When a patient discloses a potential psychotic-like experience, follow-up questions may help to determine the appropriate next step:

What is the EXPERIENCE like?

People experiencing psychosis or psychosis risk symptoms have difficulty determining what is real and what is not. To understand these symptoms, it is important to understand the nature of their experiences and how they are interpreting their experiences. Does the experience or behavior fall outside the range of what would be considered typical for the young person’s developmental, social/cultural, or diagnostic/medical context? Limitations in cognitive and expressive capacities can often confound our understanding of a young person’s experience. Young people may struggle to adequately convey subtle or abstract changes in thought process or content, or say something that sounds psychotic when it is not. Use gentle questioning and refer to specialized mental health assessment as needed.

Questions you might ask:

• Tell me more about that experience.
• What do you make of that?
• Why do you think this is happening?
• How so?

Is it IMPACTING them?

As a person’s reality testing falters, their psychotic-like experiences may begin to impact their functioning. An experience may catch their attention in a way that is hard to dismiss, or a thought may become “sticky” or difficult to ignore. Impact can be behavioral, such as wearing headphones to block out auditory hallucinations or avoiding situations that frighten them, or emotional, including feeling confused, irritated, or otherwise distressed. Both behavioral and emotional impacts suggest that the experience is becoming more convincing or difficult to control. In many cases, young people may deny or downplay the fact that an experience is impacting them. Observed behavioral and/or emotional responses must be considered in assessing whether this is indeed true.

Questions you might ask:

• What do you do when that happens?
• Do you ever do anything differently because of it?
• How do you feel when that happens?
• Does it ever bother you? How so?
• Do you ever worry that [that’s true/it’s going to get worse/you’re going to​ lose track of whether it is real or not]?

Is it RECURRING or PROGRESSING​?

In considering whether an experience is part of an emerging disorder, we look for patterns. Experiences that occur repeatedly, or are “ramping up,” are more concerning than a single, fleeting experience. Recurring, even long-standing, symptoms that indicate a person is having trouble with reality testing warrant attention by a trained mental health clinician. Onset of new symptoms suggest a shift in a young person’s mental state and a change from their mental health/functional baseline. Similarly, symptoms that have gotten worse over time suggest a more pressing clinical concern. Symptoms are considered worsening when: 1) they have increased in frequency, intensity, or duration, 2) they have begun to cause the young person more distress, 3) they have begun to impact the young person’s behavior/functioning, and/or 4) it has gotten harder for the young person to determine that the symptom is ultimately not real.

Questions you might ask:

• How often is this happening?
• Do you have any other experiences like this?
• Does it seem to be happening more now than it used to?
• When did you first begin having this experience?
• Has it changed at all over time? (for instance, ​becoming more intense or harder to dismiss)
• Has it been happening more frequently or bothering you more than it used to?