Two people sitting a few tables away start laughing just as you walk into a café. A television presenter says something that seems strangely relevant to what you were thinking about moments earlier. The same distinctive number keeps appearing throughout the day. A post shows up on social media that feels almost like a direct response to your thoughts. Most of the time, we dismiss experiences like these as coincidence, selective attention or, in the case of online content, the result of algorithms. In delusions of reference, however, ordinary and neutral events can take on a highly personal meaning. A person may become convinced that these events are specifically connected to them.
Delusions of reference are a type of psychotic symptom. A person may believe that strangers in the street are deliberately looking at them, that other people’s conversations are actually about their life, or that a song on the radio has been played specifically to send them a message. They may feel that a television presenter is communicating with them through particular words or gestures. In other cases, colours, numbers, licence plates, overheard conversations or the behaviour of complete strangers may take on a special significance. Delusions of reference are one of several types of delusions that can occur in psychotic disorders, including schizophrenia.
However, occasionally thinking “Are they talking about me?” does not necessarily indicate psychosis. Anyone can misinterpret another person’s glance, feel watched in a stressful situation or briefly wonder whether an unusual coincidence means something. In psychiatric assessment, what matters is how strongly the person believes the interpretation, how persistent the belief is, whether they are able to consider alternative explanations, and how much it affects their behaviour and everyday life.
An important distinction can be made between ideas of reference and delusions of reference. Someone experiencing an idea of reference might think, “Those people might be laughing at me,” while still being able to consider another explanation, such as, “Maybe it just feels that way.” With a fully developed delusion, the belief becomes much stronger and far more difficult to question. The person may be certain that the conversation really is about them. New events may then be interpreted as further evidence confirming what they already believe.
Delusions do not always appear suddenly as fully formed beliefs. For some people, there may first be a difficult-to-describe sense that the world around them has somehow changed. Ordinary events begin to attract more attention than before. A random gesture seems unusually significant. Another coincidence feels meaningful. The person may not yet understand what is happening, but they begin to feel that seemingly unrelated events are somehow connected. This does not happen in every case, but it illustrates an important point: the development of delusions can be a gradual process rather than a single moment.
One influential explanation is the concept of aberrant salience. In simple terms, it refers to assigning unusual or excessive significance to stimuli that would normally be considered neutral. The brain is constantly deciding which of the thousands of pieces of information reaching us are important. This allows us to ignore most irrelevant sounds, images and events while quickly noticing something that might signal danger, reward or the need to act.
During psychosis, the mechanisms involved in determining what is important may function differently. A neutral event can suddenly feel exceptionally significant. If this happens repeatedly, the person may naturally try to make sense of these experiences. Over time, a delusional explanation may develop. The concept of aberrant salience has had a major influence on research into psychosis. However, current evidence suggests that it is only one part of a much more complex process involved in the development of delusions.
Dopamine is also important in understanding psychosis. Its role is well established, but the common idea that schizophrenia is simply caused by “too much dopamine in the brain” is an oversimplification. The dopamine system is involved in learning, motivation, prediction and the way the brain updates the significance of new information. Modern research therefore focuses not only on dopamine levels, but also on how altered dopamine signalling may affect the way people form and update beliefs. A critical review published in the American Journal of Psychiatry in 2025 highlighted the need for a broader understanding of the relationship between dopamine, salience and the formation of delusions.
Researchers have also examined differences in the way information is processed. Some people with psychosis show a stronger tendency towards what researchers call “jumping to conclusions”. This means reaching a conclusion after receiving relatively little information. Other areas of research include difficulties in identifying the source of an experience and a reduced tendency to revise beliefs when presented with information that contradicts them. A large systematic review published in 2024, which included 324 studies, found associations between several cognitive biases and the schizophrenia spectrum. At the same time, these patterns were not present to the same extent in every patient.
Delusions of reference are a symptom rather than a separate diagnosis, and experiencing them does not automatically mean that someone has schizophrenia. They can occur in a range of psychotic disorders, but may also appear during a manic episode or a severe depressive episode with psychotic symptoms. Assessment should also take into account psychoactive substance use, medications and possible physical or neurological causes. Particular attention is needed when symptoms appear suddenly or for the first time, especially if they are accompanied by changes in consciousness, neurological symptoms or a marked deterioration in the person’s usual level of functioning. ICD-11 distinguishes primary psychotic disorders from other conditions in which psychosis can occur. For this reason, diagnosis requires assessment of the person’s overall clinical picture rather than focusing on a single symptom.
Modern technology has introduced new situations around which delusions of reference can develop. In the past, someone might have believed that a newspaper, radio station or television programme was sending them a special message. Today, similar beliefs may involve social media posts, recommended videos, online advertisements, smartphone notifications or search results. This can be particularly confusing because algorithms genuinely do personalise the content people see. Seeing an advertisement for a product you recently searched for is therefore not unusual. A persistent belief that a platform is deliberately publishing content to send one particular person coded messages, warnings or instructions, however, may require professional assessment.
These experiences can be extremely difficult for family members and friends to understand. A natural response may be to argue with the person: “Those people don’t even know you,” or “It’s just a television programme. It can’t be talking to you.” Strong confrontation is usually not the most helpful approach. At the same time, it is important not to reinforce the delusion by agreeing that the person really is being watched or receiving secret messages. You can acknowledge the person’s emotions without confirming the belief itself. For example, you might recognise that the experience sounds frightening or stressful and encourage them to speak with a mental health professional.
Early assessment is particularly important when symptoms of possible psychosis appear for the first time. If someone who has never had similar experiences becomes convinced that they are being watched, that other people are sending them hidden signals or that the media are communicating directly with them, professional assessment is advisable. The need for assessment becomes even more urgent if these experiences are accompanied by a significant decline in everyday functioning, severe agitation, disorganised behaviour, hallucinations or major sleep disturbance. NICE recommends specialist assessment without unnecessary delay for people showing symptoms suggestive of possible psychosis. People experiencing a first episode of psychosis should also have access to early intervention services. The relevant NICE guidance was reviewed again in July 2025, and no update was considered necessary at that time.
Treatment depends on the underlying cause, diagnosis and severity of the symptoms. A first episode of psychosis requires a thorough psychiatric assessment. This includes reviewing medications and psychoactive substance use, assessing physical health and evaluating the person’s safety. When psychosis is diagnosed, treatment may include antipsychotic medication and psychological interventions. For a first episode of psychosis, NICE recommends antipsychotic medication together with individual cognitive behavioural therapy and family intervention.
Psychotherapy for psychosis does not consist of repeatedly telling someone that “it’s all in their head” or trying to force them to admit that their experiences are not real. Cognitive behavioural therapy can help a person examine how they interpret their experiences, understand the relationship between thoughts, emotions and behaviour, and consider alternative explanations for what is happening. Therapy can also help reduce the distress caused by symptoms and improve everyday functioning.
Delusions of reference demonstrate how much our experience of the world depends on interpretation. The brain does not simply record reality like a camera. It constantly selects information, compares it with previous experiences, predicts what may happen next and decides what deserves our attention. When these processes become disrupted, an ordinary glance from a stranger, a car registration number or a sentence spoken on television may suddenly feel intensely personal and meaningful. For someone experiencing psychosis, these experiences can feel completely real. They require professional assessment and appropriate treatment rather than ridicule or simply trying to “talk some sense” into the person.
Patient FAQ:
Can someone experiencing delusions seek help from a psychiatrist on their own?
Yes. Some people retain at least partial insight and recognise that the way they perceive or interpret their surroundings has changed. Anxiety, insomnia, difficulty concentrating or increasing mistrust may also lead someone to seek medical help.
Can delusions develop for the first time in an adult with no previous psychiatric history?
Yes. A first episode of psychosis can occur in someone who has never previously been diagnosed with a psychiatric disorder. However, symptoms that begin particularly late in life or develop suddenly require careful assessment. Physical and neurological conditions, medications and psychoactive substances should also be considered as possible causes.
Do people remember their delusions after psychosis has resolved?
In many cases, yes. A person may remember what they experienced during psychosis, although the way they interpret those experiences may change once the symptoms improve. After regaining insight, some people recognise that their previous beliefs were symptoms of an illness.
Can delusions involve believing that a partner is unfaithful?
Yes. Delusions of jealousy involve a strong conviction that a partner is being unfaithful despite insufficient evidence. They may lead to repeatedly checking the partner’s phone, following them or interpreting ordinary behaviour as evidence of infidelity. These symptoms also require assessment of any potential risk of aggression.
Are delusions more common in men or women?
Delusions can occur in both men and women. In schizophrenia, the risk of developing the disorder is slightly higher in men, and symptoms generally begin earlier in men than in women.
References:
World Health Organization. Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders. Geneva: WHO; 2024.
Corlett PR, Fraser KM. 20 Years of Aberrant Salience in Psychosis: What Have We Learned? American Journal of Psychiatry. 2025;182(9):819–829. doi:10.1176/appi.ajp.20240556.
Gawęda Ł, Kowalski J, Aleksandrowicz A, et al. A systematic review of performance-based assessment studies on cognitive biases in schizophrenia spectrum psychoses and clinical high-risk states: A summary of 40 years of research. Clinical Psychology Review. 2024;108:102391. doi:10.1016/j.cpr.2024.102391.
Kapur S. Psychosis as a state of aberrant salience: a framework linking biology, phenomenology, and pharmacology in schizophrenia. American Journal of Psychiatry. 2003;160(1):13–23. doi:10.1176/appi.ajp.160.1.13.
National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management (CG178). NICE; 2014, reviewed July 2025.
