Chapter 7 Social Anxiety Disorder in Psychosis : A Critical Review

Eugene Bleuler was one of the first to emphasize the importance of affect and its pro‐ nounced impact upon the course and outcome of psychosis. The famous “Krapelian dichtoco‐ my” which supported the clear distinction between mood and psychotic illnesses on the basis of etiological origins, symptomatology, course and outcome was first challenged by Bleuler. Bleuler recognized the disorders of affect as one of the four primary symptoms (blunted 'Affect', loosening of 'Associations', 'Ambivalence', and 'Autism') of schizophrenia, as opposed to delusions and hallucinations which were perceived as secondary. Bleuler further postulated the incongruity between emotions and thought content in people with schizo‐ phrenia as well as their diminished or complete lack of emotional responsiveness. Bleuler’s recognition of the importance of affective disturbances in schizophrenia has influenced cur‐ rent diagnostic definitions and criteria of schizophrenia.


Introduction
Eugene Bleuler was one of the first to emphasize the importance of affect and its pronounced impact upon the course and outcome of psychosis. The famous "Krapelian dichtocomy" which supported the clear distinction between mood and psychotic illnesses on the basis of etiological origins, symptomatology, course and outcome was first challenged by Bleuler. Bleuler recognized the disorders of affect as one of the four primary symptoms (blunted 'Affect', loosening of 'Associations', 'Ambivalence', and 'Autism') of schizophrenia, as opposed to delusions and hallucinations which were perceived as secondary. Bleuler further postulated the incongruity between emotions and thought content in people with schizophrenia as well as their diminished or complete lack of emotional responsiveness. Bleuler's recognition of the importance of affective disturbances in schizophrenia has influenced current diagnostic definitions and criteria of schizophrenia.
The sharp distinction between affect and psychosis which has dominated both research and clinical practice during the nineteenth and twentieth century has gradually been abandoned. New evidence from epidemiological, familial and molecular genetic studies (Cardno et al, 2005; have come to light demonstrating the endemic nature of affective disturbances in psychosis. In a twin study by Cardno et al (2002), the authors identified significant overlap in risk factors between the schizophrenic, schizoaffective and manic syndromes. Specifically, considerable genetic correlations were reported between the schizophrenic and manic syndromes. This is in accordance with a review of genetic linkage studies of schizophrenia and affective disorders (Wildenauer et al, 1999) which supports the genetic overlap of the two syndromes. Furthermore, factor analytic studies of psychosis symptoms consistently point to a depression dimension in non-affective psychosis (Murray et al, 2005). Depression and social anxiety are each observed throughout the course (Koreen et al, 1993), including the prodromal phase (Hafner et al, 1999;Owens et al, 2005) and following symptomatic recovery. Post psychotic depression (PPD) has been reported in 30-50% of individuals (McGlashan et al, 1976;Birchwood et al, 2000a) and social anxiety disorder (SaD) has been observed in up to one in three (Davidson et al, 1993;Cassano et al, 1999;Goodwin et al, 2003;Pallanti et al, 2004).

Definition
According to the DSM-IV (APA, 1994), social anxiety disorder (social phobia) is defined as "a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing". People with social anxiety desire to make a favourable impression during social encounters but at the same time doubt their ability to do so; they fear that they will be scrutinized and negatively evaluated due to perceived failed social performance. These fears lead people with social anxiety to avoid all or some social situations and in extreme cases this could lead to complete social isolation (Clark & Wells, 2005). Exposure to the feared situation is almost always accompanied by physical symptoms, for example, sweating, trembling, heart racing, which could develop (although not necessarily) to panic attacks.
Evidence regarding the distinction of social phobia into two subtypes, the non-generalized and generalized social phobia, is ambiguous; although the DSM-IV does acknowledge the presence of the latter. This encompasses a wider range of fears linked to interaction situations and therefore is not restricted to particular environmental circumstances (i.e. it is "freefloating"). It may include talking to others, asking questions, meeting new people, manifest in fear and avoidance of everyday situations (Wittchen et al, 1999). These kinds of social fears have been exclusively reported in approximately two-third of people with lifetime social phobia indicating that the generalized subtype might be more prevalent compared to the non-generalized one (Kessler et al, 1998). This, sometimes also called "specific" or "discrete", is mainly characterized by performance-type fears, the most common being that of speaking in public or performing in front of an audience (Schneier et al, 1992;Stein et al, 1996). It seems therefore that the generalized subtype reflects a more pervasive and debilitating form of the illness which is supported by evidence showing higher rates of comorbidity with mood and other anxiety disorders (Wittchen et al, 1999) and lower recovery rates, compared to the non-generalized, specific subtype (Kessler et al, 1998).

Epidemiology and course
One of the largest epidemiological investigations carried out in the United States, the National Comorbidity Survey (Kessler et al, 1994), has reported prevalence estimates of 12month and lifetime social anxiety disorder as 7.1% and 12.1%, respectively. The lifetime prevalence of social anxiety in other western countries seems to range between 3.1% to 15.6 % (Favarelli et al, 2000;Furmark et al, 1999). The variation in prevalence rates among differ-ent epidemiological studies could be attributed to the application of different diagnostic criteria and instruments for the identification and assessment of social anxiety disorder.
Studies investigating the course of social anxiety have established the long-term morbidity of the illness (Chartiers et al, 1998;Yonkers et al, 2001). Social anxiety develops at an early age, usually during childhood or adolescence and once established, follows a stable, chronic course if treatment is not initiated (Chartiers et al, 1998;Yonkers et al, 2001). Recent findings show that social anxiety is also very prevalent in later life (Cairney et al, 2007). Findings regarding the sociodemographic characteristics of social anxiety disorder support that this is more prominent among the female population (Wittchen et al, 1999;Schneier et al, 1992;Davidson et al, 1993;Magee et al, 1996) although there have been studies (Stein et al, 2000) which have failed to confirm such gender differences. Moreover, higher incident rates have been consistently observed among unmarried individuals usually coming from a lower socioeconomic background, with poorer educational attainment and higher unemployment rates (Schneier et al, 1992;Davidson et al, 1993;Magee et al, 1996). The average duration of illness is approximately 29 years (Chartier et al, 1991;Keller et al, 2003) and the likelihood of a full remission or recovery is significantly lower compared to that of other anxiety disorder (Keller et al, 2003). In an eight year longitudinal study of 163 patients with social phobia, Yonkers et al (2001) found that only 38% and 32% of female and men respectively experienced a complete remission indicating the unremitting and persisting nature of the disorder. Additionally, such lower rates of recovery were found to be associated, particularly in women, with a history of suicide attempts, the presence of co-morbid disorders, the most prominent that of agoraphobia, avoidant personality disorder and alcohol abuse, and also with poor baseline functioning (Yonkers et al, 2001;Keller et al, 2003).
The highly impairing nature of the disorder is reflected in the marked disabilities affecting the majority of life domains. Deterioration of social functioning manifest in avoidance and withdrawal from social interactions, decrease in work productivity and interpersonal relations produce a significant decrease in quality of life (Wittchen et al, 2000). Despite the highly impairing nature of social anxiety only up to a half of patients seek and receive treatment during the course of the illness (Wittchen et al, 2000;Wang et al, 2005) and this is primarily in the form of pharmacological interventions. In a recent study by Michail & Birchwood (2009), social anxiety was diagnosed in 25% of people with first-episode psychosis (FEP). In addition to the 25% with an ICD-10 diagnosis of SaD, there was also a further 11.6 % who reported clear social interaction difficulties and/or signs of avoidance not sufficient though to reach formal diagnostic criteria. Social anxiety is usually accompanied by high levels of depression (Michail & Birchwood, 2009;Birchwood et al, 2007) and leads to significant social disability (Voges & Addington, 2005), lower quality of life (Pallanti et al, 2004) and poorer prognosis as it raises the possibility of an early relapse (Gumley, 2007).

Social anxiety in psychosis
Despite the high prevalence and its debilitating nature, social anxiety has not been extensively investigated and the processes that underlie its emergence in psychosis remain unclear. The relationship between social anxiety and positive psychotic symptoms, particularly paranoia, is yet to be clarified. Particularly, it is not clear whether the development and maintenance of social anxiety in psychosis is simply driven by paranoia and persecutory beliefs.

Aim
This review aims to examine the prevalence and phenomenology of social anxiety disorder in psychosis and to investigate its relationship to positive psychotic symptoms and particularly paranoia and persecutory ideation.

Methods
A systematic search strategy was conducted and consisted of electronic searches of the following databases: PsycINFO, PubMed and Science Direct using the terms "anxiety AND psychosis", "anxiety AND schizophrenia", "social anxiety AND psychosis", "social anxiety AND schizophrenia", "social anxiety AND paranoia". For inclusion, studies had to meet the following criteria:

Results
Thirteen studies fulfilled the inclusion criteria of this review (

Prevalence and phenomenology
Social anxiety appears to be among the most prevalent anxiety disorders in psychosis with prevalence rates ranging between 17% to 36%. In samples with first-episode psychosis, prevalence rates range between 25%-32% based on formal diagnostic criteria (DSM-IV or ICD-10). In a recent study by Michail & Birchwood (2009), social anxiety was diagnosed in 25% of people with first-episode psychosis. However, in addition to the 25% with formal SaD, there was also a further 11.6 % who reported clear social interaction difficulties and/or signs of avoidance not sufficient though to reach formal diagnostic criteria (ICD-10). These "borderline" cases, though not satisfying formal criteria, were nevertheless reporting interpersonal difficulties that may well warrant intervention at a clinical level. In studies with inpatient samples, the prevalence of social anxiety ranged between 11%-43% among those with schizophrenia, schizoaffective or bipolar disorder and in studies with outpatients with schizophrenia 17%-36% of them were diagnosed with social anxiety disorder or social phobia.
The highly impairing nature of social anxiety in psychosis has been consistently reported in literature. In a study of outpatients with schizophrenia, Pallanti et al (2004) reported that those diagnosed with comorbid social anxiety disorder had a higher rate of suicide attempts, lower social adjustment and overall quality of life compared to those without social anxiety.  Table 1. Studies investigating social anxiety in people with psychosis

The relationship between social anxiety and positive psychotic symptoms
The relationship between social anxiety and positive psychotic symptoms, particularly paranoia, has attracted considerable attention; however, the processes that underlie this relationship are yet to be clarified. When investigating further the inter-relationship between social anxiety and persecutory threat within this sub-group no link between level of social anxiety and persecutory threat was revealed. This is of particular interest as it suggests that even among those individuals with psychosis and social anxiety, social anxiety is not necessarily contaminated by ongoing persecutory beliefs.

Discussion
Social anxiety is among the most commonly reported and disabling of the co-morbidities in people with psychosis. It is characterized by a highly impairing nature which is evident by its impact on social functioning and social disability. Despite its elevated prevalence and severity in psychosis, social anxiety remains under-recognized and under-treated. One of the reasons for this could be that the exact relationship between social anxiety and psychotic symptoms is yet to be determined and the available empirical findings are inconclusive. Although theoretical models and empirical evidence consistently point towards a link between general anxiety and positive symptoms of psychosis, predominantly paranoia and persecutory delusions (Freeman et al, 2001), social anxiety appears to have a distinct quality and its relationship to paranoia and persecutory thinking is not straightforward.
Three pathways have been proposed for the understanding of the ontogeny of social anxiety in psychosis (Michail & Birchwood, 2009;2011)  c. social anxiety may develop for some people as a consequence of paranoid beliefs The third pathway suggests that for a sub-sample of people with psychosis, symptoms of social anxiety and avoidance may develop as a direct consequence of their paranoid ideation. Persecutory beliefs and perceived threat regarding other people's intentions to cause harm can lead to elevated social anxiety and apprehension during social encounters. As a way of protecting or "saving" oneself from such social threats, individuals may engage in safety behaviours by isolating themselves from the social world and actively avoiding all social interactions.
Following the findings of a thorough investigation into the psychological processes that underlie the emergence and maintenance of social anxiety in psychosis (Michail & Birchwood, 2012), a fourth potential pathway is provided here: d. social anxiety as a response to the shame and social stigma attached to a diagnosis of mental illness In a recent study by Michail & Birchwood (2012), the authors examined the relationship between shame cognitions, shame proneness and perceived loss of social status in people with first-episode psychosis and social anxiety disorder. Findings showed that psychotic individuals with social anxiety expressed high levels of shame proneness which was accompanied by perceived loss of social status. They also reported significantly greater negative appraisals arising from a stigmatizing illness, including shame and fear of rejection, compared to their counterparts without social anxiety. These findings were consistent with those of earlier studies (Birchwood et al, 2007, Gumley et al, 2004 reporting that dysfunctional appraisals held by socially anxious psychotic people were characterized by shamefulness, humiliation and perceived rejection by others. The authors proposed that individuals with psychosis are characterized by an established vulnerability to shame linked to early developmental anomalies. This shame proneness is likely to be catalysed by the stigma attached to the diagnosis of mental illness and there is evidence to suggest that psychosis is indeed considered as a highly stigmatized condition (Thornicroft et al, 2009). As with any type of social stigma, this can affect the social identity of the individual by suggesting qualities that deviate from the norm and are socially discrediting (Goffman, 1963). Individuals with psychosis are aware of the social stereotypes surrounding mental illness and some may even accept and endorse these (Hayward & Bright, 1997; Angermeyer et al, 2003). This internalization of stigma or self-stigma leads to increased shamefulness -particularly when individuals agree with the stigma and the associated negative responses (Corrigan & Watson, 2002a;2002b)-and fear of the illness being revealed to others due to the consequences of this discovery (e.g. social exclusion, marginalization). Hence, the authors suggested that people with psychosis will attempt to conceal their stigmatized identity to prevent or minimise this threat by promoting behaviours of submissiveness or by avoiding and withdrawing from social interactions.

Clinical implications
There is lack of evidence on the clinical effectiveness and cost effectiveness of psychological interventions for the treatment of affective dysregulation and associated distress in psychosis. Cognitive behaviour therapy (CBT) is recommended for people with psychosis (NICE, 2009); however, its focus and evaluation has primarily revolved around the reduction of psychotic symptoms, and not for comorbid depression and social anxiety. Furthermore, psychological interventions such as CBT for the treatment of affective disorders in non-psychotic populations are proposed for the management of affective dysfunction when this is comorbid in psychosis (Halperin et al, 2000;Kingsep et al, 2003). This could be challenging as such treatments in order to be effective, would need to adapt to the specific nature of symptoms and difficulties experienced by people with psychosis (Tarrier, 2005). The findings of the recent study by Michail & Birchwood (2012) suggest that the "conventional" CBT for social anxiety in psychosis could be considerably enhanced with an additional focus on shame cognitions linked to psychosis and accompanying concealment behaviours which are suggested to form part of the safety behaviour repertoire of socially anxious psychotic individuals. A randomised controlled trial testing the effectiveness of a CBT intervention in targeting shameful cognitions while reducing or eliminating concealment linked behaviours could be effective in psychosis.