Practice Practice Pointer

How to approach psychotic symptoms in a non-specialist setting

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4752 (Published 08 November 2017) Cite this as: BMJ 2017;359:j4752
  1. Musa Basseer Sami, MRC clinical research training fellow, honorary specialist registrar1 2,
  2. David Shiers, former GP, honorary reader in early psychosis3,
  3. Saqib Latif, clinical lead and consultant child and adolescent psychiatrist4,
  4. Sagnik Bhattacharyya, reader in translational neuroscience and psychiatry, consultant psychiatrist1 5
  1. 1Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
  2. 2South London and Maudsley NHS Foundation Trust, London
  3. 3Manchester University, Manchester, UK
  4. 4Kent and Medway Children & Young People Services, Sussex Partnership NHS Foundation Trust, Broadstairs, UK
  5. 5Lambeth Early Onset Inpatient Unit, Lambeth Hospital South London and Maudsley NHS Foundation Trust, London
  1. Correspondence to: M B Sami musa.sami{at}kcl.ac.uk; S Bhattacharyya sagnik.2.bhttacharyya{at}kcl.ac.uk

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

Fig 1 Puppet Schizophrene by Bryan Charnley (1949-1991), who had schizophrenia (www.bryancharnley.info). © The estate of Bryan Charnley, reproduced with permission

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:

  • Sleep disturbance

  • Anxiety, irritability, or depressive features

  • Social withdrawal

  • 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

Hallmark features are increasing distress and decline in functioning.456

How to approach psychotic symptoms:

An overview of symptoms is shown in figure 2. Psychosis maybe preceded by …

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