Anxiety in schizophrenia
- Samuel G Siris, MD
Samuel G Siris, MD
- Professor Emeritus
- Hofstra University/Northwell Health
- Raphael J Braga, MD
Raphael J Braga, MD
- Center for Treatment and Research of Bipolar Disorder
- The Zucker Hillside Hospital
Anxiety is frequently observed among patients with schizophrenia. Anxiety may present as a component of schizophrenia (particularly during an acute psychotic episode), a result of an underlying organic condition, a medication side effect, or a symptom of a co-occurring anxiety disorder. A thorough psychiatric examination, including a medical history and physical exam, and possibly intervention trials, may be needed to arrive at an accurate diagnosis. Treatment is based on this determination.
Posttraumatic stress disorder, which was redefined as a trauma-related disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), was previously studied in patients with co-occurring schizophrenia along with the anxiety disorders and is included in this topic.
The epidemiology, clinical manifestations, diagnosis, and treatment of anxiety in patients with schizophrenia are discussed here. Anxiety disorders and schizophrenia as individual, non-comorbid conditions are discussed separately. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis" and "Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis" and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Social anxiety disorder in adults: Epidemiology, clinical manifestations, and diagnosis" and "Schizophrenia: Clinical manifestations, course, assessment, and diagnosis".)
A meta-analysis of 52 studies with a total of 4,032 patients with a schizophrenia spectrum disorder found that 38.3 percent suffered from a comorbid anxiety disorder . Schizophrenia spectrum disorders include schizophrenia, schizoaffective, schizophreniform and delusional disorders, and psychosis not otherwise specified. Mean prevalence rates were as follows:
●Social anxiety disorder (social phobia) – 14.9 percent
- Achim AM, Maziade M, Raymond E, et al. How prevalent are anxiety disorders in schizophrenia? A meta-analysis and critical review on a significant association. Schizophr Bull 2011; 37:811.
- Young S, Pfaff D, Lewandowski KE, et al. Anxiety disorder comorbidity in bipolar disorder, schizophrenia and schizoaffective disorder. Psychopathology 2013; 46:176.
- Braga RJ, Mendlowicz MV, Marrocos RP, Figueira IL. Anxiety disorders in outpatients with schizophrenia: prevalence and impact on the subjective quality of life. J Psychiatr Res 2005; 39:409.
- Lysaker PH, Salyers MP. Anxiety symptoms in schizophrenia spectrum disorders: associations with social function, positive and negative symptoms, hope and trauma history. Acta Psychiatr Scand 2007; 116:290.
- Tien AY, Eaton WW. Psychopathologic precursors and sociodemographic risk factors for the schizophrenia syndrome. Arch Gen Psychiatry 1992; 49:37.
- Strakowski SM, Tohen M, Stoll AL, et al. Comorbidity in psychosis at first hospitalization. Am J Psychiatry 1993; 150:752.
- Craig T, Hwang MY, Bromet EJ. Obsessive-compulsive and panic symptoms in patients with first-admission psychosis. Am J Psychiatry 2002; 159:592.
- Muller JE, Koen L, Soraya S, et al. Anxiety disorders and schizophrenia. Curr Psychiatry Rep 2004; 6:255.
- Poyurovsky M, Kriss V, Weisman G, et al. Familial aggregation of schizophrenia-spectrum disorders and obsessive-compulsive associated disorders in schizophrenia probands with and without OCD. Am J Med Genet B Neuropsychiatr Genet 2005; 133B:31.
- Shioiri T, Shinada K, Kuwabara H, Someya T. Early prodromal symptoms and diagnoses before first psychotic episode in 219 inpatients with schizophrenia. Psychiatry Clin Neurosci 2007; 61:348.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
- Bermanzohn PC, Arlow PB, Albert C, Siris SG. Relationship of panic attacks to paranoia. Am J Psychiatry 1999; 156:1469.
- Berman I, Merson A, Viegner B, et al. Obsessions and compulsions as a distinct cluster of symptoms in schizophrenia: a neuropsychological study. J Nerv Ment Dis 1998; 186:150.
- Fenton WS, McGlashan TH. The prognostic significance of obsessive-compulsive symptoms in schizophrenia. Am J Psychiatry 1986; 143:437.
- Hwang MY, Morgan JE, Losconzcy MF. Clinical and neuropsychological profiles of obsessive-compulsive schizophrenia: a pilot study. J Neuropsychiatry Clin Neurosci 2000; 12:91.
- Birgenheir DG, Ganoczy D, Bowersox NW. Service utilization among veterans with schizophrenia and a comorbid anxiety disorder. Psychiatr Serv 2014; 65:1354.
- Druss BG, Bradford WD, Rosenheck RA, et al. Quality of medical care and excess mortality in older patients with mental disorders. Arch Gen Psychiatry 2001; 58:565.
- Narrow WE, Rae DS, Robins LN, Regier DA. Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 surveys' estimates. Arch Gen Psychiatry 2002; 59:115.
- de Leon J, Tracy J, McCann E, et al. Schizophrenia and tobacco smoking: a replication study in another US psychiatric hospital. Schizophr Res 2002; 56:55.
- Kim SW, Shin IS, Kim JM, et al. The 5-HT2 receptor profiles of antipsychotics in the pathogenesis of obsessive-compulsive symptoms in schizophrenia. Clin Neuropharmacol 2009; 32:224.
- Allen L, Tejera C. Treatment of clozapine-induced obsessive-compulsive symptoms with sertraline. Am J Psychiatry 1994; 151:1096.
- Poyurovsky M, Hermesh H, Weizman A. Fluvoxamine treatment in clozapine-induced obsessive-compulsive symptoms in schizophrenic patients. Clin Neuropharmacol 1996; 19:305.
- Rahman MS, Grace JJ, Pato MT, Priest B. Sertraline in the treatment of clozapine-induced obsessive-compulsive behavior. Am J Psychiatry 1998; 155:1629.
- Centorrino F, Baldessarini RJ, Frankenburg FR, et al. Serum levels of clozapine and norclozapine in patients treated with selective serotonin reuptake inhibitors. Am J Psychiatry 1996; 153:820.
- Yamaguchi H, Takahashi A, Takano A, Kojima T. Direct effects of short-term psychoeducational intervention for relatives of patients with schizophrenia in Japan. Psychiatry Clin Neurosci 2006; 60:590.
- Braga RJ, Petrides G, Figueira I. Anxiety disorders in schizophrenia. Compr Psychiatry 2004; 45:460.
- Poyurovsky M, Weizman A. Intravenous clomipramine for a schizophrenic patient with obsessive-compulsive symptoms. Am J Psychiatry 1998; 155:993.
- Figueira, I, Mendlowicz, M, Nardi, AE et al. Social phobia and panic disorder in psychotic patients: psychopharmacology series 6. J bras Psiq 1992; 41:259.
- Kahn JP, Puertollano MA, Schane MD, Klein DF. Adjunctive alprazolam for schizophrenia with panic anxiety: clinical observation and pathogenetic implications. Am J Psychiatry 1988; 145:742.
- Siris SG, Aronson A, Sellew AP. Imipramine-responsive panic-like symptomatology in schizophrenia/schizoaffective disorder. Biol Psychiatry 1989; 25:485.
- Takahashi H, Higuchi H, Shimizu T. Full remission of panic attacks in a schizophrenic patient after switching from haloperidol to risperidone. J Neuropsychiatry Clin Neurosci 2001; 13:113.
- Takahashi H, Sugita T, Yoshida K, et al. Effect of quetiapine in the treatment of panic attacks in patients with schizophrenia: 3 case reports. J Neuropsychiatry Clin Neurosci 2004; 16:113.
- Stern RG, Petti TA, Bopp K, Tobia A. Aripiprazole for the treatment of schizophrenia with co-occurring social anxiety: an open-label cross-taper study. J Clin Psychopharmacol 2009; 29:206.
- Halperin S, Nathan P, Drummond P, Castle D. A cognitive-behavioural, group-based intervention for social anxiety in schizophrenia. Aust N Z J Psychiatry 2000; 34:809.
- Kingsep P, Nathan P, Castle D. Cognitive behavioural group treatment for social anxiety in schizophrenia. Schizophr Res 2003; 63:121.
- Arlow PB, Moran ME, Bermanzohn PC, et al. Cognitive-behavioral treatment of panic attacks in chronic schizophrenia. J Psychother Pract Res 1997; 6:145.
- Frueh BC, Grubaugh AL, Cusack KJ, et al. Exposure-based cognitive-behavioral treatment of PTSD in adults with schizophrenia or schizoaffective disorder: a pilot study. J Anxiety Disord 2009; 23:665.
- van den Berg DP, de Bont PA, van der Vleugel BM, et al. Prolonged exposure vs eye movement desensitization and reprocessing vs waiting list for posttraumatic stress disorder in patients with a psychotic disorder: a randomized clinical trial. JAMA Psychiatry 2015; 72:259.
- CLINICAL MANIFESTATIONS
- ASSESSMENT AND INITIAL MANAGEMENT
- Differential diagnosis
- - Organic factors
- - Side effects of antipsychotics
- Obsessions and compulsions
- - Symptoms of schizophrenia
- - Anxiety disorders
- TREATMENT FOR CO-OCCURRING ANXIETY DISORDERS
- - Obsessive-compulsive disorder
- - Panic attacks
- - Social anxiety disorder
- - Other anxiety disorders
- Cognitive behavioral therapy
- SUMMARY AND RECOMMENDATIONS