Referential Delusions

1. Overview — What Are Referential Delusions?

Referential delusions, often called delusions of reference in English-language textbooks, refer to a state in which a person firmly believes that external events that should be “neutral” or “have nothing to do with them at all” are in fact sending messages to them in a highly specific way. These events can be news on TV, songs on the radio, social media posts, billboards, conversations between strangers, or even the color of a passerby’s clothes. From their point of view, these things are not just “the background of the world” but secret messages, signals, or cues designed especially for them.

The key point is that this belief reaches the level that is classified as a “delusion”, not just a passing thought or random idea, because it is fixed in nature: the person is highly confident that it is true, believing in a way that is “not just a feeling, but certainty,” and it resists other people’s reasoning. Even when there is very clear evidence that the event in question is a pre-recorded program from long ago, a standard advertisement that everyone in the country sees, or the random output of a social media algorithm, they still believe there “must be something” about it that is personally related to them.

For example, some patients may believe that a radio DJ is speaking directly to them through a live program, believe that a news anchor is “secretly sending signals” by emphasizing certain words or looking into the camera at specific moments, or believe that a car commercial that keeps appearing repeatedly on YouTube is actually a warning message from a secret organization that is monitoring them—even though in reality all of this is just standard content that everyone sees in the same way.

What makes referential delusions clinically important is that they reflect a clear change in the brain’s “world-interpretation system.” The world is the same world, the messages are the same messages, the images are the same images, the sounds are the same sounds, but the meanings extracted from them have changed. What previously should have been “just another advertisement” transforms into “this is a secret code they are sending to me.” Patients often explain it as “it’s too much of a coincidence” or “it matches exactly what I was thinking in my head—how could I possibly believe it has nothing to do with me?”

For most people, when they feel like something “seems to be about me,” there is usually a second voice in their head that steps in to brake, saying something like, “Or maybe I’m just overthinking it.” In referential delusions, however, this second layer is almost absent. Reality testing, or the ability to ask oneself “maybe it’s not actually like that,” is clearly reduced. Thoughts therefore flow almost automatically in the direction of “it must be about me” nearly every time a triggering stimulus occurs.

Because this type of belief occupies such a large space in life, many patients begin to change their behavior according to the “signals” they themselves have interpreted. For instance, they may avoid going outside because they feel that billboards and the gazes of people around them are reporting something back to a secret organization; they may stop watching TV or using social media because they feel constantly referenced or talked about. On the other hand, some people become preoccupied with “tracking the signals,” memorizing the sequence of songs, numbers, times, and colors, then arranging them into codes that they believe are messages from someone who is “talking to them through the system.”

From a psychiatric standpoint, referential delusions are not a standalone disorder, but rather a “type of delusional content” that appears in several conditions such as Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Bipolar Disorder with psychotic features, Substance-Induced Psychosis, etc. The common pattern is that wherever it appears, you see the same sequence: external stimuli → interpreted as personal messages directed at oneself → high conviction → difficult to change → leading to significant disruption in daily life.

Another frequent source of confusion is the difference between “ideas of reference” and “delusions of reference.”

Ideas of reference are thoughts like “Are they talking about me?” where the person still feels some hesitation, can still argue with themselves, can still listen to other people’s reasoning, and when they later reflect on it, they can accept that “Yeah, maybe I was just overthinking it.”

Delusions of reference, or referential delusions, are the stage where that feeling has shifted status from ‘suspicion’ to ‘fact in my world.’ Once it has been upgraded to a “fact,” the entire chain of thoughts that follows begins to revolve around that central belief and gradually wraps itself around the person’s everyday life, bit by bit.

Because of this, referential delusions are often seen as one of the “important windows” through which we can observe profound changes in a patient’s brain systems and perception of reality. They are not just temporary mistaken thoughts, but a new way of seeing the world that has drifted away from reality. And if no help is provided, it can escalate into persecutory delusions (believing one is being threatened/harassed) or grandiose/religious delusions (believing one is chosen/has a special mission) over time.

In summary, when we use the term Referential Delusions, we are talking about a state in which “the entire external world has been rebranded into a personal message board directed at me,” and the person experiencing it does not treat that as a mere strange feeling, but truly believes that this is the way the world really is. This is precisely what makes it a psychiatric symptom, not just a personality style of being over-thinky or simply paranoid.

2. Core Symptoms — Core Features of Referential Delusions

There is really only one big idea in a single sentence:

The world is still the same world, but the brain’s “interpretation system” has changed, so everything appears to be about me.

It is not just ordinary “suspiciousness,” but self-referential misinterpretation = a system that interprets everything as being “linked back to the self” in an excessive way.

Below is an expansion of each feature, showing mild–moderate–severe levels and case examples you can use for teaching or writing.

1. Personalization — Everything Points Back to Me

Deep definition
Personalization in the context of referential delusion means that the brain’s “default” is:

If anything unusual happens, the atmosphere feels strange, or someone behaves in a certain way
→ the brain immediately interprets it as “this is a sign/communication about me.”

This is different from most people, who might sometimes casually think,
“Are they talking about me?” but after a moment can still think,
“Ah, probably not, I’m just imagining it.”

In a referential delusion:

There is no phase of “Yeah, I probably just overthought it.”

There is only “It definitely is” + “Everything fits together.”

Levels of severity (you can use these as descriptive examples)

Mild level (close to ideas of reference)

Feels that coworkers in the office laugh together right after they walk past, then thinks,
“They must be gossiping about me.”

There is still some self-talk like, “Or maybe I’m just overthinking it.”

Moderate level (clearly moving into delusional territory)

Sees a TikTok video and thinks, “This clip was posted at the exact moment I opened the app = they made it specifically for me.”

Walks past a group of strangers who turn and look once → “They stared at me because they know something about me.”

Severe level (strong delusional conviction)

Believes that “the TV show adjusts its script according to what I am thinking in my head.”

Believes that “the radio DJ receives signals from my brain and then responds to me via songs.”

Does not change their belief even when others repeatedly explain that it is a live show/pre-recorded long ago.

What is commonly seen in the clinic / in the field

Patients do not say,
“It’s like the show is talking about me, that’s kind of weird, right?” (curious tone)
Instead, they come with:
“Lately the TV has been talking about my situation all the time. They know. They’re watching me.”

If you ask, “How do they know?”
→ They start explaining about surveillance systems, cameras, powerful people, aliens, secret technology, etc.

2. Message Extraction — The Brain Is Always Looking for Hidden Messages

This is the “next step” after personalization.

Concept:
It’s not just feeling “they’re talking about me,” but moving to the belief that

“The world is full of hidden codes, and these codes are being used to communicate with me specifically.”

Examples of things they interpret as “codes/signals”

Songs

Certain song lyrics = direct messages to them
Song titles / the sequence of songs being played = codes

Advertisements/Billboards

Colors, words, numbers, logos = codes

Colors of people’s clothes

If someone wears red = a warning
If someone wears white = permission/safe

Likes/Emoji reactions

If someone likes their post at 3 a.m. = they are sending an important signal
Certain emojis = special keys, underground language

Car horns / bird calls / random sounds

These are not just sounds, but are seen as patterns of “signals,” e.g.

3 honks = yes, 1 honk = no

Mechanism from a cognitive perspective

The brain is functioning in “pattern detector on steroids” mode
= it sees patterns in everything and interprets them as intentional.

Instead of thinking “this is a coincidence” → it becomes “There is no such thing as coincidence in my world.”

Case examples for teaching/communication

A patient says:

“When I leave the house, if the first car that passes by is a black pickup truck, it means I must not go run my errands that day, because they already sent a warning signal.”

Or:

“Recently the YouTube ads have all been about safety and protection. That means someone is going to attack me. They are warning me to be careful.”

Or a “romantic-delusional” style:

“He posted that song on his story because he knows I’ll see it. It’s a message for me. He wants to talk but he can’t say it directly.”

3. Conviction & Incorrigibility — Firm Belief & Resistance to Change

This is the core feature that makes it a “delusion,” not just a suspicious thought.”

Key point:

They are not “wondering”
→ They are already convinced that this is the correct meaning.

When confronted with contradictory evidence → they do not change their mind but instead reinterpret the contradicting evidence to fit their existing theory.

Common verbal patterns you hear

Question: “How sure are you that those ads are really sending messages to you?”
Delusion-level answers:

“I’m 100% sure. There’s no way it’s just a coincidence.”

“You don’t understand. It’s designed so that normal people will think it’s just a regular ad, but actually they’re sending messages to me.”

If you present evidence such as:

The broadcast times are from a normal schedule

It’s the same ad that the entire country sees

→ The patient might respond:

“Of course. They have to make it look natural. If they make it obvious, other people will know they’re following me.”

4. Selective Attention / Salience — The Brain Highlights the Wrong Things

This ties in nicely with neurobiology because it connects to the idea of
“aberrant salience” = the brain assigning importance to the wrong stimuli.

In real life it looks like this:

Walking down a street with hundreds of people
→ but they remember precisely that one person in a yellow shirt who glanced at them for one second
→ and they think about that all day: “He must be one of the people monitoring me.”

Scrolling through a Facebook feed with hundreds of posts
→ they only remember one post that hits a nerve
→ then believe “This page must know about me; that’s why they posted that as a jab.”

Things that for most people = “noise”
→ For someone with a referential delusion = “signal” (and a very important signal at that).

5. Distress & Behavioral Change — Life Changes to Survive the “Signals”

If it were only a thought and nothing more, it would be hard to call it a delusion or a serious condition.
What makes it a real problem is that

the belief forces them to change how they live.

Common behavioral patterns

Avoidance

They stop watching TV, stop using social media, because they feel constantly referenced.

They don’t leave the house at certain times/places where they previously encountered “signals.”

Changing routes/life patterns

They avoid certain roads where they once saw a “signal car.”

They change phone numbers, change LINE accounts, move house because they believe “someone” is tracking them.

Tracking/responding to signals

They keep detailed logs of the times/locations of all “signals” as if investigating a case.

They try to respond: change their profile picture, post coded messages, wear special colors to “send messages back.”

The distress underneath

Even though some cases describe these experiences with excitement, as if they are the protagonist of a secret story, if you dig deeper you often find:

Stress, insomnia, anxiety, paranoia

Profound exhaustion because the brain never gets to rest from “interpreting signals”

This is where clinicians judge that
it has begun to be a “disorder,” not just a “thinking style” of that person.

6. Co-occurring Symptoms — The Bigger Picture

A referential delusion rarely comes alone; it often appears together with:

Persecutory delusion —
Starts from “they’re talking about me” → escalates to “they’re going to do something to me.”

Hallucinations (especially auditory) —
For example, hearing people talking about them or criticizing them → then connecting those voices with the “signals” around them.

Mood symptoms —
If in a manic phase: they may interpret it as “the universe is sending signals that I am special / have a mission.”
If in a depressive phase: “Everything is punishing/judging me.”

Disorganized thinking —
When delusions get strong and thinking becomes messy → the story they tell starts jumping around, connecting tiny patterns in a way that is hard for listeners to follow.

3. Diagnostic Criteria — Detailed Diagnostic Framework

This section actually has two big levels:

Level 1: First determine whether this is truly a “delusion” at all.

Level 2: If yes → then we must “attach it to a primary disorder” in DSM-5-TR / ICD-11.

Level 1 — From “Odd Thoughts” to Calling It a “Delusion of Reference”

When clinicians assess someone, they don’t start from the word “referential” at all.
They start from the broader concept “delusion”, then ask:
“What is the delusion about? What is the theme?”

Characteristics that must all be checked to call it a delusion:

Clearly false in relation to reality

Not just a slight overinterpretation
But a conclusion that severely departs from external evidence

Fixed conviction

The person does not easily change their mind
After many conversations, they still revert to the same belief

Incorrigible (resistant to evidence)

When new evidence comes in → they reinterpret it to fit the existing belief
There is no point at which they say, “Hmm, maybe there’s some reason to think it might not be the way I thought.”

Causes impairment/distress

Makes their life harder (work, relationships, self-care)
Or there is significant suffering/stress

Clear contrast: Delusion vs. Ideas of Reference

Ideas of reference:

The person feels that others might be talking about them.

But they can still think, “Maybe I’m just reading into it too much.”

Their belief still has some flexibility left (some reality testing remains).

Delusions of reference:

The person believes, “They definitely are talking about me.”

They insist at 100%.

They even change their life or go into fight/flight mode based on this belief.

When writing for the general public, you can use something like:

The key dividing line is: “Can you still argue with yourself?”
If you can still think, “Maybe I’m overthinking this,”
that usually falls under ideas of reference.
But once you reach a point of 100% certainty and your life starts changing because of this belief,
that’s the realm of delusion.

Level 2 — Linking a Referential Delusion to a Primary Disorder

This is very important for writing in a way that clinicians / psychologists / trainees can understand:

In DSM-5-TR / ICD-11 there is no disorder called “Referential Delusion.”
There are only various disorders where one of the symptoms is “delusions,”
and we then specify “theme: referential.”

Below is a framework you can practically use when writing.

2.1 Schizophrenia Spectrum & Related Disorders

This group includes several disorders such as Schizophrenia, Schizophreniform, Schizoaffective, Brief Psychotic Disorder, etc.

Core concept:

In all of these disorders, “delusions” are one of the core symptoms.

A referential delusion is just one of several possible “contents/themes” of a delusion.

For example:

Schizophrenia

Delusions are one of Criterion A.
There must be at least 2 major symptoms (delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behavior, negative symptoms).
Duration ≥ 6 months (including prodromal phase).

Schizophreniform Disorder

Symptoms are similar to schizophrenia.
Total duration: 1–6 months.

Brief Psychotic Disorder

Psychosis occurs acutely.
Short duration: at least 1 day but less than 1 month.
After the episode, the person returns to their baseline.

Schizoaffective Disorder

There are both psychotic symptoms (including referential delusions) and a full mood episode (mania/depression).
There must be a period of at least 2 weeks where psychotic symptoms are present without any mood episode.

When writing:

Emphasize that a referential delusion is part of the “content”.

The diagnostic criteria for the disorder rely on duration + the pattern of other symptoms + functional decline.

2.2 Delusional Disorder

Here, referential delusions are often intertwined with the persecutory subtype.

DSM-5-TR (overview):

At least one delusion is present.

Duration ≥ 1 month.

Overall functioning is relatively okay compared to schizophrenia.

There are no prominent hallucinations like in schizophrenia (if present, they are usually related to the delusional content).

Key points for referential delusions:

Some patients have a world that looks “almost normal in most areas.”

But their life is largely organized around the belief that “someone is sending signals/monitoring/referencing me.”

They can still work and have a social life, but there are “no-go zones,” rituals, or restrictions created by the delusion.

In an article, you could give an example like:

In persecutory-type Delusional Disorder, a patient may believe that neighbors or some organization are sending signals through wall-knocking, flickering lights, or coded social media posts in order to monitor or harass them, even though external evidence does not support this at all.

2.3 Mood Disorders with Psychotic Features

For example:

Major Depressive Episode with psychotic features

Bipolar I/II with psychotic features

Key idea for mapping:

There must be a clear major mood episode first (depression / mania / mixed).

Psychotic symptoms (such as referential delusions) will be:

Mood-congruent = content matches the mood

Depression: “Everyone is sending messages that I’m worthless, unworthy.”
Mania: “The universe is sending signals that I am great and have an important mission.”

Or mood-incongruent = content does not match the mood (also possible, but typically implies greater severity).

When writing, you can add a comparative line like:

If a referential delusion appears “on the background of a clearly altered mood”
and the intensity of cognitive distortion rises and falls in parallel with mood waves,
clinicians are more likely to think of mood disorder with psychotic features
rather than standalone schizophrenia.

2.4 Substance/Medication-Induced & Medical Condition

Substance/Medication-Induced Psychotic Disorder:

There is a history of substance/medication use that correlates with the onset of symptoms.

A referential delusion may appear alongside:

Hallucinations
High anxiety
Agitation, insomnia, etc.

Psychotic Disorder Due to Another Medical Condition:

There is a physical/neurological illness that can explain psychosis, such as:

Certain forms of epilepsy
Brain tumors
Certain metabolic/autoimmune conditions

How to explain this clearly to readers:

If a referential delusion begins suddenly in someone with no prior history,
especially at an age that is not typical for schizophrenia onset (e.g., starting at age 50–60 and above),
clinicians are particularly strict about checking for “substances/medications/medical conditions”
before concluding that it is a primary psychotic disorder.

2.5 The “Spectrum” Nature – Not Full Psychosis Yet, but Having Ideas of Reference

Another angle that can be placed in the Notes section:

In personality styles such as paranoid, schizotypal, or borderline,

Ideas of reference can be common.
For example, feeling that a friend’s story post is indirectly attacking them.
But they can still engage in discussion, still know “maybe I’m just overthinking it.”

What pushes someone “over the line” from personality → psychotic disorder is:

The belief becomes rigid (fixed).

There is clear distortion of reality.

There is increasingly severe impact on functioning/self-care.

For psychoeducation-style writing, you can summarize this segment clearly as:

Referential experiences exist along a spectrum—
from fleeting thoughts that you can still argue with yourself about,
all the way to full-blown delusions that you believe wholeheartedly and that genuinely change your life.
The stricter diagnostic criteria kick in as the belief becomes more rigid, lasts longer, and causes more disruption to daily functioning.

4. Subtypes or Specifiers — Related Subtypes/Specifiers

4.1 Degree of “Reference”: Ideas vs. Delusions

Ideas of reference: The person still “leaves room” for the possibility that it might not be about them (some reality testing remains).

Delusions of reference: Full belief, fixed, difficult to change. Encyclopedia+1

4.2 Theme progression (commonly seen in real-world practice)

Referential → Persecutory (starting from feeling referenced → turning into feeling threatened/attacked).

Referential → Grandiose/Religious (signals = special mission/being chosen).

4.3 Specifiers at the level of disorders (not specific to referential content itself)

In Delusional Disorder (DSM-5-TR) there is a specifier for “with bizarre content” (even though the disorder itself is no longer restricted to nonbizarre content since DSM-5). Rama Mahidol University+1

In other disorders there are specifiers for episode type, severity, mood-congruence, catatonia, etc., which must follow the criteria of each disorder.

5. Brain & Neurobiology — Why Does the Brain Interpret the Whole World as “About Me”?

The big picture first:
Referential delusions are not just “overthinking” or “thinking too much,” but rather the result of abnormalities in multiple brain circuits that cause three major systems to malfunction at the same time:

The system that assigns importance to stimuli (salience) is distorted → ordinary things get highlighted as major events.

The system that predicts the world and updates beliefs (prediction error / predictive coding) malfunctions → the person learns the wrong patterns.

The system for perceiving self and others (self & social brain) is skewed → everything gets pulled back to “me.”

We’ll go through these layer by layer.

5.1 Aberrant Salience — The Brain “Highlights” Things That Shouldn’t Stand Out

One of the most commonly used concepts to explain psychosis is “aberrant salience.”

Normally, the brain has to do two things all the time:

Decide what is important and deserves attention.

Decide what is just background noise and can be ignored.

In someone with referential delusions, it’s as if this system has been twisted:

Things that should be “noise” (like songs playing in the background, YouTube ads, the color of a passerby’s shirt)
get flagged as “important signals,” and the brain fixates on them.

What does this have to do with dopamine?

The dopamine system, especially the mesolimbic pathway (from the midbrain to the striatum),
plays a role in determining “this is interesting, important, and worth learning about.”

In psychosis, we often say in simple terms that dopamine is firing randomly, causing the interpretation system to perceive that “everything has meaning, omens, and signals.”

Once everything feels “meaningful,” the brain starts “story-building” to explain:

Why this song has to come on at this exact moment.

Why this billboard has to be here.

Why this group of people looked at me all at once.

And when these stories “fit together neatly” in the person’s mind → it becomes a full delusional system.

5.2 Prediction Error & the Brain as a Bayesian Machine — The Brain Thinks It Predicts Well, but It’s Wrong

Another model views the brain as a “world-prediction machine”:

The brain has “models of the world” (beliefs/priors) already in place.

Every time new information (sensory input) arrives, it calculates:

If it matches expectations → ok, pass.
If it does not match → it sends “prediction error” signals to update the belief.

In psychosis/referential delusions, there are two major problems:

1. The brain sends prediction error signals to the wrong things.

Things that should be considered “coincidental” are interpreted as “out of the ordinary.”
It is like the brain is constantly saying, “Hey, this is unexpected, you must pay attention.”

2. Or it assigns the wrong weight to new information.

It takes very small events and magnifies their importance.
It uses extremely minor events to flip major beliefs, for example:

One car honks at them → “They know I’m being followed.”

Real-life consequences:

A normal TikTok clip → becomes “evidence” that someone is sending them messages.

A single banner ad → becomes “evidence” that an organization is watching them.

A social media timeline that happens to match their current emotional state → “The universe is responding to what I’m thinking.”

When the prediction error system is off → the brain can “learn false beliefs” very quickly and hold onto them very strongly.

5.3 Salience Network, Default Mode Network, Executive Network — Three Major Circuits Playing the Wrong Roles

On the network level:

Salience Network (SN)

Led by the anterior insula and dorsal anterior cingulate cortex (dACC).
Function: scan for importance, switch the brain from “rest” to “engage mode.”

Default Mode Network (DMN)

Includes medial prefrontal cortex, posterior cingulate cortex, precuneus, etc.
Functions:

Self-referential thinking (thinking about oneself)
Daydreaming, retrieving memories, thinking “What do others think of me?”

Central Executive Network (CEN)

Typically involving dorsolateral prefrontal cortex, etc.
Function: rational thinking, planning, cognitive control.

In psychosis:

The SN misfires → it raises “red flags” at the wrong events.

The DMN gets pulled in too much → everything gets interpreted through the lens of “about me.”

The CEN is weakened → critical thinking and belief-checking (reality testing) are impaired.

A simple picture:

SN = “Hey, this is important!”

DMN = “So how does this relate to me?”

CEN = “Wait, calm down, maybe it doesn’t.”

In referential delusions:

SN is hyperactive → flags everything.

DMN picks it up → “Of course it relates to me in this and that way…”

CEN is too weak to object → the belief races ahead at full speed.

5.4 Glutamate, GABA, and E/I Balance — The Brain Loses Its “Accelerator–Brake” Balance

Beyond dopamine, modern work emphasizes that the balance between Glutamate (excitatory) and GABA (inhibitory) is crucial:

If neural excitation is too high,

some networks may “run wild” easily,
leading to unusual pattern connections.

If inhibitory control (GABAergic inhibition) is too low,
→ thoughts that should be “stopped” because they are odd or nonsensical

end up entering the core belief networks.

Relating this to referential delusions:

The brain is firing pattern recognition processes rapidly.

But it lacks the filtering system that says “this should be discarded as mental noise.”

As a result, “strange belief networks” arise and survive, taking over mental space.

5.5 Developmental & Synaptic Pruning — Adolescent Brains That Prune at the Wrong Time

Many theories about the schizophrenia spectrum mention:

Excessive synaptic pruning in late adolescence,

Or abnormal organization of connectivity from early developmental phases.

The result that appears in the early 20s and beyond is:

Networks that control self–other boundaries, social cognition, and salience

do not function in a well-coordinated way.

For referential delusions, this paints a picture of a brain where:

The boundary between the external world and the internal self becomes blurred:

Things that should “remain outside” → leak into the self-story.
External sounds/signals/events → are incorporated into a narrative that “they are talking about me.”

5.6 Social Brain, Theory of Mind & Misreading Other People’s Intentions

Referential delusions are constantly entangled with “what they think/say about me.”
This involves regions like:

The temporo-parietal junction (TPJ)
The medial prefrontal cortex
The superior temporal sulcus, etc.

These areas are involved in:

Reading facial expressions
Inferring what others are thinking
Interpreting social cues

When this system is distorted:

Other people merely laugh → interpreted as “they are laughing at me.”
Someone simply looking their way → “They know. They’re following me.”
A vague post → “They are absolutely talking about me.”

Simply put:

The social brain, which is normally designed to be “sensitive to social signals for survival,”
gets its sensitivity over-amplified, leading to over-reading every intention,
and the default becomes “it must be about me.”

6. Causes & Risk Factors — Why Do Some People End Up with Referential Delusions?

The easiest way to think about this is a “multi-hit model”:
There is no single factor that makes a person “become ill.”
Rather, it is the stacking of three layers:

Biological and genetic baseline (biological vulnerability)
Personality, thinking style, and life experiences (psychological factors)
Current environment and context (social/environmental triggers)

Referential delusions tend to appear at the point where all three layers press down at once.

6.1 Biological / Genetic Vulnerability — A More Fragile Brain Baseline

1. Genetics and family risk

Having family members with schizophrenia spectrum disorders, bipolar with psychosis, or other psychotic disorders → increases risk.

It is not “one gene causes the illness,” but a polygenic risk = many small genetic factors + interaction with environment.

2. Neurodevelopmental factors

Events from pre-birth to birth to early childhood, such as:

Infections/lack of oxygen during birth

Severe malnutrition in utero

Childhood brain injuries

These do not make someone “sick” immediately, but they:

Leave certain brain networks starting off more fragile.

When later exposed to triggers (stress/substances/sleep deprivation) in ages 18–30 → the system begins to go off track.

3. Dopamine system sensitivity

Some people have a baseline where:

Their dopamine system responds more strongly to stressors or stimulants than others.

This makes it easier to enter a state of aberrant salience → they begin to see “patterns/signals” in the world more readily than others.

6.2 Psychological Factors — Thinking Styles and Personality That Pave the Way for Referential Beliefs

Not everyone with biological vulnerability will go on to develop delusions.
“How they think and manage their inner world” matters greatly.

1. Hypervigilance & anxiety — Constant scanning for threats

People with high baseline anxiety, especially paranoid or social anxiety styles:

Their brain’s default mode = “assume danger first.”
They interpret every situation through the lens of “What do they think about me? Are they judging me?”

When combined with aberrant salience:

Small events that get highlighted → are analyzed all day.
The more they analyze, the more convinced they become that hidden intentions exist.
Over time, what started as “They probably don’t like me” → shifts into “They must be sending signals/trying to harm me.”

2. Core beliefs: low self-esteem, world as unsafe

If the deep core beliefs are something like:

“I am worthless / no one is sincere with me.”
“The world is dangerous / people always have hidden agendas.”

Then when salience becomes distorted:

9 out of 10 added meanings the brain constructs will be colored by threat, judgment, and being watched.

Such individuals are at higher risk of landing on themes like:

Referential + persecutory (“They talk about me because they intentionally want to mock/judge/harm me”).

3. Cognitive biases — Thinking styles that allow delusions to survive

Commonly seen in psychosis:

Jumping to conclusions (JTC)

Drawing firm conclusions from minimal data.
Example: seeing one vague post → concluding it is about them.

Attribution bias

Tendency to blame others/external forces more than seeing events as random or ordinary.

Confirmation bias

Once they believe, they select only evidence that supports the belief.
Contradictory evidence → reinterpreted to fit the original theory.

In referential delusions:

Every “coincidence” that supports the belief is archived as evidence.

Any “evidence that the world doesn’t care that much about us” is ignored or rationalized away.

6.3 Trauma, Attachment, and Life Experiences

Traumatic experiences, especially in relationships and experiences of harm/neglect, play a major role.

1. Childhood trauma / bullying

Growing up in an environment where one “always has to watch what others are thinking or planning to do”

Being bullied, gossiped about behind one’s back, or set up
→ The brain learns that “being talked about behind one’s back” is a real and familiar part of life.

When entering a period where the brain is fragile + aberrant salience appears →
interpreting “everything as talking about me” then feels reasonable within their personal world.

2. Insecure attachment

Growing up with caregivers who are sometimes caring and sometimes absent or volatile:

The child must constantly guess others’ moods.
→ The social brain gets trained in “intense scanning of intentions” from early on.

As adults:

When facing ambiguous social signals → their brain’s default is “they must be sending some message to me” more easily.

6.4 Social & Environmental Triggers

1. Severe stress (major life stress)

Examples:

Job loss, divorce, loss of loved ones
Relocation, major life changes

Severe stress + little sleep + dopamine/stress hormones firing →
can ignite a psychotic episode whose theme is referential.

2. Urbanicity / living in big cities, social overload

In large cities:

There are massive amounts of stimuli: signs, people, noise, ads, online feeds.
If the brain is already in aberrant salience mode → the city becomes a “paradise of signals.”

Every sign, every gaze, every notification becomes raw material for constructing referential delusions.

3. Social isolation — spending too much time alone

Being alone, thinking, scrolling feeds
→ There is no one to help “ground” reality.

If every day consists only of your own internal voice + patterns you see in the world,
→ distorted beliefs can grow with little external feedback.

6.5 Substance Use & Sleep — Accelerators That Open the Door to Psychosis

1. Substances

High-potency cannabis, methamphetamine, cocaine, hallucinogens, etc.:

Stimulate the dopamine system and alter perception.

Cause salience and prediction error waves to deviate from normal patterns.

For some individuals:

They only use during stressful/insomniac periods.

But if the brain is already vulnerable → just a few uses may be enough to open the door to the first psychotic episode.

Referential delusions under the influence of substances + stress = a classic combo:

Music/TV/phones → become “the universe is speaking directly to me.”

2. Sleep deprivation — Not sleeping enough until the brain can’t tell what’s real

Several nights of poor sleep → attention is distorted, reality testing drops.

In already vulnerable individuals:

Images, sounds, intrusive thoughts → are immediately interpreted as “signals.”

The filter between “thoughts in my head” and “things coming from the outside world” begins to merge.

6.6 Cultural & Contextual Factors — Culture Shapes the “Tone” of the Belief

The themes of referential delusions often reflect the era/society:

In earlier eras: radio voices, TV programs, newspapers.

Now: YouTube, TikTok, live streams, algorithmic feeds, DMs, read receipts.

Key point:

We must distinguish between “shared cultural/religious beliefs” and idiosyncratic delusions.

If a belief is widely shared by most people in a community → it is not a delusion.

But if it is a highly personal belief, clearly outside cultural norms, rigid, and life-destroying → then it is a delusion.

6.7 Why Do Some People Have Psychosis But Not Much in the Way of Referential Delusions?

For deeper writing:

The themes of delusions depend on:

Personality and life experience (e.g., whether one has truly been surveilled, bullied, etc.).
Core beliefs (feeling worthless vs. grandiose vs. unsure of existence).
Culture (country/media/politics).

If a person’s life story revolves around:

Being watched

Being talked about behind their back

Feeling that they are “always at the center of others’ gaze”

→ The likelihood that their psychotic episodes will manifest with referential + persecutory themes is high.

Others might instead develop themes that are:

Religious/grandiose (God sending messages, special missions)

Somatic (believing something is wrong with their body)

Nihilistic, etc.

It depends on the narrative their brain has used throughout their life.

7. Treatment & Management — Treatment and Management

7.1 .Assess risk first (safety triage)

If there is risk of harm to self/others, refusal to eat or sleep for several days, severe agitation, or a belief that they must “do something because of the signals,” → they should see a doctor urgently/emergently (because some types of referential delusions can effectively “issue behavioral commands”).

7.2 Pharmacotherapy (core approach when psychosis reaches delusional level)

From the aberrant salience perspective, antipsychotic medication helps “reduce abnormal salience,” creating an opening for beliefs to gradually loosen. PubMed

Antipsychotics (chosen based on co-occurring symptoms/side effects/comorbidities).

If mania/depression is prominent → treat the mood episode as well (mood stabilizer/antidepressant as indicated).

7.3 Psychotherapy (very important, especially for reducing distress and loosening belief conviction)

CBTp (CBT for psychosis): The goal is not to argue “this isn’t real” head-on, but to work with:

Gradual belief testing.
Reducing safety behaviors (e.g., avoidance/checking/stalking/re-interpreting signals).
Managing worry/anxiety and attentional styles that are locked onto “signals.”

Sleep/stress interventions: restoring sleep is critical because sleep deprivation easily distorts salience (in practice this helps far more than many people realize).

7.4 Family & environmental interventions

Psychoeducation for families: reduce direct confrontation, communicate in ways that do not make the person defensive.

Reduce substance use/alcohol, structure daily life, and re-engage socially little by little.

7.5 Principles for communicating with someone experiencing these beliefs (actually useful)

Avoid blunt statements like “You’re imagining it / it’s not real.”

Use the frame: validate the feeling, without confirming the belief.

“That sounds really frightening; I understand you feel targeted.” (validate emotion)
“Can we look at the evidence/other possibilities together?” (invite alternative explanations)

Ask about impact: “What does this make you do/avoid?” in order to plan how to reduce impairment.

8. Notes — Key Points & Differential Diagnosis

8.1 Delusion of reference vs. Social anxiety

Social anxiety: fear of being observed/judged, but the person still knows this is fear and can accept the possibility that they are overthinking.

Delusion of reference: belief that there is genuine communication aimed at them, held with strong conviction.

8.2 Delusion of reference vs. Overvalued idea / rumination

Overvalued idea: a strong belief that can still be discussed and that usually has “some partial correspondence with reality.”

Delusion: a clearly false belief + fixed.

8.3 Cultural/religious context

Some beliefs about “signals” can exist within cultural/religious frameworks. But they become “delusions” when they clearly fall outside cultural norms + are rigid + significantly impair functioning/cause severe distress.

8.4 Warning signs that the condition is “escalating”

From “they’re talking about me” → “they are going to harm me” (beginning of persecutory delusions).

From “there are signs” → “I must carry out a mission / I have been chosen” (beginning of grandiose/religious delusions).

Several days without sleep + overwhelming sense of meaning in everything + high anxiety = high-risk situation.

Read Schizophrenia

Reference (suggested for endnotes)

PsychDB. Delusions and Hallucinations – Delusions of Reference. (accessed 2025). Explains the meaning of delusions of reference as the belief that random events have personal significance to the patient and situates them within psychotic disorders. PsychDB
Wikipedia. Ideas and delusions of reference. (updated 2025). Summarizes the concepts of ideas vs. delusions of reference, noting that they involve perceiving harmless events as highly personally meaningful and that they form part of the diagnostic criteria for psychotic illnesses such as schizophrenia, delusional disorder, schizoaffective disorder, and bipolar mania. Wikipedia
BetterHelp / Verywell Mind style clinical summary. Ideas of Reference vs. Delusions of Reference. Explains Jaspers’ criteria for delusions (certainty, incorrigibility, impossibility) and distinguishes ideas of reference, which still retain some insight, from delusions of reference, which are fixed false beliefs despite contrary evidence. Verywell Mind+1
Encyclopedia / academic entry. Ideas of Reference and Delusions of Reference. Clearly states that ideas of reference must be distinguished from delusions of reference by the level of conviction and preserved insight; patients with ideas of reference can still accept that others may not be talking about them. Encyclopedia+1
Wong GHY et al. Screening and assessing ideas and delusions of reference in psychiatric populations. (Schizophrenia Research, 2012). Proposes that IOR/DOR represent a “spurious sense of self-reference” and are a core component of psychopathology in psychosis, with guidelines for assessment. ScienceDirect
Kapur S. Psychosis as a State of Aberrant Salience: A Framework Linking Biology, Phenomenology, and Pharmacology in Schizophrenia. Am J Psychiatry. 2003;160(1):13–23. Proposes the aberrant salience model, stating that delusions are attempts to make sense of experiences that have been assigned “abnormal salience.” PubMed+2 Psychiatry Online+2
Gaebel W. Status of Psychotic Disorders in ICD-11. (2012). Describes the grouping of psychotic disorders in ICD-11 and the structure of the Delusional Disorder category, which includes delusions of reference among the delusional contents to be assessed. PMC+1
ICD-11 (WHO). 6A24 Delusional disorder – Clinical descriptions and diagnostic requirements. Emphasizes that this involves one or more persistent delusions for ≥3 months, with content that may include persecutory, referential, grandiose themes, etc., while other capacities remain relatively preserved. Find-A-Code+1
StatPearls. Schizotypal Personality Disorder. Notes that “ideas of reference (excluding delusions of reference)” are one of the diagnostic criteria for SPD, clearly marking the boundary between personality-level phenomena that still retain insight and full psychotic delusions. ncbi.nlm.nih.gov
Grokipedia / review on Substance-Induced Psychosis. Summarizes that psychosis due to stimulants such as amphetamine/methamphetamine often features persecutory ideation and delusions of reference because of intense dopaminergic stimulation. Grokipedia

referential delusions, delusions of reference, ideas of reference, self-referential thinking, spurious self-reference, aberrant salience, psychosis symptoms, schizophrenia spectrum, delusional disorder, schizoaffective disorder, bipolar psychosis, mood-congruent psychosis, persecutory delusions, grandiose delusions, psychotic features, reality testing, conviction and incorrigibility, Jaspers criteria, ICD-11 delusional disorder, DSM-5-TR psychotic disorders, social cognition, theory of mind, paranoia vs psychosis, early warning signs psychosis, self-referential bias, meaning-making in psychosis, hallucinations and delusions, CBT for psychosis, antipsychotic treatment

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