Journal of Affective Disorders 190 (2016) 1218

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research report

Longitudinal relationship between Personal and Social Performance

(PSP) and anxiety symptoms in schizophrenia$
In-Jo Park a,1, Dong Chung Jung b,1, Samuel Suk-Hyun Hwang c, Hee Yeon Jung d,e,
Jin-Sang Yoon f, Chul-Eung Kim g, Yong Min Ahn a,d,n, Yong Sik Kim h,i,nn
a

Department of Psychology, Yonsei University, Seoul, Republic of Korea

Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea
c
Department of Psychology, Chonnam National University, Gwangju, Republic of Korea
d
Institute of Human Behavioral Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
e
Department of Psychiatry, SMG-SNUBoramae Medical Center, Seoul, South Korea
f
Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea
g
Department of Psychiatry, Inha University Hospital, Incheon, Republic of Korea
h
Department of Psychiatry, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
i
Institute of Clinical Psychopharmacology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
b

art ic l e i nf o

a b s t r a c t

Article history:
Received 13 July 2015
Received in revised form
20 August 2015
Accepted 25 September 2015

Background: We aimed to examine the longitudinal relationship between the personal and social
functioning and anxiety symptoms in patients with schizophrenia. For this purpose, we conrmed the
validity of the anxiety subscale of the Symptom-Checklist-90-Revised (SCL-90-R) and then applied the
latent growth modeling method for longitudinal causal relationships.
Methods: Five hundred and seventy-eight patients diagnosed with schizophrenia were evaluated and
369 patients were included in the study at baseline. After conducting Rasch model analyses for the
validation of the anxiety subscale in the SCL-90-R, we applied latent growth model to determine the
causal relationship between the PSP and the anxiety symptoms.
Results: The validity of the anxiety subscale of the SCL-90-R was conrmed based on the Rasch rating
model, where the criteria for Int, Outt, item difculty, and point-measure correlations were satised.
The results from the latent growth model showed that the intercept and slope (rate of change) of the PSP
negatively predicted the slope of anxiety symptoms along the longitudinal trajectory. Together with
previous studies examining the predictive role of anxiety symptoms on quality of life, our longitudinal
ndings lend evidence for bidirectional effects between quality of life and anxiety symptoms. The
transactional nature of the relationship between anxiety symptoms and quality of life warrant further
investigation using a longitudinal cross-lagged design.
Conclusion: The anxiety subscale of the SCL-90-R may be utilized by clinicians and researcher to make
inferences about quality of life in addition to assessing anxiety symptoms in patients with schizophrenia.
& 2015 Elsevier B.V. All rights reserved.

Keywords:
Personal and Social Performance
Anxiety symptoms
SCL-90-R
Longitudinal relationship
Rasch rating model
Latent growth model

1. Introduction

This research was funded by the Janssen Research and Development. The
funding source had role in study design, but no role in analysis, interpretation, or
writing of the report. The authors have no conict of interest to report.
n
Correspondence to: Department of Neuropsychiatry, Seoul National University
Hospital, Department of Psychiatry and Behavioral Science, Institute of Human
Behavioral Medicine, Seoul National University College of Medicine, 28 YongonDong, Congno-gu, Seoul, 110-744, Republic of Korea. Fax: 82 2 744 7241
nn
Correspondence to: Department of Neuropsychiatry, Dongguk University
Medical School, 27 Dongguk-Ro, Illsandong-gu, Goyang-si, Gyeonggi-do 410-773,
Republic of Korea. Fax: 82 31 961 7236
E-mail addresses: aym@snu.ac.kr (Y. Min Ahn), kys@snu.ac.kr (Y. Sik Kim).
1
Both authors contributed equally to this study.

http://dx.doi.org/10.1016/j.jad.2015.09.048
0165-0327/& 2015 Elsevier B.V. All rights reserved.

The clinical relevance of anxiety symptoms has long been

overlooked, despite the fact that anxiety is one of the most important clinical issues in schizophrenic patients throughout their
illness (Garay, et al., 2014; Yon, et al., 2005; Tollefson and Sanger,
1999; Achim et al., 2011; Llorca et al., 2014). The properties of
anxiety symptoms in schizophrenic patients have been characterized according to various perspectives; under one view, they
can be seen in terms of dimensions such as positive, negative,
disorganizational, behavioral, cognitive, and mood-related (Tollefson and Sanger, 1999); another view places them at the lower
end of an ascending hierarchy that includes dysthymia, neurotic

I.-J. Park et al. / Journal of Affective Disorders 190 (2016) 1218

symptoms, integrated delusions and delusions of disintegration

(Angelopoulos and Economou, 2001; Hwang, et al., 2013); nally,
they can be viewed as secondary to psychotic symptoms or as a
reactive response to specic environments (Braga et al., 2013).
Some researchers (e.g., Huppert and Smith, 2001a; Seedat,
et al., 2007) working in the eld of psychotic anxiety have described anxiety symptoms as part of a progression towards psychotic disassembly in the prodromal stage of schizophrenia. Others have noted that anxiety symptoms are related to a lower
quality of life in the course of the illness (Bogren et al., 2010; Braga
et al., 2005; Huppert et al., 2001b; Picardi et al., 2006), a higher
risk for suicide (Taiminen et al., 2001), lower social functioning
(Blanchard et al., 1998), and an increased risk of relapse (Bayle
et al., 2000; Pallanti et al., 2004). With respect to the relationship
between anxiety symptoms and quality of life in schizophrenic
patients, Huppert et al (2001b) found that anxiety in schizophrenic patients inuences their subjective quality of life even
when positive, negative, and depressive symptomatology have
been controlled for, observing that changes to anxiety levels are
predictive of changes to satisfaction with ones quality of life in a
longitudinal study (Huppert and Smith, 2001a).
We predict that, in a longitudinal trajectory, quality of life may
inuence, as well as be inuenced by, anxiety symptoms. Previous
studies have demonstrated the ability of patients with schizophrenia to feel, experience and provide their patient-reported difculties (Kim, et al., 2002; Jung, et al., 2010; Sullwold, 1986; Mass
et al., 2005; Na et al., 2013; Park, et al., 2015; Kim, et al., 2013).
Regardless of the origins of anxiety symptoms, which may include
psychopathology and the side effects of medication (Kim, et al.,
2002; Jung, et al., 2010; Garay, et al., 2014), these symptoms can be
affected by personal and social performance; progress in aspects of
functioning such as self-care, personal activities, and social relationships is associated with a reduction in symptoms (Juckel and
Morosini, 2008). Empirically, Santini et al. (2015) showed that positive interactions with other such as partner were inversely related
to anxiety symptom. Psychosocial interventions like social skills
training, social training, and family psychoeducation facilitate the
effects of atypical antipsychotics to schizophrenic patients (Green,
1996; Pinto et al. 1999). Taken together, we expect that when patients with schizophrenia spend a signicant portion of their daily
lives engaged in improving their personal and social performance,
this may reduce anxiety symptoms during the course of treatment.
An additional goal of this study was to use a Rasch model to
validate the Symptom-Checklist-90-Revised (SCL-90-R) because
this instrument has not yet been validated in a sample of patients
with schizophrenia. A prior study has demonstrated the usefulness
of the Rasch model in validating a short version of the scale (Park,
et al., 2015). According to previous studies, the SCL-90-R may be
used to assess the patient-reported symptoms of patients with
schizophrenia (Kim, et al., 2002; Jung, et al., 2010; Na et al., 2013;
Kim, et al., 2013), suggesting that the 10-item anxiety subscale of
the SCL-90-R may be an appropriate tool for evaluating patientreported anxiety symptoms in schizophrenic patients. The anxiety
subscale of the SCL-90-R provides good convergent and discriminant validity (i.e., the anxiety subscale of the SCL-90-R was
correlated with the BAI total score but not with the BDI total score;
Derogatis, 2000; Holi, 2003). Lundin et al. (2015) validated the
depression and anxiety subscales of SCL-90, in a general population of Sweden. Also, Olsen et al. (2004) validated the SCL-90 and
SCL-90-R, including their anxiety subscales, in a sample of Danish
non-patients by applying item response theory (IRT); however, it
is necessary to validate the anxiety subscale of the SCL-90-R separately in a sample of patients with schizophrenia, because this
subscale was not designed for use with patients with schizophrenia, and may not be a reliable tool for evaluating their anxiety
symptoms (Derogatis, 1983; Holi, 2003).

13

The primary purpose of this study was to examine the longitudinal relationship between quality of life (i.e., personal and
social performance) and anxiety symptoms in patients with schizophrenia. To do so, the impact that the life-quality measure had
on changes in anxiety symptoms over time was evaluated using a
latent growth model which, compared to a cross-sectional study
design, is advantageous because it provides information regarding
the dynamic relationships among the variables (Hamagami and
McArdle, 2001). The second purpose of the present study was to
validate the anxiety subscale of the SCL-90-R for use with schizophrenic patients by applying the Rasch rating scale model which
has the benet for evaluating the psychometric properties of
scales (Tesio, 2003). The quality of ve response categories, including tness, item difculty, and point-measure correlation, will
be tested based on the indices of the Rasch rating scale model.

2. Methods
2.1. Participants
All participants in the present study were recruited from 25
medical centers throughout South Korea. The initial sample population comprised 578 patients who had been diagnosed with schizophrenia based on the criteria included in the Fourth Edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV;
male: 46.9%, female: 53.1%; mean age: 35.85710.91 years; inpatients: 19.9%, outpatients: 80.1%). Of the 578 patients, 369 (63.8%)
completed both the anxiety subscale of the SCL-90-R and the PSP
scale and were included in this longitudinal study at baseline (male:
44.7%, female: 55.3%; mean age: 36.77710.93 years; inpatients:
16.5%, outpatients: 83.5%; employed: 19.6, unemployed: 80.4%;
paranoid type: 69%, disorganized type: 1.4%, catatonic type: .5%,
undifferentiated type: 22.8%, residual type: 6.2%). Patients were
excluded from the present study if they had a history of neuroleptic
malignant syndrome, exhibited a high risk for aggressive behavior
and/or suicide, were pregnant or breastfeeding, had participated in
any drug trial in the 1 month prior to the screening visit, had a
history of allergic reactions to risperidone or paliperidone, and/or
were current substance abusers or dependents.
2.2. Procedures
The present study analyzed the pooled data from two openlabel investigations of patients with schizophrenia, which were
conducted by the Johnson and Johnson family of companies (Choi
et al., 2013; Kim et al., 2012; Na et al., 2013). The protocols for
these studies, the Paliperidone Effectiveness Study to Evaluate the
Subjective Symptom Change (PASS) and the Paliperidone Extended Release (ER) Effectiveness Study to Evaluate the Objective
Symptom Change and Symptomatic Remission (PERFECT), were
led with the United States Food and Drug Administration prior to
their initiation (ClinicalTrial.gov identiers: NCT00761605 and
NCT00761579, respectively).
Throughout the 12-week study period, all patients received a
daily administration of paliperidone extended-release tablets (3
12 mg) and were evaluated at baseline (Time 1) and Weeks 4
(Time 2), 8 (Time 3), and 12 (Time 4). Additionally, the anxiety
symptoms of the patients were self-reported by completing the
anxiety subscale of the SCL-90-R, and their personal and social
activities were rated by a clinician using the PSP scale. Prior to
participating in the study, all patients received a full explanation of
the objectives of the study from a clinician and then provided
written informed consent. The present study was conducted in
accordance with the Declaration of Helsinki and was approved by
the hospital's Review Board.

14

I.-J. Park et al. / Journal of Affective Disorders 190 (2016) 1218

2.3. Measures
The anxiety subscale of the SCL-90-R: the Symptom Checklist90-Revised was designed for use with psychiatric outpatients
(SCL-90-R; Derogatis et al., 1976), and is considered to be one of
the best self-report scales (Burlingame et al., 2005), with its reliability supported by normative data in Korea (Kim and Yoon,
1985). Patients are asked to respond 90 items that are aggregated
on nine symptom dimensions (somatization, obsessivecompulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic
anxiety, paranoid ideation and psychoticism) with a Likert-type
ve-point scale (04) (Jung, et al., 2010). Participants were required to answer for each item according to how much he or she
bothered or distressed over the past 4 weeks. The anxiety subscale of the SCL-90-R consists of 10 items. Sample items were as
follows: Suddenly scared for no reason, Feeling tense or keyed
up, and Spells of terror or panic. The anxiety subscale of the
SCL-90-R consists of 10 items. Sample items were as follows:
Suddenly scared for no reason, Feeling tense or keyed up, and
Spells of terror or panic. Olsen et al (2004) validated the Danish
version of the SCL-90-R using IRT, which provided unidimensionality for the anxiety subscale.
The PSP scale: the Personal and Social Performance (PSP) scale
was developed to assess psychosocial functioning in patients with
schizophrenia (Morosini et al., 2000) and consists of items across
four domains: socially useful activities, personal and social relationships, self-care, and disturbing and aggressive behavior.
Scores on the PSP scale range between 1 and 100 with higher
scores indicating better personal and social functioning. The raters
of the PSP were well trained clinicians. We did obtain the intrainter reliability with 4-week follow-up data. The intra-inter reliability (Kappa) with 4-week follow-up was .74 in this study. This
scale is currently regarded as the most appropriate instrument for
evaluating the personal and social functioning of schizophrenia
(Juckel et al., 2014). Previous studies have demonstrated that the
PSP scale exhibits good validity and reliability (Garcia-Portilla
et al., 2011; Juckel and Morosini, 2008; Tianmei et al., 2011).

Fig. 1. Option characteristic curves for Item 1 in the anxiety subscale of the SCL-90R.

3. Results
3.1. Unidimensionality
To use the Rasch rating model, a scale must be assumed to be
unidimensional. For example, Olsen et al. (2004) applied the Rasch
model to validate the SCL-90-R because the authors accepted that
the anxiety subscale was unidimensional. In the present study, a
principal component analysis was conducted to conrm the unidimensionality of the anxiety subscale of the SCL-90-R. Raw variance explained by measures has a value of 54.5%. This is an acceptable value for the assumption of unidimensionality based on
the suggestion of Linacre (2001) that a scale be considered unidimensional if the raw variance explained by measures is greater
than 50%.
3.2. Option category characteristics

2.4. Statistical analysis

The software packages SPSS 20.0 (SPSS Inc., Chicago, IL, US),
AMOS 20.0 (Amos Development Corporation, Mount Pleasant, SC,
US) and WINSTEPS 3.81.0 (Winsteps Inc. Chicago, IL, US) were used
for all statistical analyses. For the validation process, Rasch model
analyses were conducted using WINSTEPS 3.81.0 for Windows
(Park, et al., 2015). The dimensionality, item ts, item difculty,
and response categories were calculated by applying the Rating
Scale Model (RSM; Wright & Masters, 1982), which is one of the
Rasch models (Linacre, 2010). The Rasch model has previously
been used to validate scales in patients with Schizophrenia (Park,
et al., 2015).
Using the SPSS software package, a repeated measures analysis
of variance (ANOVA) was conducted to evaluate mean changes in
the variables over time by comparing scores at baseline with
scores at Time 4. A latent growth model was used to determine the
causal relationship between scores on the PSP scale and scores on
the anxiety subscale of the SCL-90-R. When building complex and
dynamic models to evaluate change, the latent growth model has
various advantages over other methods because it allows for the
analysis of associations between changes over time and both
predictor and outcome variables (Duncan et al., 2006).

Option category characteristics (OCCs) were analyzed using the

10 items from the anxiety subscale of the SCL-90-R to conrm
whether the number of item categories was appropriate in accordance with the intended scale during the development of each
item (Wolfe and Smith, 2007). In Fig. 1, the X-axis denotes the
logits of the person measure relative to item difculty while the Yaxis represents the category probability that Item 1 would be selected. From left to right, the lines represent Categories 0, 1, 2, 3,
and 4, respectively. Based on Fig. 1, if the logit of the person
measure relative to item difculty is  3.0 then the category
probabilities of person j selecting Category 0 are approximately
70% and 0% for Categories 3 and 4, respectively. To ensure the
usefulness of a response category, each response category should
have the highest probability on the specic area in the X-axis. The
present results demonstrated that all ve categories satised this
criterion.
3.3. Fit statistics and content validity
The Int and Outt statistics for all 10 items on the anxiety
subscale of the SCL-90-R are provided (Table 1). Wright and Linacre (1994) state that t statistics are useful for identifying
homogeneity among items and the absence of redundant items. Fit
indices are calculated by comparing the actual response of a rater

I.-J. Park et al. / Journal of Affective Disorders 190 (2016) 1218

demonstrated that the point-measure correlation values for all 10

items on the anxiety subscale were greater than .30 (Table 1).

Table 1
Rasch item statistics for the 578 patients that t the model.

Scale item

1. Nervous or shakiness inside

2. Trembling
3. Suddenly scared for no reason
4. Feeling fearful
5. Heart pounding or racing
6. Feeling tense or keyed up
7. Spells of terror or panic
8. Feeling so restless you could not
sit still
9. Feeling that familiar things are
strange or unreal
10. Feeling pushed to get things
done

MNSQ
Int
Outt Item
difculty

15

S.E

PMC

73
.70
.63
.67
.76
.64
.74
.73

1.02
.92
1.21
1.24
.76
1.19
.86
.88

1.08
.93
1.10
1.44
.72
1.05
.91
.84

 .77
.04
.57
 .36
 .32
.62
 .40
.03

.05
.06
.06
.05
.05
.06
.05
.06

1.19

.94

.49

.06 .65

1.09

.97

.09

.06 .70

Note: Item difculty item difculty estimate

MNSQ: mean square residuals, S.E.: standard error
PMC point-measure correlations

to an item with an expected probabilistic score from the Rasch

model, which represents the construct validity of the item and the
response of the person (Bond and Fox, 2007). In the present study,
the Int and Outt indices were used to assess the tness of each
item (Wright and Masters, 1982). If the mean values of the Int
and Outt of an item are equal to 1.0 then that item has a perfect
t. If the t value falls below .5 or above 1.5 then the item is not
acceptable as a scale item. The present results demonstrated that
all items on the anxiety subscale ranged from .84 to 1.44 and, thus,
all items satised the Int and Outt criteria (i.e., .5r mean
square residual [MNSQ] r1.5).
The content validity of the anxiety subscale was also evaluated.
Content validity refers to whether the items actually measure all of
the facets of a given construct that they are intended to evaluate
(Bryant, 2000). Similar to item-total correlations, point-measure
correlations based on the Rasch model indicate whether the responses of the rater to each item are correlated with the ability
estimates of the raters. To ensure content validity, the pointmeasure correlations ranging from  1 to 1 should be noticeably
greater than .30 (Bond and Fox, 2007; Linacre, 2010). Point-measure correlations are useful for the identication of problematic
items that do not seem to map onto the latent construct of a scale
(Guiberson and Rodriguez, 2014). The present results

3.4. Item difculty estimates and item characteristic curves

Item difculty refers to the degree to which the individual does
not agree to the given statement. The item difculty estimates and
item characteristic curves (ICCs) were also examined. As shown in
Table 1, the item difculty estimates for all 10 items on the anxiety
subscale of the SCL-90-R were distributed between  .77 and .62.
Six items had item difculty estimates that were greater than 0
(more difcult items), while four items had item difculty estimates that were less than 0 (easier items). To describe items of
varying difculty, the ICCs for the 10 items on the anxiety subscale
are presented (Fig. 2). Item 6 had an item difculty estimate of .62
and was the most difcult item while Item 1 had an item difculty
estimate of  .77 and was the easiest item. In Fig. 2, Item 6 is represented by the far-right line and Item 1 by the far-left line.
3.5. Longitudinal relationship between the PSP scale and anxiety
symptoms
Table 2 provides the descriptive statistics of the anxiety
symptoms and the PSP from baseline to Time 4. The means for the
anxiety symptoms at baseline (Time 1) and Weeks 4 (Time 2), 8
(Time 3), and 12 (Time 4) were 2.02 (standard deviation [SD]
.89), 1.78 (SD .83), 1.84 (SD .86), and 1.90 (SD .86), respectively. These means varied over time (F[1, 369] 8.27, p o.01; Table). The means of the PSP scores at baseline, Time 2, Time 3, and
Time 4 were 58.36 (SD 17.81), 69.05 (SD 11.89), 64.86
(SD 13.70), and 66.81 (SD 12.92), respectively. These means also
varied over time (F(1, 369) 3.92, p o.1; Table 2). The p value
provided was .067.
To examine the relationship between scores on the PSP (the
predictor) and anxiety symptoms (the outcome) over time (from
baseline to Time 4), a latent growth analysis was conducted using
these two variables. The t for the model was good with a TuckerLewis Index (TLI) value of .97, a Bentler Comparative Fit Index (CFI)
value of .98, and a Root Mean Square Error of Approximation
(RMSEA) value of .05. A model is regarded as acceptable if the TLI
and CFI values are greater than .9 and the RMSEA value is less than
.08 (McDonald and Ho, 2002). The path coefcient between the
intercept for the PSP and the intercept for the anxiety symptoms
indicates a signicant cross-sectional relationship between these
two variables (  .34, po.01) (Fig. 3). The path coefcient from
the intercept of the PSP to the slope of the anxiety symptoms was
not signicant (  .14, p4 .05) but there was a signicant path
coefcient between the slopes of these two variables (  .33,
po.01), which indicates a dynamic and possibly reciprocal association over time. In other words, the relationship between the PSP
and anxiety symptoms was complicated and dynamic over time.

4. Discussion

Fig. 2. Item characteristic curves for the 10 items on the anxiety subscale of the
SCL-90-R.

The primary purpose of the present study was to investigate

the relationship over time between quality of life as reected in
PSP scores and patient-reported anxiety symptoms as measured
using the SCL-90-R in patients with schizophrenia. The use of a
latent growth model allowed for an assessment of the nature of
the relationship among these variables along a longitudinal trajectory (Hamagami and McArdle, 2001). The model suggests that
scores on the PSP predicted anxiety symptoms in patients with
schizophrenia.
In the present study, the intercept of the PSP negatively predicted the intercept of the anxiety symptoms, which suggests that

16

I.-J. Park et al. / Journal of Affective Disorders 190 (2016) 1218

Table 2
Descriptive statistics for the anxiety subscale of the SCL-90-R and the PSP scale from baseline to Time 4.
Time 1 (baseline, N 369)
M
SD

Time 2 (week 4, N 322)

M
SD

Time 3 (week 8, N 267)

M
SD

Time 4 (week 12, N 235)

M
SD

F value

Anxiety

2.04

.89

1.78

.83

1.84

.86

1.90

.86

8.27

o .01

PSP

58.36

17.81

69.05

11.89

64.86

13.70

66.81

12.92

3.92

4 .05

SCL-90-R: Symptoms-Checklist-90-Revised, PSP: Personal and Social Performance scale, M: mean, SD: standard deviation

e1

e2

e3

e4

Anxiety
T1

Anxiety
T2

Anxiety
T3

Anxiety
T4

e9

Anxiety
Intercept

Anxiety
Slope

e10

-.14
-.34**

-.33**

PSP
Intercept

PSP
Slope

PSP
T1

PSP
T2

PSP
T3

PSP
T4

e5

e6

e7

e8

Fig. 3. The causalrelationship between the PSP and the anxiety symptoms in a
latent growth model.** p o .01.

schizophrenic patients with better social and personal functioning

exhibited fewer anxiety symptoms at baseline. This nding is in
agreement with a previous study indicating that engagement in
personal and social activity by patients with schizophrenia is associated with reductions in anxiety symptoms (Juckel and Morosini, 2008). Moreover, a previous study indicated that anxiety

symptoms and phobic anxiety were higher in the subgroup that

reported the lowest level of satisfaction with life relative to objective functioning (reecting a discrepancy between objective,
clinician-rated and patient, self-reported levels of functioning) in
comparison with the subgroup that reported the highest level of
satisfaction with life relative to objective functioning (Jung et al.,
2010). The slope of the PSP negatively predicted the slope of the
anxiety symptoms, which means that the rate of change of the PSP
negatively predicted the rate of change of the anxiety symptoms
along the longitudinal trajectory. The negative causal relationship
between the PSP and anxiety symptoms can be interpreted as the
inuence of a consistently higher level of personal and social activity on anxiety symptoms over time during the course of treatment in the patients with schizophrenia.
The present study extended the previous ndings of a longitudinal study by Huppert and Smith (2001a), reporting that
changes in anxiety are predictive of changes in satisfaction with
ones quality of life and results from studies showing that the
greater the anxiety symptoms, the poorer the PSP (Huppert and
Smith, 2001a; Seedat et al., 2007; Fervaha et al., 2013). In the
current study we found evidence that the reverse relationship
between anxiety symptoms and quality of life over time may also
hold. In other words, personal and social performance may affect
anxiety symptoms in a longitudinal trajectory. Our study also
suggests the importance of mitigating patient-reported anxiety
symptoms regardless of their origin, such as psychopathology and
induced side effects (Kim, et al., 2002; Jung, et al., 2010; Garay,
et al., 2014), during the maintenance treatment of schizophrenic
patients, because the management of these symptoms is expected
to contribute to superior personal and social performance (Tollefson and Sanger, 1999; Garay, et al., 2014). The current study, in
context with previous research, suggests that a reduction in the
anxiety symptoms of schizophrenic patients will be predictive of
their level of engagement in psychosocial activities, and vice versa.
Thus the relationship between these two variables changes dynamically, each inuencing the other over time.
This study also set out to validate the anxiety subscale of the
SCL-90-R for use with patients with schizophrenia; this instrument is known as one of the most comprehensive self-rating
scales for anxiety, Although Derogatis (1983) stated in his SCL-90R manual that oridly psychotic patients are not a target sample
for this instrument (Holi, 2003), our previous studies suggest the
SCL-90-R may be useful for patients with schizophrenia (Kim et al.,
2002; Jung et al., 2010; Sullwold, 1986; Mass et al., 2005; Na et al.,
2013; Park et al., 2015; Kim et al., 2013).
Upon applying the Rasch rating scale model, we observed criterion validity for item difculty, item t, and point-measure
correlations, suggesting that this anxiety subscale is a valid measure for the evaluation of anxiety symptoms in patients with
schizophrenia. Additionally, based on the OCCs of the 10 items in
the anxiety subscale, it appears that the response categories,
which used a ve-point range, are suitable for the anxiety
subscale.
The use of the SCL-90 as an outcome scale with psychotic patients is uncommon (Holi, 2003). To our knowledge, few studies

I.-J. Park et al. / Journal of Affective Disorders 190 (2016) 1218

have evaluated the validity of the SCL-90-R, applying item response theory (IRT) within a sample of typical individuals (Olsen
et al., 2004). Therefore, as previously noted, it was essential to
validate the anxiety subscale of the SCL-90-R for use in patients
with schizophrenia by applying the Rasch rating scale model,
which has been used in the psychometric evaluation of existing
scales (Tesio, 2003).
The present study had several limitations. Most notably, the
study design did not consider alternative variables that may have
impacted anxiety other than the scores on the PSP. For example, it
is possible that the subjects in this study exhibited low levels of
anxiety due to the use of medication. Second, the data were collected from 25 centers across South Korea where different medical
doctors instructed the participants and this may have led to a
rating bias. Finally, because the present study was conducted as an
open-label investigation, it is possible that the patients analyzed
here may have been biased when self-reporting their anxiety
symptoms.
Despite these limitations, the present study makes two contributions to research and clinical practice involving schizophrenia. In the past, research investigating anxiety symptoms in
patients with schizophrenia has been dominated by the causal
relationship between anxiety symptoms (as a predictor) and
quality of life (as an outcome) (Huppert et al., 2001b; Llorca et al.,
2014). As an extension of the previous works, the present study
focused on the manner in which personal and social performance
might impact anxiety symptoms in schizophrenic patients. The
present ndings suggest that the anxiety symptoms associated
with schizophrenia are likely to diminish as personal and social
activities increase over time. Pervasive impairments in the psychosocial and daily functioning of schizophrenic patients require
the integration of pharmacological and psychosocial interventions
(Green, 1996). Thus, the present ndings may aid clinicians when
giving advice to schizophrenic patients regarding ways to mitigate
anxiety symptoms in daily life while on medication (Tollefson and
Sanger, 1999; Garay et al., 2014).
The second contribution of the present study pertains to the
validation of the anxiety subscale of the SCL-90-R using the Rasch
rating model so that it may be used to evaluate anxiety in patients
with schizophrenia. In this regard, the present ndings extend the
results of a previous study (Olsen et al., 2004) which validated the
SCL-90-R using IRT. We conclude that clinicians and researchers
can reliably utilize the anxiety subscale of the SCL-90-R when
assessing anxiety symptoms in patients with schizophrenia.

5. Conclusions
The intercept and slope (rate of change) of the PSP negatively
predicted the slope of anxiety symptoms along a longitudinal
trajectory. Taken together with previous studies examining the
predictive role of anxiety symptoms on quality of life (e.g., Huppert and Smith, 2001a; Seedat et al., 2007) our ndings suggest
that quality of life inuences anxiety symptoms and, conversely, is
inuenced by these same symptoms over time. Future study is
needed to explore the transactional nature of the relationship
between these variables, preferably using a longitudinal crosslagged design (Burkholder and Harlow, 2003). In addition, we used
the Rasch rating model to assess the validity of the anxiety subscale of the SCL-90-R for patients with schizophrenia, and obtained results satisfying item difculty, item t, and point-measure
correlations; this indicates that the anxiety subscale of the SCL-90R is a valid measure for evaluating anxiety symptoms in schizophrenic patients, and may be reliably used by clinicians and researchers. Furthermore, the present ndings may be helpful to
clinicians in their attempts to advise patients with schizophrenia

17

regarding the mitigation of patient-reported anxiety symptoms in

daily life while on medication.

Conicts of Interest
The authors have no conict of interest to report.

Acknowledgments
This study was supported by Johnson and Johnson Research and Development
and Johnson & Johnson Pharmaceutical Services, LLC.

References
Achim, A.M., Maziade, M., Raymond, E., Olivier, D., Merette, C., Roy, M.A., 2011. How
prevalent are anxiety disorders in schizophrenia? A meta-analysis and critical
review on a signicant association. Schizophr. Bull. 37, 811821.
Angelopoulos, N.V., Economou, M., 2001. Hierarchical arrangement of psychiatric
symptoms in the context of schizophrenia. Eur. Psychiatry 16 (5), 267273.
Bayle, F.J., Llorca, P.M., Olie, J.P., Loo, H., 2000. Anxit et schizophrnie : situation
actuelle. Ann. Md Psychol. 158, 741749.
Blanchard, J.J., Mueser, K.T., Bellack, A.S., 1998. Anhedonia, positive and negative
affect, and social functioning in schizophrenia. Schizophr. Bull. 24, 413424.
Bogren, M., Mattisson, C., Tambs, K., Horstmann, V., Munk-Jorgensen, P., Nettelbladt,
P., 2010. Predictors of psychosis: a 50-year follow-up of the Lundby population.
Eur. Arch. Psychiatry Clin. Neurosci. 260, 113125.
Bond, T.G., Fox, C.M., 2007. Applying the Rasch model : fundamental measurement in
the human sciences. In: Mahwah, N.J. (Ed.), 2007. Lawrence Erlbaum, London.
Braga, R.J., Mendlowicz, M.V., Marrocos, R.P., Figueira, I.L., 2005. Anxiety disorders
in outpatients with schizophrenia: prevalence and impact on the subjective
quality of life. J. Psychiatr. Res. 39, 409414.
Braga, R.J., Reynolds, G.P., Siris, S.G., 2013. Anxiety comorbidity in schizophrenia.
Psychiatry Res. 210, 17.
Bryant, F.B., 2000. Assessing the validity of measurement. In: Grimm, L.G., Yarnold,
P.R. (Eds.), Reading and understanding more multivariate statistics. American
Psychological Association, Washington, DC ; London, pp. 99146.
Burlingame, G.M., Dunn, T.W., Chen, S., Lehman, A., Axman, R., Earnshaw, D., Rees, F.
M., 2005. Special section on the GAF: Selection of outcome assessment instruments for inpatients with severe and persistent mental illness. Psychiatric
Services 56 (4), 444451.
Burkholder, G.J., Harlow, L.L., 2003. An illustration of a longitudinal cross-lagged
design for larger structural equation models. Struct. Equ. Model. 10 (3),
465486.
Choi, Y.R., Jung, D.C., Kim, E.Y., Kim, S.H., Lee, H.J., Lee, N.Y., Chang, S.M., Shim, J.C.,
Joo, E.J., Kim, J.J., Lee, S.H., Chung, Y.C., Kim, Y.S., Ahn, Y.M., 2013. Tolerability,
safety and effectiveness of paliperidone ER in patients with Sshizophrenia: a
24-week interim analysis of the 48-Week open-label, prospective, switch study.
Korean J. Biol. Psychiatry 20, 1220.
Derogatis, L.R., 1983. SCL-90-R Revised Manual. John Hopkins School of Medicine,
Baltimore.
Derogatis, L.R., 2000. Brief Symptom Inventory 18. NCS Pearson, Minneapolis, MN.
Derogatis, L.R., Rickels, K., Rock, A.F., 1976. The SCL-90 and the MMPI: a step in the
validation of a new self-report scale. The British Journal of Psychiatry 128 (3),
280289.
Duncan, S.C., Duncan, T.E., Strycker, L.A., 2006. Alcohol use from ages 9 to 16: a
cohort-sequential latent growth model. Drug. Alcohol Depend. 81, 7181.
Fervaha, G., Foussias, G., Agid, O., Remington, G., 2013. Amotivation and functional
outcomes in early schizophrenia. Psychiatry Res. 210 (2), 665668.
Garay, R.P., Llorca, P.M., Young, A.H., Hameg, A., Samalin, L., 2014. Bipolar disorder:
recent clinical trials and emerging therapies for depressive episodes and
maintenance treatment. Drug. Discov. Today 19 (11), 17921800.
Garcia-Portilla, M.P., Saiz, P.A., Bousono, M., Bascaran, M.T., Guzman-Quilo, C.,
Bobes, J., 2011. Validation of the Spanish Personal and Social Performance scale
(PSP) in outpatients with stable and unstable schizophrenia. Rev. Psiquiatr.
Salud Ment. 4, 918.
Green, M.F., 1996. What are the functional consequences of neurocognitive decits
in schizophrenia? Am. J. Psychiatry 153, 321330.
Guiberson, M., Rodriguez, B.L., 2014. Rasch analysis of a Spanish language-screening
parent survey. Res. Dev. Disabil. 35, 646656.
Hamagami, F., McArdle, J.J., 2001. Advanced studies of individual differences linear
dynamic models for longitudinal data analysis. New Developments And Techniques In Structural Equation Modeling, pp. 203246.
Holi, M., 2003. of psychiatric symptoms using the SCL-90.
Huppert, J.D., Smith, T.E., 2001a. Longitudinal analysis of subjective quality of life in
schizophrenia: anxiety as the best symptom predictor. J. Nerv. Ment. Dis. 189,
669675.
Huppert, J.D., Weiss, K.A., Lim, R., Pratt, S., Smith, T.E., 2001b. Quality of life in
schizophrenia: contributions of anxiety and depression. Schizophr. Res. 51,
171180.

18

I.-J. Park et al. / Journal of Affective Disorders 190 (2016) 1218

Hwang, S.S.H., Kim, Y., Chang, J.S., Yun, D.Y., Kim, Y.S., Jung, H.Y., 2013. Examination
of categorical approach to symptom assessment: cross-validation of foulds
Delusions-Symptoms-States Inventory with Korean non-patient and patient
groups. BMC Psychiatry 13 (1), 251.
Juckel, G., Morosini, P.L., 2008. The new approach: psychosocial functioning as a
necessary outcome criterion for therapeutic success in schizophrenia. Curr.
Opin. Psychiatry 21, 630639.
Juckel, G., Siebers, F., Kienast, T., Mavrogiorgou, P., 2014. Early recognition of obsessive-compulsive disorder. The Journal of nervous and mental disease 202
(12), 889891.
Jung, H.Y., Hwang, S.S.H., Yi, J.S., Kim, Y., Kim, Y.S., 2010. Clinician-rated functioning
and patient-rated quality of life in schizophrenia: Implications of their correspondence for psychopathology and side effects. Prog. Neuro-Psychopharmacol. Biol. Psychiatry 34 (1), 225230.
Kim, J.H., Lee, B.C., Park, H.J., Ahn, Y.M., Kang, U.G., Kim, Y.S., 2002. Subjective
emotional experience and cognitive impairment in drug-induced akathisia.
Compr. Psychiatry 43 (6), 456462.
Kim, S.W., Yoon, J.S., Kim, Y.S., Ahn, Y.M., Kim, C.E., Go, H.J., Chee, I.S., Jung, S.W.,
Chung, Y.C., Kim, Y.D., Joe, S., Lee, J., Kwon, Y.J., Yoon, B.H., Jae, Y.M., 2012. The
effect of paliperidone extended release on subjective well-being and responses
in patients with schizophrenia. Prog. Neuro-psychopharmacol. Biol. Psychiatry
38, 228235.
Kim, J.H., Yoon, Y.H., 1985. Reliability and factorial invariance of Korean version of
the Symptom Checklist-90-Revision. Mental Health Res 3, 166172.
Kim, E.Y., Chang, S.M., Shim, J.C., Joo, E.J., Kim, J.J., Kim, Y.S., Ahn, Y.M., 2013. Longterm effectiveness of exibly dosed paliperidone extended-release: comparison
among patients with schizophrenia switching from risperidone and other antipsychotic agents. Curr. Med. Res. Opin. 29 (10), 12311240.
Linacre, J.M., 2001. Category, step and threshold: denitions & disordering. Rasch
measurement transactions 15 (1), 794.
Linacre, J., 2010 A User's Guide to Winsteps, Ministeps Rasch-Model Computer
Programs. Program Manual 3.73. 0., 2011.
Llorca, P.M., Lancon, C., Blanc, O., de Chazeron, I., Samalin, L., Caci, H., Lesturgeon, J.
A., Bayle, F.J., 2014. A composite scale applied to evaluate anxiety in schizophrenic patients (SAES). Eur. Arch. Psychiatry Clin. Neurosci. 264, 171178.
Lundin, A., Hallgren, M., Forsell, Y., 2015. The validity of the symptom checklist
depression and anxiety subscales: a general population study in Sweden. J.
Affect. Disord. 183, 247252.
Mass, R., Haasen, C., Borgart, E.J., 2005. Abnormal subjective experiences of schizophrenia: evaluation of the Eppendorf Schizophrenia Inventory. Psychiatry
Res. 135 (2), 91101.
McDonald, R.P., Ho, M.H., 2002. Principles and practice in reporting structural
equation analyses. Psychol. Methods 7, 6482.
Morosini, P.L., Magliano, L., Brambilla, L., Ugolini, S., Pioli, R., 2000. Development,
reliability and acceptability of a new version of the DSM-IV Social and Occupational Functioning Assessment Scale (SOFAS) to assess routine social functioning. Acta Psychiatr. Scand. 101, 323329.
Na, K.S., Kim, C.E., Kim, Y.S., Lee, J.I., Han, W.S., Kang, U.G., Park, D.H., Kim, B., Jung, H.

Y., Yoon, J.S., Lim, S.W., 2013. Effectiveness of paliperidone extended-release for
patients with schizophrenia: focus on subjective improvement. Hum. Psychopharmacol. 28, 107116.
Olsen, L.R., Mortensen, E.L., Bech, P., 2004. The SCL-90 and SCL-90R versions validated by item response models in a Danish community sample. Acta Psychiatr.
Scand. 110, 225229.
Pallanti, S., Quercioli, L., Hollander, E., 2004. Social anxiety in outpatients with
schizophrenia: a relevant cause of disability. Am. J. Psychiatry 161, 5358.
Park, I.J., Jung, D.C., Hwang, S.S.H., Jung, H.Y., Yoon, J.S., Kim, C.E., Kim, Y.S., 2015.
Renement of the SWN-20 based on the Rasch rating model. Compr. Psychiatry
60, 133141.
Picardi, A., Rucci, P., de Girolamo, G., Santone, G., Borsetti, G., Morosini, P., 2006. The
quality of life of the mentally ill living in residential facilities: ndings from a
national survey in Italy. Eur. Arch. Psychiatry Clin. Neurosci. 256, 372381.
Pinto, A., Pia, S.L., Mennella, R., Giorgio, D., DeSimone, L., 1999. Rehab rounds:
cognitive-behavioral therapy and clozapine for clients with treatment-refractory schizophrenia. Psychiatr. Serv. 50 (7), 14571459.
Santini, Z.I., Koyanagi, A., Tyrovolas, S., Haro, J.M., 2015. The association of relationship quality and social networks with depression, anxiety, and suicidal
ideation among older married adults: ndings from a cross-sectional analysis
of the Irish Longitudinal Study on Ageing (TILDA). J. Affect. Disord. 179,
134141.
Seedat, S., Fritelli, V., Oosthuizen, P., Emsley, R.A., Stein, D.J., 2007. Measuring anxiety in patients with schizophrenia. J. Nerv. Ment. Dis. 195 (4), 320324.
Sullwold, L., 1986. Frankfurt Complaints Questionnaire (3). In: Sullwold, L., Huber,
G. (Eds.), In Schizophrenic Basic Disorders (in German). Springer, Berlin,
pp. 145159.
Taiminen, T., Huttunen, J., Heila, H., Henriksson, M., Isometsa, E., Kahkonen, J.,
Tuominen, K., Lonnqvist, J., Addington, D., Helenius, H., 2001. The Schizophrenia Suicide Risk Scale (SSRS): development and initial validation. Schizophr. Res. 47, 199213.
Tesio, L., 2003. Measuring behaviours and perceptions: Rasch analysis as a tool for
rehabilitation research. J. Rehabil. Med. 35, 105115.
Tianmei, S., Liang, S., Yun'ai, S., Chenghua, T., Jun, Y., Jia, C., Xueni, L., Qi, L., Yantao,
M., Weihua, Z., Hongyan, Z., 2011. The Chinese version of the Personal and
Social Performance Scale (PSP): validity and reliability. Psychiatry Res. 185,
275279.
Tollefson, G.D., Sanger, T.M., 1999. Anxiousdepressive symptoms in schizophrenia:
a new treatment target for pharmacotherapy? Schizophr. Res. 35, S13S21.
Wolfe, E.W., Smith, Jr. E.V., 2007. Instrument development tools and activities for
measure validation using Rasch models: part II-validation activities. In: Smith,
E.V., Smith, R.M. (Eds.), Rasch measurement: Advanced and specialized applications, pp. 243290.
Wright B., Linacre, M., 1994. Reasonable mean-square t values. Rasch Measurement Transactions 8: 3. Retrieved 23:2004.
Wright, B.D., Masters, G.N., 1982. Rating Scale Analysis. Mesa Press, Chicago.
Yon, V., Loas, G., Brien, D., 2005. Subjective experiences and the psychopathological
dimensions in schizophrenia. Psychiatry Res. 137 (1), 93102.