Gajwani13Clin.psy.D.1

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A thesis submitted in partial fulfilment to the University of

Birmingham for the degree of Doctorate in Clinical Psychology

Volume I: Research Component

Relationship between social anxiety and social phobia with

paranoia in clinical and non-clinical samples

and

The understanding of suicide in young men with first episode

psychosis

Submitted by

Dr Ruchika Gajwani

Department of Clinical Psychology

School of Psychology

University of Birmingham

September 2013


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University of Birmingham Research Archive

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Overview of Thesis

This thesis was completed as part of a three-year Doctorate in Clinical Psychology at

the University of Birmingham. It comprises two volumes: a research component, and a

clinical component.

Volume I includes three research papers. Paper one is a critical literature review of the

relationship between social anxiety and social phobia with paranoia in clinical and non-

clinical samples. Paper two presents an empirical study about the understanding of suicide

in young men with first episode psychosis using interpretative phenomenological analysis.

The final paper is an executive summary of the empirical paper.

Volume II includes five clinical practice reports. The first report presents the

assessment, behavioural and systemic formulations of a 4-year-old girl (query autism

spectrum disorder) with behavioural difficulties. The second report is a clinical audit and

qualitative evaluation of staff experiences of a specialist autism spectrum disorder team.

The third report is a single-case experimental design investigating the effectiveness of a

cognitive behavioural intervention for anxiety with a 47-year-old gentleman with a mild

learning disability. The fourth report presents a case study describing a cognitive

behavioural intervention with a 31-year-old man experiencing significant distress and

anxiety, along with intrusions (hallucinations and delusions). The fifth report is an abstract

describing assessment, formulation, and intervention using cognitive analytic therapy (CAT)

with a 37 year old lady with a diagnosis of breast cancer.


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Acknowledgements

I would like to thank and show my gratitude for my supervisors, Michael Larkin and Chris

Jackson for their guidance and support. I have learnt from their extensive knowledge and

experience. Thank you.

My sincere gratitude to all the young men who agreed to participate in this research. I

would like to thank them for generously in giving their time to share their personal stories.

I am very grateful to the teams at Early Intervention Service, with a very special thank you to

the clinicians and administrative staff for their assistance and support. I would like to

especially thank Mark for his invaluable help in data collection.

A very warm and special thank you to all my friends for their encouragement and

compassion, they have been a second family to me. I am thankful to mum, family and

friends in India for their continual love and support.

Id like to thank Stephen for his loving support, humour and patience.


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Table of contents

Chapter I: Literature review .............................................................................................. 1

1.0 Abstract ........................................................................................................................... 2

1.1 Introduction .................................................................................................................... 3

1.2 Aims of the review .......................................................................................................... 7

1.3 Method ........................................................................................................................... 8

1.3.1 Inclusion and Exclusion criteria ........................................................................................... 9

1.3.2 Process of quality assessment .......................................................................................... 18

1.3.3 Summary of the methodologies employed by the studies identified .............................. 22

1.4 Narrative synthesis ....................................................................................................... 22

1.4.1 Are social anxiety and social phobia related to paranoia? If so, what are the links

between social anxiety and paranoia in clinical and non-clinical samples? ..................................... 22

1.4.2 How are the mechanisms underpinning social anxiety and social phobia similar or

different to paranoia? ....................................................................................................................... 30

1.5 Discussion ........................................................................................................................... 32

1.6 Clinical implications ...................................................................................................... 37

1.7 Methodological strengths and limitations .................................................................... 38

1.8 Conclusion ..................................................................................................................... 38

1.9 References .................................................................................................................... 39

Chapter II: Empirical paper ............................................................................................. 49

2.0 Abstract ......................................................................................................................... 50

2.1 Introduction .................................................................................................................. 51

2.2 Aims and Objectives ...................................................................................................... 55

2.3 Method ......................................................................................................................... 55

2.3.1 Design ................................................................................................................................ 55

2.3.2 Sampling ............................................................................................................................ 56

2.3.3 Recruitment Procedure ..................................................................................................... 57

2.3.4 Participants ....................................................................................................................... 59

2.3.5 Data collection .................................................................................................................. 60

2.3.6 Data analysis ..................................................................................................................... 61


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2.3.7 Reflective statement ................................................................................................. 62

2.4 Results ........................................................................................................................... 63

2.4.1 Amplified distress at rapid decline .................................................................................... 65

2.4.2 Being unsettled intra- and inter-personal relationships ................................................ 68

2.4.3 Appraisal of cumulative life events as unbearable ........................................................... 73

2.4.4 Meaning of recovery marked by individual sense of hope and imagery for the future ... 75

2.5 Discussion...................................................................................................................... 80

2.6 Clinical and Theoretical Implications ............................................................................ 82

2.7 Conclusion ..................................................................................................................... 83

2.8 References .................................................................................................................... 84

Chapter III: Executive summary ...................................................................................... 92

Appendices .................................................................................................................... 95

Appendix A: Full example of quality assessment for one article...................................................... i

Appendix B: Ethics approval for the study on Understanding suicide in young men with first

episode psychosis.............................................................................................................................. ii

Appendix C: Study information sheet ............................................................................................ iii

Appendix D: Consent form ............................................................................................................. iv

Appendix E: Semi structured interview ........................................................................................... v

Appendix F: Example of stage 2 of interpretative phenomenological analysis ............................. vi

Appendix G: Example of stage 3 of interpretative phenomenological analysis ............................ vii

Appendix H: Reflections on the research process ........................................................................ viii

List of Figures

Figure 1. Exclusion criteria used for literature search11

List of Tables

Table 1. Summary of the key empirical findings within the selected articles12

Table 2. Quality assessment scoring for systematic review..19

Table 3. Inclusion criteria.57

Table 4. Participant demographic characteristics.59

Table 5. Superordinate and subordinate themes identified..65


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1

Chapter I: Literature review

The relationship between social

anxiety and social phobia with

paranoia in clinical and non-

clinical samples.


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1.0 Abstract

Objective: This review examines studies investigating the links between social anxiety,

social phobia and paranoia in clinical and non-clinical samples, and explores the similarities

and differences between two phenotypically resembling conditions.

Method: A systematic review of the literature was undertaken using the search engines

Embase, Medline and PsycInfo from the year 1996, producing fourteen articles explicitly

examining the relationship between social anxiety/social phobia and paranoia. The evidence

contributed to our understanding of the psychological mechanisms that contribute to social

anxiety and paranoia.

Results:The rate of lifetime social phobia is 8% to 9.4% and lifetime paranoid symptoms

is10% to 15.7% in the general population. 2% met criteria for comorbid social phobia and

paranoid symptoms. Similar cognitive and affective predictive factors are associated with

social anxiety and paranoia in the general population, and affective disorders. Social anxiety

and paranoia are more distinct conditions in psychosis. The presence of cumulative risk

factors (environmental and temperamental) such as trauma and cannabis are associated

with the onset of social anxiety and paranoia.

Conclusion: The review shows that more than one causal pathway may be implicated in

the development of social anxiety and paranoia. Further investigation, using well designed

methodology with a clear clinical and research focus on different levels of paranoia and

social anxiety would help clarify the nature and phenomenology of the two conditions.

Keywords:Social anxiety, social phobia, paranoia, general population, psychosis.


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1.1 Introduction

The divide between psychosis and neurosis is narrower now than it has ever been, as the

evidence for an overlap between affective and non-affective disorders is growing (Freeman

& Garety, 2003; Murray et al., 2004; Hartley, Barrowclough & Haddock, 2013), bringing to

the forefront limitations of the Kraepelinian dichotomy maintained within the categorical

classification system (Craddock & Owen, 2005; van Os, 2009). Evidence for a common

genetic liability between schizophrenia and bipolar disorder is maintained by large scale

epidemiological studies (Cardno, Rijsdijk, Sham, Murray & McGuffin, 2002; Lichtenstein et

al., 2009). Cardno and colleagues (1999) reported heritability estimates of 82% and 85% for

schizophrenia, schizoaffective disorder, and mania. Support for a dimensional approach to

psychiatric disorders, as is in the case of psychosis, is strengthened further by the

compelling body of research demonstrating the continuity of a psychotic phenotype

(Kaymaz & Van Os, 2010), in the form of sub-clinical psychotic experiences in the general

population (Van Os, Hanssen, Bijl, Ravelli, 2000; Nuevo et al., 2012), attenuated psychotic

symptoms in the at-risk population (Yung et al, 2003), and psychotic impairment amongst

those meeting the diagnostic threshold.

The presence of sub-clinical psychotic experiences may not independently predict

psychopathology, with the majority of the symptoms being transient (Van Os, Linscott,

Myin-Germeys, Delespaul & Krabbendam, 2009). However clinical psychosis is preceded by

sub-threshold psychotic experiences in a significantly large proportion of cases (Dominguez,

Wichers, Lieb, Wittchen, & van Os, 2011). The persistence of sub-threshold psychotic

experiences of aberrant salience over a long time period is associated with poorer clinical

psychotic outcome (Yung & McGorry, 2007; Kaymaz et al., 2012) and significant deficiencies


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(Freeman & Garety, 2003; Smith et al., 2006). With reference to delusional ideation,

particularly persecutory thinking, cognitive-affective deficits such as greater anticipation of

threat and vulnerability are associated with dysfunctional affective processing (Green et al.,

2006; Bentall et al., 2009; Freeman, Dunn, et al., 2012). The prevalence of significantly

greater paranoid ideation and psychoticism is also manifested in individuals accessing

mental health services for anxiety and depressive disorders (Essau, 2005; Freeman et al.,

2011). A multifactorial model of persecutory delusions conceptualises anxiety and

depression as central to the formation and maintenance of paranoia, suggesting two

possible pathways (Freeman, Garety, Kuipers, Fowler & Bebbington, 2002). Firstly,

individuals with negative evaluations of themselves and increased generalised anxiety may

experience paranoia, which may feedback to their negative emotions and low self-esteem,

resulting in the persistence of the delusional ideation (Thewissen et al., 2011). Secondly,

those with a non-pathological sense of self but holding negative appraisals of others may

also develop persecutory and suspicious thinking often maintained by feelings of anger

(Smith et al., 2006). Recent reports provide confirmatory evidence showing that worry,

anxiety and depression predict the occurrence of paranoia (Freeman, Dunn, et al., 2012),

with subsequent anxiety amongst those experiencing intense persecutory thoughts

exacerbating delusional distress and belief conviction, whereas depression predicted

associated distress (Ben-Zeev, Ellington, Swendsen & Granholm, 2011) and longer duration

of paranoid episode (Thewissen et al., 2011).

The complex and multidimensional nature of delusions, specifically persecutory

delusional experiences, have given momentum to investigating the phenomena (Bentall,

Corcoran, Howard, Blackwood, & Kinderman, 2001). The prevalence of paranoid thoughts in


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the general UK population ranges from approximately 20% reporting mild paranoid ideation

to 1.7% reporting more severe paranoid delusion around people plotting to harm them

(Johns et al., 2004; Freeman, Dunn, et al., 2011). The presence of paranoid thinking amongst

patients with delusions and a diagnosis of non-affective psychosis are even greater

(Freeman, Dunn, et al., 2012). Advancements in the area of non-clinical paranoia, along with

the clinical spectrum of paranoid ideation, would not only expand on the nature of the

phenomena but also directly influence clinical intervention. Based on the growing research

evidence for the role of worry processes in predicting the occurrence and persistence of

persecutory delusions (Bassett, Sperlinger & Freeman, 2009), there is preliminary support

for the efficacy of cognitive interventions targeting worry reduction in the subsequent

reduction in paranoid thoughts (Foster, Startup, Potts, & Freeman, 2010; Freeman, Stahl,

et al., 2012).

The role of affective dysregulation in the development of persecutory delusions and

social anxiety is central. Attention biases, such as social threat perception and avoidance,

implicated in the formation and maintenance of social phobia (Bgels & Mansell, 2004),

have also been reported in paranoia (Green & Phillips, 2004). One of the key differences in

the two conditions may be in the conviction of anxiety beliefs; people with social phobia

recognise their anxiety as being excessive, whereas people with paranoid thinking,

particularly persecutory delusions, have conviction in their suspicious beliefs of imminent

harm from others. Similar psychological concepts, such as social consciousness, have been

studied in relation to people with social anxiety and paranoia. However, not enough is

known about the differential risk profiles for the two conditions.


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Drawing on the developmental principle of multifinality (i.e. multifinality suggests that

the influence of a component or a factor may lead to diverse outcomes in different systems)

(Cicchetti & Rogosch, 1996), there is evidence to suggest that common predictive factors

such as anxiety, depression and worry contribute to the occurrence of social anxiety and

persecutory ideation (Freeman et al., 2008). Whilst individuals with paranoid delusions

typically fear persecution from others, those with social anxiety worry about negative

evaluation from others. Although there has been more evidence in the last decade on the

association between social anxiety and paranoia in clinical (Michail & Birchwood, 2009;

Lysaker et al., 2010) and non-clinical population groups (Freeman et al., 2008; Schutters et

al, 2012), not enough is known about the genetic and psychosocial mechanisms that

differentiate the aetiology and developmental trajectories of the two syndromes. What

factors maintain continuity of the two conditions, or prompt change, and how? If similar

predictive factors exist for social anxiety and persecutory ideation, then what are the

similarities and differences between the two conditions? On-going research in this area

would bringpathwaysto the forefront of our understanding of what makes one individual

socially anxious and another paranoid (Freeman et al., 2008).

1.2 Aims of the review

The review aims to synthesise and draw on the evidence to describe the relationship

between social anxiety, social phobia, and paranoia. The systematic search will collate

papers that examine the association between the two primary phenomena of social anxiety

and paranoia, in a continuum of clinical and non-clinical samples. In order to better

understand any association, the review endeavours to answer the following two key

questions:


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1.Are social anxiety and social phobia related to paranoia? If so, what are the linksbetween social anxiety and paranoia in clinical and non-clinical samples?

2.How are the mechanisms underpinning social anxiety and social phobia similar ordifferent to paranoia?

1.3 Method

A systematic review of the literature was undertaken to answer the two questions in this

paper. Articles in the area of social anxiety and paranoia were identified using the search

engines; Embaseand Medline,via the University of Birmingham Ovid online system for the

period between 1996 to March Week 3 2013; and PsycInfo for the period 1987 to March

Week 3 2013 (papers earlier than1996 excluded). The search terms employed for the

literature search were: (social anxiety OR Social phobia OR Social interaction anxiety OR

social anxiety disorder) AND (paranoid OR paranoia OR paranoid ideation OR persecutory

ideation OR paranoid delusions OR persecutory delusions). The review focussed on explicit

links between social anxiety and paranoia, thereby excluding studies that did not aim to

investigate this association. Whilst the initial search produced a number of articles on

comorbid emotional dysfunction within psychosis and personality disorders (including

paranoid personality disorder), they were focussing on disorders and syndromes that were

not clinically descriptive of the link between social anxiety and paranoia. The initial search

generated 287 articles, of which 200 remained after duplicates were removed. Search

results for conference presentations were checked for recent publications. The subset of

articles that met the inclusion and exclusion criteria was identified for review. The articles

were reviewed for content relevant to the study and for further references within citations

that may have not been captured in the initial search.


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1.3.1 Inclusion and Exclusion criteria

The inclusion criteria were selected to produce articles that examined the association

between social anxiety and social phobia with paranoia, in clinical and non-clinical samples.

The following inclusion criteria were applied:

(i) articles published in English;(ii) published between 1996 and March 2013;(iii) papers using standardised methods of investigation and analysis, examining the

link between social anxiety and/or social phobia and paranoid

ideation/persecutory delusions in a clinical sample such as first episode

psychosis or a non-clinical sample.

The review excluded:

(i) dissertations or conference presentations/discussions;(ii) Case studies;(iii) Studies that examine generalised emotional dysfunction in clinical samples of

schizophrenia, psychosis and personality disorder;

(iv) Studies which focus on the link between generalised emotional dysfunction(anxiety, worry, depression) and paranoia;

(v) Studies which focus exclusively on processes involved in paranoia (discuss socialanxiety/social phobia as a derivative or as secondary findings);


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(vi) Studies which focus exclusively on processes involved in social anxiety or socialphobia (discuss paranoia as a derivative or as secondary findings).

The number of articles emerging from the search, and the process of exclusion criteria used

for the review, is illustrated in Figure 1. Fourteen studies met the above criteria and were

identified and included in this review; of which eight investigated the link between paranoia

and social anxiety in a non-clinical sample; and six were clinical samples. A summary of the

key empirical findings, sample and generalised methodology used within the selected

articles can be seen in Table 1. Full text articles in the review were accessed through

University of Birmingham electronic journal resources.


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Figure 1. Exclusion criteria used for literature search

287 Articles

200 remaining after

removing duplicates

94 papers excluded (papers focussing exclusively on

paranoia or exclusively on social anxiety or affective

disorders (e.g. anxiety, depression) or generalised

affective disorders in psychosis or personality disorders

37 papers excluded (papers not in English

language or not peer reviewed or before 1996)

14 papers remaining

55 papers excluded

(Conference

abstract/paper)


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Table 1. Relationship between social anxiety/social phobia and paranoia in clinical and non-clinical samples

Authors Country Aim Participants Design Key findings

Martin &

Penn (2001)

US To examine the relationship

between paranoid ideation

and social cognition

variables in a non-clinical

sample.

193 undergraduate

students (114

female), with a

mean age of 21.14

years.

Cross-sectional

study.

Higher levels of paranoid ideation were

associated with lower self-esteem,

greater social anxiety, depression and

negative self-monitoring in public.

Combs &Penn (2004)

US To investigate the effects ofsub-clinical paranoia on

social perception and

behaviour.

60 undergraduatestudents.

Cross-sectionalstudy.

High subclinical-paranoia was associatedwith greater depression, social anxiety,

self-consciousness, and lower self-

esteem compared to low subclinical

paranoia.

Persons high in subclinical paranoia

performed worse than persons low in

subclinical paranoia on measures of

emotion perception and on an in vivo

social perception task. The findings also

showed behavioural differences between

the two groups.

Gilbert

et al (2005)

UK To explore the relationship

between paranoid ideation

and social anxiety in a non-

psychotic clinical patient

group.

36 males and 35

females with a

heterogeneous non-

psychotic clinical

diagnosis.

Cross-sectional

study.

Paranoid thinking and social anxieties

were highly correlated in this population

and both were related to social rank

perceptions, power and submissive

behaviour.


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Huppert &

Smith (2005)

US Determine the link between

specific anxiety subtypes

and psychotic symptoms.

32 patients with

schizophrenia or

schizoaffective

disorder.

Cross-sectional

study.

Of the 32 patients, 20 were diagnosed

with at least one comorbid anxiety

disorder. Specific to anxiety disorders

and psychotic symptoms, there was a

significant association between self-

reported Obsessive-Compulsive

symptoms and social anxiety symptoms

with positive symptoms, bizarre

behaviour and quality of life.

Severity of social phobia, and not social

interaction anxiety, were related to

increased levels of suspiciousness/

paranoia.

Freeman

et al (2008)

UK To identify factors

associated with social

anxiety and paranoid

thoughts in an experimental

condition.

200 non-clinical

participants from

the general

population.

Cross-sectional

study.

Perceptual anomalies specifically

predicted paranoia. Anxiety, depression,

worry and interpersonal sensitivity

predicted both social anxiety and

paranoia.

Michail &Birchwood

(2009)

UK To determine thephenomenology of social

anxiety disorder with and

without psychosis.

Secondly, to investigate the

links between social anxiety

80 patients withFirst episode

psychosis (FEP) and

31 with Social

anxiety disorder

(SaD).

Cross-sectionalstudy.

25% of the FEP sample was diagnosedwith social anxiety disorder (FEP/SaD

group). Similar levels of social anxiety,

avoidance, autonomic symptoms and

depression amongst the FEP/SaD and

SaD groups. High levels of persecutory


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disorder in psychosis with

the nature and severity of

persecutory delusions.

delusions did not affect the severity of

social anxiety in first episode psychosis.

Perceived threat from persecutors was

significantly greater in FEP/SaD than

FEP/without SaD.

Rietdijk

van Os,

de Graaf,

Delespaul &

van der Gaag

(2009)

Netherlands Explore the association

between social phobia and

paranoid symptoms in a

prospective study.

7076 adults from the

general population.

Cross-sectional

and

prospective

study.

Of the original 7076 subjects at baseline,

5619 completed additional assessments.

The study comprised of 2614 men and

3005 women.

Lifetime Social phobia (SPh) and paranoid

symptoms (PS) were associated with a

dose response. SPh emerging after PS

was significant, also with a dose

response, suggesting that more PS

symptoms are linked to greater SPh

symptoms. PS emerging after SPh was

not significant.

Yamauchi,

Sudo &

Tanno(2009)

Japan To determine the difference

between socially anxious

and paranoid thoughts ondimensions of resistance,

distress, absurdity,

conviction, corrigibility,

controllability, perception

of harm, anger & frequency.

128 college

students.

Cross-sectional

study.

In comparison to socially anxious

thoughts, paranoid thoughts were

characterized by higher distress,absurdity, corrigibility, perception of

intended harm, and anger, but lower

conviction.


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Lysaker et al.

(2010)

US To determine the

prevalence of theory of

mind (ToM) deficit in

patients with paranoia.

Examine whether patients

with greater paranoia and

ToM have elevated social

anxiety.

88 patients with a

DSM-IV

diagnoses of

schizophrenia (n=51)

or schizoaffective

disorder

(n=37).

Cross-sectional

study.

High Paranoia/Poor ToM (n=14);

Low Paranoia/Good ToM (n=22); Low

Paranoia/Low Middle ToM (n=29); and

High Paranoia/

High Middle ToM (n=23)

Greater levels of paranoid features and

relatively better ToM performance had

significantly higher levels of social anxiety

than all other groups.

Tone,

Goulding

& Compton

(2011)

US Determine the association

between social anxiety and

perceptual aberration with

self-reported paranoid

ideation.

644 University

students (494

female), with a

mean age of 20.6

years.

Cross sectional

survey.

Self-reported social anxiety and

perceptual anomalies made significant

independent contributions to scores on a

multidimensional measure of paranoid

ideation, even when current negative

affect was covaried.

Social anxiety and perceptual aberration

did not interact significantly to predict

paranoia.

Schutters etal. (2012)

Germany Investigating the cross-sectional and longitudinal

relation between social

phobia and paranoid

symptoms, at a diagnostic

(DSM-IV) and symptomatic

A communitysample of 3021,

participants aged

14-24 years, with a

mean age of 21.7

years.

Observational,longitudinal

and

prospective

400 of the 2548 participants (15.7%) metcriteria for lifetime incidence of paranoid

symptoms and 239 (9.4%) for social

phobia, whereas 57 (2.2%) met criteria

for the comorbid condition.


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level. Paranoid symptoms were associated with

social phobia both at the DSM-IV

criterion level and at the symptomatic

level. Lifetime paranoid symptoms were

associated specifically with social anxiety

cognitions.

Lifetime cognitions of negative

evaluation predicted later onset of

paranoid symptoms, whereas onset of

social phobia was predicted by cognitions

of loss of control and fear avoidance of

social situations.

Matos,

Pinto-

Gouveia &

Gilbert

(2012)

Portugal To investigate the role of

shame and shame

memories in paranoid

ideation and social anxiety.

328 adults from the

general population.

Cross-sectional

study.

External shame was associated with

paranoid anxiety. Internal shame was

associated with social anxiety.

Shame memory and the central

reference of shame memory predicted

paranoia but not social anxiety, evenwhen testing for internal and external

shame.

Newman

Taylor &

Stopa (2013)

UK Examine cognitive

processes and behaviour

associated with social

13 people meeting

criteria for social

phobia, 13 with

Cross-sectional

pilot study.

There was no significant difference

between people with persecutory

delusions and social phobia on measures


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phobia, in people with

persecutory delusions.

schizophrenia

(without social

phobia), 10 with

panic disorder and

12 non-clinical

control group.

of automatic thought, underlying

assumptions, core beliefs, process and

behaviour typically associated with social

phobia.

Stopa et al

(2013)

UK To examine the experience

of being under threat in

social phobia and paranoia,

in order to better identify

the psychological processes

involved.

9 adults with social

phobia and 9

meeting criteria for

schizophrenia (with

persecutory

delusions).

Qualitative

study design.

Three major themes emerged from the

data, namely, experience of threat,

reaction while under threat and

subsequent reflections.

Typical fear responses were described by

both groups. Findings report differences

in perceptual experiences between the

groups. Participants in the social phobia

group demonstrated a greater ability to

distance themselves from the threat

following the event as opposed to the

group with persecutory delusions.


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1.3.2 Process of quality assessment

There is no single gold standard approach to assessing methodological quality which is

applicable to all systematic reviews. For this study, a critical appraisal tool (Caldwell,

Henshaw & Taylor, 2005) was selected for data synthesis, using the framework described by

Caldwell et al. (2005), after consulting a number of criteria frameworks (Caldwell et al.,

2005; Sale & Brazil, 2004; CASP, 2011) as it was most suitable for the review of quantitative

and qualitative studies. Checklists can be a reliable tool for critically investigating the quality

of studies in a standardised way (Centre for Reviews and Dissemination, 2009). The critical

appraisal tool identified strengths and weaknesses to evaluate the overall quality of the

studies included in the review.

The process of quality assessment involved critiquing each evaluative standard as ++

(indicating good and no problems identified), + (indicating minor problems identified), and

(major problems identified). Appendix A contains a full example of a quality assessment

for one article. All papers were included for review due to the small number of papers that

were pertinent to the aims of this study. As the studies in this review are not being

quantitatively pooled for a meta-analysis, it was important to critically examine the

statistical design and analysis of each paper. The quality assessment scoring for each paper

in this review is presented in Table 2.


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Table 2. Quality assessment scoring for systematic review

Martin &

Penn (2001)

Coms &

Penn (2004)

Gilbert

et al.

(2005)

Huppert &

Smith (2005)

Freeman

et al. (2008)

Quality: ++ Good + Minor issuesMajor issues

1. Title and Abstract ++ + ++ ++ ++2. Rationale clearly

described?

+ ++ ++ ++

3. Research aims clearlystated?

+ ++ ++ + ++

4. Ethical issuesaddressed?

- - + + +

5. Methodologyappropriate to theresearch question?

+ ++ + ++ ++

6. Study designidentified and the

rationale for choice

evident?

- + - - -

7. Experimentalhypotheses stated?

+ ++ - ++ ++

8. Key variablesidentified?

+ ++ + ++ ++

9. Sample populationsituated?

- + + + +

10.Selection ofparticipants

adequately

described?

- + + + +

11.Method of datacollection reliable

and valid?

+ + + ++ ++

12.Method of dataanalysis reliable andvalid?

- ++ + + ++

13.Findings clearlystated?

++ ++ ++ ++ ++

14.Comprehensivediscussion?

+ ++ + ++ +

15.Strengths andlimitations

identified?

+ ++ + ++ ++

16.Justifiableconclusions made?

- + - ++ -


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Michail &

Birchwood

(2009)

Rietdijk et

al.

(2009)

Yamauchi

et al.

(2009)

Lysaker et

al. (2010)

Tone et al.

(2011)


1. Title and Abstract ++ ++ + ++ ++2. Rationale clearly

described?

++ ++ ++ ++ ++


++ ++ ++ + +


+ + + + +

5. Methodologyappropriate to the

research question?

++ + + + +

6. Study designidentified and the

rationale for choice

evident?

- + - - +

7. Experimentalhypotheses stated?

- ++ ++ ++ ++

8. Key variablesidentified?

+ + - ++ ++


++ ++ + + +

10.Selection ofparticipants

adequately

described?

++ + + + ++

11.Method of datacollection reliable

and valid?

++ + + + +

12.Method of dataanalysis reliable and

valid?

++ ++ + ++ ++

13.Findings clearlystated?

++ ++ + ++ ++


++ ++ + ++ ++

15.Strengths andlimitations

identified?

++ ++ ++ ++ ++

16.Justifiableconclusions made?

+ + - + +


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Schutters et al.

(2012)

Matos et al.

(2012)

Newman Taylor

& Stopa (2013)

Stopa et al

(2013)


1. Title and Abstract ++ ++ ++ ++2. Rationale clearly

described?

++ ++ ++ ++


++ ++ + ++


+ ++ + +

5. Methodologyappropriate to the

research question?

++ + + ++

6. Study design identifiedand the rationale for

choice evident?

++ + + +

7. Experimentalhypotheses stated?/

Philosophical

background identified?

++ ++ + +

8. Key variablesidentified?/ Major

concepts identified?

++ ++ + ++


++ + + +

10.Selection of participantsadequately described?

++ ++ + +

11.Method of datacollection reliable and

valid?

++ + + +

12.Method of data analysisreliable and valid?

++ ++ + +

13.Findings clearly stated?Reflectivity considered

and described?

++ ++ + ++


++ ++ + ++

15.Strengths andlimitations identified?

++ ++ + +

16.Justifiable conclusionsmade?

++ ++ + +


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1.3.3 Summary of the methodologies employed by the studies identified

Of the fourteen studies included in the review, the majority employed a quantitative

design (n = 13); eleven of those utilised a cross sectional study design (Huppert & Smith,

2005; Freeman et al., 2008; Michail & Birchwood, 2009; Yamauchi, Sudo & Tanno, 2009;

Lysaker et al., 2010; Tone, Goulding & Compton, 2011; Matos, Pinto-Gouveia & Gilbert,

2012; Newman-Taylor & Stopa, 2013); one was a longitudinal prospective study (Schutters

et al., 2012),and one used both cross sectional and a prospective study design (Rietdijk, van

Os, de Graaf, Delespaul & van der Gaag, 2009). One study used a qualitative design to

examine interpersonal threat experiences in two clinical groups of people with social phobia

and schizophrenia (Stopa, Denton, Wignfield & Newman Taylor, 2013). Four studies (Martin

& Penn, 2001; Combs & Penn, 2004; Tone et al., 2011;Yamauchiet al., 2009) used student

samples to study the link between social anxiety and paranoid ideation. Two studies

employed a longitudinal design to investigate the temporal relation between social phobia

and paranoid symptoms (Rietdijk et al., 2009; Schutters et al., 2012).

1.4 Narrative synthesis

1.4.1 Are social anxiety and social phobia related to paranoia? If so, what are the links

between social anxiety and paranoia in clinical and non-clinical samples?

1.4.1.1 Rates

The majority of the studies report prevalence rates of social anxiety and paranoia within

clinical and non-clinical population groups, with only two longitudinal studies reporting

lifetime incidence cases of social phobia and paranoid symptoms in their community. The

mean age for the Netherlands Mental Health Survey and Incidence Study (NEMESIS)

(Rietdijk et al., 2009)was 41 years (SD= 12), whereas the German community based Early


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Developmental Stages of Psychopathology (EDSP) study researched adolescents and young

adults, with a mean sample age of 21.7 years (SD = 3.4). However the two studies reported

comparable levels of lifetime incidence and comorbidity of the two conditions. Rietdijk and

colleagues (2009) found in a sample of 7076 participants, 575 individuals (8%) reported

lifetime social phobia at baseline and 705 (10%) reported one or more lifetime paranoid

symptoms (sub-clinical). 132 individuals (1.9%) reported lifetime incidence of comorbid

social phobia and sub-clinical paranoid symptoms. The EDSP study (Schutters et al., 2012)

found similar results, although unlike the NEMESIS study (Rietdijk et al., 2009), it usefully

made a distinction between symptoms at a clinical and subclinical level, strengthening the

implications of their findings. In a sample of 2548 participants, a lifetime incidence of

paranoid symptoms (at any symptomatic level) in 400 participants (15.7%), of whom 238

(59.5%) reported sub-clinical paranoid symptoms and 162 (40.5%) reported clinical paranoid

symptoms. Lifetime incidence of social phobia (at any symptomatic level) was reported by

239 participants (9.4%), of whom 125 (52.3%) reported sub-clinical social phobia and 114

(47.7%) clinical social phobia. 57 (2.2%) met criteria for comorbidity of the two conditions.

Within this study (Schutters et al., 2012), paranoid symptoms were measured at a

symptomatic level based on single experiences, whereas social phobia was measured using

DSM criterion level, which has been used to explain the unusually high levels of paranoid

symptoms (15.7%) as compared to social phobia (9.4%). Also of interest is the use of trained

clinical psychologists in the EDSP study (Schutters et al., 2012) to ascertain clinical levels of

paranoia, which may differentiate lower prevalence rates reported in cross sectional studies

using self-report measures.


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1.4.1.2 The emergence and temporal relationship between social anxiety/social phobia and

paranoid symptoms

In terms of the chronological link between social phobia and paranoia, only two studies

have investigated the relationship prospectively, in community samples within the general

population of two countries. The EDSP study (Schutters et al., 2012) investigated the

chronological association between social phobia and paranoia by examining the constructs

at a symptomatic level (subclinical) as well as a diagnostic category (clinical). Although

robust in its statistical analysis, one of the limitations of this longitudinal study is that the

relationship between social phobia and paranoid symptoms was examined in the context of

a large-scale epidemiological study, using psychometric assessments to measure paranoia at

a symptomatic level and social phobia as a diagnosis. As acknowledged by the authors, this

methodological drawback may explain the unexpectedly higher rate of paranoid symptoms

compared to social phobia. The EDSP (Schutters et al., 2012) and NEMESIS (Rietdijk et al.,

2009) studies both found that paranoid symptoms at baseline were followed by the

subsequent emergence of social phobia, and not vice-versa. The unexpected temporal

association may also be explained by the choice of assessment tools, indicating that the

validity of the psychometric measures may only be useful if appropriately chosen to

examine the research questions.

In summary, the two longitudinal studies (Rietdijk et al., 2009; Schutters et al., 2012)

investigated the linear progression of social phobia and paranoia in the general population.

The findings are suggestive of paranoid ideation predicting later onset of social phobia

however the conclusions drawn from these findings are tentative due to methodological

constraints of the two studies.


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1.4.1.3 Relation between paranoid ideation and social anxiety in mixed clinical populations

Six studies (Gilbert et al., 2005; Huppert & Smith, 2006; Michail & Birchwood, 2009;

Lysaker et al., 2010; Newman Taylor & Stopa, 2013; Stopa et al., 2013) investigated the link

between social anxiety and/or social phobia with paranoia in clinical samples. Although

there is some evidence for a significant association between social anxiety and social phobia

with paranoia in clinical populations, the nature of this association needs to be described

cautiously, as there are differences in methodological design, instruments and clinical

populations within the studies. For example, Gilbert and colleagues (2005) found significant

correlations between paranoid ideation and both social interaction anxiety and social

phobia, after controlling for depression, in a clinical sample with a primary diagnosis of

affective disorders. In contrast, Huppert and Smith (2005) found in patients with a diagnosis

of schizophrenia, a significant association between levels of paranoia and the severity of

social phobia, but not social interaction anxiety. The distinction between the constructs of

social anxiety are important because social interaction anxiety, as assessed by the social

interaction anxiety scale (SIAS; Mattick & Clarke, 1998) measures anxiety about group

interaction and social phobia, whereas the social phobia scale (SPS; Mattick & Clarke, 1998)

measures performance related anxiety and a fear of scrutiny. It may also be the case that

the clinical distinction between features of social anxiety and paranoia are more discernible

in schizophrenia than affective disorders.

Examining the link cross sectionally in a sample (N = 80) of young people with first

episode psychosis (FEP), Michail and Birchwood (2009) found no relationship between

persecutory delusions and social anxiety, and no relationship between the level of

persecutory delusions and severity of social anxiety in a sub-sample of FEP patients with


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clinically significant social anxiety. However, of particular interest is their finding that a

significantly greater number of FEP participants with social anxiety as compared to those

without it (45% v.11.6%) reported persecutory threat, although there was no difference in

the quality and dimensions of persecutory threat in the two groups. Through multimodal

assessments and a robust methodological design, a useful distinction was made between

social anxiety and persecutory delusions in FEP, suggesting three possible pathways linking

social anxiety and persecutory ideation in different phases of psychosis: i) social anxiety may

predict the onset and maintenance of persecutory ideation; ii) social anxiety and paranoid

delusions develop independently and follow a parallel course in different phases of

psychosis; and iii) social anxiety is a by-product of paranoid delusions.

Along with examining the links between social anxiety and paranoia, some studies have

investigated pathways linking the two constructs. One such study by Lysaker et al. (2010), in

patients with schizophrenia spectrum disorders, examined whether social anxiety

independently predicts paranoid features or interacts with Theory of Mind (ToM). The study

revealed four patient subgroups with varying degrees of paranoia and ToM, and as

predicted, participants with high paranoia and good ToM had significantly greater social

anxiety than any other group. Although the study is cross sectional and social anxiety is

measured using a single index measure, it provides some evidence for implicating cognitive

and affective processes in paranoia. The nature of this interaction, if any, remains unclear.

The use of self-report measures compared to clinician interviews may also increase the

likelihood of false positives and Type I error, which may bias the association between social

anxiety and paranoia. In a recently published pilot study by Newman Taylor and Stopa

(2013), the author report a significant association between self-reported paranoid thinking


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and social interaction anxiety in two groups of patients; one with a DSM-IV diagnosis of

social phobia and another with schizophrenia (with persecutory delusions). These findings

are interpreted with caution because the study had a small sample size, with opportunity

sampling, and because the self-report measures used in the study for measuring paranoid

thinking and social anxiety have considerable overlap. Conversely, the study by Huppert and

Smith (2005) found greater distinction between social anxiety and paranoia when assessed

by a trained clinician, as compared to self-report by patients. Thus, studies using clinician

assessments in addition to self-report measures may provide additional validity to

investigations into social anxiety and paranoia.

To summarise the links between social anxiety and paranoia in mixed clinical samples,

the findings suggest that there is a significant overlap in cognitive and affective predictive

factors for social anxiety and paranoia in affective disorders (Gilbert et al., 2005; Freeman et

al., 2008). Social anxiety and persecutory delusions are more distinguishable in psychosis

(Huppert & Smith, 2005; Michail & Birchwood, 2009). Better theory of mind ability and

higher paranoia have been associated with greater social anxiety in schizophrenia spectrum

disorders (Lysaker et al., 2010). Multiple pathways may be involved in the development of

the two conditions (Michail & Birchwood, 2009).

1.4.1.4 Relation between paranoid ideation and social anxiety in non-clinical populations

Eight empirical papers (Martin & Penn, 2001; Combs & Penn, 2004; Tone et al., 2011;

Freeman et al., 2008; Rietdijk et al., 2009; Yamauchi et al., 2009; Matos et al., 2012;

Schutters et al., 2012) reported a significant association between social anxiety and

paranoid ideation in a non-clinical sample, of which two studies controlled for depression,

and one study controlled for neuroticism, as the two constructs overlap with anxiety


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disorders and may confound the results. For example, the NEMESIS study (Rietdijk et al.,

2009)found a dose-response relationship between social phobia and paranoid ideation in

the general population; however this relationship weakened after controlling for

neuroticism.

In a sample of 193 undergraduate students, a brief report by Martin and Penn (2001)

found that paranoid ideation was associated with greater depressed mood, lower self-

esteem, higher social anxiety and greater attention to public aspects of the self. The study

used a brief self-report measure to examine fear of negative evaluations, which they

identified as assessing social anxiety. In addition, this study uses a cross-sectional study

design and correlational analysis, without controlling for any confounding variables, which

limits the validity to infer any causal links. Similarly, Combs and Penn (2004) found that

participants reporting higher levels of paranoid ideation had lower self-esteem and greater

depression, as well as social anxiety. This study used two distinct measures of social anxiety,

both of which were associated with subclinical paranoid ideation. Contrary to these findings,

the EDSP study (Schutters et al., 2012) reported a non-significant association between

subclinical social phobia and subclinical paranoid symptoms in the general population.

However, the association was significant for clinical paranoia and social phobia. As discussed

earlier, this may be due to the methodological limitation of assessing social phobia at DSM-

IV criterion level using the Composite International Diagnostic Interview (CIDI) method,

whereas paranoid symptoms were measured at a symptomatic level. From the existing

evidence, it is unclear whether the relationship between paranoid thoughts and social

anxiety is more significant at a clinical level, and whether paranoia is more strongly


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associated with performance related anxiety (i.e. social phobia) than social interaction

anxiety.

The study by Tone and colleagues (2011) investigated the role of social anxiety along with

perceptual anomalies in the prediction of paranoid ideation. Social anxiety and perceptual

anomalies such as body image distortions, independently predicted paranoia. However,

contrary to initial research hypotheses, the two constructs did not significantly interact to

predict paranoid thoughts. Although the findings are of research interest, the use of a

predominantly female (77%) university student sample reduces the generalizability of the

findings. Also, the validity of self-report measures and singular assessments, to capture a

multidimensional construct of social anxiety and paranoia, limit the conclusions that can be

drawn from the study. Subdividing paranoia into high and low, as conducted in some studies

(Michael & Birchwood, 2009; Lysaker et al., 2010) may provide more specificity in

prediction. Despite its limitations, the strength of the study is its large sample size (N = 644),

and it provides further support for the link between social anxiety and paranoia,

independent of negative affect and perceptual anomalies.

In summary, there is a strong link between sub-threshold social anxiety and paranoia in

the general population, which can be predicted by the presence of elevated affective

dysregulation (i.e. anxiety, depression, social consciousness). Perceptual anomalies can be

an independent predictor of paranoid ideation.


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1.4.2 How are the mechanisms underpinning social anxiety and social phobia similar or

different to paranoia?

1.4.2.1 Psychological mechanisms similar to social anxiety/phobia and paranoia

The primary aim of seven studies (Gilbert et al., 2005; Freeman et al., 2008; Yamauchi et

al., 2009; Matos et al., 2012; Schutters et al., 2012; Newman Taylor & Stopa, 2013; Stopa et

al., 2013) was to identify factors that distinguish the expression of social anxiety and

paranoia, of which three studies (Gilbert et al., 2005; Newman Taylor & Stopa, 2013; Stopa

et al., 2013) were more exploratory and one had weak methodological rigour (Yamauchi et

al., 2009). Focussing on psychological concepts of social comparison in a heterogeneous

clinical sample, Gilbert et al. (2005) found that an individuals perception of their own social

power, ranking, and submissive behaviour were commonly associated with both paranoid

thinking and social anxiety.

In support for affective dysregulation as a common risk factor for psychotic and affective

states, research involving innovative virtual reality tests and sophisticated statistical analysis

demonstrated that anxiety, depression, worry and interpersonal sensitivity similarly

predicted social anxiety and paranoia in non-clinical individuals (Freeman et al., 2008).

Recent findings from two exploratory studies (Newman Taylor & Stopa, 2013; Stopa et al.,

2013) by the same authors (one quantitative and one qualitative), although cross sectional

nature, found similar affective and cognitive mechanisms, such as anxiety, depression,

negative evaluative beliefs and interpersonal threat, contributing to social anxiety and

paranoia in a small sample of individuals diagnosed with schizophrenia and those diagnosed

with social phobia.


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Different cognitive and affective mechanisms have been similarly implicated in sub-

threshold and clinical social anxiety and paranoia, demonstrating shared vulnerability

between affective and non-affective disorders.

1.4.2.2 Psychological mechanisms distinguishing social anxiety/phobia from paranoia

Whilst its important to understand the developmental risk factors and common

pathways to the two phenotypically similar conditions, its just as necessary to describe their

specific profiles in different populations. Six of the seven studies examined the difference

between social anxiety and paranoia cross-sectionally (Gilbert et al., 2005; Freeman et al.,

2008; Yamauchi et al., 2009; Matos et al., 2012; Newman Taylor & Stopa, 2013; Stopa et al.,

2013) and one longitudinally (Schutters et al., 2012). Individuals with paranoid ideation are

more likely to experience internal perceptual anomalies, heightened perception of intended

harm and absurdity, as compared to individuals experiencing social anxiety (Freeman et al.,

2008; Yamauchi et al., 2009; Stopa et al., 2013). Although not unexpected, these findings

have been reported in non-clinical samples. The causal nature remains unexplained because

of the design of these studies. Of particular interest are the findings by Schutters and

colleagues (2012), who revealed that cognitions about negative evaluation and

temperamental traits (behavioural inhibition) were similarly associated with social phobia

and paranoia, however fear/avoidance of social situations specifically predicted social

phobia and cumulative environmental risk factors such as trauma and cannabis use

significantly increased the risk of paranoid symptoms. An additional strength of this

epidemiological study was its statistical findings for those individuals presenting with

comorbid social anxiety and paranoid symptoms (as compared with each condition

separately). The presence of both temperamental and environmental risk factors over a


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period of time predicted comorbid social anxiety and paranoia. There was significantly

greater cannabis use amongst individuals with a comorbid condition. A general population

study found that the traumatic impact of shame memories and their salience specifically

predicted paranoia but not social anxiety (Matos et al., 2012). In addition, internal shame

was more specifically associated with social anxiety and external shame with paranoid

ideation.

To summarise, few studies have identified psychological features that differentiate social

anxiety and paranoia. Anomalous experiences, heightened perception of harm, presence of

cumulative environmental risk factors and trauma centrality are more significantly

associated with paranoid ideation than social anxiety.

1.5 Discussion

This review examines the evidence from relevant papers investigating specifically the link

between social anxiety and paranoia (clinical and sub-threshold) in clinical and nonclinical

samples, to summarise the nature of the association between two conditions with

phenotypical resemblance. The results of this review bring to the forefront high incidence of

lifetime social phobia (8% to 9.4%) and paranoid symptoms (10% to 15.7%), and comorbid

social anxiety and paranoia in the general population (Rietdijk et al., 2009; Schutters et al.,

2012), with a dose-response relationship between the two conditions (Rietdijk et al., 2009).

Although most of the subclinical symptoms of psychosis may be transitory (Dominguez et

al., 2011), the risk of transition to clinical psychotic disorder is greater with persistence of

symptoms and impairment amongst those exposed to additional risk factors (Van Os et al.,

2009). Persistence of psychotic experiences is progressively more likely amongst individuals

with increased affective dysregulation (van Rossum et al., 2011), with comorbid anxiety and


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symptoms, in line with psychological models of persecutory delusions (Freeman et al.,

2002). Additional research using robust longitudinal or controlled experimental design

would be beneficial to explain the nature of the association and establish causal links.

The surge in studies investigating the link between affective dysregulation and psychosis

in the last decade (Freeman & Garety, 2003; Birchwood, 2003; Hartley et al., 2013) has

raised particular interest in research examining the relation between emotional difficulties

and positive symptoms of psychosis (Smith et al., 2006; Startup, Freeman & Garety, 2007).

Although surprisingly limited (Gilbert et al., 2005; Huppert & Smith, 2006; Michail &

Birchwood, 2009; Lysaker et al., 2010; Newman Taylor & Stopa, 2013; Stopa et al., 2013),

studies investigating the link between social anxiety and paranoid thoughts in clinical

samples have provided mixed results. Studies using mixed clinical groups (Gilbert et al.,

2005; Newman Taylor & Stopa, 2013; Stopa et al., 2013) showed a significant overlap

between social anxiety and paranoid thoughts, whereas the relationship was not significant

in schizophrenia spectrum disorders, despite the high prevalence of social anxiety. It may be

that clinical features of social anxiety and subclinical paranoid thoughts overlap more in

affective difficulties such as depression and anxiety, whilst the difference between the two

clinical conditions is more distinct in psychosis, with paranoid thoughts taking a more

aberrant expression of persecutory delusions. Alternatively, clinicians within specialist

services for psychosis may be better equipped at differentiating symptoms of paranoia from

social anxiety (Huppert & Smith, 2006).

Of particular interest were the findings in a sample of individuals with first episode

psychosis. Although the study (Michail & Birchwood, 2009) found no link between

persecutory delusions and social anxiety in the complete sample, a subsample of


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participants with elevated social anxiety experienced more persecutory threat as compared

to those without social anxiety. Based on their findings in first episode psychosis, the study

(Michail & Birchwood, 2009) proposed three pathways linking social anxiety and

persecutory beliefs: firstly, social anxiety may predict the onset and maintenance of

persecutory ideation. Secondly, social anxiety and persecutory thinking develop

independently and follow a similar course in different phases of psychosis. Thirdly, social

anxiety develops as a consequence of persecutory thinking. The studies reviewed in this

paper have provided varying levels of evidence for the three different pathways suggested.

However, considerable methodological differences in design, instruments and assessment

make the conclusions tentative.

Different cognitive and affective mechanisms have been similarly implicated in

individuals experiencing elevated social anxiety and those reporting high levels of paranoid

ideation, supporting the evidence for shared vulnerability between affective and non-

affective disorders (Van Os, J., Verdoux, H., Bijl, R. V., & Ravelli, 1999). Studies (Freeman et

al., 2008; Gilbert et al., 2005; Newman Taylor & Stopa, 2013; Stopa et al., 2013)

demonstrated that anxiety, depression and worry processes similarly predict social anxiety

and paranoid beliefs. Cognitive factors related to negative evaluations of self and other

(Schutters et al., 2012), as well as negative social cognitive beliefs such as submissive

behaviour and poor social comparison (Gilbert et al., 2005) are similarly associated with

social anxiety and paranoia. Similarity in psychological processes may be best understood in

the context of a dimensional approach to mental health (van Os, 2009), whilst considering

the diagnostic categorical approach ubiquitous in adult services.


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Internal perceptual anomalies and heightened perception of harm differentially

predict social anxiety from paranoid ideation in non-clinical samples. Exposure to

cumulative temperamental and environmental risk factors of trauma and cannabis use

increased the risk of comorbid social anxiety and paranoid ideation in vulnerable individuals

(Schutters et al., 2012). This is consistent with findings from epidemiological studies using

data from national comorbidity surveys, identifying a significant cumulative relation

between environmental risk factors such as trauma (Shevlin, Dorahy & Adamson, 2007) and

victimization with an elevated probability of psychosis over other psychiatric disorders

(Bebbington et al., 2004). Exposure to cumulative risk factors such as trauma and cannabis

use is strongly associated with comorbid social anxiety and paranoia, as well as increasing

the risk of a poor prognosis for those vulnerable to psychosis (van Os et al., 2002; Cougnard

et al., 2007).

There is now strong evidence to support the consequence of negative threat

appraisals and poor contextual processing of trauma memories in the persistence of post-

traumatic stress disorder (Ehlers & Clark, 2000). Whilst shame cognitions are associated

with elevated social anxiety in clinical (Michail & Birchwood, 2013) and non-clinical samples

(Matos et al., 2012), the role of trauma memories which are salient to the individuals self-

identity and personal construct are more strongly associated with persecutory delusions

than social anxiety, particularly those intrusions which make the individual feel subordinate

and identify others as threatening (Matos et al., 2012). It may also be that individuals

predisposed to paranoia and social anxiety are more likely to evaluate negative memories as

shameful and traumatic.


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Advancements in the conceptualizations of social anxiety (Stein & Stein, 2008) have not

only helped in understanding the role of social anxiety in psychosis (Michail & Birchwood,

2012) but also in furthering the explanation of positive symptoms of psychosis, specifically

paranoid delusions. Specific self-report measures (Connor et al., 2000)have been shown to

reliably screen for social anxiety disorder, however most studies reviewed here failed to

comprehensively investigate the multidimensional nature of the condition by either using a

single index measure or by not validating the assessed constructs through clinical

interviews.

1.6 Clinical implications

It is important for services working with adolescents and young people to include regular

assessments of emotional functioning, along with any evaluation of subclinical positive

symptoms. Suitable changes to CBT techniques for anxiety may be beneficial for the

reduction and management of paranoia (Freeman, Freeman & Garety, 2006) and may

reduce the risk for transition to paranoid delusions. Evidence for the role of trauma

centrality and salience of past shame memories differentially predict persecutory ideation

and social anxiety has clinical implications for designing appropriate CBT techniques for the

two conditions, which are known to overlap. Interventions aimed at reducing emotional

salient shameful thoughts that impact self-identity and are central to the persons life script

may be beneficial for reducing paranoid thoughts and social anxiety. There is preliminary

evidence to support the positive impact of post-event processing on reducing anxiety

memory recall amongst socially anxious individuals (Field & Morgan, 2004). Specific to

paranoia, compassion-focussed intervention has shown to reduce negative emotion and

paranoid thoughts, and increase self-esteem (Lincoln, Hohenhaus, & Hartmann, 2012).


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1.7 Methodological strengths and limitations

The initial search generated a number of studies on comorbid emotional dysfunction

(generalised anxiety, depression and worry) within psychosis and personality disorders.

These were excluded from the review as the excluded studies were not specifically looking

at the association between paranoia and social anxiety or were not clinically descriptive of

the association between the two conditions. Due to the methodologically rigorous search

criteria, the review was unable to draw on the wider literature on social anxiety and

paranoia. Conference abstracts and dissertations were excluded, limiting the contribution of

unpublished material, limiting the scope of the findings. The mixed population samples

(clinical and non-clinical) and cross sectional design of most studies reviews, limits the

understanding of temporal links between the two conditions. Finally, the review may be

subject to researcher bias, which were minimised by following checklists for data extraction

and quality assessment.

1.8 Conclusion

The lifetime incidence of social phobia in the general population ranged from 8% to 9.4%

and lifetime paranoid symptoms ranged from 10 to 15.7%. Approximately 2% met criteria

for comorbid social phobia and paranoid symptoms. There is a greater phenotypical

resemblance and overlap in predictive factors for social anxiety and paranoia in the general

population and affective disorders (Gilbert et al., 2005; Freeman et al., 2008). Social anxiety

and paranoia are more discernible in psychosis (Huppert & Smith, 2005). Presence of

cumulative risk factors (environmental and temperamental) such as trauma and cannabis

are associated with the onset of social anxiety and paranoia (Schutters et al., 2012). The

presence of social anxiety constitutes a significant problem amongst those experiencing


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paranoia in psychosis. More than one causal pathway may be implicated in the

development of social anxiety and paranoia (Michail & Birchwood, 2009), which require

careful research. Further investigation, using well designed methodology with a clear clinical

and research focus in social anxiety and different phases of psychosis would enable

discussions within youth mental health and promote better identification of needs within

early intervention services.

1.9 References

Bebbington, P. E., Bhugra, D., Brugha, T., Singleton, N., Farrell, M., Jenkins, R., ... & Meltzer,

H. (2004). Psychosis, victimisation and childhood disadvantage Evidence from the

second British National Survey of Psychiatric Morbidity. The British Journal of

Psychiatry, 185(3), 220-226.

Bentall, R. P., Corcoran, R., Howard, R., Blackwood, N., & Kinderman, P. (2001). Persecutory

delusions: a review and theoretical integration. Clinical Psychology Review, 21(8),

1143-1192.

Bentall, R. P., Rowse, G., Shryane, N., Kinderman, P., Howard, R., Blackwood, N., ... &

Corcoran, R. (2009). The Cognitive and Affective Structure of Paranoid Delusions. A

Transdiagnostic Investigation of Patients With Schizophrenia Spectrum Disorders and

Depression.Archives of General Psychiatry, 66(3), 236-247.

Ben-Zeev, D., Ellington, K., Swendsen, J., & Granholm, E. (2011). Examining a cognitive

model of persecutory ideation in the daily life of people with schizophrenia: a

computerized experience sampling study. Schizophrenia Bulletin, 37(6), 1248-1256.

Birchwood, M. (2003). Pathways to emotional dysfunction in first-episode psychosis. British

Journal of Psychiatry, 182,373-375.


46/125

40

Birchwood, M., Trower, P., Brunet, K., Gilbert, P., Iqbal, Z., & Jackson, C. (2007). Social

anxiety and the shame of psychosis: A study in first episode psychosis. Behaviour

Research and Therapy, 45,1025-1037.

Bgels, S. M., Alden, L., Beidel, D. C., Clark, L. A., Pine, D. S., Stein, M. B., & Voncken, M.

(2010). Social anxiety disorder: questions and answers for the DSM V. Depression

and Anxiety, 27(2), 168-189.

Bgels, S. M., & Mansell, W. (2004). Attention processes in the maintenance and treatment

of social phobia: hypervigilance, avoidance and self-focused attention. Clinical

Psychology Review, 24(7), 827-856.

Caldwell, K., Henshaw, L., & Taylor, G. (2005). Developing a framework for critiquing health

research.Journal of Health, Social and Environmental Issues, 6(1), 45-54.

Cardno, A. G., Rijsdijk, F. V., Sham, P. C., Murray, R. M., & McGuffin, P. (2002). A twin study

of genetic relationships between psychotic symptoms. American Journal of

Psychiatry, 159(4), 539-545.

Cardno, A. G., Marshall, E. J., Coid, B., Macdonald, A. M., Ribchester, T. R., Davies, N. J., ... &

Murray, R. M. (1999). Heritability estimates for psychotic disorders: the Maudsley

twin psychosis series.Archives of General Psychiatry, 56(2), 162.

CASP (2011). Critical Appraisal Skills Programme: Making sense of evidence about clinical

effectiveness. Retrieved April15th

, 2013 fromhttp://www.casp-uk.net/

Cicchetti, D., & Rogosch, F. A. (1996). Equifinality and multifinality in developmental

psychopathology. Development and Psychopathology, 8, 597-600.

Combs, D. R., & Penn, D. L. (2004). The role of subclinical paranoia on social perception and

behavior. Schizophrenia Research, 69(1), 93-104.
http://www.casp-uk.net/http://www.casp-uk.net/http://www.casp-uk.net/http://www.casp-uk.net/


47/125

41

Connor, K. M., Davidson, J. R., Churchill, L. E., Sherwood, A., Weisler, R. H., & FOA, E. (2000).

Psychometric properties of the Social Phobia Inventory (SPIN) New self-rating scale.

The British Journal of Psychiatry, 176(4), 379-386.

Cosoff, S. J., & Julian Hafner, R. (1998). The prevalence of comorbid anxiety in schizophrenia,

schizoaffective disorder and bipolar disorder.Australian and New Zealand Journal of

Psychiatry, 32(1), 67-72.

Cougnard, A., Marcelis, M., Myin-Germeys, I., De Graaf, R., Vollebergh, W., Krabbendam, L.,

... & Van Os, J. (2007). Does normal developmental expression of psychosis combine

with environmental risk to cause persistence of psychosis? A psychosis proneness-

persistence model. Psychological Medicine, 37(4), 513-528.

Craddock, N., & Owen, M. J. (2005). The beginning of the end for the Kraepelinian

dichotomy. The British Journal of Psychiatry, 186(5), 364-366.

Dominguez, M. D. G., Wichers, M., Lieb, R., Wittchen, H. U., & van Os, J. (2011). Evidence

that onset of clinical psychosis is an outcome of progressively more persistent

subclinical psychotic experiences: an 8-year cohort study. Schizophrenia Bulletin,

37(1), 84-93.

Johns, L. C., Cannon, M., Singleton, N., Murray, R. M., Farrell, M., Brugha, T., ... & Meltzer, H.

(2004). Prevalence and correlates of self-reported psychotic symptoms in the British

population. The British Journal of Psychiatry, 185(4), 298-305.

Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder.

Behaviour Research and Therapy, 38(4), 319-345.


48/125

42

Essau, C. A. (2005). Frequency and patterns of mental health services utilization among

adolescents with anxiety and depressive disorders. Depression and Anxiety, 22(3),

130-137.

Field, A. P., & Morgan, J. (2004). Post-event processing and the retrieval of autobiographical

memories in socially anxious individuals.Journal of Anxiety Disorders, 18(5), 647-663.

Foster, C., Startup, H., Potts, L., & Freeman, D. (2010). A randomised controlled trial of a

worry intervention for individuals with persistent persecutory delusions. Journal of

Behavior Therapy and Experimental Psychiatry, 41(1), 45.

Freeman, D., Dunn, G., Fowler, D., Bebbington, P., Kuipers, E., Emsley, R., ... & Garety, P.

(2012). Current Paranoid Thinking in Patients With Delusions: The Presence of

Cognitive-Affective Biases. Schizophrenia Bulletin.

Freeman D, Freeman J, Garety P (2006). Overcoming Paranoid and Suspicious Thoughts.

Robinson Constable : London.

Freeman, D., Garety, P. A., Kuipers, E., Fowler, D., & Bebbington, P. E. (2002). A cognitive

model of persecutory delusions. British Journal of Clinical Psychology, 41(4), 331-347.

Freeman, D., & Garety, P. A. (2003). Connecting neurosis and psychosis: the direct influence

of emotion on delusions and hallucinations. Behaviour Research and Therapy, 41(8),

923-947.

Freeman, D., Gittins, M., Pugh, K., Antley, A., Slater, M., & Dunn, G. (2008). What makes one

person paranoid and another person anxious? The differential prediction of social

anxiety and persecutory ideation in an experimental situation. Psychological

Medicine, 38(8), 1121-1132.


49/125

43

Freeman, D., McManus, S., Brugha, T., Meltzer, H., Jenkins, R., & Bebbington, P. (2011).

Concomitants of paranoia in the general population. Psychological Medicine, 41(5),

923.

Freeman, D., Stahl, D., McManus, S., Meltzer, H., Brugha, T., Wiles, N., & Bebbington, P.

(2012). Insomnia, worry, anxiety and depression as predictors of the occurrence and

persistence of paranoid thinking. Social Psychiatry and Psychiatric Epidemiology,

47(8), 1195-1203.

Fusar-Poli, P., Bonoldi, I., Yung, A. R., Borgwardt, S., Kempton, M. J., Valmaggia, L., ... &

McGuire, P. (2012). Predicting psychosis: meta-analysis of transition outcomes in

individuals at high clinical risk.Archives of General Psychiatry, 69(3), 220.

Gilbert, P., Boxall, M., Cheung, M., & Irons, C. (2005). The relation of paranoid ideation and

social anxiety in a mixed clinical population. Clinical Psychology & Psychotherapy,

12(2), 124-133.

Green, C., Garety, P. A., Freeman, D., Fowler, D., Bebbington, P., Dunn, G., & Kuipers, E.

(2006). Content and affect in persecutory delusions. British Journal of Clinical

Psychology, 45(4), 561-577.

Green, M. J., & Phillips, M. L. (2004). Social threat perception and the evolution of paranoia.

Neuroscience and Biobehavioral Reviews, 28(3), 333-342.

Hartley, S., Barrowclough, C., & Haddock, G. (2013). Anxiety and depression in psychosis: a

systematic review of associations with positive psychotic symptoms. Acta

Psychiatrica Scandinavica.

Huppert, J. D., & Smith, T. E. (2005). Anxiety and schizophrenia: the interaction of subtypes

of anxiety and psychotic symptoms. CNS Spectrums, 10(9), 721.


50/125

44

Kaymaz, N., Drukker, M., Lieb, R., Wittchen, H. U., Werbeloff, N., Weiser, M., ... & van Os, J.

(2012). Do subthreshold psychotic experiences predict clinical outcomes in

unselected non-help-seeking population-based samples? A systematic review and

meta-analysis, enriched with new results. Psychological Medicine, 42(11), 2239.

Kaymaz, N., & Van Os, J. (2010). Extended psychosis phenotypeyes: single continuum

unlikely. Psychological Medicine, 40(12), 1963.

Lichtenstein, P., Yip, B. H., Pawitan, Y., Cannon, T. D., Sullivan, P. F., & Hultman, C. M. (2009).

Common genetic determinants of schizophrenia and bipolar disorder in Swedish

families: a population-based study. Lancet (London, England), 373(9659), 234-239.

Lincoln, T. M., Hohenhaus, F., & Hartmann, M. (2012). Can paranoid thoughts be reduced by

targeting negative emotions and self-esteem? An experimental investigation of a

brief compassion-focused intervention. Cognitive Therapy and Research, 1-13.

Lysaker, P. H., Salvatore, G., Grant, M. L., Procacci, M., Olesek, K. L., Buck, K. D., ... &

Dimaggio, G. (2010). Deficits in theory of mind and social anxiety as independent

paths to paranoid features in schizophrenia. Schizophrenia Research, 124(1), 81-85.

Martin, J. A., & Penn, D. L. (2001). Social cognition and subclinical paranoid ideation. British

Journal of Clinical Psychology, 40(3), 261-265.

Matos, M., PintoGouveia, J., & Gilbert, P. (2012). The effect of shame and shame memories

on paranoid ideation and social anxiety. Clinical Psychology & Psychotherapy.

Michail, M., & Birchwood, M. (2009). Social anxiety disorder in first-episode psychosis:

incidence, phenomenology and relationship with paranoia. The British Journal of

Psychiatry, 195(3), 234-241.


51/125

45

Michail, M., & Birchwood, M. (2012). Social anxiety disorder and shame cognitions in

psychosis. Psychological Medicine, 1(1), 1-10.

Murray, R. M., Sham, P., Van Os, J., Zanelli, J., Cannon, M., & McDonald, C. (2004). A

developmental model for similarities and dissimilarities between schizophrenia and

bipolar disorder. Schizophrenia Research, 71(2), 405-416.

Newman Taylor, K., & Stopa, L. (2013). The Fear of Others: A Pilot Study of Social Anxiety

Processes in Paranoia. Behavioural and Cognitive Psychotherapy, 1(1), 1-23.

NHS Centre for Reviews and Dissemination. Systematic reviews: CRDs guidance for

undertaking reviews in health care. York: University of York, 2008. www.yps-

publishing.co.uk

Nuevo, R., Chatterji, S., Verdes, E., Naidoo, N., Arango, C., & Ayuso-Mateos, J. L. (2012). The

continuum of psychotic symptoms in the general population: a cross-national study.

Schizophrenia Bulletin, 38(3), 475-485.

Pallanti, S., Quercioli, L., & Hollander, E. (2004). Social anxiety in outpatients with

schizophrenia: a relevant cause of disability. American Journal of Psychiatry, 161(1),

53-58.

Rietdijk, J., Van Os, J., Graaf, R. D., Delespaul, P., & Gaag, M. V. D. (2009). Are social phobia

and paranoia related, and which comes first?. Psychosis, 1(1), 29-38.

Rossler, W., Riecher-Rossler, A., Angst, J., Murray, R., Gamma, A., Eich, D., ... & Gross, V. A.

(2007). Psychotic experiences in the general population: a twenty-year prospective

community study. S

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