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Social anxiety disorder in first-episode psychosis: incidence, phenomenology and relationship with paranoia

  • Maria Michail (a1) and Max Birchwood (a1)

Abstract

Background

Social anxiety disorder constitutes a significant problem for people with psychosis. It is unclear whether this is a by-product of persecutory thinking.

Aims

To compare the phenomenology of social anxiety disorder in first-episode psychosis with that in a group without psychosis. The relationship between social anxiety and psychosis symptoms was investigated.

Method

A sample of people with first-episode psychosis (FEP group) was compared with a sample with social anxiety disorder without psychosis (SaD group).

Results

Of the individuals in the FEP group (n = 80) 25% were diagnosed with an ICD–10 social anxiety disorder (FEP/SaD group); a further 11.6% reported severe difficulties in social encounters. The FEP/SaD and SaD groups reported comparable levels of social anxiety, autonomic symptoms, avoidance and depression. Social anxiety in psychosis was not related to the positive symptoms of the Positive and Negative Syndrome Scale (PANSS) including suspiciousness/persecution. However, a significantly greater percentage of socially anxious v. non-socially anxious individuals with psychosis expressed perceived threat from persecutors, although this did not affect the severity of social anxiety within the FEP/SaD group. The majority of those in the FEP/SaD group did not have concurrent persecutory delusions.

Conclusions

Social anxiety is a significant comorbidity in first-episode psychosis. It is not simply an epiphenomenon of psychotic symptoms and clinical paranoia, and it has more than one causal pathway. For a subgroup of socially anxious people with psychosis, anticipated harm is present and the processes that underlie its relationship with social anxiety warrant further investigation.

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Copyright

Corresponding author

Maria Michail, School of Psychology, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. Email: m.michail@bham.ac.uk

Footnotes

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Declaration of interest

None.

Footnotes

References

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Social anxiety disorder in first-episode psychosis: incidence, phenomenology and relationship with paranoia

  • Maria Michail (a1) and Max Birchwood (a1)

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Social anxiety disorder in first-episode psychosis: incidence, phenomenology and relationship with paranoia

  • Maria Michail (a1) and Max Birchwood (a1)
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eLetters

Comorbid Social Anxiety in Psychosis �V Or Could it be Residual Ideas of Reference?

Gloria HY Wong, PhD candidate
23 November 2009

Dear Editor,

We read with interest Michail and Birchwood's work on social anxiety disorder in psychosis.

Comorbidity is an important area of work in psychosis. Apart from theclinical implications, it provides clues to the pathological mechanisms underpinning psychosis. This may particularly be the case for social anxiety, which has been noted as a candidate endophenotype for psychosis.[1]

As such, it is all the more important that we get a true picture of its prevalence and relationship with psychosis. Taking into account the 13.3% lifetime prevalence of social anxiety disorder in the normal population,[2] current data do seem to suggest an excess in psychosis, although a wide range of prevalence between 17%[3] and 36.3%[4] in outpatients have been reported. Results to-date have also been confusing about the relationship between social anxiety and schizophrenic symptoms, with studies pointing to all kinds of directions as to the association with positive symptoms, negative symptoms, or both, or neither.

Should these bewildering data be telling us anything at all, it is that there may be something elusive in the way social anxiety presents itself in psychosis that hinders reliable capturing of it. Insightful researchers such as Michail et al have already started to suspect a possible overlap with paranoia. While their study did not find any conclusive relationship between social anxiety and persecutory delusions, we propose that the other component within the paranoia construct, namely ideas of reference (IOR), may be the real target that has been overlooked in previous studies.

Social anxiety and IOR are close to each other conceptually and in their presentations. Both are prodromal signs and schizotypal features, and may manifest as increased self-consciousness, fear and avoidance in certain social situations, with the subjects being aware of the excessive nature of such feelings. More subtle differences between the two may be noticed with more careful questioning (eg, IOR seldom involves anticipation anxiety), it is doubted whether existing scales or diagnosticinstruments have enough sensitivity to tell them apart. Our group has someinitial data that suggest many items on standard social anxiety assessments load heavily on IOR (manuscript in preparation).

This immediately raises an important question: to what extent is the 'comorbid social anxiety' phenomenon contaminated by residual IOR (or viceversa)? We know that IOR is common and can be found in up to 70% of patients,[5] and more importantly, it is a warning signal for impending relapse. The suggested management for comorbid social anxiety (eg, selective serotonin reuptake inhibitors, neuroleptics dose reduction or cognitive behavioural therapy) may be ineffective if not harmful if residual IOR is at its root.

At the moment, the very first thing we can do would be to develop psychopathologically refined, 'clean' tools to measure social anxiety in schizophrenia. This has been done for depression with the Calgary Depression Scale for Schizophrenia (CDSS), which excludes negative symptoms and antipsychotic side effects as confounders. It is only after the potential contamination by IOR is safely ruled out can we start to investigate with confidence comorbid social anxiety and its relationship with psychosis.

References:1. Johnstone CE, Ebmeier KP, Miller P, Owens DGC, Lawrie SM. Predicting schizophrenia: findings from the Edinburgh High-Risk Study. Br J Psychiatry 2005; 186: 18¡V25.2. Lang AJ, Stein MB. Social phobia: Prevalence and diagnostic threshold. J Clin Psychiatry 2001;62(suppl 1):5-10.3. Braga RJ, Mendlowicz MV, Marrocos RP, Figueira IL. Anxiety disorders inoutpatients with schizophrenia: Prevalence and impact on the subjective quality of life. J Psychiatr Res 2005;39:409-414.4. Pallanti S, Quercioli L, Hollander E. Social anxiety in outpatients with schizophrenia: a relevant cause of disability. Am J Psychiatry 2004;161:53-58.5. World Health Organization. Schizophrenia: A Multinational Study. World Health Organization, Geneva; 1975.

Declaration of interest: none.
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Conflict of interest: None Declared

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