Studies investigating social anxiety in people with psychosis
\\n\\n
Dr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\\n\\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\\n\\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\\n\\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\\n\\nThank you all for being part of the journey. 5,000 times thank you!
\\n\\nNow with 5,000 titles available Open Access, which one will you read next?
\\n\\nRead, share and download for free: https://www.intechopen.com/books
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Preparation of Space Experiments edited by international leading expert Dr. Vladimir Pletser, Director of Space Training Operations at Blue Abyss is the 5,000th Open Access book published by IntechOpen and our milestone publication!
\n\n"This book presents some of the current trends in space microgravity research. The eleven chapters introduce various facets of space research in physical sciences, human physiology and technology developed using the microgravity environment not only to improve our fundamental understanding in these domains but also to adapt this new knowledge for application on earth." says the editor. Listen what else Dr. Pletser has to say...
\n\n\n\nDr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\n\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\n\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\n\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\n\nThank you all for being part of the journey. 5,000 times thank you!
\n\nNow with 5,000 titles available Open Access, which one will you read next?
\n\nRead, share and download for free: https://www.intechopen.com/books
\n\n\n\n
\n'}],latestNews:[{slug:"stanford-university-identifies-top-2-scientists-over-1-000-are-intechopen-authors-and-editors-20210122",title:"Stanford University Identifies Top 2% Scientists, Over 1,000 are IntechOpen Authors and Editors"},{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"},{slug:"oiv-awards-recognizes-intechopen-s-editors-20201127",title:"OIV Awards Recognizes IntechOpen's Editors"},{slug:"intechopen-joins-crossref-s-initiative-for-open-abstracts-i4oa-to-boost-the-discovery-of-research-20201005",title:"IntechOpen joins Crossref's Initiative for Open Abstracts (I4OA) to Boost the Discovery of Research"},{slug:"intechopen-hits-milestone-5-000-open-access-books-published-20200908",title:"IntechOpen hits milestone: 5,000 Open Access books published!"},{slug:"intechopen-books-hosted-on-the-mathworks-book-program-20200819",title:"IntechOpen Books Hosted on the MathWorks Book Program"}]},book:{item:{type:"book",id:"6503",leadTitle:null,fullTitle:"Brain Tumors - An Update",title:"Brain Tumors",subtitle:"An Update",reviewType:"peer-reviewed",abstract:'We all know that the field of neuro-oncology is heterogeneous and under continuous development with the addition of new knowledge and information on a regular basis. 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Previously she obtained her degree in Agronomical Engineering (Agri-food Industries field), in July 1997, and her second degree in Environmental Sciences (Industrial field) in October 2000.\nIn 2002, she began her career as a researcher at Department of Engineering Projects from Universitat Politècnica de València, where she became a teacher in October 2003, teaching subjects related to environmental impact assessment, eco-design, carbon footprint and life cycle assessment, among others. 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He has published papers\nin international peer-reviewed journals, conference proceedings,\nand book chapters on various topics regarding environmental and\nwaste management issues. His research aims to develop new methods and indicators to assess key environmental issues across various geographical\nscales. His research interests include environmental geography, waste management,\npollution, sanitation, sustainability, circular economy, public and environmental\npolicies, spatial analysis, and rural and regional development. He has previously edited the following books: “E-waste in Transition: from Pollution to Resource”, “Solid\nWaste Management in Rural Areas”, and “Environmental Risks”. 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He has published more than 20 books including under foreign\npublishing houses (France), and also translations of books such as Introducing à la\ngéographie humaine by. A. Bailly, H. Beguin, and R. Scariati. His research interests are\neconomic geography, rural geography, political geography, and sustainable development. 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Eugene Bleuler was one of the first to emphasize the importance of affect and its pronounced impact upon the course and outcome of psychosis. The famous “Krapelian dichtocomy” which supported the clear distinction between mood and psychotic illnesses on the basis of etiological origins, symptomatology, course and outcome was first challenged by Bleuler. Bleuler recognized the disorders of affect as one of the four primary symptoms (blunted \'Affect\', loosening of \'Associations\', \'Ambivalence\', and \'Autism\') of schizophrenia, as opposed to delusions and hallucinations which were perceived as secondary. Bleuler further postulated the incongruity between emotions and thought content in people with schizophrenia as well as their diminished or complete lack of emotional responsiveness. Bleuler’s recognition of the importance of affective disturbances in schizophrenia has influenced current diagnostic definitions and criteria of schizophrenia.
The sharp distinction between affect and psychosis which has dominated both research and clinical practice during the nineteenth and twentieth century has gradually been abandoned. New evidence from epidemiological, familial and molecular genetic studies (Cardno et al, 2005; Craddock et al, 2005; Craddock & Owen, 2005) have come to light demonstrating the endemic nature of affective disturbances in psychosis. In a twin study by Cardno et al (2002), the authors identified significant overlap in risk factors between the schizophrenic, schizoaffective and manic syndromes. Specifically, considerable genetic correlations were reported between the schizophrenic and manic syndromes. This is in accordance with a review of genetic linkage studies of schizophrenia and affective disorders (Wildenauer et al, 1999) which supports the genetic overlap of the two syndromes. Furthermore, factor analytic studies of psychosis symptoms consistently point to a depression dimension in non-affective psychosis (Murray et al, 2005). Depression and social anxiety are each observed throughout the course (Koreen et al, 1993), including the prodromal phase (Hafner et al, 1999; Owens et al, 2005) and following symptomatic recovery. Post psychotic depression (PPD) has been reported in 30-50% of individuals (McGlashan et al, 1976; Birchwood et al, 2000a) and social anxiety disorder (SaD) has been observed in up to one in three (Davidson et al, 1993; Cassano et al, 1999; Goodwin et al, 2003; Pallanti et al, 2004).
According to the DSM-IV (APA, 1994), social anxiety disorder (social phobia) is defined as “a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing”. People with social anxiety desire to make a favourable impression during social encounters but at the same time doubt their ability to do so; they fear that they will be scrutinized and negatively evaluated due to perceived failed social performance. These fears lead people with social anxiety to avoid all or some social situations and in extreme cases this could lead to complete social isolation (Clark & Wells, 2005). Exposure to the feared situation is almost always accompanied by physical symptoms, for example, sweating, trembling, heart racing, which could develop (although not necessarily) to panic attacks.
Evidence regarding the distinction of social phobia into two subtypes, the non-generalized and generalized social phobia, is ambiguous; although the DSM-IV does acknowledge the presence of the latter. This encompasses a wider range of fears linked to interaction situations and therefore is not restricted to particular environmental circumstances (i.e. it is “free-floating”). It may include talking to others, asking questions, meeting new people, manifest in fear and avoidance of everyday situations (Wittchen et al, 1999). These kinds of social fears have been exclusively reported in approximately two-third of people with lifetime social phobia indicating that the generalized subtype might be more prevalent compared to the non-generalized one (Kessler et al, 1998). This, sometimes also called “specific” or “discrete”, is mainly characterized by performance-type fears, the most common being that of speaking in public or performing in front of an audience (Schneier et al, 1992; Stein et al, 1996). It seems therefore that the generalized subtype reflects a more pervasive and debilitating form of the illness which is supported by evidence showing higher rates of comorbidity with mood and other anxiety disorders (Wittchen et al, 1999) and lower recovery rates, compared to the non-generalized, specific subtype (Kessler et al, 1998).
One of the largest epidemiological investigations carried out in the United States, the National Comorbidity Survey (Kessler et al, 1994), has reported prevalence estimates of 12-month and lifetime social anxiety disorder as 7.1% and 12.1%, respectively. The lifetime prevalence of social anxiety in other western countries seems to range between 3.1% to 15.6 % (Favarelli et al, 2000; Furmark et al, 1999). The variation in prevalence rates among different epidemiological studies could be attributed to the application of different diagnostic criteria and instruments for the identification and assessment of social anxiety disorder.
Studies investigating the course of social anxiety have established the long-term morbidity of the illness (Chartiers et al, 1998; Yonkers et al, 2001). Social anxiety develops at an early age, usually during childhood or adolescence and once established, follows a stable, chronic course if treatment is not initiated (Chartiers et al, 1998; Yonkers et al, 2001). Recent findings show that social anxiety is also very prevalent in later life (Cairney et al, 2007). Findings regarding the sociodemographic characteristics of social anxiety disorder support that this is more prominent among the female population (Wittchen et al, 1999; Schneier et al, 1992; Davidson et al, 1993; Magee et al, 1996) although there have been studies (Stein et al, 2000) which have failed to confirm such gender differences. Moreover, higher incident rates have been consistently observed among unmarried individuals usually coming from a lower socioeconomic background, with poorer educational attainment and higher unemployment rates (Schneier et al, 1992; Davidson et al, 1993; Magee et al, 1996). The average duration of illness is approximately 29 years (Chartier et al, 1991; Keller et al, 2003) and the likelihood of a full remission or recovery is significantly lower compared to that of other anxiety disorder (Keller et al, 2003). In an eight year longitudinal study of 163 patients with social phobia, Yonkers et al (2001) found that only 38% and 32% of female and men respectively experienced a complete remission indicating the unremitting and persisting nature of the disorder. Additionally, such lower rates of recovery were found to be associated, particularly in women, with a history of suicide attempts, the presence of co-morbid disorders, the most prominent that of agoraphobia, avoidant personality disorder and alcohol abuse, and also with poor baseline functioning (Yonkers et al, 2001; Keller et al, 2003).
The highly impairing nature of the disorder is reflected in the marked disabilities affecting the majority of life domains. Deterioration of social functioning manifest in avoidance and withdrawal from social interactions, decrease in work productivity and interpersonal relations produce a significant decrease in quality of life (Wittchen et al, 2000). Despite the highly impairing nature of social anxiety only up to a half of patients seek and receive treatment during the course of the illness (Wittchen et al, 2000; Wang et al, 2005) and this is primarily in the form of pharmacological interventions.
Social anxiety is among the most prevalent and debilitating affective disturbances manifest in people with psychosis (Pallanti et al, 2004; Mazeh et al, 2009; Michail & Birchwood, 2009). In a recent study by Michail & Birchwood (2009), social anxiety was diagnosed in 25% of people with first-episode psychosis (FEP). In addition to the 25% with an ICD-10 diagnosis of SaD, there was also a further 11.6 % who reported clear social interaction difficulties and/or signs of avoidance not sufficient though to reach formal diagnostic criteria. Social anxiety is usually accompanied by high levels of depression (Michail & Birchwood, 2009; Birchwood et al, 2007) and leads to significant social disability (Voges & Addington, 2005), lower quality of life (Pallanti et al, 2004) and poorer prognosis as it raises the possibility of an early relapse (Gumley, 2007).
Despite the high prevalence and its debilitating nature, social anxiety has not been extensively investigated and the processes that underlie its emergence in psychosis remain unclear. The relationship between social anxiety and positive psychotic symptoms, particularly paranoia, is yet to be clarified. Particularly, it is not clear whether the development and maintenance of social anxiety in psychosis is simply driven by paranoia and persecutory beliefs.
This review aims to examine the prevalence and phenomenology of social anxiety disorder in psychosis and to investigate its relationship to positive psychotic symptoms and particularly paranoia and persecutory ideation.
A systematic search strategy was conducted and consisted of electronic searches of the following databases: PsycINFO, PubMed and Science Direct using the terms “anxiety AND psychosis”, “anxiety AND schizophrenia”, “social anxiety AND psychosis”, “social anxiety AND schizophrenia”, “social anxiety AND paranoia”. For inclusion, studies had to meet the following criteria:
Published in an English language, peer-reviewed journal. This ensures a degree of quality assurance in the reviewing process
Published between 1990-2011
Participants with psychosis. This includes schizophrenia, schizoaffective disorder, schizophreniform, bipolar disorder and depression with psychotic features
Adult participants (≥16 years)
Diagnosis of social anxiety disorder (either ICD-10 or DSM-IV)
Following the electronic search, hand searches of identified literature were conducted in the form of citation chasing.
Thirteen studies fulfilled the inclusion criteria of this review (Table 1): three studies (Cossof & Hafner, 1998; Tibbo et al, 2003; Braga et al, 2005) investigated the prevalence of anxiety disorders, (including social anxiety) in psychosis; six examined the prevalence of social anxiety disorder in psychosis (Penn et al, 1994; Pallanti et al, 2004; Voges & Addington, 2005; Birchwood et al, 2007; Mazeh et al, 2009; Michail & Birchwood et al, 2009), three studies (Lysaker & Hammersley, 2006; Lysaker & Salyers; 2007; Romm et al, 2012) investigated the relationship of social anxiety with clinical psychotic symptoms and one review paper on anxiety disorders in schizophrenia was also identified (Muller et al, 2004). Four studies recruited a first-episode psychosis sample (Voges & Addington, 2005; Birchwood et al, 2007; Michail & Birchwood, 2009; Romm et al, 2012); three recruited in-patients with schizophrenia, schizoaffective or bipolar disorder (Cossof & Hafner, 1998; Penn et al, 1994; Mazeh et al, 2009) and three recruited outpatients with schizophrenia (Tibbo et al, 2003; Braga et al, 2005; Pallanti et al, 2004).
Social anxiety appears to be among the most prevalent anxiety disorders in psychosis with prevalence rates ranging between 17% to 36%. In samples with first-episode psychosis, prevalence rates range between 25%-32% based on formal diagnostic criteria (DSM-IV or ICD-10). In a recent study by Michail & Birchwood (2009), social anxiety was diagnosed in 25% of people with first-episode psychosis. However, in addition to the 25% with formal SaD, there was also a further 11.6 % who reported clear social interaction difficulties and/or signs of avoidance not sufficient though to reach formal diagnostic criteria (ICD-10). These “borderline” cases, though not satisfying formal criteria, were nevertheless reporting interpersonal difficulties that may well warrant intervention at a clinical level. In studies with inpatient samples, the prevalence of social anxiety ranged between 11%-43% among those with schizophrenia, schizoaffective or bipolar disorder and in studies with outpatients with schizophrenia 17%-36% of them were diagnosed with social anxiety disorder or social phobia.
The highly impairing nature of social anxiety in psychosis has been consistently reported in literature. In a study of outpatients with schizophrenia, Pallanti et al (2004) reported that those diagnosed with comorbid social anxiety disorder had a higher rate of suicide attempts, lower social adjustment and overall quality of life compared to those without social anxiety. Braga et al (2005) also reported higher levels of global functional impairment and greater limitations in the domains of work and social life in schizophrenic patients with comorbid anxiety disorder compared to those without comorbid anxiety disorder. Previous findings by Penn et al (1994) confirm the significant impact of social anxiety on social disability. Findings also show that those with schizophrenia and comorbid social anxiety have higher levels of substance abuse compared to those with no comorbid social anxiety (Pallanti et al, 2004).
The phenomenology of social anxiety in psychosis has been thoroughly investigated by Michail & Birchwood (2009). In their study comparing the severity and phenomenology of social anxiety in psychosis with that in non psychosis, the authors revealed a very similar clinical profile with regards to levels of social anxiety and social avoidance; the number and severity of autonomic anxiety symptoms and social evaluative concerns. What is more, social anxiety both in people with psychosis and non psychosis occurred in the context of an equally high level of other anxiety disorders underlying the similarity of the two groups. The presence of social anxiety in people with psychosis was also accompanied by marked levels of depression; approximately 31% of FEP people exhibited moderate to severe levels of post-psychotic depression. This is in line with findings from previous studies (Voges & Addington, 2005; Birchwood et al, 2007) and confirmed by Romm et al (2012) who found that high levels of social anxiety in people with first-episode psychosis were accompanied by high levels of depression.
\n\t\t\t\tStudy\n\t\t\t | \n\t\t\t\n\t\t\t\tParticipants\n\t\t\t | \n\t\t\t\n\t\t\t\tAim\n\t\t\t | \n\t\t\t\n\t\t\t\tKey results\n\t\t\t | \n\t\t
Penn et al. (1994) | \n\t\t\t38 in-patients with a diagnosis of schizophrenia or schizoaffective disorder according to the SCID-P | \n\t\t\tInvestigate the relationship between social anxiety and positive and negative symptoms in schizophrenia | \n\t\t\tBehavioural indices of social anxiety (e.g. slower speech rated, less fluent speech, global social anxiety) were associated with negative symptoms. Self-report measures of social anxiety and related fears (e.g. fear of being negatively evaluated, fear of walking alone in the streets, fear of talking to people in authority) were associated with positive symptomatology. Such fears may be related to certain aspects of the illness e.g. paranoia, persecutory ideation whereas behavioural manifestations of social anxiety may reflect a deficit in social skills prominent in negative symptom | \n\t\t
Cossof & Hafner (1998) | \n\t\t\t100 consecutive in-patients diagnosed with schizophrenia, schizoaffective disorder or bipolar disorder(based on the SCID) | \n\t\t\tDetermine the prevalence of anxiety disorders in treated psychiatric inpatients with a DSM-IV diagnosis of schizophrenia, schizoaffective or bipolar disorder | \n\t\t\t43% of inpatients with schizophrenia were also diagnosed with a comorbid anxiety disorder (based on the SCID): 17% social phobia (SP),12% generalized anxiety disorder (GAD), 13% obsessive-compulsive disorder (OCD) | \n\t\t
Tibbo et al (2003) | \n\t\t\t30 outpatients with a diagnosis of DSM-IV schizophrenia (based on the MINI) | \n\t\t\tDetermine the prevalence of anxiety disorders (as assessed by the MINI) controlling for anxiety symptoms related to delusions and hallucinations | \n\t\t\t16.7% prevalence of GAD 13.3% prevalence of SP 3.3% prevalence of panic disorder with/without agoraphobia 16.7% prevalence of agoraphobia without panic, excluding individuals whose anxiety symptoms were related to delusions or hallucinations \n\t\t\t | \n\t\t
Muller et al (2004) | \n\t\t\tA review of the literature on comorbid anxiety disorders in schizophrenia | \n\t\t\tReview the epidemiology, phenomenology, and neurobiologic underpinnings of comorbid anxiety symptoms and disorders in schizophrenia, and address treatment strategies | \n\t\t\tAnxiety disorders are very prevalent in schizophrenia. The mechanisms that underpin this comorbidity require further investigation. Randomized controlled trials of pharmacotherapy and psychotherapy are necessary to establish the best way of managing this comorbidity | \n\t\t
Pallanti et al (2004) | \n\t\t\t80 outpatients with schizophrenia (based on the SCID for DSM-IV) and 27 outpatients with primary diagnosis of social anxiety disorder | \n\t\t\tPrevalence and severity of social anxiety in schizophrenia Compare the severity and phenomenology of social anxiety in those with schizophrenia and those with social anxiety as primary diagnosis (no schizophrenia) | \n\t\t\t36.3% of people with schizophrenia were diagnosed with social anxiety based on the Liebowitz Social Anxiety Scale (LSES). The severity of social anxiety and avoidance in this group was as elevated in those with social anxiety without schizophrenia People with social anxiety and schizophrenia had a higher rate of suicide attempts, lower social adjustment and overall quality of life compared to those with schizophrenia only No differences in positive and negative symptoms (as assessed by the SAPS and SANS) between patients with schizophrenia and social anxiety and those with schizophrenia only | \n\t\t
Voges & Addington (2005) | \n\t\t\t60 patients with first-episode psychosis (FEP) | \n\t\t\tExamine the relationship between social anxiety and social functioning and determine whether those with psychosis have any maladaptive or irrational beliefs regarding social situations | \n\t\t\t32% of patients with FEP were diagnosed with social anxiety disorder (SCID-I for DSM-IV) Higher levels of social anxiety, as assessed by the Social Phobia and Anxiety Inventory (SPAI) were related to depression and negative symptoms but not positive symptoms. Social anxiety was associated with greater negative self-statements, and the lack of social anxiety with higher levels of positive self-statements. The authors suggest that negative self-statements may be prominent in the development and maintenance of social anxiety in first-episode patients | \n\t\t
Braga et al (2005) | \n\t\t\t53 outpatients with a DSM-IV diagnosis of schizophrenia | \n\t\t\tDescribe the prevalence of comorbid lifetime anxiety disorders in outpatients with schizophrenia and to compare the subjective quality of life of patients with and without comorbid anxiety disorders | \n\t\t\tPrevalences of anxiety comorbidity (based on SCID-IV) were: social phobia (17%), OCD (15.1%), GAD (9.4%), anxiety disorder Not Otherwise Specified (7.5%), panic disorder (5.7%), specific phobia (5.7%), Post-traumatic stress disorder (PTSD) (3.8%), and agoraphobia (1.9%) Higher levels of global functional impairment, more severe limitations in the domains of work and social life in schizophrenic patients with comorbid anxiety disorder compared to those without comorbid anxiety disorder | \n\t\t
Birchwood et al (2007) | \n\t\t\t79 participants with first-episode psychosis | \n\t\t\t1. Examine the rate and severity of social anxiety in FEP 2. investigate the relationship of social anxiety with positive and negative symptoms 3. investigate the relationship between social anxiety and shame of psychosis | \n\t\t\t29% prevalence of social anxiety in FEP (based on the SIAS/SPS) No relationship between delusions, hallucinations and suspiciousness/ persecution and social anxiety (based on the positive scale of PANSS). Also, no relationship between negative symptoms and social anxiety and avoidance Greater levels of shame attached to their diagnosis and feelings of being down-ranked and rejected in the socially anxious psychotic group compared to the non socially anxious psychotic group | \n\t\t
Mazeh et al (2009) | \n\t\t\t117 inpatients with a SCID-P for DSM-IV diagnosis of schizophrenia | \n\t\t\tInvestigate the prevalence and correlates of social phobia in patients with schizophrenia | \n\t\t\t11% were diagnosed with comorbid social phobia (based on the SCID-P) Schizophrenic patients with comorbid social phobia had higher (although not statistically significant) level of PANSS total score compare to those without social phobia The “fear” component of social phobia (as measured by the Leibowitz Social Anxiety Scale, LSAS) was related to positive psychotic symptoms Avoidance (as measured by LSAS) was associated with negative symptoms | \n\t\t
Michail & Birchwood (2009) | \n\t\t\t80 participants with FEP | \n\t\t\tDetermine the phenomenology of psychotic SaD and how this is different to non-psychotic SaD Investigate whether psychotic SaD is linked to the nature and severity of psychotic symptoms and particularly paranoia | \n\t\t\t25% of FEPs received an ICD-10 diagnosis of social anxiety based on the SCAN (WHO, 1999). Equally elevated levels of social anxiety (SIAS), avoidance (SPS), depression (CDSS) and autonomic anxiety symptoms in the psychotic and non psychotic socially anxious group No relationship between positive symptoms including suspiciousness/persecution (PANSS) and social anxiety (SIAS/SPS) in the FEP group. However, a subgroup of socially anxious psychotic people reported higher levels of persecutory threat (Details of Threat Questionnaire) compared to psychotic people without social anxiety. | \n\t\t
Romm et al (2012) | \n\t\t\t144 participants with FEP (based on SCID-I for DSM-IV) | \n\t\t\tInvestigate whether SaD in psychosis is associated with poorer premorbid functioning, higher levels of psychotic symptoms and reduced QoL | \n\t\t\t50% of FEPs suffered from severe social anxiety (LSAS). Social anxiety was associated with greater levels of depression, poorer premorbid functioning and reduced QoL. No relationship between social anxiety and positive psychotic symptoms was reported. | \n\t\t
Lysaker & Salyers (2007) | \n\t\t\t128 participants with schizophrenia & schizoaffective disorder (based on SCID for DSM-IV) | \n\t\t\tInvestigate the relationship between anxiety (as measured by the Multidimensional Anxiety Questionnaire) and psychotic symptoms (as measured by the PANSS) | \n\t\t\tHigher levels of anxiety were associated with greater hallucinations, withdrawal, depression, hopelessness, better insight and poorer function. | \n\t\t
Lysaker & Hammersley (2006) | \n\t\t\t71 participants with schizophrenia & schizoaffective disroder | \n\t\t\tExamine the possible roots of social anxiety in schizophrenia by investigating its relationship to delusions and flexibility of abstract thought | \n\t\t\tParticipants classified as having both significant delusions (based on the PANSS) and impairments in flexibility of abstract thought had significantly higher levels of social anxiety (based on the LSAS) compared to those with only one or neither of these difficulties | \n\t\t
Studies investigating social anxiety in people with psychosis
The relationship between social anxiety and positive psychotic symptoms, particularly paranoia, has attracted considerable attention; however, the processes that underlie this relationship are yet to be clarified. Ten studies identified in this review examined the relationship of social anxiety with positive symptoms (Penn et al, 1994; Tibbo et al, 2003; Pallanti et al, 2004; Voges & Addington, 2005; Birchwood et al, 2007; Mazeh et al, 2009; Michail & Birchwood, 2009; Lysaker & Hammersley, 2006; Lysaker & Salyers, 2007; Romm et al, 2012). Four studies (Penn et al, 1994; Mazeh et al, 2009; Lysaker & Hammersley, 2006; Lysaker & Salyers, 2007) reported a link between social anxiety and positive symptoms. Penn et al (1994) showed that self-report measures of social anxiety and related fears (e.g. fear of being negatively evaluated, fear of walking alone in the streets, fear of talking to people in authority) were associated with positive symptomatology. The authors suggested that such fears may be related to certain aspects of the illness e.g. paranoia, persecutory ideation whereas behavioural manifestations of social anxiety (e.g. slower speech rated, less fluent speech, global social anxiety) may reflect a deficit in social skills prominent in negative symptoms. This was also supported by Mazeh et al (2009) who found the “fear” component of social phobia in schizophrenic patients (as measured by the Leibowitz Social Anxiety Scale, LSAS) to be related to positive psychotic symptoms. Lysaker & Hammersley (2006) and Lysaker & Salyers (2007) found that in people with schizophrenia severe social anxiety was accompanied by severe levels of delusions and greater levels of hallucinations, respectively.
Five studies (Pallanti et al, 2004; Voges & Addington, 2005; Birchwood et al, 2007; Michail & Birchwood, 2009, Romm et al, 2012) reported no differences in severity levels of positive symptoms (including paranoia) between those with schizophrenia and comorbid SaD vs no SaD, suggesting that SaD may be unrelated to clinical psychotic symptoms. In a study of young people with first-episode psychosis, Michail & Birchwood (2009) conducted a thorough investigation of the relationship between positive symptoms and social anxiety. The authors compared levels of positive symptoms, including suspiciousness and persecution, as measured by the PANSS (Positive and Negative Symptom Scale) between people with psychosis and social anxiety (FEP/SaD) and those with psychosis only (FEP/no SaD). Findings revealed no differences in PANSS positive symptoms between psychotic individuals with vs. without social anxiety; including no relationship between PANSS suspiciousness/persecution and social anxiety in the whole FEP (with and without SaD) sample. Furthermore, the level of PANSS suspiciousness/persecution did not affect the severity of social anxiety within the FEP/SaD group itself. These findings confirm previous studies reporting no link between positive symptoms (similarly assessed using the PANSS) and social anxiety (Pallanti et al, 2004; Voges & Addington, 2005) which suggests that the presence of social anxiety in psychosis is not simply driven by clinical paranoia and persecutory threat. It is important to mention though findings in the Michail & Birchwood (2009) study also revealed a subgroup of socially anxious psychotic people (45%) which reported significantly more persecutory threat and anticipated harm as measured by the Details of Threat Questionnaire (Freeman et al, 2001) compared to psychotic people without social anxiety. When investigating further the inter-relationship between social anxiety and persecutory threat within this sub-group no link between level of social anxiety and persecutory threat was revealed. This is of particular interest as it suggests that even among those individuals with psychosis and social anxiety, social anxiety is not necessarily contaminated by ongoing persecutory beliefs.
Social anxiety is among the most commonly reported and disabling of the co-morbidities in people with psychosis. It is characterized by a highly impairing nature which is evident by its impact on social functioning and social disability. Despite its elevated prevalence and severity in psychosis, social anxiety remains under-recognized and under-treated. One of the reasons for this could be that the exact relationship between social anxiety and psychotic symptoms is yet to be determined and the available empirical findings are inconclusive. Although theoretical models and empirical evidence consistently point towards a link between general anxiety and positive symptoms of psychosis, predominantly paranoia and persecutory delusions (Freeman et al, 2001), social anxiety appears to have a distinct quality and its relationship to paranoia and persecutory thinking is not straightforward.
Three pathways have been proposed for the understanding of the ontogeny of social anxiety in psychosis (Michail & Birchwood, 2009; 2011) and they are summarized here:
social anxiety predates the onset of paranoia and helps maintain persecutory beliefs
This suggests that symptoms of social anxiety, avoidance and withdrawal develop in the early or prodrome phase. This is confirmed by studies showing how social withdrawal and socio-emotional dysfunction in people identified as being at risk for developing psychosis are highly predictive predicting of psychosis (Johnstone et al, 2005; Miller et al, 2002; Yung et al, 2004). The development of paranoia and persecutory ideation follows the onset of social anxiety which serves the function of maintaining or strengthening persecution ideation. The work by Freeman et al (2005a; 2005b) has shown how common social anxieties, for example, fear of rejection, interpersonal sensitivity and negative beliefs about the self are amongst the most commonly reported types of suspiciousness (2005a) and form the basis upon which ideas of reference and more severe levels of paranoid thinking are established. Furthermore, these anxieties and social evaluative concerns were found to predict paranoid thinking in a non-clinical sample (2005b).
social anxiety and paranoia develop concurrently in the early phase of psychosis and follow a similar course
This pathway suggests that for a sub-group of individuals, social anxiety and paranoia may develop at the same time and follow a similar course. According to Freeman et al (2001), social anxiety and paranoia are underlined by common fears and concerns which refer to the anticipation of threat and danger which drives behaviours of avoidance and withdrawal from social interactions. It is expected therefore that for this sub-group of people, addressing paranoid concerns and ideas of persecution, would inevitably lead to the remission of symptoms of social anxiety and avoidance.
social anxiety may develop for some people as a consequence of paranoid beliefs
The third pathway suggests that for a sub-sample of people with psychosis, symptoms of social anxiety and avoidance may develop as a direct consequence of their paranoid ideation. Persecutory beliefs and perceived threat regarding other people’s intentions to cause harm can lead to elevated social anxiety and apprehension during social encounters. As a way of protecting or “saving” oneself from such social threats, individuals may engage in safety behaviours by isolating themselves from the social world and actively avoiding all social interactions.
Following the findings of a thorough investigation into the psychological processes that underlie the emergence and maintenance of social anxiety in psychosis (Michail & Birchwood, 2012), a fourth potential pathway is provided here:
social anxiety as a response to the shame and social stigma attached to a diagnosis of mental illness
In a recent study by Michail & Birchwood (2012), the authors examined the relationship between shame cognitions, shame proneness and perceived loss of social status in people with first-episode psychosis and social anxiety disorder. Findings showed that psychotic individuals with social anxiety expressed high levels of shame proneness which was accompanied by perceived loss of social status. They also reported significantly greater negative appraisals arising from a stigmatizing illness, including shame and fear of rejection, compared to their counterparts without social anxiety. These findings were consistent with those of earlier studies (Birchwood et al, 2007, Gumley et al, 2004) reporting that dysfunctional appraisals held by socially anxious psychotic people were characterized by shamefulness, humiliation and perceived rejection by others.
The authors proposed that individuals with psychosis are characterized by an established vulnerability to shame linked to early developmental anomalies. This shame proneness is likely to be catalysed by the stigma attached to the diagnosis of mental illness and there is evidence to suggest that psychosis is indeed considered as a highly stigmatized condition (Thornicroft et al, 2009). As with any type of social stigma, this can affect the social identity of the individual by suggesting qualities that deviate from the norm and are socially discrediting (Goffman, 1963). Individuals with psychosis are aware of the social stereotypes surrounding mental illness and some may even accept and endorse these (Hayward & Bright, 1997; Angermeyer et al, 2003). This internalization of stigma or self-stigma leads to increased shamefulness -particularly when individuals agree with the stigma and the associated negative responses (Corrigan & Watson, 2002a; 2002b)- and fear of the illness being revealed to others due to the consequences of this discovery (e.g. social exclusion, marginalization). Hence, the authors suggested that people with psychosis will attempt to conceal their stigmatized identity to prevent or minimise this threat by promoting behaviours of submissiveness or by avoiding and withdrawing from social interactions.
There is lack of evidence on the clinical effectiveness and cost effectiveness of psychological interventions for the treatment of affective dysregulation and associated distress in psychosis. Cognitive behaviour therapy (CBT) is recommended for people with psychosis (NICE, 2009); however, its focus and evaluation has primarily revolved around the reduction of psychotic symptoms, and not for comorbid depression and social anxiety. Furthermore, psychological interventions such as CBT for the treatment of affective disorders in non-psychotic populations are proposed for the management of affective dysfunction when this is comorbid in psychosis (Halperin et al, 2000; Kingsep et al, 2003). This could be challenging as such treatments in order to be effective, would need to adapt to the specific nature of symptoms and difficulties experienced by people with psychosis (Tarrier, 2005). The findings of the recent study by Michail & Birchwood (2012) suggest that the “conventional” CBT for social anxiety in psychosis could be considerably enhanced with an additional focus on shame cognitions linked to psychosis and accompanying concealment behaviours which are suggested to form part of the safety behaviour repertoire of socially anxious psychotic individuals. A randomised controlled trial testing the effectiveness of a CBT intervention in targeting shameful cognitions while reducing or eliminating concealment linked behaviours could be effective in psychosis.
Risk is defined in terms of uncertain events which may have positive or negative effect on the project objectives. Risks include circumstances or situations, the existence or occurrence of which, in all reasonable foresight, results in an adverse impact on any aspect of the implementation of the project. Various definitions of risks are presented in Table 1.
Sl. no | Source | Definition |
---|---|---|
1 | Project Management Institute [10] | An uncertain event or a condition that if it occurs has a positive or negative effect on project objectives |
2 | Institute of Risk Management [7] | The combination of a probability of an event and its consequences |
3 | Association of Project Management Body of Knowledge [1] | Project Risk is an uncertain event or condition, that, if it occurs, has a positive/negative effect on project objectives. A risk has a cause and if it occurs, a consequence. |
4 | British Standard BS IEC 62198:2001 | Combination of probability of an event occurring and its consequences on project objectives |
5 | A probability or threat of damage, injury, liability, loss, or any other negative occurrence that is caused by external or internal vulnerabilities and that may be avoided through preemptive action. | |
6 | Fundamentals of Risk Management [9] | “A chance or possibility of danger, loss, injury or other adverse consequences” and the definition of risk is “exposed to danger.” However, taking risk can also result in positive outcome. A third possibility is risk related to uncertainty of outcome. |
7 | Adams [8] | Risk is the probability “that a particular adverse event occurs during a stated period of time, or results from a particular challenge.” |
8 | Philosophy of Risk [3] | Risk has been interpreted as Risk = hazard × exposure where Hazard is defined as the way in which a thing or situation can cause harm and exposure as the extent to which the likely recipient of the harm can be influenced by the hazard |
Definitions of risk.
Classification and definition of risks is furnished in Table 2.
Risk | Definitions |
---|---|
Pure risk | A risk which has chance of loss or no loss. Example. A building may get affected by fire or not. These are best covered by insurance |
Speculative risk | Involves chance of gain/loss. Example. A builder may take a risk by promoting a new venture depending upon the prevailing conditions in the vicinity of proposed project, but it may bring him gain/loss. |
Fundamental risk | These are external to a project and which, if they materialise, would be on a large scale and cannot be prevented. These risks are associated with major natural, economic, political or social changes and generate large scale losses. Examples are: Floods, earthquakes, fluctuation of exchange rates, etc. This risk may or may not be insurable. |
Particular risk | These are project specific risks and are identified within the parameters of a project and can be controlled during the implementation of a project, e.g. quality risks, safety risks, legal risks, etc. |
Classification of risks and their definitions.
Source: Project Risk Management, D Van Well-Stam et al., Kogan Page Publications, 2003.
Risk management is a planned and a structured process aimed at helping the project team make the right decision at the right time to identify, classify, quantify the risks and then to manage and control them. The aim is to ensure the best value for the project in terms of cost, time and quality by balancing the input to manage the risks with the benefits from such act. It is just a cost benefit analysis.
Risk management is a continuous process which is to be implemented in any project from inception to completion. However, in order to realise its full potential, risk management should be implemented at the earliest stage of a project, i.e. feasibility design and construction. Risk is an uncertain event or condition that, if occurs, has a positive or negative effect on a project’s objectives. Components of risk are the probability of the occurrence of an event and the impact of the occurrence of that event. There are many sources of uncertainty in construction projects, which include the performance of construction parties, resources availability, contractual relations, etc. because of which, construction projects face problems that cause delay in the project completion time. Success of a project is measured by its ability to get completed within the budgeted cost and time. These goals are interrelated where each parameter has an impact when other parameters get affected. An accurate cost estimating and scheduling should be performed in order to meet the overall budget and time deadline of a project. As such, risk management becomes an integral part of construction management which intends to identify and manage potential and unforeseen risks during the period of implementation of the project; hence, the necessity of risk management [5].
Definitions of risk management are presented in Table 3.
Sl. no | Definition of risk management |
---|---|
1 | https://en.wikipedia.org/wiki/Risk_management Risk Management is the identification, evaluation, and prioritization of risks followed by coordinated and an economical application of resources to minimise, monitor, and control the probability or impact of unfortunate events [6] or to maximize the realization of opportunities. |
2 | Nadeem Ehsan et al., 2012 Risk Management in a project involves the identification of influencing factors which could have negative impact on the the cost, schedule and quality objectives of the project and quantification of impact of potential risk and implementation of mitigation measures to minimise the potential impact of risk |
3 | Bahamid et al., 2017 Risk Management is defined as organized and comprehensive method tailored towards “ organizing”, “identifying” and “responding” to risk factors in order to achieve project goals. |
4 | www.stakeholdermap.com/risk/risk-management-construction Risk Management in construction consists of planning, monitoring and implemeting the measures needed to prevent exposure to risk. To do this, it is necessary to identify the hazards, assess the extent of risks, provision of measures to control the risks and to manage residual risk |
5 | www.vp-projects.kau.edu.sa Risk management is a systematic method of identifying, analysing, treating and monitoring the risks that are all involved in any activity/ process and is a systematic method that minimises the risks which may be an impediment to attainment of objectives |
6 | Cleden [4] Risk is exposure to the consequences of uncertainty. In a project context, it is the chance of something happening that will have an impact upon objectives. It includes the possibility of loss or gain, or variation from a desired or planned outcome, as a consequence of the uncertainty associated with following a particular course of action. Risk thus has two elements: the likelihood or probability of something happening, and the consequences or impacts if it does. |
7 | Project Risk Management, D Vanwell-Stam, Kogan Page India publications, 2004 The entire set of activities and measures that are aimed at dealing with risks in order to maintain control over a project |
8 | www.gpmfirst.com/risk.management-construction Risk Management is a means of dealing with uncertainty – identifying sources of uncertainty and the risks associated with them, and then managing those risks such that negative outcomes are minimized (or avoided altogether), and any positive outcomes are capitalised upon. |
9 | Risk Management in Construction Projects by NICMAR [2] Risk Management is the planned and structured process of bringing the project team make the right decisions at the right time by identifying, classifying and quantifying the risks and then for managing and controlling them, |
10 | Dr Patrick et al., 2006 retrieved from feaweb.aub.edu.lb Risk Management is “a systematic way of looking at areas of risk and consciously determining how each should be treated. It is a management tool that aims at identifying sources of risk and uncertainty, determining their impact, and developing appropriate management responses” |
11 | http://economictimes.indiatimes.com/definition/risk-management Risk Management refers to the practice of identifying potential risks in advance, analysing them and taking precautionary steps to reduce/curb the risk. |
Definitions of risk management.
Construction projects are extremely complex and fraught with uncertainty. Risk and uncertainty can potentially have damaging consequences for the construction projects. Hence, risk analysis and risk management has come to be a major feature of the project management in construction projects. Construction projects are unique, inherently complex, dynamic and risks emanate from multiple sources. The interests of individuals and organisations who are actively involved in a construction project may be positively or negatively affected depending upon the course which a project takes from concept to completion. Multiple stakeholders with varied experience and skills have different expectations and interests in the project which creates problems for smooth execution of the project. Risk management is a concept which many construction companies have never thought of, despite the fact that, the risks can be better controlled if they are identified in the first instance and a well-structured mitigation mechanism is in place. Risk management helps the key project participants namely the client, contractor/developer, consultant and supplier to meet their commitments and to minimise negative impacts on construction project performance in relation to cost, time and quality objectives. Success of a construction project is associated with three aspects of time, cost and quality outcomes.
Successful commissioning of any project, necessarily calls for sound planning on various fronts and getting the project executed in a competent manner. An organisation executing a project would have to reckon with the various risks to which the project may be exposed to and these have to be managed effectively. The construction industry, being vulnerable is potentially more prone to risks and uncertainties than any other industry. The process of taking a project from the conceptual stage to its final completion and putting into operation is quite complex and entails painstaking process at every stage. Construction industry is highly fragmented in that each of its participants—designers, constructors, planners, suppliers, etc. can be highly skilled in their own area and yet there is no clear perspective as to how all the players can come on the same platform for achieving the objectives.
Construction industry is also dependent on quality of its people rather than technology. The increasing technological complexity and more complex interdependencies and perpetual shortage of resources namely materials, equipment, technical/supervisory staff, finance, etc. calls for a comprehensive risk management framework which will insulate the risks of the participants to a great extent.
Given the nature of the construction sector, risk management is an extremely important process. It is most widely used in such of those projects where susceptibility to risks is very high and is characterised by planning, monitoring and controlling the risks in a more structured and formal manner. The most efficient method of identifying the risks is to study a project of similar size which was executed in the recent past which gives an insight into the failure/success of the project. In order to be sure that the project objectives are met, the portfolio of risks associated with all stakeholders should be considered across the project life cycle (PLC). In later stages, risk management when applied systemically helps to control those critical elements which can negatively impact project performance. Keeping track of identified threats will result in early warnings to the project manager if any of the objectives, time, cost or quality, are not being met. There are a plethora of risks which are to be identified in the construction industry and which can be faced in each construction project at any point of time regardless of its size and scope. Frequent change in scope is one of the major risks in any construction project. If revised scope or design is implemented, it can have effect in the form of additional resources of time and cost. Early project completion may be as troublesome as delays in a schedule. Completing too early which may be a result of insufficient planning or design problems can lead to a low quality of final product and increased overall cost. Thus it is important to keep a balance in the concept of time–cost-quality trade-off, which more widely is becoming an important issue for the construction sector. Risks may vary depending on the project scope, types and are to be treated accordingly.
Risk management process is shown in Figure 1.
Risk management process.
Risk identification, the first step in the risk management process is usually informal and is performed in various ways, depending on the organisation and the project team. Identification of risks relies mostly on past experience and study of similar executed projects. This being a preliminary stage, a combination of tools and techniques may be used to identify the risks in any project. Here are many methods that fit specific types of challenges and projects especially at identification stage. Risks and threats may be difficult to eliminate, but when they have been identified, it becomes easy to take actions and have control over them. Risk management will be more effective if the source of the risks have been identified and allocated before any problems occur. The main purpose of risk management is that the stakeholders should prepare for potential problems that can occur unexpectedly during the course of a project. Risk management will not only facilitate anticipating problems in advance, but also preparing oneself for the potential problems that may occur unexpectedly. Handling potential threats is not only a way to minimise the losses within a project, but also a way to transform risks into opportunities which can lead to economic and financial profitability. The purpose of identifying risks is to obtain a list of risks which has got the potential to have a cascading effect on the progress of project and different techniques are applied for managing/mitigating the same. In order to find all potential risks which might impact a specific project, different techniques are applied. The project team should use a method they are familiar with so that the exercise will be effective. Effective identification of risks is the first step to a successful risk management.
Parameter | Methodology |
---|---|
Documentation reviews | A structured review of project documentation, study of history of execution of similar projects and quality of plans as well as the consistency between those plans and project requirements/ assumptions would be an indicator of risks in the project |
Information gathering techniques |
|
Identification of risks: tools and techniques.
Tools and techniques for risk identification are presented in Table 4.
Various risks that confront a construction industry are not limited to and include financial, economical, political, legal environmental, technical, contractual, planning/scheduling, design, quality operational labour, stakeholder safety and security, logistics and construction.
Risk assessment is the second stage in the risk management process where collated data is analysed for potential risks. Risk assessment is described as short listing of risks starting from low impact highest impact on the project, out of all threats mentioned in the identification phase. Risk assessment consists of qualitative risk assessment and qualitative risk assessment.
This involves registration of identified risks in a formal manner. A risk register is used for formalising this process which is not limited to the following
Classification and reference
Description of the risk
Relationship of the risk to other risks
Potential impact
Likelihood of occurrence
Risk response/mitigation strategy
Allocation of risks to stakeholders.
Classification is an aid to identifying the source of risk. Examples are furnished below (Table 5).
Risk | Classification |
---|---|
Environmental | Site conditions, health and safety issues at site |
Contractual | Client, contractor, sub-contractor, etc. |
Design | Planning permission, preliminary and detailed design, etc. |
Classification of risk and its reference.
Referencing refers to unique reference number given for each of the identified risks.
This involves giving a brief description of the risk. The description must be unique in order to avoid confusion with similar risks in the risk management process.
In any project, it is extremely rare that any activity is independent of activities which occurs concurrently or consequentially and this will always be the case for risks also for successful implementation of risk management,
Impact of risk on a project is measured in terms of cost and quality. Since this assessment is done at an early stage of the project, information may not be available to accurately predict the impact of risk on the project. At this stage, the risk is classified suitably and accordingly high impact risks are to be given more fundamental consideration than that of medium/low/negligible risks by ranking the impact of risks on a scale of 1 (low) to 10 (high).
Based on intuition and experience, the likelihood of occurrence (P) of risks and its impact (I) is to be given on a suitable scale ex. 1–10 (1 refers to low probability and 10 refers to high probability). The risk factor for each of the identified risks is calculated by the formula RF = P + I – (P*I) (where the values of P and I are brought on a scale of 0–1 by dividing the values with 10).
This action is taken to reduce, eradicate or to avoid the identified risks. The most common among the risk mitigation methods are risk avoidance, risk transfer, risk reduction and risk sharing. Based on the competency in handling the risks, the identified risks are allocated to respective stakeholders who will be responsible for addressing those risks.
This risk assessment is normally taken for such of those risks which are classified are high/critical/unmanageable as per the qualitative risk assessment. The purpose of this assessment is to find the amount of contingency to be inserted in the estimate for the risks undergoing this assessment so that in case the risks occur, there would be sufficient budgeted amount to overcome the extra expenditure.
Quantitative methods need a lot of analysis to be performed. This analysis should be weighed against the effort and outcomes from the chosen method. Complex and larger projects require more in depth analysis as compared to projects which are small in size. The purpose of carrying out quantitative analysis is to estimate the impact of a risk in a project in terms of scope, time, cost and quality. The suitability of this analysis is more for medium and large projects as these projects have more complex risks as compared to smaller projects.
The detailed quantitative assessment of risk is the one which is identified as risk analysis. In undertaking quantitative assessment, the potential impact of risks in terms of time, cost and quality is quantified. While preparing the estimate, it is generally split into two distinct elements, namely (1) base estimate of those items which are known and a degree of certainty exists and (2) contingency allowance for all uncertain elements of a project. Historically, contingencies have been calculated on a rule of thumb basis varying from 5 to 10% on risk-free base estimate. By adopting risk management approach, contingencies are set up to reflect realistically the risks that are inherent in the project. When used correctly, contingency allowances ensure that expenditure against risks is controlled. The methods for quantitative risk assessment are described below.
The Monte Carlo method is based on statistics which are used in a simulation to assess the risks. This is a statistical technique whereby randomly generated data is used within predetermined parameters and produce realistic project outcomes. The overall project outcome is predicted by randomly simulating a combination of values for each risk and repeating the calculation a number of times and all outcomes are recorded. After completing the simulations required, the average is drawn from all of the outcomes, which will constitute the forecast for the risk. It is important to realise that parameters and appropriate distribution within which the random data is simulated is itself a series of subjective inputs. Accurate and realistic project outcomes will not be generated if inaccurate parameters are set. Different scenarios are generated by simulation are used for forecasting, estimations and risk analysis. Data from already executed projects is normally collected for simulation purpose. The data for variables is presented in terms of pessimistic, most likely and optimistic scenarios depending upon the risks encountered, i.e. pessimistic value means lot of risks and optimistic value means least risks. The result from this method is a probability of a risk to occur is often expressed as percentage. The most common way of performing the Monte Carlo simulation is to use the program Risk Simulator Palisade Software, where more efficient simulations can be performed.
This is a method used to demonstrate the variable impact on the whole caused by a change in one or more element or risk. It is used to test the robustness of choices made where rankings have been established, particularly when those rankings are considered to be marginal. It can identify the point where variation in one parameter will affect decision making. A typical method for carrying out sensitivity analysis is by use of a spider diagram which shows the areas in the project which are the most critical and sensitive The higher the level of uncertainty a specific risk has, the more sensitive it is concerning the objectives. In other words, the risk events which are the most critical to the project are the most sensitive and appropriate action needs to be taken (Heldman, 2005). Disadvantage with this analysis is that the variables are considered separately, which means that there is no connection between them (Perry, 1986 and Smith et al.. 2006). The method requires a project model in order to be analysed with computer software. According to Smith et al. (2006), the project stands to be benefited if the analysis is carried out in the initial phases of a project in order to focus on critical areas during the execution of the project.
Decision tree analysis is commonly used when there is sequence of interrelated possible courses of action and future outcomes in terms of time and cost. This method of analysis is commonly used when certain risks have an exceptionally high impact on the two main project objectives, i.e. time and cost. Where probabilities and values of potential outcomes are known or can be estimated, they are used for quantification to provide a more informed basis for decision making. Each decision process expected value (EV) which forms the basis for decision making process. A sample problem on decision tree is given in Table 6.
Method | Design time (months) | Construction period in months and probabilities | Total time (construction period + design time) (months) |
---|---|---|---|
Construction management | 2 | 15 (0.6) = 9 18(0.4) = 7.2 Total 16.2 months | 18.2 |
Design and construct | 3 | 12(0.3) = 3.6 Total = 13.8 months 14(0.5) = 7 16(0.2) = 3.2 | 16.8 |
Traditional method | 8 | 10(0.3) = 3 12(0.7) = 8.4 Total 11.4 months | 19.4 |
Problem on decision tree.
This can be depicted in the form of decision trees and the expected value (EV) in terms of time for each of the three scenarios is furnished. The least of this i.e. construction management will be preferred since it consumes less time.
Multiple estimating using risk analysis (MERA) attempts to provide a range of estimates. These are presented as risk free base estimate, average risk estimate (ARE) and maximum likely risk estimate (MLRE). ARE is the sum of risk free base estimate and average risk allowance and MLRE is the sum of ARE and maximum risk allowance.
MERA attempts to finds a level i.e. the estimate that has a 50% chance of being successful. This is known as average risk estimate (ARE) which is found out by multiplying the average allowance with average probability of occurrence. Maximum risk allowance is found out by multiplying the maximum allowance with maximum probability of occurrence of that risk. This is added to ARE to get MLRE which is the estimate that has 90% chance of not being exceeded.
The output of quantitative risk assessment is presented in Table 7.
Parameter | Outputs |
---|---|
Probabilistic Analysis of project | Estimates are made of potential project schedule and cost outcomes listing the possible completion dates and costs with their confidence levels. This output is described as cumulative distribution and also risk tolerances for permitting quantification of cost and time contingency reserves. Contingency reserves bring the risk of overshooting stated project objectives to acceptable levels to the organisation |
Prioritised list of quantified risks | This list includes risks that pose the greatest threat or present the greatest opportunity in a project. These risks also have the greatest impact on cost contingency |
Trends in quantitative risk analysis results | As the risk analysis is repeated, a trend becomes apparent that leads to conclusions affecting risk responses, Historical information on project’s schedule, cost, quality and performance reflects new insights gained through quantitative process. This takes the form of quantitative risk analysis report. |
Quantitative risk assessment: outputs.
The risk response will be in the form of mitigation by adopting necessary strategies in respect of positive and negative risks which is furnished below (Tables 8–10).
Risk mitigation strategy | Description |
---|---|
Risk avoidance | Risk avoidance involves changing the project management plan to eliminate the threat entirely. The project manager may isolate the project objectives that are in jeopardy. Examples: (a) Extending the schedule of an activity; (b) Changing the strategy or reducing the scope of work; (c) Changes in clauses of contract regarding abnormal price rise of any material or dealing with extra quantum of work. |
Risk transfer | Risk transfer requires shifting some or all of the negative impact of a threat along with ownership of the response to a third party. Examples are
|
Risk reduction | Risk reduction implies reduction in the probability and consequence of an adverse risk event to be within acceptable threshold limits. Conducting detailed tests or choosing a more stable supplier are some examples. Risk reduction is adopted where the resultant increase in costs is less than the potential loss that could be caused by the risk being mitigated. Examples are:
|
Risk acceptance | This strategy is adopted when it is not possible to eliminate all risks from a project. This strategy indicated that the project team had decided not to change the project management plan or is unable to identify any other suitable response strategy. This requires no action except to document the strategy leaving the project team to deal with risks as they occur |
Strategies for mitigating negative risks.
Risk mitigation strategy | Description |
---|---|
Exploit | This strategy is selected for risks with positive impacts where the organisation wishes to ensure that the opportunity is realised. This strategy seeks to eliminate the uncertainty associated with a particular risk by ensuring that the opportunity is exploited. Examples are assigning the most talented resources of the organisation to the project to reduce the time for completion or providing at a lower cost than originally planned |
Share | Sharing a positive risk involves allocating some or all of the ownership of the opportunity to a third party capable of capturing the opportunity for the benefit of the project. Risk sharing, joint ventures, etc. are examples of this strategy |
Enhance | This strategy is used to enhance the positive impact of an opportunity. Identifying and maximising key drivers of risks may increase their probability of occurrence. Examples are adding more resources to an activity for completing it before scheduled time |
Accept | Accepting an opportunity means willing to take advantage if it comes along, but not pursuing it actively. |
Contingent response strategies | Some responses are designed for implementation only if certain events occur. It is appropriate for the project team to prepare a contingency response plan that will be executed under certain predefined conditions if there will be sufficient warning to implement the plan |
Expert judgement | Expert judgement is from knowledgeable individuals pertaining to the actions to be taken on a specific and a defined risk. |
Risk mitigation strategies for positive risks/opportunities.
Source: Project Risk Management, Van Well Stam et al. 2008.
Sl. No | Contents |
---|---|
1 | Identified risk. Their descriptions, areas of project affected, their causes and how they affect project objectives |
2 | Risk owners and assigned responsibilities |
3 | Prioritised list of project risks based on the outputs from quantitative analysis reports |
4 | Agreed upon response strategies and specific actions taken to implement the strategy |
5 | Triggers, symptoms and warning signs of risks occurrence |
6 | Fallback plans as a reaction to a risk that has occurred and primary response proved to be inadequate |
7 | Contingency reserves to be calculated based on quantitative risk analysis of the project and the threshold risk of the organisation. |
Contents of risk response: outputs.
Inputs to monitoring and controlling of risks are presented in Table 11.
Tools and Techniques for monitoring and controlling risks are furnished in Table 12.
Parameter | Inputs |
---|---|
Risk register | The key inputs to risk register includes identified risks and owners of risk, agreed upon risk responses, specific actions to be implemented, symptoms/warning signs of any risk, residual/secondary risks, list of low priority risks and contingency measures in terms of time/cost |
Risk management plan | The risk management plan should contain risk tolerances, assignment of manpower including bearer of risk, time and other resources to project risk management |
Work performance information | Work performance information related to various performance results is to be quantified in terms of deliverable status, schedule progress and costs incurred. |
Performance reports | Performance reports will be analysed for variance analysis, earned value data and forecasting the likely date of completion of project |
Parameter | Explanation |
---|---|
Risk reassessment | Monitoring and controlling of risks will result in identification of new risks, reassessment of current risks and closing of risks that are not a threat to project. Project risk assessment is to be performed regularly. The frequency and depth of assessment depends on how the project progresses relative to the objectives. |
Risk audits | The purpose of risk audits is to examine and document the effectiveness of risk responses in dealing with identified risks and their root causes as well as effectiveness of the risk management process meetings. A separate risk audit meeting may be held or it may be included in routine project review meetings. |
Earned value analysis | Variance analysis is done by comparing the planned results with actual. Trends in execution of a project are reviewed using performance information and based on earned value analysis, deviation from cost and schedule targets is determined which may indicate potential impact of threat/opportunities. |
Technical performance measurement | This measures technical accomplishments during project execution and will help in forecasting degree of success in achieving the project scope and it may expose the degree of technical risk faced by the project |
Reserve analysis | This compares the amount of contingency reserves available at any time to the amount of risk remaining in the project to determine whether the reserves are adequate |
Status meetings | Project risk management should be an agenda item at all status review meetings. The amount of time for any item will depend on risks that have been identified, their priority and difficulty of response. Frequent discussions about risk make it more likely that concerned stakeholders will identify risks and opportunities. |
To maximise the efficiency of risk management, the risk management process should be continuously developed during the entire project.
The benefits from risk management finally go to the stakeholders involved. A clear understanding and awareness of potential risks in the project contributes to better management of risks by suitable mitigation techniques. Another benefit of working with risk management is increased level of control over the whole project and more efficient problem solving processes which can be supported on a more genuine basis
Risk management when conducted effectively, reduce sudden surprises. The advantage with risk management is that the stakeholders are aware as to the risk that they have to bear among all the risks that have been identified in a project and can prepare themselves accordingly, should any eventuality occur. No doubt, this formal exercise may translate into extra cost for an activity, but if taken in holistic manner, the benefits will far outweigh the costs. This has another advantage in that there is no passing of buck as risks are either shared/retained or transferred depending upon the ability of the stakeholder to handle the risk. The three approaches to risk management are normally risk natural firm which does not invest much in risk management but is still aware of important risk, risk averse firm where no investments are made and the last one is risk seeker wherein the organisation is prepared to face all risks and is often called gambler. The outcome of the objectives of project naturally depends upon the path adopted by the firms in their approach to risk management.
The fact that there are manifold risks which can be identified in any construction project is explained by their size and complexity. Bigger the project is, the larger the number of potential risks that may be faced.
Occurrence of risk is stimulated by several factors. Most often the risks faced in any project are financial, environmental (surrounding location of project and overall regulations), time, design and quality. The technology used for construction and the internal environment also contributes to risk which can have substantial bearing on the outcome of a project.
Risks are directly proportional to complexity of a project. Bigger and more complex a project is, the more resources are required to complete it. In spite of identifying all potential risks, there might be more potential threats. Therefore, the project team should not solely focus on management of those identified risks but also be alert for any new potential risks which may arise during execution.
Risk management is a tool for managing risks in a project and a project manager should be prepared for managing uncertainties not included in a risk management plan.
Effective management of risky project demands rapid and realistic predictions of alternative courses of action and positive decision making and requires flexible attitudes and procedures.
Perception of severity and frequency of occurrence of risk is to be done in tandem between the stakeholders. This will eliminate lot of unnecessary correspondence as well as misunderstanding and friction between the stakeholders
Insurance is just one aspect of risk mitigation and it cannot absorb all the risks. Insurance is project specific and it should be taken as per the needs of client/contractor. Other ways of risk mitigation needs to be explored.
Adoption of good project management practices like proper planning and implementation, willingness of stake holders to share the risks in the project is essential for success of a project
Executing a complex project requires meticulous planning, i.e. planning to the smallest details, and this can be achieved through concerted dedication from the concerned stakeholders.
Risks are to be thoroughly studied and understood before bidding for the project.
Special care should be taken regarding the seasonal variation of labourers, so that the construction activities does not get delayed due to shortfall in manpower resources during execution, which can have adverse effects on cost and time
Proper risk allocation techniques should be framed between the stakeholders so that in the event of occurrence of a risk, this will eliminate doubts as to which stakeholder should address the risk
Given its complexity, risk management is a very important process in construction projects. It is most widely used in those projects which exhibits high level of uncertainty. Formal planning, assessment and monitoring/control process characterises risk management in such projects.
Risk management procedures should be initiated in the early stages of the project where planning and contracting of work, together with the preliminary capital budget are being chalked out. In later stages, Risk management applied systemically, helps to control those critical elements which can have negative impact on project performance.
Keeping track of identified threats, will result in early warnings to the project manager if any of the objectives, time, cost or quality, is being met or not.
Risks in complex construction projects can be mitigated by entering into various agreements like execution, operation/maintenance, etc.
Proper risk strategy formulation and research is necessary based on real life experiences so that identification of potential risks and providing solutions can produce effective and efficient risk strategies to overcome impacts of risk events.
Risk identification is the first step in the risk management process. It means that the identification of risks which is informal relies mostly on past experience of similar executed projects and that of advice from experts. There are a good number of methods for identifying the risks in a project and a combination of methods may be used for identification of risks in a project.
Handling potential threats is not only a way to minimise losses within the project, but also a way to transform risks into opportunities, which can lead to economical profitability and finally, .it is suggested that if risks are given due care at all stages of the project, stakeholders will be showered with manifold benefits subsequent to commissioning of project
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