Psychotic Continuum

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However, analyses indicated a true incompatibility of magical ideation and physical anhedonia rather than sampling effects as a cause for this pattern [ 43 ]. It was suggested that people scoring high on both magical ideation and physical anhedonia are more likely to become hospitalized, which might cancel out the otherwise negative correlation in these populations.

Whereas these findings still remain to be explained, it has been speculated that magical ideation might reduce physical anhedonia by conveying meaning to sensory experiences or that both are linked through a third factor, e. However, room for interpretation is limited, as most of the aforementioned scales for PLE may contain several different constructs rather than one.

For example, the Magical Ideation Scale MIS , see [ 41 ] includes paranormal beliefs, superstitious beliefs, ideas of reference, and suspicious-paranoid thoughts [ 46 ]. Hence, it is not clear which of the contained constructs are ultimately responsible for the observed associations. Nonetheless, the results indicated that it might be important to differentiate between subtypes of PLE, as they might be variably associated with other psychological risk factors.


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The CAPE was constructed to investigate the extended psychosis phenotype [ 15 ] and has become one of the most frequently used self-report instruments for PLE [ 34 ]. A few studies have investigated which categories underlie PLE in the CAPE and how they are related to factors indicating risk for transition to psychotic disorder, i. Using exploratory factor analyses, one study identified bizarre experiences BE , persecutory ideas PI , and magical thinking MT to underlie the CAPE positive dimension in a sample of non-psychotic help-seekers [ 31 ]. Interestingly, only BE and PI were found to be associated with distress, depression, and poor functioning while MT was not.

Notably, reminiscent of the aforementioned studies implementing the MIS, the researchers also found that MT was not correlated with anhedonic depression, unless accompanied by distress. The apparent lack of associations of MT with any maladaptive feature such as depression and poor functioning lead the researchers to suggest that MT might be benign. It was thought that the lacking association of MT with indicators of disadvantage could be explained with the finding that two items referring to paranormal beliefs were more closely associated with age and cultural background than psychopathology [ 30 , 31 ].

Therefore, two corresponding items were dropped from the analyses in a subsequent study [ 29 ]. This time, PLE clustered into four classes, i. BE, PI, PA, and grandiosity while all subtypes were associated with one or more indicators of disadvantage. The authors speculated that PI and BE might lead to more evident symptoms than PA and GR, as they are more invasive experiences and more disruptive of the self-structure. Importantly, the studies showed that all forms of PLE were associated with disadvantage, once items specifically related to paranormal beliefs but not grandiosity were removed.

At the same time, however, they indicated that PLE might be maladaptive in different ways and it was speculated that they may confer varying levels of risk for psychosis and other mental disorders [ 29 ]. The study aimed at gaining first information about possible symptom-level mechanisms implicated in the emergence of mental disorders featuring psychotic symptoms and a meaningful categorization of PLE. Importantly, the researchers not only included experiences that are relevant regarding the specific extended psychosis phenotype i.

Further extending the description of PLE, a novel questionnaire was included whose items were not derived from clinical symptom presentations the revised Questionnaire for Assessing the Phenomenology of Exceptional Experiences PAGE-R , see [ 50 ] and that had just recently been introduced into psychosis research [ 44 ]. Whereas most subclinical symptoms were correlated, the researchers found unique associations between certain PLE and subclinical symptoms that were consistent across the numerous applied scales when co-occurring PLE were controlled for: paranoia-like experiences suspiciousness were uniquely associated with various scales measuring negative-like experiences.

In contrast, different hallucination-like experiences including dissociation exclusively predicted different anxiety-related experiences while ideas of reference appeared to be specifically implicated with affective symptoms anxiety and depression. Importantly, numerous negative associations between PLE and other subclinical difficulties were detected, namely between ideas of reference and physical anhedonia, magical thinking and constricted affect, PAGE-R odd beliefs e.

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Notably, unlike suspiciousness and ideas of reference, magical thinking and PAGE-R odd beliefs did not positively predict any subclinical symptoms. While these results pointed to possible symptom-level interactions implicated in the development of psychosis spectrum disorders [ 37 , 38 ], they also contributed to an empirically founded and much-needed categorization of PLE [ 30 , 39 ].

Furthermore, the findings suggested that negative associations between PLE and other subclinical symptoms might be more extensive than previously thought and indicated that some delusion-like PLE per se might be associated with less psychological difficulties while being indicative of increased psychological burden at the same time as indicated by their positive correlations with diverse psychological difficulties.

Interestingly, there are complementary findings suggesting that some PLE might not only go along with less co-occurring subclinical symptoms but also with well-being. In a sample of university students, it was found that ideas of reference positively predicted subjective well-being, e.

Notably, this finding was in line with suggestions that ideas of reference in contrast with paranoia must not necessarily be burdensome [ 52 , 53 ]. Odd beliefs as measured by the PAGE-R were prominently represented in the detected negative associations. Importantly, this sets odd beliefs apart from scales assessing e. Further, in contrast to most studied forms of delusion-like experiences e. Nonetheless, odd beliefs are conceptually similar to other delusion-like experiences and may be associated with indicators of psychosis proneness, such as biases in probabilistic reasoning and a tendency to jump to conclusions [ 55 , 56 ], alterations in attributional styles [ 57 , 58 ], differences in theory of mind [ 59 ], and magical ideation [ 60 ].

Psychosis - causes, symptoms, and treatment explained

Importantly, experiences similar to odd beliefs have been suggested to reduce distress in perceptually ambiguous or stressful situations [ 61 , 62 ] and to facilitate perceived control as well as to confer confidence and agency under lack of control [ 63 ]. Before this background, it was speculated that odd beliefs in healthy individuals might represent a psychologically stabilizing cognitive response to burdensome experiences [ 28 ].

American Academy of Neurology

Hence, despite their delusion-like quality, odd beliefs might paradoxically exert a positive effect on psychological well-being. Intriguingly, a new study investigating specificities between PLE and forms of childhood trauma found for the first time that odd beliefs in healthy adults were associated with stronger self-concept of own competences SC , when adverse childhood experiences were held constant [ 64 ].

In contrast, paranoid-like experiences remained negatively associated with SC once adjusted for childhood adversities. Notably, addressing SC might also strengthen self-esteem, which has been identified by individuals with schizophrenia to be the most important treatment target [ 68 ]. Moreover, strengthening SC in therapy might help to alleviate psychotic symptoms SC [ 66 ].

Psychotic-Like Experiences at the Healthy End of the Psychosis Continuum

Due to their positive association with SC the question was raised if odd beliefs might contribute to resilience toward mental illness, despite conferring an inaccurate perception of the world [ 64 ]. The presented findings suggest that despite their tendency to co-occur, PLE may be variously implicated in mental illness and mental health. These results are in line with earlier suggestions that a co-occurrence of characteristics seen in pathological and non-pathological conditions must not necessarily mean that they are indicators of psychopathology [ 70 ].

More specifically, some characteristics could simply be by-products of the psychosis dimension but not be clinically relevant per se.

However, it is cautioned to jump to premature conclusions and these symptom-level insights require further investigation, as there are several limitations to be considered. For example, all studies applied cross-sectional study designs, preventing any causal conclusions to be drawn. Further, the samples were not representative of the non-clinical part of the general population e. Further, it is not clear if e. It might well be that the tendency to have odd beliefs might worsen outcomes in some cases by acting as an accelerant among other PLE. Nonetheless, the reported results might serve as starting points for the creation of theoretical models and longitudinal investigations into the interplay of subclinical symptoms leading to the exacerbation of subclinical symptoms or the maintenance of mental health, respectively [ 28 ].

Self-report instruments for psychotic-like experiences PLE are a central source of information in epidemiological research on subclinical psychosis. However, it is mostly not regarded that these instruments are tied to certain conceptualizations of subclinical psychosis and originally served a specific purpose [ 24 , 25 , 34 ]. Notably, many instruments used to assess PLE stem from schizotypy research and are fundamentally influenced by the underlying schizotypy model and the assumed link between schizotypal personality features and schizophrenia.

For example, one of the earliest and most frequently used schizotypy scales is the Magical Ideation Scale MIS, see [ 41 ] [ 34 ]. Furthermore, the selection of items might not be reflective of different forms of PLE in the general population, as items with extremely high and low difficulties were chosen to attain normality of the scale score. In comparison, the popular Schizotypal Personality Questionnaire SPQ, see [ 49 ] was constructed to screen for schizotypal personality disorder according to DSM-III-R criteria and not to assess schizotypal personality organization [ 25 ].

Notably, item-level factor analyses have repeatedly produced incongruent categorizations of the experiences [ 71 ]. The CAPE was created against the theoretical background of the extended subclinical psychosis phenotype [ 15 ] and is an attractive tool for clinical and research use, as it is comprehensive and measures not only the frequency of PLE but also distress associated with them [ 48 ]. Importantly, choosing one instrument over the other may profoundly affect the ensuing results [ 25 ].

For example, although similar sex differences have been found in non-clinical samples as in schizophrenic patients [ 72 , 73 ], the non-detection of sex differences in a community sample has led researchers to conclude that they only present themselves in full-blown psychosis but not in sub-threshold states [ 74 ].

Interestingly, using a sample of healthy individuals, a study could replicate the detection and non-detection of sex differences in the latter studies, depending on the scales for PLE that were being analyzed [ 44 ]. It was suggested that scales including fewer and more severe or difficult items e. Importantly, different populations across the psychosis continuum ranging from non-disordered schizotypes, to prodromal patients, to patients with a schizotypal personality disorder, and to psychotic patients might all experience positive -like symptoms such as odd beliefs.

However, these groups might differ regarding the relative prevalence of increasingly severe forms of experiences ranging from magical thinking to full-blown delusions [ 24 ]. Hence, depending on the sample, the research question, as well as the theoretical model of psychosis, some surveys might be more adequate to be used than others.

In addition to the mostly non-transparent choice of instruments [ 34 ] and their heterogeneous designs, unclear content validity of scales may additionally entail mixed results across studies and contribute to a blurred picture of psychosis [ 25 ]. Studies investigating symptom-level associations have applied multiple regression modeling to account for overlapping variance between different PLE scales in order to gain insight into their specific psychopathological significance [ 29 , 30 ]. Whereas these results are meaningfully interpretable, the reliability of the interpretations ultimately depends on the choice of instruments and the content validity of the applied scales.

Notably, scales measuring certain PLE may often conflate different constructs impeding a reliable interpretation of results, as exemplified by the MIS [ 24 , 46 ]. Hence, to successfully elucidate the complex structure of psychosis, researchers should have detailed knowledge of existing constructs and be familiar with the limitations of their operationalizations.

A generally agreed upon and empirically substantiated categorization of PLE would be a helpful tool for clinicians as well as researchers. For example, it might help to provide more accurate screening procedures, predict risk for certain disorders featuring psychotic symptoms, facilitate more adequate treatment, and counteract stigmatization [ 29 ]. Further, it might also help to integrate findings across studies implementing different psychometric instruments and conceptualizations of PLE.

More recently, similar categorizations of three basic types of PLE have been proposed, suggesting that: 1 some indicate a specific vulnerability toward psychosis while 2 others might be non-specific and also be implicated in the development of affective disorders, and 3 some might not be associated with any clinical disorder at all [ 30 , 39 ]. It has been speculated that some PLE such as paranormal beliefs are benign and might explain why they are mostly not associated with mental illness [ 32 ]. In contrast, it has been suggested that PLE specifically associated with distress and poor functioning might be more likely to indicate vulnerability to psychotic disorders [ 30 ].

However, it yet remains to be clarified to which category certain PLE should be assigned [ 32 ]. Recently, to shed light onto possible categorizations of PLE, a study investigated unique associations of certain PLE with subclinical symptoms relevant for psychosis spectrum disorders [ 76 ], i. Referring to the model introduced above, following categorizations are suggested: Paranoid-like experiences in healthy individuals might specifically indicate vulnerability to psychosis category 1 , as they were the only significant predictor of schizophrenia-like negative symptoms physical anhedonia, no close friends, and constricted affect but were not associated with any type of affective symptoms.

In contrast, hallucination-like experiences were uniquely associated with experiences from the anxiety spectrum e. Further, ideas of reference were a positive predictor of anxiety symptoms and depressive symptoms. Therefore, the latter PLE might belong to the category of non-specific PLE, hence, predisposing toward affective and psychosis spectrum disorders category 2.

Lastly, paranormal beliefs and PAGE-R odd beliefs did not positively predict any of the subclinical difficulties, which might reflect that they are not associated with any clinical disorder at all category 3. The latter categorization was underlined by the observation that paranormal beliefs and odd beliefs were negatively associated with various psychological difficulties.

Notably, these findings raise the question if more categories for PLE might be needed that account for associations of PLE with well-being and stronger resilience [ 51 , 64 ] and lower load of negative-like symptoms. However, it remains to be determined if these findings can be accommodated within a framework encompassing three classes of PLE.

Mapping the uncanny - Assessing dimensions of psychotic-like experiences for clinical utility

The tentative categorization of PLE presented above requires more data and replications in samples representative of the healthy general population. Ultimately, longitudinal studies are needed to determine if specific PLE predict certain psychosis spectrum disorders more likely than other diagnoses and how they are implicated in the maintenance of mental health.

Notably, other symptom factors that are relevant for determining the psychopathological significance of PLE were not regarded. Amongst other factors, these include intrusiveness, distress, and frequency of experiences as well as the associated development of functional impairment [ 47 ]. Furthermore, similar analyses are needed including other subclinical difficulties that might be part of the psychosis phenotype [ 16 ], such as disorganized symptoms and mania [ 51 ].

A comprehensive and phenomenological differentiated description of psychotic-like experiences PLE might be the prerequisite for attaining reliable classifications of PLE and new insights regarding their individual roles in the exacerbation of subclinical symptoms and the maintenance of mental health [ 34 , 35 ].

Consequently, this has also influenced the way PLE are operationalized across various psychometric instruments e. However, there is evidence indicating that the phenomenological quality of psychotic experiences may differ between healthy and clinical individuals [ 28 , 77 ]. Journal logo. Psychosis Lindsey A. Article as PDF. Article Tools. Article as EPUB. Print This Article. Add to My Favorites.

Looking Below the Threshold

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