Unravelling Distress in Psychotic-Like Experiences: A Systematic Review of Non-Clinical Populations

Psychotic-like experiences (PLEs) are subthreshold psychotic phenomena that occur along the psychosis continuum and are frequently accompanied by distress. However, the factors underlying distress in individuals reporting PLEs-particularly within non-clinical populations-remain insufficiently understood. This systematic review aims to synthesise the evidence on factors directly or indirectly associated with distress in PLEs among non-clinical samples.

A systematic search of Medline, Web of Science, Embase, and Cochrane (January 2000-March 2025) using the terms psychotic-like experiences AND (distress OR resilience OR burden OR coping OR adaptive behaviour) identified 762 studies, of which 111 met inclusion criteria and were included in a narrative synthesis.

Distress related to PLEs can be differentiated into direct PLE-related distress and indirect psychological distress. Factors associated with distress clustered into three domains: (i) Symptomatology-greater frequency, intensity, persistence and specific subtypes predict higher distress, as do comorbid depression, anxiety and suicidality. (ii) Psychological factors-maladaptive metacognitive biases, poor emotion regulation and avoidant or emotion-focused coping contribute to distress, whereas self-compassion and problem-focused coping may be protective. (iii) Environmental and contextual factors-traumatic life events, discrimination, daily stressors and substance use amplify distress, often by interacting with internal vulnerabilities and emotion regulation capacities.

Distress in PLEs arises from the interaction between symptom features, internal psychological vulnerabilities and external environmental factors. Consistent with emotion regulation models, distress reflects disruptions in adaptive appraisal and coping processes that heighten emotional reactivity. Conceptualizing distress as a transdiagnostic vulnerability underscores its relevance for early identification and preventive interventions. Future research should harmonise definitions of distress, examine longitudinal pathways and evaluate resilience-building approaches to mitigate risk and improve mental health outcomes.