Parallel mediating roles of sleep and emotional problems in adolescent psychotic-like experiences_West China Medical Journal

Authors：

LI Qingwei , Lü Chunxian , DAI Xu , ZHOU Yingjing , LI Chaorong , WAN Jing ,  HUANG Caiying

Zhongshan Third People’s Hospital, Zhongshan, Guangdong 528451, P. R. China;

Corresponding?author：

HUANG Caiying, Email: 532772847@qq.com

Keywords：

Adolescent; psychotic-like experiences; sleep quality; anxiety; depression; parallel mediation model

DOI：

10.7507/1002-0179.202511169

Video：

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Objective To investigate the prevalence characteristics of psychotic-like experiences (PLE) in adolescents and to explore the mechanisms through which sleep quality, anxiety, and depression affect PLE, with a specific focus on testing the parallel mediating roles of anxiety and depression in the relationship between sleep quality and PLE. Methods Students from three grades of high schools in Zhongshan City of Guangdong Province were selected in May 2024. Assessments were conducted using the Community Assessment of Psychic Experiences, Pittsburgh Sleep Quality Index, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7. Parallel mediation analysis was performed using Structural Equation Modeling. Results A total of 4009 students were surveyed. Among them, there were 1963 male students and 2046 female students. The average age was (16.83±1.08) years old. PLE was widespread among adolescents and their distribution was significantly influenced by demographic characteristics and multi-dimensional risk factors. PLE was positively associated with sleep quality, anxiety, and depressive symptoms (P<0.01). The mediation model showed that sleep quality not only directly and positively predicted PLE (β=0.115, P<0.001), but also had a significant indirect impact on PLE through the mediating paths of anxiety (β=0.560, P<0.001) and depression (β=0.623, P<0.001). Both anxiety (β=0.359, P<0.001) and depression (β=0.277, P<0.001) could predict PLE, but the effect of anxiety was stronger. The effect decomposition indicated that the total indirect effect far exceeded the direct effect. Both the mediating paths of “sleep quality → anxiety → PLE” and “sleep quality → depression → PLE” were significant. Conclusions PLE among adolescents is influenced by multi-dimensional risk factors and is closely related to sleep and emotional problems. Sleep quality not only directly predicts PLE, but more importantly, indirectly affects PLE through the parallel mediating paths of anxiety and depression, with the “sleep quality → anxiety → PLE” path having a stronger effect. Measures such as improving sleep and anxiety can be selected as potential entry points to interrupt the development path of PLE, which is conducive to early identification and intervention of PLE in adolescents.

Citation： LI Qingwei, Lü Chunxian, DAI Xu, ZHOU Yingjing, LI Chaorong, WAN Jing, HUANG Caiying. Parallel mediating roles of sleep and emotional problems in adolescent psychotic-like experiences. West China Medical Journal, 2026, 41(6): 953-958. doi: 10.7507/1002-0179.202511169 Copy

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2.	Linscott RJ, van Os J. An updated and conservative systematic review and meta-analysis of epidemiological evidence on psychotic experiences in children and adults: on the pathway from proneness to persistence to dimensional expression across mental disorders. Psychol Med, 2013, 43(6): 1133-1149.
3.	Isaksson J, Angenfelt M, Frick MA, et al. Psychotic-like experiences from adolescence to adulthood: a longitudinal study. Schizophr Res, 2022, 248: 1-7.
4.	Dominguez MD, Wichers M, Lieb R, et al. Evidence that onset of clinical psychosis is an outcome of progressively more persistent subclinical psychotic experiences: an 8-year cohort study. Schizophr Bull, 2011, 37(1): 84-93.
5.	Kelleher I, Keeley H, Corcoran P, et al. Clinicopathological significance of psychotic experiences in non-psychotic young people: evidence from four population-based studies. Br J Psychiatry, 2012, 201(1): 26-32.
6.	Isaksson J, Vadlin S, Olofsdotter S, et al. Psychotic-like experiences during early adolescence predict symptoms of depression, anxiety, and conduct problems three years later: a community-based study. Schizophr Res, 2020, 215: 190-196.
7.	楊欣湖, 孫夢, 鐘少玲, 等. 精神病樣體驗影響因素、轉歸、干預的研究進展. 廣西醫科大學學報, 2023, 40(10): 1608-1614.
8.	Kelleher I, Connor D, Clarke MC, et al. Prevalence of psychotic symptoms in childhood and adolescence: a systematic review and meta-analysis of population-based studies. Psychol Med, 2012, 42(9): 1857-1863.
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11.	Reeve S, Sheaves B, Freeman D. The role of sleep dysfunction in the occurrence of delusions and hallucinations: a systematic review. Clin Psychol Rev, 2015, 42: 96-115.
12.	Wang D, Ma Z, Scherffius A, et al. Sleep disturbance is predictive of psychotic-like experiences among adolescents: a two-wave longitudinal survey. Sleep Med, 2023, 101: 296-304.
13.	Wang D, Li Y, Fan Y, et al. Bidirectional associations between short sleep duration, insomnia symptoms, and psychotic-like experiences in adolescents. Eur Child Adolesc Psychiatry, 2025, 34(1): 275-285.
14.	Liao W, Luo X, Kong F, et al. Association between non-restorative sleep and psychotic-like experiences among Chinese college students: a latent profile and moderated mediation analysis. Schizophr Res, 2024, 270: 295-303.
15.	Long M, Zhang P, Shi J. Association of anxiety/depressive symptoms with psychotic-like experiences: the moderation effect of sex and resilience. Children (Basel), 2024, 11(8): 969.
16.	Borsboom D. A network theory of mental disorders. World Psychiatry, 2017, 16(1): 5-13.
17.	Lee YJ, Cho SJ, Cho IH, et al. The relationship between psychotic-like experiences and sleep disturbances in adolescents. Sleep Med, 2012, 13(8): 1021-1027.
18.	Wang D, Chen H, Chen Z, et al. Current psychotic-like experiences among adolescents in China: identifying risk and protective factors. Schizophr Res, 2022, 244: 111-117.
19.	Wang D, Chen H, Chen Z, et al. Resilience buffers the association between sleep disturbance and psychotic-like experiences in adolescents. Schizophr Res, 2022, 244: 118-125.
20.	王東方, 孫夢, 歐陽萱, 等. 簡版社區心理體驗評估測評大學生的效度和信度. 中國心理衛生雜志, 2022, 36(2): 172-178.
21.	Hinterbuchinger B, Mossaheb N. Psychotic-like experiences: a challenge in definition and assessment. Front Psychiatry, 2021, 12: 582392.
22.	王東方, 孫夢, 席暢, 等. 簡式版社區心理體驗評估問卷的性別和縱向等值性. 中國臨床心理學雜志, 2020, 28(1): 41-45.
23.	姚樹橋. 心理評估. 3 版. 人民衛生出版社, 2019: 248-249.
24.	路桃影, 李艷, 夏萍, 等. 匹茲堡睡眠質量指數的信度及效度分析. 重慶醫學, 2014, 43(3): 260-263.
25.	Buysse DJ, Reynolds CF 3rd, Monk TH, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res, 1989, 28(2): 193-213.
26.	Palagini L, Hertenstein E, Riemann D, et al. Sleep, insomnia and mental health. J Sleep Res, 2022, 31(4): e13628.
27.	Betz LT, Penzel N, Rosen M, et al. Disentangling heterogeneity of psychosis expression in the general population: sex-specific moderation effects of environmental risk factors on symptom networks. Psychol Med, 2023, 53(5): 1860-1869.
28.	Jannini TB, Socci V, Schimmenti A, et al. Mapping connections between complex post-traumatic stress disorder and psychotic-like experiences among adolescents: a Gaussian and Bayesian network study. Psychol Med, 2025, 55: e61.
29.	Laurens KR, Hobbs MJ, Sunderland M, et al. Psychotic-like experiences in a community sample of 8000 children aged 9 to 11 years: an item response theory analysis. Psychol Med, 2012, 42(7): 1495-1506.
30.	張浩鵬, 張文卓, 劉勤智, 等. 大學生精神病性體驗及其心理社會學影響因素. 中國校醫, 2024, 38(9): 645-648.
31.	van Dalfsen JH, Markus CR. The influence of sleep on human hypothalamic–pituitary–adrenal (HPA) axis reactivity: a systematic review. Sleep Med Rev, 2018, 39: 187-194.
32.	Walker MP, van der Helm E. Overnight therapy? The role of sleep in emotional brain processing. Psychol Bull, 2009, 135(5): 731-748.
33.	Goldstein AN, Walker MP. The role of sleep in emotional brain function. Annu Rev Clin Psychol, 2014, 10(1): 679-708.
34.	D’Agostino A, Castelnovo A, Tononi G, et al. Sleep and mental health: unveiling the critical role of sleep in brain function and psychiatric disorders. Biol Psychiatry, 2025, 98(11): 804-806.
35.	Chellappa SL, Aeschbach D. Sleep and anxiety: from mechanisms to interventions. Sleep Med Rev, 2021, 61: 101583.
36.	Walker E, Mittal V, Tessner K. Stress and the hypothalamic pituitary adrenal axis in the developmental course of schizophrenia. Annu Rev Clin Psychol, 2008, 4: 189-216.
37.	Howes OD, Kapur S. The dopamine hypothesis of schizophrenia: version III--the final common pathway. Schizophr Bull, 2009, 35(3): 549-562.
38.	Eban-Rothschild A, Rothschild G, Giardino WJ, et al. VTA dopaminergic neurons regulate ethologically relevant sleep-wake behaviors. Nat Neurosci, 2016, 19(10): 1356-1366.
39.	Kapur S. Psychosis as a state of aberrant salience: a framework linking biology, phenomenology, and pharmacology in schizophrenia. Am J Psychiatry, 2003, 160(1): 13-23.

1. Staines L, Healy C, Coughlan H, et al. Psychotic experiences in the general population, a review; definition, risk factors, outcomes and interventions. Psychol Med, 2022, 52(15): 3297-3308.
2. Linscott RJ, van Os J. An updated and conservative systematic review and meta-analysis of epidemiological evidence on psychotic experiences in children and adults: on the pathway from proneness to persistence to dimensional expression across mental disorders. Psychol Med, 2013, 43(6): 1133-1149.
3. Isaksson J, Angenfelt M, Frick MA, et al. Psychotic-like experiences from adolescence to adulthood: a longitudinal study. Schizophr Res, 2022, 248: 1-7.
4. Dominguez MD, Wichers M, Lieb R, et al. Evidence that onset of clinical psychosis is an outcome of progressively more persistent subclinical psychotic experiences: an 8-year cohort study. Schizophr Bull, 2011, 37(1): 84-93.
5. Kelleher I, Keeley H, Corcoran P, et al. Clinicopathological significance of psychotic experiences in non-psychotic young people: evidence from four population-based studies. Br J Psychiatry, 2012, 201(1): 26-32.
6. Isaksson J, Vadlin S, Olofsdotter S, et al. Psychotic-like experiences during early adolescence predict symptoms of depression, anxiety, and conduct problems three years later: a community-based study. Schizophr Res, 2020, 215: 190-196.
7. 楊欣湖, 孫夢, 鐘少玲, 等. 精神病樣體驗影響因素、轉歸、干預的研究進展. 廣西醫科大學學報, 2023, 40(10): 1608-1614.
8. Kelleher I, Connor D, Clarke MC, et al. Prevalence of psychotic symptoms in childhood and adolescence: a systematic review and meta-analysis of population-based studies. Psychol Med, 2012, 42(9): 1857-1863.
9. Kelleher I. Annual Research Review: Psychosis in children and adolescents: key updates from the past 2 decades on psychotic disorders, psychotic experiences, and psychosis risk. J Child Psychol Psychiatry, 2025, 66(4): 460-476.
10. Unterrassner L, Wyss TA, Wotruba D, et al. The intricate relationship between psychotic-like experiences and associated subclinical symptoms in healthy individuals. Front Psychol, 2017, 8: 1537.
11. Reeve S, Sheaves B, Freeman D. The role of sleep dysfunction in the occurrence of delusions and hallucinations: a systematic review. Clin Psychol Rev, 2015, 42: 96-115.
12. Wang D, Ma Z, Scherffius A, et al. Sleep disturbance is predictive of psychotic-like experiences among adolescents: a two-wave longitudinal survey. Sleep Med, 2023, 101: 296-304.
13. Wang D, Li Y, Fan Y, et al. Bidirectional associations between short sleep duration, insomnia symptoms, and psychotic-like experiences in adolescents. Eur Child Adolesc Psychiatry, 2025, 34(1): 275-285.
14. Liao W, Luo X, Kong F, et al. Association between non-restorative sleep and psychotic-like experiences among Chinese college students: a latent profile and moderated mediation analysis. Schizophr Res, 2024, 270: 295-303.
15. Long M, Zhang P, Shi J. Association of anxiety/depressive symptoms with psychotic-like experiences: the moderation effect of sex and resilience. Children (Basel), 2024, 11(8): 969.
16. Borsboom D. A network theory of mental disorders. World Psychiatry, 2017, 16(1): 5-13.
17. Lee YJ, Cho SJ, Cho IH, et al. The relationship between psychotic-like experiences and sleep disturbances in adolescents. Sleep Med, 2012, 13(8): 1021-1027.
18. Wang D, Chen H, Chen Z, et al. Current psychotic-like experiences among adolescents in China: identifying risk and protective factors. Schizophr Res, 2022, 244: 111-117.
19. Wang D, Chen H, Chen Z, et al. Resilience buffers the association between sleep disturbance and psychotic-like experiences in adolescents. Schizophr Res, 2022, 244: 118-125.
20. 王東方, 孫夢, 歐陽萱, 等. 簡版社區心理體驗評估測評大學生的效度和信度. 中國心理衛生雜志, 2022, 36(2): 172-178.
21. Hinterbuchinger B, Mossaheb N. Psychotic-like experiences: a challenge in definition and assessment. Front Psychiatry, 2021, 12: 582392.
22. 王東方, 孫夢, 席暢, 等. 簡式版社區心理體驗評估問卷的性別和縱向等值性. 中國臨床心理學雜志, 2020, 28(1): 41-45.
23. 姚樹橋. 心理評估. 3 版. 人民衛生出版社, 2019: 248-249.
24. 路桃影, 李艷, 夏萍, 等. 匹茲堡睡眠質量指數的信度及效度分析. 重慶醫學, 2014, 43(3): 260-263.
25. Buysse DJ, Reynolds CF 3rd, Monk TH, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res, 1989, 28(2): 193-213.
26. Palagini L, Hertenstein E, Riemann D, et al. Sleep, insomnia and mental health. J Sleep Res, 2022, 31(4): e13628.
27. Betz LT, Penzel N, Rosen M, et al. Disentangling heterogeneity of psychosis expression in the general population: sex-specific moderation effects of environmental risk factors on symptom networks. Psychol Med, 2023, 53(5): 1860-1869.
28. Jannini TB, Socci V, Schimmenti A, et al. Mapping connections between complex post-traumatic stress disorder and psychotic-like experiences among adolescents: a Gaussian and Bayesian network study. Psychol Med, 2025, 55: e61.
29. Laurens KR, Hobbs MJ, Sunderland M, et al. Psychotic-like experiences in a community sample of 8000 children aged 9 to 11 years: an item response theory analysis. Psychol Med, 2012, 42(7): 1495-1506.
30. 張浩鵬, 張文卓, 劉勤智, 等. 大學生精神病性體驗及其心理社會學影響因素. 中國校醫, 2024, 38(9): 645-648.
31. van Dalfsen JH, Markus CR. The influence of sleep on human hypothalamic–pituitary–adrenal (HPA) axis reactivity: a systematic review. Sleep Med Rev, 2018, 39: 187-194.
32. Walker MP, van der Helm E. Overnight therapy? The role of sleep in emotional brain processing. Psychol Bull, 2009, 135(5): 731-748.
33. Goldstein AN, Walker MP. The role of sleep in emotional brain function. Annu Rev Clin Psychol, 2014, 10(1): 679-708.
34. D’Agostino A, Castelnovo A, Tononi G, et al. Sleep and mental health: unveiling the critical role of sleep in brain function and psychiatric disorders. Biol Psychiatry, 2025, 98(11): 804-806.
35. Chellappa SL, Aeschbach D. Sleep and anxiety: from mechanisms to interventions. Sleep Med Rev, 2021, 61: 101583.
36. Walker E, Mittal V, Tessner K. Stress and the hypothalamic pituitary adrenal axis in the developmental course of schizophrenia. Annu Rev Clin Psychol, 2008, 4: 189-216.
37. Howes OD, Kapur S. The dopamine hypothesis of schizophrenia: version III--the final common pathway. Schizophr Bull, 2009, 35(3): 549-562.
38. Eban-Rothschild A, Rothschild G, Giardino WJ, et al. VTA dopaminergic neurons regulate ethologically relevant sleep-wake behaviors. Nat Neurosci, 2016, 19(10): 1356-1366.
39. Kapur S. Psychosis as a state of aberrant salience: a framework linking biology, phenomenology, and pharmacology in schizophrenia. Am J Psychiatry, 2003, 160(1): 13-23.

West China Medical Journal

Parallel mediating roles of sleep and emotional problems in adolescent psychotic-like experiences

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