How to approach psychotic symptoms in a non-specialist settingBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4752 (Published 08 November 2017) Cite this as: BMJ 2017;359:j4752
- Musa Basseer Sami, MRC clinical research training fellow, honorary specialist registrar1 2,
- David Shiers, former GP, honorary reader in early psychosis3,
- Saqib Latif, clinical lead and consultant child and adolescent psychiatrist4,
- Sagnik Bhattacharyya, reader in translational neuroscience and psychiatry, consultant psychiatrist1 5
- 1Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
- 2South London and Maudsley NHS Foundation Trust, London
- 3Manchester University, Manchester, UK
- 4Kent and Medway Children & Young People Services, Sussex Partnership NHS Foundation Trust, Broadstairs, UK
- 5Lambeth Early Onset Inpatient Unit, Lambeth Hospital South London and Maudsley NHS Foundation Trust, London
- Correspondence to: M B Sami ; S Bhattacharyya
What you need to know
Listen carefully to the patient: frank psychotic symptoms (positive or negative) may not be apparent initially—be alert to sub-threshold symptoms such as problems with mood or sleep; alteration in personality, and functional decline
Take family concerns seriously and actively seek from them relevant information (or from school or university, as appropriate)
Accompaniment by family or carers at appointments can be particularly helpful, but ask your patient whether they also want to be seen alone during the appointment
Identification of psychotic symptoms in non-specialist settings is key to initiating timely pathways to care. A systematic review of 30 observational studies of pathways to care of first-episode psychosis showed that first contact was more usually through a physician than through emergency services.1 This article is aimed at generalists, primary care physicians, and hospital doctors, who play a critical role and who require a low threshold for referral for specialist assessment, sometimes before diagnosis is certain.2
Prompt intervention is key to improving outcome. However, patients rarely present complaining of hallucinations or delusions. Concerns that something is not quite right may first be raised to the generalist by family members, friends, neighbours, and school teachers.1
When to consider emerging psychosis
In very early stages, perceptual abnormalities and thought disorder may not be apparent, nor delusions well formed. Features may include:
Anxiety, irritability, or depressive features
Unexplained decline in academic or vocational performance3
Incoherent or unusual speech
New or unusual preoccupation with mystical or religious themes
Concerns with hacking through internet or smartphones
How to approach psychotic symptoms:
An overview of symptoms is shown in figure 2⇓. Psychosis maybe preceded by subtle changes in functioning and gathering intensity of distress. Be wary of dismissing unclear presentations as teenage angst or drug misuse. In the midst of diagnostic uncertainty, primary care providers can build rapport through repeat consultations.
Symptoms of anxiety or depression may precede psychosis and should not be assumed as the definitive diagnosis without prompting further exploration for psychotic symptoms. Positive symptoms may not be volunteered. Be prepared to actively seek out symptoms (see box 1). Sometimes these may only be inferred from behaviour.
Box 1: Specific questions to elicit psychotic symptoms and history
Starting the conversation
“It seems that there is quite a lot that is on your mind; I’d like to ask you a bit more about that and in particular about any worrying thoughts you might be having. Is that OK?
Eliciting psychotic symptoms
Have you been feeling that people are talking about you, watching you, or giving you a hard time for no reason?
Have you been feeling, seeing, or hearing things that others cannot?
Have you been spending more time alone?3
Have stressful or traumatic experiences affected you recently or in the past?
Is there any history in yourself or your family of mental health concerns?
Have you used any alcohol or other drugs recently?
Cultural background may also influence the experience of psychosis: in one UK observational study (n=123), Asian patients more commonly attributed psychosis to supernatural experiences than did white or black patients.7
Key features to elicit
Seek evidence of positive symptoms:
Hallucinations—Identify modality (commonly auditory) and content. Which features differentiate the hallucination from reality (for example, do others share the experience; are the voices attributed to people living at a distance)? Sometimes hallucinations may be suspected by observing the patient in conversation or gesturing or responding emotionally. Ask the patient what they are experiencing.
Delusions—Ask the patient about their belief and the basis for it. Is it shared by others or in keeping with cultural and religious norms? Can the patient consider alternative explanations? Are there paranoid, grandiose, or bizarre qualities? Does the patient believe that their thinking or actions are controlled by someone else (passivity)?
Thought disturbance—Does conversation with the patient maintain coherence? Does the patient jump from topic to topic (tangential) or veer off course gradually (circumstantial)?
Seek evidence of negative symptoms:
Alogia (poverty of speech)—Consider whether the conversation flows and whether the patient elaborates on their answers
Flattened affect (lack of spontaneity or reactivity of mood)—Does the patient’s facial expressions and communication during the interview feel forced or stilted?
Consider functional impairments affecting work, home, school, and relationships. Note the social network and history suggesting withdrawal from family and friends.10
Ask about family history of mental illness
Have adverse experiences occurred in earlier life?
Are there current stresses?
Consider whether pregnancy or recent delivery is contributory (“post-partum psychosis”—for a review, see Florio et al14)
Is sleeplessness contributing?
A medication history is important—for example, corticosteroids can precipitate psychosis.
Box 2: Insight in psychosis*
Insight in psychosis indicates the patient can recognise and accept that their experiences are abnormal and caused by a mental illness.15 It is not an all or nothing phenomena and may change over time. The domains of insight can be assessed by the following questions:
Identifying unusual experiences—How do you explain these experiences?
Awareness of illness—Do you think you have an illness? Could there be a mental health explanation to this?
Willingness to take treatment—Would you agree with taking medication or having therapy?
*Adapted from David15
What if the patient does not attend?
Patients may not directly present, and your first clue may come from others, sensing something may be wrong while often struggling to convince their relative to seek help. Families may feel overburdened or unsure where to turn, or the patient may lack an effective advocate. The primary care team is well placed to follow up missed appointments, use text reminders, and maintain contact with the family. If your patient does not attend appointments, consider undertaking a home visit.
It is good practice to obtain the patient’s consent when discussing the situation with carers. However, professional confidentiality is not broken by receiving information. If the patient does not want their history discussed with carers, it can be helpful to explore why—for example, if this is due to paranoid ideation. Even without consent, you can help family members to understand the nature of psychosis and general principles of treatment.
If your patient does agree, try to engage carers. In one large cohort study (n=549), the 10 year risk of unnatural death (including accidents and suicide) was decreased 90% in those with full family involvement at first contact.18
Risks will depend on the patient, illness and environment. Consider:
Risk to self—Around 5% of patients with schizophrenia die from suicide.19 Greatest risk is around initial presentation and shortly after discharge from hospital.20 Ask about suicidal ideation, previous attempts and plans, and self harm. Consider accidental and non-accidental injury. Inquiring about self harm or suicidal ideation does not increase the likelihood of self harm.
Risk to others—Be particularly concerned if the patient voices delusional ideation regarding others. Ask about confrontation with others and forensic history. If needed, act promptly to ensure the safety of vulnerable individuals such as children or dependents, considering safeguarding arrangements as appropriate in your local area.
Command hallucinations—The presence of command hallucinations should raise concerns. What is being commanded? Is the patient able to not act on the hallucination?
Risk of self neglect—This includes nutritional risk (malnutrition, dehydration, Wernicke’s encephalopathy); poor personal hygiene (risk of infections, worsening of chronic medical conditions); and fire risks (does the patient smoke or live in a chaotic home environment?).
When to refer
Refer all cases of suspected psychotic disorder to specialist services.456 Frank psychotic symptoms accompanied by high levels of risk demand urgent action in conjunction with secondary care. Consider whether assessment by the crisis response team or hospital admission is required.
Tests and investigations
If possible undertake initial physical investigations (see box 3). However, no standard battery of baseline tests exists, nor any consensus on whether they should be undertaken in primary or secondary care.21 Against this, in the absence of clear indications of organic pathology (such as head trauma, delirium, seizures), if patients are too unwell or reluctant to have investigations this should not hinder referral and treatment.
Box 3: Baseline investigations
Assessment for organic causes will be guided by the nature of the presentation and usually includes the following.
Full blood count
Urea and electrolytes
Liver and thyroid function tests
Urine sampling to rule out illicit drug use
If organic differential suspected or neurological features (such as focal neurology or seizures), test for HIV, syphilis (VDRL test), vitamin B12, anti-NMDA receptor antibodies
Consider neuroimaging (computed tomography of head or magnetic resonance imaging) particularly if neurological features (somnolence, seizures, recent head trauma) or abnormalities on neurological exam are present
Baseline metabolic assessment before starting antipsychotic medication:
Body weight and body mass index
Serum cholesterol concentration
Fasting plasma glucose concentration
Offer a baseline electrocardiogram if the patient:
Has a history of cardiac risk
Is admitted to hospital
Starts certain medications (see Summaries of Product Characteristics of individual drugs5)
What to tell the patient and carers (box 4)
Box 4: How to approach the consultation—What patients and families tell us
Adopt a non-judgmental approach through what is said and not said. Listen and understand the patient’s version of reality, however bizarre it may appear, in order to discover more about what is going on in their world
Ask focused questions if psychosis is suspected and do not too readily dismiss symptoms as the results of depression, anxiety, or substance misuse
Avoid arguing with the patient—for example, by saying, “Of course there aren't devils under the bed.” It works better to say, “I understand that this is how it appears to you, but this is how it appears to me”
Be true to the person as they were when well. Remember hostility can be a symptom of the illness
Avoid diagnostic labels at too early a stage; instead, focus the discussion around the patient’s symptoms and experiences
Avoid using stigmatising language. For example, some patients prefer “a person who experiences schizophrenia” rather than “schizophrenic”
Involve patients and seek their views. Adopt a positive approach, explaining that psychosis is treatable and in many cases can be fully treated without recurrence. Explain your thinking and acknowledge if their view differs. Try to involve carers with the patient’s consent. When referring a patient, explain its purpose and who they are likely to see and when.
Education into practice
How might you assess for psychotic symptoms in someone presenting with subtle changes in functioning and increasing distress?
Are you aware of what mental health services are available locally for people presenting with symptoms suggestive of psychosis—both for referral and clinical advice and for patients to access if in crisis?
What things might you do differently as a result of reading this article?
A patient’s perspective
A few years ago I found that I was experiencing high degrees of anxiety, mainly at work. I went to the doctors at varying times. First I was given an online CBT course, then drowsy anti-histamine tablets, then SSRIs. I decided to stop taking the medication when I heard that I might be on it for life.
Eventually I was finding working in the office so hard that I began working at home. In isolation my health declined further until I could not work, and so I went off on sick leave. I felt drawn to New Age spiritual teachings and living in the moment, but this became an unhealthy obsession which played on my mind.
Eventually I decided to see a doctor who recognised my mental ill health, but I moved back to my parents and so found a new GP at home. But this new GP was slower to identify the problem and I was prescribed anti-anxiety medication. This was partly due to me not disclosing the fullness of my ill health, since I was slow to admit it to myself. The GP did not allow me to claim the medication on the NHS as he thought my illness would only be temporary. This turned out not to be the case.
I was eventually referred to a psychiatrist who recognised my psychosis and prescribed me anti-psychotic medication.
Additional educational resources
Royal College of Psychiatrists. Carers and confidentiality in mental health. www.rcpsych.ac.uk/healthadvice/partnersincarecampaign/carersandconfidentiality.aspx
Royal College of General Practitioners. Mental health toolkit. www.rcgp.org.uk/clinical-and-research/toolkits/mental-health-toolkit.aspx
Includes GP Guidance: early detection of emerging psychosis3
National Institute for Health and Care Excellence. Psychosis and schizophrenia overview and pathways. https://pathways.nice.org.uk/pathways/psychosis-and-schizophrenia
Patients’ and carers’ perspectives of psychosis
Lawrence R, Lawrie SM. Psychotic depression. BMJ 2012;345:e6994
Ellerby M. Personal experience: Diagnosis and dilemmas—what happens when we diagnose patients with the label 'schizophrenia'. Psychiatr Bull 2014;38:182-4.
Tagore A. Personal experience: Hopes and fears—the road to recovery after psychotic illness. Psychiatr Bull 2014;38:189-90
Shiers D. Personal view: Who cares. BMJ 1998;316:785—A carer’s view of schizophrenia
How were patients involved in the creation of this article
MBS obtained feedback from a patient with psychosis and his mother on an initial draft. They advised on the approach to the doctor-patient consultation. The initial subjective experience of psychosis and the meaning of recovery has also been included. The patient wishes to remain anonymous.
The artwork (Puppet Schizophrene) is by Bryan Charnley (1949-91), an artist who had schizophrenia (www.bryancharnley.info). We thank James Charnley for permission to reproduce.
Contributors: MBS wrote the first draft. All authors were involved in further drafts and approval of the final manuscript.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following: DS is an expert adviser for the NICE Centre for Guidelines. The views presented in this article are those of the authors and not those of NICE. There are no other competing interests.
Provenance and peer review: Not commissioned; externally peer reviewed.