Psychosis

Types of Psychotic Disorders

Schizophrenia

• Diagnostic Criteria (simplified):

  • ≥2 symptoms for ≥1 month within a 6-month period, with ≥1 symptom from:

    1. Hallucinations

    2. Delusions

    3. Disorganised speech

  • Other possible symptoms: Disorganised or catatonic behaviour, negative symptoms (anhedonia, flat affect, alogia).

  • Functional impairment in work, social, or self-care.

  • Exclude mood disorders (unless mood symptoms are brief) and exclude substance/medical causes.

Schizophreniform Disorder

• Same symptom criteria as schizophrenia,

• Duration: 1–6 months,

• No significant functional impairment required.

Schizoaffective Disorder

• Two types: Bipolar type or Depressive type.

• Requires 2 psychotic episodes:

  1. One with predominant mood symptoms (mania or depression),

  2. Another lasting ≥2 weeks with minimal mood symptoms.

• Also must rule out primary mood or psychotic diagnoses.

Brief Psychotic Disorder

• Duration: 1 day–1 month,

• Often triggered by trauma or stress,

• Symptoms resolve with return to premorbid functioning.

Delusional Disorder

• Persistent delusions >1 month (paranoid, grandiose, jealous, erotomanic, somatic).

• No other psychotic features (e.g. hallucinations) or only related to the delusional theme.

• Minimal impact on daily functioning aside from delusions.

General Management

Psychological Approaches

• CBT and psychoeducation on psychosis and coping.

• Social Skills Training, community support programs.

• Lifestyle: Balanced diet, regular exercise, avoid substance use.

Baseline Monitoring (Antipsychotic Therapy)

• Blood Pressure, Heart Rate, ECG (risk of QT prolongation).

• Weight, BMI, waist circumference.

• Lipids, Glucose, HbA1c.

• Prolactin levels, menstrual history in females.

• Full Blood Count (some antipsychotics can cause dyscrasias).

• Movement assessments for extrapyramidal side effects.

Treatment Duration

• Schizophrenia or psychosis >6 months:

  • Antipsychotics at least 2 years post-resolution of acute episode.

• Brief Psychosis (<6 months):

  • Antipsychotics at least 1 year post-resolution.

• Extend therapy if high relapse risk or significant comorbidities.

Possible Diagnoses with Positive Psychotic Symptoms

Primary Psychotic Disorders

• Schizophrenia, Schizophreniform, Schizoaffective, Brief Psychotic Disorder, Delusional Disorder.

Secondary Causes

• Substance-Induced:

  • Symptoms <4 weeks post-intoxication/withdrawal (e.g. amphetamines, hallucinogens).

• Medical Conditions:

  • Autoimmune diseases (e.g., lupus, anti-NMDA encephalitis),

  • Delirium, dementia (Lewy body),

  • Neurological (temporal lobe epilepsy, stroke, tumour).

• Other Psychiatric:

  • Acute mania with psychotic features,

  • Postpartum psychosis,

  • Severe depression with psychosis.

Differential Diagnosis in Psychosis

Psychiatric Causes

• Schizophreniform, Schizophrenia, Schizoaffective.

• Brief Psychotic Disorder (1 day–1 month).

• Delusional Disorder.

• Bipolar mania with psychosis.

• Depression with psychotic features.

Organic Causes

• Neurological: Intracranial infection (meningitis, encephalitis), space-occupying lesion (tumour, haemorrhage), delirium, dementia (Alzheimer’s, Lewy body), Parkinson’s, MS, Huntington’s, seizure disorders.

• Metabolic: Electrolyte imbalances (hypoNa, hypoG), B12 deficiency, thyrotoxicosis, hyperparathyroidism, Cushing’s syndrome.

• Substance-Related: Illicit drugs (amphetamines, hallucinogens), withdrawal from alcohol/meds (anticholinergics, corticosteroids).

• Systemic: Hepatic/uraemic encephalopathy.

Pertinent History Questions

• Recent Stressors/Trauma,

• Hallucinations (auditory/visual/tactile),

• Delusions (paranoid, grandiose, bizarre),

• Depression or mania history,

• Suicidal/Self-Harm thoughts,

• Neurological Symptoms or recent head injury,

• Changes in sleep pattern (insomnia, hypersomnia),

• Elevated mood or grandiosity,

• Substance Use (type, frequency) or medication changes.

Additional Notes

• Autoimmune Encephalitis (anti-NMDA receptor) in young patients → suspect if unexplained acute psychosis + neurological changes.

• Early Detection in young males with possible prodromal phase (odd beliefs, social withdrawal) → specialist referral (early psychosis service).

• Referral: Early involvement of mental health services improves outcomes in first-episode psychosis.