Reference
Guide | Reference

39  Psychosis and Reality Testing

39.1 Summary

  • A dimensional construct describing the degree of reality distortion and impairment in testing beliefs or perceptions.

39.2 Core Construct

  • Reduced ability to distinguish internal experiences from shared reality.

39.3 Subdimensions

  • Hallucinations or perceptual distortions.
  • Delusional conviction or unusual beliefs.
  • Disorganization in thought or behavior.
  • Insight into experiences.

39.4 Severity Anchors (0-4)

  • 0: No clinically meaningful reality distortion.
  • 1: Mild, intermittent, with intact insight.
  • 2: Moderate, recurring, impacts function.
  • 3: Severe, persistent, with reduced insight.
  • 4: Extreme, disabling or unsafe.

39.5 Time-Course Patterns

  • Acute onset.
  • Episodic with remissions.
  • Chronic persistence with exacerbations.

39.6 Functional Impact

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

39.7 Developmental Expression

  • Adolescence/early adulthood: new onset with functional change.
  • Late life: new onset warrants medical evaluation.

39.8 Cultural / Context Notes

  • Evaluate beliefs within cultural or spiritual context.
  • Avoid pathologizing culturally normative experiences.

39.9 Differential and Rule-Outs

  • Delirium or acute confusional states.
  • Substance intoxication or withdrawal.
  • Medication effects.
  • Trauma-related intrusions or dissociation.
  • Neurologic or autoimmune contributors.

39.10 Measurement Prompts

  • Brief psychosis screening items.
  • Collateral history and timeline mapping.

39.11 Treatment-Relevant Correlates (non-prescriptive)

  • Lower insight suggests greater need for collateral and monitoring.
  • Disorganization often correlates with functional risk.

39.13 Documentation Snippet (1-2 lines)

  • “Psychosis domain elevated with hallucinations and reduced insight; Psychosis 3; acute onset.”