Evidence That Onset of Psychosis in the Population Reflects Early Hallucinatory
Complicated by Delusions
Feikje Smeets1, Tineke Lataster1, Maria-de-Gracia Dominguez1, Juliette Hommes1, Roselind Lieb2,3,
Hans-Ullrich Wittchen2,4, and Jim van Os1,5,*
1Department of Psychiatry and Psychology, South Limburg Mental Health Research and Teaching Network, EURON, Maastricht
Munich, Germany;3Epidemiology and Health Psychology, Institute of Psychology, University of Basel, Basel, Switzerland;4Institute of
Clinical Psychologyand Psychotherapy,Technical UniversityDresden, Dresden, Germany;5Department of Psychosis Studies, Institute of
Psychiatry, King’s College London, King’s Health Partners, London, UK
*To whom correspondence should be addressed; Department of Psychiatry & Psychology, Maastricht University, PO Box 616, 6200 MD
Maastricht, the Netherlands; tel: þ31-43-3875443, fax: þ31-43-3875444, e-mail: firstname.lastname@example.org
Objective: To examine the hypothesis that the ‘‘natural’’
combination of delusions and hallucinations in psychotic
disorders in fact represents a selection of early subclinical
hallucinatory experiences associated with delusional idea-
tion, resulting in need for care and mental health service
Germany (n 5 2524), clinical psychologists assessed hallu-
cinations and delusions at 2 time points (T2 and T3). Anal-
yses compared differences in psychopathology, familial
liability for nonpsychotic disorder, nongenetic risk factors,
both hallucinations and delusions. Results: Delusions and
hallucinations occurred together much more often (T2:
3.1%; T3: 2.0%) than predicted by chance (T2: 1.0%; T3:
0.4%; OR 5 11.0; 95% CI: 8.1, 15.1). Content of delusions
hallucinations was not contingent on presence of delusions.
displayed the strongest associations with familial affective
liability and nongenetic risk factors, as well as with persis-
tence of psychotic symptoms, comorbidity with negative
symptoms, affective psychopathology, and clinical need.
Conclusions: The early stages of psychosis may involve
hallucinatory experiencesthat,if complicated bydelusional
ideation under the influence of environmental risks and
(liability for) affective dysregulation, give rise to a poor
prognosis hallucinatory–delusional syndrome.
Key words: psychosis/delusions/hallucinations/
The early origins of psychotic illness in the general pop-
ulation remain poorly understood.1Informative findings
come from a handful of prospective general population
studies showing that the onset of psychotic disorder
sions of psychotic signs and symptoms.2–4Study results
show that the majority of persons with subthreshold ex-
pression of psychotic symptoms (prevalence: 5%–10%5)
never convert to psychotic disorder and that in those
who do, the number and severity of subthreshold psy-
chotic symptoms, and their degree of persistence, under
the influence of environmental exposures such as child-
hood trauma, cannabis use and an urban environment,6,7
ence of psychotic symptoms per se, but the psychopath-
ological and developmental context determines the
longer-term outcome, particularly the degree of admix-
ture with affective dysregulation, negative symptoms,
and premorbid social dysfunction.9–11
One importanthypothesis that has remained difficult to
examine empirically regards the relationship between per-
ceptual abnormalities and delusional ideation in the early
expression of psychosis. Whilst delusions and hallucina-
tions in psychotic disorder are seen as symptoms that nat-
in fact refer to very different phenomena and there is very
Schizophrenia Bulletin vol. 38 no. 3 pp. 531–542, 2012
Advance Access publication on October 28, 2010
? The Author 2010. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
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consequences fortheirco-occurrence. The observed corre-
been the topic of empirical research, in terms of going be-
yond mere correlation to actual investigation of what this
relations secondary to Berkson’s bias or comorbidity
bias,12,13and the fact that antipsychotic treatments suc-
cessfully suppress (clustering of) positive psychoticsymp-
toms.At thegeneralpopulation level,
comparative empirical research is valid and important,
the pathway from early expression to clinical needs may
critically depend on level of ‘‘comorbidity’’ of symptoms,
and its clinical consequences, over time.
Many of the theories that have relevance for the obser-
vation of co-occurrence of delusions and hallucina-
tions14–20contain elements that, at least in part, are
compatible with arguably the oldest and best established
theory, that delusions may be seen as ‘‘complicating’’ ab-
normal perceptual processes21–23or, as described more
recently, aberrant attribution of salience.24This theory
has some empirical support25–28and is of major clinical
relevance, as it implies that clustering of hallucinatory
of the psychotic state. There is some support for this hy-
pothesis, given evidence that clustering of hallucinations
and delusional ideation is particularly likely in the pres-
ence of affective dysregulation,29a factor which previous
work suggests is essential in the early formation and clin-
ical outcome of psychotic experiences.9,30–35
The theory that hallucinatory experiences may present
with or without delusional ideation is particularly rele-
vant from the early psychosis perspective, as it suggests
that the co-occurrence of delusions and hallucinations in
psychotic disorder may not be ‘‘natural’’ but, on the con-
trary, the result of a dynamic selection with prognostic
consequences: of the individuals in the general popula-
tion who experience anomalous perceptions, those with
velop need for care and thus become diagnosable cases
when they present to psychiatric services.
The current analysis focused on a general population
sample that was followed over time, with repeated assess-
trum of psychotic symptoms, in combination with
assessment of dysfunction and help-seeking. The follow-
ing hypotheses were examined:
1. Hallucinations and delusions cluster together more of-
ten than would be expected by chance.
2. Co-occurrence of delusions and hallucinations,
compared to either one in isolation, is more strongly
associated with parameters predicting transition to
clinical outcome, such as more persistence over
time, comorbid affective dysregulation, negative
symptoms, suicidal ideation, anxiety, and familial
3. Although it is difficult to directly examine the hypoth-
esis relating to the more theoretical issue that the dy-
namic sequence over time is from hallucinations to
secondary delusional ideation, this hypothesis can
be examined indirectly by showing that (1) the content
ofdelusions differsasafunction ofwhether or nothal-
lucinations are present whereas (2) modality of hallu-
cinations does not vary as a function of whether or not
delusions are present. In other words, confirmation of
hypothesis III would yield evidence that delusions
‘‘follow’’ hallucinations but not the other way around.
4. Co-occurrence of delusions and hallucinations, com-
pared with either one in isolation, is more strongly
Data were from the Early Developmental Stages of Psy-
chopathology (EDSP) Study, which collected data on the
prevalence, incidence, risk factors, comorbidity, and
course of mental disorders in a random, representative
population sample of adolescents and young adults in
the general population. The baseline sample was ran-
domly drawn, in 1994, from the respective population
registry offices of Munich and its 29 counties to mirror
the distribution of individuals expected to be 14–24 years
of age at the time of the baseline (T0) interview in 1995.
More details on the sampling, representativeness, instru-
ments, procedures, and statistical methods of the EDSP
Study sample have previously been presented.36,37The
EDSP study was approved by the Ethics Committee of
the Technical University Dresden.
The design of EDSP is longitudinal and prospective,
consisting of a baseline (T0) and 3 follow-up surveys,
covering a time period of on average 1.6 years (T0–T1,
SD = 0.2), 3.5 years (T0–T2, SD = 0.3), and 8.4 years
(T0–T3, range = 7.3–10.5 years, SD = 0.7). Because the
primary goal was to examine the incidence and develop-
mental risk factors for psychopathology, the younger
group (14–15 years), presumed to have the highest inci-
dence density, was sampled at twice the rate of persons
aged 16–21 years, and the oldest group (22–24 years)
was sampled at half this rate. For the same reason, sub-
jects aged 14–17 years at baseline were examined at the 4
time points, and subjects aged 18–24 years were assessed
F. Smeets et al.
preparation were completed by the authors and
coauthors of this article, who take responsibility for its
accuracy and content. The Authors have declared that
there are no conflicts of interest in relation to the
subject of this study.
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