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Cognitive functioning in people with psychotic experiences: a systematic review and meta-analysis study

Molecular Psychiatry volume 30, pages 1184–1194 (2025)Cite this article

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Abstract

Earlier research suggested that psychotic experiences (PEs), the extended-psychosis phenotype, are associated with cognitive impairment. Recent studies, however, revealed more mixed findings, and patterns and magnitude of cognitive deficits in PEs remain uncertain. We aimed to systematically review and quantitatively synthesize estimates of cognitive functioning covering a wide array of domains in individuals with versus without PEs. We systematically searched four databases from inception to 6 July 2023. We generated pooled effect size (Hedges’g) using random-effects models. Subgroup analyses and meta-regression examining the moderating effect of sex, age at PE assessment, study design, cognitive task, and PE assessment instrument on cognitive functioning were performed when applicable. The study was registered with PROSPERO (CRD42023442528). Twenty-seven and six studies were included for meta-analysis of cognitive functioning comparing individuals with versus without PEs (n = 82,561; 10,251 individuals with PEs) and individuals with high-level versus low-level PEs (n = 8062; 813 individuals with high-level PEs), respectively. Individuals with PEs exhibited worse cognitive performance in general cognition (Hedges’g = −0.10 [95%CI = −0.18 to −0.02]), verbal fluency (Hedges’g = −0.05 [95%CI = −0.10 to −0.00]), visual memory (Hedges’g = −0.21 [95%CI = −0.38 to −0.03]), and working memory (Hedges’g = −0.16 [95%CI = −0.28 to −0.04]). Meta-regression revealed that general cognition associated with PEs was related to younger age (z = 3.37, p = 0.001), male sex (z = −2.59, p = 0.010), and cognitive assessment before PE assessment (z = −2.15, p = 0.031), whereas working memory in individuals with PEs was associated with concurrent cognitive and PE assessment (z = 6.19, p < 0.001). We failed to find moderating effect of the choice of PE assessment instrument or cognitive task on cognitive functioning in PEs. Additional analysis showed no significant difference in the performance of any cognitive domains between individuals with high-level versus low-level PEs. Limitations included studies primarily derived from Western countries, no social-cognitive domains, and varied PE measurement. In sum, PEs are associated with milder and more circumscribed cognitive impairment relative to psychotic disorders. Future research is required to clarify differential cognitive trajectories between individuals with transient PEs and persistent/recurrent-PEs.

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Fig. 1
Fig. 2: Cognitive functioning across 11 cognitive domains in people with psychotic experiences.
Fig. 3: Subgroup analyses for general cognition and working memory in people with psychotic experiences.

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Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Funding

The study was supported by the Health and Medical Research Fund (HMRF) (grant number: 07181776), the Food and Health Bureau, and the Hong Kong SAR Government. The funders had no role in study design, data collection, data analysis, interpretation of the data, manuscript preparation, or journal submission.

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Authors and Affiliations

  1. Department of Psychiatry, LKS Faculty of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China

    Ryan Sai Ting Chu, Ivan Wai Lok Chu, Esther Wing-Chi Yip, Joe Kwun Nam Chan, Christy Lai-Ming Hui, Eric Yu Hai Chen, Sherry Kit Wa Chan, Edwin Ho Ming Lee, Simon Sai Yu Lui & Wing Chung Chang

  2. LKS Faculty of Medicine, School of Public Health, The University of Hong Kong, Hong Kong SAR, China

    Corine Sau Man Wong

  3. Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore

    Eric Yu Hai Chen

  4. State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR, China

    Sherry Kit Wa Chan & Wing Chung Chang

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Contributions

WCC and RSTC conceptualized and proposed the topic. RSTC and WCC developed the protocol, designed the search strategy, and defined the inclusion criteria. RSTC, IWLC, and EYCY screened the literature research, and extracted data from included studies. RSTC and IWLC did the quality assessment of the included studies. RSTC did the statistical analyses. RSTC, WCC, JKNC, and CSMW interpreted the study data. RSTC wrote the first draft. WCC and RSTC finalized the manuscript. All authors critically reviewed and approved the final version of the manuscript.

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Correspondence to Wing Chung Chang.

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Chu, R.S.T., Chu, I.W.L., Yip, E.WC. et al. Cognitive functioning in people with psychotic experiences: a systematic review and meta-analysis study. Mol Psychiatry 30, 1184–1194 (2025). https://doi.org/10.1038/s41380-024-02823-y

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