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A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness–persistence–impairment model of psychotic disorder

  • J. van Os (a1) (a2), R. J. Linscott (a1) (a3), I. Myin-Germeys (a1), P. Delespaul (a1) and L. Krabbendam (a1)...

A systematic review of all reported incidence and prevalence studies of population rates of subclinical psychotic experiences reveals a median prevalence rate of around 5% and a median incidence rate of around 3%. A meta-analysis of risk factors reveals associations with developmental stage, child and adult social adversity, psychoactive drug use, and also male sex and migrant status. The small difference between prevalence and incidence rates, together with data from follow-up studies, indicates that approximately 75–90% of developmental psychotic experiences are transitory and disappear over time. There is evidence, however, that transitory developmental expression of psychosis (psychosis proneness) may become abnormally persistent (persistence) and subsequently clinically relevant (impairment), depending on the degree of environmental risk the person is additionally exposed to. The psychosis proneness–persistence–impairment model considers genetic background factors impacting on a broadly distributed and transitory population expression of psychosis during development, poor prognosis of which, in terms of persistence and clinical need, is predicted by environmental exposure interacting with genetic risk.

Corresponding author
*Address for correspondence: Dr J. van Os, Department of Psychiatry and Neuropsychology, South Limburg Mental Health Research and Teaching Network, EURON, Maastricht University, PO Box 616 (DRT 10), 6200 MD Maastricht, The Netherlands. (Email:
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P Allen , D Freeman , L Johns , P McGuire (2006). Misattribution of self-generated speech in relation to hallucinatory proneness and delusional ideation in healthy volunteers. Schizophrenia Research 84, 281288.

L Arseneault , M Cannon , R Poulton , R Murray , A Caspi , TE Moffit (2002). Cannabis use in adolescence and risk for adult psychosis: longitudinal prospective study. British Medical Journal 325, 12121213.

M Bak , I Myin-Germeys , P Delespaul , W Vollebergh , R de Graaf , J van Os (2005). Do different psychotic experiences differentially predict need for care in the general population? Comprehensive Psychiatry 46, 192199.

TR Barrett , JB Etheridge (1992). Verbal hallucinations in normals. I: People who hear voices. Applied Cognitive Psychology 6, 379387.

RP Bentall , PD Slade (1985). Reliability of a scale measuring disposition towards hallucinations: a brief report. Personality and Individual Differences 6, 527529.

H Bergida , MF Lenzenweger (2006). Schizotypy and sustained attention: confirming evidence from an adult community sample. Journal of Abnormal Psychology 115, 545551.

T Brugha , N Singleton , H Meltzer , P Bebbington , M Farrell , R Jenkins , J Coid , T Fryers , D Melzer , G Lewis (2005). Psychosis in the community and in prisons: a report from the British National Survey of Psychiatric Morbidity. American Journal of Psychiatry 162, 774780.

E Cantor-Graae , JP Selten (2005). Schizophrenia and migration: a meta-analysis and review. American Journal of Psychiatry 162, 1224.

LJ Chapman , JP Chapman , TR Kwapil , M Eckblad , MC Zinser (1994). Putatively psychosis-prone subjects 10 years later. Journal of Abnormal Psychology 103, 171183.

TJ Crow (1998). From Kraepelin to Kretschmer leavened by Schneider. The transition from categories of psychosis to dimensions of variation intrinsic to Homo sapiens. Archives of General Psychiatry 55, 502504.

WM Dinn , CL Harris , A Aycicegi , P Greene , MS Andover (2002). Positive and negative schizotypy in a student sample: neurocognitive and clinical correlates. Schizophrenia Research 56, 171185.

G Driessen , N Gunther , M Bak , M van Sambeek , J Van Os (1998). Characteristics of early- and late-diagnosed schizophrenia: implications for first-episode studies. Schizophrenia Research 33, 2734.

MF Egan , TE Goldberg , T Gscheidle , M Weirich , R Rawlings , TM Hyde , L Bigelow , DR Weinberger (2001). Relative risk for cognitive impairments in siblings of patients with schizophrenia. Biological Psychiatry 50, 98107.

A Fanous , C Gardner , D Walsh , KS Kendler (2001). Relationship between positive and negative symptoms of schizophrenia and schizotypal symptoms in nonpsychotic relatives. Archives of General Psychiatry 58, 669673.

SV Faraone , LJ Seidman , WS Kremen , JR Pepple , MJ Lyons , MT Tsuang (1995). Neuropsychological functioning among the nonpsychotic relatives of schizophrenic patients: a diagnostic efficiency analysis. Journal of Abnormal Psychology 104, 286304.

RF Ferdinand , J van der Ende , FC Verhulst (2004). Associations between visual and auditory hallucinations in children and adolescents, and tobacco use in adulthood. Social Psychiatry and Psychiatric Epidemiology 39, 514520.

DM Fergusson , LJ Horwood , NR Swain-Campbell (2003). Cannabis dependence and psychotic symptoms in young people. Psychological Medicine 33, 1521.

M Hanssen , L Krabbendam , M Vollema , P Delespaul , J Van Os (2006). Evidence for instrument and family-specific variation of subclinical psychosis dimensions in the general population. Journal of Abnormal Psychology 115, 514.

AS Henderson , AE Korten , C Levings , AF Jorm , H Christensen , PA Jacomb , B Rodgers (1998). Psychotic symptoms in the elderly: a prospective study in a population sample. International Journal of Geriatric Psychiatry 13, 484492.

C Henquet , R Murray , D Linszen , J van Os (2005). The environment and schizophrenia: the role of cannabis use. Schizophrenia Bulletin 31, 608612.

I Janssen , M Hanssen , M Bak , RV Bijl , R de Graaf , W Vollebergh , K McKenzie , J van Os (2003). Discrimination and delusional ideation. British Journal of Psychiatry 182, 7176.

LC Johns , M Cannon , N Singleton , RM Murray , M Farrell , T Brugha , P Bebbington , R Jenkins , H Meltzer (2004). Prevalence and correlates of self-reported psychotic symptoms in the British population. British Journal of Psychiatry 185, 298305.

LC Johns , J van Os (2001). The continuity of psychotic experiences in the general population. Clinical Psychology Review 21, 11251141.

P Jones , B Rodgers , R Murray , M Marmot (1994 a). Child development risk factors for adult schizophrenia in the British 1946 birth cohort. Lancet 344, 13981402.

KS Kendler , TJ Gallagher , JM Abelson , RC Kessler (1996). Lifetime prevalence, demographic risk factors, and diagnostic validity of nonaffective psychosis as assessed in a US community sample. The National Comorbidity Survey. Archives of General Psychiatry 53, 10221031.

KS Kendler , CO Gardner (1997). The risk for psychiatric disorders in relatives of schizophrenic and control probands: a comparison of three independent studies. Psychological Medicine 27, 411419.

KS Kendler , J Hewitt (1992). The structure of self-report schizotypy in twins. Journal of Personality Disorders 6, 117.

RC Kessler , H Birnbaum , O Demler , IR Falloon , E Gagnon , M Guyer , MJ Howes , KS Kendler , L Shi , E Walters , EQ Wu (2005). The prevalence and correlates of nonaffective psychosis in the National Comorbidity Survey Replication (NCS-R). Biological Psychiatry 58, 668676.

SS Kety , D Rosenthal , PH Wender , F Schulsinger (1971). Mental illness in the biological and adoptive families of adopted schizophrenics. American Journal of Psychiatry 128, 8286.

L Krabbendam , M Marcelis , P Delespaul , J Jolles , J van Os (2001). Single or multiple familial cognitive risk factors in schizophrenia? American Journal of Medical Genetics 105, 183188.

L Krabbendam , I Myin-Germeys , M Hanssen , J van Os (2005). Familial covariation of the subclinical psychosis phenotype and verbal fluency in the general population. Schizophrenia Research 74, 3741.

TR Kwapil (1998). Social anhedonia as a predictor of the development of schizophrenia-spectrum disorders. Journal of Abnormal Psychology 107, 558565.

R Langdon , M Coltheart (1999). Mentalising, schizotypy, and schizophrenia. Cognition 71, 4371.

KR Laurens , S Hodgins , B Maughan , RM Murray , ML Rutter , EA Taylor (2007). Community screening for psychotic-like experiences and other putative antecedents of schizophrenia in children aged 9–12 years. Schizophrenia Research 90, 130146.

MF Lenzenweger , JM Gold (2000). Auditory working memory and verbal recall memory in schizotypy. Schizophrenia Research 42, 101110.

E Levine , H Jonas , MR Serper (2004). Interpersonal attributional biases in hallucinatory-prone individuals. Schizophrenia Research 69, 2328.

KE Lewandowski , N Barrantes-Vidal , RO Nelson-Gray , C Clancy , HO Kepley , TR Kwapil (2006). Anxiety and depression symptoms in psychometrically identified schizotypy. Schizophrenia Research 83, 225235.

AW MacDonald , MF Pogue-Geile , TT Debski , S Manuck (2001). Genetic and environmental influences on schizotypy: a community-based twin study. Schizophrenia Bulletin 27, 4758.

M Matsui , T Sumiyoshi , K Kato , E Yoneyama , M Kurachi (2004). Neuropsychological profile in patients with schizotypal personality disorder or schizophrenia. Psychological Reports 94, 387397.

R McGee , S Williams , R Poulton (2000). Hallucinations in nonpsychotic children. Journal of the American Academy of Child and Adolescent Psychiatry 39, 1213.

PD McGorry , RC Bell , PL Dudgeon , HJ Jackson (1998). The dimensional structure of first episode psychosis: an exploratory factor analysis. Psychological Medicine 28, 935947.

PD McGorry , C McFarlane , GC Patton , R Bell , ME Hibbert , HJ Jackson , G Bowes (1995). The prevalence of prodromal features of schizophrenia in adolescence: a preliminary survey. Acta Psychiatrica Scandinavica 92, 241249.

J McGrath , S Saha , J Welham , O El Saadi , C MacCauley , D Chant (2004). A systematic review of the incidence of schizophrenia: the distribution of rates and the influence of sex, urbanicity, migrant status and methodology. BMC Medicine 2, 13.

R McKay , R Langdon , M Coltheart (2005). Paranoia, persecutory delusions and attributional biases. Psychiatry Research 136, 233245.

PE Meehl (1962). Schizotaxia, schizotypy, schizophrenia. American Psychologist 17, 827838.

R Mojtabi (2006). Psychotic-like experiences and interpersonal violence in the general population. Social Psychiatry and Psychiatric Epidemiology 41, 183190.

CS Neumann , EF Walker (2003). Neuromotor functioning in adolescents with schizotypal personality disorder: associations with symptoms and neurocognition. Schizophrenia Bulletin 29, 285298.

MM Ohayon , AF Schatzberg (2002). Prevalence of depressive episodes with psychotic features in the general population. American Journal of Psychiatry 159, 18551861.

M Olfson , R Lewis-Fernandez , MM Weissman , A Feder , MJ Gameroff , D Pilowsky , M Fuentes (2002). Psychotic symptoms in an urban general medicine practice. American Journal of Psychiatry 159, 14121419.

E Peters , S Day , J McKenna , G Orbach (1999 a). Delusional ideation in religious and psychotic populations. British Journal of Clinical Psychology 38, 8396.

E Peters , S Joseph , S Day , P Garety (2004). Measuring delusional ideation: the 21-item Peters et al. Delusions Inventory (PDI). Schizophrenia Bulletin 30, 10051022.

TB Posey , ME Losch (1983). Auditory hallucinations of hearing voices in 375 normal subjects. Imagination, Cognition, and Personality 3, 99113.

J Read , J van Os , AP Morrison , CA Ross (2005). Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications. Acta Psychiatrica Scandinavica 112, 330350.

S Saha , D Chant , J McGrath (2008). Meta-analyses of the incidence and prevalence of schizophrenia: conceptual and methodological issues. International Journal of Methods in Psychiatric Research 17, 5561.

M Shevlin , J Murphy , MJ Dorahy , G Adamson (2007). The distribution of positive psychosis-like symptoms in the population: a latent class analysis of the National Comorbidity Survey. Schizophrenia Research 89, 101109.

CJ Simons , N Jacobs , J Jolles , J van Os , L Krabbendam (2007). Subclinical psychotic experiences and cognitive functioning as a bivariate phenotype for genetic studies in the general population. Schizophrenia Research 92, 2431.

MM Sitskoorn , A Aleman , SJ Ebisch , MC Appels , RS Kahn (2004). Cognitive deficits in relatives of patients with schizophrenia: a meta-analysis. Schizophrenia Research 71, 285295.

J Spauwen , L Krabbendam , R Lieb , HU Wittchen , J van Os (2004). Does urbanicity shift the population expression of psychosis? Journal of Psychiatric Research 38, 613618.

J Spauwen , L Krabbendam , R Lieb , HU Wittchen , J van Os (2006 b). Impact of psychological trauma on the development of psychotic symptoms: relationship with psychosis proneness. British Journal of Psychiatry 188, 527533.

NC Stefanis , P Delespaul , N Smyrnis , A Lembesi , DA Avramopoulos , IK Evdokimidis , CN Stefanis , J van Os (2004). Is the excess risk of psychosis-like experiences in urban areas attributable to altered cognitive development? Social Psychiatry and Psychiatric Epidemiology 39, 364368.

A Stueve , BG Link (1998). Gender differences in the relationship between mental illness and violence: evidence from a community-based epidemiological study in Israel. Social Psychiatry and Psychiatric Epidemiology 33, S61S67.

AY Tien (1991). Distributions of hallucinations in the population. Social Psychiatry and Psychiatric Epidemiology 26, 287292.

AY Tien , JC Anthony (1990). Epidemiological analysis of alcohol and drug use as risk factors for psychotic experiences. Journal of Nervous and Mental Disease 178, 473480.

AY Tien , WW Eaton (1992). Psychopathologic precursors and sociodemographic risk factors for the schizophrenia syndrome. Archives of General Psychiatry 49, 3746.

J van Os , M Hanssen , M Bak , RV Bijl , W Vollebergh (2003). Do urbanicity and family liability coparticipate in causing psychosis? American Journal of Psychiatry 160, 477482.

J van Os , M Hanssen , R-V Bijl , A Ravelli (2000). Straus (1969) revisited: a psychosis continuum in the general population? Schizophrenia Research 45, 1120.

J van Os , M Hanssen , RV Bijl , W Vollebergh (2001). Prevalence of psychotic disorder and community level of psychotic symptoms: an urban–rural comparison. Archives of General Psychiatry 58, 663668.

WA Vega , WM Sribney , TM Miskimen , JI Escobar , S Aguilar-Gaxiola (2006). Putative psychotic symptoms in the Mexican American population: prevalence and co-occurrence with psychiatric disorders. Journal of Nervous and Mental Disease 194, 471477.

H Verdoux , S Maurice-Tison , B Gay , J van Os , R Salamon , ML Bourgeois (1998 a). A survey of delusional ideation in primary-care patients. Psychological Medicine 28, 127134.

MM Voglmaier , LJ Seidman , MA Niznikiewicz , CC Dickey , ME Shenton , RW McCarley (2000). Verbal and nonverbal neuropsychological test performance in subjects with schizotypal personality disorder. American Journal of Psychiatry 157, 787793.

MG Vollema , H Hoijtink (2000). The multidimensionality of self-report schizotypy in a psychiatric population: an analysis using multidimensional Rasch models. Schizophrenia Bulletin 26, 565575.

MG Vollema , MM Sitskoorn , MC Appels , RS Kahn (2002). Does the Schizotypal Personality Questionnaire reflect the biological-genetic vulnerability to schizophrenia? Schizophrenia Research 54, 3945.

MG Vollema , RJ van den Bosch (1995). The multidimensionality of schizotypy. Schizophrenia Bulletin 21, 1931.

NJ Wiles , S Zammit , P Bebbington , N Singleton , H Meltzer , G Lewis (2006). Self-reported psychotic symptoms in the general population: results from the longitudinal study of the British National Psychiatric Morbidity Survey. British Journal of Psychiatry 188, 519526.

U Wolfradt , ER Straube (1998). Factor structure of schizotypal traits among adolescents. Personality and Individual Differences 24, 201206.

T Yoshizumi , S Murase , S Honjo , H Kaneko , T Murakami (2004). Hallucinatory experiences in a community sample of Japanese children. Journal of the American Academy of Child and Adolescent Psychiatry 43, 10301036.

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