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Do subthreshold psychotic experiences predict clinical outcomes in unselected non-help-seeking population-based samples? A systematic review and meta-analysis, enriched with new results

  • N. Kaymaz (a1) (a2), M. Drukker (a1), R. Lieb (a3) (a4), H.-U. Wittchen (a3) (a5), N. Werbeloff (a6), M. Weiser (a6), T. Lataster (a1) and J. van Os (a1) (a7)...



The base rate of transition from subthreshold psychotic experiences (the exposure) to clinical psychotic disorder (the outcome) in unselected, representative and non-help-seeking population-based samples is unknown.


A systematic review and meta-analysis was conducted of representative, longitudinal population-based cohorts with baseline assessment of subthreshold psychotic experiences and follow-up assessment of psychotic and non-psychotic clinical outcomes.


Six cohorts were identified with a 3–24-year follow-up of baseline subthreshold self-reported psychotic experiences. The yearly risk of conversion to a clinical psychotic outcome in exposed individuals (0.56%) was 3.5 times higher than for individuals without psychotic experiences (0.16%) and there was meta-analytic evidence of dose–response with severity/persistence of psychotic experiences. Individual studies also suggest a role for motivational impairment and social dysfunction. The evidence for conversion to non-psychotic outcome was weaker, although findings were similar in direction.


Subthreshold self-reported psychotic experiences in epidemiological non-help-seeking samples index psychometric risk for psychotic disorder, with strong modifier effects of severity/persistence. These data can serve as the population reference for selected and variable samples of help-seeking individuals at ultra-high risk, for whom much higher transition rates have been indicated.


Corresponding author

*Address for correspondence: J. van Os, Ph.D., Department of Psychiatry and Psychology, Maastricht University Medical Centre, PO Box 616 (DRT 12), 6200MD Maastricht, The Netherlands. (Email:


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Achenbach, TM (1991). Manual for the Youth Self-Report and 1991 Profile (with Dutch translation). University of Vermont: Burlington, VT.
Bak, M, Delespaul, P, Hanssen, M, de Graaf, R, Vollebergh, W, van Os, J (2003). How false are ‘false’ positive psychotic symptoms? Schizophrenia Research 62, 187189.
Bijl, RV, Ravelli, A, van Zessen, G (1998 a). Prevalence of psychiatric disorder in the general population: results of the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Social Psychiatry and Psychiatric Epidemiology 33, 587595.
Bijl, RV, van Zessen, G, Ravelli, A, de Rijk, C, Langendoen, Y (1998 b). The Netherlands Mental Health Survey and Incidence Study (NEMESIS): objectives and design. Social Psychiatry and Psychiatric Epidemiology 33, 581586.
Chapman, LJ, Chapman, JP, Kwapil, TR, Eckblad, M, Zinser, MC (1994). Putatively psychosis-prone subjects 10 years later. Journal of Abnormal Psychology 103, 171183.
Costello, A, Edelbrock, C, Kalas, R, Kessler, M, Klaric, S (1982). NIMH Diagnostic Interview for Children: Child Version. National Institute of Mental Health: Rockville, MD.
Derogatis, LR, Cleary, PA (1977). Confirmation of the dimensional structure of the SCL-90: a study in construct validation. Journal of Clinical Psychology 33, 981989.
Dominguez, MD, Saka, MC, Lieb, R, Wittchen, HU, van Os, J (2010). Early expression of negative/disorganized symptoms predicting psychotic experiences and subsequent clinical psychosis: a 10-year study. American Journal of Psychiatry 167, 10751082.
Dominguez, MD, Wichers, M, Lieb, R, Wittchen, HU, van Os, J (2011). Evidence that onset of clinical psychosis is an outcome of progressively more persistent subclinical psychotic experiences: an 8-year cohort study. Schizophrenia Bulletin 37, 8493.
Endicott, J, Spitzer, RL (1978). A diagnostic interview: the schedule for affective disorders and schizophrenia. Archives of General Psychiatry 35, 837844.
Hanssen, M, Bak, M, Bijl, R, Vollebergh, W, van Os, J (2005). The incidence and outcome of subclinical psychotic experiences in the general population. British Journal of Clinical Psychology 44, 181191.
Higgins, JP, Thompson, SG (2004). Controlling the risk of spurious findings from meta-regression. Statistics in Medicine 23, 16631682.
Kapur, S (2003). Psychosis as a state of aberrant salience: a framework linking biology, phenomenology, and pharmacology in schizophrenia. American Journal of Psychiatry 160, 1323.
Kelleher, I, Harley, M, Murtagh, A, Blanchard, M, Cannon, M (2009). Screening for subclinical psychosis in the general adolescent population [Conference Abstract]. Schizophrenia Bulletin 35 (Suppl. 1), 71.
Kwapil, TR, Miller, MB, Zinser, MC, Chapman, J, Chapman, LJ (1997). Magical ideation and social anhedonia as predictors of psychosis proneness: a partial replication. Journal of Abnormal Psychology 106, 491495.
Lieb, R, Isensee, B, von Sydow, K, Wittchen, HU (2000). The Early Developmental Stages of Psychopathology Study (EDSP): a methodological update. European Addiction Research 6, 170182.
Linscott, RJ, van Os, J (2010). Systematic reviews of categorical versus continuum models in psychosis: evidence for discontinuous subpopulations underlying a psychometric continuum. Implications for DSM-V, DSM-VI, and DSM-VII. Annual Review of Clinical Psychology 6, 391419.
Overall, JE, Gorham, DR (1962). The Brief Psychiatric Rating Scale. Psychological Report 10, 799812.
Poulton, R, Caspi, A, Moffitt, TE, Cannon, M, Murray, R, Harrington, H (2000). Children's self-reported psychotic symptoms and adult schizophreniform disorder: a 15-year longitudinal study. Archives of General Psychiatry 57, 10531058.
Regeer, EJ, Krabbendam, L, de Graaf, R, ten Have, M, Nolen, WA, van Os, J (2006). A prospective study of the transition rates of subthreshold (hypo)mania and depression in the general population. Psychological Medicine 36, 619627.
Regeer, EJ, Krabbendam, L, de Graaf, R, ten Have, MT, Nolen, WA, van Os, J (2009). Berkson's bias and the mood dimensions of bipolar disorder. International Journal of Methods in Psychiatric Research 18, 279286.
Roberts, RE, Vernon, SW (1981). Usefulness of the PERI demoralization scale screen for psychiatric disorder in a community sample. Psychiatry Research 5, 183193.
Robins, LN, Cottler, L, Bucholz, K, Compton, W (1995). Diagnostic Interview Schedule for DSM-IV. Washington University: St Louis, MO.
Robins, LN, Wing, J, Wittchen, HU, Helzer, JE, Babor, TF, Burke, J, Farmer, A, Jablenski, A, Pickens, R, Regier, DA (1988). The Composite International Diagnostic Interview. An epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Archives of General Psychiatry 45, 10691077.
Saha, S, Barendregt, JJ, Vos, T, Whiteford, H, McGrath, J (2008). Modelling disease frequency measures in schizophrenia epidemiology. Schizophrenia Research 104, 246254.
Shrout, PE, Dohrenwend, BP, Levav, I (1986). A discriminant rule for screening cases of diverse diagnostic types: preliminary results. Journal of Consulting Clinical Psychology 54, 314319.
Slade, M, Phelan, M, Thornicroft, G, Parkman, S (1996). The Camberwell Assessment of Need (CAN): comparison of assessments by staff and patients of the needs of the severely mentally ill. Social Psychiatry and Psychiatric Epidemiology 31, 109113.
StataCorp (2009). STATA Statistical Software: Release 11. Stata Corporation: College Station, TX.
Stroup, DF, Berlin, JA, Morton, SC, Olkin, I, Williamson, GD, Rennie, D, Moher, D, Becker, BJ, Sipe, TA, Thacker, SB (2000). Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. Journal of the American Medical Association 283, 20082012.
Tijssen, MJ, van Os, J, Wittchen, HU, Lieb, R, Beesdo, K, Mengelers, R, Krabbendam, L, Wichers, M (2010 a). Evidence that bipolar disorder is the poor outcome fraction of a common developmental phenotype: an 8-year cohort study in young people. Psychological Medicine 40, 289299.
Tijssen, MJ, van Os, J, Wittchen, HU, Lieb, R, Beesdo, K, Mengelers, R, Wichers, M (2010 b). Prediction of transition from common adolescent bipolar experiences to bipolar disorder: 10-year study. British Journal of Psychiatry 196, 102108.
van Nierop, M, van Os, J, Gunther, N, Myin-Germeys, I, de Graaf, R, ten Have, M, van Dorsselaer, S, Bak, M, van Winkel, R (2011). Phenotypically continuous with clinical psychosis, discontinuous in need for care: evidence for an extended psychosis phenotype. Schizophrenia Bulletin. Published online: 9 September 2011. doi:10.1093/schbul/sbr129.
van Os, J, Hanssen, M, Bijl, R, Ravelli, A (2000). Straus (1969) revisited: a psychosis continuum in the general population? Schizophrenia Research 45, 1120.
van Os, J, Hanssen, M, Bijl, RV, Vollebergh, W (2001). Prevalence of psychotic disorder and community level of psychotic symptoms: an urban-rural comparison. Archives of General Psychiatry 58, 663668.
van Os, J, Linscott, RJ, Myin-Germeys, I, Delespaul, P, Krabbendam, L (2009). A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychological Medicine 39, 179195.
Welham, J, Scott, J, Williams, G, Najman, J, Bor, W, O'Callaghan, M, McGrath, J (2009). Emotional and behavioural antecedents of young adults who screen positive for non-affective psychosis: a 21-year birth cohort study. Psychological Medicine 39, 625634.
Werbeloff, N, Drukker, M, Dohrenwend, BP, Levav, I, Yoffe, R, van Os, J, Davidson, M, Weiser, M (2012). Self-reported attenuated psychotic symptoms as forerunners of severe mental disorders later in life. Archives of General Psychiatry. Published online: 2 January 2012. doi:10.1001/archgenpsychiatry.2011.1580.
WHO (1990). Composite International Diagnostic Interview (CIDI), Version 1.0. World Health Organization: Geneva.
Wittchen, HU, Perkonigg, A, Lachner, G, Nelson, CB (1998). Early Developmental Stages of Psychopathology Study (EDSP): objectives and design. European Addiction Research 4, 1827.
Wittchen, HU, Pfister, H (1997). DIS-X-Interviews: Manual für Screening-Verfahren und Interview; Interviewheft Längsschnittuntersuchung (DIA-X-Lifetime); Ergänzungsheft (DIA-X-Lifetime); Interviewheft Querschnittsuntersuchung (DIA-X-12 Monats-Version); Ergänzungsheft (DIA-X-12 Monats-Version); PC-Programm zur Durchführung der Interviews (Längsund Querschnittsuntersuchung). Auswertungsprogramm. Swets & Zeitlinger: Frankfurt.
Zimmermann, P, Wittchen, HU, Hofler, M, Pfister, H, Kessler, RC, Lieb, R (2003). Primary anxiety disorders and the development of subsequent alcohol use disorders: a 4-year community study of adolescents and young adults. Psychological Medicine 33, 12111222.


Do subthreshold psychotic experiences predict clinical outcomes in unselected non-help-seeking population-based samples? A systematic review and meta-analysis, enriched with new results

  • N. Kaymaz (a1) (a2), M. Drukker (a1), R. Lieb (a3) (a4), H.-U. Wittchen (a3) (a5), N. Werbeloff (a6), M. Weiser (a6), T. Lataster (a1) and J. van Os (a1) (a7)...


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