Depressive and anxiety symptoms in patients with schizophrenia and schizophreniform disorder

BACKGROUND: Symptoms of depression and anxiety are frequently encountered in the course of schizophrenia and are of considerable clinical importance. They may compromise social and vocational functioning, and they are associated with an increased risk of relapse and suicide. Various treatment approaches have been reported to be successful. METHOD: The sample comprised 177 patients with DSM-III-R or DSM-IV schizophrenia or schizophreniform disorder who were participants in multinational clinical drug trials at our academic psychiatric unit over a 7-year period and who were assessed by means of the Positive and Negative Syndrome Scale (PANSS). Analysis was performed on baseline PANSS scores. The depression/anxiety score was compared in the men and women, first-episode and multiple-episode patients, and those with predominantly positive and negative syndromes. Correlations were sought between depression/anxiety scores and age, total PANSS score, positive score, negative score, general psychopathology score, and treatment outcome. Multivariate analysis was applied to determine contributions of individual variables toward depression/anxiety and outcome scores. RESULTS: Depression and anxiety symptoms were more severe in women (p = .007), first-episode patients (p = .02), and those with predominantly positive symptoms (p < .0001). Depression/anxiety scores were significantly correlated to age (r = -0.31, p < .0001), PANSS positive scores (r = 0.39, p < .0001), and treatment outcome (r = 0.25, p = .006). Multivariate analysis bore out these results, with the exception that first episode was not a significant predictor of depression and anxiety scores. CONCLUSION: PANSS depressive/anxiety scores were generally low in our sample, perhaps because patients with schizoaffective disorder were excluded. The finding that these symptoms were more prominent in women and first-episode patients is in keeping with previous literature. The higher scores in first-episode patients are likely due to the higher positive symptom scores in these patients. The association between depressive/anxiety scores and positive symptoms but not with negative symptoms points to a specific relationship between affective symptoms and the positive symptom domain of schizophrenia. The presence of depressive and anxiety symptoms may predict a more favorable outcome to treatment, although this may only apply to the acute exacerbations of the illness.     

The relationships between symptom dimensions and dysphoria in schizophrenia

Previous studies have suggested that qualitatively distinct aspects of dysphoria (anxiety and depression) are related to specific dimension of schizophrenia symptomatology. Most of these studies used simple dimensions and dysphoria models, although finer distinctions could help defining specific relationships. This study examined the relationships of distinctive aspects of depression and anxiety (both state and trait) with symptom dimensions. Forty patients with a DSM-IV diagnosis of schizophrenia were assessed for symptoms (SAPS-SANS), trait and state anxiety (STAI) and depression (CDS). Symptoms ratings were summarized as dimensional scores according to a two-, three- or five-dimensional models proposed in the literature. The correlation analysis replicates previous observations that distinct aspects of dysphoria are associated with specific dimensions of schizophrenia, with the exception of disorganization. Moreover, controlling for intercorrelated variables revealed that schizophrenia and dysphoric symptoms might act in combination and/or through indirect links to contribute to illness expression. Our data further suggested that these associations may be best understood in terms of interactions between various processing biases alluded in the most recent cognitive accounts of schizophrenia symptoms.     

Correlations between alexithymia and pain severity,depression, and anxiety among patients with chronic and episodic migraine

Aims: Some studies have found elevated alexithymia among patients with chronic pain, but the correlations between alexithymia and the severity of pain, depression, and anxiety among migraine patients are unclear. The aims of the present study were to investigate whether individuals suffering from episodic migraine (EM) differ from those with chronic migraine (CM) in regards to depression, anxiety, and alexithymia measures and to investigate the association of alexithymia with the results of depression and anxiety test inventories and illness characteristics. Methods: A total of 165 subjects with EM and 135 subjects with CM were studied. The Beck Depression Inventory (BDI), State–Trait Anxiety Inventory (STAI), and Toronto Alexithymia Scale (TAS) were administered to all subjects. The correlation between alexithymia and sociodemographic variables, family history of migraine and illness characteristics (pain severity, frequency of episode, duration of illness) were evaluated. Results: Compared with EM patients, the CM patients had significantly higher scores on measures of depression but not alexithymia and anxiety. There was a positive correlation between TAS scores and age and education in both migraine groups, but there was no correlation between TAS scores and other demographic variables. Depression and anxiety were significantly correlated with alexithymia in both migraine groups. Conclusion: Our results indicate that CM patients are considerably more depressive than EM patients. In this study, depression and anxiety were significantly correlated with alexithymia in both migraine groups. Our results demonstrate a positive association between depression, anxiety, and alexithymia in migraine patients.     

Causal illness attributions in somatoform disorders: associations with comorbidity and illness behavior

OBJECTIVE: To compare causal illness beliefs between patients with unexplained physical symptoms and different comorbid disorders and to assess the association of causal illness beliefs with illness behavior. METHODS: We examined a sample of 233 patients attending treatment in primary care. Inclusion criteria were "unexplained physical symptoms." All patients were investigated using structured interviews and self-rating scales [Screening for Somatoform Symptoms (SOMS), Beck Depression Inventory (BDI), Beck Anxiety Inventory, and a 12-item instrument to assess causal attributions]. By means of factor analysis, the following illness attributions were considered: vulnerability to infection and environmental factors, psychological factors, organic causes including genetic and aging factors, and distress (including exhaustion and time pressure). RESULTS: Most patients reported multiple illness attributions. The more somatoform symptoms patients had, the more explanations in general they considered. Especially for vulnerability and organic illness beliefs, patients with somatoform symptoms had increased scores. Comorbidity with depression and with anxiety disorders was associated with more psychological attributions. Even when the influence of somatization, depression, and anxiety is controlled for, illness beliefs still showed associations with illness behavior. Organic causal beliefs and vulnerability attributions were associated with a need for medical diagnostic examinations, increased expression of symptoms, increased illness consequences, and bodily scanning. CONCLUSIONS: Multiple causal attributions can coexist demonstrating different associations with comorbid depression and illness behavior.     

Stigma and perception of psychological distress and depression in Australian-trained medical students: Results from an inter-state medical school survey

Stigmatisation towards depression has previously been reported amongst medical students from a variety of backgrounds. This study explored personal and perceived stigmas associated with depression, and their relationship with demographics, knowledge of depression, levels of personal stress and history of medical illness amongst Australian-trained medical students. A cross-sectional survey was undertaken amongst students enroled June-to-August 2009 across four Australian medical schools. In total, 1010 students completed the survey, a response rate of 29.6%. Approximately 25% of students reported a past history of depression. Higher stress (K-10 scores) was reported by females and those with a past history of depression. On a scale of 0-to-5, the mean (±S.D.) personal and perceived stigma depression scores were 1.83±1.49 and 4.05±1.42 respectively. In multivariate analysis, higher perceived stigma and K-10 scores, a past history of anxiety and Year 3 of medical school indicated higher personal stigma scores. Perceived stigma was positively associated with K-10 scores, personal stigma scores, and a Caucasian background. Our findings suggest a high level of personal and particularly perceived stigma associated with depression amongst medical students, especially those displaying higher levels of stress. Adequate support and screening for psychological stress may de-stigmatise depression and improve mental health amongst future Australian doctors.     

Precursors of depression in World War II veterans 40 years after the war

The impact of wartime stress and other psychosocial and health variables on depressive illness in the 40 years since the Second World War is examined in this study of Australian male prisoners of the Japanese and other veterans. A random sample of 170 surviving members of the captured Eighth Division of the Australian Army residing in Sydney in 1983 (POWs) was compared with a similar sample of 172 veterans who fought in Southeast Asia during the war but were not imprisoned (non-POWs). Multiple regression analysis involving nine predictor variables revealed that self-reported nervous illness during the war and depressive illness since the war had pronounced independent effects on current depression as measured by the Zung Scale. Being married and better educated had significant protective effects against depression for the non-POWs while being employed and having higher socioeconomic status were protective for POWs. A clear linkage was shown from wartime nervous illness to postwar depressive illness to present-day depression.     

Sex differences in mental illness: a community study of the influence of physical health and sociodemographic factors

Summary This paper examines sex differences in psychiatric morbidity, using data from a community sample. The PSE-CATEGO-ID system was used to evaluate psychopathology. Six sociodemographic factors and physical illness were taken as independent variables. Females exhibit both a significantly higher psychiatric morbidity than males and a predominance of syndromes closely related to depression (SD; OD syndromes) and anxiety (GA; SA; TE; IT syndromes). Logistic modelling analysis, carried out separately for each sex, yielded different models. Psychiatric illness in men was best predicted by physical illness, unemployment and the interaction between the two. In contrast, physical illness emerged, in women, as the only factor exerting significant effects on psychiatric morbidity.     

Correlation between serum lipid concentrations and psychological distress.

This study examines the correlations between serum lipid levels and psychological distress. There were 4444 consecutive attendees of general health clinics who participated in the study. Psychological symptoms were measured by the Taiwanese version of the Symptoms Check List 90, revised (T-SCL-90-R). Levels of fasting serum lipids, including total cholesterol, total triglycerides and high-density lipoprotein cholesterol (HDL-C), were determined. Multiple linear regression analyses, with adjustment for confounders, revealed that the concentration of HDL-C had significant inverse associations with scores of depression, somatization and phobic anxiety. Women with an HDL-C level lower than 35 mg/dl scored significantly higher on depression, interpersonal sensitivity, phobia, anxiety, somatization and aggressive hostility, while subjects with a total cholesterol concentration lower than 160 mg/dl scored significantly higher on anxiety, aggressive hostility, phobia, and psychoticism. This study provides, for the first time, comprehensive data derived from the Taiwanese population on the link between lipids and psychological symptoms, revealing a reverse correlation between depression and serum concentrations of HDL-C.     

Psycho-social well-being among the parents of children with autism

This paper reports the results of a study of psycho-social well-being among an Australian sample of parents of children with autism. A variety of independent variables including: sociodemographic information, health and treatment status of the child and coping behaviours were assessed in terms of their effects on parental depression, anxiety and anger. The results of regression analysis indicated that fathers, and those parents who received more social support, had lower scores of depression, anxiety and anger. The age of symptom onset was positively related to depression, but was not significant in terms of anxiety and anger. Parents with older children, females and larger families reported lower scores of anger. These independent variables were not significantly related to depression or anxiety. Neither the type nor the extent of coping behaviours was significantly related to any of the measures of psycho-social well-being used in this study.     

Depressive and anxiety disorders in women with HIV infection

OBJECTIVE: This study examined whether there were differences in the rate of depressive and anxiety disorders between HIV-infected women (N=93) and a comparison group of uninfected women (N=62). Secondary objectives were to examine correlates of depression in HIV-infected women-including HIV disease stage and protease inhibitor use-and the associations between symptoms of depression or anxiety and other potential predictor variables. METHOD: Subjects underwent extensive semiannual clinical, psychiatric, neuropsychological, and immunological evaluations. Depressive and anxiety disorder diagnoses were assessed by using the Structured Clinical Interview for DSM-IV. Symptoms of depression and anxiety were evaluated with the Hamilton Depression Rating Scale (the 17-item version and a modified 11-item version) and the Hamilton Anxiety Rating Scale, respectively. RESULTS: The rate of current major depressive disorder was four times higher in HIV-seropositive women (19.4%) than in HIV-seronegative women (4.8%). Mean depressive symptom scores on the 17-item Hamilton depression scale also were significantly higher, overall, in the HIV-infected women (mean=8.7, SD=8.0) relative to comparison subjects (mean=3.3, SD=5.8). There was no significant between-group difference in the rate of anxiety disorders. However, HIV-seropositive women had significantly higher anxiety symptom scores (mean=8.8, SD=8.9) than did HIV-seronegative women (mean=3.6, SD=5.5). Both groups had similar substance abuse/dependence histories, but adjusting for this factor had little impact on the relationship of HIV status to current major depressive disorder. CONCLUSIONS: HIV-seropositive women without current substance abuse exhibited a significantly higher rate of major depressive disorder and more symptoms of depression and anxiety than did a group of HIV-seronegative women with similar demographic characteristics. These controlled, clinical findings extend recent epidemiologic findings and underscore the importance of adequate assessment and treatment of depression and anxiety in HIV-infected women.     

帕罗西汀合并丁螺环酮治疗抑郁症的对照研究

目的观察帕罗西汀合并丁螺环酮治疗抑郁症的临床疗效及可行性。方法对符合中国精神障碍分类与诊断标准第3版(CCMD-3)抑郁症诊断标准的80例患者随机分为帕罗西汀合并丁螺环酮组和单用帕罗西汀组,每组各40例。采用汉密顿抑郁量表(HAMD)、汉密顿焦虑量表(HAMA)、副反应量表(TESS)于治疗前及治疗后1、2、4周末分别评定临床疗效及副作用。结果研究组HAMD减分率于2、4周末均明显高于对照组(P<0.05),研究组HAMA减分率自第1周末起即明显高于对照组。两组副反应评分无显著差异,均无严重副反应。结论帕罗西汀合并丁螺环酮治疗抑郁症疗效确切,起效快,副作用较轻,特别适于伴有明显焦虑的抑郁症患者。     

Defense Styles and Personality Dimensions of Research Subjects with Anxiety and Depressive Disorders

We used the Bond Defense Style and Cloninger Tridimensional Personality questionnaires to assess defense styles and personality dimensions in subjects with anxiety and depressive disorders. When measured against a comparison group, maladaptive defense style scores were significantly higher in those with major depression, panic disorder, generalized anxiety disorder, and social phobia, and higher at a trend level in the subjects with obsessive-compulsive disorder and mixed anxiety and depression. However, there were no differences in adaptive defense style scores between the subjects and the comparison group. The harm avoidance personality dimension scores were significantly higher in subjects with both anxiety and depressive disorders than in the comparison group. The harm avoidance scores correlated positively with the maladaptive defense scores, but negatively with the adaptive defense scores. These findings are discussed in terms of severity of illness, level of functioning, and relationships between Axis I and II disorders.     

Clinical correlates and significance of separation anxiety in patients with bipolar disorder

OBJECTIVES: To evaluate frequency and severity of separation anxiety (SA) symptoms, as well as frequency of DSM-IV diagnosis of childhood separation anxiety disorder (CSAD) and adult separation anxiety disorder (ASAD), in a group of patients with bipolar disorder (BD) when compared with patients with panic disorder (PD) or major depression (MDD) and to a control group of healthy individuals (HC). METHODS: Outpatients with, respectively, bipolar I disorder (BD), PD, MDD and a group of individuals with no psychiatric diagnoses (HC) were assessed for diagnosis by the SCID-I and for SA by the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS), the Separation Anxiety Symptoms Inventory (SASI) and the Adult Separation Anxiety Checklist (ASA-CL). RESULTS: Thirty-one patients with BD without comorbid PD (BD-PD), 22 with BD with comorbid PD (BD + PD), 24 with PD, 20 with MDD and 15 HC were included in the analyses. As to childhood SA, the BD-PD group had higher scores than PD group and HC. The BD + PD group had higher scores than the PD group, MDD group and HC. As to adulthood SA, the BD-PD group had higher scores than HC on both SCI-SAS and Adult Separation Anxiety Questionnaire (ASA-27). The BD + PD had higher scores on both scales than BD-PD, PD group, MDD group and HC. The PD group and MDD group had higher scores than HC on the ASA-27. Adult SA symptoms were significantly associated with an earlier age at onset of BD. CONCLUSIONS: This is the first study, to our knowledge, exploring the frequency and severity of SA symptoms during childhood and adulthood in a sample of bipolar patients in comparison to subjects with other anxiety and mood disorders. Our data appear to be preliminary grounds for investigating further the possibility that SA may deserve greater recognition in adults with BD.     

The characteristics of the comorbidity between social anxiety and separation anxiety disorders in adult patients

Abstract

Objective: In the present study, we compared social anxiety disorder (SAD) patients with (n?=?31) and without childhood and adulthood separation anxiety disorder (SeAD) (n?=?50) with respect to suicidal behavior, avoidant personality disorder (AvPD), other anxiety disorders (ADs), and major depression as well as some sociodemographic variables.

Methods: In assessment of patients, we used Structured Clinical Interview for Separation Anxiety Symptoms, childhood and adulthood Separation Anxiety Symptom Inventories, Liebowitz Social Anxiety Scale, The SCID-II Avoidant Personality Disorder Module, Beck Depression Inventory, and Beck Scale for Suicidal Ideation.

Results: SAD patients with SeAD had higher comorbidity rates of AvPD, other lifetime ADs and panic disorder, and current major depression than those without SeAD. The current scores of SAD, depression, and suicide ideation and the mean number of AvPD symptoms were significantly higher in comorbid group compared to pure SAD subjects. The SAD and SeAD scores had significant associations with current depression, suicide ideations, and AvPD. The mean number of AvPD criteria and the current severity of depression were significantly associated with the comorbidity between SAD and SeAD.

Conclusion: Our findings might indicate that the comorbidity of SeAD with SAD may increase the risk of the severity of AvPD and current depression.     

Illness experience,depression, and anxiety in chronic fatigue syndrome

Objective: Given the high rate of psychiatric comorbidity with chronic fatigue syndrome (CFS), we considered two possible correlates of anxiety and depression: lack of illness legitimization and beliefs about limiting physical activity. Method: A total of 105 people diagnosed with CFS reported on their experiences with medical professionals and their beliefs about recovery and completed the depression and anxiety subscales of the Brief Symptom Inventory. Results: Those who said that their physician did not legitimize their illness (36%) had higher depression and anxiety scores (P's<.05) than their counterparts. Those who believed that limiting their physical exertion was the path to recovery (55%) had lower depression and anxiety scores (P's<.01) than their counterparts. Conclusion: Lack of illness legitimization ranked high as a source of dissatisfaction for CFS patients, and it may aggravate psychiatric morbidity. Many CFS patients believed that staying within what they felt to be their physical limits would improve their condition. This belief, and possibly an accompanying sense of control over their symptoms, may alleviate psychiatric morbidity.     

Serum dopamine-beta-hydroxylase activity in depression and anxiety

Three studies were done to determine whether serum dopamine-beta-hydroxylase (DBH) activity is affected by the symptoms of depression or anxiety. In the population-screening study, serum DBH activity was measured in a heterogeneous sample of 548 medical, surgical, and psychiatric outpatients. No association was found between serum DBH activity and scores on either the Zung Self-rating Depression Scale or the Taylor Manifest Anxiety Scale. In the longitudinal depression study, enzyme activity was measured in 14 patients with major depressive illness treated with imipramine. Serum DBH activity remained unchanged throughout treatment whether or not the patient recovered from the depressive illness. Furthermore, there was no association between enzyme activity and steady state antidepressant plasma levels. In the longitudinal anxiety study, evaluation of 45 anxious outpatients in a placebo-controlled double-blind evaluation of two benzodiazepines (diazepam and alprazolam) indicated that serum DBH activity failed to reflect either state changes in anxiety or pharmacological variables. These results are reviewed with respect to current knowledge regarding neuronal release and extraneuronal disposal of circulating DBH.     

Mood disorders in healthy elderly with obstructive sleep apnea: a gender effect

ObjectivePrevious studies have suggested an association between obstructive sleep apnea (OSA) and anxiety and depression, but it remains unclear as to whether this is due to OSA or other factors. The aim of this study was to evaluate this association in a large sample of healthy elderly with unrecognized OSA.Methods825 healthy elderly (aged ≥65 years) undergoing clinical, respiratory home polygraphic study and completion of questionnaires related to depression, anxiety and sleepiness were examined. According to the apnea–hypopnea index (AHI), the subjects were stratified into no-OSA, mild–moderate and severe OSA cases.ResultsAnxiety was present in 38% of the sample and depression in 8%. Anxiolytic treatment was reported by 9% of the population and antidepressant treatment in 5%. Women had high scores for anxiety and depression and they were more frequently taking anxiolytic and antidepressant medications. No differences were found for anxiety and depression scores and medication intake in the three groups of subjects stratified according to the AHI. Regression analyses adjusted for age, gender, body mass index, hypertension (HT), AHI, and indices of hypoxemia revealed that females were 5.44 times more likely to have depression with a low contribution of the time with SaO₂ < 90%.ConclusionsIn a large sample of healthy elderly with OSA, neither the existence nor the severity of the OSA was associated with anxiety and depression score, with women having higher anxiety and depression scores. This finding supports the hypothesis that depressive symptoms originate from factors other than measures of OSA severity.     

Death and suicide among former child and adolescent psychiatric patients

Background

Postnatal depression has received considerable research and clinical attention, however anxiety and stress in the postpartum has been relatively ignored. Along with the widespread use of the Edinburgh Postnatal Depression Scale (EPDS), depression has become the marker for postnatal maladjustment. Symptoms of anxiety tend to be subsumed within diagnoses of depression, which can result in anxiety being minimized or overlooked in the absence of depression. Some researchers have identified the need to distinguish between postnatal depression and anxiety, and to discern cases where depression and anxiety co-exist. The aim of this study was to assess the prevalence of postnatal distress using the EPDS and the Depression Anxiety Stress Scales (DASS-21).

Method

As part of a larger cross-sectional study, the EPDS and DASS-21 were administered to a convenience sample of 325 primiparous mothers, who ranged in age from 18 to 44 years (M = 32 years). Recruited through mother's groups and health centres in Melbourne Australia, inclusion was limited to mothers whose babies were aged between 6 weeks and 6 months. Analyses included comparisons between the classifications of women according to the EPDS and the DASS-21, and an exploration of the extent to which the EPDS identified anxious-depressed women.

Results

The EPDS identified 80 women (25%) as possibly depressed (using a cut-off of over 9), of which the DASS-21 corroborated 58%. In the total sample, 61 women (19%) were classified by the DASS-21 to be depressed. Using broader criteria for distress, it was revealed by the DASS-21 that a further 33 women (10%) showed symptoms of anxiety and stress without depression. A total of 41 women (13%) had symptoms of anxiety either in isolation or in combination with depression. The DASS-21 identified 7% of the sample as being both anxious and depressed. This at-risk sub-group had higher mean EPDS and DASS-depression scores than their depressed-only counterparts.

Conclusion

The prevalence of anxiety and stress in the present study points to the importance of assessing postnatal women for broader indicators of psychological morbidity than that of depression alone. The DASS-21 appears to be a useful instrument for this purpose.     

Anxiety and depression in children with epilepsy and their mothers

OBJECTIVE: Children with epilepsy have high rates of depression and anxiety. The majority of studies concentrate on the children with epilepsy, but the emotional impact of epilepsy on family members is of clinical concern. In this cross-sectional study we aimed to examine the association between epilepsy in childhood and adolescence, and anxiety and depression in these patients and their mothers. METHODS: We studied 35 children and adolescents with seizures (age range, 7-19 years), 35 gender-matched healthy controls (age range, 8-17) who did not have any chronic medical illness, and mothers of these individuals (n=70) in a cross-sectional analysis. We administered the Kovac Child Depression Inventory (CDI) and State-Trait Anxiety Inventory for Children (STAIc) to the children. We administered the Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI) to the mothers of these children. Pearson correlations were used to analyze dependence between variables, and Student's t test was used to compare mean values between test scores. RESULTS: Patients with epilepsy had higher CDI scores (mean+/-SD, 12.48+/-6.35) than controls (9.31+/-5.11) (P<0.05), whereas the STAIc scores did not differ between cases (34.03+/-8.29) and controls (35.20+/-6.23) (P<0.05). Mothers of children with epilepsy did not have more depression or anxiety symptoms than mothers of children without epilepsy as measured by BDI and STAI scores (P>0.05). There was no correlation between mothers' scores and patients' or controls' scores. CONCLUSIONS: These results support findings from previous studies that children and adolescents with epilepsy have a higher frequency of depressive but not anxiety symptoms than the general population of healthy children and that this is independent of their mothers' symptoms.     

Symptomatic determinants of insight in schizophrenia spectrum disorders

Impaired insight in schizophrenia spectrum disorders has been linked to several psychopathologic features including positive symptoms, although not all dimensions of psychopathology have been studied and confounds from other symptoms have not been ruled out. In addition, the nature of the association between insight and specific positive symptoms, in particular delusions, remains unclear. The present investigation examined whether, in patients with schizophrenia spectrum disorders insight is associated with specific symptom dimensions including delusional severity. The factor structure was determined from scores of 151 patients rated on the Signs and Symptoms of Psychotic Illness scale. Associations of the Signs and Symptoms of Psychotic Illness insight item with the resulting components and delusions were assessed using regression-based methodology. Principal component analysis revealed 4 orthogonal symptom clusters. Correlational analyses demonstrated that only depression/anxiety and psychomotor excitation were significantly related to insight. Hierarchical regression indicated that delusions explained unique variance in insight over and above depression/anxiety and psychomotor excitation. These results suggest that depression/anxiety is associated with better insight and that psychomotor excitation and delusions are associated with poorer insight.