Elsevier

Psychiatry Research

Volume 210, Issue 1, 30 November 2013, Pages 1-7
Psychiatry Research

Review Article
Anxiety comorbidity in schizophrenia

https://doi.org/10.1016/j.psychres.2013.07.030Get rights and content

Abstract

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.

Introduction

The phenomenological characterization of distinct anxiety subtypes in schizophrenia has been a challenge. Historically, diagnostic systems have been rooted in hierarchical reductionism, where the ostensibly more “severe” disorders take precedence over lower ranking ones (Hausmann and Fleischhacker, 2002). Similarly, the management of anxiety has presumptively been considered to be less important than the management of psychotic symptoms, with clinicians and researchers often viewing anxiety symptoms as being merely a byproduct of the psychosis and not being in any way a separate, co-existing, or important independent entity. Moreover, it has commonly been assumed that whatever influence anxiety disorders might exert on patients with schizophrenia would pale in comparison to the impact of the psychosis itself (Hausmann and Fleischhacker, 2002).

Nevertheless, symptoms of anxiety have long been described in patients with schizophrenia, and they are recognized as being a significant source of morbidity in this patient group (Bleuler, 1950, Braga et al., 2005, Buckley et al., 2009). Anxiety symptoms in schizophrenia can present in various ways, such as secondary phenomena to positive psychotic symptoms, a reactive manifestation to external circumstances, or as a discrete comorbid condition. Furthermore, this comorbidity can have profound effect on prognosis, functioning, and quality of life that is not directly correlated with positive or negative symptoms (Buckley et al., 2009, Hausmann and Fleischhacker, 2002, Siris and Bench, 2003).

The objective of the current paper is to review the available knowledge about anxiety comorbidity in schizophrenia, recognizing the term “anxiety” can be used to describe several different mental phenomena – an affect, a symptom, or one of several syndromes or diseases. Although the level of meaning intended for the term “anxiety” is often not clearly indicated in the literature, we will nevertheless do our best to describe findings in accordance with which concept of anxiety is involved.

Section snippets

Method

A computerized search of the literature published from 1966 to April 2012 was conducted on Pubmed/Medline using the words schizophrenia AND anxiety AND each anxiety disorder diagnosis listed in the DSM-IV, namely social phobia, post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), generalized anxiety disorder (GAD), panic disorder, specific phobia, and acute stress disorder. This overview was limited to papers written in English. Each reference was inspected to ensure that

Epidemiology

A number of studies have found increased rates of anxiety symptoms and syndromes in patients with schizophrenia. The literature shows higher prevalence rates than those typically reported in the general population for every anxiety disorder in patients within the schizophrenia spectrum. Initial reviews pointed out that most available studies consisted of clinical samples, with small number of subjects included, and due to that prevalence results are highly variable. For instance, studies

Discussion

Anxiety, either in the form of a symptom or in the form of one or more of the recognized anxiety syndromes, has been noted to occur commonly in the course of patients who are otherwise appropriately diagnosed as suffering from schizophrenia. The seven recognized anxiety syndromes potentially occurring in schizophrenia include OCD, panic, PTSD, social phobia, specific phobias, GAD and acute stress disorder. Additionally, anxiety can present as an isolated symptom, or be induced by untoward

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