Ideas of Reference
The psychiatric term for a patient who believes their actions have a negative effect on others is "ideas of reference" or, when more severe and fixed, "delusions of reference." 1
Core Concept
Ideas of reference describe the belief that external events, objects, or other people's behaviors have particular and unusual significance specifically related to oneself. 1 When a patient believes their actions negatively impact others in ways that are not objectively occurring, this represents a self-referential distortion of causality.
Severity Spectrum
The phenomenon exists on a continuum of insight and conviction:
Ideas of reference with intact insight: The patient recognizes these beliefs are probably not true or may not be true, maintaining some capacity for reality testing 1
Delusions of reference with poor insight: The patient thinks these beliefs are probably true, with diminished capacity to question the conviction 1
Delusions of reference with absent insight/delusional beliefs: The patient is completely convinced these beliefs are true, representing fixed false beliefs that are discordant with reality 2, 3
Differential Diagnosis Considerations
This presentation must be distinguished from several other conditions:
Obsessive-Compulsive Disorder: In OCD, the patient experiences intrusive, unwanted thoughts (ego-dystonic) about causing harm that provoke marked anxiety, with the individual attempting to neutralize these thoughts through compulsions 1, 4. The key distinction is that OCD patients recognize these thoughts as excessive or unreasonable, whereas patients with delusions of reference lack this insight 4
Depressive delusions: In psychotic depression (F32.3), guilt-related delusions may include beliefs about causing harm to others, but these are limited to the primordial themes of guilt, impoverishment, and hypochondria 5
Delusional disorder: When the belief about negatively affecting others is nonbizarre (conceivably possible in real life), persists for at least 1 month, and occurs without other significant psychopathology, delusional disorder should be considered 2
Clinical Assessment Approach
Directly assess the patient's level of conviction and distress by asking: "Do you believe with certainty that your actions are harming others, or do you have doubts about this?" and "Can you provide specific examples of how you know your actions caused these negative effects?" 4 The patient's response reveals whether this represents an idea versus a delusion, and the degree of insight present.
Evaluate for accompanying symptoms that would suggest a primary psychotic disorder (hallucinations, disorganized thinking), mood disorder (depressive or manic symptoms), or OCD (compulsions performed to neutralize the feared harm). 1, 2