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Acta Psychiatr Scand 2013: 128: 327346

All rights reserved


DOI: 10.1111/acps.12080

2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
ACTA PSYCHIATRICA SCANDINAVICA

Review

Anxiety and depression in psychosis: a


systematic review of associations with
positive psychotic symptoms
Hartley S, Barrowclough C, Haddock G. Anxiety and depression in
psychosis: a systematic review of associations with positive psychotic
symptoms.
Objective: This review explores the inuence of anxiety and depression
on the experience of positive psychotic symptoms, and investigates the
possibility of a causal role for anxiety and depression in the emergence
and persistence of psychosis.
Method: A systematic literature search was undertaken, producing a
number of papers which comment on the links between anxiety and
depression, and the experience of delusions and hallucinations. In
addition, evidence which could contribute to our understanding of the
causal role of anxiety and depression was highlighted.
Results: The ndings show that both anxiety and depression are
associated in meaningful ways with the severity of delusions and
hallucinations, the distress they elicit and their content. However, the
cross-sectional nature of the majority of studies and the focus on certain
symptom subtypes tempers the validity of the ndings. Data from nonclinical samples, studies which track the longitudinal course of psychosis
and those which examine the impact of anxiety and depression on the
prognosis for people experiencing psychosis, oer some support for the
possibility of an inuential role for anxiety and depression.
Conclusion: We conclude that anxiety and depression are related to
psychotic symptom severity, distress and content and are also linked
with sub-clinical experiences, symptom development, prognosis and
relapse. These links may imply that anxiety and depression could be
targets for therapeutic intervention. The article concludes with
suggestions for further research, highlighting avenues which may
circumvent the limitations of the body of work as it stands.

S. Hartley1,2, C. Barrowclough1,

G. Haddock1
1

School of Psychological Sciences, University of


Manchester, Manchester, UK and 2Greater Manchester
West Mental Health NHS Foundation Trust, Prestwich,
UK

Key words: psychosis; delusion; hallucination; anxiety;


depression
Samantha, Hartley, School of Psychological Sciences,
University of Manchester, 2nd FloorZochonisBuilding,
Brunswick Street, Manchester, M13 9PL, UK.
E-mail: samantha.hartley@manchester.ac.uk

Accepted for publication December 18, 2012

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

A review of studies on the rates of depression in


schizophrenia concluded that all those included
reported at least some considerable level of
depression in the context of schizophrenia, with a
328

modal rate of 25% (4). As later highlighted by the


same author (9), dierences in denitions of
depression in the context of psychosis impede our
understanding of its nature and impact. Using liberal criteria to dene the presence of depressive
symptoms, Koreen et al. (10) showed that 75% of
those in their rst episode of schizophrenia were
experiencing depression, and in general community samples, the odds of meeting criteria for
depression are substantially higher for those meeting criteria for schizophrenia (11). The convergence of depression and psychosis has been
acknowledged (12, 13), although the dichotomy
between aective concerns and psychosis originally proposed by Kraepelin (14), still persists,
and underlies the diagnostic systems that govern
medical interventions.
A recent comprehensive review of anxiety disorders in the context of schizophrenia has shown that
anxiety (when taken to mean any experience of
clinically signicant anxious symptoms) is present
in 16%85% of samples, with the overall rate for
clinical studies (as opposed to epidemiological
ones) averaging 50% (15). Similar ndings have
been reported using a sample of out-patients, with
41.5% reaching criteria for a concurrent anxiety
disorder (16). Rates are also substantial in community samples who meet criteria for a diagnosis of
schizophrenia (17) and reports of lifetime rates
even higher at 67% (18), with earlier papers reporting comparable gures (19, 20).
The diagnostic trumping and associated lowered
awareness of the role for anxiety and depression in
psychosis is, in part, founded on and reinforced by
the exclusion rules inherent in the DSM-IV diagnostic system (21). Foulds (22) described the
schizophrenia spectrum diagnoses as superseding
emotional concerns; taking primacy over and
assimilating them. In contrast, van Os et al. (23)
suggest that schizophrenia is at the upper end of a
spectrum spanning normality, aective disorders
and psychosis; thus although the hierarchy persists, the presence of aective concerns is not
superseded by the presence of psychosis, it is
merely a dierent expression of the same diathesis.
When these hierarchies and constraints of diagnostic systems are disregarded, and the co-occurrence is examined, it is clear that the two classes of
mental health problem frequently coexist. With
regard to anxiety disorders, Coso & Hafner (3)
revealed that a large proportion of an Australian
sample with schizophrenia spectrum diagnoses met
criteria for anxiety disorders, with 17% social phobia, 13% Obsessive-compulsive disorder (OCD)
and 12% generalized anxiety disorder. Crucially,
and most disturbingly, only three of those people

Anxiety, depression and psychotic symptoms


from the sample experiencing concurrent anxiety
were being oered therapeutic or medical support
for this, due to the diagnostic hierarchy. Similarly,
when Bermanzohn et al. (24) disregarded the
trumping rules, they found that 49% of participants with a diagnosis of schizophrenia or schizoaective disorder also met criteria for one or more
associated problem area, with 27% displaying
major depression, 29% OCD and 11% panic disorder. Bermanzohn et al. question whether these
concurrent diagnoses represent parallel, but separate experiences that emerge along with psychosis,
or whether the anxious and depressive symptoms
are part of the intrinsic nature of schizophrenia. In
either case, it would seem important to note that
branding these concurrent concerns as secondary
experiences on the basis of a rigid structure of
diagnostic supremacy may have impacts on therapeutic ecacy and aetiological understanding.
Furthermore, the substantial rates of anxiety and
depression in the context of psychosis underline
the importance of exploring the specic links
between the presence of high levels of these emotional conditions and the presence and experience
of delusions and hallucinations.

A more specic conceptualization of depression


in the context of psychosis as post-psychotic
depression (PPD) has also received considerable
attention (2628). The lack of a denitive framework within which to consider the impact of
anxiety and depression reduces the cohesion of
the research eld, which may limit the conclusions that can be drawn. The authors therefore
felt it important to conduct a review without the
drive of one specic theoretical model; the
research evidence will be sought systematically
and reviewed without bias to produce a summary from which the research eld can move
forward.
Aims of the study

This review will synthesize and critique the current


understanding relating to the links between anxiety
and depression, and psychosis. The systematic
search will produce a pool of papers that comment
on the associations between these emotional conditions and delusions and hallucinations, and also
papers pertaining to convergence overtime, in nonclinical samples, and with the consequences of
psychosis.

Theoretical frameworks

Although there is no universally accepted model,


various theories have been espoused to explain
in what ways and by what means anxiety and
depression may inuence the occurrence of psychotic experiences. Bentall et al. (25) suggest
that delusions, specically those of a persecutory
nature, arise in defence against low self-esteem
and depression that would otherwise have developed as a result of the gulf between perceptions
of the actual and ideal self. Other authors propose a more direct role for anxiety and depression in the formation and maintenance of
delusions and hallucinations. Garety et al. (5)
suggest that triggers or intrusions give rise to
emotional changes, which then feed back into
the processing and content of experiences, augmenting their distressing nature and encouraging
exploration of possible causes of the aective
changes. The reasoning biases that guide this
causal exploration are exacerbated by the presence of anxiety and depression. Morrison (6)
also highlighted negative mood as a critical
aspect of a cognitive model of psychosis, in
which it is the misinterpretation of essentially
normal experiences as threatening events that
leads to distress and the maintenance of symptoms via a vicious cycle of negative mood, physiological changes and safety-seeking behaviours.

Material and methods


Systematic review: search methods

To gather information relevant to the two key


questions in this article, a systematic literature
review was undertaken.
The search engine PSYCINFO was accessed via the
University of Manchester Library Ovid online system between March and April 2011. The search
term combinations used can be seen in Table 1.
Records with abstracts were obtained and reviewed
for all of the initial search results. This produced a
subset of articles that complied with the inclusion
and exclusion criteria laid out in Table 1. The criteria were selected to produce a pool of articles that
focussed on psychological approaches to the study
of mental health problems. The exclusion criteria
were imposed sequentially, that is, those earlier in
the list were applied initially; records that reached
the nal list of included articles would therefore
have avoided the endorsement of all 10 exclusion
criteria. Any papers that did not violate any of the
specic exclusion criteria but nevertheless, failed to
provide any direct analysis of, or purport any theory regarding the relationship between anxiety and/
or depression and psychosis and or delusions/hallucinations (i.e. the second inclusion criterion) were
also excluded; an example of this would be an epi329

Hartley et al.
Anxiety and depression: interrelatedness and overlap

Table 1. Literature search details


Inclusion Criteria

Exclusion criteria

Search terms
combinations

Paper published in English


Specific quantitative analyses/other standardized
investigation of the links
between anxiety and/or depression and psychosis,
delusions or hallucinations
Published between 1950 and 2011
1. Journal introductory piece or record of
conference discussion
2. Pharmacological treatment review
3. Mental health care service review/audit
4. Animal study
5. Genetic or biomarker investigation
6. Case study
7. Paper solely analysing the psychometric properties
of a measure/scale
8. Focus on psychosis in the context of a primary Axis
1 diagnosis that is not a schizophrenia spectrum
diagnosis or is a primary physical or organic diagnosis
9. Focus on carers emotional dysfunction,
rather than that of the person experiencing
psychosis
10. [for anxiety-related searches
only] Focus exclusively on attachment anxiety
All search term
Anxiety psychosis
combinations were
Anxiety delusion
entered using the AND
Anxiety hallucination
function within the abstract
Depression psychosis
field, with journal article
Depression delusion
selected as the document
Depression hallucination
type and 1950-present
designated as the time frame.

As briey noted above, one reason for conducting


a simultaneous review into anxiety and depression,
and their links with psychosis is that the former
overlap somewhat. Comorbidity among anxiety
and depression is high (29), although cognitive
models have proposed that they have divergent
content (30), and factor analysis has shown that
self-statements from each can be reliably distinguished (31). One proposition is that there is more
overlap at the more acute, symptom level than in
terms of diagnostic categories (32). Various models
have been proposed to account for the dierent
ndings; there may be discrete but sometimes concurrent syndromes that exist along a spectrum;
anxious and depressive symptoms are expressions
of one underlying diathesis; one condition predisposes to the other; or the overlap is spurious and a
result of convergence in measure items or denitions (33). Thus, the eld is somewhat divided and
the evidence ambiguous. Including both emotional
conditions in this review will oer the opportunity
for areas of convergence and divergence to be
highlighted, although elucidating the overlap
between anxiety and depression is not a core aim
of this article.

demiological paper that used the terms anxiety


and psychosis in its abstract, but that upon inspection, did not aim to investigate any links between
the two. Full texts of those articles that complied
with all of the criteria were then accessed via the
University of Manchester electronic or paper
library systems, or via inter-library loan where
required. A summary of the search process and
results can be seen in Table 2. The articles were
reviewed with regard to content relevant to the
body of this article and also for any other relevant
papers not highlighted by the initial search; these
new papers were then also sought. A total of 16
papers were added as a result of the review of
references listed in papers produced by the initial
search.

Results
In what ways do anxiety and depression relate to delusions and
hallucinations?

A summary of the empirical ndings relating to


the associations between anxiety, depression and
the dierent aspects of delusions and hallucinations can be seen in Table 3. For clarity, these have
been grouped into those examining symptom
severity, distress and content.
Depression

Severity of psychotic symptoms. The literature demonstrates that depression is signicantly associated
with symptom severity in both chronic and early

Table 2. Literature search results


Exclusions (based on each numbered exclusion criterion listed in Table 1)

Search term combinations

Number of abstracts
produced by initial search

10

Did not include


specific analyses

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

32 out-patients; diagnosed with


Schizophrenia or Schizoaffective
disorder; not acute episode.

80 participants diagnosed with


First Episode Psychosis.

57 participants diagnosed
with schizophrenia,
in remission.

25 participants with a diagnosis


of schizophrenia and
experiencing auditory
hallucinations.

30 in-patients with schizophrenia


spectrum or bipolar diagnoses,
experiencing persecutory
delusions.

100 participants with a diagnosis


of non-affective psychosis,
recruited at the time of relapse.

30 participants with a diagnosis


of Schizophrenia attending
out-patient clinics.

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

Cross-sectionally assessed anxiety,


psychotic symptoms, demographic
and general illness related variables.

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)

Anxiety was significantly


associated with both observerrated and perceived symptom
severity.
Anxiety was significantly related
to delusional severity
but not hallucinatory severity.

Cross-sectionally assessed anxiety,


depression, and beliefs about illness,
insight and self-esteem.

As above

Oosthuizen
et al. (45)

Delusional group had similar


scores on anxiety measure
to those with GAD. No
associations between anxiety
and delusional conviction.

Cross-sectional and longitudinal with


3 month follow-up period.
Assessment
of anxiety, worry, psychotic
symptoms and catastrophizing.

42 in-patients with a diagnosis


of major depression with
psychotic features (n = 25) or
a schizophrenia spectrum
disorder (n = 17) with no
previous treatment or
admissions.

Soppitt and
Birchwood (40)

Anxiety levels predicted


hallucinatory experience,
with anxiety levels increased
at the time point prior to the
emergence of the hallucination.
Retrospective reports of anxiety
occurring prior to the hallucination
were associated with decreased
conviction of the reality of the
hallucination.

Experience sampling methodology;


ten question sets over 6 days.
Anxiety, visual and auditory
hallucinations measured by single,
self-report items.
Clinical interviews with participants
assessing mood, various aspects of
belief in the reality of the
hallucination
and other psychological constructs.
Sax et al. (42)

257 participants with a


schizophrenia spectrum
diagnosis, experiencing
their first admission and
having a minimum 4
week history of positive
psychotic symptoms.
21 participants with chronic
schizophrenia, experiencing
auditory hallucinations for
at least 6 months.

Drake et al. (38)

The depression factor did not


correlate with level of positive
psychotic symptoms or with
change in total
psychotic symptom scores
over the follow-up period.

Cross-sectional; examined
relationships
between panic and social anxiety
symptoms with levels of psychotic
symptoms. Interview and self-report
questionnaires.

Longitudinal analysis at 3 time-points:


6 weeks, 3 months and 6 months.
Assessed the presence of a
Depression Factor including
depression, guilt, anxiety and
somatic concern.

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

Depression linked with persecutory


delusions, auditory hallucinations
and grandiose delusions (the latter,
negatively). Only the latter finding
persisted in a regression.
Depression associated with
conviction and preoccupation in
delusional beliefs.
Greater depression associated with
higher levels of paranoia.

Significant relationships between


depressive symptoms and
positive psychotic symptoms
scores.
Significant differences in total
depression but not total
psychosis between groups.
Significant relationship between
depression and positive psychotic
symptoms in the schizophrenia
diagnosis group but not in
depression group.
The depression factor did not
correlate with level of
positive psychotic symptoms
or with change in total
psychotic symptom scores
over the follow-up period.
Depression was significantly
associated with perceived
symptom severity but not
observer-rated severity.
Depression was not significantly
correlated with any of the
psychotic symptom measures.

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

Anxiety, depression and psychotic symptoms

331

332

Content

Distress

20 participants with a diagnosis of


non-affective psychosis, all currently
experiencing persecutory delusions
and specifically poor me paranoia;
32 non-clinical control participants
and 21 clinical controls participants
with a diagnosis of major
depression.
70 participants experiencing
persecutory delusions
and with a diagnosis of
non-affective
psychosis and recruited
at the time of relapse.

FornellsAmbrojo &
Garety (60)

Green et al. (51)

Freeman
et al. (39)

Methodology

Anxiety

As above

26 participants with acute, first


episode psychosis with a
diagnosis of schizophrenia.

Bentall
et al. (50)

Birchwood
et al. (26)

High levels of anxiety in those


experiencing poor me paranoia.

Anxiety was not found to be


vassociated with either
pervasiveness of imminence
of threat

Cross-sectional assessments of
positive psychotic symptoms,
content of persecutory delusions,
emotion and self-esteem

30 participants with a diagnosis


of schizophrenia or
schizoaffective disorder.

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)

Power of the persecutory did not


correlate with anxiety. Indication
that anxiety was higher in those
who viewed the threat as pervasive.

As above

Smith et al. (37)

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

Assessed the presence of paranoid


delusions and many psychological
constructs, including depression,
anxiety, self-esteem, attributions,
cognitive performance.

Anxious worry and catastrophizing


related to delusional
distress, although anxiety itself did not.

Anxiety as assessed by all


measures did not correlate
significantly with delusional
conviction or preoccupation.

Main findings

The clinical groups had similar levels


of anxiety and worry. Trait anxiety
and worry concerning delusional
thoughts strongly correlated with
delusional distress although
anxiety as assessed by the BAI
did not.
In a factor analytic model, a factor
consisting of depression, anxiety,
low self-esteem and pessimistic
thinking was associated with
the presence of paranoid delusions.

Cross-sectional, self-report
assessments of worry, anxiety
and worry processes.

Heterogeneous group of 173


participants with either
schizophrenia spectrum disorders or
major depression, or
late-onset schizophrenia-like
psychosis; 88 of which were
currently experiencing persecutory
delusions.
25 participants with current
persecutory delusions and diagnoses
of schizophrenia, schizoaffective
disorder or delusional disorder

As above

15 participants diagnosed with


paranoid schizophrenia or
delusional disorder and
experiencing current
persecutory beliefs and 14
participants with GAD.
As above

Sample

Bentall
et al. (50)

Freeman &
Garety (44)

Startup et al.
(58)

Freeman &
Garety (44)

Study

Table 3. (Continued)

Depression was related to the


perceived threat posed
by the persecutors

Cross-sectional assessment
of psychotic symptoms,
depression, beliefs about
persecution and threat and
safety behaviours.

Derogatory voice content and


malevolence of voices was
associated with depression,
as was voice intrusiveness
and loudness, although clarity,
distractibility and frequency
were not.

Depression was significantly


associated with amount
and intensity of distress in
relation to delusional beliefs
and auditory hallucinations.
Depression did not correlate
with delusional distress.

Depression did not correlate with


delusional conviction
or preoccupation.

Main findings

Higher levels of depression were


associated with greater
perceived power of the voice
and also malevolent voice
content.
A factor consisting of depression,
anxiety, low self-esteem
and pessimistic thinking was
associated with the presence
of paranoid delusions.

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

A trend for higher evaluation


of the power of the
persecutor to be associated
with higher levels of
depression.
Feelings of more power in
comparison to the persecutor
were related to lower levels
of depression. The power
differential between the
persecutory agent and the
participant was related to
levels of depression.
Those who rated the voice
as more powerful and of a
higher social rank than
themselves were also
more depressed
As above

As above

125 participants with a


schizophrenia spectrum
diagnosis and a history
of voice hearing

Freeman
et al. (39)

Green et al. (51)

Birchwood
et al. (47)

As above

Sample
Methodology
Study

Table 3. (Continued)

Sample

Anxiety

Main findings

Study

Depression

Methodology

Main findings

Anxiety, depression and psychotic symptoms


psychosis groups, with study sample sizes ranging
from 15 to 257. Eight papers reported ndings
regarding links between depression and the
severity of delusional and hallucinatory experiences, with ve investigating positive symptoms
generally and one focussing on persecutory beliefs.
Examining the relationship cross-sectionally in a
sample of people with a diagnosis of non-aective
psychosis, with measures including the Positive and
Negative Syndrome Scale (PANSS) (34), Scale for
the Assessment of Positive Symptoms (SAPS) (35)
and Beck Depression Inventory (BDI) (36), Smith
et al. (37) found that the presence of greater depression and reduced self-esteem were related to the
severity of auditory hallucinations and persecutory
delusions. Similarly, in a sample of people experiencing their rst admission with a schizophrenia
spectrum diagnosis, Drake et al. (38) demonstrated
that depression was related to the severity of paranoia. The subjectively perceived severity of symptoms at the point of relapse has also shown to be
associated with levels of depression (39), although
the same study diverged from previous ndings to
show that observer-rated symptoms were not.
Thus, depression is related to the severity of experiences in both chronic samples, those with at rst
admission and at the point of relapse.
Soppitt & Birchwood (40) demonstrated that the
number of positive symptoms as assessed using
structured SCAN (41) interviews and scores on the
BDI were signicantly, positively related, in a
group of people with a chronic schizophrenia diagnosis and a recent history of voice hearing. More
specically, the ndings showed that voice intrusiveness and loudness (in other words, distinct,
specic aspects of severity) were related to BDI
scores, although voice frequency was not.
The signicant associations across a range of
conceptualizations of severity are suggestive of a
linear relationship between depression and positive
symptoms, that is as depression increases, so does
the severity of delusions and hallucinations; their
number, intensity and perceived intrusiveness.
However, the results of a mixed-population study
temper this conclusion. Sax et al. (42) utilized two
groups of individuals: one with a diagnosis of
major depressive disorder, with concurrent psychotic features and the other with schizophrenia
spectrum diagnoses also experiencing depressive
features. The ndings revealed that the association
between depressive features and positive psychotic
experiences was evident only in the latter group.
Thus, although both groups experienced both psychosis and depression, the two experiences were
only statistically related in the group with a diagnosis of schizophrenia. These ndings provide cau333

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

sual, although it has been postulated that the


themes can be related to underlying emotionality.
Freeman & Garety (2) proposed that, in psychosis, all the major emotions have delusions that
can be thematically linked with them, which is
consistent with a direct role for emotion in delusion formation (although the opposite causal
pathway cannot be ruled out). There is some
consistency in terms of the studies reviewed, in
demonstrating that depression seems to be associated with specic aspects of delusional themes or
appraisals of them. Seven papers reported on
links between depression and the content of
beliefs and voices. One study proposed a model
of a specic delusional experience, although did
not provide any empirical data and therefore is
not included in summary ndings. Four concentrated on links within a specic delusional themeparanoia, whereas three investigated links within
voice-hearing experiences.
For example, Soppitt & Birchwood (40)
reported that depression was signicantly linked
with derogatory voice content in verbal hallucinations (as opposed to non-derogatory voice content), although clarity, distractibility and
frequency were unrelated to the severity of depression. Similarly, assessing people with a diagnosis
of schizophrenia or schizoaective disorder, Lucas
& Wade (46) showed that depression was higher in
those with subjectively appraised malevolent voice
content, and beliefs that the voice is more powerful, a nding which has since been replicated (47).
However, as with the other ndings reported
here, a cross-sectional design fails to provide evidence as to the direction of the relationship
between depression and voice content; it is not
clear whether the presence of depression contributes to the derogatory nature of voice content, or
that the derogatory content develops independently from levels of depression, but once present,
increases depression due to its impact on general
negative aect. In addition, ndings that depression and negative self-evaluation are related in
people with schizophrenia (48) indicate that the
latter could be mediating the relationship between
depression and derogatory comments.
Some delusional themes are so intrinsic to the
experience that they become labelled as syndromes in their own right; Cotards syndrome
describes the pervasive feeling that one is dead or
does not exist. Exploring this very specic delusional subtype, Gerrans (49), suggests various ways
by ways depression could be linked with the emergence and persistence of feeling that oneself is
unreal, although the lack of empirical evidence
provided means that this paper should not be

Anxiety, depression and psychotic symptoms


included in summary analysis of the ndings in this
section.
Paranoid delusions have been shown to relate to
high levels of depression in a mixed sample study,
Bentall et al. (50), although the lack of specicity
in the predictor variable used (which conated
depression, anxiety, low self-esteem and pessimistic
thinking) reduces the utility of the ndings in partialling out the unique inuence of depression.
Furthermore, the diagnostically heterogenous nature of the sample reduces the possibility of generalizing the ndings. In addition to the objective
appraisal of the content of experiences, depression
has also been found to relate to beliefs about the
delusion or hallucination, and the subjective experience of these positive symptoms. Accordingly, in
persecutory delusions, there is a trend for higher
levels of depression to be associated with higher
ratings of the power of the persecutor, and, similarly, the control of the persecutory situation (39).
Furthermore, there are indications that the pervasive threat content of the delusional experience and
levels of depression are related in a rst episode
sample (26).
Focussing again on persecutory beliefs in a nonaective psychosis sample, Green et al. (51) examined the specic content of delusional ideas,
mapped on to a categorical coding frame including
assessments of the agent and nature of the threat,
the signicance, pervasiveness and imminence of
the persecutor and the relative power of the individual and perceived persecutor. Pertinent to the
current review is the relationship between these
aspects of the delusional content and levels of
depression, which the authors also examined. The
ndings revealed that various aspects of the delusional experience correlated signicantly with levels of depression, including a negative relationship
with ratings of power of the participant and, as
expected, the reverse relationship with power of
the persecutor. Interestingly, the dierence
between the rated power of the persecutor and participant correlated signicantly with levels of
depression, suggesting that it is this gulf in perceived power that is most pertinent, rather than
the absolute power of either party. In addition,
participants who rated their persecution as
deserved exhibited higher levels of depression.
In conclusion, all four studies into persecutory
beliefs revealed some signicant link between
depression and the content or appraisal of the
experience, such as beliefs around power and
threat. Similarly, those investigating voice hearing
revealed relationships with heightened depression
and malevolent and powerful voice content.
Despite these ndings, the concentration of evi-

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

depression) that may have been revealed with the


use of independent measures of these constructs,
especially given the divergence in ndings for the
two emotions thus far revealed by the studies outlined above.
In addition to clinically rated symptom severity,
there is evidence that perceived symptoms as
assessed with the Illness Perception Questionnaire
(56) are related to the severity of anxiety (57),
although the use of a sample who were at the point
of relapse reduces the generalizability of these ndings. Regarding both depression and anxiety, the
discovery that subjectively perceived symptom
severity is related to the level of these emotions
could have multiple implications; perceived symptom severity may be akin to actual symptom severity, and so the nding supplements those reported
above. Alternatively, it may signify that it is the
subjective appraisal of ones own illness experience
that leads to (or develops from) feelings of anxiety
and depression, which would converge with ndings in the realm of PPD (27). Watson et al. noted
that the correlation between anxiety and depression and symptomatology was stronger for perceived symptoms, rather than observer-rated,
adding weight to the latter hypothesis.
The ndings seem to suggest that anxiety is
related to the severity of delusions and hallucinations, although the evidence is not as extensive or
multifaceted as that related to depression. Some
studies also did not use the usual construct of anxiety, with one focussing specically on social anxiety and one conating anxiety with other aective
features such as guilt and depression, so specicity
with regard to links with anxiety per se is reduced.
Distress. There is evidence that anxiety is related
to the level of distress experienced as a result of
delusional beliefs, although there is a relative paucity of studies. Two studies have provided data relevant to this link.
Focussing on mechanisms rather than syndromes, Startup et al. (58) observed that processes
usually associated with anxiety, such as general
worry and catastrophizing, are related to distress
concerning persecutory delusions, However, measures of anxiety as a construct (rather than the specic thought processes discussed above) did not
produce any signicant eects, and further, the
authors conceded that the possibility that worry
and anxiety are consequences of delusional distress
cannot be discounted. The ndings relating to anxious thought processes, although intriguing and
possibly indicative of future research avenues,
cannot be included in any overarching conclusions
regarding anxiety as a general construct. As previ-

Anxiety, depression and psychotic symptoms


ously reported, the inclusion of people meeting criteria for a bipolar rather than schizophrenia spectrum diagnosis reduces the generalizability of the
ndings somewhat.
Also in the context of persecutory delusions,
Freeman & Garety (44) demonstrated that trait
anxiety was strongly correlated with delusional distress. Thus, there is evidence that delusional distress
is linked with anxiety, the lack of replication may be
due to issues with sample characteristics. There is
no evidence for a link between anxiety and distress
associated with auditory hallucinations.
Content. Comparisons can be drawn between anxious experience and the content of delusions and
hallucinations. Freeman and Garety discerned
that, like anxiety, persecutory delusions concern
anticipation of danger and have a content of
physical, social or psychological threat (59). Four
empirical papers reported ndings on links
between anxiety and the content or appraisal of
positive psychotic experiences and these focussed
largely on paranoid beliefs.
In a cross-sectional study utilizing structural
equation modelling, Bentall et al. (50) report that
paranoid delusions are associated with a pessimistic thinking style and high rates of anxiety,
although comparisons to those with specic delusions of other types were not made.
Furthermore, there are indications that the pervasive threat content of the delusional experience
and levels of anxiety are related (39), although this
has not been replicated (51) and similar analyses
relating to the power of the persecutor did not
reveal signicant associations with anxiety (39).
Justications for persecution that rest on blame
(poor-me paranoia) seem to be associated with
high levels of anxiety, possibly due to the anticipation of danger (60) although lack of explicit comparison with other groups renders the conclusions
limited.
Anxiety seems to be related to threat and beliefs
around lack of self-blame, although ndings
around threat content are ambivalent and a general lack of comparison groups limits the inferences that can be made.
Is there evidence to suggest that anxiety and depression play a
causal role in the development and experience of psychosis?

Relevant research. Uncovering causal relationships


in psychological research is fraught with diculty,
not least because experimental manipulations,
which would seek to test potential triggers or
contributory factors by inducing unpleasant mental states violate numerous ethical principles. Fur-

thermore, the multitude of factors potentially


involved renders uncovering independent causal
pathways dicult. The ndings discussed above
provide some clarity as to the precise relationship
between anxiety and depression and the experience
of psychotic symptoms, although the role of these
emotions in the development and maintenance of
delusions and hallucinations is less well elucidated.
Sources of information that could point towards
(but, admittedly, not ultimately conrm) a causal
role for psychological factors in the development
of mental health problems include prospective longitudinal research; research that focuses on the
stage of rst illness development and examines
links that may be present prior to experiences
reaching diagnostic levels (where the chronicity of
the illness and associated consequences are less
confounding); and research that assesses the
impact of potential causal factors on the course
and consequences of the experience. In this section
of the review, such relevant information resulting
from the literature search will be considered, and
pertinent conclusions oered that could contribute
to the understanding of a potential role for anxiety
and depression in the development or experience
of psychosis.
The emergence and persistence of emotional disturbance and chronological relationship with psychotic
experiences. A total of 25 papers produced by the
literature search provided evidence pertaining to
the chronological relationship between emotional
dysfunction and psychotic experiences. The
sequential primacy of emotional disturbance over
delusional or hallucinatory experience, and the
persistence and stability of emotional disturbance
may help to clarify whether or not anxiety and
depression inuence or trigger the development of
psychotic symptoms.
Studies have indicated that emotional disturbance can predate the onset of psychosis (61).
Retrospectively, Herz & Mellville (62) identied
dysphoric symptoms as the most prevalent prior to
relapse. Hamera et al. (63) replicated this nding,
showing that self-evaluated signs of relapse were
often coded as anxious (41%) or depressive (28%)
in type. Interestingly, the authors also showed that
many people took actions to divert relapse following their awareness of the indicator, and that those
with anxious and depressive indicators had better
concurrent functioning than those with psychotic
indicators.
A study of depression in the context of rst
episode psychosis has revealed that almost half
of the sample (49%) met the lifetime criteria for
at least one major depressive episode, with 21%

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

Anxiety, depression and psychotic symptoms


them developing after or during the onset of
schizophrenia. There is also evidence that depression and anxiety tend to remit with recovery from
acute psychosis (10).
Findings indicate that anxiety and depression
predate the development of psychotic experiences,
and often precede exacerbations in their severity,
thus supporting the hypothesis that they have
some role in their development or resurgence.
Anxiety and depression in non-clinical samples.
A total of 21 papers reported investigations into
the role of anxiety and depression in non-clinical
samples. Evidence from this type of study may help
to clarify the causal proximity of emotion on psychotic experience; if the two constructs are linked
outside of the clinically signicant range, then the
possibility that emotional dysfunction is only present as a reaction to the highly distressing nature of
a psychotic episode can be somewhat undermined.
There is evidence that risk factors for non-clinical psychotic features overlap with those for other
psychological disturbances, including anxiety and
depression (88). Furthermore, that depressive
features co-vary with delusional and hallucinatory
experiences in a similar way in both non-clinical
and clinical samples (89) and that anxious individuals in the general population have more hallucinatory experiences (90).
More generally, investigations into the psychometric dimension of schizotypy revealed that selfreported depressive and anxious symptoms are
positively associated with psychometric ratings of
schizotypy, especially positive symptoms (91) and
this nding has recently been replicated (92).
Repeated diagnostic assessments made by general
practitioners also show that psychosis proneness is
associated with higher incidences of depression
(93). Similarly, Paulick et al. (94) demonstrated
that predisposition to hallucinations is associated
with rates of anxiety in a group that were not currently active hallucinators, thus undermining proposals that anxiety is merely a product of
distressing hallucinatory experiences. In a later
study, Paulick et al. (95) extended this, replicating
their initial nding and also showing that anxiety
may mediate the relationship between resistance to
intrusions and the tendency to experience hallucinatory phenomena.
The ndings are not conclusive in this area,
however; Cangas et al. (96) and Morrison et al.
(97) showed that mood variables did not signicantly predict vulnerability to experience auditory
hallucinations in a sample of students and health
professionals, although the use of a composite
depression and anxiety predictor variable in the

latter study may have shrouded signicant independent relationships.


With regard to delusional beliefs in non-clinical
samples, Lincoln et al. (98) have used experimental
manipulation to show that anxiety may mediate
the relationship between stress and paranoia, indicating that those exposed to stress may experience
paranoia if it is in the context of high trait anxiety.
In a similar model, Freeman et al. (99) revealed
that anxiety and depression may moderate the
relationship between insomnia and paranoia in
non-clinical samples. Furthermore, Bensi et al.
(100) have shown that decits in data gathering,
often linked to the experience of paranoia, are
associated with anxiety in the general population.
A further clarication of the relationship between
anxiety and paranoia has been made by Jones &
Fernyhough (101), who showed that anxiety interacts with attempts to suppress thoughts to increase
the experience of persecutory ideation, with
thought suppression having the greatest impact
when anxiety levels are high. However, the crosssectional natures of these analyses render conclusions about the causal primacy of anxious experiences on paranoia ambiguous. Furthermore, as the
authors of the latter study themselves note, the low
proportion of the variance in persecutory ideation
accounted for by this interaction eect (4.5%)
highlights that there must be other more pertinent
factors, or indeed a multitude of factors that come
together to produce persecutory thoughts.
The associations between anxiety, depression
and hallucinatory and delusional tendencies in
non-clinical samples have been neatly summarized in a study by Cella et al. (102), showing
that both emotions predicted scores on measures
of delusional ideation (as previously demonstrated) (103) and voice hearing, and highlighting
that depression was the better predictor of
delusion proneness.
Extending the role of trauma in psychosis (104)
to a non-clinical population, Freeman & Fowler
(105) found that anxiety (but not depression) signicantly predicted the presence of paranoid
thoughts, while anxiety and trauma experiences
both predicted the presence of auditory hallucinations, with both relationships independent of
socio-demographic factors. This nding points to
the possibility of an interactive model of childhood
vulnerability and anxiety leading to the presence of
positive symptoms in later life.
A fundamental component of theories of psychosis is the role of dysfunctional reasoning processes in the development and maintenance of
psychotic experiences (5). The notion of negative
emotions and reasoning biases interacting to
339

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

ence. Various others (110113), have replicated


these ndings with regard to suicidality and a
recent study has shown that formally assessed anxious and depressive features are higher in those
with a history of suicide (114). Furthermore, Ran
et al. (115) have extended the support of an association between depressive experiences and suicide
attempts in psychosis to the Chinese community,
while Harvey et al. (116) have shown that the signicant proportion of self-harm in rst episode
psychosis can be predicted by the presence of
depression. However, Harkavy-Friedman et al.
(117) highlighted that although depression and suicide are frequently associated in psychosis,
attempts do occur outside of depressive episodes.
Not all aspects of outcome are related to emotional features; Naeem et al. (118) found no association between anxiety symptoms at baseline and
the outcome of cognitive therapy in a group of
patients with schizophrenia, a result which brings
with it some optimism for successful interventions.
As part of a large scale longitudinal research
programme, Sands & Harrow (119) reported that
depression in schizophrenia is associated with poor
overall outcome, and additional consequences such
as suicidal tendencies, work impairment and rehospitalizations, with some of the ndings later replicated (120). Similarly, Salkongas et al. (121) have
revealed associations between depression, poor
functioning and health status in both primary care
and out-patient settings. Furthermore, Blackburn,
Berry and Cohen (122) have provided a possible
route from depression to low therapeutic ecacy,
in the form of low attachment to care services.
However, Koreen et al. (10) showed that depressive symptoms do not predict time to remission or
global outcome in those experiencing rst episode
schizophrenia.
Huppert et al. (123) observed that both anxiety
and depression signicantly predicted assessments
of quality of life in those people with schizophrenia, with the latter nding subsequently replicated
(124129). Uzeno (130) has demonstrated that
subjective psychological well-being is negatively
related to levels of depression in an early psychosis
sample, even when controlling for negative
psychotic symptoms. One reason for these ndings
could be that comorbid anxious and depressive
features impact on peoples appraisals of psychosis
as a life event; indeed, Karatzias et al. (131) have
shown that those with concurrent aective
disorder diagnoses hold more negative appraisals
of entrapment surrounding their experience and
have lower self-esteem. Similarly, Mausbach et al.
(132) demonstrated that the intensity of depression
correlated with satisfaction with the activities that

Anxiety, depression and psychotic symptoms


people engage in, highlighting a potential route to
low quality of life reports.
There are some studies which point to depression and anxiety leading to better outcomes in
some respects; Cougnard et al. (133) showed that
the presence of anxiety and depression was associated with non-compulsory (rather than compulsory) admissions. In rst admitted patients,
Bottlender et al. (134) revealed the unexpected
nding that greater depression was related to better outcome. However, the specic context of the
latter ndings (acute hospital stay) may impinge
on the ability to extrapolate the results to form
more general conclusions. It may be, for example,
that those individuals who were more depressed in
this context were more motivated to overcome
their positive psychotic symptoms.
Peralta & Cuesta (13) investigated the impact of
anxious and depressive features on outcome in the
context of non-aective psychosis. They examined
the correlates of an anxiety factor (composed of
various features of anxiety including tension and
restlessness) and a depression factor (comprising
various aspects of depression including hopelessness and circadian disturbances). The ndings
showed that anxiety dened in this way was associated with a more chronic course of illness, poorer
response to treatment but, conversely, better global functioning and shorter duration of the episode, portraying a very mixed picture of the
inuence of this emotional condition. The depression factor was associated with suicidal behaviour
(although the fact that suicidal ideation was a specied component of the depression factor makes
this nding somewhat tautological) and more cognitive disorganization. Retaining the single symptoms rather than consolidating them into factors
may have made these results less ambiguous;
although there is a clear indication that depression
and anxiety (as dened here) do have a signicant
impact on outcomes in psychosis, the precise
mechanisms involved remain unclear.
To summarize, anxiety and depression seem to
lead to greater likelihood of numerous negative
consequences, such as relapse, admissions, selfharm, functioning and quality of life and suicide,
with the evidence especially strong for the latter
two outcomes. There is some ambivalence with
regard to more global measures of outcome or
prognosis, and anxiety does not seem to be detrimental to therapeutic ecacy.
Discussion

This review has summarized ndings relevant to


the role of anxiety and depression in the experience

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

of relationships between anxiety and depression


and positive psychotic symptom characteristics,
and the other is the need to focus on specic processes or subtypes of experience, to enable theoretical ndings to be translated in implementable
therapeutic methods. The understandable dearth
of experimental studies in this area makes it dicult to construct any conclusions about causality.
Researchers should seek to employ innovative
methods, such as experience sampling methodology (54), which can circumvent the diculties with
experimental procedures while providing observational data that captures a more detailed view of
the relationships between anxiety and depression
and psychotic symptoms. Moreover, the varied
way in which depression and anxiety are conceptualized, whether as diagnoses, symptoms, emotions or self-assessed dysphoria, renders the nature
of any conclusions drawn from the data described
here ambiguous. A number of studies have utilized
samples with specic experiences (such as social
anxiety) rather than more generic anxious features,
which might be explored more rigorously in future
work, although it may also make conclusions
regarding anxiety in general more ambiguous. In
addition, some investigations reported here (50)
have confounded levels of anxiety and/or depression with other factors such as self-esteem, guilt.
Studies exploring the unique inuence of anxiety
and/or depression may oer less ambiguous conclusions, although such work might also control
for levels of other pertinent factors as these clearly
may have a role to play. Alternatively, utilization
of more distinctly and specically dened processes
would enable more rm conclusions to be drawn,
and for these to feed in the development of targeted therapeutic procedures. The transdiagnostic
inuence of numerous thought processes, including
those traditionally associated with anxiety and
depression, such as rumination and worry, has
been highlighted (136). If the relationship between
these processes and the experience of specic psychotic events can be duly unpacked then contributions could be made to working psychological
models of delusions and hallucinations and to the
therapeutic resources available.
Additional relevant papers

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

Anxiety, depression and psychotic symptoms


both paranoia and hallucinatory experiences in the
general population, although others (138) have
established that there is not only some overlap in
early signs but also distinctiveness in those who
later go on to develop depression vs. psychosis.
Longitudinal work (139) has shown that anxiety
and depression were associated with the persistence of voices over 3 years in a sample comprised
of 80 adolescents. This is in contrast to Wigman
et al. (140), who found that depression and psychosis were associated cross-sectionally at points
along a longitudinal follow-up, but not over time.
Echoing previous ndings (53), Thewissen et al.
(141) used experience sampling methodology to
demonstrate that increased anxiety predicted the
onset of paranoia within daily life, and that depression was predictive of longer paranoid episodes.
Acknowledgements
This review was supported by Greater Manchester West Mental Health NHS Foundation Trust via the Recovery research
programme.

Declaration of interest
None.

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