Schizophrenia Research 52 (2001) 215229

www.elsevier.com/locate/schres

Integrating psychopathological dimensions in functional

psychoses: a hierarchical approach
M.J. Cuesta*, V. Peralta
Psychiatric Unit I of the Virgen del Camino Hospital, Irunlarrea 4, 31008 Pamplona, Spain
Received 17 July 2000; revised 28 November 2000; accepted 7 December 2000

Abstract
Previous factor analysis studies of psychotic symptomatology have demonstrated three psychopathological dimensions:
positive, negative and disorganization. However, few studies have analyzed non-schizophrenic samples and most use a
syndrome-level of analysis or only schizophrenic symptom scales. This study examined how many dimensions underlie
psychosis, and whether within psychosis there is a hierarchical organization of dimensions.
A total of 660 inpatients with an acute psychotic episode were studied. Psychopathology was measured through a wide
psychopathological assessment using the Manual for the Assessment and Documentation of Psychopathology (AMDP-system).
Principal component factor analysis was carried out on 64 psychopathological symptoms scoring 1 or higher in at least 10%
of the sample. A 15-factor solution was obtained which failed to depict a psychosis model on clinical and methodological
grounds. Further predetermined factor analyses ranging from 1 to 15 factors were carried out to examine alternative factor
solutions. A 10-dimensional model was the best model on clinical, statistical and conceptual grounds. Moreover, the examination of the 1 to 10 dimensional models allowed us to infer a hierarchical model of psychopathological dimensions, which can be
represented in the frame of a tree-structure. The model permitted transitions between psychiatric categories and psychopathological dimensions, and it was able to integrate previous factor solutions with different numbers of resulting dimensions.
The ndings have implications for the design of future studies and for the hierarchical conceptualization of psychopathological dimensions. q 2001 Elsevier Science B.V. All rights reserved.
Keywords: Psychosis; Schizophrenia; Psychopathological dimensions; Positive and negative symptoms; Positive and negative dimensions;
Hierarchy of dimensions; Assessment and documentation of psychopathology (AMDP)

1. Introduction
The great clinical variability within the same
patient across different episodes and between subjects
with the same diagnosis is the `core' problem in the
concept of schizophrenia. To date, it has not been
determined whether this phenomenological heterogeneity is related to the existence of discrete subtypes
with overlapping symptomatology (Tsuang et al.,
* Corresponding author. Fax: 134-948-429924.
E-mail address: mj.cuesta.zorita@cfnavarra.es (M.J. Cuesta).

1990; Carpenter et al., 1993; Buchanan and Carpenter,

1997) or whether schizophrenic disorders are extreme
manifestations of a continuum from normality (van
Os et al., 1999). In the absence of compelling
evidence to support categorical or dimensional
models of schizophrenia, the solution of the clinical
heterogeneity problem of schizophrenic disorders
over the last century have been focused on searching
for links between etiological, pathogenic, and
phenomenological levels (Tsuang et al., 1990; Weinberger, 1999). Moreover, many studies aiming to
disentangle the heterogeneity at all levels of the

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M.J. Cuesta, V. Peralta / Schizophrenia Research 52 (2001) 215229

etiological chain have been carried out. In this respect,

the investigation of psychopathological dimensions
seems to be one of the best approaches for dening
potential phenotypes of schizophrenia.
Psychopathological symptoms are not randomly
distributed in schizophrenic disorders and certain
groups or clusters of symptoms seem to be characteristic of the illness. This fact led to the development of
concept-driven classications of psychosis, such as
classic nosologies, and to a consensus among experts
to generate modern classications such as DSM-IV or
ICD-10. Both classic and current nosotaxias have
represented univariate approaches to the heterogeneity problem. They have remained overwhelmingly
descriptive and have to some extent hampered the
advance in research. More recently, multivariate
statistical methods have provided new approaches to
identify typologies of psychoses (Manton et al., 1994;
Kendler et al., 1998), and to investigate dimensional
models within psychoses (Sham et al., 1996; Serreti
et al., 1996). From the latter dimensional approach,
evidence has accumulated in support of the view that a
three-syndrome model, comprising psychotic or
reality distortion, negative and disorganization dimensions is the most feasible factor structure of schizophrenic symptomatology (Liddle, 1987). The same
symptomatology structure has been reported through
cluster analysis (Farmer et al., 1983; Morrison et al.,
1990), multidimensional scaling technique (Minas et
al., 1992), and complex statistical procedures based
upon correlational analysis (Lin et al., 1998). Moreover, two denitive statistical methods conrmatory factor analysis, which allows for verication of
exploratory factor structures (Peralta and Cuesta,
1994; Harvey et al., 1996), and meta-analysis
(Grube et al., 1998; Smith et al., 1998) have
given additional support to the three-syndrome
model. Finally, the longitudinal independence over
time of three-dimensional model (3D) has also been
demonstrated in most (Ardnt et al., 1991; Maziade
et al., 1995; van der Does et al., 1995) but not all
(Eaton et al., 1995) studies.
At least three limitations of the 3D model have been
reported. First, most studies included only schizophrenic patients, though psychiatric categories have not
yet been validated (van Os et al., 1996; McGorry
et al., 1998). Second, the level of analysis used is
denitive in the extraction of psychopathological

dimensions, since when global or subscale ratings

were used the 3D model was supported, but analysis
at symptom level produced more complex factor
structures (Minas et al., 1994; Peralta and Cuesta,
1998). Third, few studies use comprehensive psychopathological instruments that cover the whole range of
symptoms; studies based, for instance, on positive and
negative symptom scales are hindered by the selection
of items and their results are instrument-dependent.
These limitations suggest that the 3D model may be
an oversimplication of the psychosis phenotype,
which might limit its use in the search for putative
neurobiological disturbances in psychosis.
In the light of these shortcomings, we sought to
address two specic questions: (1) How many dimensions underlie psychotic symptomatology? (2) Are the
underlying dimensions hierarchically associated?

2. Subjects and methods

2.1. Sample selection and subject recruitment
The sample consisted of 660 consecutive patients
admitted between 1989 and 1996 to the Psychiatric
Unit of Virgen del Camino Hospital (Pamplona,
Spain). To be included in the study, subjects had to
present at least one psychotic symptom. Patients with
organic brain syndrome or severe drug abuse were
excluded. All patients gave informed consent after
all procedures had been fully explained, and the
research protocol was approved by the Ethical
Committee of our hospital.
The composition of the sample was 382 male (58%)
and 278 female (42%). Mean age was 36 years SD
14:0; mean age at onset 26.9 years SD 10:6;
mean number of hospitalizations 3.4 SD 4:3;
and mean years of education nine years SD
10:1: Patients were assessed using a semi-structured
interview, specically designed for the schizophrenic
disorder (Landmark, 1982) and partially modied by
both researchers. Although diagnosis was made by
several criteria, only diagnoses using the Diagnostic
and Statistical Manual of Mental Disorders, Third
Edition, Revised (DSM-IIIR) are reported here.
DSM-IIIR diagnosis was established by consensus
between the two authors, using all available sources
of information (hospital records, interview with

M.J. Cuesta, V. Peralta / Schizophrenia Research 52 (2001) 215229

informants, the patient, nurses and social workers).

Sample diagnoses were as follows: 352 schizophrenia
(53%); 88 schizophreniform disorder (13%); 37 schizoaffective disorder (6%); 83 mood disorder (13%);
25 delusional disorder (4%); 25 brief reactive psychosis (4%); and 50 atypical psychosis (8%). At the time
of assessments, patients were receiving the medication prescribed by their attending psychiatrists.
Premorbid adjustment was assessed by means of the
abbreviated form of the Phillips Rating Scale (Harris,
1975), and the StraussCarpenter scale (Strauss and
Carpenter, 1972) was used to measure of severity of
illness.
2.2. Psychiatric measures
Psychopathological status was assessed with the
Manual for the Assessment and Documentation of
Psychopathology (AMDP). The AMDP system is a
psychopathological inventory based upon denitions
of classical psychopathology (Scharfetter, 1983). It
includes operationalized denitions for 100 psychiatric symptoms, and is used in European psychiatric
institutions for purposes of documentation and
research. The presence and severity of symptoms
are scored from 0 (absence) to 3 (severe) (Guy and
Ban, 1982). Validations in different languages were
available, including English (Guy and Ban, 1982) and
Spanish (Lopez Ibor, 1980).
The rationale for using the AMDP was twofold:
rst, to use an exhaustive inventory of psychiatric
symptoms that is not restricted to psychotic symptoms; second, to use an instrument conceptually independent of scales based upon positive and negative
symptomatology, in order to avoid bias of symptom
selection derived from any aprioristic criteria. The
AMDP was administered in the context of the clinical
interview, by compiling information in the rst ve
days after admission regarding the most prominent
symptomatology of the last month. The reliability
and validity of the semistructured interview and the
AMDP were not tested explicitly in this study, though
good to excellent psychometric properties have been
reported elsewhere (Pietzcker et al., 1983). The
formal interrater reliability assessment was substituted in our study by periodical consensus meetings
between evaluators throughout the study, at both
psychopathological and diagnostic levels.

217

2.3. Statistical analysis

In keeping with the goals of the study, AMDP
symptoms were inspected and selected for their base
rate frequencies, since symptoms with very low
prevalence might produce artifacts. Sixty-four out of
100 AMDP symptoms scoring 1 or higher in at least
10% of patients were included. This selection also
contributed indirectly to achieving the right balance
between the number of variables and cases for the
performance of factor analysis, as factor analysis
requires a minimum of 10 subjects per variable
(Gorsuch, 1974). In our case we included 660 patients
for 64 variables.
Symptom interrelationships were studied through
factor analysis by the principal component method,
and an oblique rotation which assumes the existence
of interdependence among clinical dimensions was
chosen. Kaiser's criterion (eigenvalue greater than
unity) to obtain the factors and a Scree plot was also
inspected. Item loading with absolute values greater
than 0.40 was used to describe the factors.
A second set of analysis was carried out in order to
ascertain the best possible factor solution on clinical
and conceptual grounds. Specically we wanted to
nd parsimonious solutions in order to avoid noninterpretable factors, and to identify all clinically relevant underlying dimensions. To this end, and for the
purposes of exploration (Hair et al., 1992), we undertook predetermined factor solutions ranging from 1 to
15 dimensions, since 15 dimensions were obtained
using the Kaiser method (see below). External validation of the nal factor solution was undertaken by
means of Pearson correlation coefcients between
factor scores and relevant demographic and clinical
variables. The reliability of the nal factor structure
for each psychopathological dimension was evaluated
through estimations of internal consistency (Cronbach, 1951).

3. Results
3.1. Psychopathological dimensions
Factor analysis of 64 AMDP symptoms resulted
in 15 factors with eigenvalue greater than unity,
accounting for 63.1% of the total variance. This factor

218

M.J. Cuesta, V. Peralta / Schizophrenia Research 52 (2001) 215229

Fig. 1. Scree plot of AMDP factors.

solution produced a high number of dimensions and

presented two major shortcomings. First, there
was a duplication of four dimensions (delusional,
hallucinatory, dysphoria and psychomotor poverty
dimensions), and other dimensions, such as derealizationdepersonalization, are not recognized as independent dimensions on clinical and conceptual
grounds. Moreover, an inspection of the Scree plot
did not display a clear factor solution, because there
were several possible break points of the curve
(Fig. 1).
To solve this discrepancy in the number of factors,
we analyzed predetermined factor solutions, from 1 to
15 factors, on psychometric and conceptual grounds.
We established four general criteria in order to obtain
the best factor solution: clinical interpretability of
dimensions, parsimony, independence among dimensions, and adequate representation of dimensions by
symptoms. In the ideal factor solution, all dimensions
are clinically interpretable; the solution should
comprise the least number of dimensions with the
greatest explained variance, it should have few significant correlation coefcients among dimensions, and
it should contain enough component symptoms on
each dimension, providing as much representation of
the underlying construct as possible.
As can be seen in Table 1, in factor solutions
comprising 10 or fewer factors all dimensions were
clinically interpretable; we therefore disregarded
solutions with a higher number of factors. From solutions with 10 factors or fewer, both the 9th and 10th
solutions achieved better statistical parameters on
number of items loading in only one factor (both
53), number of factors with substantial loading symp-

toms, and in number of signicant intercorrelations

between factors. Although the 9th factor solution
was more parsimonious, the 10th factor solution had
the best involvement of symptoms in all factors, and it
accounted for the largest percentage of explained
variance.
The rst dimension in the 10-dimensional (10D)
model (Table 2) was a `pure' paranoid dimension
with heavy loadings in items regarding delusions
and suspiciousness, except the other delusions
item, which comprised religious and other infrequent
delusions. It was a relatively pure dimension since no
items concerning other symptoms or dimensions
showed great weightings. The mania dimension
emerged as second factor, comprising euphoria,
excessive social contact, exaggerated self-condence,
increased drive, pressured thinking and delusions of
grandeur. The third dimension was dened by
perplexity, blocking, derealization, concentration
and retarded thinking and was named the negative
catatonia dimension. The depression dimension
included depressed mood, hopelessness, feelings of
inadequacy, loss of vitality, feelings of loss and suicidal tendencies. The fth dimension was the dysphoria
dimension, which was characterized by irritability,
aggressiveness, dysphoria and refusal of treatment.
This dimension shared high loading on suspiciousness
with the paranoid dimension, and on the dysphoria
item with the depressive dimension. Disorganization
dimension appeared as the sixth dimension and was
made up of incoherence, ight of ideas, rumiation,
circumstantial thinking and parathymia. The seventh
dimension reected `schneiderian' symptoms, since
it included broadcasting, insertion or withdrawal of

Number
of factor
solutions

Number of
non-clinically
interpretable
factors

Eigenvalue

Percentage
of variance
explained

Number of
items with
Communality
$0.40

Number of
factors with
#5 high
loading
symptoms

Number of
items loading
(.0.40) on only
one factor

Number of
items loading
(,0.40) on
any factor

Number of
items loading
(.0.40) on more
than one factor

Number of
signicant
correlations
between factors

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

0
0
0
0
0
0
0
0
0
0
1
2
3
3
4

7.59
5.69
4.80
4.06
3.06
2.48
2.04
1.73
1.56
1.51
1.40
1.19
1.16
1.04
1.00

11.9
20.8
28.3
34.6
39.4
43.3
46.5
49.2
51.6
54
56.2
58
59.9
61.5
63.1

0
2
10
25
32
35
43
45
50
54
56
60
64
64
64

0
0
0
0
0
0
0
1
1
1
3
4
6
5
9

20
36
42
49
52
49
52
49
53
53
55
52
50
45
51

44
28
18
12
7
5
4
4
4
2
1
0
5
6
2

0
4
3
5
10
8
12
7
9
8
12
9
13
11

0
0
1
0
1
4
5
6
6
9
11
11
11
16

M.J. Cuesta, V. Peralta / Schizophrenia Research 52 (2001) 215229

Table 1
Statistical parameters of 1 to 10 factor solutions of psychopathological symptoms

219

Prevalence
%

21.2
51.2
22.6
31.8
34.5
22.3
17.4
17.3
38.6
15.2
20.5
43.1
63.8
61.1
29.8
54.8
91.5
69.1
80
57.3
70
19.2
36.2
55.9
23.3
17.7
24.5
21.2
25.2
33
13.3
33.3
30
24.4
11.6
44.5
11.6
26.5

Depression Dysphoria Disorganization

factor
factor
factor

0.53
0.52

20.43

Psychomotor
poverty
factor

0.79
0.49

20.65
20.74
20.49

0.57
0.56

0.45

0.60

20.77

0.50
0.51
0.43
0.36
0.59

0.57
0.49

0.68

Insight
factor

0.54

20.57

0.73

0.56
0.57
0.44
0.59
0.78
0.66
0.81
0.63
0.77

Schneiderian
factor

0.40
0.75
0.65
0.78
0.74
0.64
0.76
0.81

0.81

Positive
catatonic
factor
20.60
20.42
M.J. Cuesta, V. Peralta / Schizophrenia Research 52 (2001) 215229

Symptoms
Apperception
Concentration
Retarded thinking
Circumstantial
Restricted thinking
Perseveration
Rumination
Pressured thinking
Flight of ideas
Tangential
Blocking
Incoherence
Suspiciousness
Delusional mood
Delusional perception
Sudden delusional ideas
Delusional ideas
Systematized delusions
Delusional dynamics
Delusions of reference
Delusions of persecution
Delusions of grandeur
Other delusions
Verbal hallucinations
Other auditory hallucinations
Visual hallucinations a
Bodily hallucinations
Derealization
Depersonalization
Thought broadcasting
Thought withdrawal
Thought insertion
Other feelings of alien inuence
Perplexity
Feeling of loss feeling
Blunted affect
Loss of vitality
Depressed mood

Paranoid Mania Negative

factor
factor catatonic
factor

220

Table 2
Factor loadings and Factor pattern correlation matrix of 10D model of psychopathological symptoms

Table 2 (continued)
Prevalence
%

Factor inter-correlations

1
1.00
20.01
0.02
20.09
0.11
0.14
0.25
0.02
20.24
20.06

0.78

0.74

Psychomotor
poverty
factor

Positive
catatonic
factor
20.31

0.56
0.74
0.43

20.58
20.47
20.46

0.75
0.63

0.52

0.73

0.40

20.56
20.49

0.47
0.53
0.64

0.72
0.74
0.73
0.41

0.49
11.8
0.85

Insight
factor

0.82
0.36

0.82

0.59
20.51
0.77

Schneiderian
factor

8.9
0.85

7.5
0.70

6.3
0.84

4.8
0.75

3.9
0.75

3.2
0.80

2.7
0.80

1.00
20.00
20.08
0.05
20.09
20.02
0.07
20.16
20.07

1.00
0.11
20.08
20.05
0.08
20.03
0.09
20.16

1.00
20.16
0.10
20.10
20.09
0.08
20.01

1.00
20.10
20.04
0.00
20.07
20.03

1.00
0.02
0.06
20.07
0.12

1.00
20.07
20.09
20.04

1.00
0.05
20.01

1.00
20.06

Only item loadings .40 are shown, except for visual hallucinations and anxiety, which had only inferior loadings.

0.44
2.4
0.81
10

1.00

2.4
0.67

221

1. Paranoid
2. Mania
3. Negative catatonia
4. Depression
5. Dysphoria
6. Disorganization
7. Scheneiderian
8. Insight
9. Psychomotor poverty
10. Positive catatonia

20.5
39.8
16.2
33.3
53
48.3
10
13.2
33.5
32.6
37.3
34.1
11.8
15.8
39.4
12.1
14.4
11.2
74.7
11.8
33.3
21.5
79.4
83.9
56.2
10

Depression Dysphoria Disorganization

factor
factor
factor

M.J. Cuesta, V. Peralta / Schizophrenia Research 52 (2001) 215229

Hopelessness
Anxiety a
Euphoria
Dysphoria
Irritability
Inner restlessness
Feelings of inadequacy
Exaggerated self-condence
Ambivalence
Parathymia
Affective rigidity
Lack of drive
Inhibition of drive
Increased drive
Motor restlessness
Parakinesis
Mutism
Logorrhea
Reduced social contact
Excessive social contact
Aggressiveness
Suicidal tendencies
Lack of feeling of illness
Lack of insight
Refusal of treatment
Lack of self-care
% Variance accounted for
Reliability (a )

Paranoid Mania Negative

factor
factor catatonic
factor

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M.J. Cuesta, V. Peralta / Schizophrenia Research 52 (2001) 215229

Table 3
Pearson correlation coefcients between psychopathological dimensions of the 10D model and sociodemographic, premorbid and outcome
variables r 0:12 or higher p , 0:001
Sociodemographic, premorbid and outcome variables
Gender
Paranoid
Mania
Negative catatonia
Depression
Dysphoria
Disorganization a
Schneiderian
Insight
Psychomotor poverty
Positive catatonia a
a

Single
0.12

20.13

Number of admissions
0.20

0.13

20.15

0.13

Age at onset

Education

Strauss/Carpenter scale

0.15

0.12
0.28
0.24

20.22
0.12

20.13

0.14

20.19

20.50

Phillips social
20.25

0.33

Disorganization and Positive catatonia factors were composed of negative loadings.

thoughts, other feelings of alien inuence and

auditory and bodily hallucinations. The insight
dimension was the eighth dimension and comprised
unawareness of symptoms or unawareness of illness
and refusal to treatment items, without high loading of
symptoms corresponding to other dimensions. Nonetheless, the refusal of treatment item also had a high
loading on the dysphoria dimension. Finally, the ninth
and tenth dimensions corresponded to the psychomotor poverty and positive catatonia dimensions. The
psychomotor poverty dimension was identied by a
prole of negative or decit symptoms including
blunted affect, restricted thinking, affective rigidity,
lack of drive, retarded thinking and reduced social
contact. And the positive catatonia dimension
comprised inner or motor restlessness and parakinesis,
and high loading on two cognitive symptoms, such as
decit in apperception and concentration. Two out
of the 10 dimensions were composed of negative
loadings (disorganization and positive catatonia).
Good to excellent internal consistency indexes
(Cronbach's a ) of the 10 dimensions were obtained
(Table 2).
Six signicant correlation coefcients among the
10 dimensions were found, after applying a conservative statistical approach to avoid type I error (Bonferroni correction for a 10 10 matrix was r 0:14,
p , 0:001; (Table 2). The paranoid dimension
showed a positive signicant association with schneiderian dimension and with the disorganization dimen-

sion, but an inverse signicant association with the

psychomotor poverty dimension. Inverse signicant
associations were found between mania and psychomotor poverty dimensions, between depression and
dysphoria, and between the two catatonia dimensions
(Table 2).
Correlations between the 10 psychopathological
dimensions and external variables are shown in
Table 3. Male sex was only signicantly associated
with the dysphoria dimension. Single status was associated with higher scores on the psychomotor poverty
dimension and inversely with mania and depression
dimensions. Number of admissions showed signicant associations with both mania and psychomotor
poverty dimensions. Early onset of illness was associated with greater disturbance in dysphoria, and a
later age of onset with higher insight into illness and
higher paranoid and disorganization dimensions
(Table 3). Education was only inversely and signicantly linked with the psychomotor poverty dimension. Decit on social premorbid adjustment was
associated with higher scores on the psychomotor
poverty dimension but with lower scores on the
mania dimension. Better outcome measures, as
measured by the StraussCarpenter scale, were associated with the mania, negative catatonia and paranoid
dimensions. In contrast, the psychomotor poverty
dimension and dysphoria dimensions were associated
with poorer indexes of psychosocial functioning
(Table 3).

223

Fig. 2. 10D Hierarchical model.

M.J. Cuesta, V. Peralta / Schizophrenia Research 52 (2001) 215229

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M.J. Cuesta, V. Peralta / Schizophrenia Research 52 (2001) 215229

3.2. Hierarchy of psychopathological dimensions

Inspection of the structure matrices of the predetermined 1 to 10-factor solutions allowed for inferences
about whether dimensions were hierarchically associated or not. Fig. 2 shows the descending structure
of dimensions of consecutive models from 1 to 10
dimensions. No factor solutions with higher number
of dimensions were analyzed, so as to avoid the
presence of non-clinical interpretable dimensions.
The most remarkable nding of this structure was
the stability of truncal dependence on their original
branches of descending psychopathological dimensions (10D model). There were two truncal
dimensions: the manic-depressive dimension, and a
large non-affective dimension, made up of paranoid,
hallucinatory, disorganization and psychomotor
poverty dimensions. These two truncal dimensions
arborized into respective branches from which leaves
appeared. From the manic-depressive dimension two
separate dimensions for mania and depression
emerged; from the depression dimension a positive
catatonia dimension arose, followed by a dysphoria
dimension, and nally the insight dimension was
derived from the dysphoria dimension. The non-affective truncal dimension separated the paranoid-hallucinatory dimension from the psychomotor poverty
dimension at the rst step. The former was divided
into a purely paranoid dimension and a schneiderian
dimension at the seventh step. Finally, the psychomotor poverty branch generated a disorganization dimension at step 6, and produced the negative catatonia
dimension at step 9.

4. Comment
4.1. Psychopathological dimensions
In the present study the 10D model was the best
tting model of psychopathological symptoms of
psychosis, on conceptual, clinical and statistical
grounds. This 10D model reected the whole range
of psychotic symptomatology with the exception of
low prevalence symptoms. Dimensions were by order
of extraction: paranoid, manic, negative catatonia,
depressive, dysphoria, disorganization, schneiderian,
insight, psychomotor poverty and positive catatonia

dimensions. Dimensions were adequately represented

in number of symptoms and in item loading and
presented good to excellent internal consistency. In
addition, the 10D model achieved good external validation regarding epidemiological, premorbid adjustment and outcome variables, since only the
Schneiderian dimension did not show signicant relationships with external variables. This nding added
support to our recent description of the lack of diagnostic signicance of the First-Rank symptoms
(Peralta and Cuesta, 1999). Alternative factor solutions with fewer dimensions were feasible but had
poorer psychometric properties and explained a
lower percentage of variance. In addition, the 10D
model was more parsimonious and had greater clinical and conceptual support than models with higher
numbers of factors. The present 10D model was also
in agreement with studies addressing the structure of
symptoms of psychotic patients carried out in the
years before the positive and negative scales (Lorr
et al., 1961; Wittenborn and Holzberg, 1950), and
with the results from validation studies of the
AMDP inventory (Pietzcker et al., 1983).
4.2. Number of psychopathological dimensions in
psychosis
There are great discrepancies in the reports of the
number of dimensions underlying psychosis, and a
wide variety of solutions have been described. There
is no denitive consensus about the number of dimensions underlying the psychosis construct and, until
denitive demonstration of their neurobiological
correlates, conceptual and psychometric basis should
be emphasized. As a rule, a balance should be sought
between the use of excessively parsimonious solutions and solutions comprising a high number of
dimensions. Excessive parsimony would reect a
restrictive, aprioristic selection of symptoms,
which may hamper associations with subtle, hypothetical neurobiological dysfunctions. For instance,
dimensions clearly relevant for behavior and hypothetically related to neurofunctional dysfunction, such as
the affective dimension or the two catatonia dimensions, are beyond the scope of the three-syndrome
model. Moreover, results from neuroimaging studies,
for instance, have demonstrated separate neurofunctional disturbances for delusions and hallucinations,

M.J. Cuesta, V. Peralta / Schizophrenia Research 52 (2001) 215229

the two group of symptoms that underlie the positive

or `reality distortion' dimension of the 3D model
(Sabri et al., 1997). In contrast, a large number of
dimensions would almost lead to a symptom-analysis
approach, neglecting the advantages of natural clustering or groupings of symptoms over the symptom
approach analysis (Mojtabai and Rieder, 1998).
4.3. Hierarchy of psychopathological dimensions
The structure of psychopathological dimensions
can be explained by an arborizational organization:
a tree-structure representing the trunk of all psychopathological phenomena within psychosis. The two
great truncal dimensions correspond to the classic
categorical and diagnostic approaches to functional
psychoses, since the rst truncal division showed the
classic distinction between the two great psychoses
described by Kraepelin (1919): affective psychoses
and schizophrenia. Truncal dimensions evolved
towards branches and leaves, which were expressed
as nal ramications. Pure dimensions, which are
not interpretable in categorical terms (i.e. they do not
have diagnostic value) were exhibited as nal ramications (Fig. 2). Taken together, the present tree-structure depicted a global psychopathological model of
symptoms of psychoses, which could integrate transitions from the category level to dimensional level, and
where symptoms were derived from dimensions.
Following the tree example, focusing on the study
of leaves (nal dimensions) would produce a negrained analysis of relationships between dimensions
of psychopathology and specic neurobiological
dysfunction. On the other hand, the analysis of
common or overlapping branches or the examination
of the arms and trunk of the tree would help in the
search for shared etiopathophysiological mechanisms
among psychopathological dimensions. Likewise, the
study of trunk or rst branches could enable us to
address psychiatric categories.
Our 10D model was in agreement with most significant psychopathological models since recent models
based upon positive and negative schizophrenic
symptomatology can be integrated within the frame
of our dimensional hierarchy. For instance, the paranoid-hallucinatory-psychomotor poverty arm was a
bipolar factor, resembling earlier descriptions of positive and negative symptomatology of schizophrenia

225

(Andreasen and Olsen, 1982). In the next step a

dichotomy produced two groupings of symptoms
(paranoid-hallucinatory and psychomotor poverty
dimensions) resembling Type I and Type II schizophrenia (Crow, 1980). The next step depicted a four
factor structure similar to Kay's pyramid model (Kay
and Sevy, 1990). In addition, a three-syndrome structure of psychotic symptomatology with a slight variation but with high resemblance to three syndrome
models reported in literature (Strauss et al., 1974;
Bilder et al., 1985; Liddle, 1987) arose at step 6
from the non-affective branch of psychotic symptomatology. Negative and disorganization dimensions
were clearly depicted as psychomotor poverty and
disorganization dimensions respectively. However,
the positive or `reality distortion' dimension was
divided in two related dimensions: a pure paranoid
dimension and a dimension made up of Schneiderian
First-Rank symptoms, which is in agreement with
studies reporting a partial independence of these
two domains (Gur et al., 1994; Peralta and Cuesta,
1999). Further steps in this tree-structure model of
psychopathology of psychosis produced subdimensions, which were validated by their clinical
relevance.
Pure three-syndrome models do not include affective dimensions, as these symptoms are not assessed
through Andreasen's positive and negative scales
(Andreasen, 1984a,b). But, whenever affective symptoms were added to SAPS and SANS scales (Lindenmayer et al., 1994; Arora et al., 1997; Salokangas,
1997), or when both psychotic and affective symptoms were pooled together (Kay and Sevy, 1990;
Harvey et al., 1996; Lindenmayer et al., 1994; van
der Does et al., 1995; van Os et al., 1996; Grube et
al., 1998) depressive and manic dimensions were
reported, as this study found. In addition to the
manic and depressive dimensions another affectivederived dimension appeared, the dysphoria
dimension. This dimension is often neglected in
psychopathological studies but it is widely believed
to exert considerable inuence on patients' behavior.
Controversial relationships with affective dimensions
have been reported. Dysphoria has been associated
with positive symptoms (Norman et al., 1998; Lysaker
et al., 1995), and with negative symptomatology
(Sommers, 1985), and in a recent study the two
aspects of dysphoria, depression and anxiety, were

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M.J. Cuesta, V. Peralta / Schizophrenia Research 52 (2001) 215229

associated with negative and positive symptomatology

respectively (Norman et al., 1998). In the present
study the dysphoria dimension was a relatively independent dimension since it was only signicantly but
inversely associated with the depressive dimension
r 20:16, p # 0:001:
An interesting nding in our 10D hierarchical model
was that the original truncal dependence of psychopathological dimensions remained stable across consecutive arborizations. That is, each nal dimension
originated from only one truncal dimension and no
interchange of dimensions between branches was
found. Another interesting nding of our nal structure
was that two signicantly correlated catatonia dimensions were identied: the positive catatonia dimension,
mostly made up of psychomotor agitation symptoms,
and the negative catatonia dimension, mainly composed
of psychomotor inhibition symptoms. The presence of
two catatonia dimensions has also been reported in
empirical studies (Abrams and Taylor, 1979; McKenna
et al., 1991; Peralta et al., 1999) and a catatonic bipolarity was also the characteristic hallmark of certain
subtypes of psychosis within Leonhard's nosology,
such as Motility Psychosis or Periodic Catatonia (Leonhard, 1957). Moreover, the two catatonia dimensions
were derived from opposite branches of psychotic
psychopathology since the negative catatonia dimension arose from affective dimensions and the positive
catatonia dimension emanated from non-affective
dimensions. Finally, the insight dimension was
extracted independently of the remaining psychopathological dimensions, as has been previously reported (van
Os et al., 1996; Cuesta et al., 1998).
There are no studies that address the structure of
dimensions' psychosis from a hierarchical point of
view; most studies have attempted to develop a hierarchy of symptoms for diagnostic purposes (Foulds
and Bedford, 1975). However, the attempts to validate
this symptom hierarchy have failed due to the
inuence of nosologic diagnosis (Sturt, 1981). In the
case of the present study, dimensions were chosen as
hierarchical matter, irrespective of diagnosis.
However, certain dimensions were very close to
classic types of psychosis, i.e. the mania, depression
and paranoid-hallucinatory dimensions, among
others, as reported in other studies (Serreti et al.,
1996). This overlap between dimensions and
categories added support to the view that the two

approaches are not exclusive but complementary,

and that both approaches may characterize potential
phenotypes of psychosis.
4.4. Conclusion
Two conclusions may be drawn from our data. (1)
The 10D model integrated nearly the whole range of
symptoms reported in acute psychotic episodes. This
model achieved good conceptual and clinical validity,
and had adequate internal consistency and good external validity. (2) The data also support arguments for a
hierarchical and dimensional system of psychopathological dimensions. This structure may be represented
within a tree-structure with a common trunk which
arborizes in two truncal dimensions, namely the affective and non-affective (paranoid-impoverishment)
dimensions. Further arborizations from these dimensions produced consecutive branches (intermediate
dimensions) and 10 nal dimensions (leaves). This
hierarchical model enabled us to integrate previous
conceptual models of psychopathological symptoms
in psychosis, synthesizing both categorical and
dimensional approaches within the same model, and
giving relevance to the non-positive and non-negative
schizophrenic dimensions in the realm of psychotic
symptomatology.
4.5. Implications for future research
At the very start of their research, investigators
should bear in mind the constraints of the dimensional
model selected, and it is highly recommendable that
they set a priori the level of study (i.e. n-dimensions).
If they are willing to deal with `basic' neurobiological
processes they should select a `ne-grained' or highorder level of dimensionality (i.e. between 5 and 10
dimensions). In contrast, if they seek to ascertain
shared neurobiological mechanisms underlying
psychotic domains, a `gross-grained' or low-order
level of dimensionality should be chosen (i.e. three
to ve dimensions).
4.6. Limitations
The present results should be understood in the
context of certain potentially signicant methodological limitations. First, assessment of psychopathological dimensions was cross-sectional and caution is

M.J. Cuesta, V. Peralta / Schizophrenia Research 52 (2001) 215229

warranted in the generalization of these results to

longitudinal hierarchy of dimensions of psychosis.
Second, our study was carried out in acute episodes of
a predominant chronic sample and generalization to
rst-episode or recent-onset psychosis has been criticized due to chronicity bias (McGorry et al., 1998).
These authors reported a more complex factor solution
in a large set ofrst-episode psychosis. However, a longitudinal analysis of symptom dimension on neurolepticnaive patients provided further support for the 3D model
(Ardnt et al., 1991). Third, symptom selection on the
basis of the low prevalence would hypothetically miss
psychopathological dimensions. However, one of the
strengths of the study was that we used an instrument
comprising the whole range of psychopathology, without any aprioristic selection, and included a high number
of symptoms n 64: Fourth, it has been reported that
the inclusion of patients in different phases of illness
(Mellers et al., 1996) and with different duration of
illness (Hori et al., 1999; Mojtabai, 1999) may introduce
bias in comparative studies. Our patients were in a similar phase (acute psychotic episode) but differed in duration of illness. Fifth, our study started from the
hypothesis that all symptoms scored equally, but it is
still not known whether they have different or equal
weight for neurobiological and diagnostic aims (van
Praag, 1997). Sixth, although AMDP inventory covers
all range of psychopathological phenomena it is not so
exhaustive in the assessment of certain dimensions (i.e.
motor or catatonic dimensions) than specic scales. And
nally, the present 10D model needs replication through
conrmatory factor analysis techniques, and prospective assessments in follow-up studies should be
conducted in order to avoid the bias of cross-sectional
assessments.
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