Skip to main content Accessibility help

Latent structure of psychosis in the general population: results from the Singapore Mental Health Study

  • M. Subramaniam (a1), E. Abdin (a1), J. A. Vaingankar (a1), S. Verma (a1) and S. A. Chong (a1)...



Few studies have examined the latent construct of psychotic symptoms or distinguished between the latent construct and its manifest indicators. The current study aimed to investigate the latent structure of psychotic symptoms using factor mixture modeling (FMM) and to use the best-fitting model to examine its sociodemographic and clinical correlates.


The Singapore Mental Health Study (SMHS) was based on an adult representative sample of the Singapore population. Psychotic symptoms were assessed by using the Psychosis Screen section of the Composite International Diagnostic Interview version 3.0 (CIDI 3.0). FMM analyses were applied to determine the latent construct of psychotic symptoms. Sociodemographic and clinical correlates of the latent structure of psychosis symptoms were examined using multiple linear and logistic regression analyses.


The overall weighted lifetime prevalence of any psychotic experience was 3.8% in the SMHS after excluding subthreshold experiences. The FMM analysis clearly supported the dimensional model of the latent structure of psychotic symptoms. On deriving the total score for ‘psychosis symptoms’ in accordance with the one latent trait model, and correlating it with sociodemographic factors, we found that female gender, vocational education, current and past smokers were positively associated with the ‘psychosis’ total score.


There is a need for an increased understanding of, and research into, this intermediate state of ‘psychosis symptoms’ that do not meet diagnostic criteria for psychosis. It is also important to learn more about the group of individuals in the community who may have preserved functioning to elucidate the protective factors that prevent transition to psychosis.


Corresponding author

* Address for correspondence: M. Subramaniam, M.B.B.S., M.H.S.M., Deputy Director, Research Division, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, Singapore 539 747, Singapore. (Email:


Hide All
Ahmed, AO, Buckley, PF, Mabe, PA (2012). Latent structure of psychotic experiences in the general population. Acta Psychiatrica Scandinavica 125, 5465.
Alptekin, K, Ulas, H, Akdede, BB, Tümüklü, M, Akvardar, Y (2009). Prevalence and risk factors of psychotic symptoms: in the city of Izmir, Turkey. Social Psychiatry and Psychiatric Epidemiology 44, 905910.
Borsboom, D, Cramer, AO, Schmittmann, VD, Epskamp, S, Waldorp, LJ (2011). The small world of psychopathology. PLoS One 6, e27407.
Broome, MR, Woolley, JB, Tabraham, P, Johns, LC, Bramon, E, Murray, GK, Pariante, C, McGuire, PK, Murray, RM (2005). What causes the onset of psychosis? Schizophrenia Research 79, 2334.
Carpenter, WT, van Os, J (2011). Should attenuated psychosis syndrome be a DSM-5 diagnosis? American Journal of Psychiatry 168, 460463.
Chong, SA, Mythily, , Lum, A, Chan, YH, McGorry, P (2005). Determinants of duration of untreated psychosis and the pathway to care in Singapore. International Journal of Social Psychiatry 51, 5562.
Chong, SA, Vaingankar, J, Abdin, E, Subramaniam, M (2012). The prevalence and impact of major depressive disorder among Chinese, Malays and Indians in an Asian multi-racial population. Journal of Affective Disorders 138, 128136.
Correll, CU, Lencz, T, Smith, CW, Auther, AM, Nakayama, EY, Hovey, L, Olsen, R, Shah, M, Foley, C, Cornblatt, BA (2005). Prospective study of adolescents with subsyndromal psychosis: characteristics and outcome. Journal of Child and Adolescent Psychopharmacology 15, 418433.
EuroQol Group (1990). EuroQol – a new facility for the measurement of health-related quality of life. Health Policy 16, 199208.
Georgiades, S, Szatmari, P, Boyle, M, Hanna, S, Duku, E, Zwaigenbaum, L, Bryson, S, Fombonne, E, Volden, J, Mirenda, P, Smith, I, Roberts, W, Vaillancourt, T, Waddell, C, Bennett, T, Thompson, A; Pathways in ASD Study Team (2013). Investigating phenotypic heterogeneity in children with autism spectrum disorder: a factor mixture modeling approach. Journal of Child Psychology and Psychiatry, and Allied Disciplines 54, 206215.
Guardiano, B, Dairymple, KL, Zimmermann, M (2009). Prevalence and clinical characteristics of psychotic versus nonpsychotic major depression in a general psychiatric outpatient clinic. Depression and Anxiety 26, 5464.
Hanssen, M, Bak, M, Bijl, R, Vollebergh, W, van Os, J (2005). The incidence and outcome of subclinical psychotic experiences in the general population. British Journal of Clinical Psychology 44, 181191.
Johns, LC, van Os, J (2001). The continuity of psychotic experiences in the general population. Clinical Psychological Review 21, 11251141.
Kelleher, I, Cannon, M (2011). Psychotic-like experiences in the general population: characterizing a high-risk group for psychosis. Psychological Medicine 41, 16.
Kelleher, I, Keeley, H, Corcoran, P, Lynch, F, Fitzpatrick, C, Devlin, N, Molloy, C, Roddy, S, Clarke, MC, Harley, M, Arseneault, L, Wasserman, C, Carli, V, Sarchiapone, M, Hoven, C, Wasserman, D, Cannon, M (2012). Clinicopathological significance of psychotic experiences in non-psychotic young people: evidence from four population-based studies. British Journal of Psychiatry 201, 2632.
Kendler, KS, Gallagher, TJ, Abelson, JM, Kessler, RC (1996). Lifetime prevalence, demographic risk factors, and diagnostic validity of nonaffective psychosis as assessed in a US community sample. The National Comorbidity Survey. Archives of General Psychiatry 53, 10221031.
Kendler, KS, Zachar, P, Craver, C (2011). What kinds of things are psychiatric disorders? Psychological Medicine 41, 11431150.
Kessler, RC, Birnbaum, H, Demler, O, Falloon, IR, Gagnon, E, Guyer, M, Howes, MJ, Kendler, KS, Shi, L, Walters, E, Wu, EQ (2005). The prevalence and correlates of nonaffective psychosis in the National Comorbidity Survey Replication (NCS-R). Biological Psychiatry 58, 668676.
Kessler, RC, Ustun, TB (2004). The World Mental Health (WMH) Survey Initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). International Journal of Methods in Psychiatric Research 13, 93121.
Kessler, RC, Wittchen, HU, Abelson, J, Zhao, S (2000). Methodological issues in assessing psychiatric disorder with self-reports. In The Science of Self-Report: Implications for Research and Practice (ed. Stone, AA, Turrkan, JS, Bachrach, CA, Jobe, JB, Kurtzman, HS and Cain, VS), pp. 229255. Lawrence Erlbaum Associates: Mahwah, NJ.
Lichtenstein, P, Yip, BH, Björk, C, Pawitan, Y, Cannon, TD, Sullivan, PF, Hultman, CM (2009). Common genetic determinants of schizophrenia and bipolar disorder in Swedish families: a population-based study. Lancet 373, 234239.
Lo, YT, Mendell, NR, Rubin, DB (2001). Testing the number of components in a normal mixture. Biometrika 88, 767778.
Loch, AA, Wang, YP, Rössler, W, Tófoli, LF, Silveira, CM, Andrade, LH (2011). The psychosis continuum in the general population: findings from the São Paulo Epidemiologic Catchment Area Study. European Archives of Psychiatry and Clinical Neuroscience 261, 519527.
Lubke, G, Neale, M (2006). Distinguishing between latent classes and continuous factors: resolution by maximum likelihood? Multivariate Behavioral Research 41, 499532.
Lubke, G, Tueller, S (2010). Latent class detection and class assignment: a comparison of the MAXEIG taxometric procedure and factor mixture modeling approaches. Structural Equation Modelling: A Multidisciplinary Journal 17, 605628.
Markon, KE, Krueger, RF (2006). Information-theoretic latent distribution modeling: distinguishing discrete and continuous latent variable models. Psychological Methods 11, 228243.
Meehl, PE (1995). Bootstraps taxometrics. Solving the classification problem in psychopathology. American Psychologist 50, 266275.
Muthén, B (2006). Should substance use disorders be considered as categorical or dimensional? Addiction 1, 616.
Muthén, B (2008). Latent variable hybrids: overview of old and new models. In Latent Variable Mixture Models (ed. Hancock, G. R. and Samuelsen, KM), pp. 124. Information Age: Charlotte, NC.
Muthén, L, Muthén, B (2009). Mplus 5.21 User's Guide. Muthén & Muthén: Los Angeles, CA.
Nuevo, R, Chatterji, S, Verdes, E, Naidoo, N, Arango, C, Ayuso-Mateos, JL (2012). The continuum of psychotic symptoms in the general population: a cross-national study. Schizophrenia Bulletin 38, 475485.
Nylund, KL, Asparouhov, T, Muthén, B (2007). Deciding on the number of classes in latent class analysis and growth mixture modeling: a Monte Carlo simulation study. Structural Equation Modelling: A Multidisciplinary Journal 14, 535569.
Poulton, R, Caspi, A, Moffitt, TE, Cannon, M, Murray, R, Harrington, H (2000). Children's self-reported psychotic symptoms and adult schizophreniform disorder: a 15-year longitudinal study. Archives of General Psychiatry 57, 10531058.
Poyurovsky, M, Faragian, S, Shabeta, A, Kosov, A (2008). Comparison of clinical characteristics, co-morbidity and pharmacotherapy in adolescent schizophrenia patients with and without obsessive-compulsive disorder. Psychiatry Research 159, 133139.
Poyurovsky, MD, Fuchs, C, Weizman, A (1999). Obsessive-compulsive disorder in patients with first-episode schizophrenia. American Journal of Psychiatry 156, 19982000.
Razali, SM, Najib, MA (2000). Help-seeking pathways among Malay psychiatric patients. International Journal of Social Psychiatry 46, 281289.
Rössler, W, Riecher-Rössler, A, Angst, J, Murray, R, Gamma, A, Eich, D, van Os, J, Gross, VA (2007). Psychotic experiences in the general population: a twenty-year prospective community study. Schizophrenia Research 92, 114.
Schwarz, G (1978). Estimating the dimension of a model. Annals of Statistics 6, 461464.
Shioiri, T, Shinada, K, Kuwabara, H, Someya, T (2007). Early prodromal symptoms and diagnoses before first psychotic episode in 219 inpatients with schizophrenia. Psychiatry and Clinical Neurosciences 61, 348354.
Strakowski, SM, Keck, PE Jr, McElroy, SL, Lonczak, HS, West, SA (1995). Chronology of comorbid and principal syndromes in first-episode psychosis. Comprehensive Psychiatry 36, 106112.
Subramaniam, M, Vaingankar, J, Heng, D, Kwok, KW, Lim, YW, Yap, M, Chong, SA (2012). The Singapore Mental Health Study: an overview of the methodology. International Journal of Methods in Psychiatric Research 21, 149157.
Thomson, KN, Conus, PO, Ward, J, Phillips, LJ, Koutsogiannis, J, Leicester, S, McGorry, PD (2003). The initial prodrome to bipolar affective disorder: prospective case studies. Journal of Affective Disorders 77, 7985.
Tibbo, P, Warneke, L (1999). Obsessive-compulsive disorder in schizophrenia: epidemiologic and biologic overlap. Journal of Psychiatry and Neuroscience 24, 1524.
van Os, J, Linscott, RJ, Myin-Germeys, I, Delespaul, P, Krabbendam, L (2009). A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychological Medicine 39, 179195.
Verdoux, H, van Os, J (2002). Psychotic symptoms in non-clinical populations and the continuum of psychosis. Schizophrenia Research 54, 5965.
Verdoux, H, van Os, J, Maurice-Tison, S, Gay, B, Salamon, R, Bourgeois, ML (1999). Increased occurrence of depression in psychosis-prone subjects: a follow-up study in primary care settings. Comprehensive Psychiatry 40, 462468.
Xiang, YT, Ma, X, Cai, ZJ, Li, SR, Xiang, YQ, Guo, HL, Hou, YZ, Li, ZB, Li, ZJ, Tao, YF, Dang, WM, Wu, XM, Deng, J, Lai, KY, Ungvari, GS (2008). Prevalence and socio-demographic correlates of schizophrenia in Beijing, China. Schizophrenia Research 102, 270277.



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed