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THE NETWORK AND DIMENSIONALITY STRUCTURE OF

AFFECTIVE PSYCHOSES: AN EXPLORATORY GRAPH ANALYSIS
APPROACH

Victor Peralta , Gustavo J. Gil-Berrozpe , Ana Sánchez-Torres ,

Manuel J. Cuesta

PII: S0165-0327(20)32604-5
DOI: https://doi.org/10.1016/j.jad.2020.08.008
Reference: JAD 12321

To appear in: Journal of Affective Disorders

Received date: 3 April 2020

Revised date: 27 May 2020
Accepted date: 8 August 2020

Please cite this article as: Victor Peralta , Gustavo J. Gil-Berrozpe , Ana Sánchez-Torres ,
Manuel J. Cuesta , THE NETWORK AND DIMENSIONALITY STRUCTURE OF AFFECTIVE PSY-
CHOSES: AN EXPLORATORY GRAPH ANALYSIS APPROACH, Journal of Affective Disorders
(2020), doi: https://doi.org/10.1016/j.jad.2020.08.008

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© 2020 Published by Elsevier B.V.

THE NETWORK AND DIMENSIONALITY STRUCTURE OF AFFECTIVE PSYCHOSES: AN

EXPLORATORY GRAPH ANALYSIS APPROACH

1,2 2,3
Victor Peralta, MD, PhD *, Gustavo J. Gil-Berrozpe, MSc , Ana Sánchez-Torres, PhD2,3,
2,3
Manuel J. Cuesta, MD, PhD

1
Mental Health Department, Servicio Navarro de Salud-Osasunbidea

2
Navarrabiomed and Instituto de Investigación Sanitaria de Navarra (IdISNa)

3
Psychiatry Service, Complejo Hospitalario de Navarra

* Corresponding author:

Mental Health Department, Servicio Navarro de Salud – Osasunbidea,

Tudela 20, 31002 Pamplona, Spain

Tel +34 848 422040, Fax +34 848 420389

victor.peralta.martin@cfnavarra.es

Highlights

 Network analyses allow exploring symptom relationships across classes of

affective psychoses.
 Classes of affective psychoses significantly differed in network structure but
not in global network connectivity.
 The connectivity pattern between mood and psychotic symptoms highly
depends on the specific diagnosis of affective psychosis.
 Differences in symptom patterns might give rise to tailored treatment
hypotheses.

ABSTRACT

1
Background: The dimensional symptom structure of classes of affective psychoses, and more

specifically the relationships between affective and mood symptoms, has been poorly

researched. Here, we examined these questions from a network analysis perspective.

Methods: Using Exploratory Graph Analysis (EGA) and network centrality parameters, we

examined the dimensionality and network structure of 28 mood and psychotic symptoms in

subjects diagnosed with schizoaffective disorder (n=124), psychotic bipolar disorder (n=345) or

psychotic depression (n=245), such as in the global sample of affective psychoses.

Results: EGA identified four dimensions in subjects with schizoaffective or bipolar disorders

(depression, mania, positive and negative) and three dimensions in subjects with psychotic

depression (depression, psychosis and activation). The item composition of dimensions and the

most central symptoms varied substantially across diagnoses. The most central (i.e.,

interconnected) symptoms in schizoaffective disorder, psychotic bipolar disorder and psychotic

depression were hallucinations, delusions and depressive mood, respectively. Classes of

affective psychoses significantly differed in terms of network structure but not in network global

strength.

Limitations: The cross-sectional nature of this study precludes conclusions about the causal

dynamics between affective and psychotic symptoms.

Conclusion: EGA is a powerful tool for examining the dimensionality and network structure of

symptoms in affective psychoses showing that both the interconnectivity pattern between

affective and psychotic symptoms and the most central symptoms vary across classes of

affective psychoses. The findings outline the value of specific diagnoses in explaining the

relationships between mood and affective symptoms.

KEYWORDS

Network analysis, network structure, factor analysis, dimensionality, affective psychoses,

symptom connectivity

2
1. INTRODUCTION

Affective psychoses, i.e., schizoaffective disorder (SAD), psychotic bipolar disorder (PBD) and

psychotic depression (PD) are thought to be different disorders in current classification systems

(APA, 2013; World Health Organization, 2004). Furthermore, SAD is deemed to be an

intermediate disorder between schizophrenia and major mood disorders in terms of risk factors,

course and impairment (Kingston et al., 2018). For diagnosing affective psychoses, subjects

need to present with a major mood syndrome and psychotic symptoms; however, and in

addition to the temporal relationships between mood and psychotic symptoms established

within the specific diagnostic criteria, little is known about the association pattern among these

two types of symptoms in the whole group of affective psychosis and in each specific diagnosis.

1.1. The structure of mood and psychotic symptoms in affective psychoses

Most of the knowledge about the relationships between affective and psychotic symptoms

comes from factor analysis and other related data-reduction techniques. However, previous

studies have been limited by the unbalanced number of symptoms for each domain to be factor

analyzed and the lack of studies examining their factor structure in each diagnostic class of

affective psychoses. Most studies on the factor structure of symptoms either have included a

majority of affective symptoms relative to psychotic symptoms, as is the case with the use of

rating scales devoted to assess specific mood syndromes such as the Mania Rating Scale

(Young et al., 1978) or the Hamilton Depression Rating Scale (Hamilton, 1967), or they have

used rating instruments devoted to assessing psychotic symptoms, which poorly rate mood

symptoms such as the Positive and Negative Symptom Scale (PANSS) (Kay et al., 1987) and

the Brief Psychotic Rating Scale (BPRS) (Overall and Gorham, 1962). To the best of our

knowledge, we are aware of only one rating scale adequately weighting affective and psychotic

symptoms, namely, the Hamilton Depression Rating Scale-Brief Psychiatric Rating Scale

(HAMD-BPRS) (Ostergaard et al., 2015a; Ostergaard et al., 2015b); unfortunately, however, the

scale’s factor structure has not been reported.

The structure of psychotic and mood symptoms in terms of the number of underlying factors

and their item composition has varied considerably across study samples and measures

(Anderson et al., 2017; Biancosino et al., 2010; Muller et al., 2001; Ostergaard et al., 2015a;

3
Peralta and Cuesta, 2001; Peralta et al., 1997; Perugi et al., 2014; Serretti et al., 1999; Stein et

al., 2020; Toomey et al., 1998). A common finding of previous studies is that they ascertain

separate dimensions for affective and psychotic symptoms by identifying at least one major

mood syndrome and one or more psychotic dimensions. In this regard, some authors consider

that mood disorders with and without psychotic symptoms are differentiated disorders with

affective and psychotic states being viewed as separate (i.e., comorbid) conditions (Altamura et

al., 2019; Jääskeläinen et al., 2018). Nevertheless, beyond the general finding that affective and

psychotic symptoms load on different factors, the specific symptom structure of affective

psychoses remains to be established. In contrast to extensive data about the factor structure of

symptoms in schizophrenia and mixed diagnostic samples of psychotic disorders, no study has

focused on examining the symptom structure in each specific diagnoses of affective psychosis

using the same rating instrument(s). A further limitation concerns the factor analytical approach

itself, since it focuses on determining how highly correlated items cluster together into factors,

but it is uninformative about the relationships among items across factors. An alternative

approach is to examine the network structure of symptoms, an analytical approach that makes it

possible to examine the connectivity among a large number of variables, the most central (i.e.,

interconnected) symptoms in the network and the dimensional structure underlying the

symptoms. For example, network analysis may give insight about how affective and psychotic

symptoms are inter-related as a whole inter-connected web, and how affective symptoms can

eventually activate a co-occurring psychotic state by identifying those factors that are both

strongly related to an affective state and to the development of psychosis (for instance sleep,

mood or activation). To date, no published study has used a network analysis approach to

investigate the symptom structure of affective psychoses, and more specifically, the association

pattern between mood and psychotic symptoms.

1.2. Network psychometrics and Exploratory Graph Analysis (EGA)

Network psychometrics is a rapidly developing field that has been applied to many

psychopathological constructs (Contreras et al., 2019; Robinaugh et al., 2020). Psychometric

network models consist of nodes that represent variables (e.g., affective symptoms) and edges

or connections that represent relations between the nodes (e.g., partial correlations given all

other nodes in the network). Partial correlations are the unique shared variance between nodes

4
in the network, which typically shrink many relations near or to zero. Often, larger relations that

remain form communities, i.e., clusters or dimensions, of many connected nodes in the network.

Exploratory Graph Analysis (EGA) (Golino and Epskamp, 2017) is a network methodology that

has been proposed as an alternative approach to identify the dimensional structure of

psychopathological constructs. EGA applies a Gaussian graphical model, which is estimated

using the graphical least absolute shrinkage and selection operator (glasso), and then, a

community detection algorithm is applied to identify the dimensions of the network (Bettinelli et

al., 2012). The dimensions discovered by EGA are deterministic and require no direction from

the researcher.

EGA offers a potential advantage over other exploratory dimension reduction methods such as

Principal Component Analysis (PCA). First, in EGA the content and the number of dimensions

are immediately interpretable without the need to interpret component loadings of individual

items. Second, an advantage of psychometric network models more generally is that they allow

a representation of item-level relations that afford interpretations across hierarchical resolutions,

that is, the influence of item-level relations can be understood between items, within and

between dimensions, and at the level of the construct itself (Blanken et al., 2018; Goekoop et

al., 2012). Third, unique to the EGA approach is that symptoms can be represented as a

network of interconnections within and between psychopathological dimensions, thus revealing

plausible modularity and identifying the key roles of individual items and clusters in the network.

Fourth, EGA appears to outperform other data-reduction methods in estimating the number of

dimensions underlying the data, and the accuracy of EGA has been shown to be least affected

by sample size, correlations among factors, and the number of items and factors (Golino and

Christensen, 2019; Golino and Epskamp, 2017). Lastly, network clusters explain more variance

in the data than PCA, suggesting that EGA provides a better representation of the data

(Goekoop et al., 2012).

1.3. Present study

The goal of the present research was to examine the dimensional network structure of psychotic

and mood symptoms using EGA in a large sample of subjects with affective psychoses and in

the specific diagnoses of SAD, PBD and PD. We examined the main centrality parameters of

5
the networks and compared the network structure of symptoms across diagnoses, and more

specifically, we sought to examine the pattern of associations between mood and psychotic

symptoms across diagnoses. As a secondary aim, and given that PCA continues to be the main

symptom reduction technique in psychopathology, we performed a PCA of symptoms, and the

results were qualitatively compared with those from EGA.

2. METHODS

2.1. Study sample

The study population for the present study was derived from a broader sample of 2240 subjects

with the full spectrum of psychotic disorders aimed at examining the network structure of 73

symptoms in the whole sample of psychotic disorders (Peralta et al., 2010). In the current study

we examined the subpopulation of 714 subjects with a lifetime diagnosis of affective psychosis,

which included exclusively major mood disorders with psychotic features or schizoaffective
th
disorder according to the Diagnostic and Statistical Manual of Mental Disorders, 4 edition

(DSM-IV) criteria (APA, 1994). This study population was derived from consecutive admissions

to the Psychiatry ward of the Complejo Hospitalario de Navarra between 1988 and 2012

(n=245) and outpatient facilities from the same catchment area between 2012 and 2014

(n=469). At study entry, and according to the modified remission criteria of Andreasen et al.

(2005), defined as a score of mild or less (≤2) in the global rating for psychotic and mood

symptoms simultaneously, 270 subjects (37.8%) fulfilled the criteria for a symptomatic remission

of the illness. Specific details about study methodology, enrolment procedure and assessment

of the subjects have been described in detail elsewhere (Peralta et al., 2020). Exclusion criteria

included drug abuse confounding diagnosis, major medical disease interfering with the

assessment procedure and neurological disorders including intellectual disability. The study was

approved by the ethics committee of the Regional Health Service of Navarra and written

informed consent was obtained from all study participants or their legal representatives.

The diagnostic breakdown of the study population was as follows: schizoaffective disorder

(n=124, 17.4%), bipolar disorder (n=345, 48.3%) and major depression (n=245, 34.3%). The

main demographic and clinical characteristics of the study population are displayed in Table 1.

2.2. Clinical and psychopathological assessment

6
Subjects underwent an extensive clinical examination by means of the Comprehensive

Assessment of Symptoms and History (CASH) (Andreasen, 1987). The CASH is a semi-

structured interview that served to assess demographics, illness-related variables,

psychopathology and diagnosis of psychotic and major mood disorders. Ratings were

performed by experienced psychiatrists or clinical psychologists who conducted face-to-face

interviews with the subjects and collected information provided by treating physicians, clinical

records and significant others. Interviewers showed good inter-rater reliability (intraclass

correlation coefficient >0.80) on most CASH items (Peralta et al., 2013). A lifetime diagnosis of

psychotic disorder according to the DSM-IV criteria (APA, 1994) was reached by consensus

among the senior authors (VP and MJC) using all available information.

The current condition module of the CASH includes a total of 73 symptoms that were rated at

their worst over the past month on a 6-point scale. The symptoms are grouped into a psychotic

syndrome (including 55 individual symptoms that are grouped into 10 symptom global ratings),

a major depression syndrome (including 10 individual symptoms and a global rating for the

syndrome) and a manic syndrome (including 8 symptoms and a global rating for the syndrome).

To maintain a balanced composition of mood and psychotic symptoms, in the present study we

included for analysis the 8 manic symptoms, the 10 depressive symptoms and the 10 global

ratings of psychotic symptoms. Mood items included in the CASH are very similar to those

included in current diagnostic systems of mania and major depression. We defined 4 a-priori

symptom domains, namely, mania, depression, positive and negative (Table 2).

2.3. Statistical analysis

2.3.1. Exploratory Graph Analysis and network estimation

We estimated the domain network structure of symptoms in the whole sample of affective

psychoses and within individual diagnoses. To evaluate the number and composition of

dimensions of psychotic and mood symptoms, we applied EGA using the EGAnet package

(Golino and Christensen, 2019) in R, which uses the igraph (Csardi and Nepusz, 2005) and

qgraph (Epskamp et al., 2012) packages to apply the walktrap and glasso methods,

respectively. The glasso method was estimated using a penalized maximum likelihood solution

based on the extended Bayesian information criterion (EBIC) (Chen and Chen, 2008; Epskamp

7
et al., 2018). The walktrap algorithm uses “random walks” (i.e., steps or jumps from one node to

another in the network) to identify the content and number of dimensions in the network. Each

node is repeatedly used as a starting point, traversing over neighboring edges, with larger edge

weights (i.e., partial correlation values) being more likely to be traversed. In this process,

communities form based on a node's proportion of many, densely connected edges and few,

sparsely connected edges. Nodes represent the individual symptoms and edges represent

partial Pearson's correlations between two symptoms controlling for all other symptoms in the

network.

2.3.2. Centrality estimation

Using the qgraph package we quantified the importance of each node to the network by

estimating 4 centrality indices: strength, closeness, betweenness and expected influence (EI).

Node strength is usually considered the main centrality parameter (McNally, 2016), however,

because EI also takes into account negative associations among nodes, it represents a more

accurate approach to node centrality than strength (Fonseca-Pedrero et al., 2018; Robinaugh et

al., 2016). Thus, in the present article, EI will be considered the main centrality measure. Items

with EI values ≥ 1 were considered as the most central items.

We measured the stability of the network using two statistics (Epskamp et al., 2018). The

stability of the EI parameter was evaluated using the node-dropping subset bootstrap, which

estimates the mean node EI of each variable for all subsets networks. The accuracy of edge

weights was measured by the 95% Confidence Intervals (CIs) obtained from 1000 bootstrap

samples drawn from the study population: the narrower the CI, the more accurate is the

estimate of the edge weights.

2.3.3. Network comparison

Networks were compared with the Network Comparison Test (NCT) (Van Borkulo et al., 2017).

The NCT is a permutation-based test in which network connectivity is estimated repeatedly

(1000 times in our analyses) for randomly re-grouped participants. The NCT assesses whether

two networks differ in global strength (overall connectivity, the weighted absolute sum of all

edges in the network) and network structure (distribution of edge weights). Furthermore, we

examined a similarity index (Rhemtulla et al., 2016) and the number of edges that significantly

8
differ across networks. Paired tests were 2-sided with an alpha threshold set at 0.05, and a

Bonferroni-Holm correction was applied to control for multiple testing.

2.3.4. Principal Component Analysis (PCA)

For the sake of comparability with previous studies and with data from EGA, we performed a

PCA of symptoms in the whole sample and in each diagnostic group. The eigenvalue >1

criterion was used to determine the number of factors to retain, and the promax method was

used to rotate the factors.

3. RESULTS

3.1. Dimensional network structure

EGA results of 28 CASH symptoms in the global sample and specific diagnoses are presented

in the Figure 1. In the global sample, EGA revealed 4 dimensions, namely, depression, mania,

positive and negative, which closely aligned with the predefined syndromes. SAD showed 4

dimensions: depression, core mania, positive and negative. Two depressive symptoms

(psychomotor agitation and suicidal thoughts/behavior) and 3 manic symptoms (distractibility,

talkativeness and racing thoughts) clustered together with the positive dimension, and 2 positive

symptoms (catatonia and attention) clustered together with the negative dimension. Of

particular interest was the position of suicidal thoughts/behavior, which clustered together with

the positive dimension rather than the depressive dimension and showed strong connections

with hallucinations, anhedonia and depressive mood. Symptoms of PBD clustered into four

dimensions: mania, depression, positive and negative. With the sole exception of psychomotor

agitation, which clustered together with the positive dimension rather than the depressive

dimension, all other symptoms clustered within their predefined syndromes. In PD, three

dimensions were observed: depression, activation and psychosis. The depressive dimension

was composed of all depressive symptoms plus two negative symptoms (avolition/apathy and

anhedonia/asociality). The activation dimension comprised only the symptoms of increase in

activity, decreased need for sleep and euphoric mood, while all other mania symptoms

clustered within an overarching psychotic dimension. The psychotic dimension comprised

9
positive, negative and some mania symptoms and to some extent had a “bipolar” structure with

some negative connections among symptoms mainly involving the manic ones.

3.2. Centrality estimation

EI centrality estimates varied widely across symptoms and diagnoses (Figure 2 and

Supplementary Figure 1). According to this parameter, the most central symptoms (z score >1)

in decreasing order of importance, for each diagnostic group, were as follows: whole sample:

delusions, increase in activity, bizarre behavior and depressive mood; schizoaffective disorder:

hallucinations, insomnia or hypersomnia, and increase in activity; bipolar disorder: delusions,

decreased need for sleep and increase in activity; and psychotic depression: depressive mood,

feelings of worthlessness, increase in activity, affective flattening and bizarre behavior. Of note,

increase in activity was a central symptom across all diagnostic groups. Items with the largest

variations in EI centrality (± 2 standard deviation) across diagnoses were decreased need for

sleep, hallucinations, anhedonia/ asociality, delusions and feelings of worthlessness

(Supplementary Figure 1).

EI centrality remained stable in all diagnostic groupings until 60% of nodes were sampled,

except in PD, where unsteadiness was observed after dropping a small proportion of the

sample (Supplementary Figure 2). Bootstraping indicated that edges were accurately estimated

in all subject groups except in SAD, in which larger 95% CIs were obtained (Supplementary

Figure 3).

3.3. Network comparison across diagnoses of affective psychosis

Types of affective psychoses significantly differed in their network structure (p<0.05) but not in

their network global strength (p>0.05) (Table 3). Compared to SAD and PBD, PD showed the

most dissimilar network structure. Furthermore, SAD and PBD had different network strength,

although at a trend level (p=0.098).

3.4. PCA of symptoms

PCA results are presented in Table 4. In the global sample, PCA resulted in four factors, which

were very similar to those observed in EGA analysis, except that some positive symptoms such

as formal thought disorders and catatonia loaded onto the mania and negative factors,

10
respectively. In subjects with SAD, PCA resulted in four factors plus an additional and difficult-

to- interpret mixed factor. In PBD, an additional fifth factor was observed that mainly included

catatonic behavior. In PD, 6 factors were obtained, and the EGA psychotic dimension broke up

into the factors of negative, positive and disorganization. Notably, between 18% and 29% of

items in each diagnostic class showed either lack of meaningful loadings or cross-loadings, thus

suggesting the lack of a clear symptom structure, which was particularly evident in PD.

4. DISCUSSION

This is the first study examining the dimensionality and network structure of psychotic and mood

symptoms in affective psychoses. Four were the main findings of this study: (a) classes of

affective psychoses largely differed in terms of number or item composition of dimensions,

network structure, and centrality of symptoms; (b) the connectivity pattern between mood and

psychotic symptoms highly depended on the specific diagnoses; and (c) EGA produced more

parsimonious and interpretable symptom structures than did EFA. In the following sections, we

will discuss these findings thorough.

4.1 Dimensionality and network structure by diagnosis

In the global sample, EGA resulted in four dimensions (mania, depression, positive and

negative) that were highly similar to the predefined syndromes with respect to symptom

composition. The most central (i.e., interconnected symptoms) were delusions, increase in

activity, bizarre behavior and depressive mood.

In SAD, EGA resulted in the dimensions of core mania, depression, positive and negative.

Notably, the positive dimension captured some depressive symptoms (psychomotor agitation,

suicidal thoughts/behavior ) and some mania symptoms (talkativeness, racing thoughts and

distractibility). Particular attention should be given to the strong connections of suicidal

thoughts/behavior across dimensions of psychopathology: hallucinations (positive),

anhedonia/asociality (negative) and depressive mood (depression). The most central symptoms

were hallucinations, insomnia/hypersomnia and hyperactivity.

In PBD, four dimensions were observed, which were very similar to those obtained in SAD but

with a cleaner symptom structure. The mania and positive dimensions were mainly connected

11
by the symptoms of increased self-esteem and delusions, which acted as “bridge symptoms”.

Furthermore, the depression and negative dimensions were mainly interconnected by the

respective symptoms of psychomotor retardation and alogia. The most interconnected

symptoms were delusions, decreased need for sleep and hyperactivity.

In PD, the symptoms clustered within three dimensions: depression, psychosis and activation.

The depressive dimension subsumed two negative symptoms (avolition/apathy and

anhedonia/asociality), and the psychosis dimension had a rather complex structure comprising

positive, negative and some manic symptoms. Interestingly, the psychosis and activation

dimensions were strongly interconnected, mainly through the item “increase in activity”,

suggesting that psychotic symptoms in PD may be drifted by a behavioral activation component

(Biondi et al., 2005). The activation component, which also comprises euphoric mood, suggests

a continuity between bipolar disorder and depressive disorder (Akiskal and Benazzi, 2005), and

supports previous findings that manic-like symptoms can be identified even in strictly diagnosed

unipolar depressives (Goldberg et al., 2009; Maj et al., 2006). The most central symptoms in PD

were depressive mood, feelings of worthlessness, hyperactivity, affective flattening and bizarre

behavior.

4.2. Similarities and differences across diagnoses

Major similarities across diagnoses were as follows: (a) the mania, depression and psychosis

dimensions were recognized in each diagnostic class, although with substantial variability

regarding their item composition, (b) increased in activity was among the most central

symptoms across diagnoses and in the global sample, and (c) networks did not differ in their

global network strength of the connections. Furthermore, broad similarities were observed

between SAD and PBD regarding the number and type of dimensions obtained such as their

main defined symptoms, a pattern that was also observed in the whole sample.

Beyond these similarities, important differences were observed among diagnoses in most of the

parameters examined. The item composition of the observed dimensions highly varied across

dimensions. Symptom networks significantly varied across diagnoses of affective psychoses,

which was particularly manifested by the different connectivity pattern of certain symptoms. For

example, as mentioned above, suicidality was strongly interconnected with hallucinations,

12
depressive mood and anhedonia/asociality in SAD, whereas it was mainly connected with

depressive mood in PBD and with feelings of worthlessness in PD. Delusions and hallucinations

also presented a differential connectivity pattern with mood symptoms depending on the specific

diagnosis; in SAD hallucinations were strongly connected with increased self-esteem, whereas

they were poorly connected with mood symptoms in PBD and PD. In a similar vein, delusions

were poorly connected with mood symptoms in SAD, but they were connected with increased

self-esteem in PBD and with depressive mood and feelings of worthlessness in PD.

Two negative symptoms, avolition/apathy and anhedonia/asociality, were strongly related to

depressive symptoms and formed integral part of the depressive cluster in PD. A similar

association pattern has been reported in mixed samples of psychotic disorders (Serretti and

Olgiati, 2004) that the authors explained by conceptual similarity among these two symptom

constructs. However, this explanation is unlikely, since this association pattern is disorder-

specific as it was only evident in PD. Indeed, it appears that, in PD, avolition/apathy and

anhedonia/asociality do not index negative features but depressive ones.

In line with the different network structure of classes of affective psychoses, node centrality also

showed important differences across disorders. The most central symptoms in SAD, PBD and

PD were hallucinations, delusions and depressive mood, respectively.

4.3. Comparison with previous studies

Given the lack of previous studies examining the dimensionality and network structure of

symptoms in classes of affective psychoses, a direct comparison with the literature is not

possible. Numerous studies have examined the symptom network structure of non-psychotic

depressive disorders (see(Contreras et al., 2019)for a systematic review); generally, they

reported centrality parameters of symptoms to vary across studies, and more specifically that

the most central symptoms are not necessarily those included in the DSM criteria (Fried et al.,

2016). Three previous studies examined the symptom network structure in bipolar disorder.

One study reported that the most interconnected symptoms highly varied as a function of

course type, and that loss of energy was a central symptom irrespective of the course type

(Koenders et al., 2015). Another study examined the differential network structure of negative

symptoms in schizophrenia and bipolar disorder, and found that anhedonia was most central in

13
bipolar disorder while alogia and avolition were the most central symptoms in schizophrenia

(Strauss et al., 2019). Last, a study of 272 adolescents with or at high risk for bipolar disorder

showed that fatigue, depressed mood and motor hyperactivity were the most central symptoms

(Weintraub et al., 2020). The different symptom centrality reported in these studies and in ours

may be explained by differences in the methodology among studies including sample

composition.

Another perspective about the symptom structure in affective psychoses comes from factor

analytical studies. As mentioned in the introduction, a major problem when examining this

question is the marked variability among studies regarding sample composition and rating

instruments to assess symptoms. Indeed, most studies have examined the symptom factor

structure in individual diagnoses, a few studies have examined pairs of diagnoses using

different rating scales (Anderson et al., 2017; Toomey et al., 1998), and no previous study has

used the same rating instrument(s) to assess symptoms in each diagnosis of affective

psychosis. Nonetheless, some findings from previous studies deserve consideration. In line with

previous factor analytical studies, we found that (a) affective and psychotic symptoms segregate

into separate dimensions (see for example(Ostergaard et al., 2015a; Serretti et al., 1999), (b)

combined diagnoses of affective psychoses exhibit a cleaner symptom structure than specific

diagnoses thereof (Anderson et al., 2017; Toomey et al., 1998), (c) the depressive dimension

had unique relationships with positive and negative symptoms in PD and SAD (Muller et al.,

2001), and (d) the factor structure of positive psychotic symptoms varies as a function of

specific diagnoses of affective psychoses (Anderson et al., 2017; Toomey et al., 1998).

However, unlike previous studies reporting a segregation of that dimension into reality-distortion

and disorganization subcomponents in mixed samples of affective and non-affective psychotic

disorders (Anderson et al., 2017; Stein et al., 2020), we found a single positive dimension

across diagnoses. Taken together, these findings while suggesting some continuity in the

dimensional structure of affective and non-affective psychoses, they are also indicative of

meaningful discontinuities between affective and non-affective psychoses and within classes of

affective psychoses, discontinuities that mainly concern the structure of positive symptoms and

their associations with mood symptoms.

4.4. Comparing the EGA dimensions and PCA factors

14
EGA appears to outperform traditional PCA of symptoms in some specific aspects. First, for

each diagnostic class, the EGA solutions were more parsimonious than the PCA solutions.

Second, EGA exhibited a more interpretable dimensional structure of symptoms than PCA,

which is mainly due to the graphical output showing the whole interconnections of nodes both

within and across dimensions. The EGA results, for example, provided graphical evidence for

the potential of some bridge symptoms to mediate between psychotic and mood dimensions,

whereas in PCA the interconnectedness of symptoms across dimensions is manifested by

cross-loadings of symptoms, which are often difficult to interpret. Third, and from a

methodological perspective, EGA outperforms traditional reduction techniques in terms of the

reliability of the parameters to be estimated as observed in simulation studies (Golino and

Epskamp, 2017) and in other psychopathological realms such as the study of psychological

constructs (Forkmann et al., 2018), and personality traits (Goekoop et al., 2012). The reason for

the superiority of EGA over PCA is that PCA identifies patterns of associations among variables

by isolating the factor that explains most variance in the data, after which its effect is linearity

subtracted from the data and the process repeats. Instead, EGA builds patterns of items in a

bottom-up process taking into account the whole picture of the data set by means of regularized

regression (Goekoop et al., 2012; Golino and Christensen, 2019).

Nonetheless, it should be acknowledged that, in the case of PD, the poor network stability, the

complex structure of the EGA psychotic dimension and the complex factor structure resulting

from PCA may all be due to intrinsic symptom structure heterogeneity and complexity in that

diagnosis.

4.4. Implications

We found EGA to be a robust methodology for determining the dimensional and network

structure of symptoms in affective psychoses. Our study adds to the emerging literature

demonstrating that EGA can produce reliable dimensional results, which together with network

metrics allows for determining the network structure and the most interconnected symptoms in

the network (Epskamp et al., 2018). An advantage of EGA was that the dimensions were

discovered without a priori direction and were interpreted without having to decipher the item

content of each dimension. In addition, this methodology provides a more detailed

15
representation of how items are interrelated and how the dimensions are located in

multidimensional space to one another. Relatedly, the network approach offers some

advantages over the DSM classification for conceptualizing and treating psychotic disorders.

Categorical classifications assume that symptoms are simply a result of the underlying disorder,

rather than influencing each other. As a result, categorical diagnoses are excessively rigid,

comorbid, heterogeneous and unable to capture the complex interactions between symptoms

from several psychopathological domains as is the case of psychotic and affective symptoms.

The finding that the dimensional and network structure of symptoms highly differs across types

of affective psychoses indicates that the employment of mixed samples of affective psychoses,

or more generally of psychotic disorders, may obscure the diagnostic-specific network

relationships between mood and psychotic symptoms. In this regard, our findings do not support

a transdiagnostic approach to psychotic disorders from a network perspective, since we could

not demonstrate a similar structure of symptoms both within and across diagnostic categories

(Barch, 2020).

The observed differences in the association pattern between mood and psychotic symptoms

might give rise to tailored treatment hypotheses. Within a network framework, two type of

interventions are possible, those that target nodes (node-interventions) and those that target

connections (edge interventions) (Isvoranu et al., 2020). For example, in PD a node-intervention

would be directly aimed at the reduction of depressive mood and feelings of worthlessness, the

most central symptoms, with antidepressants drugs, while in PBD and SAD the treatment would

be directed to reducing delusions and hallucinations, respectively, by means of antipsychotic

drugs. An example of an edge-intervention targeting relations between symptoms would be that

directed to the strong link between suicidal thoughts/behavior and hallucinations in SAD. In this

regard, interventions aimed at improving the coping skills strategies of the person with the

auditory hallucinations by means of cognitive-behavioral therapy may reduce the suicidal risk.

The disorder-specific association between some negative symptoms such as avolition/apathy

and anhedonia/asociality in PD has implications on how negative symptoms are defined in

psychotic disorders. A well-established fact is that negative symptoms may be secondary to a

number of conditions including depression, the so-called “secondary negative symptoms”

16
(Carpenter et al., 1988). Such a distinction, however, is not always feasible as some individuals

show a mixture of primary and secondary negative features (Peralta and Cuesta, 2004). Thus, it

is important to disentangle which negative symptoms are more related to depressive symptoms

across types of psychotic disorders. In this regard, our study shows that avolition/apathy and

anhedonia/asociality are more linked to depressive symptoms than other negative features

across affective psychoses, and that in presence of psychotic depression they should not be

considered as negative symptoms at all.

The present findings also suggest useful directions for further studies about the symptom

network structure of affective psychoses, since, for instance, it has yet to be determined those

bridge symptoms by using specific bridge centrality parameters (Jones et al., 2019).

4.5. Limitations

While we collected a broad sample of subjects with affective psychoses, the frequency of

individual diagnoses highly varied. More specifically, the sample of subjects with SAD may have

been too small to apply network psychometrics reliably (Fried and Cramer, 2017), as shown by

the broad bootstrapped CIs. Thus, results concerning this diagnosis need to be interpreted

cautiously and considered provisional.

The dimensional structure of symptoms is highly dependent on the method used to assess

symptoms. In this study, we tried to balance the most relevant mood and psychotic symptoms

using a comprehensive rating instrument to assess them, however, this does not exhaust the

broad range of meaningful mood and psychotic symptoms in defining the networks, and rating

instruments with different item content would likely result in different findings. In this regard, it

has been reported that some non-DSM depressive symptoms may be more central that some

DSM symptoms in depressive disorders (Fried et al., 2016) and that mood lability and irritability

are "bridge" symptoms connecting the two mood poles in bipolar disorder (Weintraub et al.,

2020). Furthermore, the use of global, rather than item-level, ratings of psychotic symptoms

might have obscured some relationships of affective symptoms with more fine-grained psychotic

features.

17
Previous studies have shown that the stage and course of the illness may influence the

symptom or network structure of symptoms (Koenders et al., 2015; Maziade et al., 1995; Peralta

et al., 2002). We did not perform separate analysis for subjects stratified on the basis of these

and other variables (i.e., inpatient vs outpatient status or remitted vs. unremitted subjects) due

to limited sample size, and future studies should address these issues in larger samples of

affective psychoses.

Due to the cross-sectional nature of the data, the estimated networks do not provide information

about the direction of the relationships among symptoms. For affective psychoses, it would be

of paramount importance to disentangle such a directionality, for example, the degree to which

mood symptoms may trigger psychotic symptoms (outdegree centrality) or vice-versa (indegree

centrality). Longitudinal studies monitoring the temporal sequence of symptoms allow for

differentiating between these two types of centrality, and future work focusing on the

directionality of affective and psychotic symptoms promises important insights in this regard.

Last, a limitation of the community detection algorithm of EGA is that items deterministically

belong to only one community. For psychopathological data, where symptoms are highly

connected, this is an issue. However, examining the edge strengths of a given item allows for

determining the extent to which the item is connected with other dimensions. In this sense, the

development of algorithms that allow items to belong to multiple communities at the same time

is a desirable goal.

Credit authorship contribution statement

Victor Peralta: Conceptualization, Methodology, Writing. Gustavo J. Gil-Berrozpe: Statistical

analyses, Editing. Review. Ana M. Sánchez-Torres: Statistical analyses, Editing. Review.
Manuel J. Cuesta: Conceptualization, Methodology, Review. All authors have approved the
final version of the manuscript.

Funding

The study was funded by the Carlos III Health Institute (FEDER Funds) from the Spanish
Ministry of Economy and Competitiveness (grant number PI16/02148) and the Regional
Government of Navarra (grant number 31/17).

18
The funding sources had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approval of the
manuscript; and decision to submit the manuscript for publication.

Declaration of Competing Interest

All the authors have no relevant conflicts of interest to report.

Acknowledgements

We thank all participants of the study and their families.

Table 1. Demographic and clinical characteristics of the study sample

Schizoaffective Bipolar Psychotic

Total
disorder disorder depression
(n=714)
(n=124) (n=345) (n=245)

Age, y 39.9 (14.9) 41.9 (15.7) 45.6 (15.7) 42.8 (15.7)

Gender, male, n (%) 62 (50) 161 (46.7) 102 (41.6) 325 (45.5)

Civil status, single, n (%) 67 (54.0) 158 (45.8) 84 (34.3) 309 (43.3)

Education, y 10.2 (3.49) 10.2 (3.50) 9.40 (3.05) 9.92 (3.37)

Age at illness onset 26.4 (9.88) 27.9 (11.53) 33.8 (12.8) 29.7 (12.1)

Number of hospitalizations 4.73 (5.39) 3.34 (4.24) 1.47 (1.82) 2.94 (4.02)

Course pattern 1.70 (0.66) 1.30 (0.58) 1.32 (0.55) 1.38 (0.60)

Global assessment of functioning 68.1 (19.1) 76.2 (15.7) 78.0 (14.9) 75.4 (16.4)

Full employment 33 (26.6) 164 (47.5) 133 (54.3) 330 (46.2)

Table 2. Mean scores of symptoms in the networks and their abbreviations grouped by a priori
defined symptom domains

Item domain Item label Item description Mean (SD)

Mania eup Euphoric mood 0.98 (1.54)
act Increase in activity 0.82 (1.37)
rac Racing thoughts 0.64 (1.20)
tal Talkativeness/pressure of speech 0.65 (1.27)
est Inflated self-esteem 0.73 (1.42)
sle Decreased need for sleep 0.87 (1.37)
dis Distractibility 0.66 (1.25)
jud Poor judgment 0.71 (1.34)

19
Depression dep Depressive mood 1.26 (1.75)
app Change in appetite or weight 0.77 (1.28)
smn Insomnia or hypersomnia 1.25 (1.51)
agi Psychomotor agitation 0.75 (1.36)
ret Psychomotor retardation 0.72 (1.33)
ple Loss of interest or pleasure 1.32 (1.76)
ene Loss of energy 1.02 (1.57)
wor Feelings of worthlessness 0.97 (1.57)
cnc Inability to think or concentrate 1.35 (1.56)
sui Suicide thoughts/behavior 0.58 (1.21)
Positive DEL Delusions 1.26 (1.78)
HAL Hallucinations 0.64 (1.30)
FTD Formal thought disorders 0.62 (1.21)
BIZ Bizarre behavior 0.84 (1.35)
ATT Attentional disturbances 1.14 (1.57)
CAT Catatonia 0.40 (0.95)
Negative FLA Affective flattening 0.62 (1.16)
ALO Alogia 0.56 (1.20)
AVO Avolition/Apathy 0.95 (1.55)
ANH Anhedonia/Asociality 1.07 (1.62)
Table 3. Network comparison across diagnoses of affective psychoses

Group comparison S (p) M (p) SI

Schizoaffective disorder vs Psychotic bipolar

1.819 (0.098) 0.359 (0.019) 0.327
disorder

Schizoaffective disorder vs Psychotic

0.363 (0.712) 0.466 (0.026) 0.271
depression

Psychotic bipolar disorder vs Psychotic

1.455 (0.128) 0.517 (<0.001) 0.205
depression

S= network global strength, M= network structure (maximum difference value in any of the edge
weights of the compared networks); SI=similarity index.

a
Number (and %) of edges that significantly differ across a pair of networks over the total of
edges (n=714).

Table 4. Principal Component Analysis of mood and psychotic symptoms in the global sample,
schizoaffective disorder, psychotic bipolar disorder and psychotic depression

Global sample Schizoaffective disorder Psychotic bipolar disorder Psychotic depression (n=245)
M D N
(n=714) P M D (n=124)
N P M M D (n=345)
N P M D M N P A D
Euphoric .8
A .0
E E- .0
O .6
A E- .0
E .1
O .0
IX .9
A .0
E .0
E .0
O O- E- .4
A .1
E O- .5
C -I
Increase
mood in .9
N7 .0
0
P G-
.0 .0
4
S .7
N3 P-
.1 G0- .1
9
S .0
2 .9
N2 0-
P G2- .0
5
S T-
.1 P-
.0 .8
N1 .0
G3 S-
.0 .1
8
T .0
.1
S
Talkativene .7 .0 .5 .8 .5
activity 1 1 6-
.0 .1
3 7 3-
.0 .0- .2
3 .2
9 0 0- .0- .0
5 .0
.0
4 .0
.0
3 .1
3 5- .3
.0
8 4 .0
6
4
Racing
ss/Pressure .7
8 0- 4-
.1 .1
9 .6
6 8-
.0 2-
.0 7- .2
3 .6
3 1-
.0 2-
.0 .1
7 .1
4
2 .0
4
5 2- .3- .0
0
1 .8
6 .0
5
Inflated self-
thoughts/Fli
of speech .8
2 .0- 0-
.0 3- .7
6 9-
.1 4-
.0 .2
.0 2- .9
6 4-
.0 4-
.1 1- 3- .0
7 .9
.2 0-
.0 .0
2 9- .0
6
Decreased
esteem
ght of ideas .9
7 .1
.0
5 6-
.0 .0- .9
0 .1
.0
1 4-
.0 1-
9 .1- .9
3 .1
.0
3 4-
.0 .1- .0- 1- .4
6
9 .2
.0
1 0- .5
.0 0-
Distractibilit
need for .8
8 .0
4
1 .1
.0
7 1-
.2 .8
9 .1
6
4 .2
.0
8 .2- 5-
.0 .6
7 .1
7
2 2-
.0 2-
.2 .3
.1
6 .0
.0 .9
6 8-
1 .0- 8-
0 .0
.0
Poor
ysleep .9
4 .0
2 6-
3 4-
.1 .8
5 .1
1 6-
0 1-
.1 .1
.0
6 .9
4 .0
3 4-
.1 2-
.0 1-
6 .0
5
6 .9
5 .0- 8-
.0 .1- .0
0
8
Depressive
judgment 2- .8
5 .0
.0 .0
.0
4 7- .8
0 .0- .2
.0
5 .1
3
4 .0
3 .8
0 .2
.0
0 9-
.1 .0- .8
7 0- .0
.0
9 .1
.0
2 .0
.2
1 3-
Change in
mood .0
.0 .9
5 6-
7 7-
5 .1
.2 .9
0 6-
.0 4-
0 .2
1 .0
8 .8
0 3-
1 .0
.0
2 .0
.1
2 .9
2 .0
.0 .0
9
4 5-
2 5-
4 .1
.0
appetite or 5
6 3 .0 .0 1
2 2 .1
3 .1 3 0 8 .1 9
9 3
1 7 5
8 1 .1 .0 1
2
weight 7 2 1 2 9 8 5
20
Insomnia or .1 .8 - .2 .2 .7 - - .4 .0 .7 - .5 - .9 .0 - - .0 .1
Psychomoto
hypersomni .0
2 .3
6 .2- .6
1 .2
0 .2
6 .0- .0
.0 .7
4 3- .1
1 .2- .8
0 .2- .5
4 5- .1- .1
.0 .1
1 .5
3
Psychomoto
ra agitation .0
4 .5
8 .4
.2
0 8- .0
3 .5
0 .5
.0
7 .0
9
4 3- .0- .6
8 .1
.1
1 6- .4
.0
0 .5
5 .0
.0 .5
.2
1 8-
1 3- 3-
rLoss of
retardation .0
1 .9
4 .0
8
2 .1- 6- .8
1 .0
0
5 7- .0
.3 .0
.1
2 .9
4 .0
3
1 .1- 7-
0 .9
2 1-
1 .0
3
4 .0- .0
.0 .0
.0
Loss of or
interest .0
3 .8
5 .2
3 6-
.1 .0- .7
7 .2
6 .0
.1 3-
1 .0
5
4 .8
2 .2
3 3-
.1 .0- .8
7 .0- .2
3 2-
.1 3-
2 2-
0
Feelings of
energy
pleasure 4- .8
1 2- .1
.1
6 .0
.0
2 .8
5 0- .1
4
2 .0- 8- .7
2 0- .0
.1
6 .2
.0
6 .8
2 .0
.0
1 6- .1
.1
3 .1
.0 .1-
Diminished
worthlessne .1
.0 .6
2 .2
.0 8-
5 .1
6
8 .5
8 .4
.1 9- 6-
.0 .0
.1 .6
1 .0
.0 .1
4
7 .1
9
2 .7
4 .0
3
4 .2
.1 1-
5 .0
0
1 .2
.0
4
Suicidal
ability
ss to 6-
6 .5
4 8-
6 .3
.0 9- .4
3 7-
7 .4
.0 .0
.0
9 7-
2 .3
9 .3
0
4 .1
8 6- .5
0 .0
4 2-
3 .4
.2 1- 2-
9
Delusions
thoughts/be
think or .1
.2 .0
9 .0
.1 .7
2
4 .0
.4 .1
3 .0- .8
0
4 .1
7
1 .3
.0 8- .2
7 .4
4 .3- .2
1 1- .0
.3 .6
6
0 .0
.0 .0
.0
Hallucinatio
havior 5-
5 9- .0
4
5 .8
2 5-
1 .1
3 7-
.1 .9
2 0- 2-
9 .1- .0
7 .8
8 .0
.0
8 3- .0- .1
9
1 .8
2 .0
5
7 .0
7
7
concentrate
Bizarre
ns .4
.1 .0- .2
9 .4
3 .1
.0 7- .2
.0
9 .4
3 .3
.1 .5
.1 6-
.1 .2
9 .1
3 .1
3
1 .2- .2
.1
3 4 .4
8 .1
5 .4
8
Formal
behavior .4
5
1 9-
.1 .3
0 .2
2 .1
6
7 .2- .3
6
2 .6
5 1-
1 .4
7
0 4-
.2 .1
0 .0
7 .4
6 0-
.1 .0
8
1 .6
.1 7- .0
2 .6
0
Attentional
thought .3
4 .0
.2
9 .3
5 .3
9 .2
3 5-
.1 .6
0 .2
2 .0- .3
9 .1
.1
0 1- .3
7 .3
2 .0
.1
7 0- .3
1
4 .2
.0 2- .5
8
Catatonic
disturbance
disorders .2
2 5-
0 .6
6 1- .2
4 0-
.0 .6
5 .0
4 5-
.0 .0
3 .0
6
2 .0
.0 8- .7
0 .0
8
7 .0- .7
3 8-
2 .1
.1 .1
2
Affective
motor
s 1- .0- .8
6 .1
.0 3- 7-
.0 .8
5 .0
6 .1
.1
1 7- .0
8 .6
3
1 .2
.0 .2
6 .0
8 .0
.0
3 .7
4 .2
.1 5-
8 .0
7
Alogia
flattening
behavior .1- 4-
.0 .9
1 4-
7 .2- .0
.1
6 .8
3 4- .0
7
4 .0
.1 .0
2 .7
8 1-
3 .2
0 5- 9-
8 .8
0 .1
9
4 .1- .2
7
Avolition/Ap 7-
.0 .2
.0
2 .6
5 .0
.1 5-
.0 .0
0
2 .5
8 .2- .6
2 .0
0
6 .0
1-
8 .8
7 .0
.0
.1
.0 .4
4 .4
.2
.00 6-
.0 1-
Anhedonia/
athy 4-
.0 .2
3
7 .5
5 .2
5
4 2-
.1 .1
2 .5
6 .0
.1
1 .3
0 5- .0
.0-
4 .8
9 .0
1
95-
9 .3
3 .4
.4
3
80 .0
.0
9 .2-
MAN=mania,
Asociality DEP=depression,
.2
8 8 4NEG=negative,
0 3 POS=positive,
.1 5 8 7MIX=mixed,
6 1 .0 MOT=motility,
2 5 ACT=activation,
4 .1
1 1 DIS=disorganization
.0 3 1 5
6 .1
0
0 are boldfaced
Factor loadings ≥.40 8 4 6 7 4

Figure 1. The dimensional and network structure of affective psychoses.

21
Each node (circle) represents a symptom, and each edge (line) represents the association
between two symptoms. Positive edges appear green, negative red, and stronger and saturated
represent regularized partial correlations.
See Table 2 for abbreviations.

22
Figure 2. Expected influence centrality across diagnostic groupings.

See Table 2 for abbreviations

23
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