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2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
ACTA PSYCHIATRICA SCANDINAVICA
Review
S. Hartley1,2, C. Barrowclough1,
G. Haddock1
1
Summations
Anxiety and depression are related to psychotic symptom severity, distress and content.
They are also associated with sub-clinical psychotic experiences, symptom development, prognosis
and relapse.
These links may imply that anxiety and depression could be targets for therapeutic intervention.
Considerations
The data are largely cross-sectional and/or correlational in nature and so conclusions of causality
may be invalid.
Many studies have focussed on specic symptom subtypes, such as persecutory delusions.
327
Hartley et al.
Introduction
People meeting criteria for a schizophrenia spectrum diagnosis will frequently experience one or
more comorbid conditions, which may impact on
the prognosis and understanding of psychosis (1).
The pertinence of investigating the links between
concurrent emotional conditions and psychosis has
been demonstrated (2), despite the diagnostic and
aetiological barriers that are seen to separate the
two. This review will seek to highlight the research
evidence available, providing a focus on anxiety
and depression as two specic emotional conditions, which have been selected due to their prevalence (3, 4), and hypothesized role in causal models
of psychosis (5, 6). Given their considerable interrelatedness (7), it seems valuable for the investigation of the inuences of anxiety and depression on
psychosis to be carried out in conjunction, to elucidate where there is overlap, and where divergence,
in terms of their relationship with psychosis. First,
an overview of the prevalence of anxiety and
depression in psychosis will be provided, followed
by a summary of the theoretical frameworks that
have been put forward to account for the relationships. The results of the systematic review will then
be presented, within which the authors will seek
the answers to two key questions: in what ways are
anxiety and depression related to the experience of
delusions and hallucinations; and is there evidence
that anxiety and depression could have a causal
role in the development and experience of psychosis? The ndings of the review will be synthesized
and interpreted and nally, avenues of research
that require further investigation or clarication
will be highlighted.
Part of the review will focus on the relationship
between key variables, and delusions or auditory
hallucinations, rather than psychosis as a syndrome, or schizophrenia as a diagnostic entity.
This single symptom approach has recently
enjoyed a surge in usage owing to the key advantages it aords, which were identied some time ago
(8). Delusions and auditory hallucinations are the
quintessential experiences of psychosis and often
the most distressing, therefore providing clarity in
this area will not only elucidate common experiences but also provide some insight into therapeutic opportunities.
Prevalence
Theoretical frameworks
Hartley et al.
Anxiety and depression: interrelatedness and overlap
Exclusion criteria
Search terms
combinations
Results
In what ways do anxiety and depression relate to delusions and
hallucinations?
Severity of psychotic symptoms. The literature demonstrates that depression is signicantly associated
with symptom severity in both chronic and early
Number of abstracts
produced by initial search
10
Anxiety + psychosis
Anxiety + delusion
Anxiety + hallucination
Depression + psychosis
Depression + delusion
Depression + hallucination
865
73
39
1926
102
41
9
0
0
20
0
0
75
5
1
322
8
1
16
0
0
62
0
0
11
0
0
15
0
0
28
3
1
179
9
1
46
12
3
90
18
6
31
2
1
69
3
0
220
15
12
491
23
13
6
0
0
10
0
0
7
0
0
N/A
N/A
N/A
391
25
16
608
33
15
330
Final
inclusion
25
11
5
60
8
5
Severity
57 participants diagnosed
with schizophrenia,
in remission.
Oosthuizen
et al. (45)
Delespaul
et al. (53)
Ramanthan (55)
Startup
et al. (58)
Watson
et al. (57)
Moorey &
Soni (17)
Sample
Huppert &
Smith (43)
Study
As above
As above; depression
measured by the Beck
Depression Inventory (BDI)
and the Depression subscale
of the DASS 41 and the
Watson
et al. (57)
Huppert &
Smith (43)
As above
Oosthuizen
et al. (45)
Soppitt and
Birchwood (40)
Cross-sectional; examined
relationships
between panic and social anxiety
symptoms with levels of psychotic
symptoms. Interview and self-report
questionnaires.
Sample
100 participants with a
diagnosis of non-affective
psychosis, recruited within
3 months of a relapse
in positive symptoms.
Study
Smith et al. (37)
Main findings
Social anxiety symptoms related to
positive symptoms.
Panic and social anxiety were
related to paranoia.
Methodology
Anxiety
Table 3. Relationships between anxiety and depression, the severity and content of delusions and hallucinations and the distress associated with these experiences
Cross-sectional assessments of
positive and negative psychotic
symptoms, depression, selfesteem, and core schema.
Cross-sectional assessments of
content of and beliefs about
voices, depression.
Cross-sectional measures of
positive and negative psychotic
symptoms and depression
As above
Cross-sectional assessments of
paranoia, insight, depression,
and self-esteem.
Main findings
Methodology
Depression
331
332
Content
Distress
FornellsAmbrojo &
Garety (60)
Freeman
et al. (39)
Methodology
Anxiety
As above
Bentall
et al. (50)
Birchwood
et al. (26)
Cross-sectional assessments of
positive psychotic symptoms,
content of persecutory delusions,
emotion and self-esteem
Cross-sectional measures of
attributional styles, emotion, and
a semi-structured interview
assessing beliefs about the
persecution.
As above
Soppitt and
Birchwood (40)
Lucas &
Wade (46)
As above
Freeman &
Garety (44)
As above
Cross-sectional assessments of
depression, anxiety, self-esteem,
safety behaviours and
psychotic symptoms.
As above; depression
measured by the (BDI)
Sample
Freeman &
Garety (44)
Study
Main findings
Cross-sectional, self-report
assessments of worry, anxiety
and worry processes.
As above
Sample
Bentall
et al. (50)
Freeman &
Garety (44)
Startup et al.
(58)
Freeman &
Garety (44)
Study
Table 3. (Continued)
Cross-sectional assessment
of psychotic symptoms,
depression, beliefs about
persecution and threat and
safety behaviours.
Main findings
Methodology
Cross-sectional assessments
of beliefs about voices,
psychotic symptoms,
depression and
medication compliance
Depression
Hartley et al.
Depression measured
by the BDI, Voice power
differential scale and
social comparison scale
As above
Freeman
et al. (39)
Birchwood
et al. (47)
As above
Sample
Methodology
Study
Table 3. (Continued)
Sample
Anxiety
Main findings
Study
Depression
Methodology
Main findings
Hartley et al.
tion against conceptualizing psychosis as simply
the end product of a severe depressive episode. It
may be that there is a distinct aspect of experience,
appraisal, predisposition or processing in those
who go on to develop psychosis that supports the
relationship between depressive and positive psychotic symptoms, which also serves to augment
their psychosis to a level that attracts a primary
diagnosis of a schizophrenia spectrum disorder.
Huppert & Smith (43) did not nd any links
between depression and a range of psychotic symptom measures, while Freeman & Garety (44)
showed that depression did not correlate with delusional conviction or preoccupation, although the
small sample size (n = 15) may have been an issue
for the latter study. In addition, a study by Oosthuizen et al. (45) revealed that a depressive factor
(which also included a measure of anxiety, guilt
and somatic concern) did not correlate with the
severity of positive symptoms in a sample of people
with rst episode psychosis. However, the inclusion of other aspects of experience within the construct renders specic conclusions regarding the
links with depression ambiguous.
In conclusion, depression is associated with the
severity of both delusions and hallucinations and
positive symptoms more generally. Five of the
eight papers revealed signicant links between
depression and some aspects of positive symptoms
(but not all those that were under investigation in
each study); including the severity of auditory hallucinations, persecutory delusions, grandiose delusions, levels of paranoia and specic aspects of
voice hearing. Evidence to the contrary may be
limited by small samples sizes and confounding
factors. Findings pertaining to delusions have
tended to focus on those of a persecutory nature,
so generalizability is reduced.
Distress associated with psychotic symptoms. In
terms of the psychological reaction to psychotic
experiences, only two studies investigated this relationship, in samples of people with non-aective
psychosis and those specically experiencing
paranoia. Findings have shown that individuals
with more depression are more distressed by their
experiences and have more auditory hallucinations
of negative content and a higher degree of negative
content (37). However, distress associated with
paranoia has been shown to be unrelated to
depression (44), although the small sample size of
the latter study will have raised the possibility of a
type II error.
Content of psychotic symptoms. Delusional and
hallucinatory content often appears to be unu-
334
dence around specic delusional themes (i.e. paranoia), although providing a homogenous sample
and thus rm conclusions, does not allow us to
conclude that depression is related to delusional
themes; the research evidence does not so far
extend beyond this single type of experience.
Anxiety
Severity. Findings relevant to the severity of psychotic experiences have demonstrated that anxiety
is related to levels of paranoia, delusions and can
trigger acute augmentation in auditory hallucinations. Eight papers investigated the links between
anxiety and delusional and hallucinatory severity,
with sample sizes ranging from 15 to 100. Four of
these examined positive symptoms in general,
whereas two studied auditory hallucinations in
particular and two concentrated on delusional
severity.
Huppert et al. (43) showed that social anxiety
symptoms were related to positive symptoms and
bizarre behaviour, and that panic and social anxiety were related to levels of suspiciousness and
paranoia, in a sample of people with a diagnosis of
schizophrenia or schizoaective disorder. However, the specicity of the anxious experience
investigated (i.e. related to social interactions)
reduces the generalizability of the ndings to conclusions regarding the impact of generic anxious
features.
Moorey & Soni (17) revealed that anxious symptoms and delusions were related in a community
sample, although the same was not true for auditory hallucinations. The sample was relatively
small, with only 30 people with a diagnosis of
schizophrenia, although the random selection of
participants reduces bias and thus may add gravity
to the authors conclusion.
Freeman et al. (52) highlight one route by which
the presence of anxiety could impact on the severity or persistence of an archetypal positive psychotic symptom, paranoia. They uncovered a
signicant association between anxiety and safety
behaviours, which are a strategy often adopted by
those experiencing ideas of persecution. Safety
behaviours are those carried out with the intention
of avoiding the harm predicted by the persecutory
belief. If anxiety makes safety behaviours more
likely then it also increases the likelihood that the
belief in the potential persecution is reinforced, as
the lack of harm subsequent to performing safety
behaviour is misattributed to the adoption of the
safety behaviour rather than the lack of potential
for harm; the opportunity to gain disconrmatory
evidence is lost.
335
Hartley et al.
A major limitation of the cross-sectional data
hitherto reported is that the potential causal proximity of anxiety to the occurrence or severity of
delusions and hallucinations cannot be reliably
elucidated. Delespaul et al. (53) used momentary
sampling techniques to investigate the occurrence
of auditory hallucinations over a short time period,
using repeated self-report assessments of emotional
intensity and voice hearing in the context of an
experience sampling study (54). Using analyses
that appropriately accounted for the nested-nature
of the ESM data, Delespaul et al. established that
anxiety was signicantly increased immediately
prior to an increase in the severity of voice hearing.
The use of these momentary assessments provides
a unique insight not aorded to the largely crosssectional investigations in the area of depression.
The authors of the aforementioned study suggest
that these ndings may support a model in which
hallucinations arise to buer against the cognitive
dissonance caused by increased anxiety. Whether
or not that is the case, these data at least point to
the possibility of anxiety as a causal or catalytic
factor in the day-to-day occurrence of auditory
hallucinations. Ramanthan (55) provided an early
prequel to this study, showing that increased anxiety prior to an incidence of voice hearing was associated with lower convictions in the reality of the
hallucination; whether this measure relates directly
to severity or not is not clear.
Drawing together these ndings, anxiety has
been shown to be associated with the severity of
delusions and auditory hallucinations, and putative mechanisms have been explored. The eld is
not conclusive, though; Startup et al. (58) showed
that anxiety was not related to delusional conviction in a sample of in-patients experiencing persecutory delusions, although it is not clear if
conviction can be viewed as synonymous with
severity. In addition, the sample included both
people meeting criteria for a schizophrenia spectrum diagnosis and those with a bipolar disorder
diagnosis, somewhat undermining the generalizability to more homogenous diagnostic groups.
Freeman & Garety (44) also demonstrated that
anxiety (assessed by multiple measures) was not
related to delusional conviction or preoccupation,
although as previously reported, the small sample
size (n = 15) may have increased the possibility of
a type II error. As part of a depressive factor,
including measures of guilt, depression, somatic
concern and anxiety, Oosthuizen et al. (45) showed
that anxiety was not signicantly associated with
positive psychotic symptom severity. However, the
inclusive nature of the factor used may have
clouded any pertinent results for anxiety (or
336
337
Hartley et al.
meeting criteria at the time of assessment (64),
reecting earlier ndings (65). These co-occurrences, early in the development of the psychosis,
may point to depression having a fundamental formative role. Alternatively, it could be that both
syndromes share a common cause, as Romm et al.
(64) suggested. Furthermore, the retrospective nature of the self-reported presence of depression tempers the validity of the ndings, especially as
depressive episodes often involve concurrent memory biases (66).
Additional ndings from an early psychosis
sample were presented by Sim et al. (67), who
examined the comorbidity of depressive and anxious syndromes in people experiencing rst episode
psychosis. Disregarding the rules surrounding
diagnostic hierarchy, the authors found depression
to be present (historically or currently) in 16.5% of
cases; OCD in 5.1% and social phobia in 8.9%
and other studies have shown that depression and
anxiety constitute key aspects of the prodromal
period (6870).
Signicantly, Yung et al. (71) showed that the
presence of depression and anxiety in prodromal/
high risk groups appears to increase the risk of
transition into psychosis. Similarly, Krabbendam
et al. (72, 73) reported that, given the presence of
hallucinatory experiences, those with depressed
mood at year 1 were at increased risk of psychosis
at a 3-year follow-up assessment.
Prospective assessments have shown that the
existence of panic at baseline can predict the presence of psychotic symptoms after 24 months, in
those with a diagnosis of schizophrenia or schizoaective disorder (74). The use of a rst admission
sample in this study serves to highlight the importance of anxious features at this early stage of illness development, although the specicity of the
anxious event reduces the generalizability of the
ndings. Similarly, Iyer et al. (69) describe depression and anxiety as being the most frequent early
signs in a sample of people with rst episode psychosis, even with a large pool of 27 possible factors
including social withdrawal and sleep disturbance.
Specically in terms of paranoid beliefs, there is
evidence from correlational analyses that anxiety
contributes to a detrimental change in the level of
persecutory beliefs over a 3-month follow-up
period (58).
Birchwood et al. (75) completed an ongoing,
prospective assessment of various specic aspects
of psychopathology, monitored by both participants themselves and observers at fortnightly
junctures. Plotting of the data revealed that over
half of the sample relapsed in the course of
9 months and within this group, 50% showed
338
increases on the scales (including anxiety, depression and disinhibition) between 2 and 4 weeks
prior to relapse. A similar, more recent study of
relapse predictors found correlations between delusion formation and aective events akin to standardized constructs of anxiety and depression,
including feeling anxious and feeling depressed
or low (76). Koreen et al. (10) provide caution
against generalizing the results relating to depression described above as a trigger of psychotic episodes to other groups, as their ndings indicated
that depression was prodromal to schizophrenia in
only 7% of a sample experiencing their rst
episode of psychosis.
As part of a pharmacological trial, Tollefson
et al. (77) identied ve items from the PANSS
that appeared to predict relapse in psychotic symptoms: depression, anxiety, guilt, somatic concern
and preoccupation, (the PANSS Depression cluster). Extending this, the results showed that participants with reduced depression were subsequently
at less risk of relapse during the following 4 weeks,
compared to those whose depression had worsened
or remained stable. This dynamic relationship
points to the aective features identied in the cluster being fundamentally related to relapse, which
was dened as reduction in symptoms followed by
a worsening of them. However, the addition of
preoccupation, somatic concern and guilt in the
predictor variable render conclusions relevant to
the current review somewhat ambiguous.
Birchwood (78) and others (79) have found evidence to suggest that depression can follow the
same course as positive symptoms and can also
present during follow-up without a change in positive symptoms i.e. post psychotic depression or
PPD (80, 81). The picture is complicated by ndings that severity of depression in the acute phase
is not necessarily correlated with the appearance of
PPD (82), therefore divergent mechanisms may
underlie these two phenomena, with earlier work
(27, 83) suggesting that illness beliefs and appraisals are key to the development of PPD, a nding
extended by Shahar et al. (84) to a mid-episode,
substance using sample.
Green et al. (85) followed participants with
recent-onset psychosis for 1 year, showing depression was concurrent with psychosis more often
than would be likely by chance, and earlier ndings
have showed that in-patients with schizophrenia
experience depression at onset and during the
acute phase (86). Tibbo et al. (87) have demonstrated similar ndings for anxiety, showing that
participants retrospectively report the onset of
anxious features to occur prior to the onset of psychosis, although a proportion also experienced
Hartley et al.
support the formation of psychotic experiences has
been given weight by a non-clinical study of paranoid ideation. Lincoln et al. (106) looked at the
impact of anxiety and jumping to conclusions
biases (107) on self-reported paranoia in a student
sample. The authors used an experimental manipulation of anxiety to assess the interaction of
induced mood states and pre-existing paranoid ideation. The ndings showed that anxiety was associated with paranoid ideation, but only in those with
pre-existing high levels of paranoia (as tested prior
to the experimental manipulation). Furthermore,
this relationship was mediated by jumping to conclusions biases. Thus, increased anxiety may lead
to more prominent paranoia as a result of its
impact on jumping to conclusions, but this eect
only occurs in those individuals with high baseline
levels of paranoia. In opposition to this, So et al.
(108) failed to support a similar model in a Chinese
sample of rst episode participants, showing the
jumping to conclusions was not more evident in a
group induced to feel anxious.
A number of studies have demonstrated that the
links seen in those meeting diagnostic criteria are
also evident in sub-syndromal samples and may
increase conversion to experiences meeting
diagnostic criteria, with ndings also relating the
level of anxiety and depression to other, welldocumented risk factors.
Anxiety and depression, and outcome in psychosis. A
total of 29 papers provided ndings related to the
inuence of anxiety and depression on clinical outcome in psychosis. Investigations into the impact
of various psychological constructs on the prognosis of psychosis-related diculties have tended to
group into distinct categories; those that seek to
establish whether high levels of anxiety and/or
depression lead to more occurrences of a discrete
negative event (such as self-harm or suicide); those
that attempt to quantify participants quality of
life (from either an observer-rated or self-report
perspective) and assess whether this is related to
the presence of anxiety and/or depression; and
those that examine generic illness concepts such
as admission, relapses and chronicity, with many
linking these outcomes to levels of anxiety and
depression.
Roy (109) demonstrated that concurrent depression in schizophrenia is related to higher rates of
relapse and suicide, and comparisons by Coso &
Hafner (3) showed that those who meet criteria for
concurrent anxiety disorder have had a greater
number of hospital admissions than those who do
not, conrming the need to clarify the role of anxiety and depression in symptomatology and experi-
340
of psychosis. Clearly, there is an abundance of evidence to suggest that these two aective conditions
have signicant associations with the severity, distress and content of psychotic experiences. However, most of the investigations generated by the
search are also limited by their cross-sectional
design; there is no opportunity to discern whether
increases in anxiety and depression precede or lead
to greater symptom severity, or distress, thus conclusions of causality in any instance must be
avoided. Similarly, it is not clear whether the content of symptoms develops from the nature of the
emotional milieu, or that some specic types of
experiences lead to greater levels of anxiety and
depression, with the cause rooted elsewhere.
Moreover, there has been a tendency for much
of the research output to focus on paranoia or persecutory delusions and thus restrict the study sample to people with these particular experiences.
Although the high prevalence of this particular
type of experience might provide a rationale for
this strategy, another possible factor is that most
of the studies reported here have the primary aim
of elucidating the mechanisms behind paranoia,
with analyses of the role of anxiety and depression
as somewhat secondary. The ndings are not necessarily undermined because of this, but a more
general investigation, using a heterogeneous sample, or multiple studies each focussing on discrete
experiences (such as grandiose or somatic delusions, visual hallucinations) with consistent designs
to facilitate cross-comparison, may allow more
rm conclusions to be made that can then be generalized to psychotic experiences on the whole.
Longitudinal investigations have reported that
anxiety and depression can predate the rst episode of psychosis, or acute relapses, which may
indicate their causal inuence or role in triggering
distressing experiences. Conclusions in this context
rest on the assumption that, if anxiety and depression occur prior to the development of psychosis,
persist throughout its course and occur prior to
exacerbations in symptoms, then they are likely to
be involved as causal forces in its development,
rather than as emotional consequences of its presence. This assumption is not without its aws; anxiety and depression could merely be more readily
diagnosed or acknowledged (formally or informally) and therefore their occurring prior to psychosis is merely an artefact of the lower threshold
for awareness of their presence. In addition, the
assumption rests on commitment to the hypothesis
that temporal precedence is equivalent to causality;
it may be that there is a common cause, which both
psychosis and anxiety and depression are triggered
by, which leads to the development of both, but
341
Hartley et al.
which does not rely on the two being linked
causally.
Evidence of the links between anxiety and
depression and psychotic experiences in the general
population undermines the suggestion that these
negative emotions are only relevant in the context
of clinical samples as emotional reactions to the
distressing experiences (and possibly reections on
illness identities); instead, the ndings point to
fundamental relationships between anxiety and
depression and the experience of delusional beliefs
and hallucinatory experiences. Moreover, ndings
demonstrating that anxiety and depression can
increase conversion to diagnostic levels of psychotic experience are suggestive of a possible causal role of emotional dysfunction in the
transformation to distressing and unhelpful experiences; depression and anxiety may be the catalysts
that trigger distressing experiences of psychosis in
some individuals with predisposition or dicult
early life experiences.
Studies of outcome for people experiencing psychosis have revealed that depression and anxiety
are often associated with poorer consequences in
terms of more hospitalizations, admissions and
subjective appraisal of the negative impact of
psychosis-related diculties. In addition, rates of
suicide and self-harm are shown to be related to
levels of depression and anxiety, highlighting a
need to further elucidate the process by which
these aective experiences increase the likelihood
of these events in the context of psychosis. More
subjective measures, such as quality of life, entrapment and satisfaction with life are also related to
levels of anxiety and depression, although whether
these appraisals feed into the prevalence of the
more discrete events listed above is not clear.
The ndings indicate that therapeutic eort
directed towards the reduction of anxiety and
depression may be benecial to those experiencing
psychosis. Given the noted links prior to clinical
caseness, increases preceding elevations in symptoms and impact on outcome, it is likely that these
interventions could be relevant throughout the
course of psychosis. Cognitive behavioural therapy
is already well-evidenced and recommended for
those meeting criteria for a diagnosis of schizophrenia (135) and this review suggests that it may
be pertinent to routinely consider strategies to
reduce anxiety and depression in the context of
positive psychotic symptoms. Particular strategies
might include acknowledging and reducing safety
behaviours, relaxation techniques, activity planning, thought diaries and behavioural experiments.
Two pertinent issues have emerged from this
study: one is the need to clarify the causal direction
342
The authors have been made aware of several additional papers, not produced by this review, which
may be of interest to the reader. These are not
included in summary statements so as not to introduce bias into the systematic search process. A
large cross-sectional study (137) demonstrated that
so-called neurotic symptoms were associated with
Declaration of interest
None.
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