Reference
Guide | Reference

27  Reality Distortion and Psychosis-Spectrum Experiences

27.1 Summary

  • Experiences where perception, belief, or thought content departs from shared reality or is held with reduced insight.

27.2 Patient-Language Phrases

  • “I hear voices when no one is there.”
  • “People are watching or sending me messages.”
  • “My thoughts don’t feel like my own.”
  • “Things feel unreal or distorted.”

27.3 Core Features

  • Hallucinations or perceptual distortions.
  • Fixed or unusual beliefs held with high conviction.
  • Disorganized thought or behavior.
  • Reduced ability to test reality.

27.4 Boundary Markers

  • What it is: persistent or recurrent reality-distorting experiences with reduced insight.
  • What it is not: culturally normative beliefs, grief-related phenomena, or transient misperceptions tied to sleep loss or substances.

27.5 Variants / Spectrum

  • Auditory, visual, or tactile hallucinations.
  • Delusional themes (persecution, grandiosity, reference).
  • Thought insertion, withdrawal, or broadcasting.
  • Disorganization or catatonia-like states.
  • Insight continuum from intact to minimal.

27.6 Severity Anchors (0-4)

  • 0: No reality-distortion symptoms.
  • 1: Mild, intermittent, with intact insight.
  • 2: Moderate, recurring, impacts function.
  • 3: Severe, persistent, with impaired insight or safety concerns.
  • 4: Extreme, disabling or unsafe.

27.7 Time-Course Patterns

  • Acute onset.
  • Episodic with remissions.
  • Chronic persistence with exacerbations.
  • Progressive functional decline.

27.8 Functional Impact

  • Work/school: disorganization or reduced performance.
  • Relationships: mistrust, withdrawal, or conflict.
  • Self-care: neglected routines or safety concerns.

27.9 Common Mimics / Differential

  • Trauma-related intrusions or dissociation.
  • Severe mood episodes with psychotic features.
  • Obsessional intrusions with intact insight.

27.10 Medical / Substance Rule-Outs

  • Delirium or acute confusional states.
  • Substance intoxication or withdrawal.
  • Medication effects.
  • Seizure, autoimmune, infectious, or neurodegenerative mimics.

27.11 Developmental Expression

  • Adolescence: new onset with functional change.
  • Adulthood: episodic or persistent patterns.
  • Late life: new onset warrants medical workup.

27.12 Cultural / Context Notes

  • Assess beliefs within cultural, spiritual, or community context.
  • Language and meaning may shape symptom description.

27.13 Measurement Prompts

  • Brief psychosis screening questions.
  • Collateral reports and timeline checks.

27.15 Documentation Snippet (1-2 lines)

  • “Reports auditory hallucinations and fixed beliefs with reduced insight; Psychosis 3; acute onset.”