Deficits in theory of mind and social anxiety as independent paths to paranoid features in schizophrenia

Social Cognition and Functioning in Patients With Social Anxiety Disorder and/or Attention-Deficit/Hyperactivity Disorder

ABSTRACT

In recent years, social cognition and one of its dimensions, the theory of mind, have been more commonly investigated in patients with social anxiety disorder (SAD) and attention-deficit/hyperactivity disorder (ADHD). In this study, SAD, ADHD, comorbid SAD-ADHD, and healthy control (HC) groups, each consisting of 30 participants, were included and compared in terms of social cognition and functionality. Mean global functioning assessment scores were found to be significantly higher in the HC group compared with the other three groups and in the ADHD group compared with the SAD and SAD-ADHD groups. Mean Dokuz Eylül Theory of Mind Index total scores were found to be significantly higher in the HC group compared with the other three groups and in the SAD and SAD-ADHD groups compared with the ADHD group. These findings suggest that SAD patients with or without ADHD show better social cognition but worse functioning compared with pure ADHD patients.

Comparison of Social-Evaluative Anxiety and Theory of Mind Functions in Social Anxiety Disorder, Schizophrenia, and Healthy Controls

INTRODUCTION

Despite the similarities in poor social competence and clinical manifestations of poor social behavior, no study has compared the theory of mind performance between social anxiety disorder (SAD) and schizophrenia, considering the effect of social-evaluative anxiety and neurocognitive functions. In our study, we aimed to compare the theory of mind functions and social-evaluative anxiety between patients with SAD and schizophrenia and healthy controls and to examine the relationship between the theory of mind, neurocognitive skills, and social-evaluative anxiety.

METHODS

Thirty-four consecutive patients with schizophrenia, 29 patients with SAD, and 30 controls matched by age, education level, and sex were enrolled in the study. Structured Clinical Interview for DSM, Beck Depression Inventory, Liebowitz Social Anxiety Scale, Theory of Mind measures (Reading the Mind in the Eyes Test, Hinting Task, Faux Pas Test), Social Appearance Anxiety Scale, Fear of Positive Evaluation Scale, Fear of Negative Evaluation Scale-Short Form, and neuropsychological tests were administered to all participants.

RESULTS

A greater significant deterioration in theory of mind and neurocognitive functions was found in patients with schizophrenia compared to those with SAD and healthy controls. Social evaluation anxiety was highest in patients with SAD. Although social-evaluative anxiety was associated with the theory of mind function in schizophrenia, only fear of positive evaluation was associated with SAD. In all groups, neither theory of mind nor neurocognitive ability measures were correlated with social anxiety levels and related symptoms.

CONCLUSIONS

The impaired theory of mind functioning detected in our study is more prominent in the schizophrenia group and largely independent of anxiety in schizophrenia and SAD. Although social evaluation anxiety, as a transdiagnostic concept, seems to be independent of theory of mind function in general, fear of positive evaluation seems to be associated with hinting in both disorders.

Disentangling Cognitive Heterogeneity in Psychotic Spectrum Disorders

Neuropsychological impairments represent a central feature of psychosis-spectrum disorders. It is characterized by a great both within- and between-subjects variability (i.e. cognitive heterogeneity), which needs to be better disentangled. The present study aimed to describe the distribution of performance on the Brief Assessment of Cognition in Schizophrenia (BACS) by using the Equivalent Scores, in order to balance statistical methodological problems. To do so, cognitive performance groups were branded, identifying the main factors contributing to cognitive heterogeneity. A sample of 583 patients with a diagnosis of Schizophrenia or Psychotic Disorder Not Otherwise Specified was enrolled and assessed for neurocognition and intellectual level. K-means cluster analysis was performed based on BACS Equivalent Scores. Differences among clusters were analyzed throughout Analysis of Variance and Discriminant Function Analysis in order to identify the most significant predictors of cluster membership. For each cognitive task, roughly 40% of patients displayed poor performance, while up to 63% displayed a symbol-coding deficit. K-means cluster analysis depicted three profiles characterized by "near-normal" cognition, widespread impairment, and "borderline" profile. Discriminant analysis selected Verbal IQ and diagnosis as predictors of cluster membership. Our findings support the usefulness of Equivalent Scores and cluster analysis to explain cognitive heterogeneity, and tailor better interventions.

Candidate Factors Maintaining Social Anxiety in the Context of Psychotic Experiences: A Systematic Review

Social anxiety is common in psychosis and associated with impaired functioning, poorer quality of life, and higher symptom severity. This study systematically reviewed factors maintaining social anxiety in people with attenuated, transient, or persistent psychotic experiences. Other correlates of social anxiety were also examined. MEDLINE, Embase, CENTRAL, and PsycINFO were searched for relevant literature up to October 19, 2020. Forty-eight articles were eligible for narrative synthesis: 38 cross-sectional studies, 8 prospective studies, 1 uncontrolled trial, and 1 qualitative study. From 12060 participants, the majority was general population (n = 8771), followed by psychosis samples (n = 2532) and those at high risk of psychosis (n = 757). The methodological quality and risk of bias were assessed using the Mixed Methods Appraisal Tool. Ninety percent of studies were rated as high to very-high quality. Poorer quality studies typically failed to adequately control for confounds and provided insufficient information on the measurement validity and reliability. Prominent psychological factors maintaining social anxiety included self-perceptions of stigma and shame. Common correlates of social anxiety included poorer functioning and lower quality of life. In conclusion, stigma and shame could be targeted as a causal mechanism in future interventional studies. The integration of findings from this review lead us to propose a new theoretical model to guide future intervention research.

Anxiety Mediates the Relationship between Psychotic-Like Experiences and Social Functioning in the General Population

INTRODUCTION

Within the psychosis continuum that includes schizophrenia (SZ) at the severe end and the general population at the mild end, anxiety may negatively impact social functioning more than psychosis or psychotic-like experiences (PLE). This claim is supported by previous reports that show anxiety mediates the relationship between psychosis and social functioning in SZ, suggesting anxiety is critical to social functioning in SZ. Yet no studies have examined a similar relationship in the general population, and this is important because people with PLE are at a significantly higher risk for developing full-blown psychosis.

METHODS

Similar to those with SZ, we predicted heightened anxiety would mediate the relationship between PLE, as measured by The -Oxford-Liverpool Inventory of Feelings and Experiences, and social functioning, as measured by Social Adjustment Scale - Self-Report, in the general population.

RESULTS

Indeed, the current study showed that the relationship between PLE and social functioning was mediated by anxiety (z = 7.81, p < 0.001) within an unselected crowdsourcing sample representative of the general population (Amazon M-Turk; n = 197, mean age 32.38 years).

CONCLUSION

Taken together with previous reports, the current findings suggest that anxiety is a functionally relevant dimension across the psychosis continuum and improving anxiety may improve social functioning across this continuum.

Moral Emotions and Social Economic Games in Paranoia

Impaired social cognitive processes are putative psychological mechanisms implicated in the formation and maintenance of paranoid beliefs. Paranoia denotes unfounded fears about the hostile intentions of others and is prevalent in a significant proportion of the general population. We investigated social cognition in healthy participants selectively recruited to have a broad occurrence of paranoid thinking (n = 89). Participants completed a novel computerized task of moral emotions and two social economic exchange games (Prisoner's Dilemma, Ultimatum Game) from the EMOTICOM neuropsychological test battery. Regression analyses revealed that delusional ideation predicted shameful feelings when the victim of deliberate harm by another person. Cooperative behavior on the Prisoner's Dilemma was greatest when the participant and opponent contributed equally to joint earnings. Participants demonstrated significantly more punishment behavior when contributions were unequal and stole more from the opponent using a suspicious strategy of gameplay. In addition, paranoid thinking was positively associated with more stealing from the cooperative opponent. On the Ultimatum Game, participants accepted significantly more unequal offers when the opponent contributed more and sensitivity to fairness was greatest when the participant contributed more. These data demonstrate that delusional ideation predicts a maladaptive emotional response to interpersonal harm and that paranoid thinking may lead to reduced cooperation toward mutual reward. The effects of paranoia on moral emotions and pro-social behavior at more severe levels of persecutory thinking warrant further investigation.

Examining relationships between psychotic experiences and suicidal ideation in adolescents using a network approach

BACKGROUND

Suicide is one of the leading causes of death in young individuals. Timely and adequate identification of individuals with suicidal ideation could prevent from suicidal behavior. Psychotic experiences (PE) have been shown to increase levels of suicidal ideation (SI) in the general population. Therefore, detailed investigation of the relationship of PE and SI is relevant. However, the exact nature of the relationship between these two phenomena remains unclear. Understanding psychopathology as a complex network of interacting symptoms could be helpful to elucidate specific associations existing between PE and SI.

METHOD

A specific type of network analysis, the Ising model, was used to examine connections between dichotomized questions on psychotic experiences and suicidal ideation in a cross-sectional study with 1685 adolescents from the general population aged 13-18 years.

RESULTS

SI was mostly connected to the PE domains perceptual anomalies (PA) and bizarre experiences (BE), which have higher strength values in the network. Central nodes within these domains, as indexed by higher centrality measures (strength and betweenness) were: auditory experiences (PA1: hearing voices when you are alone), persecutory ideation (BE1: feelings of being persecuted; BE2: conspiracy against you), and social anxiety (SANX) (SANX1: I cannot get close to people).

CONCLUSIONS

Suicidal ideation is differentially connected to specific psychotic experiences. Auditory PE, persecutory ideation, and social anxiety symptoms could play a central role in the interconnectedness of the two constructs.

Schizotypal traits and their relation to rejection sensitivity in the general population: Their mediation by quality of life, agreeableness and neuroticism

Schizotypal traits are a cluster of personality styles suggesting a potential liability for schizophrenia-spectrum disorders. Interpersonal schizotypal traits include cognitive disorganisation which consists of social anxiety, and introvertive anhedonia which consists of a lack of pleasure in social activities. Rejection sensitivity is evident all along this continuum. This study aimed to determine whether psychosocial quality of life (QOL), neuroticism and agreeableness mediates the relation between schizotypy and rejection sensitivity. Three hundred and eighteen participants from a predominantly University student population completed an online survey measuring schizotypy, rejection sensitivity, quality of life, and the five-factor personality traits. A regression analysis determined the prediction of rejection sensitivity by schizotypy, quality of life, and the five personality traits. Analyses examined the mediation of the relation between interpersonal schizotypy and rejection sensitivity by psychological QOL, social QOL, neuroticism, and agreeableness. Cognitive disorganisation and introvertive anhedonia predicted greater rejection sensitivity, which in turn were mediated by psychological QOL, social QOL, neuroticism, and agreeableness. The findings show that interpersonal schizotypy relates to greater rejection sensitivity. Psychosocial factors that lower one's ability to have positive feelings, trusting relationships, and prosocial behaviour, and personality traits that increase worrying mediate this association.

Cognitive Reserve Profiles in Chronic Schizophrenia: Effects on Theory of Mind Performance and Improvement after Training

OBJECTIVES

Cognitive reserve (CR), defined as individual differences in the ability to cope with brain damage, seem to be associated to the several psychopathological features in psychiatric patients, such as the functional outcome. This study aims to identify different profiles of CR by combining intelligence quotient (IQ) and premorbid functioning, two measures independently associated to CR in previous works, as well as to explore CR effect on both Theory of Mind (ToM) baseline performance and improvement after socio-cognitive trainings.

METHODS

Sixty patients with chronic schizophrenia underwent a socio-cognitive rehabilitation. All patients were assessed for psychopathology, neurocognition, and ToM at baseline and post-treatment. CR profiles were explored with K-means cluster analysis, while differences between clusters in both baseline assessments and post-treatment ToM improvement, were analyzed by means of analysis of variance and repeated measures analysis of covariance.

RESULTS

The analysis revealed three CR profiles, respectively, characterized by low early premorbid functioning and mild intellectual impairment, average/high early premorbid functioning trend with moderate intellectual impairment and good early premorbid functioning associated to IQ within normal limits. Analyses showed a significant effect of CR on both baseline ToM performance and treatment outcome: patients with higher CR reached significantly better ToM scores.

CONCLUSIONS

These results underline the clinical relevance of defining CR profiles of patients to customize trainings: subjects with a lower CR may benefit from more intensive programs. A deeper knowledge about CR may considerably increase our understanding of individual differences and thus potentiate treatment outcome. (JINS, 2018, 24, 563-571).

Social anxiety and risk factors in patients with schizophrenia: Relationship with duration of untreated psychosis

Social anxiety is commonly reported as a comorbid condition among people with schizophrenia. The aims of this study were to elucidate the associations between demographic/clinical features and social anxiety. A total of 207 outpatients with schizophrenia underwent assessments for social anxiety, psychiatric symptoms, social cognition, cognitive function, social functioning, and quality of life (QOL). To confirm the prediction model for social anxiety, we conducted multiple linear regressions using the Liebowitz Social Anxiety Scale (LSAS) score as an outcome variable and demographic/clinical variables as predictors. Of the 207 patients, 30 (14.5%) met the criteria for social anxiety disorder and 109 (52.7%) had a mean LSAS score higher than 30, suggesting that their social anxiety symptoms had reached a clinical level. Social anxiety was significantly correlated with psychiatric symptoms, social functioning, and QOL, whereas significant correlations with social cognition and cognitive function were not observed. A multiple regression analysis identified social functioning, gender, age of onset, and duration of untreated psychosis (DUP) as predictors that were most closely associated with the LSAS score. We confirmed that social anxiety symptoms were highly prevalent among outpatients with schizophrenia and were closely associated with social functioning and DUP, rather than social cognitive impairments.

Schizophrenia dissection by five anxiety and depressive subtype comorbidities: Clinical implications and evolutionary perspective

Twenty patients with DSM5 schizophrenia were comprehensively and formally assessed by an experienced psychiatrist. All subjects were assessed for: positive and negative psychotic symptoms; social anxiety; panic anxiety; obsessive compulsive disorder, atypical depression; major depression; suicide risk; and global assessment of functioning. Different profiles of clinical presentation and symptom evolution emerged for patients with schizophrenia who had co-morbid depression (15%), OCD (15%), panic or limited symptom attacks (55%) and social anxiety (5%). At least eighty percent of the sample had one or more of these co-morbidities. Summing up, the data support our previous finding that panic is highly prevalent in Schizophrenia with Auditory Hallucinations (>73% here, versus 100% before), and panic was paroxysmally concurrent with voice onset. Moreover, characteristic clinical findings may help point clinicians to five specific co-morbidity psychosis subtypes. Moreover, co-morbidity dissection of psychotic diagnoses recalls and parallels the historical psychopharmacologic dissection of non-psychotic anxiety and depressive subtypes diagnoses. Larger studies should further test and explore these preliminary findings.

Measuring fluctuations in paranoia: Validity and psychometric properties of brief state versions of the Paranoia Checklist

Research increasingly assesses momentary changes in paranoia in order to elucidate causal mechanisms. Observed or manipulated changes in postulated causal factors should result in fluctuations in state paranoid ideation. Previous studies often employed a state-adapted Paranoia Checklist (Freeman et al., 2005) to measure state paranoia. This study examined whether the Paranoia Checklist or subsets of its items are appropriate for this purpose. Thirteen studies (N=860) were subjected to meta-analyses of each Paranoia Checklist item. We selected items based on (1) whether they showed pre-to-post change in the expected direction and (2) whether this effect was larger in experimental vs. control conditions. All resulting item selections were cross-validated on a hold-out sample (n=1893). Finally, we explored how much variation in paranoia was captured by the state-adapted version in a brief ambulatory assessment study (N=32). A thirteen item State Paranoia Checklist as well as a five item and a three item Brief State Paranoia Checklist were extracted. Cross validation revealed better model fit and increased sensitivity to change. Multilevel analysis indicated 25-30% of the variance in the Brief State Paranoia Checklists to be due to intra-individual daily fluctuations in paranoia. Our analyses produced reliable and valid revised scales. Increases in change sensitivity indicate that future assessment of state paranoia in experimental and ambulatory assessment studies can be optimized by using the revised scales.

Hypersensitivity to Contingent Behavior in Paranoia: A New Virtual Reality Paradigm

Contingency in interpersonal relationships is associated with the development of secure attachment and trust, whereas paranoia arises from the overattribution of negative intentions. We used a new virtual reality paradigm to experimentally investigate the impact of contingent behavior on trust along the paranoia continuum. Sixty-one healthy participants were randomly allocated to have a social interaction with a pleasant virtual human (avatar) programmed to be highly responsive or not (high/low contingency). Perceived trustworthiness and trusting behavior were assessed alongside control variables attachment and anxiety. Higher paranoia and dismissive attachment were associated with larger interpersonal distances. Unexpectedly, extremely paranoid individuals experienced the highly contingent avatar as more trustworthy than their low contingency counterpart. Higher dismissive attachment was also associated with more subjective trust in both conditions. Extreme paranoia is associated with hypersensitivity to noncontingent behavior, which might explain experiences of mistrust when others are not highly responsive in everyday social situations.

PARANOID INDIVIDUALS WITH SCHIZOPHRENIA SHOW GREATER SOCIAL COGNITIVE BIAS AND WORSE SOCIAL FUNCTIONING THAN NON-PARANOID INDIVIDUALS WITH SCHIZOPHRENIA

Paranoia is a common symptom of schizophrenia that may be related to how individuals process and respond to social stimuli. Previous investigations support a link between increased paranoia and greater social cognitive impairments, but these studies have been limited to single domains of social cognition, and no studies have examined how paranoia may influence functional outcome. Data from 147 individuals with schizophrenia were used to examine whether actively paranoid and non-paranoid individuals with schizophrenia differ in social cognition and functional outcomes. On measures assessing social cognitive bias, paranoid individuals endorsed more hostile and blaming attributions and identified more faces as untrustworthy; however, paranoid and non-paranoid individuals did not differ on emotion recognition and theory of mind tasks assessing social cognitive ability. Likewise, paranoid individuals showed greater impairments in real-world interpersonal relationships and social acceptability as compared to non-paranoid patients, but these differences did not extend to performance based tasks assessing functional capacity and social competence. These findings isolate specific social cognitive disparities between paranoid and non-paranoid subgroups and suggest that paranoia may exacerbate the social dysfunction that is commonly experienced by individuals with schizophrenia.

Evidence from paranoid schizophrenia for more than one component of theory of mind

We previously reported finding that performance was impaired on four out of five theory of mind (ToM) tests in a group of 21 individuals diagnosed with paranoid schizophrenia (pScz), relative to a non-clinical group of 29 individuals (Scherzer et al., 2012). Only the Reading the Mind in the Eyes Test did not distinguish between groups. A principal components analysis revealed that the results on the ToM battery could be explained by one general ToM factor with the possibility of a latent second factor. As well, the tests were not equally sensitive to the pathology. There was also overmentalization in some ToM tests and under-mentalisation in others. These results led us to postulate that there is more than one component to ToM. We hypothesized that correlations between the different EF measures and ToM tests would differ sufficiently within and between groups to support this hypothesis. We considered the relationship between the performance on eight EF tests and five ToM tests in the same diagnosed and non-clinical individuals as in the first study. The ToM tests shared few EF correlates and each had its own best EF predictor. These findings support the hypothesis of multiple ToM components.

The relation between schizotypy and early attention to rejecting interactions: The influence of neuroticism

OBJECTIVES

Schizotypy relates to rejection sensitivity (anxiety reflecting an expectancy of social exclusion) and neuroticism (excessive evaluation of negative emotions). Positive schizotypy (e.g., perceptual aberrations and odd beliefs) and negative schizotypy (e.g., social and physical anhedonia) could relate to altered attention to rejection because of neuroticism.

METHODS

Forty-one healthy individuals were assessed on positive and negative schizotypy and neuroticism, and event-related potentials during rejecting, accepting and neutral scenes. Participants were categorised into high, moderate and low neuroticism groups. Using temporo-spatial principal components analyses, P200 (peak latency = 290 ms) and P300 amplitudes (peak latency = 390 ms) were measured, reflecting mobilisation of attention and early attention, respectively.

RESULTS

Scalp-level and cortical source analysis revealed elevated fronto-parietal N300/P300 amplitude and P200-related dorsal anterior cingulate current density during rejection than acceptance/neutral scenes. Positive schizotypy related inversely to parietal P200 amplitude during rejection. Negative schizotypy related positively to P200 middle occipital current density. Negative schizotypy related positively to parietal P300, where the association was stronger in high and moderate, than low, neuroticism groups.

CONCLUSIONS

Positive and negative schizotypy relate divergently to attention to rejection. Positive schizotypy attenuates, but negative schizotypy increases rejection-related mobilisation of attention. Negative schizotypy increases early attention to rejection partly due to elevated neuroticism.

Judging Strangers' Trustworthiness is Associated with Theory of Mind Skills

Trusting people requires evaluating them to assess their trustworthiness. Evaluating a stranger's intentions is likely to be one method of assessing trustworthiness. The present study tested the hypothesis that judgments of trustworthiness are associated with mind reading skills, also called theory of mind (ToM). We tested a group of healthy participants and a group of patients with paranoid schizophrenia. Both groups made ToM judgments and judged the trustworthiness of strangers. Participants were also assessed for their disposition to trust as well as levels of paranoid belief. As anticipated, healthy participants had a normal ToM scores and patients with paranoid schizophrenia had poor ToM scores. In paranoid patients, better ability to read others' minds was associated with judging others as more trustworthy, while the reverse was found in the healthy participants (better mind reading was associated with judging others as less trustworthy), suggesting a non-linear relationship between trust in others and being able to read their intentions.

Cognitive-Behavioral Treatment of Social Anxiety Disorder and Comorbid Paranoid Schizophrenia

We report on the cognitive-behavioral treatment (CBT) of a patient with comorbid social anxiety disorder (SAD), schizophrenia, and major depressive disorder, complicated by alcohol abuse. Symptoms included auditory hallucinations that commented on the patient’s behavior and paranoid thoughts. The paranoid symptoms affected his social interactions as this included the fear that his thoughts may be heard and judged by others. Therapeutic activities raised awareness as to how avoidance interferes with and perpetuates the cycle of depression and psychosis while maintaining symptoms of SAD. Psychoeducation was provided about factors that maintain social anxiety and increase social isolation. New skills were obtained by helping the patient discover alternative ways to view social situations, experimentation, and real-world application to disprove notions about others’ predicted behavior. Treatment led to a great reduction in social anxiety, depression, and suspicious thinking. This case study demonstrates that SAD symptoms in a patient experiencing psychosis can be effectively treated using CBT.

Greater positive schizotypy relates to reduced N100 activity during rejection scenes

Social anxiety due to rejection sensitivity (RS) exacerbates psychosis-like experiences in the general population. While reduced dorsal anterior cingulate cortex (dACC) activity during social rejection in high schizotypy has suggested self-distancing from rejection, earlier stages of mental processing such as feature encoding could also contribute to psychosis-like experiences. This study aimed to determine the stage of mental processing of social rejection that relates to positive schizotypy. Forty-one healthy participants were assessed for schizotypy and RS. Event-related potential amplitudes (ERPs) were measured at frontal, temporal and parieto-occipital sites and their cortical sources (dACC, temporal pole and lingual gyrus) at early (N100) and late (P300 and late slow wave, LSW) timeframes during rejection, acceptance and neutral scenes. ERPs were compared between social interaction types. Correlations were performed between positive schizotypy (defined as the presence of perceptual aberrations, hallucinatory experiences and magical thinking), RS and ERPs during rejection. Amplitude was greater during rejection than acceptance or neutral conditions at the dACC-P300, parieto-occipital-P300, dACC-LSW and frontal-LSW. RS correlated positively with positive schizotypy. Reduced dACC N100 activity during rejection correlated with greater positive schizotypy and RS. Reduced dACC N100 activity and greater RS independently predicted positive schizotypy. An N100 deficit that indicates reduced feature encoding of rejection scenes increases with greater positive schizotypy and RS. Higher RS shows that a greater tendency to misattribute ambiguous social situations as rejecting also increases with positive schizotypy. These two processes, namely primary bottom-up sensory processing and secondary misattribution of rejection, combine to increase psychosis-like experiences.

Theory of mind impairments in social anxiety disorder

Social anxiety disorder (SAD) is a common psychiatric disorder characterized by a persistent, excessive fear and avoidance of social and performance situations. Research on cognitive biases indicates individuals with SAD may lack an accurate view of how they are perceived by others, especially in social situations when they allocate important attentional resources to monitoring their own actions as well as external threat. In the present study, we explored whether socially anxious individuals also have impairments in theory of mind (ToM), or the ability to comprehend others' mental states, including emotions, beliefs, and intentions. Forty socially anxious and 40 non-socially-anxious comparison participants completed two ToM tasks: the Reading the Mind in the Eyes and the Movie for the Assessment of Social Cognition. Participants with SAD performed worse on ToM tasks than did non-socially-anxious participants. Relative to comparison participants, those with SAD were more likely to attribute more intense emotions and greater meaning to what others were thinking and feeling. These group differences were not due to interpretation bias. The ToM impairments in people with SAD are in the opposite direction of those in people with autism spectrum conditions whose inferences about the mental states of other people are absent or very limited. This association between SAD and ToM may have important implications for our understanding of both the maintenance and treatment of social anxiety disorder.

A composite scale applied to evaluate anxiety in schizophrenic patients (SAES)

Anxiety in schizophrenia possesses specific features and is difficult to assess because no specific evaluating tool is currently available. The aim of this study was to develop and validate a hetero-assessment-based scale to specifically measure anxiety in schizophrenia. A literature review and a survey among psychiatrists allowed the selection of 29 items from 4 previous scales evaluating anxiety. Factor analysis allowed building up a final 22-item composite scale of anxiety evaluation in schizophrenia (SAES), which was then validated in 147 schizophrenic patients. One hundred and forty-seven (147) schizophrenic patients (70.8 % male, mean age = 36.9 years) were included in the study. Principal component analysis of the SAES revealed three factors, namely "expressed and perceived anxiety," "somatic anxiety," and "anxiety and environment". All total and factor scores of the SAES were significantly correlated (p < .001) with total and factor scores of the original scales. Finally, the SAES showed good inter-rater reliability [intra-class correlation coefficient (ICC) = .82]. In conclusion, a specific tool for evaluating anxiety in schizophrenia (SAES) was developed and validated in a sample of schizophrenic patients. The SAES can be useful to investigate clinical, psychopathological, and therapeutic aspects of anxiety in schizophrenia.

Prevalence of psychotic-like experiences in young adults with social anxiety disorder and correlation with affective dysregulation

Social anxiety disorder (SAD) is associated with psychotic-like experiences (PLEs) and is a frequent diagnosis in the prodromal phases of psychosis. We investigated whether psychopathological factors could discriminate which subjects with SAD are more likely to develop PLEs. A sample of 128 young adults with SAD was split into two subsamples according to the presence of clinically relevant PLEs. Correlations between PLEs and other psychopathological markers were explored. The SAD with PLEs group showed higher level of anxiety, depression, and intolerance of uncertainty (IU) compared with the SAD without PLEs group. A limitation of this study is that the cross-sectional design precluded the analysis of causality. In our sample, the presence of PLEs is related to higher levels of depression, anxiety, and IU. The current findings are consistent with hypotheses suggesting that cognitive disturbances, together with social anxiety, may result in PLEs.

Anxiety comorbidity in schizophrenia

Diagnostic and treatment hierarchical reductionisms have led to an oversight of anxiety syndromes in schizophrenia. Nevertheless, recent data have indicated that anxiety can be a significant source of morbidity in this patient group. This paper reviews current knowledge concerning anxiety comorbidity in schizophrenia, its epidemiology, course, and treatment. A computerized search of the literature published from 1966 to July 2012 was conducted on Medline. Comorbid anxiety disorders are present in 38.3% of subjects with schizophrenia spectrum disorders. The most common anxiety disorder is social phobia followed by post-traumatic stress disorder and obsessive compulsive disorder. The presence and severity of symptoms of anxiety are associated with more severe clinical features and poorer outcomes. Available literature on the treatment consists primarily of case reports and open trials. Fragments of data support the notion of treating these anxiety states and syndromes as co-occurring clinical conditions with adjunctive medications and psychosocial interventions. However, additional work remains to be done on this issue before firm conclusions can be drawn.

Impact of social anxiety on social cognition and functioning in patients with recent-onset schizophrenia spectrum disorders

Schizophrenia patients display important rates of comorbid social anxiety disorder (SAD) but few studies have directly examined how SAD affects the presentation of schizophrenia, notably social cognition deficits and functioning.

AIMS

To compare social cognition performance of schizophrenia patients who meet the diagnostic criteria for a comorbid SAD (SZ+) relative to patients without such comorbidity (SZ-) and to determine if the impact of social cognition performance on functioning is moderated by that comorbidity.

METHOD

Social cognition performance (emotion recognition, social knowledge, and mentalizing), a control non-social reasoning task, as well as clinical symptoms and functioning were assessed in 26 patients with comorbid SAD (SZ+), 29 SZ- and 84 healthy controls.

RESULTS

Patient groups significantly differed from each other on social knowledge performance, but not in levels of symptoms or overall functioning. Relative to healthy controls, SZ+ were impaired uniquely on mentalizing, whereas SZ- showed a more encompassing social cognition deficit that included mentalizing, social knowledge and non-social reasoning impairments. Mentalizing was the best predictor of functioning across both patient groups. Importantly, non-social reasoning negatively influenced mentalizing and in turn functioning only in the SZ- group.

CONCLUSIONS

The overall pattern of results indicates common mentalizing deficits in SZ+ and SZ-; however, these deficits appear linked to different underlying deficits and different pathways to functional impact in the two patient subgroups. This study highlights some distinctive characteristics of schizophrenia patients with comorbid SAD and signals a need for further investigations into the sources of the mentalizing and functioning impairments in SZ+ patients.

Emotional episodes in the everyday lives of people with schizophrenia: the role of intrinsic motivation and negative symptoms

Research on emotional experience has indicated that subjects with schizophrenia experience less positive, and more negative emotional experience than non-psychiatric subjects in natural settings. Differences in the experience of emotion may result from differences in experiences such that everyday activities may evoke emotions. The purpose of this study was to identify if everyday experience of competence and autonomy were related to positive and negative emotion. Adults with schizophrenia spectrum disorders were recruited from day treatment programs (N=45). Data were collected using experience-sampling methods. A number of subjects failed to meet data adequacy (N=13) but did not differ from retained subjects (N=32) in symptoms or cognition. Positive and negative emotion models were analyzed using hierarchical linear modeling Everyday activities were characterized by those reported as easily accomplished and requiring at most moderate talents. Positive emotional experiences were stronger than negative emotional experiences. The majority of variance in positive and negative emotion existed between persons. Negative symptoms were significantly related to positive emotion, but not negative emotion. The perception that motivation for activity was external to subjects (e.g. wished they were doing something else) was related to decreased positive emotion and enhanced negative emotion. Activities that required more exertion for activities was related to enhanced positive emotion, whereas activities that subjects reported they wanted to do was associated with reduced negative emotion. The implications of this study are that everyday experiences of people with schizophrenia do affect emotional experience and that management of experience to enhance positive emotion may have therapeutic benefits.

A study of theory of mind in paranoid schizophrenia: a theory or many theories?

Social cognitive psychologists (Frith, 1992; Hardy-Baylé et al., 2003) sought to explain the social problems and clarify the clinical picture of schizophrenia by proposing a model that relates many of the symptoms to a problem of metarepresentation, i.e., theory of mind (ToM). Given the differences in clinical samples and results between studies, and considering the wide range of what is considered to constitute ToM, one must ask if there a core function, or is ToM multifaceted with dissociable facets? If, there are dissociable dimensions or facets, which are affected in patients with paranoid schizophrenia? To answer these questions, a group of 21 individuals diagnosed with paranoid schizophrenia and 29 non-clinical control subjects, were tested on a battery of five different measures of ToM. The results confirmed that there was little difference in specificity of three of the tests in distinguishing between the clinical and non-clinical group, but there were important differences in the shared variance between the tests. Further analyses hint at two dimensions although a single factor with the same variance and the same contributing weights in both groups could explain the results. The deficits related to the attribution of cognitive and affective states to others inferred from available verbal and non-verbal information. Further analyses revealed that incorrect attributions of mental states including the attribution of threatening intentions to others, non-interpretative responses and incomplete answers, depending on the test of ToM.

Severe social anxiety in early psychosis is associated with poor premorbid functioning, depression, and reduced quality of life

OBJECTIVE

The main aim of the present study was to examine whether patients with first-episode psychosis (FEP) with severe social anxiety show poorer premorbid and current functioning, higher level of current clinical symptoms, and better "insight into illness." Furthermore, we wanted to explore whether social anxiety is associated with reduced quality of life (QoL).

METHOD

A sample of 144 individuals with an FEP was divided into 3 groups depending on current level of social anxiety symptoms measured by the Liebowitz Social Anxiety Scale. Analysis of variance was performed including measures of demographic and clinical characteristics. A hierarchical regression analysis was performed to explore possible predictors of QoL.

RESULTS

The most severe social anxiety group revealed poorer premorbid adjustment, lower social functioning, and higher levels of depression. Furthermore, this group revealed a higher awareness of illness and experienced reduced QoL. Overall, social anxiety was associated with reduced QoL even after adjusting for psychotic symptoms and depression.

CONCLUSION

Severe social anxiety in FEP is associated with poor premorbid functioning and distinct clinical characteristics, besides being a possible predictor of QoL.

Recognition and repair of communicative failures: the interaction between Theory of Mind and cognitive complexity in schizophrenic patients

The aim of the present research is to perform a detailed and empirical investigation of schizophrenia patients' deficits in recognizing and recovering a communicative failure. In particular, this paper investigates the role of Theory of Mind (ToM) and of the complexity of the mental representations involved in explaining patients' deficits in recognizing and recovering different kinds of communicative failures, i.e. failure of the expressive act, failure of communicative meaning and failure of the communicative effect. Twenty-two patients with schizophrenia and an equal number of healthy controls took part in the experiment. The experimental protocol consisted of videotaped stories in which two agents interact, showing a communicative failure; the participants were asked to recognize and repair the observed failure. Some classical ToM tests (Sally and Ann, Modified Smarties and a selection of six Strange Stories) were also administered. Our results revealed a deficit in patients, when compared with healthy controls, in recognizing and recovering communicative failures. Furthermore, focusing on schizophrenia patients' performance per se, we observed a trend with regard to the increasing difficulty of understanding and recognizing different kinds of communicative failures, i.e. failure of expression act, failure of communicative meaning, and failure of the communicative effect.

LEARNING OUTCOMES

The reader becomes aware that schizophrenic patients perform less well than healthy controls in recognizing and recovering different kinds of communicative failures, and of the role played by Theory of Mind, and representational complexity involved in such different kinds of failures, in explaining patients' performance.

Perception of other people's mental states affects humor in social anxiety

BACKGROUND AND OBJECTIVES

The present study examined the relationship between social anxiety and the appreciation of specific types of humor. It was expected that social anxiety would hinder the enjoyment of jokes particularly if the resolution of incongruity involves processing social cues and assessing the (false) mental states of others. Fifty-six participants rated three types of cartoons and a control condition for comprehensibility and funniness.

RESULTS

High degrees of social anxiety were associated with less enjoyment of cartoons that involved the interpretation of others' mental states (Theory of Mind), but not of semantic cartoons or visual puns. Furthermore, high social anxiety was related to longer response latencies of the funniness ratings, especially in the case of Theory of Mind cartoons.

LIMITATIONS

A possible limitation is that the present study was conducted in individuals with social anxiety in the non-clinical range.

CONCLUSIONS

The findings suggest that highly socially anxious people do not have a general humor processing deficit, but may feel threatened by tasks involving the mental states of others. The negative affect evoked by TOM humor may hinder the experience of funniness in highly socially anxious individuals, and it may also make it more difficult for them to rate their own amusement.

Theory of mind and its relevance in schizophrenia

PURPOSE OF REVIEW

Social cognitive impairments are considered to be core features of schizophrenia and have been hypothesized to play a mediator role between basic neurocognition and patients' outcomes. In this context, theory of mind (ToM) abilities are of special relevance, and deficits in this area may represent trait markers of schizophrenia.

RECENT FINDINGS

In this review, studies published since September 2010 have been summarized with a particular focus on the relationships between ToM and psychopathology, neurocognition, and psychosocial outcomes in patients with schizophrenia, as well as on ToM abilities in high-risk individuals. In addition, recent neuroimaging data as well as treatment interventions have been described.

SUMMARY

The reviewed literature strengthens the hypothesis that ToM deficits have the potential to be valid markers for schizophrenia.

Psychotic symptoms in social anxiety disorder patients: report of three cases

Background

Social Anxiety Disorder (SAD) is mainly characterized by an individual's intense concern about other people's opinion of the individual. Notably, among those with severe anxious symptoms, we can often observe self-referential feelings.

Objective

Faced with little research directed toward the exploration of psychotic symptoms in SAD patients, we will approach the topic by describing three cases.

Discussion

Three explanations seem possible for the psychotic manifestations in SAD. The first one depends on the individual's ability or inability to challenge the impression of being criticized by people. A second possibility would be the stressor and perpetuating role of SAD, which would make individuals more likely to present with more severe mental disorders such as delusional disorder (DD). The third explanation would be the possibility that SA is caused by a primary thought abnormality (psychotic self-reference) in some cases, instead of an affective disturbance (anxious insecurity), which led to intense concern about others' opinions. We also observed that antipsychotics did not produce significant improvement in any of the three cases. This result may be related to dopaminergic circuits and the D2 receptor hypoactivity.

Conclusion

The differentiation between delusion and anxious concern may be inaccurate and may change throughout the disorder's evolution. New diagnostic subcategories or the enlargement of the social anxiety diagnostic is proposed to overcome the current diagnostic imprecision. There seems to be a symptomatic spectrum between SAD and DDs.