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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.
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
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
Table 1
Rasch item statistics for the 578 patients that t the model.
Scale item
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
4. Discussion
Fig. 2. Item characteristic curves for the 10 items on the anxiety subscale of the
SCL-90-R.
16
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
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.
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
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.
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