Content uploaded by Mwansisya Tumbwene
Author content
All content in this area was uploaded by Mwansisya Tumbwene on May 08, 2020
Content may be subject to copyright.
This article appeared in a journal published by Elsevier. The attached
copy is furnished to the author for internal non-commercial research
and education use, including for instruction at the authors institution
and sharing with colleagues.
Other uses, including reproduction and distribution, or selling or
licensing copies, or posting to personal, institutional or third party
websites are prohibited.
In most cases authors are permitted to post their version of the
article (e.g. in Word or Tex form) to their personal website or
institutional repository. Authors requiring further information
regarding Elsevier’s archiving and manuscript policies are
encouraged to visit:
http://www.elsevier.com/authorsrights
Author's personal copy
Psychotic-like experiences and associated socio-demographic factors
among adolescents in China
Meng Sun
a
, Xinran Hu
b
, Wen Zhang
a
,RuiGuo
a
,AiminHu
a
, Tumbwene Elieza Mwansisya
c
,LiZhou
a
,
Chang Liu
a
, Xudong Chen
a
, Xiaojun Huang
a
, Jingcheng Shi
d
, Helen F.K. Chiu
e
, Zhening Liu
a,
⁎
a
Institute of Mental Health, The Second Xiangya Hospital of Central South University, Changsha, China
b
School of Medicine and Institute for Public Health, Washington University, St. Louis, USA
c
College of Health Sciences, University of Dodoma, P.O. Box 395, Dodoma, Tanzania
d
School of Public Health, Central South University, Changsha, China
e
Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, China
abstractarticle info
Article history:
Received 29 January 2015
Received in revised form 6 May 2015
Accepted 19 May 2015
Available online 4 June 2015
Keywords:
CAPE
Psychosis
Trauma history
Left-behind children
Objective: Adolescents with persistent psychotic-like experiences (PLEs) may be at high risk for later develop-
ment of psychoses. Exploring early age risk factors for PLEs may provide useful information for prevention of
mental disorders and improvement of mental health.
Method: A total of 5427 adolescents (aged between 10 and 16) participated in a cross-sectional survey, with so-
cial and demographic information collected. The Positive Subscale of Community Assessment of Psychic Experi-
ences (CAPE) was used to measure PLEs, and the CAPE Depressive and Negative Subscales were used to examine
depressive and negative experiences. The Trauma History Questionnaire (childversion) was used to assess expe-
riences of previous traumatic events.
Results: In our study, 95.7% of the adolescents reported more than one episode of PLEs, while 17.2% reported
“nearly always”having PLEs. High positive correlations were shown both between frequency scores among ex-
periences of three dimensions (PLEs, depressive and negative experiences), and between frequency and distress
scores. Factors associatedwith a higher risk for more frequent and distressing PLEs include: urban setting, family
history of psychiatric illnesses, and higher impact from previous traumatic events at present.
Conclusions: Episodes of PLEs are common in Chinese adolescents, however only a smallproportion have persis-
tent PLEs, withworsening distressas the frequency increased. PLEs shared similarenvironmentaland genetic risk
factors not only with the clinical phenotypes,which is consistentwith the continuity model of PLEs, but alsowith
depressive and negative experiences, which may imply etiologic relation between different dimensions of psy-
chosis at the subclinical level.
© 2015 Elsevier B.V. All rights reserved.
1. Introduction
Psychotic-like experiences (PLEs) are common in childhood and ad-
olescence, and mostly transient in nature. However, it may persist in a
small population before developing further into clinical psychoses
(van Os et al., 2009; Dominguez et al., 2011). Data shows that nearly
half of all lifetime mental disorders start by mid-adolescence (Kessler
et al., 2005, 2007), which indicates that adolescence is an important pe-
riod in development of mental disorders. Therefore, exploring the risk
factors of PLEs at this early age may provide useful information in un-
derstanding the development of mental disorders and throw light on
the prevention of mental disorders.
PLEs are defined as experiences that resemble the positive symp-
toms of psychosis as encountered in clinical samples but which do not
cause the levels of distress or impairment that would lead to clinically
significant distress, disability or loss of functioning. Two continuity
models have been proposed on PLEs. The quasi-dimensional model con-
ceptualizes PLEs as formefrustes or variants of mental disorders (Meehl,
1962, 1989), while the fully dimensional model of psychosis proposes
that PLEs are part of personality (Claridge, 1972, 1994). Preliminary ev-
idence has suggested that in a minority of individuals PLEs in childhood
and adolescence may be risk factors for later psychiatric disorders and
poor psychosocial outcome (Dhossche et al., 2002; Hanssen et al.,
2005; Kaymaz et al., 2012). The risk for transition topsychosis is associ-
ated with thedegree of PLEs' persistence, associated distress, and the se-
verity of PLEs (Wigman et al., 2011). However, few studies have
explored the associated psychosocial factors and psychopathological
difficulties in young people at a crucial age (Lataster et al., 2006;
Nishida et al., 2008; Armando et al., 2012; Fisher et al., 2013).
In order toassess the prevalence of PLEs in our study, we selected the
Positive Subscale of Community Assessment of Psychic Experiences
Schizophrenia Research 166 (2015) 49–54
⁎Corresponding author. Tel.: +86 731 85292136; fax: +86 731 85292470.
E-mail address: zningl@163.com (Z. Liu).
http://dx.doi.org/10.1016/j.schres.2015.05.031
0920-9964/© 2015 Elsevier B.V. All rights reserved.
Contents lists available at ScienceDirect
Schizophrenia Research
journal homepage: www.elsevier.com/locate/schres
Author's personal copy
(CAPE). Previous research found that there was evidence for the exis-
tence of PLEs and depressive and negative experiences in the general
population and significant correlations between them, which suggest
they may share similar risk factors (Stefanis et al., 2002). Longitudinal
studies also show psychosis proneness is strongly associated with de-
pression, suggesting that a continuum of vulnerability may exist be-
tween psychotic disorders and affective disorders (Verdoux et al.,
1999). Therefore we also explored characteristics and risk factors of
the depressive and negative experiences with Depressive and Negative
Subscales of CAPE.
During the past 30 years, there is a massive migration of residents of
rural areas to work in the urban areas in China. By the end of 2013, the
number of internal migrants in China amounted to 245 million. As a re-
sult, there are many “left-behind”children, referring to the children and
adolescents left behind in hometown by one or both of their migrating
parents (Jia and Tian, 2010). Recent estimates place the number of
“left-behind”children in China as approximately 58 million (Jia and
Tian, 2010; Ding and Bao, 2014). They endure severe stress caused by
migration of parents. Data from recent studies show that they are at
greater risk for developing mental disorders (He et al., 2012; Wang
et al., 2014). In regard to urbanization, studies have demonstrated that
being raised in urban area confers a greater risk of psychiatric disorders
(Pedersen and Mortensen, 2001; Peen et al., 2010). Previous studies
have indicated ethnic minority as a risk factor of PLEs (Morgan et al.,
2009). Finally, a few studies have found positive correlation between
childhood trauma and PLEs (Jeronimus et al., 2013; Matheson et al.,
2013).
Our study has two main aims. First, we would like to investigate the
prevalence and characteristics of PLEs and depressive and negative ex-
periences among adolescents in Hunan Province, China. Second, some
potential genetic and environmental factors associated with more fre-
quent and distressing PLEs were explored in order to provide useful in-
formation for mental disorder prevention.
Unlike previous studies that usually evaluate childhood traumas in
adulthood, our study evaluated the impact of childhood traumas during
the period of childhood and adolescence, which may be more relevant.
Besides, in order to identify children's distress in the acute aftermath of
traumatic events, our study included their impact felt by the children,
both at the time of the event and at the survey.
2. Method
2.1. Sample
Eleven Middle schools in both Xiangxi Region and Changsha City of
Hunan Province were sampled using random cluster method. A total
of 5427 students of the first grade from Middle schools were surveyed.
All participants and their parent/guardian gave written consent for the
study. In general, it took 45 min for the students to fill in the question-
naires. The study was approved by the EthicsCommittees of the Second
Xiangya Hospital of Central South University.
2.2. Instruments
Socio-demographic information to be collected included: gender,
age, ethnicity, boarding options, residency status, sources of income,
“left-behind”child status, divorced family, parental death, single child
status, family history of psychiatric illnesses and past history of any psy-
chiatric conditions for participants. Exclusion criteria for the study in-
clude participants with history of any psychiatric conditions and who
had N25% of CAPE data missing. We excluded the children with history
of psychiatric conditions according to the socio-demographic informa-
tion in the questionnaires and provided by schools and teachers.
The CAPE was used to evaluate the lifetime positive, depressive and
negative experiences in the general population (Stefanis et al., 2002;
Konings et al., 2006). This self-report instrument consists of 42 items
covering positive, depressive and negative dimensions (PD, DD and
ND) on both a frequency scale (1 = never, 2 = sometimes, 3 = often,
4 = nearly always) and a distress scale (1 = not distressed, 2 = a bit
distressed, 3 = quite distressed, 4 = very distressed). It includes 20
items of positive psychotic experiences derived from Peters et al. Delu-
sions Inventory (PDI-21) (Peters et al., 1999), 14 items exploring nega-
tive experiences derived from an instrument of subjective experience of
negative symptoms (SENS) (Selten et al., 1998), and 8 cognitive depres-
sive experiences (Kibel et al., 1993). Previous results have indicated the
CAPE to be stable, reliable and valid (Konings et al., 2006). In our study,
PLEs were measured through items of PD in the CAPE, while depressive
and negative experiences used items of DD and ND, respectively.
To assess adolescents'histories of trauma, the Trauma History Ques-
tionnaire (THQ) child version (Stover et al., 2010) was used. The scale
contains 15 items. Each item was designed to assess the child's history
of traumatic events in the lifetime as well as the level of impact on the
child, both at the time of the event and at present. Respondents can se-
lect a number from “not at all (0)”to “extremely (4)”.
Both the Chinese version of CAPE and THQ childversion were trans-
lated and validated for the first time. Both questionnaires showed good
reliability and validity. The papers on the reliability and validity are now
under preparation.
2.3. Analyses
Analyses were conducted using IBM SPSS Statistics version 19.0. De-
scriptive statistics were performed for group characteristics. The preva-
lence was calculated both at the level of “at least sometimes”and
“nearly always”respectively in all three dimensions. Frequency of
each item was also counted. Correlation analysis was conducted
through Pearson's correlation coefficient to investigate associations be-
tween frequency scores among the three dimensions, and then between
frequency and distress scores.
Due to the lack of generally acknowledged cut-off points separately
in three dimensions, hierarchical linear cluster analyses were per-
formed on the sample to get high, medium and low score groups. The
whole sample was divided into three clusters according to both fre-
quency and distress scores of each dimension, respectively. The same
statistical method was also used for the THQ to divide the sample into
three groups, respectively according to the level of impact at the time
of the event and at present. To investigate the predictors of more fre-
quent and distressing PLEs and depressive and negative experiences,
we conducted ordinal logistic regression analyses to calculate odds ra-
tios (ORs) and 95% confidence intervals (95% CI). We entered all dichot-
omous socio-demographic variables and levels of impact from previous
trauma as independent variables, using age as covariate variable. We
considered p-value less than 0.05 to be statistically significant.
3. Results
3.1. Description of the sample
All 5427 students agreed to participate in our survey. A total of 131
participants who had N25% of CAPE data missing and 23 participants
who had history of psychiatric conditions were subsequently removed
from further analyses, leaving 5273 with valid data. These participants
were aged between 10.0 and 16.6 years, and mean age was 12.6 years
(SD = 0.627). Table 1 shows some of the other social-demographic
characteristics.
3.2. Characteristics of experiences of three dimensions in the sample
Almost all the adolescents in our sample experienced at least one
CAPE item during lifetime (entire CAPE = 98.50%, PD (PLEs) =
95.66%, DD = 95.01%, ND = 94.06%). However, prevalence decreased
sharply when the frequency increased to “nearly always”(entire
50 M. Sun et al. / Schizophrenia Research 166 (2015) 49–54
Author's personal copy
CAPE = 26.74%, PD (PLEs) = 17.24%, DD = 7.53%, ND = 15.78%). Fre-
quency of each item sharessimilar characteristics, but varied in different
items (Table 2). Correlations between frequency scores in the three di-
mensions were positive and significant (pb.01) (Table 3).
The positive correlation between frequency and distress scores for
entire CAPE was significant and very strong (Fig. 1). The correlation
was also very strong for PD (PLEs), DD and ND (r= 0.932, 0.932 and
0.920, p= .000 for all the above)
3.3. Factors associated with more frequent and distressing experiences of
three dimensions
The samplewas divided into high, medium and low score groups re-
spectively in three dimensions (Fig. 2).The groups were confirmed to be
significant (p= .000) using the ANOVA method. No reason for potential
multicollinearity of all variables was found, with the variance inflation
factor (VIF) values of 1.26 and below (O'Brien, 2007). The results are
presented in Table 4.
In this sample, family history and higher impact from previous trau-
ma at present predicted more frequent and distressing experiences of
all three dimensions. Adolescents with urban household registration
had more frequent and distressing PLEs and depressive experiences
than their rural counterparts, while females and “left-behind”children
had more frequent and distressing depressive and negativeexperiences.
In addition, adolescents who had parental death experienced more fre-
quent and distressing depressive experiences only.
As impact from previous trauma at present showed high ORs in all
three dimensions, further analysis of covariance was conducted be-
tween clusters of trauma impact and frequency scores of each CAPE di-
mension, using age as covariance (Table 5). In comparison between the
two groups, symptoms from all three dimensions associated with medi-
um trauma impact are significantly higher than low trauma impact
(pb.05). However, there is no significant difference between medium
and high trauma impact, which may be explained by the small sample
size of the high trauma impact group.
4. Discussion
A median prevalence of 17% (range from 5% to 35.3%) was reported
in a recent review on PLEs (Kelleher et al., 2012). Only items on auditory
hallucinations were chosen for the analysis in Kelleher et al.'s review,
while our study examined a broader range of symptoms. It can explain
why the prevalence in our study was much higher. However, when we
examined items related to auditory hallucinations in our sample, the
prevalence of the question “Do you ever hear voices when you are
alone”with a frequency of “at least “sometimes”,is36.9%.Thisiscom-
patible with the findings in the studies used in this meta-analysis. How-
ever, PLEs are common in adolescents, with a small proportion having
frequent PLEs, which suggest that transient PLEs are not pathological.
Therefore the focus of our study was the risk factors associated with
more frequent and distressing PLEs.
Our results showed more PLEs in adolescents with urban household
registration, although they enjoyed more social benefits. Similarly, there
is a higher prevalence of psychotic disorders in urban areas versus rural
Table 2
Frequency of each item in the three dimensions of the CAPE.
Never
(%)
At least sometimes
(%)
Nearly always
(%)
Positive dimension (PLEs)
2. Double meaning 42.8 57.2 0.7
5. Messages from magazines or TV 75.2 24.8 0.5
6. False appearance 36.9 63.1 2.6
7. Being persecuted 70.5 29.5 0.6
10. Conspiracy 69.9 30.1 0.9
11. Being important 42.0 58.0 4.5
13. Being special 63.3 36.7 3.5
15. Telepathy 46.0 54.0 3.5
17. Influenced by devices 53.1 46.9 3.5
20. Voodoo 72.1 27.9 2.8
22. Odd looks 59.8 40.2 1.8
24. Thought withdrawal 80.6 19.4 0.5
26. Thought insertion 76.1 23.9 0.8
28. Thought broadcasting 70.6 29.4 1.4
30. Thought echo 49.0 51.0 2.5
31. External control 77.8 22.2 1.1
33. Verbal hallucinations 63.1 36.9 1.6
34. Voices conversing 76.5 23.5 0.9
41. Capgras 79.7 20.3 1.2
42. Visual hallucinations 80.6 19.4 0.6
Depressive dimension
1. Sad 18.9 81.1 0.7
9. Pessimism 53.4 46.6 1.3
12. No future 79.6 20.4 1.1
14. Not worth living 78.7 21.3 3.5
19. Frequently cry 74.9 25.1 1.2
38. Guilty 40.8 59.2 1.3
39. Failure 63.1 36.9 1.5
40. Feeling tense 21.1 78.9 3.7
Negative dimension
3. Lack of enthusiasm 51.5 48.5 3.9
4. Not talkative 46.1 43.9 3.1
8. No emotion 50.2 49.8 1.6
16. No interest in others 72.3 27.7 1.2
18. No motivation 43.8 56.2 2.9
21. No energy 66.2 33.8 1.3
23. Empty mind 57.2 42.8 0.8
25. Lack of activity 47.6 52.4 2.4
27. Blunted feelings 69.2 30.8 1.0
29. Lack of spontaneity 50.2 49.8 2.4
32. Blunted emotions 68.3 31.7 1.1
35. Lack of hygiene 71.5 28.5 0.9
36. Unable to terminate 73.6 26.4 0.9
37. Lack of hobby 76.4 23.6 2.7
Note: CAPE, the C ommunity Assessment of Psychic Experiences; PL Es, psychotic-like
experiences.
Table 1
Descriptive statistics of social-demographic variables*.
Characteristics %
Gender (female) 48.8
Ethnicity (Han) 48.7
Boarding options (at school) 24.9
Residency status** (urban) 34.5
Family has stable income?*** (no) 6.6
“Left-behind”child status 19.9
Divorced family 4.5
Parental death 1.3
Single child status 32.1
Family history 3.0
Note: *All the variables are dichotomous. **Residency status represents
urban or rural household registration. There is a strict household registra-
tion system in China, which divided residents into urban and rural. Rural
residents are not able to enjoy the equal social benefits of urban residents,
no matter how long they have lived or worked in the cities. ***Stable in-
come means that the family has stable source of income and can support
the family members without others' help. On the contrary, not having sta-
ble income meansthat the family needs help fromother people or govern-
ment aid.
Table 3
Correlations between dimensions of the CAPE frequency scale.
PD (PLEs) DD ND CAPE total
PD (PLEs) 1
DD 0.670** 1
ND 0.614** 0.710** 1
CAPE total 0.906** 0.852** 0.869** 1
Note: ** pb.01. CAPE, the Community Assessmentof Psychic Experiences; PD, positive di-
mension; PLEs, psychotic-like experie nces; DD, depressive dim ension; ND, negative
dimension.
51M. Sun et al. / Schizophrenia Research 166 (2015) 49–54
Author's personal copy
areas in some previous studies (Faris and Dunham, 1939; Mortensen
et al., 1999; Peen et al., 2010). Epidemiologic research has documented
the associations that particular features of the urban environment, such
as concentrated disadvantage (i.e., areas characterized by high poverty,
unemployment, and other socio-economical disadvantages), residential
segregation, social disorganization, and less green space, contribute to
the risk of psychotic disorders (Faris and Dunham, 1939; Galea et al.,
2011; McKenzie et al., 2013). Recent studies attempting to explore the
mechanism between urban areas and psychotic disorders, found that
urban upbringing could impact brain architecture (Haddad et al., 2014),
change the (re)activity of the HPA axis (Steinheuser et al., 2014), or
make changes in DNA methylation (Galea et al., 2011). Although the
exact mechanisms are unknown, harmful influence of urban environment
may start as early as growing stage according to our study.
It is well-known that having a family history of psychiatric illness is
associated with elevated risk for developing psychotic disorders
(Mortensen et al., 1999). Studies on monozygotic and dizygotic twins
have also demonstrated that genetic contribution was apparent for
self-reported PLEs in the general population (Lataster et al., 2009;
Wigman et al., 2011). In our study we found individuals with family his-
tory tended to have more frequent and distressing PLEs. Therefore we
speculate that genetic influence may play an important role in aggravat-
ing severity of PLEs.
A recent meta-analysis reported a medium to large effect of child-
hood adversity in people with psychosis (Matheson et al., 2013). How-
ever, there was no significant relation between PLEs and impact from
trauma at the time of the event in our study, whereas adolescents
who had more impact from previous trauma at present had a much
higher risk of PLEs. Therefore we can infer that different changes have
taken place in these adolescents after the trauma. As we have known,
people's responses to trauma vary widely. Some develop mental disor-
ders or mild to moderate psychological symptoms that resolve rapidly,
and others report no new psychological symptoms (Southwick and
Charney, 2012). The different responses depend on different processes
of adaptation in face of traumas, which can be called resilience. So it is
not traumas themselves but the poor resilience of the subjects that
leads directly to higher level of impact at present and results in more
frequent and distressing PLEs finally. Resilience depends on numerous
emotion regulation, social, physical health, cognitive factor, neurobio-
logical risk and protective factors. Therefore early age cognitive behav-
ioral therapy interventions, and measures on improving emotion
regulation (i.e., delay gratification and frustration education) and phys-
ical health may be beneficial to prevention of psychotic disorders.
However,there was no significant relation between PLEs and ethnic-
ity in our study, which was thought to be a risk factor. Ethnic minority
status is considered to be a risk factor of psychotic disorders, which
Fig. 1. Relationship between frequency and distress scores for entire CAPE (r= 0.934, p= .000). CAPE, the Community Assessment of Psychic Experiences questionnaire.
Fig. 2. Results of cluster analyses in three dimensions. PD, positive dimension (or psychotic-like experiences); DD, depressive dimension; ND, negative dimension.
52 M. Sun et al. / Schizophrenia Research 166 (2015) 49–54
Author's personal copy
may be explained by discrimination and rejection sensitivity (Anglin
et al., 2014; Berg et al., 2014). The different result in our study may be
partly interpreted as the result of policy for the protection of minorities
in China. Most of the minority we investigated lived in the minority
compact-communities, with no long-term experience of exclusion.
“Left-behind”children, as a unique social phenomenon in contem-
porary China, have attracted increasing attention. Previous research
found the “left-behind”children have lower self-concept and more
mental health problems (He et al., 2012; Wang et al., 2014). However,
no higher risk for PLEs, but depressive and negative experiences was
found in our study. Loneliness (Jia and Tian, 2010), high risk for suffer-
ing abuse and bullying in schools caused by lack of care (Givaudan
and Pick, 2013), may give rise to the frequent and severe depressive ex-
periences. Lack of adequate family bonding, and enough time for school
activities may cause lack of necessary mental stimulation in the critical
period of brain development, which may result in more negative expe-
riences. However, follow-up study is needed to find the internal relation
between development of psychoses and “left-behind”children.
In summary, similar to psychotic disorders, more frequent and
distressing PLEs are probably associated with genetic factors as well as
environmental factors, which are consistent with the continuity model
of PLEs.
The dimensional representation of the psychosis phenotype sug-
gests that psychosis is the simultaneous variation of correlated
symptom dimensions. However, this distribution of psychosis can
extend into general population as well, which is proved in our
study. The subclinical depressive and negative experiences also
shared similar risk factors with the corresponding symptoms at the
clinical level, which may further prove the continuum of psychosis
in dimensional approach.
In our study, there are also many overlapping risk factors in three di-
mensions, which can also be found between affective and non-affective
psychotic syndromes. So it is attractive to speculate from the subclinical
level that etiologic relation exists between different symptom dimen-
sions of psychosis.
There are some limitations for the study. First, as self-reported ques-
tionnaires were used, and participants were very young, it is possible
that some of the questionnaires were not carefully completed. So the
findings of our study have to be interpreted with caution. Second,
there were no strict exclusion criteria for participants who had history
of psychiatric conditions, as we did not adopt structured instrument
for making diagnoses. Third, family history of psychiatric illnesses is
not necessarily due to genetic etiology as it can also be related to a
shared environment, or other reasons.
It may be helpful to improve the global mental health if we can iden-
tify adolescents with high-risk PLEs, and provide support or interventions
for them from an early stage. However, further prospective studies are re-
quired to examine if PLEs in adolescence are associated with a higher risk
to develop psychoses in adulthood, and we are planning to follow up our
cohort of subjects prospectively to address this question.
Role of funding source
The work was suppor ted by the National Natural Science Foundation of China
(81271485, 81471362 to Z.N. Liu) and the Hunan Provincial Natural Science Foundation
of China (07JJ3046 to Z.M. Xue).
Contributors
Authors Meng Sun, Xinran Hu, Wen Zhang and Zhening Liu designed the study and
wrote the protocol. All authors participated in data collection. Authors Meng Sun and
Jingcheng Shi undertook the statistical analysis, and author Meng Sun wrote the first
draft of the manuscript. Authors Helen Chiu and Zhening Liu modified the manuscript.
All authors contributed to and have approved the final manuscript.
Conflict of interest
None.
Acknowledgments
The authors would like to thank Dr. Eric Chen and Dr. Sherry Kit wa Chan from the
University of Hong Kong. Both of them offered advice on the study design.
References
Anglin, D.M., Greenspoon,M., Lighty, Q., Ellman, L.M., 2014. Race-based rejectionsensitiv-
ity partially accounts for the relationsh ip between racial discr imination and
distressing attenuated positive psychotic symptoms. Early Interv. Psychiatry http://
dx.doi.org/10 .1111/eip.12184 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=25234291&query_hl=1).
Armando, M., Saba, R., Monducci, E., Papaleo, F., Dario, C., Righetti, V., Brandizzi, M., Fiori,
N.P., 2012. Subtypes of psychotic-like experiences in a community sample of young
adults: socio-demographic correlates and substance use. Riv. Psichiatr. 47 (5),
424–431.
Berg, A.O., Aas, M., Larsson,S., Nerhus, M., Hauff,E., Andreassen, O.A., Melle, I., 2014. Child-
hood trauma mediates the association between ethnic minority status and more se-
vere hallucinations in psychotic disorder. Psychol. Med. http://dx.doi.org/10.1017/
S0033291714001135 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
Retrieve&db=pubmed&dopt=Abstract&list_uids=25065296&query_hl=1).
Claridge, G., 1972. The schizophrenias as nervous types. Br. J. Psychiatry 121 (560), 1–17.
Claridge, G., 1994. Single indicator of risk for schizophrenia: probable fact or likely myth?
Schizophr. Bull. 20 (1), 151–168.
Table 4
Logistic regression of predictors of more frequent and distressing experiences of three dimensions.
Model PD (PLEs) Model DD Model ND
OR (95%CI) OR (95%CI) OR (95%CI)
Gender 1.03 (0.63, 1.69) 1.81** (1.24, 2.64) 1.49** (1.16, 1.91)
Ethnicity 1.47 (0.87, 2.49) 0.95 (0.63, 1.39) 1.14 (0.89, 1.48)
Boarding options 0.61 (0.31, 1.19) 1.02 (0.68, 1.54) 1.06 (0.81, 1.40)
Residency status 2.32** (1.36, 3.96) 1.55* (1.04, 2.31) 1.20 (0.91, 1.58)
Stable income 1.08 (0.41, 2.83) 1.35 (0.73, 2.48) 1.33 (0.88, 2.01)
“Left-behind”child status 1.45 (0.78, 2.72) 1.65* (1.08, 2.52) 2.00*** (1.52, 2.63)
Divorced family 1.63 (0.64, 4.19) 1.18 (0.54, 2.55) 1.11 (0.63, 1.96)
Parental death 2.62 (0.77, 8.96) 2.73* (1.09, 6.82) 1.78 (0.82, 3.88)
Single child 0.96 (0.55, 1.69) 1.32 (0.87, 2.01) 1.05 (0.79, 1.40)
Family history 2.62* (1.06, 6.46) 2.13* (1.04, 4.33) 1.81* (1.09, 3.01)
THQ1 0.57 (0.11, 2.98) 1.05 (0.30, 3.67) 1.48 (0.61, 3.60)
THQ2 8.44*** (4.60, 15.50) 4.92*** (2.84, 8.54) 3.31*** (2.14, 5.13)
Note: *pb.05, **pb.01, ***pb.001. PD, positive dimension; PLEs, psychotic-like experiences;DD, depressive dimension; ND, negative dimension; CI, confidence intervals; OR, odds ratio;
THQ1 represents impact from trauma at the time of the event; THQ2 impact from trauma at present.
Adjusted for age.
Table 5
Comparison among differenttrauma impact groupsat present on frequencyscores of each
dimension (mean ± SD).
Low score group Medium score group High score group p
PD (PLEs) 28.55 ± 6.459 37.16 ± 8.995 35.22 ± 6.671 b.001
DD 12.25 ± 2.938 15.63 ± 4.429 16.05 ± 2.162 b.001
ND 20.77 ± 5.045 24.95 ± 6.685 21.91 ± 2.206 b.001
Note: SD, standard deviation; PD, positive dimension; PLEs, psychotic-like experiences;
DD, depressive dimension; ND, negative dimension.
Adjusted for age.
53M. Sun et al. / Schizophrenia Research 166 (2015) 49–54
Author's personal copy
Dhossche, D., Ferdinand, R., Van der Ende, J., Hofstra, M.B., Verhulst, F., 2002. Diagnostic
outcome of self- reported hallucinati ons in a community sample of adolescents.
Psychol. Med. 32 (4), 619–627.
Ding, G., Bao,Y., 2014. Editorial perspective: assessing developmental risk in cultural con-
text: the case of ‘left behind’children in rural China. J. Child Psychol. Psychiatry 55
(4), 411–412.
Dominguez, M.D., Wichers, M., Lieb, R., Wittchen, H.U., 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. Schizophr. Bull. 37 (1), 84–93.
Faris, R.,Dunham, H., 1939. Mental disorders in urbanareas: an ecological studyof schizo-
phrenia and other psychoses. The University of Chicago Press, Chicago.
Fisher, H.L., Schreier, A., Zammit, S., Maughan, B., Munafo, M.R., Lewis, G., Wolke, D., 2013.
Pathways between childhood victimiza tion and psychosis-li ke symptoms in the
ALSPAC birth cohort. Schizophr. Bull. 39 (5), 1045–1055.
Galea, S., Uddin, M., Koenen, K., 2011. The urban environment and mental disorders: epi-
genetic links. Epigenetics 6 (4), 400–404.
Givaudan,M., Pick, S., 2013. Children left behind: how to mitigate the effects and facilitate
emotional and psychosocial development: supportive community networks can di-
minish the negat ive effects of parental mi gration. Child Abuse Neg l. 37 (12),
1080–1090.
Haddad, L., Schafer, A., Streit, F., Lederbogen, F., Grimm, O., Wust, S., Deuschle, M., Kirsch,
P., Tost, H., Meyer-Lindenberg, A., 2014. Brain structure correlates of urban upbring-
ing, an environmental risk factor for schizophrenia. Schizophr. Bull. http://dx.doi.org/
10.1093/schb ul/sbu072 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
Retrieve&db=pubmed&dopt=Abstract&list_uids=24894884&query_hl=1).
Hanssen, M., Bak, M., Bijl, R., Vollebergh, W., van Os, J., 2005. The incidence and outcome
of subclinical psychotic experiences in the general population. Br. J. Clin. Psychol. 44
(Pt 2), 181–191.
He, B., Fan, J., Liu, N., Li, H., Wang, Y., Williams, J., Wong, K., 2012. Depression risk of ‘left-
behind children’in rural China. Psychiatry Res. 200 (2-3), 306–312.
Jeronimus, B.F., Ormel, J., Aleman, A., Penninx,B.W., Riese, H., 2013. Negative and positive
life events are associated with small but lasting change in neuroticism. Psychol. Med.
43 (11), 2403–2415.
Jia, Z., Tian, W.,2010. Loneliness of left-behind children:a cross-sectional survey in a sam-
ple of rural China. Child Care Health Dev. 36 (6), 812–817.
Kaymaz,N., Drukker, M., Lieb,R., Wittchen, H.U.,Werbeloff, N., Weiser, M., Lataster, T., van
Os, J., 2012. Do subthreshold psychotic experiences predict clinicaloutcomes in unse-
lected non-help-seeking population-based samples? A systematic review and meta-
analysis, enriched with new results. Psychol. Med. 42 (11), 2239–2253.
Kelleher,I., Connor, D., Clarke, M.C., Devlin,N., Harley, M., Cannon, M., 2012. Prevalence of
psychotic symptoms in childhood and adolescence: a systematic review and meta-
analysis of population-based studies. Psychol. Med. 42 (9), 1857–1863.
Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., Walters, E.E.,2005. Lifetime
prevalence and age-of-onset distributions of DSM-IV disorders in the National Co-
morbidity Survey Replication. Arch. Gen. Psychiatry 62 (6), 593–602.
Kessler,R.C., Amminger, G.P.,Aguilar-Gaxiola, S., Alonso, J., Lee, S., Ustun, T.B.,2007. Age of
onset of mental disorders: a review of recent literature. Curr. Opin. Psychiatry 20 (4),
359–364.
Kibel, D.A., Laffont, I., Liddle, P.F., 1993. The composition of the negative syndrome of
chronic schizophrenia. Br. J. Psychiatry 162, 744–750.
Konings, M., Bak, M., Hanssen, M., van Os, J., Krabbendam, L., 2006. Validity and reliability
of the CAPE: a self-report instrument for the measurement of psychotic experiences
in the general population. Acta Psychiatr. Scand. 114 (1), 55–61.
Lataster, T., van Os, J., Drukker, M., Henquet, C., Feron, F., Gunther, N., Myin-Germeys, I.,
2006. Childhood victimisation and developmental expression of non-clinical delu-
sional ideation and hallucinatory experiences: victimisation and non-clinical psy-
chotic experiences. Soc. Psychiatry Psychiatr. Epidemiol. 41 (6), 423–428.
Lataster, T., Myin-Germeys, I., Derom, C., Thiery, E., van Os, J., 2009. Evidence that self-
reported psychotic experiences represent the transitory developmental expression
of genetic liabi lity to psychosis in th e general population. Am. J. Med. Genet. B
Neuropsychiatr. Genet. 150B (8), 1078–1084.
Matheson, S.L., Shepherd, A.M., Pinchbeck, R.M., Laurens, K.R., Carr, V.J., 2013. Childhood
adversity in schizophrenia: a systematic meta-analysis. Psychol. Med. 43 (2),
225–238.
McKenzie,K., Murray, A., Booth,T., 2013. Do urban environments increase the risk of anx-
iety, depression and psychosis? An epidemiological study. J. Affect. Disord. 150 (3),
1019–1024.
Meehl, P.E., 1962. Schizotaxia, schizotypy, schizophrenia. Am. Psychol. 17, 827–838.
Meehl, P.E., 1989. Schizotaxia revisited. Arch. Gen. Psychiatry 46 (10), 935–944.
Morgan, C., Fisher, H., Hutchin son, G., Kirkbride, J., Craig, T.K., Morgan, K ., Dazzan, P.,
Boydell, J., Doody, G.A., Jones, P.B., Murray, R.M., Leff, J., Fearon, P., 2009. Ethnicity, so-
cial disadvantage and psychotic-like experiences in a healthy population based sam-
ple. Acta Psychiatr. Scand. 119 (3), 226–235.
Mortensen, P.B., Pedersen, C.B., Westergaard, T., Wohlfahrt, J ., Ewald, H., Mors, O.,
Andersen, P.K., Melbye, M., 1999. Effects of family history and place and season of
birth on the risk of schizophrenia. N. Engl. J. Med. 340 (8), 603–608.
Nishida, A., Tanii, H., Nishimura, Y., Kajiki, N., Inoue, K., Okada, M., Sasaki, T., Okazaki, Y.,
2008. Associations be tween psychotic-like experiences and mental health status
and other psychopathologies among Japanese early teens. Schizophr. Res. 99 (1-3),
125–133.
O'Brien,R.M., 2007. A caution regarding rules of thumb for variance inflation factors. Qual.
Quant. 41 (5), 673–690.
Pedersen, C.B., Mortensen, P.B., 2001. Evidence of a dose–response relationship between
urbanicity during upbringing and schizophrenia risk. Arch. Gen. Psychiatry 58 (11),
1039–1046.
Peen, J., Schoevers, R.A., Beekman, A.T., Dekker, J., 2010. The current status of urban-rural
differences in psychiatric disorders. Acta Psychiatr. Scand. 121 (2), 84–93.
Peters, E.R., Joseph, S.A., Garety, P.A.,1999. Measurementof delusional ideationin the nor-
mal population: introducing the PDI (Peters et al. Delusions Inventory). Schizophr.
Bull. 25 (3), 553–576.
Selten, J.P., Gernaat, H.B., Nolen, W.A., Wiersma, D., van den Bosch, R.J., 1998. Experience
of negative symptoms: comparison of schizophrenic patients to patients with a de-
pressive disorder and to normal subjects. Am. J. Psychiatry 155 (3), 350–354.
Southwick, S.M., Charney, D.S., 2012. The science of resilience: implications for the pre-
vention and treatment of depression. Science 338 (6103), 79–82.
Stefanis, N.C., Hanssen, M., Smirnis, N.K., Avramopoulos, D.A., Evdokimidis, I.K., Stefanis,
C.N., Verdoux, H., Van Os, J., 2002. Evidence that three dimensions of psychosis
have a distribution in the general population. Psychol. Med. 32 (2), 347–358.
Steinheuser, V., Ackermann, K., Schonfeld, P., Schwabe, L., 2014. Stress and the city: im-
pact of urban upbringing on the (re)activity of the hypothalamus–pituitary–adrenal
axis. Psychosom. Med. http://dx.doi.org/10.1097/PSY.0000000000000113 (http://
www.ncbi.nlm.nih.gov/ent rez/query.fcgi?cmd=R etrieve &db=pu bmed&do pt=
Abstract&list_uids=25333499&query_hl=1).
Stover, C.S., Hahn, H., Im, J.J., Berkowitz,S., 2010. Agreement ofparent and child reports of
trauma exposure and symptoms in the peritraumatic period. Psychol. Trauma 2 (3),
159–168.
van Os, J., Linscott, R.J., Myin-Germeys, I., Delespaul, P., Krabbendam, L., 2009.Asystemat-
ic review and meta-analysis of the psychosis continuum: evidence for a psychosis
proneness-persistence-impairment model of psychotic disorder. Psychol. Med. 39
(2), 179–195.
Verdoux, H., van Os, J., Maurice-Tison, S., Gay, B., Salamon, R., Bourgeois, M.L., 1999. In-
creased occurrence of depression in psychosis-prone subjects: a follow-up study in
primary care settings. Compr. Psychiatry 40 (6), 462–468.
Wang, X., Ling, L., Su, H., Cheng, J., Jin, L., Sun, Y.H., 2014. Self-concept of left-behind chil-
dren in China: a systematic review of the literature. Child Care Health Dev. http://dx.
doi.org/10.1111/cch.12172 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
Retrieve&db=pubmed&dopt=Abstract&list_uids=25039693&query_hl=1).
Wigman, J.T., van Winkel, R., Jacobs, N., Wichers, M., Derom, C., Thiery, E., Vollebergh,
W.A., van Os, J., 2011. A twin study of genetic and environmental determinants of ab-
normal persistence of psychotic experiencesin young adulthood. Am. J. Med. Genet.B
Neuropsy chiatr. Gen et. 156B (5), 5 46–552.
54 M. Sun et al. / Schizophrenia Research 166 (2015) 49–54
