S120. CANDIDATE FACTORS MAINTAINING SOCIAL ANXIETY IN PSYCHOTIC EXPERIENCES: A SYSTEMATIC REVIEW
Authors: Aunjitsakul Warut , McGuire Nicola , McLeod Hamish , Gumley Andrew 
Published: May 2020

Abstract

Background
Social anxiety disorder (SAD) is common in people experiencing psychosis, with a pooled prevalence rate of 21% (16%-26%). It is evidenced that the factors maintaining SAD in psychosis is inconclusive, and more work is needed to understand the causal and maintenance mechanisms in order to develop more targeted therapies. So far, no previous systematic review has investigated factors that maintain SAD in psychosis. An integrated analysis of key factors from the literature combined with existing therapeutic knowledge (e.g. Cognitive Behavioural Therapy) could positively impact clinical practice. We therefore aimed to identify candidate factors maintaining SAD in psychosis, along with the factors related social anxiety in those with psychotic experiences.

Methods
MEDLINE, Embase, CENTRAL and PsycINFO databases were searched on 31 October 2018. Which search terms used for Population were ((psychosis) or (psychotic) or (schizophreni*) or (schizoaffective) or (delusion*) or (paranoi*) or (clinical high risk*) or (ultra high risk*) or (attenuated) or (at risk mental state*) or (recent onset) or (first episode psycho*) or (early psycho*)), and for Outcome were ((social anxi*) or (social phob*)). According to included studies are highly heterogeneous data, then we planned a narrative synthesis. The methodological quality and risk of bias of included studies were assessed using the Mixed Methods Appraisal Tool (MMAT) - Version 2011.

Results
Of 43 out of 3982 studied were eligible for narrative synthesis. The studies included cross-sectional (33 studies), prospective (7 studies), randomised controlled trials (1 studies), a non-randomised clinical trial (1 study) and a qualitative study (1 study). Total participants were 11,825; the majority were drawn from the general population (N=8680), followed by psychosis samples (N=2512) and those at high risk of psychosis (N=633). General quality of the literature (41 studies) were determined as good to high quality.
Regarding the objective, the psychological factors that may play a role in the maintenance of SAD in psychosis were identified. The major factors were cognitive factors; here are stigma, low self-esteem, shame, low social rank, negative thoughts, hopelessness and post-event processing, respectively. Metacognitive factors were found in different factors: mentalization, theory of mind, metacognition and reasoning bias. Few studies examined safety behaviours factor. Other maintenance factors were adult attachment, empathy, intolerance of uncertainty and coping style.
We also identified the factors related social anxiety in psychotic context. There were poorer quality of life (QoL), poorer daily functioning with poorer premorbid functioning, poorer well-being, poorer family functions, more traumatic events, personality problems, more anomalous experiences, impaired executive function, suicidality, subclinical paranoia, persecutory threat and anhedonia.

Discussion
The results of this review have raised three main factors: cognitive, metacognitive and behavioural factors. A high number of candidate cognitive factors were identified, and stigma is the most commonly maintenance factors. Poor QoL and daily function were common impairments associated with social anxiety. The evidence of metacognitive and behavioural factors is limited and needed more research attention. Due to lack of research examining factors across cultures in social anxiety and psychosis, future research required empirical evidence for cross-cultural aspects. Limitations are the major studies were cross-sectional, which is far less conclusive of causation; and the heterogeneous data which prevented us from applying meta-analysis.