Treatment of psychotic disorders has mainly focused on reducing positive psychotic symptoms, while comorbid disorders such as anxiety and depression have received less attention. There seems to be two main reasons for this. Firstly, there has been a general lack of awareness of other symptom dimensions co-occurring in psychosis due to the hierarchical approach to diagnostic evaluations. Symptoms of emotional dysfunction, defined as mood symptoms and/or anxiety disorders following the Diagnostic and Statistical Manual of mental disorders (DSM-IV), have not been acknowledged because they are regarded less important in severe psychotic disorders both with regard to diagnosis and treatment. Secondly, studies show that even though clinicians acknowledge the co-occurrence of other symptom dimensions, there is no consensus as to whether it should be treated as a separate condition or not (Addington et al., 2002).
The current thesis focused on depression and social anxiety and seeks to conceptualize these co-occurring symptom dimensions in the context of psychotic disorders. Depression and social anxiety interact, as people afflicted by these disorders have a common tendency to make negative evaluations of themselves in relation to others and the world. Embedded in this context lies a feeling of inferiority and low self-esteem. Consequently, a focus on selfesteem was natural.
In the first paper (paper I) we investigated the prevalence and time course of lifetime major depressive episodes in first episode psychosis (FEP) and examined whether there were differences between those with and without previous episodes. We also examined possible contributing factors to development of depressive symptomatology. Almost 50% of the sample had experienced one or more lifetime episodes of major depression, with no indications of demographic or clinical differences. Poor premorbid childhood adjustment, substance abuse and excitative symptoms were associated with higher levels of current depressive symptomatology. Furthermore, findings indicated possible gender differences regarding alcohol and excitative symptoms as possible explanatory factors related to depressive symptoms. Alcohol use was associated with current severity of depression in men while excitative symptoms were associated in women.
In the second paper (paper II) we examined whether premorbid adjustment was associated with the afflicted individuals’ self-esteem and whether lowered self-esteem may contribute to the development of delusions and hallucinations in FEP. We found indications that premorbid adjustment was an important factor in the development of self-esteem, and that reduced self-esteem was significantly associated with raised level of positive psychotic symptoms.
The third and fourth papers (paper III and IV) were concerned with symptoms of social anxiety disorder. Paper III was a psychometric paper aimed at validating the Liebowitz Social Anxiety Scale – self-rated version. This is a widely used scale, but the self-rated version has never been validated when applied to psychotic disorders. We reproduced factor analytically derived subscales similar to those found elsewhere in the literature in non-psychotic samples. Furthermore, the scales showed satisfactory psychometric properties. Additionally, we found support for the assumption that the scale measures social anxiety as an independent domain in psychotic disorders.
In paper IV we found that severe social anxiety was related to poor premorbid- and current functioning in addition to level of depression, but not to level of current psychotic symptoms. Insight into illness was more related to level of social anxiety and depression than to psychotic symptoms. Furthermore, higher level of social anxiety and depression were associated with poorer quality of life.
The findings of the present thesis support the relevance of an active approach towards recognition and treatment of emotional dysfunction as it is prevalent and constitutes a major additional burden for patients with a first episode of psychosis.
List of papers. Papers I and III are removed from the thesis due to copyright restrictions.
Paper I: Kristin Lie Romm, Jan Ivar Røssberg, Akiah Ottesen Berg, Elizabeth Ann Barrett, Ann Færden, Ingrid Agartz, Ole A. Andreassen, Ingrid Melle. Depression and depressive symptoms in first episode psychosis. J Nerv Ment Dis. 2010 Jan;198(1):67-71. doi:10.1097/NMD.0b013e3181c81fc0
Paper II: Kristin Lie Romm, Jan Ivar Røssberg, Charlotte F. Hansen, Elisabeth Haug, Ole A. Andreassen, Ingrid Melle. Self-esteem is associated with premorbid adjustment and positive psychotic symptoms in first episode psychosis. Submitted version. BMC Psychiatry 2011, 11:136
doi:10.1186/1471-244X-11-136Published under a Creative Commons Attribution License.
Paper III: Kristin Lie Romm, Jan Ivar Røssberg, Akiah Ottesen Berg, Charlotte F. Hansen, Ole A. Andreassen, Ingrid Melle. Assessment of social anxiety in first episode psychosis using the Liebowitz social anxiety scale as a self-report measure. Eur Psychiatry. 2011 Mar;26(2):115–121. doi:10.1016/j.eurpsy.2010.08.014
Paper IV: Kristin Lie Romm , Ingrid Melle , Christian Thoresen , Ole A. Andreassen, Jan Ivar Røssberg. Severe social anxiety in early psychosis: associated with poor premorbid functioning, depression and reduced quality of life. NOTICE: this is the author’s version of a work that was accepted for publication in Comprehensive Psychiatry. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version was subsequently published in:
Compr Psychiatry. 2011. Available online 6 August 2011. doi:10.1016/j.comppsych.2011.06.002