It started with strange noises through the wall, quiet and barely recognizable, as if someone were eavesdropping.

Over time, I could make out the voice of my neighbor. I had to investigate.

At first, I only heard his voice in my apartment, but later he followed me to other places.

Then it dawned on me - he's an agent!

What are you most curious about?

It started with strange noises through the wall, quiet and barely recognizable, as if someone were eavesdropping.

Over time, I could make out the voice of my neighbor. I had to investigate.

At first, I only heard his voice in my apartment, but later he followed me to other places.

Then it dawned on me - he's an agent!

Psychotic experiences refer to disruptions in the way a person perceives, interprets, or connects with reality.

They include alterations in perception (e.g. hearing voices), thought content (e.g. delusions), speech, and behavior.

They reflect a breakdown of reality monitoring—the ability to distinguish internal experiences from external events.

Hallucinations: Perceptual experiences without external stimuli (e.g. voices, visions)

Delusions: Fixed, false beliefs (e.g. paranoia, grandiosity)

Disorganized Speech: Tangential, incoherent, or illogical language

Thought Insertion: Belief that thoughts are being placed in one's mind

Passivity Experiences: Feeling controlled by external forces

Schizophrenia Spectrum Disorders

Brief Psychotic Disorder

Schizoaffective Disorder

Bipolar Disorder (with psychotic features)

Major Depression (with psychotic features)

Delusional Disorder

Substance- or Medication-Induced Psychotic Disorder

Criterion A – Core Symptoms:

• Two or more of the following, present for ≥1 month. At least one must be (1), (2), or (3):
• (1-3) Delusions, Hallucinations, Disorganized speech
• (4-5) Disorganized/catatonic behavior, negative symptoms

Criterion B – Functional Impairment: Work, relationships, or self-care markedly below prior functioning

Criterion C – Duration: Continuous signs of disturbance for ≥6 months, including ≥1 month of active symptoms

Criterion D – Mood Exclusion: Schizoaffective disorder and mood disorders with psychotic features must be ruled out

Criterion E – Substance/Medical Exclusion

Criterion F – Neurodevelopmental Exclusion: In ASD or communication disorders, schizophrenia is diagnosed only if delusions or hallucinations are prominent and persist for ≥1 month

Specifiers: Include course (e.g. first episode, remission), severity, and catatonia

Core Symptoms:

• Both require ≥1 first-rank or equivalent symptoms (e.g., thought insertion, delusional perception)

Duration: Psychotic symptoms must persist for ≥1 month in both systems

Functionality:

• ICD-10: Does not require functional impairment
• ICD-11: Still does not require it, but impairment may support diagnosis

Subtypes:

• ICD-10 includes subtypes (e.g., paranoid, hebephrenic, catatonic)
• ICD-11 removes subtypes entirely

Symptom Specifiers: (ICD-11 only)

• Positive symptoms, Negative symptoms
• Depressive, Manic, Psychomotor, Cognitive

Course Specifiers:

• ICD-10: episodic/continuous/remission patterns
• ICD-11: structured specifiers (e.g., first episode in remission, multiple episodes in acute phase)

Early: It began slowly. I was 19. First, I couldn’t sleep. Then I felt like people on the bus were talking about me.

By 21, I had dropped out of university. I thought my professors were recording my thoughts.

They took me to the hospital after I stood outside in the rain all night, convinced the sky was trying to send me messages.

In treatment: After the hospital, things got quiet. Too quiet. My family said I was better, but I did not feel very much.

I started antipsychotics, moved back in with my mother, and stopped speaking much. I had trouble concentrating, and was sleepy most of the time. I lost my phone three times in a month!

Long-term course: Years have passed. I have some good days. I volunteer now and then. But the world still feels distant, like it’s behind glass.

Prevalence: Schizophrenia affects about 1 in 200 people globally (~0.5%).

Incidence is slightly higher in urban vs. rural areas, and among migrants and vulnerable populations.

Men are affected earlier (late teens to early 20s), women typically later (late 20s to early 30s).

Prodromal Phase: Often includes social withdrawal, reduced motivation, subtle emotional or cognitive changes.

First Episode: Characterized by acute psychosis, usually requiring hospitalization.

Afterward: Symptom course varies: may remit, recur, or become chronic depending on factors like support, early intervention, and adherence.

~ 20% of individuals recover fully with treatment and support

~ 40% experience intermittent relapses with significant periods of stability

~ 40% have chronic symptoms, often dominated by negative or cognitive deficits

Factors predicting better outcome: female sex, later onset, short duration of untreated psychosis, good premorbid functioning, and social support

Early intervention services significantly improve outcomes

Mrs. X was always a sensitive child—quiet, withdrawn, lost in thought.

In adolescence, she struggled with anxiety and feelings of detachment.

After a stressful breakup and increased cannabis use, the voices began.

She later learned that her uncle had been hospitalized with similar symptoms.

Genetic predisposition: Family history increases risk

Early adversity: Trauma, neglect, or abuse during childhood

Substance use: Especially cannabis, amphetamines, psychedelics

Stress & life events: Breakups, migration, academic stress

Neurodevelopmental factors: Complications during birth or development

Diathesis-Stress Model: Psychosis emerges when vulnerability meets stress

Cognitive Model: Maladaptive interpretations of internal experiences

Neurodevelopmental Model: Early brain insults predispose to later symptoms

Biopsychosocial Integration: No single cause—multiple levels interact

If you could reduce one societal risk factor for psychosis, what would it be?

Mrs. X had recently returned to work after being absent for a few months. At first, she was quiet in meetings. Then she began skipping them altogether.

When a colleague called, she whispered that the office phones were tapped. She said "they know everything I think."

She agreed to an assessment only after her partner noticed she hadn't eaten in two days and was afraid to leave the house.

Unusual suspiciousness, perceptual changes, or fixed odd beliefs

Sudden social withdrawal, functional decline, or flat affect

Disorganized speech, derailment, or illogical thoughts

Reports of "mind reading," "being watched," or "hearing things"

Family/friend concern without clear explanation

Start with a collaborative, stigma-free interview

Include direct but gentle questions about unusual beliefs and perceptions

Assess insight, reality testing, affect, and coherence of thought

Consider structured tools (e.g., BPRS, PANSS, CAPS, PDI, SAPS, SANS, etc.) in at-risk cases

Always ask about suicidality, substance use, and recent stressors

Uses digital pre-screening to flag potential early psychosis risk

Incorporates AI-informed triage and structured intake interviews

Focus on fast access to care, including therapist-matching

Follows up on flags with specialized evaluation (telehealth or in-person)

Care pathways may include CBTp, medication consults, and family support

What are your challenges in working with people who experience psychosis? What has helped?

Mrs. X described a moment when her reflection no longer felt like her own.

She feared that something had taken over her body, and even her voice seemed unfamiliar.

The therapist’s calm response didn’t make the fear vanish — but it prevented things from escalating.

In that moment, what helped was not reassurance, but simply being seen without alarm.

Establish Safety: Maintain a calm tone and open posture. Avoid sudden movements or challenges.

Validate the Experience: You don’t have to agree with the belief, but you can acknowledge the emotional impact.

Stay Curious: Ask open-ended questions to explore the meaning and context of the experience.

Limit Confrontation: Challenging delusional content directly may increase defensiveness or distress.

Respect Autonomy: Emphasize collaboration and choice wherever possible.

Start with rapport: In both messaging and video sessions, tone and empathy matter deeply. Use the person's name and reflect their language.

Assess stability early: Is the person grounded in reality? Are they experiencing perceptual distortions or paranoia?

Use simple, direct language: Avoid metaphors or abstract explanations in early phases. Clarity reduces uncertainty.

Offer structure: Provide predictable session formats, summaries, and check-ins to reduce fear and disorientation.

Document concerns: Clearly note flags like disorganized speech, flat affect, or delusional themes while maintaining trust.

Mrs. X was brought to urgent care by her sister after weeks of increasing isolation and disorganized behavior.

She believed her neighbors were sending her coded messages and hadn’t slept in days.

She received antipsychotic medication, but treatment didn’t stop there.

A coordinated team helped her rebuild routines, process trauma, and gradually reconnect with others.

Medication: Antipsychotics reduce acute symptoms. Careful titration and shared decisions matter for adherence.

Psychoeducation: Empowering patients and families with knowledge improves engagement and reduces stigma.

CBTp: Helps process distressing beliefs without invalidation. Evidence-based and effective in reducing relapse.

Family Work: Reduces expressed emotion, improves coping, and strengthens support networks.

Supported Employment & Housing: Restores identity and purpose — foundational to long-term recovery.

Hope and empowerment: A belief in recovery and personal growth is central to treatment culture.

Shared decision-making: Patients define goals, preferences, and acceptable risks.

Integrated care: Address comorbidities, substance use, and unmet social needs holistically.

Digital tools: When used thoughtfully, apps and messaging platforms can support continuity, symptom tracking, and reminders.

After discharge, Mrs. X had trouble managing her appointments, prescriptions, and daily structure.

Her GP was unsure how to support her and hadn’t received the discharge summary.

A case manager reconnected the dots — coordinating care, checking in regularly, and involving her family doctor in the plan.

This continuity prevented relapse and supported her reintegration into daily life.

Early planning: Begin discharge planning from day one, involving patient, family, and outpatient teams.

Bridging the gap: Provide follow-up appointments and low-threshold check-ins. Consider home visits or digital touchpoints.

Clear communication: GPs and social workers need timely, comprehensible discharge summaries.

Relapse prevention: Develop individualized crisis plans and involve the full support network.

Psychiatric support: Continue monitoring, med adjustments, and therapeutic engagement.

Primary care: Address comorbidities, monitor metabolic effects, and serve as accessible anchor point.

Case management: Ensure coordination, advocate for housing, benefits, and daily structure.

Peer support: Lived experience provides hope and authentic connection that complements clinical care.

A., 21, recently moved into a student dorm. He started noticing whispers through the walls at night.

He believed the neighbor had installed listening devices and was trying to provoke him.

Though still attending university, he became preoccupied and distrustful. Early intervention helped prevent further deterioration.

L., 34, called a crisis hotline, reporting that government officials were broadcasting her thoughts via the radio.

She was terrified and disoriented, unable to distinguish internal thoughts from external voices.

This was her first psychotic break, precipitated by recent job loss, isolation, and sleep deprivation.

T., 28, became convinced that his parents had been replaced by identical impostors.

He described emotional disconnection and a strong sense of unreality at home.

A deeper trauma history surfaced later in therapy, suggesting that delusional misidentification masked unresolved emotional wounds.

F., 25, an accomplished student, began missing deadlines and isolating socially.

She stopped returning calls, often sitting silently for hours, lost in thought.

Only months later did she reveal she had been hearing voices criticizing her actions and doubting her own thoughts.