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Schizophrenia — an anxiety disorder?

  • Jeremy Hall (a1)


Anxiety and affective symptoms are prominent features of schizophrenia which are often present in the prodromal phase of the illness and preceding psychotic relapses. A number of studies suggest that genetic risk for the disorder may be associated with increased anxiety long before the onset of psychotic symptoms. Targeting anxiety symptoms may represent an important strategy for primary and secondary prevention in schizophrenia.

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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
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Schizophrenia — an anxiety disorder?

  • Jeremy Hall (a1)
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Schizophrenia & Anxiety: Yes, they are relatives not just neighbors

Andrea Bulbena-Cabre, Icahn School of Medicine at Mount Sinai
Antonio Bulbena, Professor of Psychiatry, Universitat Autonoma de Barcelona
24 January 2018

We are thrilled to see that the study of anxiety among psychotic spectrum disorders is gaining recognition. The paper published by Dr. Halls provides a good insight about common grounds between the two disorders and highlights the advantages of studying anxiety among psychotic disorders. One of the problems of studying anxiety is that it is often overshadowed when the diagnosis of schizophrenia is given to a patient. However, anxiety is often underdiagnosed and untreated regardless of the primary diagnosis which represents a significant economic burden. One of the possible hypothesis for this diagnostic delay is the fact that current anxiety nosology is characterized by many subjective cognitive (anticipatory anxiety), behavioral (avoidance behavior) and psychological (worry, fear) aspects of anxiety, but the often-comorbid somatic or physical conditions are neglected.

Our group found that anxiety disorders (ADs) are indeed very common among patients with schizophrenia, with estimated prevalences of 30% [1]. We also found that those with comorbid ADs were more likely to display positive symptoms and greater fears, suggesting that those patients with comorbid anxiety had a specific profile of symptoms [2]. Interestingly, patients with this phenotype suffered from greater joint hypermobility syndrome (JHS), which has been associated to anxiety in clinical and non-clinical populations. Our group initially described this associated in 1988 in a letter to the Lancet and this field has expanded significantly during the past years [3]. This phenotype is rich in somatic and bodily complaints which seems to be mediated by an autonomic nervous system dysfunction, and many of these patients suffer from stress related illnesses such as chronic pain, irritable bowel syndrome or dysautonomia. Other hypothesized underlying mechanisms behind this association include genetic risks, atypical body perception profiles, increased interoception and exteroception and decreased proprioception[4]. Neuroimaging studies showed that joint hypermobility is associated with the expression of anxiety through autonomic hyper-reactivity linked to aberrant engagement of the amygdala and insula [5].

Taking into account that heightened anxiety may be important in both the development of psychosis and psychosis relapses as described by Dr. Hall, it is imperative to ensure a proper anxiety assessment. The JHS can be a helpful marker for identifying the somatic and bodily complaints, and it is particular significant in schizophrenia because it is associated with greater fears and anxiety severity and higher frequency of positive symptoms. Besides, this phenotype may open opportunities for new therapeutic interventions that should be further studied in subsequent studies.


1.Bulbena, A., et al., Joint hypermobility in schizophrenia: a potential marker for co-morbid anxiety. The open psychiatry journal, 2007. 1: p. 31-3.

2.Bulbena, A., et al., Panic/phobic anxiety in schizophrenia: a positive association with joint hypermobility syndrome. Neurology Psychiatry and Brain Research, 2005. 12(2): p. 95-100.

3.Smith, T.O., et al., The relationship between benign joint hypermobility syndrome and psychological distress: a systematic review and meta-analysis. Rheumatology (Oxford), 2014. 53(1): p. 114-22.

4.Bulbena, A., et al., Psychiatric and psychological aspects in the Ehlers-Danlos syndromes. Am J Med Genet C Semin Med Genet, 2017. 175(1): p. 237-245.

5.Eccles, J., et al., Joint hypermobility and autonomic hyperactivity: an autonomic and functional neuroimaging study. The Lancet. 387: p. S40.
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Conflict of interest: None declared

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