Welcome to the 22nd WCP Congress Program Scheduling

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Although social anxiety disorder (SAD) is a common comorbidity in schizophrenia, there are no current guidelines on its treatment. To develop effective treatments, it was suggested that mechanisms underlying social anxiety in psychotic experiences should be investigated. This study aimed to examine which mechanisms potentially mediate social anxiety and paranoia relationship. We hypothesized that, firstly, negative social appraisals: stigma or shame; and secondly, safety behaviours: anxious avoidance or in situ defence behaviours significantly mediate social anxiety and paranoia relationship in schizophrenia.

A cross-sectional study conducted outpatients with a chronic stage of schizophrenia. Data on social anxiety, paranoia, depression, shame, stigma, anxious avoidance and in situ behaviours were collected. Mediation analysis with 10,000 bias-corrected bootstrap samples with 95%confidence intervals was used to test indirect effects of mediators.

Participants (n=113, 59.3%male) with mean age 44.2-year-old were recruited. Regarding multiple mediation analyses (co-varying for depression), stigma and shame (Hypothesis 1) did not show significant indirect effects while in situ behaviours (Hypothesis 2) showed a significant indirect effect through social anxiety-paranoia relationship.

Safety behaviours could be the key mechanism underlying relationship between social anxiety and persecutory thinking in people with established psychosis, which the in situ defence behaviours was found to be a full mediator. This study did not find negative social appraisals (shame or stigma) as a significant mediator, larger clinical study should be repeated. A greater focus on causal and mechanistic approach could produce robust findings of safety behaviours for development of targeted intervention treating SAD and paranoia in people with psychosis.

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Several theories have been put forward to understand the link between social anxiety and psychosis. These include the paranoia hierarchical model and post-psychotic stigma/shame, which suggest different direction of causal relationship between psychosis and social anxiety, different focus of the anxiety in social situations (e.g., embarrassment, performance). Recent evidence suggests the interplay between social anxiety and psychosis symptoms is complex with multiple pathways, including ideas of reference and negative symptoms. As research on symptom networks advances, which has the potential to unveil quantitatively how social anxiety develops/is maintained in people with psychosis, a revisit of the psychopathologies is needed to ensure that current symptom labels contain sufficient information about their potential relationships. Using the Ideas and Delusions of Reference Interview Scale (IRIS), which captures qualitative descriptions of self-referential experiences, we examined the detailed psychopathology of ideas of reference and the associated anxiety in social situations in psychosis outpatients. We noted the following phenomena: (1) (mis)interpretation of neutral information as suggesting social evaluation, such as others’ coughing; (2) anxiety linked to a heightened sensitivity to hint of social evaluation, such as glances of passer-by, without a clear possibility of humiliation/embarrassment that is core to social anxiety; and (3) more ‘understandable’ social anxiety with a link to potential scrutinization by others, such as suggestions of others’ being aware of one’s secrets or inadequacies. We discuss how these fine-grained descriptive psychopathologies can be used to inform further research and intervention design, drawing on classic understanding including primary delusions and sensitive delusions of reference.

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Self-referential psychopathology is extremely common and occurs in psychotic and non-psychotic disorders. However, to date there have been comparatively few research efforts undertaken to understand how ideas and delusions of reference arise and how they might be maintained. In ‘Der sensitive Beziehungswahn’, Kretschmer proposed a concept of paranoid psychosis precipitated by adverse life events on the background of a ‘sensitive personality’. Although there is no consensus that sensitive delusions of reference constitute a separate illness entity, his ideas on utilising a multidimensional diagnostic approach are now commonplace in psychiatric practice.

The talk will outline Kretschmer’s conceptualisation of ideas and delusions of reference, their aetiology and course. His case studies provide rich descriptions of premorbid personality traits, adverse life circumstances and the evolution of self-referential delusions. It is argued that by refocusing on detailed psychopathological descriptions and the context in which they arise, advances can be made in the understanding of delusion formation, their relationship with premorbid personality traits, adverse life events and the development of social anxiety.