Young people are unlikely to spontaneously share their early experiences of psychosis. As such, it is important to be ready and willing to ask about these experiences.
Tips for Talking about Psychosis
- Be curious and matter of fact. Clearly convey that you’re there to help. You don’t have to know a lot about psychosis, but they need to know that you are not afraid and won’t be overwhelmed to hear what they are experiencing.
- “You might be surprised how common your experiences are. I’m here to figure this out with you.
Do your best to explain what’s going on.”
- “You might be surprised how common your experiences are. I’m here to figure this out with you.
- Start with simple open-ended questions:
- “You seem distracted. Can you describe what's going on in your mind right now?” (or "when you're staring off," "pacing like that," etc.)
- "Can you help me understand what you're experiencing?"
- Be ready to follow up with additional questions such as:
- “Can you give me an example?"
- If you notice odd behaviors that the patient denies, consider gathering more information from a parent or caregiver.
- Move to more specific questions as it makes sense (see the PQ-16 below for examples). Include these as part of your overall interview without special emphasis, hesitation, or implication that they carry more significance than other experiences being queried (eg. insomnia, anxiety, headache).
The following Yes/No questions cover a range of symptoms and are written at a fifth grade reading level. If any are endorsed, ask open-ended follow-up questions to determine if this is a psychotic-like experience. For additional tips on working with youth ages 10 and under, reference the HeadsUp resource here.
A number of self-report screening tools, listed below, can help to identify psychotic-like experiences. None of the available screens have established thresholds for screening in general medical settings, especially for children and adolescents. However, they can help elicit the initial disclosure of experiences. See the video here for an example of how to discuss these further.
SASHA: SOMETHING IS WRONG WITH MY BODY
Fifteen-year-old Sasha just hasn’t seemed like herself lately. Her dad brought her in for an appointment this afternoon. He says she stopped going to track practice a couple of months ago, and now he’s noticed she’s only showering about once per week. Sasha denies that anything is wrong, saying she just doesn’t like doing those things anymore, and doesn’t have the energy to do them. You ask her why she doesn’t like showering or going to track anymore, and she says, “I don’t know, sometimes I just think my body can’t. Or shouldn’t, because it’ll be bad for me.” You encourage Sasha to tell you more, and she explains, “I’ve been having thoughts that my legs aren’t working right. Sometimes I think they’re detached from my body, like there’s a gap where they used to connect at my hips. Running will make it worse, and showering might let water in.”
EXPERIENCE: Thinking that one’s body is no longer working correctly or in the same way is a somatic delusion (THOUGHTS). In Sasha’s case, this is the thought that her legs are no longer connected directly to her body.
IMPACTING: Sasha has stopped participating in activities she normally does and enjoys, including a social, extracurricular activity and hygiene routines (FUNCTIONING).
PROGRESSING: This experience is recurring, and has begun to impact Sasha’s functioning; her thought that running will worsen the gap between her legs and body, and that water may get into the gap during a shower, indicate that it may be becoming increasingly difficult for her to maintain insight into the fact that this experience is ultimately not real.
Justin: SOMETHING IS WRONG WITH MY Brain
Justin’s aunt brought him in this afternoon for a checkup. He (age 12) is healthy with no evidence of a visual disturbance or neurological abnormality. During his appointment, however, Justin told you he’s been seeing shadows around him, especially in a particular hallway at school. He thinks something is wrong with one of his eyes or that maybe he has a brain tumor that is pressing on his eye. When you ask why he thinks that, he says he knows what’s happening is not normal, that no one else sees what he sees, and it’s beginning to freak him out. Last week, he skipped a few classes because they’re in that part of the building and he didn’t want to go over there.
EXPERIENCE: Justin appears to be developing an attenuated somatic delusion (THOUGHTS) based on ATYPICAL perceptual experiences. He knows that his visual experience is not shared by others and is interpreting this as a sign that something is seriously wrong.
IMPACTING: Justin is distressed and has skipped class just to avoid the experience.
PROGRESSING: Justin says this is “beginning to freak [him] out.”
When you’re seeing 13-year-old Lamar for his physical, his mom tipped you off that he’s not doing well at school. You ask him what’s going on and he says he just doesn’t care about school. “What’s changed?” He tells you he’s having a harder time paying attention. You ask, “How so?” and he says, “I’m just thinking about a lot of stuff and feeling distracted.” You ask, “What’s distracting you?” Lamar says, “It’s like random things seem meaningful, like somebody’s chosen a certain color combination in their clothes to try to tell me something, or if a particular song comes on before I’m about to do something, it’s a sign I shouldn’t do it. It’s all little stuff, but it’s like it’s bombarding my mind.”
EXPERIENCE: Lamar is having difficulty filtering environmental stimuli and is beginning to make meaning of little things, interpreting inconsequential details as messages intended to communicate something to him (THOUGHTS).
IMPACTING: Lamar is distracted by this experience and feels “bombarded.”
PROGRESSING: He is having a harder time in school because of this.
Sam: AFRAID TO EAT
Fourteen-year-old Sam came in for her physical for the basketball team last week. In looking at her records, you notice she’s lost a notable amount of weight since her last appointment; Sam says she hadn’t thought much about the weight loss, but has had little interest in eating over the past several weeks. She doesn’t expand further, but you ask her to tell you more about when that started. Sam then says, “My parents are messing with my food and I think they may be trying to poison me. A few weeks ago I noticed people at school were looking at me so I knew it was true. Now I only eat stuff that’s sealed in packages I open, which doesn’t end up being much.”
EXPERIENCE: Sam’s thoughts that her parents are trying to hurt her via poisoning her food indicate paranoia (THOUGHTS).
IMPACTING: As a result of these thoughts, Sam has limited what she eats to the point that she has lost a significant amount of weight (FUNCTIONING).
PROGRESSING: This experience is recurring, and Sam’s level of conviction increased after an incident at school a few weeks ago when she “knew it was true.”
CORY: Weird things are happening
Last week, 16-year-old Cory told you he’s been feeling off the last several months. You say, “How so?” and he explains that it feels like weird things are happening and he feels distant from himself. “Can you give me an example of the weird things?” He says he’s heard whispering/talking that others don’t seem to hear. You ask him to tell you more, and he says, “Sometimes, mostly when I’m in class or at home in my room, I think I hear somebody talking even when it’s quiet. Most of the time I can’t make out what the person is saying, but it usually sounds like it’s coming from a corner of the room.” You ask, “What do you do when that happens?” Cory says, ”I turn to check where it’s coming from, but nobody’s there.”
EXPERIENCE: Cory is aware that something “weird” is happening to him and he’s “feeling off,” and “distant from himself” (THOUGHTS – a subjective change in the sense of self may be particularly concerning). He is interpreting internal stimuli as external to himself (ATYPICAL perceptual experiences). In particular, he hears the sound of the voice is coming from outside his head (from a corner of the room).
IMPACTING: The voice catches Cory’s attention and he checks his surroundings for a source of the sound.
RECURRING: He’s having this experience regularly.
While in your office to get her flu shot, 18-year-old Breanna mentions that she’s been spending more time alone than she did last semester. When you ask her why that is, she says she’s been feeling really nervous and uncomfortable around people. You ask, “How so?” and Breanna says, “I don’t know where this is coming from, but I just feel really uneasy when I’m around people, especially in public, like people are watching me or have it in for me somehow.” “Enough to feel you need to be on guard?” “I feel like I really have to pay close attention to everything around me. I’m constantly checking over my shoulder and looking at everyone around me.”
EXPERIENCE: Breanna is feeling suspicious that others intend her harm (THOUGHTS). Her own comment, “I don’t know where this is coming from,” suggests that she knows there is no actual threat.
IMPACTING: She is uneasy, hypervigilant, and spending time alone because of this experience.
PROGRESSING: She reports spending more time alone now than she did last semester.
Avery: Dreading school
During a check-up, 17-year-old Avery mentions that they're beginning to dread going to school. You check in about a variety of potential mental health concerns. They seem disconnected, like something’s just “off,” so you have them fill out the PQ-16, a self-report psychosis risk screen. Avery indicates feeling like they're not always in control of their own ideas and thoughts, so you ask them to tell you more about this experience. Avery says, “I know this probably sounds weird, but I think other people may be able to read my mind, especially if I’m thinking about something violent or embarrassing.” When you ask them if they do anything differently because of this, they say, “I look around to see if anybody’s looking at me weirdly, and I try to make my mind blank.”
EXPERIENCE: Avery thinks that others may be able to know/access the content of their thoughts telepathically, not just based on their facial expressions or body language (THOUGHTS).
IMPACTING: Avery is checking whether people around them seem to be reacting to their thoughts, and is trying change their thoughts to prevent their being read.
PROGRESSING: It’s clear this is RECURRENT, but they're also beginning to dread going to school, signaling a growing impact on functioning.
Lee: Thoughts circle outside my reach
While seeing 15-year-old Lee, you noticed she kept asking you to repeat your questions. You commented that this seemed unusual for her, and asked her to tell you more about what was going on for her that she was having trouble taking in or holding onto your questions. Lee said, “I know, I’m sorry. It seems like I’m thinking and then I’m not. Words float around insensibly. Clouds float too. Minds are not what they used to be. I feel like I can’t explain myself well anymore. After 10 seconds no trace ideas of where I was going. Thoughts circle outside my reach.” You ask if anyone else has noticed. “My English teacher. My last paper, she couldn’t follow. I have to rewrite it.”
EXPERIENCE: Lee is demonstrating disorganization in her SPEECH that suggests an underlying thought disorder. Importantly, this is new, not part of a longstanding attentional or language disorder. Difficulty following conversations, losing her train of thought and putting words together in an unusual way that is hard to follow, are all examples of this. English teachers may be the first to pick up on this, and asking to see someone’s writing can be very helpful in grasping the extent of this difficulty.
IMPACTING: Lee’s trouble following conversations and expressing herself is clearly affecting her ability to interact with you. The disorganization in her thinking and writing is impacting her schoolwork.
PROGRESSING: This is new since you last saw her.
Tariq: Things feel unreal
During his annual physical, 15-year-old Tariq mentioned that he’s worried about his mind. His dreams sometimes seem really vivid, to the point that he’s unsure if something actually happened. You encourage him to tell you more about this experience, and Tariq says, “It’s really weird; it’s like I don’t always know what’s real anymore. I’ve mentioned things to friends a couple of times and they have no idea what I’m talking about. It must just be something that happened in a dream.” As part of gathering more information, you also ask, “Has this been getting worse?” Tariq says, “Yeah, even though it started when I was little, it seems more real over the past few months. I just keep getting confused whether something really happened or not.”
EXPERIENCE: Tariq is experiencing difficulty knowing the difference between what is real and what is not, a hallmark of psychosis risk/early psychosis (THOUGHTS).
IMPACTING: At times, he needs input from other people in order to determine whether a thought/ experience is reality-based.
PROGRESSING: Tariq is finding it increasingly more difficult to maintain insight into what is real.