title: Cognitive behavioural approaches to understanding shared mechanisms of social anxiety and paranoia
Creators: name: Aunjitsakul, Warut
Publisher: name: University of Glasgow
Year: 2021

description: Social anxiety disorder (SAD) is a common comorbidity in people experiencing psychosis and this comorbidity causes negative impacts including poor functioning, low self-esteem, depression or lack of social relationship. However, effective interventions for the treatment of SAD in people with psychosis are currently limited. The research described in this thesis aimed to contribute towards answering two big problems – what are 1) the candidate mechanisms of social anxiety in psychosis and 2) the key mechanisms between social anxiety and paranoia in psychosis for treatment development? Thesis content is divided into six chapters including four studies ranging from comprehensive review to empirical investigations in analogue and clinical samples. The first chapter provides the general background to the subject area of schizophrenia, paranoia and social anxiety, including the phenomenology of the overlapping constructs between paranoia and social anxiety. This chapter addresses the importance of psychological treatment, the need for understanding mechanisms to develop better treatment, and the cultural contexts affecting these potential mechanisms for people with social anxiety in psychosis. Chapter 2 is a systematic review to identify and analyse candidate factors that maintain social anxiety in the context of psychotic experiences. This review was published in the Schizophrenia Bulletin (doi: 10.1093/schbul/sbab026) and found that negative social evaluations, stigma and shame, are candidate factors that commonly associated with individuals with SAD in the context of psychosis. Based on previous cognitive behavioural understandings of SAD, paranoia and stigma, the findings of the systematic review were integrated into a theoretical model to guide future intervention and research into SAD in psychosis. To test potential mechanisms of social anxiety and paranoia, an empirical survey in an analogue sample was conducted, entitled Personal Attitudes towards Social life related to Oneself (the PASO survey). The survey recruited participants from the general population in Thailand and in the UK, including two parts: a cross-sectional and a prospective PASO study. The study in Chapter 3 aimed to investigate potential mechanisms of the relationship between social anxiety and paranoia and to compare mechanism outcomes cross-culturally using a cross-sectional design. Eight hundred and forty-two participants completed the survey which 427 from Thailand (68.9% female; mean age 36.2±10.4) and 415 from the UK (80.0% female; mean age 34.3±12.4). External shame was cross-culturally found to be a significant mediator in both Thai and UK samples, while self-esteem and safety behaviours were significant mediators in the UK sample. External shame, self-esteem and safety behaviours could be targeted in the treatment development of social anxiety and paranoia in psychosis intervention studies. This study has been submitted to Psychiatry Research. In Chapter 4, a prospective (3-month follow-up) study using combined both national samples examined the potential mechanisms of social anxiety and paranoia. At follow-up, 422 participants completed the survey which 186 from Thailand (70.4% female; mean age 34.9±9.1) and 236 from the UK (81.4% female; 35.7±12.7). Consistently, cross-cultural data showed that external shame significantly mediated the relationship between social anxiety at baseline and paranoia at follow-up. These data suggested the potential for treatments of social anxiety and paranoia in psychosis by targeting shame-related cognitions. This longitudinal PASO survey has been submitted to Clinical Psychology and Psychotherapy. In Chapter 5, a clinical study examined the mechanisms of the relationship between social anxiety and paranoia in people with schizophrenia in Thailand. One hundred and thirteen participants were recruited (59.3% female; mean age 44.2±13.1). Regarding negative social appraisals, stigma and shame did not show significant indirect effects through social anxiety-paranoia relationship. Meanwhile, in situ defence behaviours not anxious avoidance, of safety behaviours, showed a significant indirect effect. Safety behaviours, particularly in situ defence behaviours, should be targeted to alleviate social anxiety and paranoia in psychological interventions for people with psychosis. This study has been submitted to Schizophrenia Research. Chapter 6 summarizes all significant and non-significant results drawn from the systematic review (Chapter 2), cross-cultural studies in analogue sample (Chapter 3 and 4) and clinical study (Chapter 5). Strengths and weaknesses of the research conducted and the relevance and importance of the body of work are also presented in this chapter. Potential mechanisms underlying the social anxiety and paranoia relationship include shame related cognitions and safety behaviours. The next phase of research related to potential factors (i.e., stigma, shame, safety behaviours) should test on the manipulative study to confirm its causal evidence and examine them in clinical trials.