GPAtlas🧭 When to suspect
Suspect psychosis when a person develops positive symptoms and/or negative symptoms.
• Positive: hallucinations (most often auditory), delusions (fixed, false beliefs not amenable to reason), or thought disorder (disorganised, tangential or incoherent speech).
• Negative: for example social withdrawal, blunted affect and loss of motivation.
The diagnosis is usually preceded by a prodrome, with rising distress before any florid symptoms appear:
• A gradual decline in social and occupational functioning.
• Sleep disturbance and suspiciousness.
• New or unusual preoccupations.
In primary care, think recognition and timely referral, not diagnosis or initiation of treatment.
• Around 0.5% of adults are treated for a psychotic disorder each year, but a first presentation is uncommon for any individual GP, so a low threshold for suspicion matters.
• Take third-party concern from family or friends seriously: the person often has limited insight and may be brought by someone else.
| Positive symptoms (added experiences) | Negative symptoms (lost functions) |
|---|---|
| Hallucinations – auditory most common (voices commenting or commanding); also visual or somatic | Blunted affect – reduced emotional range and expression |
| Delusions – fixed false beliefs, frequently persecutory or referential | Avolition – loss of drive and goal-directed activity |
| Thought disorder – disorganised, tangential or incoherent speech | Anhedonia – loss of pleasure and interest |
| Passivity phenomena – thoughts or actions experienced as externally controlled | Social withdrawal, poverty of speech and self-neglect |
Key modifiable and non-modifiable risk factors include cannabis and stimulant use, a family history of psychosis (a first-degree relative raises risk roughly six- to eight-fold), childhood adversity, urban upbringing, migrant or minority-ethnic status, and male sex for earlier onset.
Source: NICE CG178 · Royal College of Psychiatrists
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