BMJ 2017;359:j4752 doi: 10.1136/bmj.

j4752 (Published 2017 November 08) Page 1 of 6

Practice

PRACTICE

PRACTICE POINTER

How to approach psychotic symptoms in a

non-specialist setting
1 2
Musa Basseer Sami MRC clinical research training fellow, honorary specialist registrar , David
3
Shiers former GP, honorary reader in early psychosis , Saqib Latif clinical lead and consultant child
4
and adolescent psychiatrist , Sagnik Bhattacharyya reader in translational neuroscience and
1 5
psychiatry, consultant psychiatrist
1
Institute 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

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
Hallmark features are increasing distress and decline in
functioning.4-6
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.
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

• Social withdrawal Key features to elicit

• 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
• 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.

Correspondence to: M B Sami musa.sami@kcl.ac.uk; S Bhattacharyya sagnik.2.bhttacharyya@kcl.ac.uk

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PRACTICE

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

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

Establishing context
• 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?

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
Anhedonia (lack of pleasure in activities)—“Have you lost
interest in activities that you used to enjoy before?”8 9
Flattened affect (lack of spontaneity or reactivity of
mood)—Does the patient’s facial expressions and
communication during the interview feel forced or stilted?
Avolition (lack of drive)—“How do you spend your
time?”8 9
Social withdrawal—“Have you found yourself turning
down any opportunities to go out with your friends? Do
you prefer to be with others or your own?”8 9
• Consider functional impairments affecting work, home,
school, and relationships. Note the social network and
history suggesting withdrawal from family and friends.10
• Risk factors:
– Ask about family history of mental illness
– Have adverse experiences occurred in earlier life?
– Ask about use of alcohol, nicotine, and other drugs. In
particular ask about cannabis, given its association with
psychosis onset11 and poor outcome12 13
– Are there current stresses?
– Consider whether pregnancy or recent delivery is
contributory (“post-partum psychosis”—for a review, see
Florio et al14)
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– Is sleeplessness contributing?
– A medication history is important—for example,
corticosteroids can precipitate psychosis.
• Assessing insight is important (see box 2). Good insight
mediates engagement with treatment and self management,
whereas poor insight increases risk of relapse.16 17
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
Risk assessment
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
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BMJ 2017;359:j4752 doi: 10.1136/bmj.j4752 (Published 2017 November 08)
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
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.4-6 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.
What to tell the patient and carers (box 4)
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.
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
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Page 3 of 6
PRACTICE
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.
1 Anderson KK, Fuhrer R, Malla AK. The pathways to mental health care of first-episode
psychosis patients: a systematic review. Psychol Med 2010;359:1585-97.. doi:10.1017/
S0033291710000371 pmid:20236571.
2 Marwaha S, Thompson A, Upthegrove R, Broome MR. Fifteen years on - early intervention
for a new generation. Br J Psychiatry 2016;359:186-8.. doi:10.1192/bjp.bp.115.
170035 pmid:27587758.
3 French P, Shiers D, Jones P. GP guidance: early detection of emerging psychosis. 2014.
www.rcgp.org.uk/clinical-and-research/toolkits/~/media/
9B51AC832D27424F86C0B4ED8AD2593A.ashx.
4 National Institute for Health and Care Excellence. Psychosis and schizophrenia in children
and young people recognition and management (clinical guideline155). 2016. www.nice.
org.uk/guidance/cg155.
5 National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults:
prevention and management (clinical guideline 178). 2014. www.nice.org.uk/guidance/
cg178.
6 Orygen. Australian clinical guidelines for early psychosis. 2nd ed. 2016. www.orygen.org.
au/Skills-Knowledge/Resources-Training/Resources/Free/Clinical-Practice/Australian-
Clinical-Guidelines-for-Early-Psychosis.
7 Singh SP, Brown L, Winsper C, et al. Ethnicity and pathways to care during first episode
psychosis: the role of cultural illness attributions. BMC Psychiatry 2015;359:287.. doi:10.
1186/s12888-015-0665-9 pmid:26573297.
8 First MB, Spitzer RL, Gibbon M, Williams JBW. Structured clinical interview for DSM-IV-TR
axis I disorders. Research version, patient edition. Biometrics Research. New York State
Psychiatric Institute, 2002.
9 Kay SR, Opler LA, Fiszbein A. Significance of positive and negative syndromes in chronic
schizophrenia. Br J Psychiatry 1986;359:439-48. doi:10.1192/bjp.149.4.439 pmid:3814927.
10 Gayer-Anderson C, Morgan C. Social networks, support and early psychosis: a systematic
review. Epidemiol Psychiatr Sci 2013;359:131-46.. doi:10.1017/S2045796012000406 pmid:
22831843.
11 Moore THM, Zammit S, Lingford-Hughes A, et al. Cannabis use and risk of psychotic or
affective mental health outcomes: a systematic review. Lancet 2007;359:319-28.. doi:10.
1016/S0140-6736(07)61162-3 pmid:17662880.
12 Schoeler T, Petros N, Di Forti M, et al. Association between continued cannabis use and
risk of relapse in first-episode psychosis: a quasi-experimental investigation within an
observational study. JAMA Psychiatry 2016;359:1173-9.. doi:10.1001/jamapsychiatry.
2016.2427 pmid:27680429.
13 Schoeler T, Monk A, Sami MB, et al. Continued versus discontinued cannabis use in
patients with psychosis: a systematic review and meta-analysis. Lancet Psychiatry
2016;359:215-25.. doi:10.1016/S2215-0366(15)00363-6 pmid:26777297.
14 Di Florio A, Smith S, Jones I. Postpartum psychosis. Obstetrician Gynaecologist
2013;359:145-50. doi:10.1111/tog.12041.
15 David AS. Insight and psychosis. Br J Psychiatry 1990;359:798-808.. doi:10.1192/bjp.
156.6.798 pmid:2207510.
16 Drake RJ, Dunn G, Tarrier N, Bentall RP, Haddock G, Lewis SW. Insight as a predictor
of the outcome of first-episode nonaffective psychosis in a prospective cohort study in
England. J Clin Psychiatry 2007;359:81-6. doi:10.4088/JCP.v68n0111 pmid:17284134.
17 Sendt K-V, Tracy DK, Bhattacharyya S. A systematic review of factors influencing
adherence to antipsychotic medication in schizophrenia-spectrum disorders. Psychiatry
Res 2015;359:14-30.. doi:10.1016/j.psychres.2014.11.002 pmid:25466227.
18 Revier CJ, Reininghaus U, Dutta R, et al. Ten-year outcomes of first-episode psychoses
in the MRC ÆSOP-10 study. J Nerv Ment Dis 2015;359:379-86.. doi:10.1097/NMD.
0000000000000295 pmid:25900547.
19 Hor K, Taylor M. Suicide and schizophrenia: a systematic review of rates and risk factors.
J Psychopharmacol 2010;359(Suppl):81-90.. doi:10.1177/1359786810385490 pmid:
20923923.
20 Nordentoft M, Madsen T, Fedyszyn I. Suicidal behavior and mortality in first-episode
psychosis. J Nerv Ment Dis 2015;359:387-92.. doi:10.1097/NMD.0000000000000296 pmid:
25919385.
21 Freudenreich O, Schulz SC, Goff DC. Initial medical work-up of first-episode psychosis:
a conceptual review. Early Interv Psychiatry 2009;359:10-8.. doi:10.1111/j.1751-7893.
2008.00105.x pmid:21352170.
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PRACTICE

Box 3: Baseline investigations

Assessment for organic causes will be guided by the nature of the presentation and usually includes the following.
• Blood tests:
– 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
– Waist size
– 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)

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”

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.

Figures

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PRACTICE

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.

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

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Fig 2 Overview of psychotic symptoms

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