Skip to main content Accessibility help

Mood, anxiety and psychotic phenomena measure a common psychopathological factor

  • J. Stochl (a1) (a2), G. M. Khandaker (a1) (a2), G. Lewis (a3), J. Perez (a1) (a2), I. M. Goodyer (a1), S. Zammit (a4) (a5), S. Sullivan (a5), T. J. Croudace (a6) and P. B. Jones (a1) (a2)...



Psychotic phenomena are common in the general population but are excluded from diagnostic criteria for mild to moderate depression and anxiety despite their co-occurrence and shared risk factors. We used item response theory modelling to examine whether the co-occurrence of depressive, anxiety and psychotic phenomena is best explained by: (1) a single underlying factor; (2) two separate, uncorrelated factors; (3) two separate yet linked factors; or (4) two separate domains along with an underlying ‘common mental distress’ (CMD) factor. We defined where, along any latent continuum, the psychopathological items contributed most information.


We performed a secondary analysis of cross-sectional, item-level information from measures of depression, anxiety and psychotic experiences in 6617 participants aged 13 years from the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort and 977 participants aged 18 years from the ROOTS schools-based sample. We replicated results from one sample in the other and validated the latent factors against an earlier parental measure of mental state.


In both cohorts depression, anxiety and psychotic items were best represented as a bi-factor model with a single, unitary CMD factor on which psychotic items conveyed information about the more severe end (model 4); residual variation remained for psychotic items. The CMD factor was significantly associated with the prior parental measure.


Psychotic phenomena co-occur with depression and anxiety in teenagers and may be a marker of severity in a single, unitary dimension of CMD. Psychotic phenomena should be routinely included in epidemiological assessments of psychiatric morbidity, otherwise the most severe symptomatology remains unmeasured.


Corresponding author

* Address for correspondence: P. B. Jones, Department of Psychiatry, University of Cambridge, Cambridge Biomedical Campus, Box 189, Cambridge CB2 0QQ, UK. (Email:


Hide All
Akaike, H (1974). A new look at the statistical model identification. IEEE Transactions on Automatic Control 19, 716723.
American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association: Washington, DC.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Publishing: Arlington, VA.
Angold, A, Costello, EJ, Messer, SC, Pickles, A, Winder, F, Silver, D (1995). The development of a short questionnaire for use in epidemiological studies of depression in children and adolescents. International Journal of Methods in Psychiatric Research 5, 237249.
Benros, ME, Nielsen, PR, Nordentoft, M, Eaton, WW, Dalton, SO, Mortensen, PB (2011). Autoimmune diseases and severe infections as risk factors for schizophrenia: a 30-year population-based register study. American Journal of Psychiatry 168, 13031310.
Benros, ME, Waltoft, BL, Nordentoft, M, Ostergaard, SD, Eaton, WW, Krogh, J, Mortensen, PB (2013). Autoimmune diseases and severe infections as risk factors for mood disorders: a nationwide study. JAMA Psychiatry 70, 812820.
Boyd, A, Golding, J, Macleod, J, Lawlor, DA, Fraser, A, Henderson, J, Molloy, L, Ness, A, Ring, S, Davey Smith, G (2013). Cohort profile: the ‘children of the 90s’ – the index offspring of the Avon Longitudinal Study of Parents and Children. International Journal of Epidemiology 42, 111127.
Caspi, A, Houts, RM, Belsky, DW, Goldman-Mellor, SJ, Harrington, H, Israel, S, Meier, MH, Ramrakha, S, Shalev, I, Poulton, P, Moffitt, TE (2014). The p factor: one general psychopathology factor in the structure of psychiatric disorders? Clinical Psychological Science 2, 119137.
Foulds, GA, Bedford, A (1975). Hierarchy of classes of personal illness. Psychological Medicine 5, 181192.
Fraser, A, Macdonald-Wallis, C, Tilling, K, Boyd, A, Golding, J, Davey Smith, G, Henderson, J, Macleod, J, Molloy, L, Ness, A, Ring, S, Nelson, SM, Lawlor, DA (2013). Cohort profile: the Avon Longitudinal Study of Parents and Children: ALSPAC mothers cohort. International Journal of Epidemiology 42, 97110.
Goldberg, DP, Bridges, K, Duncan-Jones, P, Grayson, D (1987). Dimensions of neuroses seen in primary-care settings. Psychological Medicine 17, 461470.
Goldberg, DP, Hillier, VF (1979). A scaled version of the General Health Questionnaire. Psychological Medicine 9, 139145.
Goodman, R (1997). The Strengths and Difficulties Questionnaire: a research note. Journal of Child Psychology and Psychiatry 38, 581586.
Goodyer, IM, Croudace, T, Dunn, V, Herbert, J, Jones, PB (2010). Cohort profile: risk patterns and processes for psychopathology emerging during adolescence: the ROOTS project. International Journal of Epidemiology 39, 361369.
Green, EK, Grozeva, D, Jones, I, Jones, L, Kirov, G, Caesar, S, Gordon-Smith, K, Fraser, C, Forty, L, Russell, E, Hamshere, ML, Moskvina, V, Nikolov, I, Farmer, A, McGuffin, P; Wellcome Trust Case Control Consortium, Holmans, PA, Owen, MJ, O'Donovan, MC, Craddock, N (2010). The bipolar disorder risk allele at CACNA1C also confers risk of recurrent major depression and of schizophrenia. Molecular Psychiatry 15, 10161022.
Hanssen, M, Peeters, F, Krabbendam, L, Radstake, S, Verdoux, H, van Os, J (2003). How psychotic are individuals with non-psychotic disorders? Social Psychiatry and Psychiatric Epidemiology 38, 149154.
Horwood, J, Salvi, G, Thomas, K, Duffy, L, Gunnell, D, Hollis, C, Lewis, G, Menezes, P, Thompson, A, Wolke, D, Zammit, S, Harrison, G (2008). IQ and non-clinical psychotic symptoms in 12-year-olds: results from the ALSPAC birth cohort. British Journal of Psychiatry 193, 185191.
Hui, C, Morcillo, C, Russo, DA, Stochl, J, Shelley, GF, Painter, M, Jones, PB, Perez, J (2013). Psychiatric morbidity, functioning and quality of life in young people at clinical high risk for psychosis. Schizophrenia Research 148, 175180.
Jones, P, Rodgers, B, Murray, R, Marmot, M (1994). Child development risk factors for adult schizophrenia in the British 1946 birth cohort. Lancet 344, 13981402.
Kass, RE, Raftery, AE (1995). Bayes factors. Journal of the American Statistical Association 90, 773795.
Kelleher, I, Connor, D, Clarke, MC, Devlin, N, Harley, M, Cannon, M (2012 a). Prevalence of psychotic symptoms in childhood and adolescence: a systematic review and meta-analysis of population-based studies. Psychological Medicine 42, 18571863.
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 b). Clinicopathological significance of psychotic experiences in non-psychotic young people: evidence from four population-based studies. British Journal of Psychiatry 201, 2632.
Kessler, RC, Andrews, G, Colpe, LJ, Hiripi, E, Mroczek, DK, Normand, SL, Walters, EE, Zaslavsky, AM (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine 32, 959976.
Khandaker, GM, Barnett, JH, White, IR, Jones, PB (2011). A quantitative meta-analysis of population-based studies of premorbid intelligence and schizophrenia. Schizophrenia Research 132, 220227.
Khandaker, GM, Clarke, M, Cannon, M, Jones, PB (2013). Schizophrenia and related psychosis. In A Life Course Approach to Mental Disorders (ed. Koenen, K. C., Rudenstine, S., Susser, E. and Galea, S.), pp. 6175. Oxford University Press.
Khandaker, GM, Pearson, RM, Zammit, S, Lewis, G, Jones, PB (2014). Association of serum interleukin 6 and C-reactive protein in childhood with depression and psychosis in young adult life: a population-based longitudinal study. JAMA Psychiatry 71, 11211128.
Khandaker, GM, Zimbron, J, Dalman, C, Lewis, G, Jones, PB (2012). Childhood infection and adult schizophrenia: a meta-analysis of population-based studies. Schizophrenia Research 139, 161168.
Kirkbride, JB, Jones, PB (2011). The prevention of schizophrenia – what can we learn from eco-epidemiology? Schizophrenia Bulletin 37, 262271.
Kounali, D, Zammit, S, Wiles, N, Sullivan, S, Cannon, M, Stochl, J, Jones, P, Mahedy, L, Gage, SH, Heron, J, Lewis, G (2014). Common versus psychopathology-specific risk factors for psychotic experiences and depression during adolescence. Psychological Medicine 44, 25572566.
Krueger, RF (1999). The structure of common mental disorders. Archives of General Psychiatry 56, 921926.
Lewis, G, Pelosi, AJ, Araya, R, Dunn, G (1992). Measuring psychiatric disorder in the community: a standardized assessment for use by lay interviewers. Psychological Medicine 22, 465486.
Lichtenstein, P, Yip, BH, Bjork, 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.
Loehlin, JC (1992). Latent Variable Models: an Introduction to Factor, Path, and Structural Analysis. Lawrence Erlbaum: Hillsdale, NJ.
Masyn, KE, Henderson, CE, Greenbaum, PE (2010). Exploring the latent structures of psychological constructs in social development using the dimensional–categorical spectrum. Social Development 19, 470493.
Murray, GK, Jones, PB (2012). Psychotic symptoms in young people without psychotic illness: mechanisms and meaning. British Journal of Psychiatry 201, 46.
Nicewander, WA (1993). Some relationships between the information function of IRT and the signal/noise ratio and reliability coefficient of classical test theory. Psychometrika 58, 139141.
Nishida, A, Tanii, H, Nishimura, Y, Kajiki, N, Inoue, K, Okada, M, Sasaki, T, Okazaki, Y (2008). Associations between psychotic-like experiences and mental health status and other psychopathologies among Japanese early teens. Schizophrenia Research 99, 125133.
O'Donovan, MC, Craddock, N, Norton, N, Williams, H, Peirce, T, Moskvina, V, Nikolov, I, Hamshere, M, Carroll, L, Georgieva, L, Dwyer, S, Holmans, P, Marchini, JL, Spencer, CC, Howie, B, Leung, HT, Hartmann, AM, Moller, HJ, Morris, DW, Shi, Y, Feng, G, Hoffmann, P, Propping, P, Vasilescu, C, Maier, W, Rietschel, M, Zammit, S, Schumacher, J, Quinn, EM, Schulze, TG, Williams, NM, Giegling, I, Iwata, N, Ikeda, M, Darvasi, A, Shifman, S, He, L, Duan, J, Sanders, AR, Levinson, DF, Gejman, PV, Cichon, S, Nothen, MM, Gill, M, Corvin, A, Rujescu, D, Kirov, G, Owen, MJ, Buccola, NG, Mowry, BJ, Freedman, R, Amin, F, Black, DW, Silverman, JM, Byerley, WF, Cloninger, CR; Molecular Genetics of Schizophrenia Collaboration (2008). Identification of loci associated with schizophrenia by genome-wide association and follow-up. Nature Genetics 40, 10531055.
Polanczyk, G, Moffitt, TE, Arseneault, L, Cannon, M, Ambler, A, Keefe, RS, Houts, R, Odgers, CL, Caspi, A (2010). Etiological and clinical features of childhood psychotic symptoms: results from a birth cohort. Archives of General Psychiatry 67, 328338.
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.
Rossler, W, Hengartner, MP, Ajdacic-Gross, V, Haker, H, Gamma, A, Angst, J (2011). Sub-clinical psychosis symptoms in young adults are risk factors for subsequent common mental disorders. Schizophrenia Research 131, 1823.
Schwarz, GE (1978). Estimating the dimension of a model. Annals of Statistics 6, 461464.
Sclove, S (1987). Application of model-selection criteria to some problems in multivariate analysis. Psychometrika 52, 333343.
Shaffer, D, Fisher, P, Lucas, CP, Dulcan, MK, Schwab-Stone, ME (2000). NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. Journal of the American Academy of Child and Adolescent Psychiatry 39, 2838.
Sharp, C, Goodyer, IM, Croudace, TJ (2006). The Short Mood and Feelings Questionnaire (SMFQ): a unidimensional item response theory and categorical data factor analysis of self-report ratings from a community sample of 7- through 11-year-old children. Journal of Abnormal Child Psychology 34, 379391.
Smoller, JW, Craddock, N, Kendler, K, Lee, PH, Neale, BM, Nurnberger, JI, Ripke, S, Santangelo, S, Sullivan, PF (2013). Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis. Lancet 381, 13711379.
Spearman, C (1904). “General intelligence,” objectively determined and measured. American Journal of Psychology 15, 201292.
Sturt, E (1981). Hierarchical patterns in the distribution of psychiatric symptoms. Psychological Medicine 11, 783792.
Sullivan, SA, Wiles, N, Kounali, D, Lewis, G, Heron, J, Cannon, M, Mahedy, L, Jones, PB, Stochl, J, Zammit, S (2014). Longitudinal associations between adolescent psychotic experiences and depressive symptoms. PLOS ONE 9, e105758.
Van der Linden, WJ, Hambleton, RK (eds) (1997). Handbook of Modern Item Response Theory. Springer: New York.
van Os, J, Jones, P, Lewis, G, Wadsworth, M, Murray, R (1997). Developmental precursors of affective illness in a general population birth cohort. Archives of General Psychiatry 54, 625631.
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.
van Rossum, I, Dominguez, M-d-G, Lieb, R, Wittchen, H-U, van Os, J (2011). Affective dysregulation and reality distortion: a 10-year prospective study of their association and clinical relevance. Schizophrenia Bulletin 37, 561571.
Varese, F, Smeets, F, Drukker, M, Lieverse, R, Lataster, T, Viechtbauer, W, Read, J, van Os, J, Bentall, RP (2012). Childhood adversities increase the risk of psychosis: a meta-analysis of patient–control, prospective- and cross-sectional cohort studies. Schizophrenia Bulletin 38, 661671.
Varghese, D, Scott, J, Welham, J, Bor, W, Najman, J, O'Callaghan, M, Williams, G, McGrath, J (2011). Psychotic-like experiences in major depression and anxiety disorders: a population-based survey in young adults. Schizophrenia Bulletin 37, 389393.
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.
Widom, CS, DuMont, K, Czaja, SJ (2007). A prospective investigation of major depressive disorder and comorbidity in abused and neglected children grown up. Archives of General Psychiatry 64, 4956.
Wigman, JT, van Os, J, Abidi, L, Huibers, MJ, Roelofs, J, Arntz, A, Kelleher, I, Peeters, FP (2014). Subclinical psychotic experiences and bipolar spectrum features in depression: association with outcome of psychotherapy. Psychological Medicine 44, 325336.
Wigman, JTW, van Nierop, M, Vollebergh, WAM, Lieb, R, Beesdo-Baum, K, Wittchen, H-U, van Os, J (2012). Evidence that psychotic symptoms are prevalent in disorders of anxiety and depression, impacting on illness onset, risk, and severity – implications for diagnosis and ultra-high risk research. Schizophrenia Bulletin 38, 247257.
Wolke, D, Waylen, A, Samara, M, Steer, C, Goodman, R, Ford, T, Lamberts, K (2009). Selective drop-out in longitudinal studies and non-biased prediction of behaviour disorders. British Journal of Psychiatry 195, 249256.
World Health Organization (1992). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization: Geneva.
World Health Organization (1994). SCAN: Schedules for Clinical Assessment in Neuropsychiatry Version 2.0. Psychiatric Publishers International/American Psychiatric Press Inc.: Geneva, Switzerland.
Zigmond, AS, Snaith, RP (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica 67, 361370.


Type Description Title
Supplementary materials

Stochl Supplementary Material
Figure S1

 Word (173 KB)
173 KB
Supplementary materials

Stochl Supplementary Material
Figure S2

 Word (57 KB)
57 KB

Mood, anxiety and psychotic phenomena measure a common psychopathological factor

  • J. Stochl (a1) (a2), G. M. Khandaker (a1) (a2), G. Lewis (a3), J. Perez (a1) (a2), I. M. Goodyer (a1), S. Zammit (a4) (a5), S. Sullivan (a5), T. J. Croudace (a6) and P. B. Jones (a1) (a2)...


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