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Confirmatory Factor Analysis of the Indonesian Version of Community Assessment of Psychic Experiences

The Community Assessment of Psychic Experiences (CAPE) is a popular self-report questionnaire that measures lifetime psychotic experiences. However, despite being popular, a consistent factorial structure across nations has not been found. Furthermore, the factorial structure of the Indonesian version has not been examined questioning the types of symptoms that can be measured. Cross-sectional community sample from Indonesia (N = 844) was used in this study. Confirmatory factor analyses results showed that the original three dimensions and nine dimensions factorial structure of the CAPE were found to have an acceptable fit to the data. However, the nine dimensions factorial structure has significantly better fit than the three dimensions. Therefore, the Indonesian version of the CAPE consists of positive symptoms (bizarre experiences, hallucinations, paranoia, magical thinking and grandiosity), negative symptoms (affective flattening, social withdrawal, and avolition) and depressive symptoms.


Introduction
Schizophrenia is a mental condition with severe consequences for the individual and the community, costing on average 106 USD thousand per person per year in developed countries (Evensen et al., 2015). According to the DSM-5, an individual can be diagnosed with schizophrenia if at least two of the following symptoms occurring notably in a one month period, delusion, hallucination, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (American Psychiatric Association, 2013). However, this view of schizophrenia as a diagnostic category has been contested, at least since 50 years ago (Strauss, 1969). This leads to the development of a continuum view of schizophrenia.
Several tenets of the most recent and elaborated continuum of psychosis theory that is proposed by van Os and colleagues (Johns & van Os, 2001;Linscott & van Os, 2010) may worth elaborating. First, the idea of a psychosis continuum does not imply a continuum of disorder. This is important to be stated because even though around 5.8% of the general population in 18 countries around the globe reports having some kind of psychotic experiences (McGrath et al., 2015), only 0.55% of the population is diagnosed with schizophrenia (McGrath, Saha, Chant, & Welham, 2008). In other words, those who have some kind of psychotic experiences may not necessarily suffer from it and do not need help. Secondly, the psychosis continuum is most likely to be positively skewed (Johns & van Os, 2001). This distribution means that most people have no to very low level of symptoms and there is a significant proportion of the population with non-zero values. Third, the continuum view of psychosis holds that psychotic symptoms at the subclinical level, also called psychotic experiences, are on the same continuum with psychotic disorder. Psychotic symptoms experienced by individuals without a diagnosis of psychotic disorder differ only in frequency, severity, and/or distress in comparison to psychotic symptoms experienced by individuals with a diagnosis of psychotic disorder. In other words, they do not differ in kind.
One of the most popular research instruments (in contrast to clinical instruments) for measuring psychosis in a continuum view is the self-report questionnaire called The Community Assessment of Psychic Experiences (CAPE), which measures lifetime psychotic experiences (Stefanis et al., 2002). The questionnaire measures both the frequency and distress of psychotic experiences in the form of both positive (e.g., Do you ever hear voices when you are alone?) and negative symptoms (e.g., Do you ever feel that your emotions are blunted?) The CAPE is so far the only self-report questionnaire that measures psychotic experiences comprehensively, unlike other popular psychotic experiences self-report questionnaires that only measure a dimension of psychotic experiences such as paranoia (paranoia checklist, (Freeman et al., 2005)) and hallucination (Launay-Slade hallucination scale, (Launay & Slade, 1981)). Its popularity is also illustrated in a meta-analysis study examining the psychometric properties of the CAPE that involves 111 studies (Mark & Toulopoulou, 2015). The results of the meta-analysis show that various factorial structures of CAPE have been proposed in addition to the original three dimensions, for example Ziermans' (2013) fourdimension structure. At the same time, the metaanalysis also suggests that no studies agreed on the best factorial solution. Mark and Toulopoulou (2015) argued that the most plausible explanation for the inconsistent factorial structure across studies is the differing countries and/or languages. For example, in the original validation study in Greece the optimal factorial structure of the Greek version of the CAPE is the three correlated factor structure consisting of positive, negative and depressive symptoms dimensions (Stefanis et al., 2002), but in a study in Germany the most optimal factorial structure of the German version of the CAPE was a hierarchical nine dimensional factor structure consisting of a higher order of positive (bizarre experiences, hallucinations, paranoia, magical thinking, grandiosity), negative (social withdrawal, affective flattening, avolition experiences) and depressive symptoms factors (Schlier, Jaya, Moritz, & Lincoln, 2015).
Without a firm understanding on the factorial structure of the CAPE, we do not know whether the questionnaire contains dimensions measuring what it purports to assess. For example, the German version of the CAPE may adequately be able to measure symptom dimension such as hallucinations and paranoia, but it is not known whether the Greek or Indonesian version of the CAPE can too. This knowledge would help researchers and clinicians to make informed decisions about whether the questionnaire could fulfill their assessment needs. Importantly, keeping in mind that language or country differences may have an influence in the factorial structure of CAPE, it becomes necessary to validate previous findings in each language or country. In this regard, the factorial structure of the Indonesian version of CAPE has not been examined.
The present study aimed to confirm previously published factorial structures of CAPE using a large community sample from Indonesia. The original factorial structure of three dimensional CAPE that was found using a Greek version (Stefanis et al., 2002) and the nine dimensional CAPE that was found using a German version (Schlier et al., 2015) were examined in an Indonesian sample. This study is the first study that examined the psychometric property of CAPE in Indonesia, and to a larger extent the first study that validated a self-report questionnaire for psychotic experiences in Indonesia.

Methods
Participants from Indonesia were recruited online through Crowdflower and other websites (e.g. internet forums and social networking websites) to complete an anonymous 30-minute online survey. Crowdflower is a crowdsourcing website, similar to Amazon MTurk, on which users can do tasks in exchange for financial compensation.
Participants recruited from Crowdflower received 0.50 US$ following the median hourly wage in Amazon MTurk (Buhrmester, Kwang, & Gosling, 2011). Participants recruited from other websites were not given compensation for reasons of data security. Only participants who agreed with the consent statements and indicated to be above 18 years old were allowed to enter the study. Afterwards, only participants who completed the survey and fulfilled the inclusion criteria (e.g. longstring, (Johnson, 2005) not providing the same answer consecutively for 50 items) were included in the final sample. The final sample consisted of 844 Indonesian participants. A part of the sample of this study has been used in other analyses (Jaya, Ascone, & Lincoln, 2016;. The Community Assessment of Psychic Experience (CAPE) is a measure of psychotic experiences consisting of 42 items that cover positive symptoms (20 items), negative symptoms (14 items) and depressive symptoms (8 items, (Stefanis et al., 2002)). The items were answered on a 4-point Likert scale from "never" to "nearly always" to measure the frequency of the occurrence of symptoms and from "not distressed" to "very distressed" to measure the appraisal of symptoms. In this version of the CAPE participants were asked to answer the items according to their experiences in the past four weeks. Backtranslation procedure and cultural adaption of measures was conducted with a native Indonesian speaker (ESJ) following a published guideline for cultural adaptation and translation of measures (Schmitt & Eid, 2007). The items of the scale are available in the appendix (Appendix 1).
The original three dimensional and nine dimensional factorial structures of the CAPE were examined using confirmatory factor analysis (CFA). The CFA were conducted with structural equation modeling (SEM) using the lavaan package ver. 0.5-22 (Rosseel, 2012) in R version 3.2.3. Specifically, all analyses were estimated using maximum likelihood procedure with robust standard errors and a Satorra-Bentler scaled test statistic. The following fit indices along with the proposed cut-off criteria were used to assess the fit between hypothesized models and the data: CFI > 0.95, RMSEA < 0.06, and SRMR < 0.08 (Hu & Bentler, 1999). The χ² is reported but not used as a fit criterion because it tends to reject models that are based on large sample size (Bentler & Bonett, 1980). To compare fit of the two possible factorial structures of the CAPE, we used the chi-square difference test to compare nested models following the Satorra-Bentler formula (Satorra & Bentler, 2001) and the Akaike Information Criterion (AIC) fit index, in which a smaller index indicates a better fit (Akaike, 1974).

Results
The participants' were mostly male (n = 631, 74.8%) with an average age of 29.55 years old (SD = 8.43) of whom the youngest participant was 18 years old and the oldest was 66 years old. In addition, 24.1% of the participants self-reported that they had ever experienced a mental health problem (such as depression, insomnia) and 2.1% of the participants (n = 18) self-reported that they had ever received a schizophrenia spectrum diagnosis. A detailed description of the socio-economic status of the participants and its comparison with the Indonesian census data have been described elsewhere . Briefly, the participants were more educated than the average Indonesian with 87.8% of participants having completed at least high school (sekolah menengah atas) or similar (paket formal setara A, B, C), of whom only 49% of the Indonesian population has attained such similar level of education (Badan Pusat Statistik, 2010, 2013b. The participants were richer than the average Indonesian, 89% of the participants spent more than Rp 1.000.000 per month, whereas only 12.8% of the Indonesian population spent more than Rp 1.000.000 per month (Badan Pusat Statistik, 2011, 2013a. The mean, standard deviation (SD), and range score of the questionnaire are reported in Table 1.
The original three and nine dimensions factorial structures of the Indonesian version of the CAPE had acceptable fit, with the indices meeting two out of three cut-off criteria. The original three-dimension factorial structure met the criteria for the RMSEA and SRMR, but not the CFI (χ² (816) = 2368, p < 0.001, CFI = 0.852, RMSEA = 0.055 [90% CI 0.053, 0.058], SRMR = 0.060, AIC = 68090). Similarly, the nine dimensions factorial structure met the criteria for the RMSEA and SRMR, but not the CFI (χ² (808) = 1903, p < 0.001, CFI = 0.90, RMSEA = 0.040 [90% CI 0.038, 0.040], SRMR = 0.054, AIC = 67470). However, the ninedimension factorial structure had a significantly better fit than the three-dimension factorial structure (χ² difference (8) = 360, p < 0.001) and smaller AIC. Factor loadings of the nine dimensions factorial structure and each dimension's Cronbach's α a n d Average Variance Extracted are presented in Table 2. For the three dimensions factorial structure, the factor loadings and each dimension's Cronbach α a r e presented in Appendix 2. Both factorial structures are presented graphically in Appendix 3 and 4.

Discussion
In this study we examined the validity of previously proposed factorial structures of the CAPE in Indonesia. We found that the Indonesian version of the CAPE conform to previous findings in that both the three dimensional and nine dimensional factorial structures of the CAPE fit the data. Although both factorial structures were found to be valid, the nine dimensions factorial structure was found to fit the data best. Interestingly, this pattern of results is similar to the CFA study of the CAPE in the German sample (Schlier et al., 2015).
Having a valid nine dimensions factorial structure means that the Indonesian version of the CAPE has covered many but not all aspects of psychosis. In other words, the Indonesian version of the CAPE has covered the delusions, hallucinations and negative symptoms aspect of psychosis diagnosis according to DSM-5 (American Psychiatric Association, 2013). Importantly, this includes some particularly important aspects of psychosis such as bizarre delusions and affective flattening and avolition aspects of negative symptoms.
However, the results also show that the disorganized speech and catatonic behavior aspect of psychosis diagnosis are not covered. It is important to recognize this limitation because such motoric symptoms are the fifth most regarded symptoms of psychosis throughout the historical literature, and to put this into context, changes in volition ranked sixth and bizarre/primary delusion only ranked seventh (Kendler, 2016).
Furthermore, it is worth mentioning that not all dimensions of the nine dimensional factorial structure of the CAPE has acceptable level of Cronbach's Alpha and average variance extracted. For example, the social withdrawal and affective flattening dimensions have below acceptable level of Cronbach's Alpha and low average variance extracted. It means that caution is warranted in using these symptom dimensions. Another example is the paranoia dimension, which can be considered to have acceptable level of Cronbach's Alpha (i.e. above 0.70, (Bland & Altman, 1997) , but less than acceptable level of average variance extracted. This means that cautions in using these dimensions in research are necessary, and further research is necessary before using these dimensional scores for research or clinical purposes. However, the fit indices indicate that the nine dimensions factorial structure is the best factorial solution for the CAPE. This means that studies using the CAPE that use SEM to analyze the data should use the nine dimensions factorial structure in their analysis.
In practical terms, a valid nine dimensions factorial structure of the CAPE provides the evidence base for the creation of a summed up dimensional score of positive, negative and depressive symptoms, as well as the summed up dimensional score of bizarre experiences, hallucinations, paranoia, magical thinking, grandiosity, social withdrawal, affective flattening, avolition and depressive symptoms. This could be important because heterogeneous findings may arise if we look into these subscales, which has been hypothesized in a theoretical formulation of specific pathways to specific symptoms of psychosis (Bentall et al., 2014).
There are obviously many avenues for future studies of the CAPE. However, the most pressing issue is the question of convergent validity of the Indonesian version of the CAPE. This could be challenging because many well-known scales that may provide convergent validity for the CAPE have not been studied in Indonesian context. For example, a well-known diagnostic instrument called Composite International Diagnostic Interview (CIDI, (Smeets & Dingemans, 1993) has not been examined psychometrically in Indonesian context. Another potential scale that can be used for gathering evidence of convergent validity is Paranoia Checklist (Freeman et al., 2005) and Launay-Slade Hallucination Scale (Launay & Slade, 1981), but the psychometric evidence of the Indonesian version of both scales are not yet examined and, to my knowledge, they are not yet translated. Another important future research direction is to examine the clinical utility and validity of the Indonesian CAPE. There have been evidence that the CAPE can be used to screen individuals being at high risk of psychosis in Austria (Bukenaite et al., 2017) and China (Mark & Toulopoulou, 2017). The results from the two studies in Austria and China are suggestive of possible universal clinical utility of the CAPE.

Conclusion
The Indonesian version of the CAPE measures nine dimensions of psychosis that consists of higher hierarchy of three dimensions (positive, negative and depressive symptoms), which contains more dimensions of psychosis (positive symptoms: bizarre experiences, hallucinations, paranoia, magical thinking, grandiosity; negative symptoms: social withdrawal, affective flattening, avolition). Importantly, the similarity of the factorial structure of the Indonesian and the German version of the CAPE indicates that it has cross-cultural validity and may be universal.