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. 2018 Dec 1;75(12):1271-1279.
doi: 10.1001/jamapsychiatry.2018.2475.

The Latent Structure of Negative Symptoms in Schizophrenia

Gregory P Strauss  1 , Alicia Nuñez  2 , Anthony O Ahmed  3 , Kimberly A Barchard  2 , Eric Granholm  4   5 , Brian Kirkpatrick  6 , James M Gold  7   8 , Daniel N Allen  2
Affiliations

The Latent Structure of Negative Symptoms in Schizophrenia

Gregory P Strauss et al. JAMA Psychiatry. .

Abstract

Importance: Negative symptoms are associated with a range of poor clinical outcomes, and currently available treatments generally do not produce a clinically meaningful response. Limited treatment progress may be owing in part to poor clarity regarding latent structure. Prior studies have inferred latent structure using exploratory factor analysis, which has led to the conclusion that there are 2 dimensions reflecting motivation and pleasure (MAP) and diminished expressivity (EXP) factors. However, whether these conclusions are statistically justified remains unclear because exploratory factor analysis does not test latent structure. Confirmatory factor analysis (CFA) is needed to test competing models regarding the latent structure of a construct.

Objective: To evaluate the fit of 4 models of the latent structure of negative symptoms in schizophrenia using CFA.

Design, setting, and participants: Three cross-sectional studies were conducted on outpatients with schizophrenia who were rated on the 3 most conceptually contemporary measures: Scale for the Assessment of Negative Symptoms (SANS), Brief Negative Symptom Scale (BNSS), and Clinical Assessment Interview for Negative Symptoms (CAINS). Confirmatory factor analysis evaluated the following 4 models: (1) a 1-factor model; (2) a 2-factor model with EXP and MAP factors; (3) a 5-factor model with separate factors for the 5 domains of the National Institute of Mental Health consensus development conference (blunted affect, alogia, anhedonia, avolition, and asociality); and (4) a hierarchical model with 2 second-order factors reflecting EXP and MAP and 5 first-order factors reflecting the 5 consensus domains.

Main outcomes and measures: Outcomes included CFA model fit statistics derived from symptom severity scores on the SANS, BNSS, and CAINS.

Results: The study population included 860 outpatients with schizophrenia (68.0% male; mean [SD] age, 43.0 [11.4] years). Confirmatory factor analysis was conducted on each scale, including 268 patients for the SANS, 192 for the BNSS, and 400 for the CAINS. The 1- and 2-factor models provided poor fit for the SANS, BNSS, and CAINS as indicated by comparative fit indexes (CFIs) and Tucker Lewis indexes (TLIs) less than 0.950, RMSEAs that exceeded the 0.080 threshold, and WRMRs greater than 1.00. The 5-factor and hierarchical models provided excellent fit, with the 5-factor model being more parsimonious. The CFIs and TLIs met the 0.95 threshold and the 1.00 threshold for both factor models with all 3 measures. Interestingly, the RMSEAs for the 5-factor model and the hierarchical model fell under the 0.08 threshold for the BNSS and the CAINS but not the SANS.

Conclusions and relevance: These findings suggest that the recent trend toward conceptualizing the latent structure of negative symptoms as 2 distinct dimensions does not adequately capture the complexity of the construct. The latent structure of negative symptoms is best conceptualized in relation to the 5 consensus domains. Implications for identifying pathophysiological mechanisms and targeted treatments are discussed.

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Conflict of interest statement

Conflict of Interest Disclosures: Drs Strauss and Kirkpatrick reported being original developers of the Brief Negative Symptom Scale (BNSS) and receiving royalties and consultation fees from ProPhase, LLC, in connection with commercial use of the BNSS and other professional activities; these fees are donated to the Brain and Behavior Research Foundation. Dr Kirkpatrick reported receiving honoraria and travel support from ProPhase, LLC, for training pharmaceutical company raters on the BNSS; consulting fees and travel support from Genentech/Roche, Minerva Neurosciences, and ProPhase, LLC; consulting fees from anonymized pharmaceutical companies through Decision Resources, Inc, from an investment capital company through Guideposts, and from Wockhardt Bio AG for consulting on a legal issue; receiving fees from Walsh Medical Media for editorial services; and receiving fees for editorial services from Physicians Postgraduate Press, Inc. Dr Gold reported receiving royalties from the Brief Assessment of Cognition in Schizophrenia and consulting for Amgen, Takeda Pharmaceuticals USA, Inc, and Roche Pharmaceuticals. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Five-Factor and Hierarchical Models of the Scale for the Assessment of Negative Symptoms (SANS)
The 5 factors of anhedonia, asociality, avolition, blunted affect, and alogia were included in the consensus model. The hierarchical model consists of the 5 factors and the second-order factors of motivation and pleasure (MAP) and diminished expressivity (EXP). Solid lines represent factor loadings and curved lines represent the correlation among factors (A) and second-order factors (B). Numbers indicate item numbers on each scale.
Figure 2.
Figure 2.. Five-Factor and Hierarchical Models of the Brief Negative Symptom Scale (BNSS)
The 5 factors of anhedonia, asociality, avolition, blunted affect, and alogia were included in the consensus model. The hierarchical model consists of the 5 factors and the second-order factors of motivation and pleasure (MAP) and diminished expressivity (EXP). Solid lines represent factor loadings and curved lines represent the correlation among factors (A) and second-order factors (B). Numbers indicate item numbers on each scale.
Figure 3.
Figure 3.. Five-Factor and Hierarchical Models of the Clinical Assessment Interview for Negative Symptoms (CAINS)
The 5 factors of anhedonia, asociality, avolition, blunted affect, and alogia were included in the consensus model. The hierarchical model consists of the 5 factors and the second-order factors of motivation and pleasure (MAP) and diminished expressivity (EXP). Solid lines represent factor loadings and curved lines represent the correlation among factors (A) and second-order factors (B). Numbers indicate item numbers on each scale.
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