You are on page 1of 11

Psychotic-like experiences in a community

sample of adolescents: implications for the


continuum model of psychosis and prediction
of schizophrenia
Alison R. Yung, Barnaby Nelson, Kathryn Baker, Joe A. Buckby,
Gennady Baksheev, Elizabeth M. Cosgrave

Objective: Studies conducted in community samples suggest that psychotic-like


experiences are common in the general population, leading to suggestions that they are
either variations of normal personality or are different expressions of underlying
vulnerability to psychotic disorder. Different types of psychotic symptoms may exist,
some being normal variants and some having implications for mental health and
functioning. The aim of the present study was to determine if different subtypes of
psychotic-like experiences could be identified in a community sample of adolescents and to
investigate if particular subtypes were more likely to be associated with psychosocial
difficulties, that is, distress, depression and poor functioning, than other subtypes.
Method: Eight hundred and seventy-five Year 10 students from 34 schools participated in
a cross-sectional survey that measured psychotic-like experiences using the Community
Assessment of Psychic Experiences; depression using the Centre for Epidemiologic
Studies Depression Scale; and psychosocial functioning using the Revised
Multidimensional Assessment of Functioning Scale. Factor analysis was conducted to
identify any subtypes of psychotic experiences.
Results: Four subtypes of psychotic-like experiences were identified: Bizarre
Experiences, Perceptual Abnormalities, Persecutory Ideas, and Magical Thinking.
Intermittent, infrequent psychotic experiences were common, but frequent experiences
were not. Bizarre Experiences, Perceptual Abnormalities and Persecutory Ideas were
strongly associated with distress, depression and poor functioning. Magical Thinking was
only weakly associated with these variables. Overall these findings may suggest that
infrequent psychotic-like experiences are unlikely to be a specific risk factor for onset of a
psychotic disorder in community samples.
Conclusions: Given that the different subtypes had varying associations with current
difficulties it is suggested that not all subtypes confer the same risk for onset of psychotic
disorder and poor outcome. Bizarre Experiences, Perceptual Abnormalities and

Alison R. Yung, Professor (Correspondence); Barnaby Nelson,


Research Fellow; Joe A. Buckby, Research Assistant; Gennady
Baksheev, Research Assistant; Elizabeth M. Cosgrave, Research Fellow
Orygen Youth Health Research Centre and Department of Psychiatry,
University of Melbourne, Locked Bag 10, Parkville, Vic. 3052, Australia.
Email: aryung@unimelb.edu.au

Kathryn Baker, Clinical Psychologist


Orygen Youth Health, Melbourne, Victoria, Australia
Received 20 August 2008; accepted 7 October 2008.

# 2009 The Royal Australian and New Zealand


College of Psychiatrists
Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on May 16, 2016

A.R. YUNG, B. NELSON, K. BAKER, J.A. BUCKBY, G. BAKSHEEV, E.M. COSGRAVE

119

Persecutory Ideas may represent expressions of underlying vulnerability to psychotic


disorder, but Magical Thinking may be a normal personality variant.
Key words: continuum, prodrome, psychosis, schizophrenia, ultra-high risk.

Australian and New Zealand Journal of Psychiatry 2009; 43:118 128

It has long been suggested that positive psychotic


symptoms exist on a continuum, with schizophrenia at
one end and non-clinical psychotic symptoms (or
psychotic-like experiences: PLE) at the other. Two
models of continuity have been proposed: the quasidimensional model and the fully dimensional model.
The quasi-dimensional model conceptualizes PLE as
forme frustes or variants of disorder, for example,
incompletely expressed schizophrenia. This suggests
discontinuity with the normal population. A proponent of this quasi-dimensional model was Meehl, who
proposed the existence of a schizoid taxon, which
would have different phenotypic expressions including
schizophrenia [1,2]. This model also implies that those
with PLE would be at increased risk, or vulnerable to,
developing psychotic disorder. For example, the work
of Chapman et al., and Chapman and Chapman
suggests that individuals in the normal population
with certain features, including PLE but also social
and physical anhedonia, are psychosis prone [35].
Others also concur with this forme fruste or psychosis
prone idea [615]. The theory is that if the psychosis
prone or schizotypal individual is subject to sufficient
psychosocial stress, then onset of psychotic disorder
may occur, consistent with the stress vulnerability
model [16]. There have even been treatment trials of
these hypothetically vulnerable individuals [17,18].
Clinical services have been developed for help-seeking
individuals with PLE [1924], and have been the
setting for several interventions trials [2527].
The fully dimensional model of psychosis proposes
that PLE are part of personality [28,29]. For example
Claridge et al. described schizotypal features (including positive psychotic symptoms and anhedonia) as
healthy diversity and noted that they range from
disorder to normal functioning [30]. This model
implies no discontinuity from the normal population.
It has even been proposed that schizotypy may confer
an advantage on some individuals, with the suggestion that the schizophrenia spectrum displays an
inverted-U relationship with creativity [31]. That is,
the presence of some schizotypal features are associated with heightened creativity, whereas further
along the schizophrenia spectrum, towards frank
schizophrenia, the relationship is attenuated. Positive

schizotypal traits (such as unusual perceptual experiences and magical beliefs) have been found to be of
particular relevance to artistic creativity [3133],
whereas negative schizotypal traits (such as physical
and social anhedonia and introversion) have been
related to mathematical or scientific creativity [33].
This has led some researchers to suggest that creative
advantage, among other benefits, may be a major
reason that genes related to psychopathology remain
in the gene pool, despite the costs of psychopathology
to individual fitness [32,3436].
There is evidence for the continuum theory in the
findings of high prevalence of PLE in the general
population [8,11,3741]. So is the continuity due to
healthy diversity? That is, could some PLE not be
associated with any distress or other problems in
living, and not indicate underlying vulnerability to
schizophrenia or other psychotic disorders in the
longer term? Or is the continuity due to a group in the
community who have heightened vulnerability to
schizophrenia or other psychotic disorders but who
do not manifest the full clinical syndrome at the time
of assessment, but who may do so in the future if
sufficiently stressed? That is, these vulnerable individuals may never develop a full psychotic disorder if
not sufficiently stressed. It is therefore difficult to
distinguish between the models. Perhaps endophenotypic measures on, and detailed phenomenological
exploration of, those with PLE but no clinical
disorder may shed some light on this issue [42].
Another central question is whether all psychotic
symptoms are the same. That is, could some psychotic-like symptoms be an indication of underlying
vulnerability, while others might be benign and be
due to healthy diversity? Longitudinally we could
begin to answer this question by following up
individuals with different types of PLE to see if any
are more likely to be associated with onset of
psychotic disorder. We know that subthreshold PLE
in general confer increased risk of development of
psychotic disorder, in both community [8,15] and
clinical samples [4346]. But the literature varies
about which particular PLE are associated with
increased risk. The clinical studies, based on individuals considered to be at ultra-high risk (UHR) or

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on May 16, 2016

120

PSYCHOTIC-LIKE EXPERIENCES IN THE COMMUNITY

prodromal for psychotic disorder, found that unstable ideas of reference, and visual and auditory
perceptual disturbances [47,48] and elevated scores on
measures of unusual thought content, suspiciousness,
perceptual disturbance and conceptual disorganization were associated with increased risk of development of psychotic disorder within UHR groups
[21,45].
We previously investigated a clinical sample of
help-seeking non-psychotic young people who were
not thought to be at risk of psychotic disorder [49].
This largely depressed group had high levels of
undetected subthreshold psychotic experiences. We
found that three distinct subtypes of PLE could be
identified: bizarre experiences (BE), persecutory ideas
(PI), and magical thinking (MT). BE included
symptoms such as subthrehold forms of thought
broadcasting and perceptual abnormalities (PA). PI
included suspiciousness and other subthreshold versions of PI. MT included, for example, belief in the
occult and thoughts that telepathy could exist (without actually experiencing it). Cross-sectionally in this
sample, BE and PI were associated with distress,
depression and poor functioning, but MT was not.
Unlike in clinical samples, community samples
have tended to focus on PLE in general, without
distinguishing between different types of PLE. Similar to our study of apparently non-psychotic helpseekers [49], we could postulate that PLE found in
community samples would be of different subtypes,
and that cross-sectionally those that are most likely to
be indicative of underlying vulnerability will be those
associated with problems in living, such as distress,
depression and poor functioning. The aim of the
present study was to investigate this issue by measuring PLE in a community sample of adolescents. We
chose to study PLE in a sample of adolescents aged
1416 years, because this would capture a group
largely before the onset of first-episode psychosis,
which typically begins in late adolescenceearly
adulthood. Additionally, it was also felt that this
would enable us to identify large numbers of adolescents with subtle attenuated psychotic symptoms,
because these are thought to be more common in
adolescents than adults [15,5052].
The purpose of the present study was therefore to
determine if different subtypes of PLE could be
identified in a community sample of adolescents,
and to investigate if particular subtypes were more
likely to be associated with psychosocial difficulties,
that is, distress, depression and poor functioning,
than other subtypes. The hypotheses were as follows.

(1) That different subtypes of PLE would be


identified in the sample. We postulated that by factor
analysis three subtypes would emerge: BE, PI, and
MT. This was based on a factor analysis conducted
on a clinical sample of non-psychotic young people
[49].
(2) That BE and PI would be associated with
distress, depression and poor functioning, but that
MT would not. This was based on the findings in the
clinical sample.

Method
Procedures and sample
Subjects were recruited via schools that were asked permission to
survey their Year 10 secondary students. Sixty secondary schools in
the western metropolitan region of Melbourne were approached to
participate in the study and 34 consented to participate (20
government, five Catholic and nine independent schools). Students
from each school were assessed via questionnaire during one 48 min
study period. Trained research assistants were present in the class
room to answer queries. The study was approved by Research and
Ethics Committees at the University of Melbourne, Victorian
Department of Education and the Catholic Education Office. All
participants provided written informed consent from themselves
and their parent/guardian.

Instruments
PLE were assessed with the Community Assessment of Psychic
Experiences (CAPE) positive symptoms scale [53]. This self-report
scale measures the occurrence of PLE in the past 12 months on both
a frequency scale (1never, 4nearly always) and a distress scale
(1not distressed, 4 very distressed). The Centre for Epidemiologic Studies Depression Scale (CES-D) was used to assess level of
self-reported depressive symptomatology in the past week. The CESD consists of 20 items that rate frequency of depressive symptoms
from 1 (rarely) to 4 (mostly) [54]. Scores of ]24 have been used to
indicate caseness of depression. The Revised Multidimensional
Assessment of Functioning Scale (RMAFS) was used to assess
functioning. This is a 23-item self-report scale that generates a Total
Functioning score and three subscale scores: General Functioning,
Peer Relationships and Family Functioning. For a more detailed
description of the RMAFS see [49].

Data analysis
Analyses were conducted using SPSS version 12.0 for Windows
(SPSS Inc., Chicago, IL, USA). Data were initially screened for
missing values and for the assumptions of normality, linearity,
homogeneity and outliers. Six participants had 25% of data
missing and were subsequently removed from further analyses,
leaving 875 with valid data.

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on May 16, 2016

A.R. YUNG, B. NELSON, K. BAKER, J.A. BUCKBY, G. BAKSHEEV, E.M. COSGRAVE

121

The correlations matrix of the CAPE items was examined. There


were many significant correlations between items, indicating that
factor analysis was a meaningful technique. A factor analysis of the
frequency scale for the CAPE items was run using the maximum
likelihood technique with direct oblimin rotation to determine the
appropriate number of factors. Two tests were conducted to
determine whether the dataset was factorable. First the Kaiser
MeyerOlkin measure of sampling adequacy tests was used to
measure the size of the partial correlations among variables. Values
]0.60 are required for good factor analysis [55]. The second test
was Bartletts test of sphericity, which assesses whether the factor
model is appropriate. The oblique rotation was chosen because it
was predicted that the CAPE factors would be correlated.
A number of methods were used to determine the optimum
number of factors for the current dataset. First, five factors had
eigenvalues 1. Second, the scree plot was inspected. There was a
noticeable drop-off at the second and third factors. Both these
methods, however, have been criticized as having shortcomings
[56], therefore a parallel analysis using a Monte Carlo simulation
was conducted.
Once the factor structure was identified, correlations were
conducted to assess the relationship between the CAPE total score
and subtype scores and measures of functioning and symptomatology. x2 and t-tests were run to compare scores with variables such
as age and gender.

Factor 1 related to BE, Factor 2 to PA, Factor 3 to PI and


Factor 4 to MT. Item 13 (Have you ever felt that you are a very
special or unusual person?) had equal loading on Factors 3 and 4.
A sensitivity analysis was carried out examining the impact of
removing item 13 or including the item in either Factor 3 or 4. The
internal consistency of the CAPE scale and subscales was
maximized by retaining item 13 in Factor 4.
Table 2 presents the means and standard deviations for the total
CAPE score and the BE, PA, PI, and MT subscales. There was a
significant difference between boys and girls for the total CAPE
score and PI, with girls scoring higher.

Results

Prevalence of psychotic-like experiences in the sample

Sample characteristics
From a total potential sample of 4797 Year 10 students, 946
students agreed to participate, a response rate of 19.7%. Sixty-five
participants were absent on the day of assessment, reducing the
total sample to 881, and six participants had 25% of CAPE data
missing, so were excluded from further analysis, making the total
number of subjects 875 (response rate 18.2%). There were 411 boys
(46.9%), 462 girls (52.8%) and two participants with gender not
recorded. Mean age was 15.64 years. Participants were aged
between 13.7 and 17.6 years (SD0.46 years), with one significant
outlier of 19.6 years. Only 36 (0.9%) non-consenters returned
demographic forms. Given this small sample size demographic
details of non-consenters were not examined.
Twenty out of 28 Government schools that were approached
agreed to participate, compared to five out of 17 Catholic schools
and nine out of 15 independent schools. Government schools were
significantly more likely than Catholic schools to participate
(x2(1)7.563, p 0.006).

Subtypes of psychotic-like experiences


Four subtypes of PLE were found using a Monte Carlo
simulation (Table 1). Closer inspection of factor loadings confirmed this solution as best representing the current data. The fourfactor solution offered low numbers of cross-loading items (r 0.30
across factors) and low-loading items (rB0.25).

Psychometric properties of the four CAPE factors


Inter-correlations between identified subscales were analysed
using Pearsons correlation coefficient. Correlations between all
subscales were positive and significant (Table 3). BE, PA and PI
subscales demonstrated good internal consistency with Cronbachs
alphas 0.70, but MT was lower. This was not surprising given the
difficulty in obtaining convergence among a low number of items
for a subscale with heterogeneous content. The internal consistency
of the total CAPE scale was excellent (r0.85). Only item 11 (have
you ever felt as though you were destined to be someone very
important?) demonstrated a low item-total correlation (r 0.29).
Removing this item did not improve the total alpha, thus all 20
items were retained for further analyses.

To determine the prevalence of each PLE item in the sample,


participants responses were dichotomized. Responses were recoded
to 0 (never) or 1 (at least sometimes). PLE were common in this
sample, but prevalence rates varied according to PLE subtypes and
frequency (Table 1). PI and MT were the most commonly
experienced PLE. More than half of the sample reported that
they had experienced one of these PLE at least sometimes. The
prevalence rates for BE and PA were lower and less varied; the
majority of participants reported that they had never had one of
these PLE.
Responses of always/almost always were also analysed. Prevalence rates substantially decreased as the frequency rate increased. Very few endorsed experiencing an item within the BE, PA
or PI subtypes for a large proportion of time. MT was the most
common subtype of PLE experienced always or almost always.

Distress associated with PLE


Correlations between distress and frequency scores of the CAPE
were examined for each subscale and the total CAPE scores. The
distress score is a measure of distress associated with the PLE (not a
general distress score). The correlation between frequency and
distress score for total CAPE score was very strong (r 0.78, pB
0.001). The correlation between frequency and distress was very
strong for BE and PI (r 0.79, p B0.001 for both), high for PA
(r0.68, pB0.001) but only moderate for MT (r 0.45, pB0.001).
Correlations between frequency and distress for the different

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on May 16, 2016

122

Table 1. CAPE positive items: factor loading and frequency

Item
no.

24
26

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on May 16, 2016

28
17

34
33
42

2
7
22
6
10
5
41

15
20
11
13

Bizarre experiences
Have you ever felt as if the thoughts in your head are being taken
away from you?
Have you ever felt as if the thoughts in your head were not your
own?
Have you ever heard your thoughts being echoed back to you?
Have you ever felt as if you are under the control of some force or
power other than yourself?
Have your thoughts ever been so vivid that you were worried
other people would hear them?
Have you ever felt as if electrical devices such as computers can
influence the way you think?

Magical Thinking
Have you ever thought that people can communicate
telepathically?
Have you ever believed in the power of witchcraft, voodoo or the
occult?
Have you ever felt as if you are destined to be someone very
important?
Have you ever felt that you are a very special or unusual person?

CAPE, Community Assessment of Psychic Experiences.

Never

Frequency (%)
At least
sometimes

Always/
nearly
always

0.75

73.4

26.6

0.9

0.59

68.2

31.8

0.9

0.50
0.45

61.6
73.3

38.4
26.7

0.9
2.4

0.38

65.4

34.6

1.0

0.33

52.1

47.9

3.7

0.70

89.1

10.9

1.4

0.68
0.57

72.1
79.8

27.9
20.2

1.9
1.4

0.62

28.6

71.4

1.9

0.61
0.60

46.6
34.3

53.4
65.7

1.7
5.0

0.49

8.5

91.5

5.7

0.23

0.45
0.25

57.9
60.0

42.1
40.0

3.1
1.3

0.17

0.21

74.7

25.3

1.0

0.63

54.9

45.1

2.7

0.53

65.2

34.8

3.9

0.33

33.8

66.2

7.0

0.25

40.0

60.0

9.1

Perceptual Abnormalities
Have you ever heard voices talking to each other when you were
alone?
Have you ever heard voices when you were alone?
Have you ever seen objects, people or animals that other people
cant see?
Persecutory Ideation
Have you ever felt as if people seem to drop hints about you or
say things with a double meaning?
Have you ever felt that you are being persecuted in some way?
Have you ever felt that people look at you oddly because of your
appearance?
Have you ever felt as if some people are not what they seem to
be?
Have you ever felt as if there is a conspiracy against you?
Have you ever felt as if things in magazines or on TV were written
especially for you?
Have you ever felt as if a double has taken the place of a family
member, friend or acquaintance?

Facor
4

0.23

PSYCHOTIC-LIKE EXPERIENCES IN THE COMMUNITY

30
31

Factor 1

Factor loading
Factor
Factor
2
3

A.R. YUNG, B. NELSON, K. BAKER, J.A. BUCKBY, G. BAKSHEEV, E.M. COSGRAVE

Table 2.

Descriptive statistics for CAPE total and subscales

Total sample
31.41 (7.07)
8.59 (2.56)
3.76 (1.38)
12.03 (3.04)
7.03 (2.19)

CAPE
BE
PA
PI
MT

123

Male
30.74 (7.32)
8.48 (2.60)
3.82 (1.53)
11.53 (3.04)
6.92 (2.23)

Female
32.02 (6.81)
8.70 (2.51)
3.71 (1.23)
12.49 (2.99)
7.12 (2.16)

p
0.01
0.21
0.23
B.001
0.18

BE, Bizarre Experiences; CAPE, Community Assessment of Psychotic Experiences; PA, Perceptual Abnormalities; PI, Persecutory
Ideation; MT, Magical Thinking.

subscales were compared to determine whether they were statistically different from each other. Subscale totals were converted to zscores to allow for the different scale ranges. Z-scores were
compared using a formula described by Hinkle et al. [57] to
examine the difference between two independent correlations.
There was no significant difference between BE and PI (z0,
p1.0). The correlation between frequency and distress for BE and
PI was significantly higher than that for PA (z5.06, p B0.001 for
both) and MT (z12.25, pB0.001 for both). The correlation
between frequency and distress for PA was significantly higher than
that for MT (z7.19, pB0.001).

Relationship between PLE and depression


Self-reported depressive symptoms were moderately and significantly correlated with total CAPE scores (r 0.54, pB0.001).
Depressive symptoms were moderately and significantly correlated
with all subscales, but more weakly correlated with MT than the
other subscales (BE r0.44, PI0.59, PA0.35, MT0.20; pB
0.001 for all). Standard linear regression was used with CES-D
scores as the dependent variable. Age and gender significantly
explained 4% of the variance in CES-D scores (R2 0.04,
F(2,861)19.50, p B0.001). After controlling for the effects of
these variables, a series of univariate regression analyses were
conducted. Total CAPE score and each subscale were individually
input in the second block to determine whether PLE were
associated with self-reported depressive symptoms. All
CAPE scales significantly explained variance in CES-D scores,
indicating that as PLE increased, depressive symptoms also

Table 3. Internal consistency and inter-correlations


between CAPE subscales (Cronbach alpha)

BE
PA
PI
MT

BE
(0.71)
0.43**
0.54**
0.46**

PA

PI

MT

(0.73)
0.37**
0.32**

(0.74)
0.44**

(0.58)

BE, Bizarre Experiences; CAPE, Community Assessment of


Psychotic Experiences; PA, Perceptual Abnormalities; PI,
Persecutory Ideation; MT, Magical Thinking; **p B0.001.

increased (Table 4). BE, PI and PA, however, were associated with
a greater increase in depression than MT. That is, for example, for
each unit increase in PA, there was a 2.71 unit increase in CES-D
score, but for each unit increase in MT there was only a 0.85
increase in CES-D score, indicating that MT had a weaker
association with depressive symptoms than did the other types of
PLE.

Relationship between PLE and functioning


Correlations between PLE and self-reported functioning were
generally negative and significant, indicating that higher PLE
scores were associated with poorer functioning (Table 5). This
finding was weaker for the Friends subscale of the RMAFS that
measures peer relationships. MT showed a lower correlation across
each of the RMAFS scales than CAPE Total, BE, PA and PI.

Discussion
Intermittent PLE were common in this sample, but
more frequent PLE were less common. For example,
nearly 28% of the group reported sometimes hearing
voices, but only 1.9% reported this always or nearly
always. The rate of 28% is higher than that found in
other community studies, with the median hallucination rate in a recent met-analysis being 4% [58].
More than 26% of the present sample reported
feeling that their thoughts were being taken away or
were not their own but only 0.9% described this as
occurring always or nearly always. This is similar to
the prevalence found in a representative sample of the
Australian population, in which 0.7% experienced
thought interference in a way others would find hard
to believe [51]. The higher rates in this sample may be
due to sampling error, or to certain demographic
factors known to be associated with higher reporting
of PLE that were consistent with the present sample,
such as low socioeconomic status [51], urban environment [11,59,60], and younger age [15,5052].
As hypothesized, different subtypes of PLE were
evident in this community sample. Unlike the clinical

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on May 16, 2016

124

PSYCHOTIC-LIKE EXPERIENCES IN THE COMMUNITY

Table 4.

Block 1
Block 2

Association between PLE and depressive symptoms


B
0.99
4.18
0.76
1.70
2.71
1.92
0.85

Age
Gender
Total CAPE
BE
PA
PI
MT

b
0.04
0.21
0.53
0.43
0.36
0.57
0.18

t
1.26
6.15
5.48
14.21
11.55
20.73
5.59

p
.21
B0.001
B0.001
B0.001
B0.001
B0.001
B0.001

CI
2.530.55
2.845.51
0.680.84
1.461.93
2.253.17
1.742.10
0.551.15

sr2
0.00
0.04
0.29
0.19
0.13
0.33
0.03

BE, Bizarre Experiences; CAPE, Community Assessment of Psychotic Experiences; CI, confidence interval; PA, Perceptual
Abnormalities; PI, Persecutory Ideation; PLE, psychotic-like experiences; MT, Magical Thinking; sr2, amount of unique explained
variance in depression scores for each independent variable; Depression measured by Centre for Epidemiologic StudiesDepression
Scale (CES-D).

sample analysed previously [49], however, an additional factor was found in the present cohort. This
was due to the BE factor in the clinical sample being
divided into first-rank-type symptoms (such as
thought insertion and withdrawal), and PA (such as
hearing voices), in this community sample. It is
possible that the difference in samples (i.e. community vs help-seeking sample) could account for this
finding. It may also be due to the higher numbers in
the present sample compared to our previous study.
The second hypothesis was also largely supported,
with the findings that BE, PI and PA were more
strongly associated with distress, depression and poor
functioning than MT. MT was also more commonly
and frequently experienced than the other subtypes of
PLE.
The present findings suggest that PLE should not
be regarded as a homogenous entity. They therefore
require greater subtlety in our understanding.
In a given individual, PLE might either be: (i) an
expression of an underlying, more fundamental disturbance, such as self or ipseity disturbance (a
disrupted sense of myness) at the psychological level
[61], or an expression of some neurological distur-

Table 5.

RMAFS Total
RMAFS: General
RMAFS: Friends
RMAFS: Family

bance suggesting vulnerability to a psychotic disorder


such as schizophrenia; (ii) clinical noise around a
non-psychotic syndrome and not necessarily associated with distress, disability, or risk of schizophrenia, these symptoms might be expected to remit with
treatment of the non-psychotic illness [62]; we have
previously called these incidental PLE [63]; or (iii)
present in non-clinical normal individuals, and not
associated with distress or disability or increased
vulnerability to psychotic disorder.
In terms of clinical care, PLE belonging to the first
category would be of greatest concern, followed by
PLE in the second category. PLE in the third
category may reflect a form of happy [64] or benign
[65] schizotypy and probably do not warrant clinical
attention. In fact, clinical attention for these forms of
PLE may have a counterproductive effect by raising
anxiety about essentially benign experiences.
A theoretical implication is that both the fully
dimensional model of PLE [29,30] and the quasi
dimensional model [1,2] may be correct. That is, MT
may be a normal healthy variant, with no impact
either cross-sectionally or longitudinally on mental
health, whereas BE, PI and PA may be indicative of

Correlations between PLE and self-reported functioning

CAPE Total
0.35**
0.32**
0.08*
0.35**

BE
0.28**
0.27**
0.07*
0.25**

PA
0.27**
0.24**
0.03
0.30**

PI
0.39**
0.37**
0.13**
0.35**

MT
0.11**
0.08*
.02
0.17**

BE, Bizarre Experiences; CAPE, Community Assessment of Psychotic Experiences; PA, Perceptual Abnormalities; PI, Persecutory
Ideation; PLE, psychotic-like experiences; MT, Magical Thinking; RMAFS, Revised Multidimensional Assessment of Functioning; *p B
0.005, **pB0.001. CAPE BCommunity Assessment of Psychotic Experiences.

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on May 16, 2016

A.R. YUNG, B. NELSON, K. BAKER, J.A. BUCKBY, G. BAKSHEEV, E.M. COSGRAVE

underlying vulnerability and may actually, both


cross-sectionally and longitudinally, be bad for
you. That is, they are associated with problems in
living cross-sectionally, consistent with other community studies. For example Van Os et al. found that
more frequent PLE were associated with worse
functioning than less frequent PLE [11], and Shevlin
et al. found that those with most PLE were more
likely to be living alone, unemployed and on a low
income [9]. These studies, however, did not distinguish between different types of PLE.
One study limitation was that we relied on a selfreport instrument, the CAPE, to assess PLE. Some
have suggested that self-reporting and use of lay
interviewers may over-estimate the prevalence of
PLE, because participants may misinterpret questions
[39]. For example Kendler et al. found that 28.4% of
the cohort in the US National Comorbidity Survey
endorsed one or more probes for psychosis [39]. Only
0.16%, however, were diagnosed as having a narrowly defined psychotic illness. Kendler et al attributed this discrepancy to misinterpretation of probes
by subjects or lay interviewers. But there is also
evidence that self-report measures can give valid
estimates of PLE. Konings et al. and Liraud et al.
both showed good correlation between the CAPE
[53], and interviewer-rated psychosis [66,67]. Poulton
et al. used self report to assess psychotic symptoms
[8]. Responses were reviewed by psychiatrists and
clinical psychologists, and the researchers commented
that they seemed genuine in content. Bak et al. reinterviewed 142 subjects who had reported incident
PLE and found that 83 of these had genuine PLE
[68]. Thus 59 were false positives (i.e. approx. 60%
truly had PLE, and 40% did not).
Hence, even allowing for some degree of misinterpretation, these studies suggest a high prevalence of
PLE in the community, and thus support for the
continuity of psychosis. A recent meta-analysis draws
the same conclusion [58].
A major limitation of the present study was the low
response rate and lack of demographic details about
non-consenters. This is possibly related to needing
active consent from participants and their guardians.
Furthermore, all adolescents were recruited from the
western metropolitan region of Melbourne, a relatively socially disadvantaged group. These two issues
raise concerns about the generalizability of our
findings. We could speculate that more disturbed
and unwell adolescents did not consent, thus underestimating the prevalence of PLE in this population.
The overrepresentation, however, of low social economic status could have led to an overestimation.

125

Additionally, only self-report measures were used,


possibly resulting in some participants misinterpreting questions and leading to an overestimation. Given
these limitations caution is required with generalizing
our findings.
Nonetheless, there are two further implications
from this research. The first is a practical one. There
are many services around the world, including our
own, the Personal Assessment and Crisis Evaluation
clinic [24], which recruit individuals with PLE on the
grounds that they may be at UHR or prodromal for
psychotic disorder [21,23]. This study highlights that,
because they are common, PLE are unlikely to be a
specific risk factor for onset of psychotic disorder in
community samples. Thus the sample, that is, community versus clinical, needs to be considered when
taking into account the potential risk of PLE and the
need for intervention. This is a base rate issue: the
base rate of onset of psychotic disorder in a community sample is much lower than in a clinical sample.
Hence, it is much less likely that someone with PLE in
the general population will develop a psychotic
disorder compared to someone with PLE seeking
help [63]. A further practical point is speculative. It
may be that not all subtypes of PLE confer the same
degree of risk for onset of disorder, for instance, BE,
PI and PA may be more strongly associated with
increased risk of poor outcome in contrast to MT,
given that they were more strongly associated with
distress and depression. Further longitudinal research
is needed and is currently under way with this sample
and clinical samples, both UHR and non-UHR, in
order to investigate the developmental course of PLE
and their association with onset of psychotic disorder.
Finally, our ability to identify which of the three
categories of PLE mentioned earlier (fundamental
disturbance, incidental PLE, normal variant) appears
in clinical presentations remains poor. This is reflected in our limited capacity at present to predict
which UHR patients with attenuated psychotic
symptoms will go on to develop full-blown psychotic
disorder. A clinical and research challenge remains to
further close in on risk factors for psychosis onset by
identifying phenotypic factors that predict psychosis
onset in addition to PLE. It may be that the presence
of PLE in combination with other factors, such as
functional decline [45,48,63], high levels of distress
[6971] or self-disturbance [72,73], may place an
individual at greater risk of full-blown psychotic
disorder. Also, the particular combination of PLE
with other factors may be related to onset of
particular types of psychotic disorder. The evidence
to date suggests the PLE in combination with

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on May 16, 2016

126

PSYCHOTIC-LIKE EXPERIENCES IN THE COMMUNITY

self-disturbance may be predictive of schizophrenia


spectrum conditions [72,73]; PLE in combination
with some other factors, such as mood or personality
disturbance, may be more predictive of mood disorder with psychotic features or psychotic episodes in
the context of personality disorder. Additionally,
identification of endophenotypes or genotypes, in
addition to PLE, may aid our prediction of risk
within the UHR sample.
The challenge to achieve further specificity in our
understanding of PLE is salient given recently
observed declining rates of transition to full-blown
psychotic disorder in UHR samples [74]. We cannot
complacently continue to believe that the UHR
criteria indicate prodromal schizophrenia, and that
those who do not make transition to psychotic
disorder have somehow been prevented from doing
so by our intervention.

7.
8.

9.

10.

11.

12.
13.

Conclusion
In the PLE literature there has been a tendency to
lump all PLE together. Some PLE, however, could
confer higher risk for psychotic disorder than others.
There is also a need to consider PLE in adolescents
somewhat differently from those in older adults. It
seems that PLE are much more common in adolescents [15,5052]. Can they be grown out of? These
issues can be further explored in longitudinal studies.

14.
15.
16.
17.

18.

Acknowledgements
This research was funded by the Colonial Foundation and an NHMRC Program Grant (350241). The
authors gratefully acknowledge the participation of
the students and the schools in this research project.

19.

20.
21.

References
1. Meehl PE. Schizotaxia, schizotypy, schizophrenia. Am
Psychologist 1962; 17:827838.
2. Meehl PE. Schizotaxia revisited. Arch Gen Psychiatry 1989;
46:935944.
3. Chapman LJ, Edell WS, Chapman JP. Physical anhedonia,
perceptual aberration, and psychosis proneness. Schizophr
Bull 1980; 6:639653.
4. Chapman JP, Chapman LJ. Psychosis proneness. In: Alpert
M, ed. Controversies in schizophrenia: changes and constancies.
New York: Guilford, 1985:157174.
5. Chapman LJ, Chapman JP. The search for symptoms
predictive of schizophrenia. Schizophr Bull 1987; 13:497503.
6. Cougnard A, Marcelis M, Myin-Germeys I et al. Does normal
developmental expression of psychosis combine with

22.

23.
24.
25.

environmental risk to cause persistence of psychosis? A


psychosis proneness-persistence model. Psychol Med 2007;
37:513527.
Hanssen M, Bak M, Bijl R, Vollebergh W, van Os J. The
incidence and outcome of subclinical psychotic experiences in
the general population. Br J Clin Psychol 2005; 44:181191.
Poulton R, Caspi A, Moftt TE, Cannon M, Murray R,
Harrington H. Childrens self-reported psychotic symptoms
and adult schizophreniform disorder: a 15-year longitudinal
study. Arch Gen Psychiatry 2000; 57:10531058.
Shevlin M, Murphy J, Dorahy MJ, Adamson G. The
distribution of positive psychosis-like symptoms in the
population: a latent class analysis of the National
Comorbidity Survey. Schizophr Res 2007; 89:101109.
Spauwen J, Krabbendam L, Lieb R, Wittchen H-U, van Os J.
Impact of psychological trauma on the development of
psychotic symptoms: relationship with psychosis proneness.
Br J Psychiatry 2006; 188:527533.
van Os J, Hanssen M, Bijl RV, Vollebergh W. Prevalence of
psychotic disorder and community level of psychotic
symptoms: an urban-rural comparison. Arch Gen Psychiatry
2001; 58:663668.
Verdoux H, van Os J. Psychotic symptoms in non-clinical
populations and the continuum of psychosis. Schizophr Res
2002; 54:5965.
Vollema MG, Sitskoorn MM, Appels MC, Kahn RS. Does
the Schizotypal Personality Questionnaire reect the
biological-genetic vulnerability to schizophrenia? Schizophr
Res 2002; 54:3945.
Allardyce J, Suppes T, Van Os J. Dimensions and the
psychosis phenotype. Int J Methods Psychiatr Res 2007;
16(S1):3440.
Rossler W, Riecher-Rossler A, Angst J et al. Psychotic
experiences in the general population: a twenty year
prospective community study. Schizophr Res 2007; 92:114.
Zubin J, Spring B. Vulnerability: a new view of schizophrenia.
J Abnorm Psychol 1977; 86:103126.
Nordentoft M, Thorup A, Petersen L et al. Transition rates
from schizotypal disorder to psychotic disorder for rstcontact patients included in the OPUS trial. A randomized
clinical trial of integrated treatment and standard treatment.
Schizophr Res 2006; 83:2940.
Tsuang MT, Stone WS, Tarbox SI, Faraone SV. An
integration of schizophrenia with schizotypy: identication of
schizotaxia and implications for research on treatment and
prevention. Schizophr Res 2002; 54:169175.
Broome MR, Woolley JB, Johns LC et al. Outreach and
support in south London (OASIS): implementation of a
clinical service for prodromal psychosis and the at risk mental
state. Eur Psychiatry 2005; 20:372378.
Cornblatt B, Lencz T, Correll C, Author A, Smith C. Treating
the prodrome: naturalistic ndings from the RAP program.
Acta Psychiatr Scand 2002; 106:44.
Haroun N, Dunn L, Haroun A, Cadenhead K. Risk and
protection in prodromal schizophrenia: ethical implications
for clinical practice and future research. Schizophr Bull 2006;
32:166178.
Miller TJ, McGlashan TH, Rosen JL et al. Prodromal
assessment with the structured interview for prodromal
syndromes and the scale of prodromal symptoms: predictive
validity, interrater reliability, and training to reliability.
Schizophr Bull 2003; 29:70315.
Olsen KA, Rosenbaum B. Prospective investigations of the
prodromal state of schizophrenia: review of studies. Acta
Psychiatr Scand 2006; 113:247272.
Yung AR, McGorry PD, McFarlane CA, Jackson HJ, Patton
GC, Rakkar A. Monitoring and care of young people at
incipient risk of psychosis. Schizophr Bull 1996; 22:283303.
McGlashan TH, Zipursky RB, Perkins D et al. Randomized,
double-blind trial of olanzapine versus placebo in patients

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on May 16, 2016

A.R. YUNG, B. NELSON, K. BAKER, J.A. BUCKBY, G. BAKSHEEV, E.M. COSGRAVE

26.

27.

28.
29.
30.

31.
32.
33.
34.

35.

36.

37.

38.

39.

40.
41.

42.

43.

44.

45.

46.

prodromally symptomatic for psychosis. Am J Psychiatry


2006; 163:790799.
McGorry PD, Yung AR, Phillips LJ et al. Randomized
controlled trial of interventions designed to reduce the risk of
progression to rst episode psychosis in a clinical sample with
subthreshold symptoms. Arch Gen Psychiatry 2002; 59:921
928.
Morrison AP, French P, Walford L et al. Cognitive therapy
for the prevention of psychosis in people at ultra-high risk:
randomised controlled trial. Br J Psychiatry 2004; 185:291
297.
Claridge G. The schizophrenias as nervous types. Br J
Psychiatry 1972; 121:117.
Claridge G. Single indicator of risk for schizophrenia:
probable fact or likely myth? Schizophr Bull 1994; 20:151168.
Claridge G, McCreery C, Mason O et al. The factor structure
of schizotypal traits: a large replication study. Br J Clin
Psychol 1996; 35:10315.
Schuldberg D. Six subclinical spectrum traits in normal
creativity. Creativity Res J, -2001 2000; 13:516.
Nettle D. Strong imagination: madness, creativity and human
nature. Oxford: Oxford University Press, 2001.
Nettle D. Schizotypy and mental health among poets, visual
artists, and mathematicians. J Res Pers 2006; 40:876890.
Gottesman II. Personality and natural selection. In:
Vandenberg SG, ed. Methods and goals in human behavior
genetics. New York: Academic, 1965:6380.
Jarvick LF, Chadwick SB. Schizophrenia and survival. In:
Hammer SB, Salzinger K, Sutton S, eds. Psychopathology.
New York: Wiley, 1972:5773.
OReilly T, Dunbar R, Bentall R. Schizotypy and creativity:
an evolutionary connection? Pers Individ Differ 2001;
31:10671078.
Eaton WW, Romanoski A, Anthony JC, Nestadt G.
Screening for psychosis in the general population with a selfreport interview. J Nerv Ment Dis 1991; 179:689693.
Johns LC, Cannon M, Singleton N et al. Prevalence and
correlates of self-reported psychotic symptoms in the British
population. Br J Psychiatry 2004; 185:298305.
Kendler KS, Gallagher TJ, Abelson JM, Kessler RC. Lifetime
prevalence, demographic risk factors, and diagnostic validity
of nonaffective psychosis as assessed in a US community
sample: the National Comorbidity Survey. Arch Gen
Psychiatry 1996; 53:10221031.
Tien AY. Distributions of hallucinations in the population.
Soc Psychiatry Psychiatr Epidemiol 1991; 26:287292.
Dhossche D, Ferdinand R, Van der Ende J, Hofstra MB,
Verhulst F. Diagnostic outcome of self-reported
hallucinations in a community sample of adolescents. Psychol
Med 2002; 32:619627.
Nelson B, Yung AR. Psychotic-like experiences as
overdetermined phenomena: when do they increase risk for
psychotic disorder. Schizophr Res 2008 [Epub ahead of print].
Cannon T, Cadenhead K, Cornblatt B et al. Prediction of
psychosis in ultra high risk youth: a multi-site longitudinal
study in North America. Arch Gen Psychiatry 2008; 65:2837.
Mason O, Startup M, Halpin S, Schall U, Conrad A, Carr V.
Risk factors for transition to rst episode psychosis among
individuals with at-risk mental states. Schizophr Res 2004;
71:227237.
Yung AR, Phillips LJ, Yuen HP et al. Psychosis prediction:
12-month follow up of a high-risk (prodromal) group.
Schizophr Res 2003; 60:2132.
Yung AR, Phillips LJ, Yuen HP, McGorry PD. Risk factors
for psychosis in an ultra high-risk group: psychopathology
and clinical features. Schizophr Res 2004; 67:131142.

127

47. Klosterkotter J, Hellmich M, Steinmeyer EM, Schultze-Lutter


F. Diagnosing schizophrenia in the initial prodromal phase.
Arch Gen Psychiatry 2001; 58:158164.
48. Mason O, Startup M, Halpin S, Schall U, Conrad A, Carr V.
State and trait predictors of transition to rst episode
psychosis among individuals with at risk mental states.
Schizophr Res 2004; 71:227237.
49. Yung AR, Buckby JA, Cotton SM et al. Psychotic-like
experiences in non-psychotic help-seekers: associations with
distress, depression and disability. Schizophr Bull 2006;
32:352359.
50. Verdoux H, van Os J, Maurice-Tison S, Gay B, Salamon R,
Bourgeois M. Is early adulthood a critical developmental
stage for psychosis proneness? A survey of delusional ideation
in normal subjects. Schizophr Res 1998; 29:247254.
51. Scott J, Chant D, Andrews G, McGrath J. Psychotic-like
experiences in the general community: the correlates of CIDI
psychosis screen items in an Australian sample. Psychol Med
2006; 36:231238.
52. Spauwen J, Krabbendam L, Lieb R, Wittchen HU, van Os J.
Sex differences in psychosis: normal or pathological?
Schizophr Res 2003; 62:4549.
53. Stefanis NC, Hanssen M, Smirnis NK et al. Evidence that
three dimensions of psychosis have a distribution in the
general population. Psychol Med 2002; 32:347358.
54. Radloff LS. The CES-D Scale: a self-report depression scale
for research in the general population. Appl Psychol Measure
1977; 1:385401.
55. Tabachnick B, Fidell L. Using multivariate statistics. New
York, NY: Harper Collins, 1996.
56. Hayton JC, Allen DG, Scarpello V. Factor retention decisions
in exploratory factor analysis: a tutorial on parallel analysis.
Organ Res Methods 2004; 7:191205.
57. Hinkle DE, Wiersma W, Jurs SG. Applied statistics for the
behavioural sciences. Boston: Houghton Mifin, 1998.
58. Van Os J, Linscott RJ, Myin-Germeys I, Delespaul P,
Krabbendam L. A systematic review and meta-analysis of the
psychosis continuum: evidence for a psychosis pronenesspersistence-impairment model of psychotic disorder. Psychol
Med 2008 [Epub ahead of print].
59. Spauwen J, Krabbendam L, Lieb R, Wittchen H-U, van Os J.
Does urbanicity shift the population expression of psychosis?
J Psychiatr Res 2004; 38:613618.
60. Spauwen J, Krabbendam L, Lieb R, Wittchen H-U, van Os J.
Evidence that the outcome of developmental expression of
psychosis is worse for adolescents growing up in an urban
environment. Psychol Med 2006; 36:407415.
61. Nelson B, Yung AR, Bechdolf A, McGorry PD. The
phenomenological critique and self-disturbance: implications
for ultra-high risk (prodrome) research. Schizophr Bull 2008;
34:381392.
62. Yung AR, Buckby JA, Cosgrave EM et al. Association
between psychotic experiences and depression in a clinical
sample over 6 months. Schizophr Res 2007; 91:246253.
63. Yung AR, Stanford C, Cosgrave E et al. Testing the ultra high
risk (prodromal) criteria for the prediction of psychosis in a
clinical sample of young people. Schizophr Res 2006; 84:57
66.
64. McCreery C, Claridge G. A study of hallucination in normal
subjects: -I. Self report data. Pers Individ Differ 1996; 21:739
747.
65. Jackson MC. Benign schizotypy? The case of spiritual
experience. In: Claridge G, ed. Schizotypy: implications for
illness and health. Oxford: Oxford University Press, 1997:227
250.
66. Konings M, Bak M, Hanssen M, Van Os J, Krabbendam L.
Validity and reliability of the CAPE: a self-report instrument

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on May 16, 2016

128

67.
68.

69.
70.

PSYCHOTIC-LIKE EXPERIENCES IN THE COMMUNITY

for the measurement of psychotic experiences in the general


population. Acta Psychiatr Scand 2006; 114:5561.
Liraud F, Droulout T, Parrot M, Verdoux H. Agreement
between self-rated and clinically assessed symptoms in
subjects with psychosis. J Nerv Ment Dis 2004; 192:352356.
Bak M, Myin-Germeys I, Delespaul P, Vollebergh W, de
Graaf R, van Os J. Do different psychotic experiences
differentially predict need for care in the general population?
Compr Psychiatry 2005; 46:192199.
Freeman D, Garety PA. Connecting neurosis and psychosis:
the direct inuence of emotion on delusions and
hallucinations. Behav Res Ther 2003; 41:923947.
Escher S, Romme M, Buiks A, Delespaul P, Van Os J.
Formation of delusional ideation in adolescents hearing

71.
72.
73.

74.

voices: a prospective study. Am J Med Genet 2002; 114:


913920.
Broome MR, Woolley JB, Tabraham P et al. What causes the
onset of psychosis? Schizophr Res 2005; 79:2334.
Handest P, Parnas J. Clinical characteristics of rst-admitted
patients with ICD-10 schizotypal disorder. Br J Psychiatry
2005; 48 (Suppl):s49s55.
Parnas J, Handest P, Jansson L, Saebye D. Anomalous
subjective experience among rst-admitted schizophrenia
spectrum patients: empirical investigation. Psychopathology
2005; 38:259267.
Yung AR, Yuen HP, Berger G et al. Declining transition rate
in ultra high risk (prodromal) services: dilution or reduction
of risk? Schizophr Bull 2007; 33:67381.

Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on May 16, 2016