The purpose of the study was to examine the relationship between social anxiety and social functioning in first episode psychosis, and to determine whether those with psychosis have any maladaptive or irrational beliefs regarding social situations. A sample of 60 first episode patients (41 males, 19 females) participated in the study. The presence of social phobia was determined using the Structured Clinical Interview for DSM-IV (SCID-I). Measures included The Social Phobia and Anxiety Inventory (SPAI), the Social Functioning Scale (SFS), the Quality of Life Scale (QLS) and the Social Interaction Self-Statement Test. Thirty-two percent of the sample met SCID-I criteria for social phobia and approximately 60% of participants were experiencing elevated levels of social anxiety according to the SPAI (M=69.57, S.D.=27.42). Results were that negative symptoms and negative self-statements, but not social anxiety, were significant predictors of social functioning. This has implications for addressing these negative cognitions in early psychosis.
Since the onset of schizophrenia typically occurs in young adults, disability can last for a lifetime and creates tremendous suffering for the affected individual and their family. One year after treatment for a first episode, 75% to 90% achieve remission from positive symptoms (Addington et al., 2003a and Lieberman et al., 1993). However, functional (e.g., social, vocational, interpersonal) recovery remains a major challenge since symptom improvement is not always matched with functional improvement (Addington et al., 2003b). A recent model of the contributing factors to poor outcome in first episode psychosis demonstrated a role for such factors as negative symptoms, premorbid functioning, and cognitive functioning (Addington, 2000, Addington and Addington, 1999 and Addington and Addington, 2004).
One potential contributing factor to poor social functioning is social anxiety (Pallanti et al., 2004 and Wetherell et al., 2003). Social anxiety has been identified in schizophrenia as a comorbid diagnosis in 7–40% of individuals (Blanchard et al., 1998, Cassano et al., 1998, Cosoff and Hafner, 1998, Kendler et al., 1996 and Strakowski et al., 1993). This wide range most likely reflects the different settings (inpatient vs. outpatient) and different stages of illness. Yet, despite the fact that many individuals at various stages of psychotic illness have comorbid social anxiety, it has been given little attention in the literature (Heinssen and Glass, 1990).
In one of the few studies addressing social anxiety in schizophrenia, Penn et al. (1994) investigated the relationship between social anxiety and positive and negative symptoms of schizophrenia in an inpatient sample with a chronic course of illness. These patients experienced an elevated level of social anxiety; negative symptoms were related to behavioral ratings of social anxiety (e.g., slower and less fluent speech) and positive symptoms were related to self-report measures of anxiety. Cassano et al. (1998) reported that social anxiety disorder compared to other comorbid disorders showed the greatest association with psychotic symptoms. Contrary to these findings Pallanti et al. (2004) reported no association between social anxiety and positive and negative symptoms. Finally, Blanchard et al. (1998) found that poor social functioning in individuals with schizophrenia was positively correlated with a measure of social anxiety.
The mechanisms underlying social anxiety are not clear. Perhaps social anxiety is intrinsic to the psychosis diathesis. Alternatively, it may be developmental and related to the early social isolation and withdrawal that occurs long before the onset of psychotic symptoms (Hafner et al., 1999). Thirdly, it could be a reaction to the psychosis in terms of a loss of social contacts or a coping strategy in response to perceived threats or other symptoms such as positive, negative or depression.
A review of the general literature on social anxiety revealed that one of the most studied variables was the patterns of maladaptive or irrational self-statements (Glass and Furlong, 1990 and Hofmann, 2000). Individuals with anxiety disorders tend to overestimate the probability of a negative outcome and underestimate their ability to cope (Beck et al., 1985). For those with social anxiety, these distorted thoughts might focus on the anticipation of rejection, disapproval, or embarrassment. Such negative internal dialogue has been implicated as a maintaining factor of social anxiety by facilitating negative emotional reactions and inhibiting performance in social situations (Dodge et al., 1988 and Spurr and Stopa, 2002). There is, however, very limited information on the influence of non-psychotic dysfunctional beliefs on the social functioning of those with schizophrenia (Heinssen and Glass, 1990). Whether those with schizophrenia have similar maladaptive or irrational beliefs regarding social evaluative situations and the possible relationship between these cognitions, social anxiety and social functioning is yet to be explored.
The purpose of this preliminary study was to examine the relationship between social anxiety and social functioning in a sample who had recently experienced their first episode of psychosis, and secondly to determine whether those with psychosis have any maladaptive or irrational beliefs regarding social situations. We predicted that poor social functioning would be associated with social anxiety and with increased negative self-statements and decreased positive self-statements.
