Describing Psychotic Experiences Through Online Psychosis Screens: A Content Analysis

BACKGROUND: Psychotic experiences are commonly reported in population-based surveys, yet brief self-report screening instruments often yield high false-positive rates by capturing normative, culturally sanctioned, or other non-psychotic phenomena. Large surveys and administrative datasets increasingly include free-text responses that could contextualize these endorsements; however, qualitative data are under-analyzed due to resource constraints. METHODS: Using data from a US adult online survey, respondents who endorsed at least one item on the abbreviated World Health Organization Composite International Diagnostic Interview (WHO CIDI) psychosis screen were asked whether they could describe their experiences in an open-ended format. Using reflexive thematic analysis, three coders developed codes that were grouped into categories, and ultimately classified responses as probably psychotic, probably not psychotic, or unclear. RESULTS: Content analysis identified 13 thematic categories, including hallucinations, paranoia, emotional distress, interpersonal conflict, spiritual or paranormal beliefs, sleep-related experiences, and unintelligible responses. Nearly half of the responses were classified as unlikely to reflect psychotic experiences, while approximately 9% were deemed probably psychotic and 41% remained unclear due to insufficient context. Many responses reflected affective distress, stress-related interpretations, grief, or ambiguous experiences rather than clear psychotic phenomena. Descriptions capturing distress, functional impact, and insight were clinically informative but were inconsistently reported. CONCLUSIONS: Brief qualitative descriptions accompanying psychosis screening items provide valuable context that can clarify whether psychotic experiences reflect clinically meaningful psychotic phenomena or normative experiences. Integrating qualitative free-response fields may improve the interpretability and precision of psychosis screening, inform early detection efforts, and reduce the risk of over-pathologization.