腦幹與大腦半球梗塞對情緒狀態之影響:長期性追蹤研究

行政院國家科學委員會專題研究計畫成果報告

Effects of Brainstem and Hemispheric Infarction on Emotional Status: A Longitudinal Study (I)

中文摘要： 第一年研究主要目的是檢驗腦幹中風病人的情緒狀態。總共五組中風病人分別為 左側大腦與右側大腦皮質中風病人、左側與右側皮質下腦部中風病人以及腦幹中 風病人，以及一組正常受試者參與本研究。每位受試者皆接受一組情緒功能的測 驗，這六組受試者在年齡教育程度與性別相互配對。資料分析結果顯示：腦幹病 人有輕微程度情緒功能的改變；憂鬱是主要的症狀。除此以外情緒功能的問題上 包括極輕微到輕微體化型、強迫性意念與行為以及焦慮等症狀，由於目前這些結 果來自有限病人之樣本，因此進一步繼續探討這些問題是否真正存在是有其必要 性的。至於原計畫在第一年欲探討部分有關這些腦幹中風病人情緒功能改變的現 象是否為短暫性質或持久性質的問題，同樣的，在相當有限的追蹤資料情況下， 僅能留待第二年的研究計畫來探討。 關鍵字：憂鬱症、情緒功能狀態、腦幹中風

ABSTRACT

The aim of the first-year study was to examine the emotional status of the patients

with brainstem stroke. An emotional function test battery was administered to five

groups of the adult patients with cerebral hemispheric, subcortical, and brainstem

strokes, and one group of normal control adults. Members of these six groups were

matched in terms of age, educational level, and sex. Comparing the test results

revealed that the patients with brainstem had a mild impairment of emotional function,

mainly depression. In addition, otherwise psychopathological manifestations

including slight to mild somatization, obsessive-compulsive symptom, and anxiety

were also noticed. Since our findings were based on the limited data, further

investigation is necessary. Likewise, only a few patients have received the 6-month

follow-up evaluation of their emotional function in this first-year study. The issue

regarding whether or not emotional changes evident in the patients with brainstem

stroke are transient or persistent, thus, awaits the second-year investigation.

Stroke is a common disease of central nervous system. In Taiwan this disease has

been the second leading cause of death for all ages (Huang, Chiang & Lee, 1997).

Physical disability, and a variety of cognitive impairments, such as aphasia, amnesia,

apraxia, agnosia, aprosodia, dysarthria, attentional problem, neglect, and visuospatial

disorientation are frequent consequences of cerebral hemispheric stroke (Heilman &

Valenstein, 1993; Lezak, 1995; Walsh, 1994). In addition to these deficits, emotional

changes are also a common sequela (Hosking, Marsh & Friedman, 1996). The

disturbances include depression, emotional lability, apathy, irritability, agoraphobia,

social withdrawal, self-neglect, and anxiety (House, Dennis, Mogridge, Warlow,

Hawton & Jones, 1991;Morris, Robinson, & Raphael, 1993; Nelson, Cicchetti, Satz,

Sowa & Mitrushina, 1994).

The implied clinical and economic impacts of these emotional disturbances on the

stroke patients are multifold (Spencer, Tompkins & Schultz, 1997). First, the patients

with emotional problems undertake more negative thinking and stress negative results

(Ingram, Kendall, Smith, Donnell & Ronan, 1987). Consequently, sundry cognitive

function changes in these patients might be exaggerated though cognitive impairments

tend to co-occur with emotional problems (Seibert & Ellis, 1991; Speedie et al., 1990).

Secondly, sundry cognitive function changes, such as depression can be a vital

and their caregivers might be changed tensely by these emotional sequelae (Spencer et

al.,1997). Therefore, in order to offer the patients the supreme opportunity for

treatment profits, a great care for their emotional disturbances is merited.

Depression has generally been considered to be the most common emotional

consequence of cerebral hemispheric stroke (Nelson, 1994; Price, 1990). The

prevalence rate of poststroke depression, however, varies extensively from less than

25% up to more than 60% (Astrom, Adolfsson & Asplund, 1993). Methodological

discrepancies mainly including the selection of patients, the time of evaluation since

the stroke and the duration of the assessment period, as well as diverse diagnostic

criteria and psychopathological measures have a significant contribution to this

variation (Astrom et al., 1993; Hosking et al., 1996). Furthermore, the proportion of

poststroke depression does not keep steady throughout the poststroke period (Astrom

et al., 1993). The manifestations of otherwise emotional problems, such as

agoraphobia, social withdrawal, anxiety, mania, catastrophic reactions, and apathy

recently have also been observed in the patients following cerebral hemispheric stroke

(e.g., House et al., 1991; Morris et al., 1993; Robinson & Starkstein, 1997). The issue

regarding whether or not depression is the most frequent emotional result of cerebral

hemispheric stroke, thus, becomes controversial and awaits further investigation.

though the literature in this area is less extensive than that of cerebral hemispheric

stroke. Generally, depression is significantly related to lesions of left basal ganglia

(Starkstein, Robinson, Berthier & Price, 1988). However, mania, bipolar affective

disorders, and psychosis are highly associated with right subcortical (basal ganglia or

thalamus) lesions (Robinson et al., 1988; Starkstein et al., 1991; Starkstein, Robinson

& Berthier, 1992; Trimle & Cummings, 1981). Anxiety and apathy have a high

frequency of lesions involving the posterior limb of the internal capsule (Robinson &

Starkstein, 1997; Starkstein et al., 1993a) while catastrophic reactions are notably

related to anterior subcortical lesions (Starkstein et al., 1993b).

The dysfunction of the biogenic amine system has been hypothesized to be one of

the mechanisms that may play an important role in the cause of depression (Beatty,

1995; Conn, 1995). Both noradrenergic and serotonergic cell bodies are located in the

locus coeruleus and raphe nucleus of the brainstem, and send ascending projections to

the frontal cortex through the median forebrain bundle. The ascending pathways then

arc posteriorly and travel longitudinally through the deep layers of the cortex,

arborizing and sending terminal projections into the superficial cortical layer

(Morrison, Molliver, & Grzanna, 1979). On the basis of neuroanatomical evidences

and clinical findings, Robinson and his colleagues (1984) proposed that poststroke

due to lesions in either the frontal cortex or basal ganglia. If this is the case,

depressive symptoms should also be evident in the patients with brainstem stroke

involving the rostral pons and caudal mesencephalon which are sites for the

serotonergic raphe nucleus and the noradrenergic locus coeruleus (Lang, 1991).

The literature of emotional disturbances in the patients following brainstem stroke,

however, is very limited. Trimble and Cumminings (1981) reported that

manifestations of suicidal ideation, unstable mood, euphoria, depressive feelings, and

emotional lability were noted in two patients with brainstem stroke. However, the

definite lesioned areas of both patients determined by the CT scan were located in the

thalamus rather than the brainstem. Starkstein, Robinson, Berthier and Price (1988)

found that patients with posterior circulation lesions involving the brainstem and/or

cerebellum had a remarkably low frequency of depression, and a significantly short

duration of depressive symptoms. Unfortunately, since no otherwise

psychopathological measures, with the exception of depression and anxiety tests, were

used in their study, the issue of whether or not other emotional sequelae might also be

manifested in patients following brainstem stroke remains unknown.

The report of emotional disturbances in poststroke patients in Taiwan is lacking.

In order to explore the above unclear issue, and to document the literature in Taiwan,

that is, 5 patient cohorts and 1 group of normal controls will be included. 5 patient

groups consist of 1 group of patients following brainstem stroke, 1 with left and 1

with right cortical stroke, and 1 with left and 1 with right basal ganglion stroke. The

first-year study goal is to complete 1- and 6-monthss poststroke assessment of

emotional function; the second-year study goal is to complete 1-year poststroke

evaluation of emotional status. The specific aims of the study, thus, are to examine the

following questions: 1) Is there an impairment of emotional status in patients with

brainstem stroke? 2) If so, does the deficit only involve depression, as Starkstein et

al’s observation (1988), or also include otherwise emotional function tested? 3) If

depression or/and otherwise emotional changes does/or occur in the patients with

brainstem stroke, is/are the deficit(s) transient or persistent?

METHOD

Par ticipants. Because of a very high dropout rate of the participants, 6 groups with

only 55 volunteer adults were included in the first-year study. There were 37 stroke

patients including 12 with brainstem (Group 1), 3 with left cortical (Group 2), 5 with

left subcoritcal (Group 3), 8 with right cortical (Group 4), and 9 with right subcortical

(Group 5) lesions, and 18 normal control subjects (Group 6). The lesion locations

were verified by MRI, and all of these patients were victims of the first stroke in the

drug treatment), and psychiatric history. The patients were also free of dementia,

confusional state, anosognosia, and moderate or severe comprehension deficits.

The mean differences in age were not significantly different, with the exception of

Groups 4 and 5 and Groups 4 and 6. That is, the mean age of the patients with right

cortical stroke was significantly younger than that of the patients with right

subcortical stroke and of the normal controls (Table 1). The mean differences in

education were also not significantly different. All participants were right-handed in

which hand dominance was ascertained by the history that the participant has always

used his/her right hand preferentially for doing skillful activities, such as writing and

holding chopsticks.

Tests and procedure. After giving informed consent, each participant will receive a

series of neuropsychological tests. They included cognitive function and emotional

status measures. The Temporal Orientation Test (Benton, Hamsher, Varney & Spreen,

1983), the Orientation to Personal Information and Place (Hamsher, 1983), Object

Naming Test (Spreen & Benton, 1969), and Aural Comprehension (Benton &

Hamsher, 1978) were used to rule out the participants suspectable for dementia,

moderately or severely receptive aphasia, confusional state, and anosognosia. The test

battery of emotional status consisted of Symptom Checklist-90-R (Derogatis, 1977),

1987), and a semi-structured Standard Neurobehavioral Interview Inventory

(Hamsher, 1983). In addition, Canadian Neurological Scale and Barthel Index

(Mahoney & Barthel, 1965) were also used to measure the severity of the patient’s

physical disability, and evaluate the degree of his/her independence in basic activities

of daily living respectively. The assessment was administered in an examing room

between 11 AM and 2PM to minimize any possible effects of diurnal mood variation

on interview responses, as Starkstein, Cohen, Fedoroff, Parikh, Price, and Robinson

(1990). All measures were Chinese versions.

In order to obtain reliable and valid ratings of the patient’s emotional status, we

also asked the participant’s significant others, particularly family caregivers of the

patient, to rate the emotional status of the participant. All of the significant informants

of the patients will be free of emotional disturbances, dementia, and psychiatric

history. For the present, our available patients only received the first examination, that

is, they were examined at the poststroke periord of 1 month while a few (2 patients)

received the second examination, that is, 6 months after the onset of stroke.

RESULTS

Since the measures of emotional status are ordinal scales, Kruskal-Wallis one-way

analysis of variance by Ranks (Marascuili and McSweeney, 1977) was used to

Inventory and SCL-90-R was different from that of the normal control participants.

On the Beck Depression Inventory, the patients with brainstem stroke had the highest

mean rank followed by the patients with left subcortical stroke, the patients with right

subcortical stroke, the patients with right cortical stroke, the patients with left cortical

stroke, and the normal controls. The mean rank differences among the participant

groups did reach a statistical difference (Chi square=17.92, df = 5, p<.05). Nemenyi’s

post-hoc pairwise contrasts with Bonferroni corrections for a control of Type I error

were subsequently used to analyze the data. The results, however, did not reveal any

significant differences between the participant groups (Tables 2 and 3).

Likewise, on the SCL-90-R, the highest mean rank to the lowest on the

Somatization subscale was the patients with brainstem stroke, the patients with left

subcortical stroke, the patients with right cortical stroke, the patients with right

subcortical stroke, the normal controls, and the patients with left cortical stroke. On

the Obsessive-Compulsive subscale, the patients with brainstem stroke had the

highest mean rank followed by the patients with right subcortical and cortical stroke,

the patients with left subcortical and cortical stroke, and the normal controls. On the

Interpersonal Sensitivity subscale, the highest mean rank to the lowest was the

patients with brainstem stroke, with left subcortical stroke, with right subcortical

brainstem stroke had the highest mean rank on the Depression subscale, followed by

the patients with right and left subcortical stroke, with right cortical stroke, the normal

controls, and left cortical stroke. On the Anxiety subscale, the patients with brainstem

stroke had the highest mean rank followed by the patients with right cortical stroke,

with right and left subcortical stroke, the normal controls, and with left cortical stroke.

The highest mean rank on the Hostility subscale was the patients with brainstem

stroke, followed by the patients with left and right subcortical stroke, the normal

controls, and the patients with right and left cortical stroke. On the Phobia subscale,

the highest mean rank to the lowest was the patients with brainstem stroke, with right

cortical stroke, with left and right subcortical stroke, the normal controls, and the

patients with left cortical stroke. The highest mean rank to the lowest on the Paranoid

Ideation subscale was the patients with right cortical stroke followed by the patients

with brainstem stroke, the normal controls, the patients with left and right subcoritcal

stroke, and with left cortical stroke. On the psychoticism subcalse, the highest mean

rank score was the patients with brainstem stroke, followed by the patients with right

cortical stroke, with left subcortical stroke, the normal controls, the patients with right

subcortical stroke, and the patients with left cortical stroke. The differences of the

mean rank over these subcales, however, only involved Somatization (Chi

Global (Chi square=12.15, df =5, p<.04) reached a statistically significant level. No

significant differences were found when Nemenyi’s post-hoc pairwise contrasts with

Bonferroni corrections for controlling Type I error were subsequently performed.

The highest mean rank to the lowest of the significant informants of the

participants on the BDI was the patients with brainstem stroke, followed by the

patients with left and right subcortical stroke, the patients with right and left cortical

stroke, and the normal controls. The mean rank differences, analyzed by

Kruskall-Wallis one-way ANOVA revealed, did reach a statistical significant level (Chi

square=3.74, df=5, p<.007). Nemenyi’s post-hoc pairwise comparisons with

Bonferroni corrections for controlling Type I error were subsequently performed.

However, none reached a statistically significant level.

The rating of the significant informants of the participants on the subscales of the

SCL-90-R was as followed. On the Somatization subscale, the patients with brainstem

stroke had the highest mean rank, followed by the patients with left subcortical stroke,

with right cortical and subcortical stroke, the normal controls, and the patients with

left cortical stroke. The highest mean rank to the lowest on the Obsessive-Compulsive

subscale was the patients with brainstem stroke, followed by the patients with right

subcortical and cortical stroke, with right coritcal and subcortical stroke, with left

Sensitivity subscale, the patients with brainstem stroke had the highest mean rank,

followed by the patients with left subcortical stroke, with right cortical and subcortical

stroke, the normal controls, and the patients with left cortical stroke. The highest

mean rank to the lowest on the Depression subscale was the patients with the patients

with brainstem, followed by the patients with right subcortical and cortical stroke,

with left subcortical and cortical stroke, and the normal controls. On the Anxiety

subscale, the patients with brainstem stroke had the highest mean rank, followed by

the patients with right subcortical stroke, with left cortical stroke, with right cortical

and left subcortical stroke, and the normal controls. On the Hostility subscale, the

patients with brainstem stroke had the highest mean rank, followed by the patients

with right subcortical and cortical stroke, with left subcortical stroke, the normal

controls, and the patients with left cortical stroke. The highest mean rank to the lowest

on the Phobia subcale was the patients with right subcortical and cortical stroke, with

left subcortical stroke, the normal controls, and the patients with left cortical stroke.

On the Paranoid Ideation subscale, the patients with brainstem stroke had the highest

mean rank, followed by the patients with right cortical and left subcortical stroke,

with right subcortical stroke, the normal controls, and the patients with left cortical

stroke. The highest mean rank on the Psychoticism subscale was the patients with

with left subcortical stroke, the normal controls, and the patients with left cortical

stroke.

The data analysis by Kruskall-Wallis one-way ANOVA revealed that the mean

rank differences of Somatization (Chi square= 11.28, df=5, p<.05),

Obsessive-Compulsive (Chi square=12.04, df=5, p<.04), Depression (Chi square=11.80, df=5,

p<.04), Anxiety (Chi square=11.24, df=5, p<.05), and Psychoticism (Chi

square=12.13, df=5, p<.04) subscales among these subject groups reached a

statistically significant level. Subsequent Nemenyi’s post-hoc pairwise contrasts

with Bonferroni corrections for controlling Type I error, however, did not reach a

statistically significant level.

In order to determine whether or not the ratings of the participants and their

significant informants on the BDI and SCL-90-R were different. On the BDI, the

discrepant score between the participant and his/her significant informant for each

subject group was calculated, and then a match-paired t test was used to analyze the

data. The result revealed that the differences did not reach a statistically significant

level. Likewise, for each subject group the ranking differences between the

participant and his/her significant informant on each of the subscales of the SCL-90-R

were not statistically significant.

Is there an impairment of emotional status in the patients with brainstem stroke?

Because of the high dropout of the patients, our results based on the limited data did

not revealed that the patients with brainstem stroke had remarkably emotional

impairments compared with their normal counterparts. For the time being the answer

for our first question, thus, seems to be negative. Meanwhile, our preliminary results

also appear to further support Starkstein and his co-workers’ findings (1988) in which

they noted the patients with brainstem stroke having a significant low frequency of

emotional changes. However, our results also revealed some degree of subtle to mild

emotional changes in these patients with brainstem stroke. The definite conclusion,

thus, awaits the second-year investigation.

If so, does the deficit only involve depression, as Starkstein and his colleagues’

observation (1988), or also include otherwise emotional function tested? Accordingly,

the definite answer for the first question is pending. Thus, it appears to be

appropriate to make some comments on this issue. Our patients with brainstem

stroke not only had mild depression, but also had other emotional changes. These

otherwise emotional problems consisted of somtization, obsessive-compulsive

symptoms, anxiety, hostility, paranoid ideation, and psychoticism.

Most of the literature showed that depression was major emotional changes

1990). Our findings based on the patients with either the left or right cerebral

hemispheric stroke, however, were not consistent with these earlier observations.

Instead, somatization was mainly evident in our patients with right cerebral

hemispheric stroke. In addition, obsessive-compulsive symptom and anxiety were

also evident in the patients with right cerebral hemispheric stroke. These results

seemed to be consistent with the researchers’ observations (e.g., House et al., 1991;

Morris et al., 1993; Robinson & Starkstein, 1997).

Depression has often been seen in the patients with lesions of the subcortical

regions, particularly the areas of left basal ganglia (Starkstein Robinson, Berthier &

Price, 1988). Generally, our results were compatible with these observations.

Nevertheless, we did not note our patients having any remarkably asymmetric

manifestation between the two subcortical hemispheric strokes in terms of this

specific aspect of emotional changes. Robinson and Starkstein (1997), and Starkstein

and his co-workers (1993) reported that the patients with lesions involving the

posterior limb of the internal capsule were often evident of anxiety. We did also

notice our patients with the subcortical stroke having the symptom of anxiety.

However, the lesion area in our patients not only involved the subcortical white

matters, but also the adjacent subcortical gray regions. The findings of mania, bipolar

in the patients with subcortical lesions (e.g., Robinson et al., 1988; Starkstein et al.,

1991; Starkstein, Robinson, & Berthier, 1992; Trimble & Cummings, 1981; Starkstein

et al., 1993). We have not yet observed these emotional changes in our patients with

the subcortical stroke. However, the manifestation of somatization and

obsessive-compulsive symptom was also evident in our patients.

The dysfunction of the biogenic amine system has been hypothesized to be one of

the mechanisms that may play an essential role in the cause of depression (Beatty,

1995; Conn, 1995). Since both noradrenergic and serotonergic cell bodies are located

in the locus coeruleus and raphe nucleus of the brainstem, depressive symptoms

should be evident in the patients with brainstem stroke involving the rostral pons and

caudal mesencephalon which are sites for these two nuclei. In fact, depression was

the cardinal psychopathological symptom in our patients with brainstem stroke.

Accordingly, our results seemed to be accordance with the hypothesis of the

dysfunction of the biogenic amine system. In addition, somatization,

obsessive-compulsive symptoms, and anxiety were also evident in these patients.

In line with this hypothesis and on the basis of neuroanatomical evidences and

clinical findings, Robinson and his co-workers (1984) also claimed that poststroke

depression might be as a result of depletion of norepinephrine and/or serotonin due to

evident in the patients with subcortical stroke seemed to substantiate these

researchers’ proposition.

In summary, our preliminary results seemed to implicate that a slight to mild

impairment of emotional status was evident in the patients with brainstem stroke, and

depression was the cardinal psychopathological symptom though these were not on

the statistical basis. In addition, otherwise slightly to mildly emotional changes

including somatization, obsessive-compulsive symptom, and anxiety were also

noticed in these patients. Since the available data were limited, the proposed questions

require further investigation.

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Table 1. Demograpnic Characteristics of Subject Groups

Sex Age Edu TO OPIP ON AC

F : M Mean SD Range Mean SD Range Mean SD Range Mean SD Range Mean SD Range Mean SD Range Brain stem stroke 6 6 62.08 9.57 42~77 3.75 4.88 0~12 1.08 1.62 0~5 11.50 1.24 8~12 15.58 1.44 11~16 14.83 3.74 8~18

R cortical 5 3 55.63 11.93 40~65 6.88 3.83 0~12 1.25 1.28 0~3 10.25 2.25 6~12 15.75 0.71 14~16 14.75 3.11 10~18 R subcortical 4 5 70.11 5.86 61~80 4.67 5.72 0~14 1.56 1.67 0~4 10.56 1.24 9~12 15.44 1.13 13~16 15.44 3.81 6~18

L cortical 0 3 68.67 15.63 52~83 6 6 0~12 2 2 0~4 6.67 6.11 0~12 16 0 16 12.33 6.03 6~18 L subcortical 2 3 67.60 6.19 61~76 2 2.83 0~6 2.40 1.95 0~5 11 0.71 10~12 15.60 0.89 14~16 14.20 3.11 11~18

健診 7 11 68.78 5.95 60~82 4.33 4.24 0~15 0.22 0.55 0~2 12 0 12 16 0 16 18 0 18

Table 2. Performance Scores of the BDI

P F

BDI

Brain stem stroke 16.30 16.1 1~45 11.8 11.4 0~43 R cortical 5.75 5.65 1~16 6.29 2.50 4~11 R subcortical 7.33 7.62 1~24 7.67 6.58 1~21 L cortical 2.33 2.08 0~4 2.67 2.52 0~5 L subcortical 9.80 6.98 1~20 7.00 7.04 2~19

Table 3. Patient’s and Patient’s Significant Informant’s Rating Scores on the SCL-90-R

Brain stem stroke R cortical R subcortical L cortical L subcortical 健診

SCL _{P F P F P F P F P F P F} Mean 0.94 0.87 0.65 0.49 0.56 0.41 0.23 0.37 0.90 0.86 0.42 0.37 SD 0.68 0.64 0.27 0.25 0.44 0.26 0.12 0.31 0.32 0.56 0.52 0.46 Somatization Range 0.2~2.8 0.3~2.3 0.3~1.1 0.1~0.8 0.1~1.3 0~0.8 0.1~0.3 0.1~0.7 0.6~1.4 0.3~1.8 0~2.1 0~1.9 Mean 0.66 0.54 0.44 0.45 0.59 0.46 0.27 0.43 0.40 0.48 0.21 0.16 SD 0.63 0.49 0.36 0.27 0.56 0.51 0.25 0.23 0.29 0.51 0.32 0.26 Obsessive-Compulsive Range 0.1~2 0~1.3 0.1~1.1 0.2~0.9 0~1.6 0~1.5 0~0.5 0.3~0.7 0~0.7 0~1.3 0~1.1 0~1 Mean 0.33 0.23 0.10 0.09 0.07 0.13 0 0.07 0.12 0.36 0.06 0.05 SD 0.66 0.26 0.24 0.10 0.11 0.21 0 0.12 0.08 0.48 0.19 0.11 Interpersonal Sensitivity Range 0~2 0~0.6 0~0.7 0~0.3 0~0.3 0~0.6 0 0~0.2 0~0.2 0~1.2 0~0.8 0~0.4 Mean 0.70 0.60 0.41 0.26 0.52 0.54 0.13 0.13 0.48 0.58 0.18 0.12 SD 0.93 0.52 0.59 0.15 0.63 0.54 0.06 0.06 0.58 0.73 0.26 0.24 Depression Range 0.1~2.9 0~1.5 0~1.8 0~0.5 0~1.9 0~1.6 0.1~0.2 0.1~0.2 0~1.4 0~1.8 0~0.8 0~1 Mean 0.58 0.53 0.39 0.16 0.29 0.23 0.03 0.17 0.28 0.32 0.16 0.12 SD 0.95 0.51 0.74 0.17 0.45 0.28 0.06 0.06 0.48 0.45 0.21 0.20 Anxiety Range 0~3 0~1.5 0~2.2 0~0.5 0~1.3 0~0.9 0~0.1 0.1~0.2 0~1.1 0~1.1 0~0.6 0~0.7 Mean 0.33 0.50 0.10 0.28 0.16 0.34 0.07 0.10 0.28 0.54 0.15 0.17 SD 0.36 0.43 0.19 0.24 0.15 0.44 0.12 0.17 0.31 0.68 0.27 0.25 Hostility Range 0~1 0~1.2 0~0.5 0~0.7 0~0.3 0~1.3 0~0.2 0~0.3 0~0.7 0~1.5 0~1 0~0.7 Mean 0.38 0.18 0.24 0.11 0.17 0.27 0 0 0.22 0.18 0.01 0.02 SD 0.86 0.29 0.56 0.20 0.36 0.45 0 0 0.44 0.40 0.03 0.07 Phobic Anxiety Range 0~2.7 0~0.9 0~1.6 0~0.6 0~1.1 0~1.3 0 0 0~1 0~0.9 0~0.1 0~0.3 Mean 0.19 0.28 0.21 0.25 0.02 0.19 0 0.17 0.04 0.42 0.06 0.05 SD 0.37 0.28 0.36 0.29 0.07 0.26 0 0.29 0.09 0.52 0.18 0.10 Parachnoid Ideation Range 0~1.3 0~0.8 0~1 0~0.7 0~0.2 0~0.7 0 0~0.5 0~0.2 0~1.2 0~0.7 0~0.3 Mean 0.33 0.23 0.04 0.08 0.01 0.21 0 0 0.04 0.24 0.02 0.03 SD 0.53 0.26 0.07 0.09 0.03 0.31 0 0 0.05 0.38 0.04 0.08 Psychoticism Range 0~1.6 0~0.7 0~0.2 0~0.2 0~0.1 0~0.9 0 0 0~0.1 0~0.9 0~0.1 0~0.3 Mean 0.55 0.47 0.34 0.25 0.30 0.32 0.10 0.20 0.38 0.46 0.15 0.13 SD 0.64 0.37 0.33 0.11 0.28 0.32 0.10 0.10 0.30 0.48 0.21 0.20 Global Severity Index

Range 0.1~1.9 0.1~1.1 0.1~1.1 0.1~0.4 0~0.9 0~1 0~0.2 0.1~0.3 0.2~0.9 0.1~1.3 0~0.7 0~0.8 Mean 1.65 1.47 1.56 1.19 1.71 1.70 1.10 1.30 1.72 1.58 1.38 1.39 SD 0.50 0.27 0.40 0.20 0.34 0.90 0.10 0.44 0.31 0.33 0.37 0.46 Positive Symptom Distress Index Range 1.1~2.7 1~1.8 1.2~2.4 1~1.6 1.3~2.2 1.1~4 1~1.2 1~1.8 1.4~2.1 1.2~1.9 1~2.2 1~2.2 Mean 25.91 28.25 17.60 19.40 14.90 19.20 9.33 13.00 18.60 24.60 9.12 8.61 SD 21.82 18.86 12.06 7.65 11.60 16.40 6.03 5.00 12.28 22.88 9.27 11.4 Total