Schizophrenia Research 63 (2003) 121 129

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Cognitive behavioural group treatment for social anxiety

in schizophrenia
Patrick Kingsep a,*, Paula Nathan a, David Castle b
a

WA Institute for Psychotherapy Research, 223 James Street, Northbridge, Western Australia 6003, Australia
b
Mental Health Research Institute, 155 Oak Street, Parkville, Victoria 3052, Australia
Received 4 February 2002; accepted 24 July 2002

Abstract
Anxiety symptoms reported by individuals with schizophrenia have been traditionally seen as symptoms associated with the
principal disorder and therefore not requiring special attention. The primary aim of this paper is to therapeutically target social
anxiety symptoms in individuals with schizophrenia in order to determine the effectiveness of the cognitive behavioural group
treatment model as an intervention for social anxiety in this participant group. Thirty-three individuals with schizophrenia and
co-morbid social anxiety were allocated to a group-based cognitive behaviour (CBGT) intervention or waitlist control (WLC).
Baseline, completion and follow-up ratings consist of measures of social anxiety: the Brief Social Phobia Scale (BSPS), Brief
Fear of Negative Evaluation scale (BFNE) and the Social Interaction Anxiety Scale (SIAS); measures of general
psychopathology: the Calgary Depression Scale for Schizophrenia (CDSS) and Global Severity Index (GSI) from the Brief
Symptom Inventory (BSI); and the Quality of Life, Enjoyment and Satisfaction Questionnaire (QLESQ). Pre- and posttreatment measures were subjected to statistical evaluation. All outcome measures displayed statistical improvement in the
intervention group compared with no change in the control group. These treatment gains were maintained at follow-up. CBGT
for social anxiety in schizophrenia was demonstrated to be effective as an adjunctive treatment for this population.
D 2002 Elsevier Science B.V. All rights reserved.
Keywords: Schizophrenia; Social anxiety; Cognitive behavioural group

1. Introduction
Schizophrenia is a multi-dimensional disorder
(Andreasen, 1995). Aspects of this disorder go further
than the traditional group of positive and negative

*
Corresponding author. Tel.: +61-8-92274399; fax: +61-893285911.
E-mail address: patrick.kingsep@health.wa.gov.au
(P. Kingsep).

symptoms established in diagnosis (Tollefson and

Sanger, 1999). Symptoms such as anxiety and depression are frequently described by patients. Despite this,
co-morbid social anxiety has received minimal attention in patient management. This is in sharp contrast
with studies on depression in schizophrenia (Siris,
2000).
The clinical course of individuals with schizophrenia is characterised by higher rates of relapse, disability and suicide when sufferers concurrently
experience anxiety symptoms (Roy, 1989; Hirsch and

0920-9964/02/$ - see front matter D 2002 Elsevier Science B.V. All rights reserved.
doi:10.1016/S0920-9964(02)00376-6

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P. Kingsep et al. / Schizophrenia Research 63 (2003) 121129

Jolley, 1989). Cossoff and Hafner (1998) examined the

prevalence of social anxiety in individuals with schizophrenia (n = 60), and reported a 17% prevalence.
Cassano et al. (1998) reported a similar rate (16.1%).
This, together with the added disability and higher rates
of relapse present in people experiencing schizophrenia and social anxiety, reinforces the need to include
treatment for anxiety as part of total patient management. Effective psychological treatment studies for
social anxiety have been developed and evaluated
(see meta-analysis by Gould et al., 1997; Taylor,
1996; and review by van Dyck, 1996). Specifically, a
combined programme including exposure treatment
together with cognitive therapy delivered in a group
format has evidenced significant outcome when compared to a control group (e.g. Butler et al., 1984;
Heimberg et al., 1990, 1995; Hope et al., 1995; Mattick
et al., 1989; Turner et al., 1994). Thus, evidence-based
treatment strategies are available to clinicians for the
treatment of social anxiety.
These available treatments have received negligible application to the treatment of social anxiety in
persons with schizophrenia, likely due to social anxiety being discounted as secondary to the central
schizophrenia pathology. A recent exception to this
was a study examining the efficacy of cognitive
behavioural group treatment (CBGT) for social anxiety in schizophrenia (Halperin et al., 2000). This
controlled pilot study demonstrated statistical and
clinically significant benefits to group participants
on a range of clinical outcome measurements.
The present study investigates whether CBT
administered within a group format is effective in
treating co-morbid social anxiety in individuals with
schizophrenia. The aims of this study were to develop
a clinical protocol with accompanying training manual, and to evaluate this psychological intervention to
determine the statistical and magnitude of treatment
effects.

(11 males and 6 females). The subjects attended a

community-based living skill rehabilitation programme delivered at the Inner City Mental Health
Service of Royal Perth Hospital and at Fremantle
Hospital. The study was carried out by the West
Australian Institute for Psychotherapy Research
(WAIPR), a comprehensive clinical/research unit,
with a grant received from the Mental Health Division
of the Health Department of Western Australia. Eligibility criteria included a diagnosis of schizophrenia
by the patients psychiatrist, fluency in English, a comorbid diagnosis of social anxiety on the Mini International Neuropsychiatric Interview-Plus (Sheehan et
al., 1997) and a score > 20 on the Brief Social Phobia
Scale (Davidson et al., 1997). The exclusion criteria
included organic psychosis, substance dependence
(not misuse) and an IQ < 70.
2.2. Design
A between subjects, repeated measure two-factor
design was used, the independent factors being treatment (CBGT vs. waitlist control (WLC)) and time
(pre-treatment, post-treatment and follow-up). The
dependent measures are described below.
2.3. Diagnostic measures
The diagnosis of schizophrenia had been assigned
by the study participants consultant psychiatrist.
Cases of social anxiety were ascertained by the use
of a structured assessment tool (Mini International
Neuropsychiatric Interview-Plus MINI-Plus; Sheehan
et al., 1997). The MINI-Plus is both a reliable and
valid short diagnostic structured interview for axis 1
psychiatric disorders.
2.4. Treatment outcome measures
The six measures utilised in this study were
divided into three categories.

2. Method
2.1. Subjects
Subjects were 33 schizophrenia patients consisting
of 16 people in the treatment group (12 males and 4
females) and 17 in the waitlist control (WLC) group

2.4.1. Measures of social anxiety

(1) Brief Social Phobia Scale (BSPS) developed by
Davidson et al. (1991). The BSPS is an 11-item
observer rated assessment scale, which measures fear,
avoidance and physiological symptoms associated
with common social situations.

P. Kingsep et al. / Schizophrenia Research 63 (2003) 121129

(2) Social Interaction Anxiety Scale (SIAS) of

Mattick and Clarke (1998). The SIAS is a 20-item
self-report measure consisting of statements pertaining to social situations in which the respondent rates
how characteristic the statement is of them.
(3) Brief Fear of Negative Evaluation scale
(BFNE) developed by Watson and Friend (1969).
The BFNE is a 12-item self-report questionnaire,
which assesses concerns about being evaluated negatively by others.
2.4.2. Measures of general psychopathology
(4) Calgary Depression Scale for Schizophrenia
(CDSS) of Addington et al. (1990). The CDSS is a
9-item observer rated measure specifically designed
for measuring depression in schizophrenia. It compensates for the negative symptoms and extrapyramidal side effects of medication associated with
schizophrenia.
(5) Brief Symptom Inventory (BSI) developed by
Derogatis (1993). The BSI is a measure of psychological symptom patterns. Although the BSI provides
information related to each of the psychological symptoms measured by the scale, the Global Severity Index
(GSI) was used in this study to provide a measure of an
individuals general psychological distress.
2.4.3. Measure of quality of life
(6) Quality of Life, Enjoyment and Satisfaction
Questionnaire (QLESQ) by Endicott et al. (1993). The
QLESQ is a self-report measure used as a determination of the quality of life.
Participant evaluation of treatment: At termination
of group contact, a WAIPR consumer evaluation and
feedback questionnaire was administered.
2.5. Process
This study was carried out in a real-life setting,
and as a result gold-standard randomisation methodology was modified. Randomisation occurred as follows: as individuals were referred to the programme,
the first person remaining on the treatment as usual
(waitlist control group), and the next referral to the
programme was allocated to the treatment condition.
This process continued until sufficient subjects were
referred for the group treatment to begin. This study
was conducted in a real-life clinical setting; therefore,

123

treatment could not be withheld from the waitlist

control groups for clear ethical reasons. As this is
effectiveness and not efficacy research, the waitlist
control group received treatment at the point at which
the experimental group completed treatment.
2.6. Therapy procedure
CBGT was delivered in small groups, which were
then aggregated for statistical analysis. Each group
was led by two facilitators. The therapist in all groups
was a clinical psychologist (PK), whilst the second
therapist was either a psychiatric nurse or occupational therapist. Treatment techniques/strategies and
resource material (e.g. handouts) are contained in the
treatment manual (Kingsep and Nathan, 2001) especially written for this population with special needs.
Additionally, this treatment manual specifies the session by session agenda. Weekly individual supervision with PN or DC was provided. The group sessions
were recorded on audiotape (with participant consent)
and reviewed by a senior clinical psychologist to
ensure the treatment protocol was followed, and the
integrity and consistency of treatment maintained. The
CBGT therapists were neither the case manager nor
the treating medical doctor. In all cases, psychiatric
management of the subjects of this study was provided by their own psychiatrist and community case
manager.
The intervention consisted of 12 weekly group
sessions of 2-h duration. This was followed by a
follow-up session, 2 months after the last treatment
session. Five therapeutic techniques were used: a
psycho-educational component (teaching participants
about the physiological, behavioural and cognitive
aspects of social anxiety), exposure simulations (gradual confrontation of a feared event/situation), cognitive restructuring (disputation of unhelpful thinking
styles), role-play (behavioural acting out) and intrasession assignments (homework). A summary of the
programme follows.
Session 1: familiarise group participants to group
context, facilitate and direct the clients motivation to
change, provide psychoeducation and group treatment
information, and to initiate monitoring of perceptions
of anxiety in social situations.
Session 2: further extend the concept of monitoring
anxiety levels, provide information concerning breath-

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P. Kingsep et al. / Schizophrenia Research 63 (2003) 121129

ing physiology and retraining, introduction to thought

monitoring.
Session 3: homework review, increased emphasis
on techniques used in diaphragmatic breathing, introduction to progressive muscle relaxation, introduction
to link between activating event, thoughts and feelings, identifying unhelpful thoughts.
Session 4: homework review, discussion of difficulties encountered in relaxation, differentiating
between thoughts, feelings and situations, introduction to challenging unhelpful thoughts.
Session 5: homework review, introduction to exposure testing, discussion of hierarchy construction.
Session 6: homework review, introduction to a
covert relaxation exercise, discuss group members
attempts at constructing the steps for exposure, review
session on exposure.
Session 7: homework review, discuss outside group
exposure helpful hints, introduction to use of
imagery for accurate exposure step perception, introduction to within group role-play.
Session 8: homework review, watch and discuss
exposure step video (Rapee and Lampe, 1998), further
elaboration of role-play.
Session 9: homework review, introduction to coping cards, role-play of hierarchy steps.
Session 10: homework review, discuss relapse
prevention, early warning signs and means of remedying minor setbacks discussed, further role-play.
Session 11: homework review, review SSTG programme, further role-play.
Session 12: review of group feedback forms (formal post-treatment assessment to follow), celebration
of group member progress.
Two-month follow-up: review of principal group
content (exposure, cognitive restructuring and roleplay), discuss progress and accomplishments, current
difficulties in social situations simulations and collaboratively generated solutions.
2.7. Procedure for assessments
Data were collected at three assessment points: pretreatment (baseline), end of treatment (post-treatment)
and follow-up (2 months post-treatment). Subjects in
this study were assessed by clinical psychologists at
WAIPR who were independent from the therapists and
blind to the patients treatment conditions.

3. Results
3.1. Attrition
Initially, 41 individuals consented for participation
in the study, and a total of 8 (6 males and 2 females)
dropped out of the study. Reasons for drop out from
the study included early drop out from the CBGT (at
session 2 or 3) and scheduling clashes. Two of the
eight individuals, which dropped out of the CBGT,
were the result of scheduling clashes (psychiatrist
appointments and activities at the Living Skills Centre
they attended).
3.2. A priori data analysis
The means for the Dependent Variables (DVs) and
the Standard Deviations (SDs) for the three evaluation
junctures and the two groups are shown in Table 1.
3.2.1. Distribution of variables
The distributions of the dependent variables (DVs)
were analysed with Z scores for Skew for each
variable at each phase of the study, divided by the
Standard Error Skew. These analyses confirmed that
the DVs were normally distributed allowing use of
parametric statistics.
3.2.2. Baseline analyses of group means
At baseline, there were no significant differences
between the CBGT and control groups on the SIAS,
BFNE, CDSS, GSI and the QLESQ ( p>0.20). There
was a trend for the groups to differ on the BSPS
( p = 0.09), with the means being highest for the
CBGT group.
3.3. Treatment outcome analyses
Individual one-way analyses of covariance
(ANCOVAs) were completed at the end of treatment
on each DV using the pre-treatment score as a
covariate. This form of statistical analysis was chosen
due to the relatively small number of subjects in
groups. Additionally, ANCOVA provides a more
powerful evaluation of the effect of CBGT on the
dependent variables (assessment measures) by minimising error variance (Tabachnick and Fidell, 1989).
An alpha level of 0.05 was used for all statistical tests.

P. Kingsep et al. / Schizophrenia Research 63 (2003) 121129

125

Table 1
Unadjusted means (and SDs) for the major measures for the two groups
Variable

Pre-treatment
CBGT

Post-treatment

Follow-up

Control

CBGT

Control

CBGT

Control

Measures of social anxiety

SIAS
48.56 (10.01)
BSPS
47.13 (11.79)
BFNE
49.78 (10.12)

44.53 (15.03)
39.71 (12.16)
46.88 (8.43)

34.44 (11.25)
36.81 (7.12)
37.78 (11.98)

44.24 (14.25)
38.82 (11.66)
48.00 (9.75)

34.33 (10.36)
36.87 (9.45)
36.13 (10.55)

n/a
n/a
n/a

Measures of general psychopathology

CDSS
9.25 (3.36)
GSI
53.38 (24.30)

8.94 (3.83)
57.25 (17.19)

4.06 (2.89)
46.38 (20.97)

9.29 (2.87)
57.74 (15.01)

5.07 (3.06)
n/a

n/a
n/a

Measure of quality of life

QLESQ
49.43 (12.80)

54.65 (11.83)

59.03 (8.64)

54.23 (11.440)

57.77 (5.96)

n/a

SIAS, Social Interaction Anxiety Scale; BSPS, Brief Social Phobia Scale; BFNE, Brief Fear of Negative Evaluation Scale; CDSS, Calgary
Depression Scale for Schizophrenia; GSI, Global Symptom Index; QLESQ, Quality of Life, Enjoyment Satisfaction Questionnaire.

3.3.1. Measures of social anxiety

For the CBGT group, the SIAS, BSPS and BFNE
all showed statistical significance over the control
group. Specifically, the SIAS was statistically significant, F(1,30) = 18.41, p < 0.001, as with the BSPS,
F(1,30) = 8.23, p = 0.007. Finally, the BFNE was
statistically significant, F(1,30) = 26.04, p < 0.001.
3.3.2. Measures of general psychopathology
For the CBGT group, the CDSS and GSI demonstrated statistical significance over the control group.
Specifically, the CDSS was statistically significant,
F(1,30) = 38.01, p < 0.001, as with the GSI,
F(1,30) = 6.07, p = 0.02.
3.3.3. Measure of quality of life
For the CBGT group, the QLESQ demonstrated
statistical significance over the control group. Specifically, the QLESQ was statistically significant,
F(1,30) = 21.82, p < 0.001.
3.4. Supplementary analyses
3.4.1. Effect size
Statistically significant results were demonstrated
for all of the assessment measures at post-treatment.
The data were subsequently examined for the strength
of association (effect size). Effect sizes were derived
using Smith and Glasss delta procedures (Glass et al.,
1981). Effect sizes were calculated by subtracting the
mean of the post-treatment control group from the

post-treatment experimental group(s), and then dividing it with the standard deviation of the control group
at post-treatment:
ESd Mt  Mc =SDc
Cohen (1988) defined effect sizes as small, d = 0.2,
medium, d = 0.5 and large, d = 0.8 The statistically significant results in Table 2 indicate that the
effect sizes for the BFNE and the CDSS were of large
size. Two of the measures (SIAS and the GSI) were

Table 2
Effect sizes for major measures at post-treatment
Variables

Post-treatment
Effect size d

Mean effect size

Measures of social anxiety

SIAS
0.69
BSPS
0.17
BFNE
1.05

0.64

Measures of general psychopathology

CDSS
1.82
GSI
0.76

1.29

Measure of quality of life

QLESQ
0.42

0.42

SIAS, Social Interaction Anxiety Scale; BSPS, Brief Social Phobia

Scale; BFNE, Brief Fear of Negative Evaluation Scale; CDSS,
Calgary Depression Scale for Schizophrenia; GSI, Global Symptom
Index; QLESQ, Quality of Life, Enjoyment Satisfaction Questionnaire.

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P. Kingsep et al. / Schizophrenia Research 63 (2003) 121129

medium to large size, QLESQ was approaching

medium size, whereas the BSPS was approaching a
small effect size.
3.4.2. Follow-up
The waitlist control group could not be measured at
follow-up, therefore determination for maintenance of
treatment effects was conducted on the CBGT only.
Pre-treatment and follow-up assessment scores were
entered into the analysis. All measures of social
anxiety were statistically significant; the SIAS
t(14) = 4.28, p = 0.001; the BSPS, t(14) = 3.91,
p = 0.002; and the BFNE t(7) = 6.23, p < 0.001. The
CDSS was statistically significant, t(14) = 3.86,
p = 0.002. The measure of quality of life (QLESQ)
was also statistically significant t(8) =  3.18,
p = 0.013. Additionally, an examination of the mean
scores at post-treatment and follow-up showed no
significant improvement during this assessment phase.
Thus, the treatment effect had been maintained at 2month follow-up.
3.4.3. Participant evaluation of treatment
In the final session of treatment, a WAIPR consumer evaluation and feedback questionnaire were
provided to group participants. These were designed
to assess client perceptions of the usefulness of the
CBGT and the programme overall. Four domains of
interest were examined using a five-point Likert scale,
and participants provided the following feedback.
With regards to problems with social anxiety improving, 86% of group participants rated this as better.
For a willingness to recommend this group to others,
71% of participants judged this as good to very
likely. In terms of group members satisfaction with
the group format for treatment, 57% rated this as
very satisfactory. For the final domain of being
better able to cope with life in general, 100%
considered their abilities as better.

4. Discussion
This study explored whether CBGT is an effective
means of addressing the deleterious effects that social
anxiety plays in the life of an individual with schizophrenia. The treatment programme was based on an
evidence-supported protocol for the treatment of

social phobia (Heimberg et al., 1995) with modifications so that the intervention was suitable for individuals with schizophrenia. The outcome of treatment
was examined in terms of social anxiety, general
psychopathology and quality of life. The statistical
analyses demonstrated the effectiveness of the intervention with a significant reduction in measures of
social anxiety and general psychopathology, and an
increase in quality of life scores.
The symptoms of social anxiety are multifaceted
and required multiple assessment measures. The three
measures which directly measured social anxiety
symptomatology, including the BSPS, SIAS and the
BFNE, demonstrated statistical significance in the
CBGT group. Statistical and effect magnitude on the
three direct measures of social anxiety provide support for the validity of the claim that CBGT reduces
social anxiety in individuals with schizophrenia.
Depression has been used in this study as a
measure of general psychopathology. It has been
shown to be a core part of schizophrenia that occurs
at the height of psychosis and decreases over the
course of treatment (Koreen et al., 1993). Additionally, this affective condition aggravates the negative
bias in psychopathology, thus compounding the difficulties in good treatment outcome (Fennell, 1989).
Specifically, confronting social situations associated
with high levels of subjective anxiety can be attenuated by the diminished expectancies of success often
associated with heightened levels of depression. The
CBGT intervention provided a significant reduction in
depression at post-treatment when compared to the
waiting list control. The elevation in mood may have
contributed to group participants having increased
abilities to contest the anergia and attentional/concentration impediments typically associated with schizophrenia. This may have enabled participants to better
learn and apply treatment strategies to challenge their
social anxiety.
Mental health and specifically anxiety disorder
research has focused primarily on symptomatic relief,
often neglecting the individuals perception of their
quality of life (Wittchen et al., 1999). Participants in
this study showed statistically significant improvement in quality of life after the completion of the
CBGT compared to control subjects. Due to the
significant increases in quality of life, enjoyment
and satisfaction scores for the CBGT group partic-

P. Kingsep et al. / Schizophrenia Research 63 (2003) 121129

ipants, it is suggested that an improvement in the

global betterment of psychological health has
occurred. Quality of life is a useful evaluative framework against which to assess the outcomes of programme interventions (Barry and Crosby, 1996).
Additionally, it has been shown to contribute independently to end of treatment results in anxiety
management interventions (French and Nathan,
2002). There may be some argument that within the
results there may have been some change in nonspecific factors (e.g. greater care and attention in the
treatment group). This is a general problem in nonlaboratory studies, and as such future studies could
utilise an attention/placebo comparison group to determine whether such factors are significantly contributing to treatment effects. Future studies would benefit
from a more typical measure of symptomatic expression in schizophrenia. This would potentially aid in
the determination of whether the CBGT of co-morbid
social anxiety additionally targets the principal
symptoms of schizophrenia.
Very few interventions for the treatment of comorbid anxiety and schizophrenia have been conducted; therefore, effect sizes can be used to determine the impact of interventions on the statistical
change in psychometric measures. In terms of the
Halperin et al. (2000) study, effect sizes were calculated using Smith and Glasss delta procedures (Glass
et al., 1981). So as to aid comparison, only measures
used in the present study were calculated. For the
Halperin study, the following effect sizes were calculated: SIAS (0.30), BSPS (0.09), CDSS (1.76), GSI
(0.13) and the QLESQ (0.38). It is interesting to note
that when comparing these results to that contained in
Table 2, the BSPS is shown to reflect minimal change
in social anxiety symptomatology as a result of treatment in both studies.
Participant evaluation feedback is useful for mental
health practitioners who develop treatment protocols.
A major proportion of participants reported that CBT
was useful in addressing their concerns with social
anxiety and providing them with enhanced coping
mechanisms. This and the statistical evidence suggest
strong effectiveness of CBGT in the management of
co-morbid social anxiety in individuals with schizophrenia.
Some of the key factors which facilitated adaptation of CBGT to this population include (but are not

127

limited to): engagement, rapport, specificity/slower

pace, intra-session activities (homework), treatment
team involvement and awareness of therapists beliefs/
prejudices. Building rapport is enhanced by not solely
focusing on the therapists rehabilitation agenda (i.e.
social anxiety management). The CBT techniques
may be incorporated within a broader client therapist
discussion encompassing the clients housing, finance,
upcoming trip plans, medication and other support
needs. As the therapist engages in further contact with
the client, the focus of discussion becomes progressively more therapy oriented. Since one major therapeutic challenge involves maintaining client interest
and motivation, the previously mentioned strategy of
not allocating 100% of contact time to pure therapy
encourages and sustains engagement. Although there
was relatively high attrition in the CBGT component
of this programme, Chadwick et al. (1996) suggest
that there exists a pattern of high and early drop out in
studies examining the effectiveness of cognitive
approaches within the psychotic spectrum of disorders. That said, future intervention in this area could
benefit from widening the rehabilitation agenda early
on in treatment.
Due to the potential information processing deficits
in this clinical population and its role in social impairment (Penn et al., 1995), it is important to engage in
task specificity and progress at a slower pace than
typically associated with other less severe psychiatric
disorders. This involves persistence in the application
of therapeutic tools and strategies. As was mentioned
in the Results section, clients dropped out of the
programme in the initial stages. This attrition rate
was predominantly in the CBGT during the 2nd or
3rd session. This highlights the importance of pace as
a maintaining or deleterious factor in the CBGT. In
order to determine whether this was a defining factor
in a participants choice to drop out, it may be useful to
lengthen the rapport and associated engagement building stage associated with the beginning of treatment.
There are a number of limitations to this study.
Firstly, schizophrenia is a heterogeneous disorder. A
larger sample size may better address validity of the
treatment gains reported in the present study. The lack
of measurement of schizophrenic specific symptomatology was a second limitation of the study. The GSI
was shown to be significant in the treatment group,
thus reflecting a reduction in the CBGT clients level

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P. Kingsep et al. / Schizophrenia Research 63 (2003) 121129

of psychological distress. Yet, this does not accurately

suggest the treatment programme concurrently
affected changes in schizophrenia symptoms along
with reductions in social anxiety and depressive
symptoms. Subjects in this study were recruited if
they were stable and well maintained by their treating
consultant psychiatrist, thus, the typical positive and
negative symptom expression was well managed. This
said, it would be advantageous to determine whether
symptoms considered part and parcel of the stable
clinical picture were significantly changed as a result
of CBGT for social anxiety. The final limitation was
that due to both ethical implication of non-treatment
and that this study took place within a real-life
clinical setting, therefore treatment could not be withheld from individuals in the wait list control group. It
has long been recognised that treatment developed in
clinical trials might not translate to the typical clinical
setting. This study provides evidence that treatment
developed in research units can be applied to a study
population in a real-life setting. Whilst this impacts on
traditional research methodology, the use of effectiveness research makes direct contributions to the
practicing clinician.
Mental health professionals may erroneously view
schizophrenia as a chronic deteriorating disease, and
as such are pessimistic about psychological treatment
for psychotic disorders. This assumption fails under
the scrutiny of recent clinical and research evidence.
Thus, adjunctive CBGT for social anxiety in schizophrenia may serve to confront and begin to tackle the
countless aspects of human functioning that are compromised in these individuals.
Acknowledgements
Supported by the Mental Health Division, Western
Australia. We thank Dr. Clare Rees for her comments,
and Lesley Jeffreys and Steve Halperin for their
assistance.
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