The factor structure for the Positive and Negative Syndrome Scale (PANSS) in recent-onset

psychosis Robin Emsleya *, Jonathan Rabinowitzb , Martijn Torremanc and the RIS-INT35 Early Psychosis Global Working Group a Department of Psychiatry, University of
Stellenbosch, Tygerberg, Cape Town, South Africa b Bar Ilan University, Israel c Janssen
Cilag Published in: Schizophrenia Research 2003; 61(1): 47-57
Numerous attempts have been made to elucidate the complexities of schizophrenia by exploring
relationships between its various symptoms. The diversity of these symptoms has been difficult
to explain, and has led to the proposal of pathophysiological heterogeneity as a conceptual model
for the disorder (Buchanan and Carpenter, 1994). A landmark change in our thinking entailed
replacing the classical subtypes of schizophrenia with the division of symptoms into positive and
negative components. Although this distinction had long been considered (Reynolds, 1896;
Jackson, 1931), it was only relatively recently that attention focussed on these two components
as possibly representing separate pathological processes in schizophrenia. Strauss, Carpenter and
Bartko (1974) described positive, or productive symptoms and negative, or deficit symptoms.
Based on this model, Crow (1980) hypothesised that the positive and negative symptoms
represent different subtypes of schizophrenia, the former reflecting a hyperdopaminergic state,
and the latter a consequence of structural brain-deficit. In order to investigate this distinction
empirically, methods of phenomenologic description and nosologic categorisation were required.
The Scale for the Assessment of Negative Symptoms (SANS), and the Scale for the Assessment
of Positive Symptoms (SAPS), were developed according to Crows concept at the time,
attempting to group all of the symptoms into positive and negative categories (Andreasen, 1983;
Andreasen, 1984). While the original factor analysis of the SANS and SAPS appeared to support
the validity of the positive and negative dichotomy, most subsequent studies called the twodimensional model into question, preferentially yielding a three-factor structure. These factors
comprise a negative symptom factor and two positive symptom factors - a psychosis
dimension and a disorganisation dimension (Andreasen and Olsen, 1982; Andreasen and
Grove, 1986; Moscarelli et al., 1987; Liddle, 1987; Arndt et al., 1991; Miller et al., 1993; Bilder
et al., 1985; Kulhara et al., 1986; Lenzenweger et al., 1989; Schuldberg et al., 1990; Gur et al.,
1991; Minas et al., 1992; Brown et al., 1992; Peralta et al., 1992). Andreasen et al. (1995)
summarised the results of the published factor analytic studies for the SANS and SAPS, noting
strong similarities in the findings. These similarities were all the more striking considering that
they included patients meeting various diagnostic criteria, at different stages of the illness, and
with varying medication status. In addition, samples were often small and a variety of statistical
techniques were employed. These factors have also been found to be stable over the course of
time (Arndt et al, 1995), and to be resistant to cultural influences (Emsley et al, 2000). The
Positive and Negative Syndrome Scale (PANSS) was later developed in an attempt to provide a
more comprehensive assessment of the symptoms of schizophrenia (Kay, Fisbein and Opler,
1987; Kay, Opler and Lindenmayer, 1988; Kay, Opler and Lindenmayer, 1989). The scale
comprises 30 items, and was designed to assess three main domains: the positive subscale (7
items), the negative subscale (7 items) and the general psychopathology subscale (14 items). The
scale includes all of the items from the BPRS (Brief Psychiatric Rating Scale) (Overall and
Gorham, 1988) and select items from the Psychopathology Rating Scale (Singh and Kay, 1987)
The PANSS is widely used in clinical and research settings, and is regarded as a reliable means

of symptom assessment (Bell, et al 1992; Muller, et al 1998). To assess the factorial validity of
the PANSS, the authors conducted a principal component analysis with equamax rotation on 240
schizophrenic inpatients (Kay and Sevy, 1990). The two main components to emerge were the
negative and positive syndromes. These two factors were very robust, with eigenvalues of 7.08
and 3.74 respectively, and together accounted for 36.1% of the total variance. They also found
five additional components of significance: excitement, depression, cognitive dysfunction,
suspiciousness/persecution, and stereotyped thinking. Of the 7 components, the first four had
eigenvalues > 2 and explained 52.3% of the total variance. They were clearly distinct, and
statistically unrelated. Also, these 4 components embraced 5 or more items each, while the other
3 components together had only 5 items. For these reasons, they decided to retain only the first 4
components. However, subsequent studies (Lepine et al, 1989; Dolfus et al, 1991; Lindstrom and
von Knorring, 1993; Bell et al, 1994; Lindenmeyer et al, 1994; Kawasaki et al, 1994;
Lindenmeyer et al, 1995; Marder et al, 1997; White et al, 1997; Lancon et al, 1998; Lancon et al,
1999; Lancon et al, 2000; Lykouras et al, 2000; Mass et al, 2000; Wolthaus et al 2000), as well as
a re-analysis of the original sample of Kay and Savy (Lindenmeyer et al, 1995) overwhelmingly
favoured a five-factor solution i.e. negative, positive, disorganised (or cognitive), excited and
depression/anxiety factors. As was the case with the SANS and SAPS, the PANSS factor
structure does not appear to be affected by age, severity of symptoms, chronicity of illness
(White et al, 1997), or by short-term medication withdrawal (Lindenmayer et al, 1995).
However, all but one (Wolthaus et al 2000) of the published analyses were conducted in subjects
who were mostly medicated and in a chronic phase of the illness. The present study examines the
PANSS factor structure in a large sample of subjects with recent-onset schizophrenia,
schizophreniform disorder and schizo-affective disorder who had been exposed to very limited
antipsychotic medication, and compares the results with previously published studies.