Hostname: page-component-7d684dbfc8-hsbzg Total loading time: 0 Render date: 2023-09-29T10:58:45.371Z Has data issue: false Feature Flags: { "corePageComponentGetUserInfoFromSharedSession": true, "coreDisableEcommerce": false, "coreDisableSocialShare": false, "coreDisableEcommerceForArticlePurchase": false, "coreDisableEcommerceForBookPurchase": false, "coreDisableEcommerceForElementPurchase": false, "coreUseNewShare": true, "useRatesEcommerce": true } hasContentIssue false

Social anxiety disorder and shame cognitions in psychosis

Published online by Cambridge University Press:  21 May 2012

M. Michail*
Division of Nursing, School of Nursing, Midwifery and Physiotherapy, University of Nottingham, UK
M. Birchwood
Youth Services Programme, Birmingham and Solihull Mental Health Foundation Trust, Early Intervention Service, Birmingham, UK School of Psychology, University of Birmingham, Edgbaston, Birmingham, UK
*Address for correspondence: Dr M. Michail, Division of Nursing, School of Nursing, Midwifery and Physiotherapy, University of Nottingham, Nottingham NG7 2HA, UK. (Email:



Social anxiety disorder (SAD) is surprisingly prevalent among people with psychosis and exerts significant impact on social disability. The processes that underlie its development remain unclear. The aim of this study was to investigate the relationship between shame cognitions arising from a stigmatizing psychosis illness and perceived loss of social status in co-morbid SAD in psychosis.


This was a cross-sectional study. A sample of individuals with SAD (with or without psychosis) was compared with a sample with psychosis only and healthy controls on shame proneness, shame cognitions linked to psychosis and perceived social status.


Shame proneness (p < 0.01) and loss of social status (p < 0.01) were significantly elevated in those with SAD (with or without psychosis) compared to those with psychosis only and healthy controls. Individuals with psychosis and social anxiety expressed significantly greater levels of shame (p < 0.05), rejection (p < 0.01) and appraisals of entrapment (p < 0.01) linked to their diagnosis and associated stigma, compared to those without social anxiety.


These findings suggest that shame cognitions arising from a stigmatizing illness play a significant role in social anxiety in psychosis. Psychological interventions could be enhanced by taking into consideration these idiosyncratic shame appraisals when addressing symptoms of social anxiety and associated distress in psychosis. Further investigation into the content of shame cognitions and their role in motivating concealment of the stigmatized identity of being ‘ill’ is needed.

Original Articles
Copyright © Cambridge University Press 2012

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


Andrews, B (1995). Bodily shame as a mediator between abusive experiences and depression. Journal of Abnormal Psychology 104, 277285.CrossRefGoogle ScholarPubMed
Andrews, B (1997). Bodily shame in relation to abuse in childhood and bulimia: a preliminary investigation. British Journal of Clinical Psychology 36, 4150.CrossRefGoogle ScholarPubMed
Angermeyer, MC, Matschinger, H (2003). The stigma of mental illness: effects of labeling on public attitudes towards people with mental disorder. Acta Psychiatrica Scandinavica 108, 304309.CrossRefGoogle Scholar
Averill, MP, Diefenbach, J, Gretchen, S, Mellings, A, Breckenridge, KJ, Lusby, B (2002). Assessment of shame and guilt in a psychiatric sample: a comparison of two measures. Personality and Individual Differences 32, 13651376.CrossRefGoogle Scholar
Bienvenu, OJ, Hettemma, JM, Neale, MC, Prescott, CA, Kendler, KS (2008). Low extraversion and high neuroticism as indices of genetic and environmental risk factors for social phobia, agoraphobia and animal phobia. American Journal of Psychiatry 164, 17141721.CrossRefGoogle Scholar
Birchwood, M, Iqbal, Z, Chadwick, P, Trower, P (2000 a). Cognitive approach to depression and suicidal thinking in psychosis: 1. Ontogeny of post-psychotic depression. British Journal of Psychiatry 177, 516521.CrossRefGoogle ScholarPubMed
Birchwood, M, Iqbal, Z, Chadwick, P, Trower, P (2000 b). Cognitive approach to depression and suicidal thinking: 2. Testing the validity of a social ranking model. British Journal of Psychiatry 177, 522528.CrossRefGoogle Scholar
Birchwood, M, Mason, R, Macmillan, F, Healy, J (1993). Depression, demoralization and control over psychotic illness: a comparison of depressed and non-depressed patients with a chronic psychosis. Psychological Medicine 23, 387395.CrossRefGoogle ScholarPubMed
Birchwood, M, Trower, P, Brunet, K, Gilbert, P, Iqbal, Z, Jackson, C (2007). Social anxiety and the shame of psychosis: a study in first-episode psychosis. Behaviour Research and Therapy 45, 10251103.CrossRefGoogle ScholarPubMed
Buss, AH (1980). Self-Consciousness and Social Anxiety. W. H. Freeman: San Francisco, CA.Google Scholar
Cook, DR (1993). Internalized Shame Scale: Professional Manual. Channel Press: Menomonie, WI.Google Scholar
Corrigan, PW, Watson, CA (2002 a). The paradox of self-stigma and mental illness. Clinical Psychology and Science Practice 9, 3553.CrossRefGoogle Scholar
Corrigan, PW, Watson, CA (2002 b). Understanding the impact of stigma on people with mental illness. World Psychiatry 1, 1620.Google ScholarPubMed
Dalrymple, KL, Herbert, JD (2007). Onset of illness and developmental factors in social anxiety disorder. Preliminary findings from a retrospective interview. Journal of Psychopathology and Behavioural Assessment 29, 101110.CrossRefGoogle Scholar
Fischer, K, Tangney, J (eds) (1995). Self-Conscious Emotions. The Psychology of Shame, Guilt, Embarrassment and Pride. Guilford Press: New York.Google Scholar
Gilbert, P (1992). Depression: The Evolution of Powerlessness. Guilford Press: New York.Google Scholar
Gilbert, P (1997). The evolution of social attractiveness and its role in shame, humiliation, guilt and therapy. British Journal of Medical Psychology 70, 113147.CrossRefGoogle ScholarPubMed
Gilbert, P (1998). What is shame? Some core issues and controversies. In Shame: Interpersonal Behaviour, Psychopathology and Culture (ed. Gilbert, P. and Andrews, B.), pp. 338. Oxford University Press: New York.Google Scholar
Gilbert, P (2000). The relationship of shame, social anxiety and depression: the role of the evaluation of social rank. Clinical Psychology and Psychotherapy 7, 174189.3.0.CO;2-U>CrossRefGoogle Scholar
Gilbert, P, Allan, S (1994). Assertiveness, submissive behaviour and social comparison. British Journal of Clinical Psychology 33, 295306.CrossRefGoogle ScholarPubMed
Gilbert, P, Allan, S (1998). The role of defeat and entrapment (arrested flight) in depression: an exploration of an evolutionary view. Psychological Medicine 28, 585598.CrossRefGoogle ScholarPubMed
Gilbert, P, Price, JS, Allan, S (1995). Social comparison, social attractiveness and evolution. How might they be related? New Ideas in Psychology 13, 149165.CrossRefGoogle Scholar
Gilbert, P, Trower, P (1990). The evolution and manifestation of social anxiety. In Shyness and Embarrassment: Perspectives from Social Psychology (ed. Crozier, W. R.), pp. 144177. Cambridge University Press: Cambridge.CrossRefGoogle Scholar
Goffman, E (1963). Stigma: Notes of the Management of Spoiled Identity. Penguin: London.Google Scholar
Goss, K, Gilbert, P, Allan, S (1994). An exploration of shame measures. The Other as Shamer Scale. Personality and Individual Differences 17, 713771.CrossRefGoogle Scholar
Gross, CA, Hansenn, NE (2000). Clarifying the experience of shame: the role of attachment style, gender and investment in relatedness. Personality and Individual Differences 28, 897907.CrossRefGoogle Scholar
Gumley, A, O'Grady, M, Power, K, Schwannauer, M (2004). Negative beliefs about self and illness: a comparison of individuals with psychosis with and without comorbid social anxiety disorder. Australian and New Zealand Journal of Psychiatry 38, 960964.CrossRefGoogle ScholarPubMed
Halperin, S, Nathan, P, Drummond, P, Castle, D (2000). A cognitive-behavioural, group-based intervention for social anxiety in schizophrenia. Australian and New Zealand Journal of Psychiatry 34, 809813.CrossRefGoogle Scholar
Hayward, P, Bright, J (1997). Stigma and mental illness: a review and critique. Journal of Mental Health 6, 345354.CrossRefGoogle Scholar
Hayward, C, Wilson, KA, Lagle, K, Kramer, HC, Killen, JD, Taylor, CB (2008). The developmental psychopathology of social anxiety in adolescents. Depression and Anxiety 25, 200206.CrossRefGoogle ScholarPubMed
Iqbal, Z, Birchwood, M, Chadwick, P, Trower, P (2000). Cognitive approach to depression and suicidal thinking: II. Testing the validity of a social ranking model. British Journal of Psychiatry 177, 522528.CrossRefGoogle Scholar
Janseen, I, Krabbendam, L, Bak, M, Hanssen, M, Vollebergh, W, de Graaf, R, van Os, J (2004). Childhood abuse as a risk factor for psychotic experiences. Acta Psychiatrica Scandinavica 109, 3845.CrossRefGoogle Scholar
Johnstone, CE, Ebmeier, PK, Miller, P, Owens, GCD, Lawrie, MS (2005). Predicting schizophrenia: findings from the Edinburgh High-Risk study. British Journal of Psychiatry 186, 1825.CrossRefGoogle ScholarPubMed
Kaufman, G (1993). The Psychology of Shame. Routledge: London.Google Scholar
Kay, SR, Fiszbein, A, Opler, LA (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin 13, 261276.CrossRefGoogle Scholar
Kessler, R, Stang, P, Wittchen, H, Stein, M, Walters, E (1999). Lifetime comorbidity between social phobia and mood disorders in the US National Comorbidity Survey. Psychological Medicine 29, 555567.CrossRefGoogle ScholarPubMed
Kim, EY (2005). The effect of decreased safety behaviours on anxiety and negative thoughts in social phobics. Journal of Anxiety Disorders 19, 6986.CrossRefGoogle ScholarPubMed
Kingsep, P, Nathan, P, Castle, D (2003). Cognitive behavioural group treatment for social anxiety in schizophrenia. Schizophrenia Research 63, 121129.CrossRefGoogle Scholar
Lewis, M (1998). Shame and stigma. In Shame: Interpersonal Behaviour, Psychopathology and Culture (ed. Gilbert, P. and Andrews, B.), pp. 126140. Oxford University Press: New York.Google Scholar
Lutwark, N, Ferrari, JR (1997). Shame-related social anxiety: replicating a link with various social interaction measures. Anxiety, Stress and Coping 10, 335340.CrossRefGoogle Scholar
Mattick, RP, Clarke, JC (1998). Development and validation of measures of social phobia and scrutiny fear and social interaction anxiety. Behavioural Research and Therapy 36, 455470.CrossRefGoogle ScholarPubMed
McManus, F, Sacadura, C, Clark, DM (2008). Why social anxiety persists: an experimental investigation of the role of safety behaviors as a maintaining factor. Journal of Behavior Therapy and Experimental Psychiatry 39, 147161.CrossRefGoogle ScholarPubMed
Michail, M, Birchwood, M (2009). Social anxiety disorder in first-episode psychosis: incidence, phenomenology and relationship with paranoia. British Journal of Psychiatry 195, 234241.CrossRefGoogle ScholarPubMed
Mills, RSL (2005). Taking stock of the developmental literature on shame. Developmental Review 25, 2663.CrossRefGoogle Scholar
NICE (2009). Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. Clinical Guideline CG82. National Institute for Health and Clinical Excellence.Google Scholar
Ollendick, TH, Hirshfeld-Becker, DR (2002). The developmental psychopathology of social anxiety disorder. Biological Psychiatry 51, 4458.CrossRefGoogle ScholarPubMed
Owens, C, Miller, P, Lawrie, S, Johnstone, EC (2005). Pathogenesis of schizophrenia: a psychopathological perspective. British Journal of Psychiatry 186, 386393.CrossRefGoogle ScholarPubMed
Pallanti, S, Quercioli, L, Hollander, E (2004). Social anxiety in outpatients with schizophrenia: a relevant cause of disability. American Journal of Psychology 161, 5358.CrossRefGoogle ScholarPubMed
Peters, L (2000). Discriminant validity of the Social Phobia and Anxiety Inventory (SPAI), the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS). Behavioural Research and Therapy 38, 943950.CrossRefGoogle Scholar
Read, J, Agar, K, Argyle, N (2003). Sexual and physical assault during childhood and adulthood as predictors of hallucinations, delusions and thought disorder. Psychology and Psychotherapy 76, 122.CrossRefGoogle ScholarPubMed
Read, J, Argyle, N (1999). Hallucinations and thought disorder among adult psychiatric inpatients with a history of child abuse. Psychiatric Services 50, 14671472.CrossRefGoogle ScholarPubMed
Rooke, O, Birchwood, M (1998). Loss, humiliation and entrapment as appraisals of schizophrenic illness: a prospective study of depressed and non-depressed patients. British Journal of Clinical Psychology 37, 259268.CrossRefGoogle Scholar
Salkovskis, PM (1991). The importance of behaviour in the maintenance of anxiety and panic: a cognitive account. Behavioural Psychotherapy 19, 619.CrossRefGoogle Scholar
Schofield, CA, Coles, ME, Gibb, BE (2009). Retrospective reports of behavioural inhibition and young adults' current symptoms of social anxiety, depression and anxious arousal. Journal of Anxiety Disorders 23, 884890.CrossRefGoogle Scholar
Shorter, E, Tyrer, P (2003). Separation of anxiety and depressive disorders: blind alley in psychopharmacology and classification of disease. British Medical Journal 327, 158160.CrossRefGoogle ScholarPubMed
Stein, M, Fuetsch, M, Muller, N, Hofler, M, Lieb, R, Wittchen, H (2001). Social anxiety and the risk of depression. Archives of General Psychiatry 58, 251256.CrossRefGoogle Scholar
Stein, M, Tancer, M, Gelernter, C, Vittone, B, Uhde, T (1990). Major depression in patients with social phobia. American Journal of Psychiatry 147, 637663.Google ScholarPubMed
Swan, S, Andrews, B (2003). The relationship between eating disorders and disclosure in treatment. British Journal of Clinical Psychology 42, 367378.CrossRefGoogle ScholarPubMed
Tarrier, N (2005). Co-morbidity and associated clinical problems in schizophrenia: their nature and implications for comprehensive cognitive-behavioural treatment. Behaviour Change 22, 125142.CrossRefGoogle Scholar
Taylor, PJ, Gooding, P, Wood, AM, Johnson, J, Pratt, D, Tarrier, N (2010). Defeat and entrapment in schizophrenia: the relationship between suicidal ideation and positive psychotic symptoms. Psychiatry Research 178, 244248.CrossRefGoogle ScholarPubMed
Taylor, PJ, Gooding, P, Wood, AM, Tarrier, N (2011). The role of defeat and entrapment in depression, anxiety and suicide. Psychological Bulletin 137, 391420.CrossRefGoogle ScholarPubMed
Taylor, PJ, Wood, AM, Gooding, P, Johnson, J, Tarrier, N (2009). Are defeat and entrapment best defined as a single construct? Personality and Individual Differences 47, 795797.CrossRefGoogle Scholar
Thompson, A, Kent, G (2001). Adjusting to disfigurement: processes involved in dealing with being visibly different. Clinical Psychology Review 21, 663682.CrossRefGoogle ScholarPubMed
Thompson, KJ, Coovert, MD, Stormer, SM (1999). Body image, social comparison and eating disturbance: a covariance structure modeling investigation. International Journal of Eating Disorders 26, 4351.3.0.CO;2-R>CrossRefGoogle ScholarPubMed
Thornicroft, G, Brohan, E, Rose, D, Sartorius, N, Leese, M (2009). Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. Lancet 373, 408415.CrossRefGoogle ScholarPubMed
Tyrer, P (2001). The case for cothymia: mixed anxiety and depression as a single diagnosis. British Journal of Psychiatry 179, 191193.CrossRefGoogle ScholarPubMed
Wells, A, Clark, DM, Salkovskis, P, Ludgate, J, Hackmann, A, Gelder, MG (1995). Social phobia: the role of in-situation safety behaviors in maintaining anxiety and negative beliefs. Behaviour Therapy 26, 153161.CrossRefGoogle Scholar
WHO (1993). The ICD-10 Classification of Mental and Behavioural Disorders. World Health Organization: Geneva.Google Scholar
WHO (1999). Schedules for Clinical Assessment in Neuropsychiatry, Version 2.1. World Health Organization: Geneva.Google Scholar
Wittchen, H-U, Stein, M, Kessler, R (1999). Social fears and social phobia in a community sample of adolescents and young adults: prevalence, risk factors and comorbidity. Psychological Medicine 29, 309323.CrossRefGoogle Scholar