social phobia [OR, 2.4; 95% CI, 1.1-4.8; P= .02]). The findings for
parental overprotection were similar, but failed to reach
significance.
An examination of the conditional effects of parental psychopathology and parenting styles on adolescents
social phobia (Table 5) revealed that when controlling
for parenting style, all assocations between parental psychopathology and offsprings social phobia remained significant. Likewise, controlling for parental psychopathology resulted in only slightly lower, but still significant,
associations between parental overprotection and parental rejection and respondents social phobia.

0.96
0.94
0.92
0.90
0.88

No Parental Psychopathology (Nw = 259)

Parental Psychopathology Without Social Phobia
Parental Social Phobia

0.86
0.84
1

10 11 12 13 14 15 16 17 18 19

Age, y

Onset of social phobia among respondents with parents with social phobia
(n=134), parents with psychopathology, excluding social phobia (n=654),
and those whose parents had no psychopathology (n=259). Nw indicates
weighted N.

ing is in line with the results of prior family studies in

patient samples,30-35 but it extends those findings to a community sample. Providing the first study in an epidemiological sample, unaffected by potential clinical selection
and help-seeking bias likely to occur in patient samples,
we demonstrated that offspring of parents with social phobia are significantly more likely to have DSM-IV social
phobia than offspring of healthy parents, and the parentoffspring association can be found even in adolescents
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Table 4. Associations of Parenting Styles and Family Functioning (Metric Covariates) and DSM-IV Social Phobia in Respondents*
Respondents Social Phobia Status
Family Environment Variable

No Social Phobia
(Nw = 989), Meanw

DSM-IV Social Phobia

(Nw = 58), Meanw

Adjusted Odds
Ratio (95% CI)

1.8
5.9
0.9

2.3
5.6
1.4

1.4 (1.0-1.9)
0.7 (0.5-1.1)
1.4 (1.1-1.9)

.008
.06
.007

3.8

3.9

1.1 (0.7-1.5)

.66

Parenting style (FEE)\

Overprotection
Emotional warmth
Rejection
Family functioning (FAD)\
General functioning

*Nw indicates weighted N; meanw, weighted mean; CI, confidence interval; FEE, Questionnaire of Recalled Parental Rearing Behavior (German version); and FAD,
McMaster Family Assessment Device.
Adjusted for age and sex.
P values by Wald test.
Scores are means of the maternal and paternal subscales.
\Scores were divided by their estimated SDs.
P,.05.

Table 5. Conditional Associations Between

Parental Psychopathology, Parenting
Style, and Social Phobia in Offspring*
Conditional
Association,
OR (95% CI)
Parental Psychopathology Status, Adjusted for Parenting Style
Social phobia (Nw = 134)
5.0 (1.6-15.3)
3.4 (1.2-9.1)
Any other anxiety disorder (Nw = 387)\
3.4 (1.2-9.1)
Any depressive disorder (Nw = 381)\
3.2 (1.1-9.0)
Any alcohol use disorder (Nw = 301)\
Comorbidity with social phobia
7.4 (1.7-32.3)
Social phobia, 1 other diagnosis (Nw = 42)
2.5 (0.3-17.6)
Social phobia, 2 other diagnoses (Nw = 43)
6.9 (1.8-25.4)
Social phobia, 3 other diagnoses (Nw = 42)
Parenting Style (FEE) Adjusted for Parental Psychopathology Status
Overprotection
1.4 (1.0-1.8)
Emotional warmth
0.8 (0.5-1.1)
Rejection
1.4 (1.0-1.8)
*OR indicated odds ratio; CI, confidence interval; Nw, weighted N; and FEE,
Questionnaire of Recalled Parental Rearing Behavior (German version).
Logistic regression on DSM-IV social phobia in adolescents. All effects
are adjusted for age and sex of the respondent.
Psychopathologic features in either parent.
P,.05 by Wald test.
\Parents with social phobia were excluded.

set of the disorder. Data further suggest that the parentoffspring association may be stronger for the generalized subtype 34,35 ; however, these findings require
confirmation because of the small number of youth with
the generalized subtype.
Genetic and/or environmental factors might be responsible for the parent-offspring association since twin
and adoption studies are needed to discriminate heritable sources of variance. A twin study of social phobia
by Kendler et al17,19 reveals that both genetic and nongenetic factors influence the liability to social phobia. Environmental models of the development of social phobia in offspring could include modeling or restricted
opportunities to learn social skills.23,24
In accordance with reports from the National Comorbidity Survey,10 increased rates of DSM-IV social pho(REPRINTED) ARCH GEN PSYCHIATRY/ VOL 57, SEP 2000
864

bia were also found in respondents whose parents suffer

from other anxiety disorders, depression, or alcohol use
disorders; these associations remained stable when controlled for adolescents comorbidity. Although this finding confirms the results of previous family studies that
demonstrate common familial influences for social phobia and depression (M.B.S., M.F., N. Mueller, MD, M.H.,
H.-U.W., unpublished data, 2000),5,18 the finding that parental alcoholism and other anxiety disorders increase
the risk for social phobia in offspring seem to differ somewhat from the findings of 3 patient-based family studies30,32,33 and the Yale Family Study of Comorbidity of Substance Use and Anxiety, where half of the sample of
anxiety probands was community-based.20 These studies argue for a lack of a familial link between social phobia and these disorders. We can only speculate that the
contradictory findings may be attribuable to different design features.
Similar to previous studies,36 none of the family characteristics assessed with the FAD was associated with respondents social phobia. However, there were associations with parenting style as perceived by the respondent
regarding parental overprotection and rejection. This result is in accordance with the findings in clinical
samples,39-42 but provides stronger evidence because information about parenting style was obtained directly from
adolescents still living at home (94%), suggesting that
the associations are not merely the result of recall bias.
All associations between parenting styles and adolescents social phobia remained stable when controlled for
parental psychopathology, suggesting that parental rejection and overprotection may be additional familyenvironment risk factors for social phobia independent
of parental psychopathology. Previous studies39,40 suggest potential explanations for how parental characteristics may contribute to social phobia: overprotection may
restrict the offsprings development of autonomy and social competence; the combination of rejection and overprotection may lead to a dysfunctional parent-child bond,
which may result in difficulties and anxieties in social
situations; in addition, overprotection may keep the offspring from engaging in social situations, thereby restricting the opportunities to learn social skills.23,24
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CONCLUSIONS

The data suggest that multiple familial factors are involved in the development of social phobia. Our findings indicate that not only parental social phobia, but also
other parental psychopathology, particularly parental depression and parenting style (individually and in combination), may contribute to the development of social
phobia.
Limitations of the study include the lack of direct interviews with fathers regarding social phobia and depression; this was likely to yield underestimates of paternal psychopathology.57-59 In addition, because youth have not
passed through the entire risk period for onset of social
phobia, the findings are still not conclusive; future analyses that include cases of later-onset findings will most likely
lead to even stronger parent-offspring associations.
Accepted for publication April 11, 2000.
Supported by project 01EB94056 from the German Ministry of Research and Technology, Bonn (Dr Wittchen). The
preparation of this article was supported by an unrestricted educational grant from SmithKline Beecham, Philadelphia, Pa.
We thank Robin Carter, BA, for her helpful comments
and suggestions.
Corresponding author: Roselind Lieb, PhD, Max Planck
Institute of Psychiatry, Clinical Psychology and Epidemiology Unit, Kraepelinstrasse 2, Munich 80804, Germany
(e-mail: lieb@mpipsykl.mpg.de).
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