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119
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
120
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.
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.
121
Results
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).
122
Item
no.
24
26
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?
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
30
31
Factor 1
Factor loading
Factor
Factor
2
3
Table 2.
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).
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)
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.
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
124
Table 4.
Block 1
Block 2
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
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.
125
126
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.
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