Psychosis and Schizophrenia

🔍 When to Suspect

Presence of positive symptoms (hallucinations, delusions, thought disorder) and/or negative symptoms (avolition, anhedonia, flat affect, social withdrawal)

From the full topic in The Ocean Library: Psychosis and Schizophrenia

🧭 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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