548287
research-article2014
ISP0010.1177/0020764014548287International Journal of Social PsychiatryErol et al.
E CAMDEN SCHIZOPH
Original Article
The impact of insight on social functioning in patients with schizophrenia
International Journal of Social Psychiatry 1–7 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764014548287 isp.sagepub.com
Almila Erol1, Hakan Delibas2, Ozlem Bora3 and Levent Mete1
Abstract Background: It is still unclear whether insight has a direct association with social functioning in schizophrenia, independent of its association with symptoms. Aim: This study aimed to investigate the relationship of insight and its dimensions with social functioning in schizophrenia. Methods: A total of 170 outpatients with schizophrenia were included in this study. All patients were evaluated with the Scale to Assess Unawareness of Mental Disorder (SUMD), Positive and Negative Syndrome Scale (PANSS) and Personal and Social Performance Scale (PSP). Patients with impaired insight and patients with unimpaired insight were compared for PSP score through independent samples t test. Pearson’s correlation analysis was used to determine the correlations between study variables. Multiple stepwise linear regression analysis was used in order to determine the variables that predict social performance. Results: The PSP score of patients with impaired insight was significantly lower than that of patients with unimpaired insight. There were significant correlations between insight dimensions and PSP score. PANSS negative scale score, awareness of achieved effects of medication and awareness of anhedonia/asociality were significant predictors of social performance. Conclusion: Insight has a significant impact on social functioning in schizophrenia, and some, but not all, insight dimensions have direct impact on social performance, independent of their association with symptoms. Keywords Schizophrenia, insight, social functioning
Introduction Insight is a fundamental concept in schizophrenia. It not only refers to the knowledge of having a mental disorder but also includes the ability to relabel unusual mental events as pathological, adhere to treatment and be aware of the consequences of the disorder. Lack of insight is an important symptom of schizophrenia that has been defined and measured in descriptive and correlational studies (Baier, 2010; Dickerson, Boronow, Ringel, & Parente, 1997; Johnson, Sathyaseelan, Charles, Jeyaseelan, & Jacob, 2012; Lysaker, Bryson, & Bell, 2002; Sevy, Nathanson, Visweswaraiah, & Amador, 2004). Most researchers agree that insight should be regarded as a multidimensional phenomenon rather than a categorical, unitary concept. David (1990) hypothesized that insight comprises three dimensions: recognition that one has a mental illness, the ability to relabel unusual mental events as pathological and adherence to treatment. On the other hand, Amador, Strauss, Yale, and Gorman (1991) proposed a multidimensional model of insight which distinguishes between the two main components of insight: unawareness of illness and incorrect attribution of deficit or consequence of illness. Amador et al. (1993) also
proposed that insight may be modality-specific, that is, the level of insight can vary across the many manifestations of illness. Subsequently, research conducted in schizophrenia showed that insight is not uniform for all symptoms and impairments, but it fractionates (Gilleen, Greenwood, & David, 2011). Independence of insight dimensions within a multidimensional conceptualization suggests that each dimension may interfere with different factors. It has been shown that social functioning is impacted by various factors in schizophrenia, including symptomatology, cognitive functions, emotional functions and environmental factors (Erol, Keleş Unal, Tunç Aydin, & Mete, 2009). Although previous research on schizophrenia has brought evidence that insight has a significant influence on 1Clinic
of Psychiatry, Izmir Ataturk Training and Research Hospital, Izmir, Turkey 2Clinic of Psychiatry, Bozyaka Training and Research Hospital, Izmir, Turkey 3Clinic of Psychiatry, Gaziemir State Hospital, Izmir, Turkey Corresponding author: Almila Erol, Clinic of Psychiatry, Izmir Ataturk Training and Research Hospital, Basinsitesi, Izmir 35250, Turkey. Email: [email protected]
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International Journal of Social Psychiatry
treatment compliance and clinical outcome (Amador et al., 1993; Flyckt, Taube, Edman, Jedenius, & Bjerkenstedt, 1999; Rosen & Garety, 2005; Saravanan et al., 2010), the association of insight with functional outcome and social functioning continues to be examined yet. As insight may correlate with global, positive and negative symptoms of schizophrenia (Mintz, Dobson, & Romney, 2003), it is still unclear whether insight has a direct association with social functioning, independent of its association with symptoms. To date, most of the studies exploring the impact of insight on functioning in schizophrenia have focused on general functioning. Few studies examined the relationship of insight and social functioning, and their findings are somewhat conflicting. While some of the studies reported positive associations between insight and social functioning (Amador et al., 1994; Brissos, BalanzaMartinez, Dias, Carita, & Figueira, 2011; Dickerson et al., 1997; Gharabawi et al., 2007; Mohamed et al., 2009; van Baars, Wierdsma, Hengeveld, & Mulder, 2013; White, Bebbington, Pearson, Johnson, & Ellis, 2000; Yen, Yeh, Chen, & Chung, 2002), some others found no evidence linking insight to social outcome (Drake et al., 2007; Lysaker et al., 2002; Simon, Berger, Giacomini, Ferrero, & Mohr, 2004; Sitzer, Twamley, Patterson, & Jeste, 2008; Smith et al., 1999; Startup, Jackson, & Startup, 2010). Some studies even reported a negative association between insight and social functioning (Mutsatsa, Joyce, Hutton, & Barnes, 2006). The aim of our study was to investigate the relationship of insight and its dimensions with social functioning in schizophrenia. We hypothesized that patients with impaired insight would have poorer social performance compared to patients with unimpaired insight. We also hypothesized that insight had a direct impact on social performance, independent of its association with symptomatology, and that different insight dimensions should influence social performance to varying degrees.
Methods
All patients were required to be literate. Information about these criteria was derived from direct interviews with patients. In all, 41 patients who did not meet inclusion criteria were excluded from the study. Of those, 15 patients had depressive disorder, 11 had substance abuse, 5 had obsessive compulsive disorder, 5 did not meet age criteria, 4 did not give informed consent and 1 had neurological disorder. Finally, 170 patients with schizophrenia who met inclusion criteria were included in the study. Every patient who matched inclusion criteria was approached. After description of the study, written informed consent was obtained from all patients. All patients were stable and on atypical antipsychotic medications. Patients’ psychopathological symptoms were rated by means of the Positive and Negative Syndrome Scale (PANSS). Social performance was rated by the Personal and Social Performance Scale (PSP). Insight was assessed by the Scale to Assess Unawareness of Mental Disorder (SUMD). The scales were administered in three consecutive sessions, in the same order by different investigators. O.B. administered PANSS, L.M. administered PSP and H.D. administered SUMD. The interviewing and screening process with SCID-I was carried out by A.E. The investigators were blind to each other’s evaluations. Patients were generally categorized as having impaired or unimpaired insight based on their SUMD total scores derived from the three general items (awareness of mental disorder, awareness of the achieved effects of medication and awareness of the social consequences of having a mental disorder). Patients whose SUMD scores reflected either full awareness on all three dimensions (a total score of 3) or full awareness on two dimensions and partial awareness on one (total score = 4) were classified as having unimpaired insight. Patients with at least one rating of severe unawareness or more than one rating of partial awareness (total score >4) were classified as having impaired insight (Lysaker & Bell, 1994, Lysaker, Bell, Bryson, & Kaplan, 1998).
Study instruments
Subjects A total of 211 patients with schizophrenia who applied to the outpatient clinic of Izmir Ataturk Education and Research Hospital, Department of Psychiatry, were subsequently evaluated for the study. Patients were diagnosed using Structured Clinical Interview for DSM-IV (SCID-I) (First, Spitzer, Gibbon, & Williams, 1997; Özkürkçügil, Aydemir, Yildiz, Esen, & Köroğlu, 1999). The ones who had current co-morbid psychiatric diagnosis were not included in the study. Exclusion criteria also included mental retardation, identifiable neurological disorder or significant medical illness, substance use in the past 6 months and age less than 18 years and more than 65 years.
The PANSS. The PANSS is a 30-item instrument that measures positive, negative and general psychiatric symptoms. It includes 7 items for positive symptoms, 7 items for negative symptoms and 16 items for general psychiatric symptoms. All items are scored between 1 and 7 (Kay, Fiszbein, & Opler, 1987; Kostakoglu, Batur, Tiryaki, & Göğüş, 1999). The PSP. The PSP is a 100-point single-item rating scale, subdivided into 10 equal intervals. The ratings are mainly based on the assessment of patient’s functioning in four main areas: socially useful activities, personal and social relationships, self-care, and disturbing and aggressive
Downloaded from isp.sagepub.com at UNIV NEBRASKA LIBRARIES on April 10, 2015
3
Erol et al. Table 1. Comparison of sociodemographic characteristics of patients with unimpaired and impaired insight. Patients with unimpaired insight
Patients with impaired insight
Statistical test
(n = 84)
(n = 86)
n
n
34 50
33 53
χ2 = 0.08, p = .78
55 18 11
58 16 12
χ2 = 0.22, p = .90
44 14 16 6 6
51 14 11 5 5
χ2 = 5.77, p = .57
80 4
83 3
p = .89
Gender Female Male Marital status Single Married Divorced Employment Unemployed Homemaker Worker Student Retired Living arrangements With family Alone
behaviors. A single rating considers those four domains on a scale of 0–100, describing a continuum ranging from grossly impaired functioning to excellent functioning. Operational criteria to rate the levels of disabilities have been defined for those mentioned areas (Aydemir et al., 2009; Morosini, Magliano, Brambilla, Ugolini, & Pioli, 2000). The SUMD. The SUMD provides separate assessment of insight into mental disorder, social consequences, need for treatment and perception of each present symptom and attribution of symptom to disorder (Amador et al., 1993, 1994). The short form of SUMD, used in this study, includes three general items and seven subscales from which 10 summary scores can be calculated. The general items were devised to assess the global awareness of mental disorder, awareness of the achieved effects of medication and awareness of the social consequences of having a mental disorder. The subscales were devised to assess awareness and attribution of specific signs and deficits: hallucinations, delusions, thought disorder, alogia, flat affect, apathy and anhedonia/asociality. All scores range from 1 to 5, with higher scores indicating poorer awareness or attribution (Amador et al., 1994; Bora, Özdemir, & Özaşkinli, 2006).
Statistical analysis The data analysis was carried out with the Statistical Package for Social Sciences (SPSS) program, version 15.0
for Windows. Gender distribution, marital status and employment status of patients with impaired insight and unimpaired insight were compared using the chi-square test. Living arrangements were compared using Fisher’s test. As the data were normally distributed, patients with impaired insight and patients with unimpaired insight were compared for age, education level, duration of illness, number of hospitalizations and PSP and PANSS scores through independent samples t test. Pearson’s correlation analysis was used to determine the correlations between age, education level, duration of illness and PANSS, SUMD and PSP scores. Multiple stepwise linear regression analysis was used in order to determine the variables that predict social performance. In all analyses, p levels less than .05 were considered statistically significant.
Results There were 84 (49.4%) patients with unimpaired insight and 86 (50.6%) patients with impaired insight. Patients with unimpaired insight and impaired insight did not differ significantly for gender distribution, marital status, employment status and living arrangements (Table 1). Patients with unimpaired and impaired insight did not differ significantly for age, education level, duration of illness and number of hospitalizations. They did not differ significantly for PANSS negative, positive and general symptom scale scores either. The PSP score of patients with impaired insight was significantly lower than that of patients with unimpaired insight (Table 2).
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International Journal of Social Psychiatry
Table 2. Comparison of clinical characteristics of patients with unimpaired and impaired insight. Patients with unimpaired insight
Patients with impaired insight
Statistical test
(n = 84)
(n = 86)
mean ± SD
mean ± SD
Age Education (years) Duration of illness (years) Number of hospitalizations PANSS positive PANSS negative PANSS general PSP
38.12 ± 11.06 8.68 ± 3.66 13.17 ± 9.51 2.45 ± 1.93 10.38 ± 4.59 18.83 ± 6.37 21.95 ± 5.96 61.49 ± 21.16
35.38 ± 11.41 8.54 ± 3.45 11.31 ± 8.03 2.17 ± 2.11 11.43 ± 4.75 19.42 ± 5.99 23.67 ± 5.66 54.36 ± 19.29
t = −1.59, p = .12 t = −0.32, p = .74 t = −1.37, p = .17 t = −0.63, p = .53 t = 1.46, p = .14 t = 0.59, p = .55 t = 1.93, p = .06 t = −2.29, p = .02*
PANSS: Positive and Negative Syndrome Scale; PSP: Personal and Social Performance Scale. *p
research-article2014
ISP0010.1177/0020764014548287International Journal of Social PsychiatryErol et al.
E CAMDEN SCHIZOPH
Original Article
The impact of insight on social functioning in patients with schizophrenia
International Journal of Social Psychiatry 1–7 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764014548287 isp.sagepub.com
Almila Erol1, Hakan Delibas2, Ozlem Bora3 and Levent Mete1
Abstract Background: It is still unclear whether insight has a direct association with social functioning in schizophrenia, independent of its association with symptoms. Aim: This study aimed to investigate the relationship of insight and its dimensions with social functioning in schizophrenia. Methods: A total of 170 outpatients with schizophrenia were included in this study. All patients were evaluated with the Scale to Assess Unawareness of Mental Disorder (SUMD), Positive and Negative Syndrome Scale (PANSS) and Personal and Social Performance Scale (PSP). Patients with impaired insight and patients with unimpaired insight were compared for PSP score through independent samples t test. Pearson’s correlation analysis was used to determine the correlations between study variables. Multiple stepwise linear regression analysis was used in order to determine the variables that predict social performance. Results: The PSP score of patients with impaired insight was significantly lower than that of patients with unimpaired insight. There were significant correlations between insight dimensions and PSP score. PANSS negative scale score, awareness of achieved effects of medication and awareness of anhedonia/asociality were significant predictors of social performance. Conclusion: Insight has a significant impact on social functioning in schizophrenia, and some, but not all, insight dimensions have direct impact on social performance, independent of their association with symptoms. Keywords Schizophrenia, insight, social functioning
Introduction Insight is a fundamental concept in schizophrenia. It not only refers to the knowledge of having a mental disorder but also includes the ability to relabel unusual mental events as pathological, adhere to treatment and be aware of the consequences of the disorder. Lack of insight is an important symptom of schizophrenia that has been defined and measured in descriptive and correlational studies (Baier, 2010; Dickerson, Boronow, Ringel, & Parente, 1997; Johnson, Sathyaseelan, Charles, Jeyaseelan, & Jacob, 2012; Lysaker, Bryson, & Bell, 2002; Sevy, Nathanson, Visweswaraiah, & Amador, 2004). Most researchers agree that insight should be regarded as a multidimensional phenomenon rather than a categorical, unitary concept. David (1990) hypothesized that insight comprises three dimensions: recognition that one has a mental illness, the ability to relabel unusual mental events as pathological and adherence to treatment. On the other hand, Amador, Strauss, Yale, and Gorman (1991) proposed a multidimensional model of insight which distinguishes between the two main components of insight: unawareness of illness and incorrect attribution of deficit or consequence of illness. Amador et al. (1993) also
proposed that insight may be modality-specific, that is, the level of insight can vary across the many manifestations of illness. Subsequently, research conducted in schizophrenia showed that insight is not uniform for all symptoms and impairments, but it fractionates (Gilleen, Greenwood, & David, 2011). Independence of insight dimensions within a multidimensional conceptualization suggests that each dimension may interfere with different factors. It has been shown that social functioning is impacted by various factors in schizophrenia, including symptomatology, cognitive functions, emotional functions and environmental factors (Erol, Keleş Unal, Tunç Aydin, & Mete, 2009). Although previous research on schizophrenia has brought evidence that insight has a significant influence on 1Clinic
of Psychiatry, Izmir Ataturk Training and Research Hospital, Izmir, Turkey 2Clinic of Psychiatry, Bozyaka Training and Research Hospital, Izmir, Turkey 3Clinic of Psychiatry, Gaziemir State Hospital, Izmir, Turkey Corresponding author: Almila Erol, Clinic of Psychiatry, Izmir Ataturk Training and Research Hospital, Basinsitesi, Izmir 35250, Turkey. Email: [email protected]
Downloaded from isp.sagepub.com at UNIV NEBRASKA LIBRARIES on April 10, 2015
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International Journal of Social Psychiatry
treatment compliance and clinical outcome (Amador et al., 1993; Flyckt, Taube, Edman, Jedenius, & Bjerkenstedt, 1999; Rosen & Garety, 2005; Saravanan et al., 2010), the association of insight with functional outcome and social functioning continues to be examined yet. As insight may correlate with global, positive and negative symptoms of schizophrenia (Mintz, Dobson, & Romney, 2003), it is still unclear whether insight has a direct association with social functioning, independent of its association with symptoms. To date, most of the studies exploring the impact of insight on functioning in schizophrenia have focused on general functioning. Few studies examined the relationship of insight and social functioning, and their findings are somewhat conflicting. While some of the studies reported positive associations between insight and social functioning (Amador et al., 1994; Brissos, BalanzaMartinez, Dias, Carita, & Figueira, 2011; Dickerson et al., 1997; Gharabawi et al., 2007; Mohamed et al., 2009; van Baars, Wierdsma, Hengeveld, & Mulder, 2013; White, Bebbington, Pearson, Johnson, & Ellis, 2000; Yen, Yeh, Chen, & Chung, 2002), some others found no evidence linking insight to social outcome (Drake et al., 2007; Lysaker et al., 2002; Simon, Berger, Giacomini, Ferrero, & Mohr, 2004; Sitzer, Twamley, Patterson, & Jeste, 2008; Smith et al., 1999; Startup, Jackson, & Startup, 2010). Some studies even reported a negative association between insight and social functioning (Mutsatsa, Joyce, Hutton, & Barnes, 2006). The aim of our study was to investigate the relationship of insight and its dimensions with social functioning in schizophrenia. We hypothesized that patients with impaired insight would have poorer social performance compared to patients with unimpaired insight. We also hypothesized that insight had a direct impact on social performance, independent of its association with symptomatology, and that different insight dimensions should influence social performance to varying degrees.
Methods
All patients were required to be literate. Information about these criteria was derived from direct interviews with patients. In all, 41 patients who did not meet inclusion criteria were excluded from the study. Of those, 15 patients had depressive disorder, 11 had substance abuse, 5 had obsessive compulsive disorder, 5 did not meet age criteria, 4 did not give informed consent and 1 had neurological disorder. Finally, 170 patients with schizophrenia who met inclusion criteria were included in the study. Every patient who matched inclusion criteria was approached. After description of the study, written informed consent was obtained from all patients. All patients were stable and on atypical antipsychotic medications. Patients’ psychopathological symptoms were rated by means of the Positive and Negative Syndrome Scale (PANSS). Social performance was rated by the Personal and Social Performance Scale (PSP). Insight was assessed by the Scale to Assess Unawareness of Mental Disorder (SUMD). The scales were administered in three consecutive sessions, in the same order by different investigators. O.B. administered PANSS, L.M. administered PSP and H.D. administered SUMD. The interviewing and screening process with SCID-I was carried out by A.E. The investigators were blind to each other’s evaluations. Patients were generally categorized as having impaired or unimpaired insight based on their SUMD total scores derived from the three general items (awareness of mental disorder, awareness of the achieved effects of medication and awareness of the social consequences of having a mental disorder). Patients whose SUMD scores reflected either full awareness on all three dimensions (a total score of 3) or full awareness on two dimensions and partial awareness on one (total score = 4) were classified as having unimpaired insight. Patients with at least one rating of severe unawareness or more than one rating of partial awareness (total score >4) were classified as having impaired insight (Lysaker & Bell, 1994, Lysaker, Bell, Bryson, & Kaplan, 1998).
Study instruments
Subjects A total of 211 patients with schizophrenia who applied to the outpatient clinic of Izmir Ataturk Education and Research Hospital, Department of Psychiatry, were subsequently evaluated for the study. Patients were diagnosed using Structured Clinical Interview for DSM-IV (SCID-I) (First, Spitzer, Gibbon, & Williams, 1997; Özkürkçügil, Aydemir, Yildiz, Esen, & Köroğlu, 1999). The ones who had current co-morbid psychiatric diagnosis were not included in the study. Exclusion criteria also included mental retardation, identifiable neurological disorder or significant medical illness, substance use in the past 6 months and age less than 18 years and more than 65 years.
The PANSS. The PANSS is a 30-item instrument that measures positive, negative and general psychiatric symptoms. It includes 7 items for positive symptoms, 7 items for negative symptoms and 16 items for general psychiatric symptoms. All items are scored between 1 and 7 (Kay, Fiszbein, & Opler, 1987; Kostakoglu, Batur, Tiryaki, & Göğüş, 1999). The PSP. The PSP is a 100-point single-item rating scale, subdivided into 10 equal intervals. The ratings are mainly based on the assessment of patient’s functioning in four main areas: socially useful activities, personal and social relationships, self-care, and disturbing and aggressive
Downloaded from isp.sagepub.com at UNIV NEBRASKA LIBRARIES on April 10, 2015
3
Erol et al. Table 1. Comparison of sociodemographic characteristics of patients with unimpaired and impaired insight. Patients with unimpaired insight
Patients with impaired insight
Statistical test
(n = 84)
(n = 86)
n
n
34 50
33 53
χ2 = 0.08, p = .78
55 18 11
58 16 12
χ2 = 0.22, p = .90
44 14 16 6 6
51 14 11 5 5
χ2 = 5.77, p = .57
80 4
83 3
p = .89
Gender Female Male Marital status Single Married Divorced Employment Unemployed Homemaker Worker Student Retired Living arrangements With family Alone
behaviors. A single rating considers those four domains on a scale of 0–100, describing a continuum ranging from grossly impaired functioning to excellent functioning. Operational criteria to rate the levels of disabilities have been defined for those mentioned areas (Aydemir et al., 2009; Morosini, Magliano, Brambilla, Ugolini, & Pioli, 2000). The SUMD. The SUMD provides separate assessment of insight into mental disorder, social consequences, need for treatment and perception of each present symptom and attribution of symptom to disorder (Amador et al., 1993, 1994). The short form of SUMD, used in this study, includes three general items and seven subscales from which 10 summary scores can be calculated. The general items were devised to assess the global awareness of mental disorder, awareness of the achieved effects of medication and awareness of the social consequences of having a mental disorder. The subscales were devised to assess awareness and attribution of specific signs and deficits: hallucinations, delusions, thought disorder, alogia, flat affect, apathy and anhedonia/asociality. All scores range from 1 to 5, with higher scores indicating poorer awareness or attribution (Amador et al., 1994; Bora, Özdemir, & Özaşkinli, 2006).
Statistical analysis The data analysis was carried out with the Statistical Package for Social Sciences (SPSS) program, version 15.0
for Windows. Gender distribution, marital status and employment status of patients with impaired insight and unimpaired insight were compared using the chi-square test. Living arrangements were compared using Fisher’s test. As the data were normally distributed, patients with impaired insight and patients with unimpaired insight were compared for age, education level, duration of illness, number of hospitalizations and PSP and PANSS scores through independent samples t test. Pearson’s correlation analysis was used to determine the correlations between age, education level, duration of illness and PANSS, SUMD and PSP scores. Multiple stepwise linear regression analysis was used in order to determine the variables that predict social performance. In all analyses, p levels less than .05 were considered statistically significant.
Results There were 84 (49.4%) patients with unimpaired insight and 86 (50.6%) patients with impaired insight. Patients with unimpaired insight and impaired insight did not differ significantly for gender distribution, marital status, employment status and living arrangements (Table 1). Patients with unimpaired and impaired insight did not differ significantly for age, education level, duration of illness and number of hospitalizations. They did not differ significantly for PANSS negative, positive and general symptom scale scores either. The PSP score of patients with impaired insight was significantly lower than that of patients with unimpaired insight (Table 2).
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International Journal of Social Psychiatry
Table 2. Comparison of clinical characteristics of patients with unimpaired and impaired insight. Patients with unimpaired insight
Patients with impaired insight
Statistical test
(n = 84)
(n = 86)
mean ± SD
mean ± SD
Age Education (years) Duration of illness (years) Number of hospitalizations PANSS positive PANSS negative PANSS general PSP
38.12 ± 11.06 8.68 ± 3.66 13.17 ± 9.51 2.45 ± 1.93 10.38 ± 4.59 18.83 ± 6.37 21.95 ± 5.96 61.49 ± 21.16
35.38 ± 11.41 8.54 ± 3.45 11.31 ± 8.03 2.17 ± 2.11 11.43 ± 4.75 19.42 ± 5.99 23.67 ± 5.66 54.36 ± 19.29
t = −1.59, p = .12 t = −0.32, p = .74 t = −1.37, p = .17 t = −0.63, p = .53 t = 1.46, p = .14 t = 0.59, p = .55 t = 1.93, p = .06 t = −2.29, p = .02*
PANSS: Positive and Negative Syndrome Scale; PSP: Personal and Social Performance Scale. *p
