GPAtlas🧭 When to suspect
Suspect psychosis when a person develops positive symptoms – hallucinations (most often auditory), delusions (fixed, false beliefs not amenable to reason), or thought disorder (disorganised, tangential or incoherent speech) – and/or negative symptoms such as social withdrawal, blunted affect and loss of motivation. The diagnosis is usually preceded by a prodrome: a gradual decline in social and occupational functioning, sleep disturbance, suspiciousness and new or unusual preoccupations, with rising distress before any florid symptoms appear.
In primary care the task is 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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