Chapter 7

Social anxiety disorder and schizophrenia

The importance of recognizing social anxiety disorder comorbidity in schizophrenia rests largely in the fact that once recognized, it can be effectively treated and consequently improve the social integration and overall life enjoyment of the individual. A common trap is to assume that social withdrawal in someone with schizophrenia is a consequence of negative symptoms of schizophrenia: that might be the case, but it also might well be that the individual is experiencing anxiety about socializing. The tendency to interpret the behaviours of people as consequent upon their diagnostic label is what Thomas Scheff (1974) called ‘labelling theory’. It does people a dis-service and results in specific problems not being adequately addressed (see also Chapter 3). Thus, this chapter explores the rates of social anxiety disorder in people with schizophrenia; provides clinical tips as to how to delineate social anxiety from psychotic symptoms; addresses other important comorbidities; and outlines a treatment approach to managing social anxiety symptoms in people with schizophrenia.

How common is social anxiety disorder in people with schizophrenia?

The prevalence of social anxiety disorder in people with schizophrenia has been the subject of a recent systematic review and meta-analysis (McEnery et al. 2019). The review encompassed 92,522 people from 25 studies conducted across 13 countries. The pooled prevalence rate for social anxiety disorder was 21% (16–26%). Rates were overall higher in outpatient compared to inpatient samples: 25% (19–31%) in the former and 9% (7–12%) in the latter.

Perhaps most important in the evaluation of social anxiety disorder in people with schizophrenia is to ensure the correct clinical questions are asked, and not pre-judging behaviours as ‘due to’ the schizophrenia itself. As outlined above, negative symptoms in particular can result in social withdrawal; and positive symptoms can cause the individual substantial distress and lead them to avoid social situations in which they feel threatened or at risk in some way. As detailed in Chapter 10, depression is common amongst people with schizophrenia and is also a contributor to social withdrawal.

Thus, the key differentiating questions that need to be asked are those that interrogate the core behaviours and cognitions associated with social anxiety disorder, notably fear of negative evaluation by others and avoidance behaviours. Enquiry should be made about specific cognitions in social situations as well as any autonomic symptoms. It can be useful to ask the individual to think about the last time they were in a social setting and what they felt and thought at the time. Exploring the cognitions can be instructive in differentiating psychotic beliefs (e.g. being persecuted or spied upon, or having referential ideation) from fear of embarrassment in social anxiety disorder. Anticipatory anxiety prior to social engagements is very common in people with social anxiety disorder. Unlike with negative symptoms, the person desires to socialize but feels too anxious; people with predominant negative symptoms simply don’t have the wherewithal to socialize and it is not really on their agenda. People with more prominent positive symptoms will often have a more specific delusional set of beliefs that lead them to avoid socializing. Additionally, it is generally the case that social anxiety concerns are seen by the individual as excessive, whereas delusional beliefs are not amenable to question.

A number of different assessment schedules have been used in studies of social anxiety in schizophrenia. There is no absolute ‘gold standard’ scale in this regard, but the Liebowitz Social Anxiety Scale (LSAS) (Liebowitz 1987) has been widely used and the domains covered seem readily applicable in people with schizophrenia in whom social anxiety disorder is suspected (see Box 7.1). A cut-off score of 29/30 has been applied in schizophrenia samples (Lowengrub et al. 2015).

Related posts:

Generalized anxiety and panic disorder in schizophrenia Personality disorders and schizophrenia Post-traumatic stress disorder and schizophrenia Schizophrenia and obsessive compulsive disorder Understanding and assessing substance use in schizophrenia Why are psychiatric comorbidities so common in schizophrenia and why are they so often missed in clinical practice?

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