Psychosomatics 41:418-425, October 2000
© 2000 The Academy of Psychosomatic Medicine
Dimensions of Psychopathology in the Medically Ill
A Latent Trait Analysis
David M. Clarke, M.B.B.S., M.P.M., Ph.D., FRANZCP,
Andrew J. Mackinnon, Ph.D.,
Graeme C. Smith, M.B.B.S., M.D., D.P.M., FRANZCP,
Dean P. McKenzie, B.A., and
Helen E. Herrman, M.B.B.S., M.D., FRANZCP
Received November 24, 1999; revised February 4, 2000; accepted April 27, 2000. From the Consultation-Liaison Psychiatry Research Unit and the Mental Health Research Institute, Department of Psychological Medicine, Monash University; the Victorian Transcultural Psychiatry Unit; and the Department of Psychiatry, University of Melbourne, Australia. Address correspondence and reprint requests to Dr. Clarke, Department of Psychological Medicine, Monash Medical Center, 246 Clayton Road, Clayton, Victoria 3168, Australia; e-mail: david.clarke{at}med.monash edu.au
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ABSTRACT
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The authors examined the latent structure of psychiatric symptoms occurring in patients with medical illness. Symptom data were collected from 312 hospitalized medically ill patients using the Monash Interview for Liaison Psychiatry and subjected to latent trait analysis. A model with 5 dimensions provided an acceptable fit to the data. Dimensions were characterized as demoralization, anhedonia, autonomic anxiety, somatic symptoms, and grief. The demoralization dimension was similar to the concept of demoralization described by Frank and to the "giving up-given up complex" described by Engel. The concepts of demoralization, grief, and anhedonia may be useful in increasing understanding of the minor depressions in people with medical illness and in increasing the specificity of psychological and pharmacological treatments for these disorders.
Key Words: Grief • Demoralization • Depression
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INTRODUCTION
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There is a considerable amount of literature highlighting the difficulty of the traditional psychiatric diagnostic systems to adequately describe the nature and range of clinical phenomena seen in patients presenting with comorbid physical and psychiatric disturbances.1,2 An example of this is the diagnosis of depression, where questions arise concerning the significance of somatic symptoms,3 the relationship between depressed mood and biological factors,4,5 and the importance of minor depression and mixed emotional states.6,7 Therefore, we decided to examine the relationships between psychiatric symptoms in patients presenting with medical illness in a manner not constrained by current diagnostic structures. A dimensional approach, considered most suitable for non-psychotic illness,8,9 was used. The structure of the symptom data was examined from a group of patients admitted to a general hospital for non-psychiatric reasons using latent trait analysis, which is used by researchers for similar purposes in primary care.10,11 Because the range of symptoms to be explored was wider than the range used in current diagnostic systems and in other structured interviews, a new interview schedule was developed and used—the Monash Interview for Liaison Psychiatry (MILP). The reliability and validity of this interview have been described.12
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METHOD
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Sample
We conducted the study at Monash Medical Center, a metropolitan, university-affiliated general hospital in Melbourne, Australia. During the study period all patients admitted to the general medical wards, who were able and willing, completed a 36-item version of the General Health Questionnaire (GHQ).13 To increase the overall prevalence of symptoms in the dataset and to approximate a clinical sample of the type referred to consultation-liaison (C-L) psychiatry, patients who were selected scored above a 20/ 21 cutoff (using binary scoring in the manner of Goodchild and Duncan-Jones).14 This cutoff was used on the basis that it has good sensitivity for a broad range of disturbance in a medical population.15 We excluded patients who were unable to complete the forms because of mental or physical incapacity or inadequate fluency in the English language. During the study, 2,927 patients were screened and 988 (34%) scored above the cutoff. Of these, 312 patients were chosen at random for interview. The mean age of the patients interviewed was 47.5 years (range: 18–85 years) and 61% were women—similar characteristics to those of the patient population.16 Other demographic characteristics of the sample were as follows: 72% Australian-born; 10% immigrant from non-English speaking countries; 80% completed 9 years of schooling (mid-secondary level); 50% married; 70% living at home; 23% living alone; 43% supported by pension or benefits. The most common medical diagnoses given were cardiovascular (22%), gastrointestinal (17%), respiratory (15%), rheumatological (13%), and neurological (11%).
The Monash Interview for Liaison Psychiatry
The MILP is a structured interview that includes information necessary to make DSM-IV and ICD-10 diagnoses, but it also includes a wider range of symptom data as described in the literature relevant to the medically ill. The MILP was developed as part of the current research program, in the same population, and has been described fully elsewhere.12 Symptoms were determined at the interview to be present or absent, and their duration recorded. In the case of physical symptoms, a judgment was made concerning the likely cause, and symptoms were coded as one or more of the following: medical illness or injury, medication, drugs or alcohol, psychogenic, or "unexplained." The mean kappa coefficient of agreement for coding items between two raters was 0.83.12 Interviews were carried out by two research psychologists who had been involved in the original development and reliability testing of the MILP; the interview occurred within the first 3 days of the patients' admission to the hospital.
Data Analysis
Analysis was confined to symptoms within the depression, anxiety, and somatic sections of the interview. Symptoms were recorded as "present" if they were present during the previous month and judged by the interviewer— after consultation with treating doctors if necessary—not to be solely because of a physical cause (illness, medication, drugs, or alcohol). That is, symptoms were either "unexplained" or thought to be of a psychological origin.
The interview contained 166 symptom items in the relevant sections. Forty-six items with a prevalence of less than 5% were excluded from subsequent analyses. Although rare symptoms may be important markers of certain dimensions, they are statistically uninformative as discriminators of dimensions common to the item pool. One item specific to women was also omitted, leaving 119 items. Eleven items had been asked contingent on responses to a "gatekeeper" question and were not included in the main analysis, but they were examined independently. These questions related to the experience of grief and of posttraumatic stress. Thus, 108 items were entered into the main analysis.
Commonly used methods of establishing the latent structure of a set of variables, such as factor analysis, are not applicable to binary data. Accordingly, the multidimensional latent trait model developed by McDonald17,18 was used. The latent trait model, also adopted by Goldberg et al.10 and Ormel et al.,11 may be thought of as an analog of factor analysis applicable to binary data. Latent trait analysis yields for each symptom a slope parameter that indicates the discriminating power of the symptom on a dimension, and a threshold parameter characterizing where the symptom lies on the underlying dimension. Because we focused on the number and nature of the dimensions underlying the pool of symptoms studied, slopes were transformed into correlations between each item and the trait using the formula a=s/ (1+s2), where a is the correlation and s is the slope. These correlations can be interpreted in the same way as factor loadings and may also be manipulated by orthogonal or oblique rotation methods. The loadings presented in this analysis were subject to varimax rotation. The NOHARM computer program was used to estimate and transform model parameters.19
The first phase of the analysis was to determine the number of dimensions required to adequately represent the 108 symptoms. We examined exploratory solutions having from 1 to 10 dimensions. Goodness of fit of each solution was summarized by Tanaka's Index and by the root mean square (RMS) of residuals of the proportion of symptom co-occurrence predicted by the model and those observed in the data (RMS residual).18 The former coefficient takes a value of 1.0 if the model fits the data perfectly and 0.0 if the fit is no better than chance. The latter index has no upper bound but takes smaller values as fit improves and has a value of zero if the model is a perfect fit to the data. Experience suggests that a Tanaka's Index exceeding 0.80 is indicative of an acceptable level of fit. In a manner analogous to factor analysis, it is also possible to calculate the percentage of the variance that is accounted for by a solution and by individual factors. These percentages relate to unit normal traits assumed to underlie each binary symptom.
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RESULTS
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Figure 1 shows Tanaka's Index and the RMS residual for exploratory models ranging from 1 to 10 dimensions. Both plots show that substantial improvement in fit occurs from 1 to 2 dimensions and from 2 to 3 dimensions. Improvements in fit with the addition of further dimensions are more modest. Accordingly, we examined in detail the structures of the 4-dimensional and several higher dimensioned solutions. Although better values of the goodness of fit indices may be preferable on technical grounds, solutions with more than 4 dimensions resulted in minor and indistinct dimensions emerging, containing only a few items with substantial loadings. Percentages of variance accounted for rose linearly with increasing dimensionality, thus providing no additional support for the choice of any particular solution. Considering all these factors, we adopted the 4-dimensional solution; this solution accounted for 34% of the total variance.
4-Dimensional Solution
The results of the 4-dimensional solution appear in Table 1. Dimension 1 accounted for 12% of the variance and includes symptoms of dysphoric and flattened mood (depressed, sad, irritable, angry, loss of reactivity), anxiety (feeling anxious, apprehensive, keyed up), low self-esteem and confidence (self-reproach and guilt), suicidal thought, feelings of losing control, and being helpless and unable to cope. This dimension is broader than depression, and it appears to be a distress syndrome similar to the "demoralization" as described by Frank.20 Anhedonia appeared as a distinct dimension (Dimension 2) accounting for 8% of the variance. Dimension 3 clearly represents anxiety with a large number of autonomic symptoms, worry about health, and feeling panicky and phobic, accounting for only 3% of total symptom variance. Dimension 4 contains the remaining somatic symptoms of fatigue, musculoskeletal aches and pains, and gastrointestinal disturbance, accounting for 11% of the variance.
In addition to the orthogonal rotation presented, an oblique rotation (promax) of the dimensions was undertaken. This left the interpretation of the dimensions unchanged but suggested that moderate correlations between some dimensions might exist. This is explored below.
Analysis of Grief and Posttraumatic Stress Items
We administered 5 items concerning grief in the MILP only after patients responded positively to a "gatekeeper" question acknowledging that they could identify a "loss" and could attribute their mood disturbance to that "loss." Similarly, 23 items relating to posttraumatic symptoms were asked only if patients acknowledged having had memories of a particularly traumatic event. Because these questions were not asked of all patients, their inclusion was precluded in the main analysis. The number of patients affirming the presence of posttraumatic stress symptoms was too small (less than 5% for 17 symptoms) for a subsidiary analysis, even though it has been shown that such symptoms are important in surgical and other medical settings.21 However, 140 patients (45%) acknowledged a "loss" experience, and we analyzed the 5 grief symptoms separately for these patients using the same method applied to the larger pool.
A unidimensional model fitted the grief data well. The RMS residual for this model was 0.0100 and the Tanaka's Index was 0.9933. All 5 items loaded positively and substantially on the single dimension (see Table 2). Given that the stem question did not load significantly on any of the 4 dimensions found for the main item pool, this analysis provides evidence that grief reaction is a dimension in the data substantially independent of the other dimensions already described.
Correlation of Dimensions
Scale scores corresponding with each dimension were derived by summing the number of symptoms affirmed present by each patient loading 0.40 or greater. Pearson correlations between scale scores are presented in Table 3. The 3 dimensions of demoralization, autonomic anxiety, and somatic symptoms were moderately correlated. Anhedonia was moderately correlated with demoralization but not autonomic anxiety or somatic symptoms. Grief was not highly correlated with any other dimension.
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DISCUSSION
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In our analysis of symptom data obtained from patients admitted to a general hospital with medical illness, 5 moderately correlated "dimensions" of psychopathology have been identified by latent trait analysis. No similar analysis has previously been undertaken on a sample of hospitalized medically ill patients. A number of studies report latent trait analyses of symptoms in patients seen in primary care. Goldberg et al.10 studied data derived from the interview of 283 patients drawn from general practices in Manchester, England. Goldberg et al.10 used the Psychiatric Assessment Schedule22 to assess patients and entered 36 items into a latent trait analysis, finding two highly correlated dimensions of anxiety and depression. Ormel et al.11 repeated the procedure on data from 301 patients drawn from general practices in the Netherlands. Assessment was by the Present State Examination23 and entered 32 items into the analysis, including 5 items not included in the Manchester study. Analysis revealed a third dimension, with anxiety splitting into generalized anxiety and phobic anxiety. The latter dimension included ideas of self-reference, pathological guilt, and self depreciation; symptoms perhaps usually considered depressive.
However, the important difference between these two studies and the present one is the increased number of dimensions found in this study, with differentiation of grief and somatic symptom dimensions and the elaboration of demoralization. Frank20 describes demoralization resulting principally from a "failure to cope with internally or externally induced stresses" and being characterized by feelings of impotence, isolation, and despair. Although depression and anxiety are common accompanying symptoms, demoralization is not simply a combination of anxiety and depression. Also, demoralization is similar to the "giving up-given up complex" described by Engel,24 where there is "an inability to cope, variously voiced as "discouragement," "despair," "giving up," or "depression," accompanied typically by the affects of hopelessness and helplessness. Interestingly, suicidal ideation loaded on the demoralization dimension rather than the anhedonia dimension, and this is consistent with research showing the association between suicidality and hopelessness.25
The most important difference methodologically between the present study and the ones by Goldberg et al.10 and Ormel et al.11 is the range of symptoms included. After excluding items with a prevalence of less than 5%, the present study was able to use 108-symptom items in the main analysis, reflecting the breadth of the MILP inquiry. The other studies both had only 1 item for "loss of interest" compared with the 4 in this study. Similarly, the present study included a wider range of somatic symptoms than the other two studies, including pain, autonomic, gastrointestinal, and musculoskeletal symptoms. This may explain why the somatic and anhedonia dimensions emerged. Also, the patients in our study were probably more medically ill than patients in the other two studies; although this would not be expected to change the fundamental latent structure of psychopathology, it may affect the range of symptoms described.
Our results support the view that anhedonic depression can be distinguished—as a different "thing" in the taxonomic sense26—from demoralization or a syndrome of general distress. This idea is not new27 and may help to clarify what might be different between "major" and "minor" depressions. Although differences in the respective clinical pictures and treatments of major depression compared with adjustment disorders have been described,28,29 these have been differences of degree rather than of substance. However, de Figueiredo30 distinguishes demoralization from depression on phenomenological grounds, noting that the hallmark of demoralization is incompetency— being uncertain about the appropriate direction of action— while with depression the problem is a loss of motivation, even when the appropriate direction of action is known. Snaith31 argues that, amidst the common and nonspecific symptoms of distress, anhedonia determines what is likely to be biogenic and to respond to biological treatments. This was also the view of Klein32 who created the term "endogenomorphic depression" to describe the syndrome. Furthermore, the results of this study have a similarity with the tripartite model of Clark and Watson,33 which includes dimensions of general distress ("negative affectivity"), specific depression (anhedonia), and specific anxiety.
The results also support the concept of "grief" in the medically ill—that is, a mood disturbance understood as a reaction to a real or imagined loss.34,35 If grief in medically ill patients can be further validated, then this concept has implications for understanding the process of many mood disturbances in the medically ill as well as providing a model to enable intervention. Whether grief can be separated from depression cannot be answered from our study because we examined the symptoms separately, although the single item representing grief in the main analysis did not load significantly on any of the 4 dimensions. However, there is evidence elsewhere that complicated grief can be distinguished from depression.36
It is of interest that somatic symptoms were mostly divided between 2 dimensions: autonomic anxiety and the remaining symptoms grouped together. Our analyses found no distinction made among fatigue, musculoskeletal, or gastrointestinal groups of symptoms. Goldberg et al.10 and Ormel et al.11 found no somatic dimensions in their analyses; this may simply reflect the fact that there were few somatic symptoms entered into the analyses. However, using data from the World Health Organization (WHO) study of psychological problems in primary care,37 Goldberg9 has described a model with 3 dimensions of depression, anxiety, and somatic symptoms created by symptom counts. The 3 dimensions were substantially correlated (rank correlations=0.48, 0.53, and 0.68, respectively). Few studies have sought to examine the latent structure of somatic syndromes. Swartz et al.38 conducted a "grade-of-membership" analysis on symptom data collected on 1,626 people in North Carolina during the National Institute of Mental Health Epidemiologic Catchment Area study. They included 47 somatization symptoms, together with 3 depression symptoms and 1 anxiety symptom. Swartz et al.'s results support the presence of a general "somatization" class and a class of autonomic symptoms; although some other, less well-defined groups, also emerged. Kirmayer and Robbins39 used confirmatory factor analysis to test a 5-dimensional model involving the syndromes of fibromyalgia, chronic fatigue, irritable bowel, somatic depression, and somatic anxiety. Kirmayer and Robbins used 23-symptom items relevant to these syndromes, obtained by interviewing 698 general practice attendees. Similar to the findings in Robbins et al.,40 Kirmayer and Robbins concluded that the 5-dimensional model fitted the data better than alternative models. Both Kirmaer and Robbins39 and Robbins et al.40 used restricted datasets. A factor analysis of somatic symptoms in the large WHO primary care study was interpreted to reveal 4 "meaningful groups";41 although an examination of the contents of these groups suggests that differentiation might not be as clear as first thought. Certainly studies in chronic somatizing patients indicate that monosymptomatic types of persistent somatizing are rare,42 and it is evident from community samples43 and primary care9 that multisomatic symptom presentations are common and highly correlated with distress expressed as depression and anxiety.
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CONCLUSION
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Our study examines the dimensionality of the psychopathology found in hospitalized people who are medically ill. We collected a broad range of symptom data at interview and applied an appropriate method of numerical taxonomy. The sample is representative of a large and important group of patients presenting in the general health sector. Most differences between the results of our study and other similar studies are explained by the range of clinical data collected and analyzed. The analyses suggest that the concepts of demoralization, grief, and anhedonia are distinct and may be clinically useful to further characterize minor depressions and provide increased specificity for the prescription of psychological or pharmacological treatments of mood disorders in the medically ill. It will, of course, be important to validate these concepts in a range of populations with medical illness and to examine the effects of specifically targeted interventions.
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ACKNOWLEDGMENTS
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This work was supported by the National Health and Medical Research Council of Australia. The authors thank Kevan Pitcher and Anne Silbereisen who conducted the interviews.
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ABSTRACT
INTRODUCTION
