Various comorbidities are common in individuals with schizophrenia, including anxiety disorders. It is well established that panic disorder, obsessive-compulsive disorder, and posttraumatic stress disorder are prevalent in this population, and treatment of these comorbid conditions has been linked to improved outcomes.¹

Emerging evidence has begun to elucidate the prevalence and outcomes associated with social anxiety disorder (SAD) in schizophrenia. Findings thus far have demonstrated greater disability, elevated rates of substance abuse, lower quality of life, and a higher risk for suicide in patients with comorbid SAD.^1,2

Prevalence and effect

In a study published by Lowengrub et al in 2015, 38% of a randomly selected sample of adult outpatients with schizophrenia (n=45) or schizoaffective disorder (n=5) was found to have comorbid SAD, as determined by a cutoff score of 29/30 on the total Liebowitz Social Anxiety Scale score.³

The etiology underlying this prevalent comorbidity is unclear. For example, SAD could stem from a fear of the stigma associated with having a mental disorder, or there may be a shared biological mechanism linking the 2 disorders.³ Another possible cause is the use of atypical neuroleptic medications including clozapine and olanzapine, which can precipitate SAD.⁴

The results of the 2015 study further revealed that patients with vs without comorbid SAD had worse scores on the Schizophrenia Quality of Life Scale, whereas scores on the Positive and Negative Syndrome Scale and the Global Assessment of Functioning Scale were similar between groups.³

In addition, the researchers conducted a retrospective chart review and determined that none of the patients with SAD had previously been diagnosed with the disorder. This is likely in part a result of the shared features between SAD and schizophrenia. “The symptom overlap between SAD and schizophrenia may result in missed diagnosis of comorbid SAD when positive symptoms mask SAD or SAD overdiagnosis if negative symptoms are prominent,” they wrote.³ It can be challenging to differentiate symptoms of SAD from some of the positive symptoms of schizophrenia, such as paranoia and ideas of reference, and negative symptoms such as social withdrawal.

Screening and treatment

To screen for SAD in outpatients with schizophrenia, the authors suggest that clinicians should ask whether patients avoid particular social situations or have an intense fear of being embarrassed in front of others. Patients with comorbid SAD “will experience the avoidant behavior as ego-dystonic and therefore qualitatively different from avoidant behavior due to anhedonia or lack of social interest,” the researchers explained.³

In addition, these individuals are “generally motivated to gain control of the anxiety symptoms, whereas avoidant behavior due to negative symptoms is typically accompanied by impaired motivation to change.” Although self-report tools for SAD (including the Mini-Social Phobia Inventory) are available for use in managed care settings, they have not been adequately studied in patients with schizophrenia.

According to the limited evidence pertaining to SAD comorbidity in schizophrenia, the following treatment approaches may be effective:

• Group-based cognitive-behavioral therapy consisting of psychoeducation, exposure stimulation, cognitive restructuring, role-play exercises, and between-session homework assignments was effective in reducing SAD symptoms in patients with schizophrenia.³
• A psychotherapeutic approach called Morita therapy, named for a Japanese psychiatrist, may increase social functioning through its emphasis on an outward-focused life perspective. In a 2008 review, standard treatment combined with Morita therapy was found to improve daily living in patients with schizophrenia compared with standard treatment alone.⁵ This approach warrants further study in this patient group.
• Selective serotonin reuptake inhibitors may be useful in reducing SAD symptoms, but may also cause akathisia.²
• Oxytocin has shown promise for schizophrenia and SAD treatment, although results have been mixed overall.⁶ “Oxytocin reverses emotional recognition deficit and might restore the sense of trust in patients with schizophrenia and has been shown to attenuate (and normalize) fear-related brain activation and reactivity to emotionally negative cues in SAD,” Lowengrub et al noted.³

To learn more about SAD in schizophrenia, Psychiatry Advisor spoke with Marc-André Roy, MD, MSc, FRCP, associate professor in the Department of Psychiatry and Neurosciences at Laval University in Québec, Canada, and coauthor of a recent paper on the topic that was published in the Journal of Psychiatry & Neuroscience.

Psychiatry Advisor: How does SAD affect patients with schizophrenia?

Dr Roy: Social anxiety hampers everyday life in these patients, and in particular, relationships. This is on top of the [other] social challenges that people dealing with schizophrenia experience. However, this is a grossly understudied issue.

Psychiatry Advisor: What are some of the challenges in diagnosing and treating SAD in these patients?

Dr Roy: Most clinicians assume that social relationship deficits are inherent to schizophrenia, which has been proven wrong repeatedly. Hence, social withdrawal, which is a hallmark of SAD, will be typically interpreted as a negative symptom and will be thereafter deemed impossible to address.

We must acknowledge that it is difficult to identify SAD in people dealing with a psychotic disorder.

But it is important to try to circumvent these difficulties, as proper identification of the source of problems such as social withdrawal may lead to life-changing interventions.

Psychiatry Advisor: What are additional clinical implications and remaining research needs in this area?

Dr Roy: Future studies should examine how we can implement, as a routine practice, the assessment of SAD in people dealing with a psychotic disorder, as well as the effect of the various strategies to address this problem. The bottom line is that although there are very simple ways to address seemingly complex problems, it looks as though we are interested only in highly sophisticated technological strategies, whereas existing simple interventions could have a significant effect.

In other words, we already have ready access to very efficient, and relatively simple, interventions, yet we do not have a full grasp on how to use them. The development of high-tech interventions is a promising area, yet the proper application of low-tech interventions is a grossly underused strategy. This is a very important issue to consider if we really want to improve the odds of sustained recovery for people dealing with a psychotic disorder. 

References

1. Pallanti S, Quercioli L, Hollander E. Social anxiety in outpatients with schizophrenia: a relevant cause of disability. Am J Psychiatry. 2004;161(1):53-58.
2. Roy MA, Demers MF, Achim AM. Social anxiety disorder in schizophrenia: a neglected, yet potentially important comorbidity. J Psychiatry Neurosci. 2018;43(4):287-288.
3. Lowengrub KM, Stryjer R, Birger M, Iancu I. Social anxiety disorder comorbid with schizophrenia: the importance of screening for this under recognized and under treated condition. Isr J Psychiatry Relat Sci. 2015;52(1):40-45.
4. Pallanti S, Quercioli L, Pazzagli A. Social anxiety and premorbid personality disorders in paranoid schizophrenic patients treated with clozapine. CNS Spectr. 2000;5(9):29-43.
5. Li C, He Y. Morita therapy for schizophrenia. Schizophr Bull. 2008;34(6):1021-1023.
6. Bradley ER, Woolley JD. Oxytocin effects in schizophrenia: Reconciling mixed findings and moving forward. Neurosci Biobehav Rev. 2017;80:36-56.