Psychotic symptoms in social anxiety disorder patients: report of three cases

BACKGROUND: Social Anxiety Disorder (SAD) is mainly characterized by an individual's intense concern about other people's opinion of the individual. Notably, among those with severe anxious symptoms, we can often observe self-referential feelings. OBJECTIVE: Faced with little research directed toward the exploration of psychotic symptoms in SAD patients, we will approach the topic by describing three cases. DISCUSSION: Three explanations seem possible for the psychotic manifestations in SAD. The first one depends on the individual's ability or inability to challenge the impression of being criticized by people. A second possibility would be the stressor and perpetuating role of SAD, which would make individuals more likely to present with more severe mental disorders such as delusional disorder (DD). The third explanation would be the possibility that SA is caused by a primary thought abnormality (psychotic self-reference) in some cases, instead of an affective disturbance (anxious insecurity), which led to intense concern about others' opinions. We also observed that antipsychotics did not produce significant improvement in any of the three cases. This result may be related to dopaminergic circuits and the D2 receptor hypoactivity. CONCLUSION: The differentiation between delusion and anxious concern may be inaccurate and may change throughout the disorder's evolution. New diagnostic subcategories or the enlargement of the social anxiety diagnostic is proposed to overcome the current diagnostic imprecision. There seems to be a symptomatic spectrum between SAD and DDs.