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Social anxiety disorder and shame cognitions in
psychosis
Michail, M.; Birchwood, M.
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10.1017/S0033291712001146
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Michail, M & Birchwood, M 2013, 'Social anxiety disorder and shame cognitions in psychosis', Psychological
Medicine, vol. 43, no. 01, pp. 133-142. https://doi.org/10.1017/S0033291712001146
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Social anxiety disorder and shame cognitions
in psychosis
M. Michail
1
* and M. Birchwood
2
,
3
1
Division of Nursing, School of Nursing, Midwifery and Physiotherapy, University of Nottingham, UK
2
Youth Services Programme, Birmingham and Solihull Mental Health Foundation Trust, Early Intervention Service, Birmingham, UK
3
School of Psychology, University of Birmingham, Edgbaston, Birmingham, UK
Background. Social anxiety disorder (SAD) is surprisingly prevalent among people with psychosis and exerts
significant impact on social disability. The processes that underlie its development remain unclear. The aim of this
study was to investigate the relationship between shame cognitions arising from a stigmatizing psychosis illness and
perceived loss of social status in co-morbid SAD in psychosis.
Method. This was a cross-sectional study. A sample of individuals with SAD (with or without psychosis) was
compared with a sample with psychosis only and healthy controls on shame proneness, shame cognitions linked to
psychosis and perceived social status.
Results. Shame proneness (p<0.01) and loss of social status (p<0.01) were significantly elevated in those with SAD
(with or without psychosis) compared to those with psychosis only and healthy controls. Individuals with psychosis
and social anxiety expressed significantly greater levels of shame (p<0.05), rejection ( p< 0.01) and appraisals of
entrapment (p<0.01) linked to their diagnosis and associated stigma, compared to those without social anxiety.
Conclusions. These findings suggest that shame cognitions arising from a stigmatizing illness play a significant role
in social anxiety in psychosis. Psychological interventions could be enhanced by taking into consideration these
idiosyncratic shame appraisals when addressing symptoms of social anxiety and associated distress in psychosis.
Further investigation into the content of shame cognitions and their role in motivating concealment of the stigmatized
identity of being ‘ill ’ is needed.
Received 31 May 2011; Revised 6 March 2012 ; Accepted 29 April 2012 ; First published online 21 May 2012
Key words : Entrapment, psychosis, shame, social anxiety, social status, stigma.
Introduction
Social anxiety is among the most commonly re-
ported and disabling of the co-morbidities in people
with psychosis (Birchwood et al. 2007; Michail &
Birchwood, 2009). The processes that underlie its
development in psychosis remain unclear as there
is no evidence that it is directly linked to psychosis
-vulnerability or symptoms (Pallanti et al. 2004;
Michail & Birchwood, 2009). In social anxiety in gen-
eral, a developmental psychopathology framework
has been adopted (Ollendick & Hirshfeld-Becker,
2002; Hayward et al. 2008) according to which there is
evidence for continuity of social anxiety symptoms
from childhood to adolescence and the involvement
of multiple and interacting factors. Among the most
prominent of these are early temperamental and
behavioural traits including behavioural inhibition,
shyness, neuroticism and shame proneness, which
have shown to increase susceptibility for the later
development of social anxiety disorder (SAD)
(Dalrymple & Herbert, 2007 ; Bienvenu et al. 2008 ;
Schofield et al. 2009). Shame proneness in particular
has received considerable attention in the literature,
where its relationship with social anxiety has been
theoretically and empirically validated (Buss, 1980 ;
Averill et al. 2002; Mills, 2005).
Shame and social anxiety in non-psychosis
Shame is an emotion that affects the personal identity
of the individual (Kaufman, 1993) and is triggered
when the individual believes they hold qualities that
are unattractive or unfavourable (e.g. having a mental
illness) and could therefore lead to social rejection and
loss of social status (Gilbert, 1998, 2000). Shame is seen
as an involuntary submissive reaction in an attempt
* Address for correspondence : Dr M. Michail, Division of Nursing,
School of Nursing, Midwifery and Physiotherapy, University of
Nottingham, Nottingham NG7 2HA, UK.
(Email : maria.michail@nottingham.ac.uk)
Psychological Medicine (2013), 43, 133–142. f Cambridge University Press 2012
doi:10.1017/S0033291712001146
ORIGINAL ARTICLE
to defend oneself from being down-ranked and serves
the function of inhibiting further attacks to the self
and to one’s social identity. Gilbert (1998) makes a
distinction between internal and external shame.
Internal shame refers to negative or critical percep-
tions the individual has about their own behaviour
(self-evaluation); external shame relates to how one
thinks others see oneself (usually in a negative way)
and involves a social comparison process during
which the individual becomes an object in the eyes of
others.
Shame and social anxiety, although not similar,
share some common underlying processes. One
of these, according to Gilbert (1998, 2000), is fear of
negative evaluation and rejection. A shame episode
is similar to social anxiety to the extent that both
are characterized by significant apprehension ac-
companied by heightened self-consciousness, fear of
exposure and evaluative concerns (Gilbert & Trower,
1990; Fischer & Tangney, 1995). Based on this, Mills
(2005) suggested that shame could be a vulnerability
factor for the development of social anxiety through
the shared process of self-consciousness. The use of
safety behaviours has also been identified as a com-
mon process in shame and social anxiety (Gilbert,
1998, 2000). These are behaviours intended to mini-
mize or prevent imminent threat resulting from situ-
ations that entail negative evaluation and rejection and
can include avoiding eye contact, withdrawal from
social interactions or showing signs of submissiveness
to prevent a potential ‘attack ’ to the self (Salkovskis,
1991). When encountered with social threats, safety
behaviours are used in both shame and social anxiety
as a way of minimizing the perceived danger and its
consequences (e.g. being down-ranked or humiliated),
thus ‘saving’ the self.
Shame and social anxiety in psychosis
In psychosis, developmental risk factors such as
trauma, dysfunctional attachment relationships and
emotional difficulties (Read & Argyle, 1999; Read et al.
2003; Janssen et al. 2004 ; Johnstone et al. 2005 ; Owens
et al. 2005) are present during the prodrome phase and
before symptom formation. The presence of these de-
velopmental risk factors has been suggested to pre-
dispose individuals to shame and increase sensitivity
to ‘ put-downs ’ by others (Lutwark & Ferrari, 1997;
Gross & Hansenn, 2000). For example, studies on at-
tachment and dysfunctional parenting styles (Lutwark
& Ferrari, 1997; Gross & Hansenn, 2000) have shown
that early maladaptive attachment relationships and
parental overcontrol and overprotection were related
to the later development of shame proneness. There-
fore, in individuals with psychosis it is proposed that
there is an established vulnerability to shame linked
to early developmental anomalies. We have argued
that shame proneness is likely to be catalysed by the
stigma attached to the diagnosis of mental illness
(Birchwood et al. 2007). Psychosis is considered as a
highly stigmatized condition (Thornicroft et al. 2009)
and, as with any type of social stigma, this can affect
the social identity of the individual by suggesting
qualities that deviate from the norm and are socially
discrediting (Goffman, 1963). Individuals with psy-
chosis are aware of the social stereotypes surround-
ing mental illness and some may even accept and
endorse these (Hayward & Bright, 1997 ; Angermeyer
& Matschinger, 2004). This internalization of stigma or
self-stigma leads to increased shamefulness, par-
ticularly when individuals agree with the stigma
and the associated negative responses (Corrigan &
Watson, 2002a,b) and furthermore assume responsi-
bility or engage in self-blame (Lewis, 1998). Self-blame
is required to elicit feelings of shamefulness as a result
of being stigmatized (Lewis, 1998). In individuals
with psychosis, appraisals of shame and social un-
attractiveness are significant (Birchwood et al. 1993,
2000a) and lead to feelings of loss of social status,
humiliation and entrapment (Rooke & Birchwood,
1998).
Therefore, we argue that psychotic individuals are
developmentally vulnerable to shame and, in this
context, receiving a diagnosis of mental illness makes
the social stigma attached to mental illness difficult to
resist and individuals can internalize and accept the
stigma and the cultural stereotypes surrounding
mental illness. This internalized stigma subsequently
leads to increased shamefulness. However, the pro-
cesses by which these appraisals of shame might con-
taminate social interaction in people with psychosis is
not understood.
Aim of the study
The aim of this study was to examine the relationship
between shame cognitions, shame proneness and
perceived loss of social status in people with first-
episode psychosis (FEP) and SAD. The following
hypotheses were tested:
(1) People with SAD (with or without psychosis) will
report higher levels of shame proneness and lower
perceived social status, compared to those with no
social anxiety.
(2) People with psychosis and SAD will hold stronger
negative appraisals about psychosis in terms of (a)
shame arising from the illness and perceived social
rejection and (b) loss of social status, inability to
escape the diagnosis and to control the illness,
compared to those with psychosis alone.
134 M. Michail and M. Birchwood
Method
Sampling
Inclusion criteria
Four groups of participants aged between 16 and 35
years were sampled with: (a) non-psychotic SAD,
(b) FEP, (c) FEP with SAD (FEP/SAD) and (d) healthy
controls. All participants were assessed using the
Schedules for Clinical Assessment in Neuropsychiatry
(SCAN; WHO, 1999) by M.M. who received formal
training
1
# to criterion levels of reliability. Individuals
in the SAD group were required to conform to ICD-10
(WHO, 1993) criteria for social anxiety (F40.1); and in
the FEP group, to ICD-10 criteria for schizophrenia or
related disorder (F20, 22, 23), in the absence of a pri-
mary diagnosis of organic disorder. An age-matched
community sample with no psychiatric disorders was
drawn from the general population and invited to take
part in the study.
Recruitment
Participants with FEP were recruited from consecutive
cases managed in the Early Intervention Service of
Birmingham and Solihull Mental Health National
Health Service (NHS) Foundation Trust, UK. The
service manages all cases of FEP, age 14–35 years, in
Birmingham. People with SAD were recruited
through a self-help organization, Social Anxiety UK
(www.social-anxiety.org.uk), and through local com-
munity mental health teams.
Assessments
Social anxiety
Two scales widely used together in the social phobia
literature were administered. The Social Interaction
Anxiety Scale (SIAS; Mattick & Clarke, 1998) is a 20-
item scale measuring anxiety in interpersonal en-
counters. Using a cut-off score of 36, the SIAS has been
demonstrated to discriminate between social anxiety,
other anxiety disorders and community samples
(Peters, 2000) with a sensitivity of 0.93 and positive
predictive value (PPV) of 0.84. The Social Phobia Scale
(SPS), designed to be administered alongside the
SIAS, is used to detect and assess performance anxiety
in situations where the individual fears they are being
observed and scrutinized by others (e.g. carrying a
tray across a cafeteria, eating/drinking in public).
Psychosis
The Positive and Negative Syndrome Scale (PANSS ;
Kay et al. 1987) includes scales of positive symptoms,
negative symptoms and general psychopathology and
is used widely in schizophrenia research.
Cognitive appraisals of psychosis
The Personal Beliefs about Illness Questionnaire
(PBIQ; Birchwood et al. 1993) measures patients’ be-
liefs about their psychotic illness and its impact on
their future goals and roles (loss), social status
(shame), social marginalization (group fit) and the ex-
tent to which their illness is perceived to trap the in-
dividual, preventing them from asserting their aspired
identity and role (entrapment). This measure has been
widely used to study patients’ adaptation to psychosis
(Birchwood et al. 2000b) and has extensive psycho-
metric validation including retest reliabilities of
the scales from 0.77 to 1.0 and Cronbach’s a from 0.68
to 0.77.
Shame
The Other as Shamer Scale (OAS; Goss et al. 1994) is an
18-item self-report scale that measures judgments
about how the self is evaluated by others (e.g. ‘I think
that other people look down on me ’). The frequency
with which individuals share such feelings and ex-
periences is rated on a five-point Likert scale (0–4). The
OAS is a modification of the Internalized Shame
Scale (ISS ; Cook, 1993), which is used to assess self-
evaluations (internal shame) and therefore covers trait
shame. The OAS was developed to assess external
shame, i.e. shame received by others (Goss et al. 1994).
The scale was found to correlate highly with the ISS
(r=81), indicating that the OAS can be used as a
measure of shame proneness (trait shame) and more-
over that shame involves both self and other evalu-
ations (Goss et al. 1994). Cronbach’s a was found to be
0.92 supporting its high internal consistency. It has
been widely used in the literature (Gilbert, 2000 ;
Birchwood et al. 2007).
Social status
The Social Comparison Scale (SCS ; Gilbert & Allan,
1994) was designed to assess individuals’ judgments
of their rank/status and group fit. The scale includes
six bipolar items : inferior–superior, less competent–
more competent, likable–less likable, less reserved–
more reserved, left out–accepted, different–same. The
first five items are referred to as rank items and the
sixth item, which measures the degree of perceived
similarity with others, is called social comparison/
group fit. Each item is rated on a 10-point scale
according to how people perceive themselves in re-
lation to their social others. Higher scores indicate
higher perceived status. Cronbach’s a for the rank
# The note appears after the main text.
SAD and shame cognitions in psychosis 135
scale was reported as 0.87, indicating good internal
reliability (Gilbert & Allan, 1994), and the test–retest
reliability over a 4-month period was 0.84 (Gilbert
et al. 1995).
Results
The sample
Of the 84 patients with FEP who were approached to
take part in this study, 80 (95.2%) consented. Twenty
(25%) out of these 80 people with FEP received an
ICD-10 diagnosis of social anxiety disorder (FEP/
SAD) based on the SCAN. All 20 scored above the cut-
off points on both the SIAS (>36) and the SPS (>26).
An age-matched healthy control group (n=24) was
also recruited. Table 1 presents information on the
demographic characteristics of the samples. The mean
age of those in the SAD group was approximately 3
years more than those in the other groups. Both SAD
groups showed a female excess whereas in the FEP (no
SAD) group the expected male excess was observed.
x
2
tests showed significant differences in ethnicity
(x
2
12
=59.7, p<0.01), education (x
2
9
=43.5, p<0.01) and
occupation (x
2
9
=42.3, p<0.01) but not in marital status
(x
2
9
=9.1, N.S.). These differences reflect the expected
higher functioning of the non-psychotic socially anx-
ious participants. The main clinical characteristics of
the sample are presented in Table 2. The two social
anxiety groups with (FEP/SAD) and without psy-
chosis (SAD) reported similar severity levels of social
anxiety and avoidance (SIAS : F
1
,
49
=2.55, N.S., SPS:
F
1
,
49
=1.65, N.S.). Similar levels of depression were also
reported (F
1
,
49
=0.26, N.S.), with 64.5 % of the SAD and
65% of the FEP/SAD groups shown to be at least
moderately depressed (Michail & Birchwood, 2009).
The two psychotic groups (with and without social
anxiety) reported no significant differences in the
overall occurrence of delusions (F
1
,
69
=0.137, N.S.), in-
cluding delusions of grandiosity (F
1
,
69
=0.76, N.S.) and
persecution ( F
1
,
69
=2.24, N.S.) ; similarly, the level of
hallucinations did not differ between the two groups
(F
1
,
69
<1, N.S.).
Table 1. Demographic characteristics of participants
FEP (no SAD)
(n=60)
FEP/SAD
(n=20)
SAD
(n=31)
Healthy community
group (n=24)
Sex
Male 46 7 11 11
Female 14 13 20 13
Age (years), mean (
S.D.) 24.6 (4.5) 24.4 (5.1) 27.6 (5) 24.2 (5)
Ethnic origin
Afro-Caribbean 9 2 0 1
Asian 30 8 1 13
British White 11 7 29 10
British Black 10 2 1 0
Other 0 1 0 0
Education
Dropped out of school 27 5 2 5
GSCE 9 5 8 1
A levels 17 7 12 2
Degree/HND 7 2 9 16
Occupation
Employed 10 4 15 12
Unemployed 41 12 10 0
Student 8 3 4 11
Household 1 1 2 1
Marital status
Single 50 17 20 17
Cohabiting 3 1 5 3
Married 6 1 6 3
Separated 1 1 0 1
S.D., Standard deviation ; FEP, first-episode psychosis ; SAD, social anxiety disorder.
136 M. Michail and M. Birchwood
