Anxiety and Social Functioning in Psychotic Disorders

Anxiety is a prevalent and debilitating comorbidity in individuals with psychotic disorders, affecting up to half of those diagnosed with conditions such as schizophrenia or schizoaffective disorder. It encompasses both syndromal presentations—such as generalised anxiety disorder and social anxiety disorder—and undifferentiated anxiety symptoms that resist clear diagnostic categorisation. Anxiety in psychosis is closely linked with impaired social functioning, manifesting as reduced social engagement, avoidance of interpersonal scenarios and diminished vocational and recreational activities. These impairments compound the core features of psychosis, exacerbating negative symptoms such as social withdrawal and blunted affect, and undermining recovery. Mechanistically, anxiety may arise from interpretations of psychotic experiences, heightened threat perception or cognitive biases that amplify social evaluative fears. Measurement challenges have driven the development of psychosis-specific rating scales to capture both specified and undifferentiated anxiety. Clinically, targeting anxiety through psychological and biofeedback interventions has shown promise in improving social connectedness and overall quality of life, reinforcing the need to integrate anxiety management into standard care pathways for psychotic disorders.

Research from Nature Portfolio

Recent studies have begun to chart the interplay between anxiety symptoms and executive function across the psychosis continuum. In a non-clinical cohort exhibiting psychosis-like experiences, individuals with higher levels of subthreshold psychotic phenomena also reported elevated anxiety. Paradoxically, within this group, greater anxiety was associated with improved cognitive flexibility and fewer perseverative errors on rule-learning tasks. In contrast, in those with lower psychosis-like experiences, increased anxiety predicted poorer task performance. These findings suggest a nuanced psychosis vulnerability × anxiety interaction, in which anxiety may exert differential effects on cognitive control depending on underlying psychosis-risk status. Such insights point to the potential of anxiety as both a marker of vulnerability and, in some contexts, a facilitator of adaptive executive processes.

Anxiety and Social Functioning in Psychotic Disorders publication trend

The graph below shows the total number of articles in anxiety and social functioning in psychotic disorders across all publications each year (not limited to Nature Index journals).

Technical terms

Psychotic disorders: Severe mental illnesses characterised by delusions, hallucinations and impaired reality testing.

Social functioning: Capacity to engage in interpersonal relationships, work or educational activities and community roles.

Social anxiety: Excessive fear of negative evaluation or rejection in social situations, often leading to avoidance.

Psychosis-like experiences (PLEs): Subclinical perceptual or belief disturbances observed in non-clinical populations at risk for psychosis.

Cognitive flexibility: Ability to adapt thinking and behaviour in response to changing rules or environmental demands.

Virtual reality exposure therapy (VRET): Simulation-based technique that uses immersive virtual environments to desensitise anxiety through controlled exposure.

References

1. Discerning undifferentiated anxiety from syndromal anxiety in acute-phase schizophrenia. Annals of General Psychiatry (2020).
2. Validity and Reliability of the Staden Schizophrenia Anxiety Rating Scale. Diagnostics (2022).
3. Cardiac Coherence Training to Reduce Anxiety in Remitted Schizophrenia, a Pilot Study. Applied Psychophysiology and Biofeedback (2015).
4. Anxiety symptoms, rule learning, and cognitive flexibility in non-clinical psychosis. Scientific Reports (2022).
5. Manualized group cognitive behavioral therapy for social anxiety in first-episode psychosis: a randomized controlled trial. Psychological Medicine (2022).
6. Exploring stigma, shame, and safety behaviours in social anxiety and paranoia amongst people diagnosed with schizophrenia. Behavioural and Cognitive Psychotherapy (2024).
7. Application of a virtual reality-based cognitive-behavioural therapy of social phobia in the treatment of inpatients diagnosed with schizophrenia and social anxiety – a feasibility study. Frontiers in Psychiatry (2024).