Table 2.
Studies Addressing Psychological Maintenance Factors of Social Anxiety in Psychotic Experiences Contexts
| Citation | Design | Sample Characteristic (N) | Measurements 1. Diagnostic Criteria 2. Symptom Scales |
Maintenance Factors | Findings | Quality Criteria Meta | |
|---|---|---|---|---|---|---|---|
| Psychosis | Social anxiety | ||||||
| Michail et al25 | Cross-sectional | Total 135 FEP (60) FEP+SAD (20) SAD (31) NC (24) | 1. ICD-10 2. PANSS | 1. ICD-10 2. SIAS, SPS |
Stigma - PBIQ Shame - OAS Social rank - SCS |
FEP+SAD reported higher levels of PBIQ: entrapment, loss of social goals, poorer illness control and lower perceived social status (F1,79 = 14.5, F1,79 = 12 and F1,79 = 13.1 and F1,79 = 12 respectively) than FEP. Plus, FEP+SAD reported higher level of OAS (F1,135 = 123.1) and lower level of SCS (F1,135 = 49.6) than SAD. All ps < 0.01. | 4**** |
| Gumley et al58 | Cross-sectional | Total 38 SZ (19) SZ+SAD (19) | 1. DSM-IV 2. PANSS | 1. DSM-IV |
Stigma - PBIQ Self-esteem - RSES |
SZ+SAD reported higher levels of PBIQ: self vs illness (F1,36 = 5.0, P < .05); entrapment (F1,36 = 12.7, P < .01); and shame (F1,36 = 10.6, P < .01)) and lower level of RSES (F1,36 = 10.2, P < .01) than SZ. | 5***** |
| Birchwood et al59 | Cross-sectional | Total 79 SZ (56) SZ+SAD (23) | 1. ICD-10 2. PANSS, IS | 2. SIAS, FNE |
Stigma - PBIQ Social rank - SCS Shame - OAS |
SZ+SAD reported less controllable of being psychosis and more entrapping (multivariate F = 15.6, P < .001), and more SCS (F = 27.4, P < .001) compared to SZ. Regarding regression analysis, the PBIQ shame (OR = 1.4, P = .038), PBIQ group fit (OR = 1.3, P = .018) and OAS (OR = 1.1, P = .039) were associated with the presence of SAD, after controlling depression. | 5***** |
| Lysaker et al60 | Prospective | SZ (78) | 1. DSM-IV 2. PANSS | 2. MAQ social anxiety |
Stigma - ISMIS |
Regarding stepwise regression, baseline ISMIS discrimination experience and PANSS negative symptoms significantly predicted MAQ social anxiety at 5 months, after controlling social anxiety at baseline (R2 = 0.45, P < .001). | 5***** |
| Pyle et al61 | Prospective | CAARMS (288) | 1. CAARMS 2. GPTS-PP | 2. SIAS |
Stigma - PBEQ |
Based on hierarchical regression, SIAS at baseline predicted SIAS at 6 months (B = 0.218, partial r = .205, t = 2.347, P = <.05). Plus, internalized stigma: negative appraisal and social acceptance experiences, did not predict SIAS at follow-up. | 5***** |
| Vrbova et al62 | Cross-sectional | Total 61 SZ (42) SZ+SAD (19) | 1. ICD-10 2. PANSS, CGI | 2. LSAS |
Stigma - ISMIS |
SZ+SAD reported higher level of ISMIS (t = 4.251, P < .0001). | 5***** |
| Sutliff et al75 | Cross-sectional | Total 42 SZ (24) SZ+SAD (18) | 1. DSM-IV 2. PANSS | 2. LSAS |
Social rank - SCS |
SZ+SAD reported lower level of SCS than SZ (t = 2.90, P = .006). | 5***** |
| Aherne et al63 | Cross-sectional | FEP (45) | 1. ICD-10 2. Paranoid checklist | 2. SIAS, SPS |
Shame - TADS - CES - IES-R - ISS - OAS |
Regression model showed TADS, CES, IES-R, ISS and OAS were associated with SPS (R2 = 0.299, F1,37 = 6.587, P < .000) and SIAS (R2 = 0.242, F1,37 = 7.134, P < .000). TADS, CES, IES-R, ISS and OAS was associated with paranoia (R2 = 0.092, F4,37 = 3.007, P = .032). | 5***** |
| Romm et al70 | Cross-sectional | FEP (144) | 1. DSM-IV 2. PANSS | 2. LSAS-SR |
Self-esteem - RSES |
Regarding regression analysis, RSES and PANSS suspiciousness were associated with LSAS-SR (B = -0.04, P = .000 and B = 0.07, P = .047, adjusted R2 = 0.46). | 5***** |
| Romm et al71 | Cross-sectional | Total 144 FEP (30) FEP+NonGSAD (46) FEP+GSAD (68) |
1. DSM-IV 2. PANSS, IS | 2. LSAS-SR |
Self-esteem - RSES |
FEP+GSAD reported lower level of RSES than FEP+NonGSAD and FEP alone (F40.39, P < .001). | 5***** |
| Lysaker et al72 | Prospective | SZ (39) | 2. PANSS | 2. LSAS |
Self-esteem - MSEI |
Regarding regression analysis, baseline MSEI predicted LSAS at 6 months (R2 = 0.06, P < .05), after controlling for baseline LSAS (F2,36 = 17.93, P < .001). | 5***** |
| Lecomte et al73 | Cross-sectional | Total 47 SZ (25) SZ+SAD (22) | 1. DSM-IV-TR | 2. BSPS, SIAS |
Self-esteem - SERS-SF ToM - FEIT - FEDT - METT - Emotional recognition (a real- life situation) |
SZ+SAD reported lower level of SERS-SF compared to SZ (P < .01). There were no significant differences between SZ and SZ+SAD for any of the total scores for emotional recognition. | 5***** |
| Katherine et al43 | Cross-sectional | Total 48 SZ (13) SAD (13) Panic (10) NC (12) | 1. DSM-IV-TR 2. PS | 1. DSM-IV-TR 2. SIAS |
Negative self- referent appraisals - SCQ - SAQ-R - EBS |
There were no significant differences of automatic thought (SCQ), underlying assumptions (SAQ-R) and schema (EBS) between people with SZ (with persecutory delusions) and social phobia. | 4**** |
| Voges et al76 | Cross-sectional | SZ (60) | 1. DSM-IV 2. PANSS | 1. DSM-IV 2. SPAI |
Negative self- referent appraisals - SISST |
Patients reported SISST negative self- statement subscale positively correlated with lower level of SPAI (r = .74, P < .004). | 5***** |
| Wong77 | Cross-sectional | SZ (137) | 1. DSM-IV 2. SAPS, SANS | 1. LSAS-SR |
Negative self- referent appraisals - SUMD - IRIS - SPQ - SAPS |
After removing all non-significant paths in the hypothetical model, the final model suggested only 2 direct paths to social anxiety: ideas of reference (standardized path coefficient β = 0.26, P = .002) and negative symptoms (β = 0.29, P < .001) | 5***** |
| Stopa et al78 | Cross-sectional (Qualitative study) | Total 18 SZ (9) Social phobia (9) | 1. DSM-IV-TR | 1. DSM-IV-TR | Negative self- referent appraisals (interview) | Three common themes of interpersonal threat experiences were found in both groups: participants’ experience of threat, reactions while under threat, and subsequent reflections on threat situations, as well as the superordinate theme of narrative coherence. Key differences emerged between the groups in their perceptual experiences, ability to stand back from the threat following the event, and narrative coherence. | 5***** |
| Piccirillo et al53 | Cross-sectional | General population (179) | 2. GPTS | 2. SIAS |
Post-event processing - PEP questionnaire |
Higher SIAS and higher GPTS persecutory paranoia subscale (GPTS-PP) were significantly associated with higher levels of PEP at post-social exclusion intervention (SIAS: B = 0.36, P < .001 and GPTS-PP: B = 0.16, P < .05) and 1 week later (SIAS: B = 0.09, P < .05 and GPTS-PP: B = 0.09, P < .05). | 3*** |
| Achim et al82 | Cross-sectional | Total 140 SZ (29) SZ+SAD (26) NC (84) | 1. DSM-IV 2. PANSS | 2. LSAS |
Mentalization - BICS |
Across all SZ patients or when assessed separately for the SZ− or the SZ+ groups, there were no significant correlations between level of LSAS and BICS. All ps > 0.26. | 5***** |
| Lysaker et al79 | Cross-sectional | Total 88 (all SZ) Paranoia+/ Poorest ToM (14) Paranoia-/Low- middle ToM (29) Paranoia+/High- middle ToM (23) Paranoia-/Highest ToM (22) | 1. DSM-IV 2. PANSS | 2. LSAS |
Theory of Mind - ToM test batteryb |
Paranoia+/high-middleToM group reported higher levels of LSAS than other groups: paranoia+/poorestToM; paranoia-/ highestToM and paranoia-/low-middleToM (LSAS avoidance: F = 5.03, P < .01; and LSAS fear: F = 3.31, P < .05), where paranoia+ refers to significantly higher paranoia than paranoia-. | 5***** |
| Pepper et al80 | Cross-sectional | Total 199 ASD (53) EP (51) SAD (64) NC (31) | 1. DSM-IV | 1. ADIS-IV/V |
Theory of Mind - FPRT - FBPST - FEEST - EQ - RMET - Movie Stills task (with and without face condition) |
SAD reported higher score of RMET (P < .01) and Movie Still with (P < .001) and without face (P < .01) than EP. There were no significant differences of ToM (FPRT, FBPST, FEEST and EQ) between SAD and EP. | 5***** |
| Lysaker et al81 | Cross-sectional | Total 98 (All SZ) Low mastery (33) Intermediate- mastery (52) High mastery (13) | 1. DSM-IV | 2. MAQ social anxiety |
Metacognitive mastery - MAS |
Intermediate-mastery group reported more MAQ social anxiety (F = 3.48, P < .05). | 5***** |
| Achim et al46 | Cross-sectional | Total 82 SZ (29) SZ+SAD (12) NC (41) | 2. PANSS | 1. DSM-IV 2. LSAS |
Reasoning bias - brief-IPSAQ |
SZ+SAD reported significantly lower level of brief-IPSAQ externalizing bias subscale than controls. There were no significant differences of brief-IPSAQ personalizing bias subscale amongst the 3 groups (F2,79 = 0.39, P = .68). | 4**** |
| Rus-Calafell et al55 | Non- randomized controlled trials | SZ (12) Intervention: avatars for social skills enhancement | 1. DSM-IV-TR 2. PANSS | 2. SADS, AI, SSIT | Social avoidance - SADS | When compared between pre- and post-treatment, and post-treatment and follow-up, patient reported significantly improvement of levels of social anxiety: SSIT anxiety subscale (F2,22 = 39.76, P < .05, Cohen’s d = 0.48); and SADS avoidance (F2,22 = 14.80, P < .05, Cohen’s d = 0.58). | 4**** |
| Gajwani et al85 | Cross-sectional | UHR (51) | 2. SIPS | 2. SIAS, SPS |
Attachment - RAAS |
RAAS was associated SIAS and SPS (β = 0.47, P < .001, R2 = 0.22 and 0.39, P < .01, R2 = 0.15). A significant relationship between SIAS and RAAS was mediated by BDI (F 2,49 = 14.66, P < .001, R2 = 0.38). | 5***** |
| Michail et al86 | Cross-sectional | Total 135 FEP (60) FEP+SAD (20) SAD (31) NC (24) | 1. ICD-10 2. PANSS | 1. ICD-10 2. SIAS, SPS |
Attachment - RAAS |
FEP+SAD and SAD reported higher level of insecure adult attachment than FEP and NC (x21 = 38.5, P < .01). | 5***** |
| Russo et al45 | Cross-sectional | Total 120 UHR (60) NC (60) | 1. CAARMS | 2. SSI social anxiety subscale |
Attachment - PAM anxiety and avoidance subscale |
Amongst UHR, there were no significant correlations between SSI social anxiety and insecure anxiety (r = .36, P = .07), and SSI social anxiety and avoidant attachment (r = .28, P = .14). | 3*** |
| Achim et al87 | Cross-sectional | Total 62 FEP (31) NC (31) | 1. DSM-IV 2. PANSS | 2. LSAS |
Empathy - IRI |
Amongst FEP, there was significant correlations between LSAS and IRI perspective taking subscale (r = −.51, P = .004). | 5***** |
| Armando et al88 | Cross-sectional | Total 169 PLEs+SAD (32) SAD (96) Control Group (41) | 1. CAPE | 1. DSM-IV |
Intolerance of uncertainty - IUS |
PLEs+SAD reported higher levels of IUS and BDI-II, BAI and CAPE negative than those SAD alone (P < .0001). | 5***** |
Note: ADIS, Anxiety Disorders Interview Schedule for DSM-IV or V; AI, Assertion Inventory; ASD, Autism Spectrum Disorder; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; BDI-II, BDI 2nd edition; BFNE, Brief Fear of Negative Evaluation scale; BICS, Batterie Intégrée de Cognition Sociale; CAARMS, Comprehensive Assessment of At Risk Mental State; CAPE, Community Assessment of Psychic Experiences; CES, Centrality of events Scale; CGI, Clinical Global Impression; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders 4th edition; DSM-IV-TR, DSM-IV Total Revision; EBS, Evaluative Beliefs Scale; EP, Early Psychosis; EQ, Empathy Quotient of Cambridge Behaviour Scale; ES, Effect Size; FBPST, False Belief Picture Sequencing Task; FEDT, Facial Emotion Discrimination Test; FEEST, Facial Expressions of Emotions: Stimuli and Tests; FEIT, Facial Emotion Identification Test; FEP, First Episode Psychosis; FNE, Fear of Negative Evaluation scale; FPRT, Faux Pas Recognition Task; GPTS, Green Paranoid Thoughts Scale; GSAD, Generalized SAD; IAS, Interaction Anxiousness Scale; ICD-10, International Classification of Diseases 10th edition; IES-R, Impact of Event scale-Revised; IHS, Inventory of Hostility and Suspiciousness; IPSAQ, Internal Personal and Situational Attributions Questionnaire; IRI, Interpersonal Reactivity Index; IRIS, Ideas and Delusions of Reference Interview Scale; IS, Insight Scale; ISMIS, Internalised Stigma of Mental Illness Scale; ISS, Internalised Shame Scale; IUS, Intolerance of Uncertainty Scale; LSAS, Liebowitz Social Anxiety Scale; LSAS-SR, LSAS Self Rating version; MAQ, Multidimensional Anxiety Questionnaire; MAS, Metacognition Assessment Scale; METT, Ekman’s Micro-Expression Training Tool; MSEI, Multidimensional Self-Esteem Inventory; NC, Normal Control; OAS, Other as Shame Scale; PAM, Psychosis Attachment Measure; PANSS, Positive and Negative Syndrome Scale; PBEQ, Personal Beliefs about Experiences Questionnaire; PBIQ, Personal Beliefs about Illness Questionnaire; PEP, Post-Event Processing; PLE, Psychotic-Like Experiences; PS, Paranoia Scale; RAAS, Revised Adult Attachment Scale; RMET, Reading the Mind in the Eyes; RSES, Rosenberg Self-Esteem Scale; SAD, Social Anxiety Disorder; SADS, Social Avoidance and Distress Scale; SANS, Scale for the Assessment of Negative Symptoms; SAPS, Scale for the Assessment of Positive Symptoms; SAQ-R, Social Attitudes Questionnaire Revised; SCQ, Social Cognitions Questionnaire; SCS, Social Comparison Scale; SERS-SF, Self-Esteem Rating Scale-Short Form; SIAS, Social Interaction Anxiety Scale; SIPS, Structured Interview for Prodromal Syndromes; SISST, Social Interaction Self-Statement Test; SPAI, Social Phobia and Anxiety Inventory; SPS, Social Phobia Scale; SPQ, Schizotypal Personality Questionnaire; SSI, Schizotypal Symptoms Inventory Brief Version; SSIT, Simulated Social Interaction Test; SUMD, Scale to Assess Unawareness of Mental Disorder; SZ, SchiZophrenia spectrum disorder; TADS, Trauma And Distress Scale; ToM, Theory of Mind; UHR, Ultra High Risk; VR-CBT, Virtual-Reality-based Cognitive Behavioural Therapy
aScoring as number of quality criteria met; for example, 4**** means 4 criteria (of totally 5) of a study design were met.
bToM test battery includes the Hinting Test, the Bell-Lysaker Emotional Recognition Task, the eyes test, and the Picture arrangement subtest of Wechsler Adult Intelligence Scale III.