Psychotic Disorders (Psychosis)
Psychotic Disorders Overview
Primary Psychotic Disorders
| Disorder | High-yield distinguishing features |
|---|---|
| Schizophrenia |
|
| Schizophreniform disorder |
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| Schizoaffective disorder |
|
| Brief psychotic disorder |
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| Delusional disorder |
|
Secondary Psychosis and Other Mimics
Important mimics / differentials: [Ref1][Ref2]
| Disorder | High-yield distinguishing features |
|---|---|
| Substance / medication-induced psychotic disorder (drug-induced psychosis) |
|
| Psychotic disorder due to another medical condition (secondary / organic psychosis) | New psychosis (esp. prominent visual hallucinations) + neurological / systemic abnormalities or atypical presentation → consider secondary / organic psychosis
Key causes:
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| Mania with psychotic features (bipolar disorder) |
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| Schizotypal personality disorder |
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| Schizoid personality disorder |
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Psychosis Features
There are 4 core features of psychosis: [Ref]
| Core feature | Core concept |
|---|---|
| Delusions | Abnormal beliefs that are firmly held despite evidence to the contrary |
| Hallucinations | Abnormal perceptions occurring without a corresponding external stimulus |
| Disorganised thoughts or speech | Abnormal thought / speech |
| Disorganised or abnormal behaviour | Abnormal actions |
Negative symptoms (e.g. lack of motivation, social withdrawal, reduced speech) may accompany psychotic disorders, particularly schizophrenia, but are covered in more detail in the schizophrenia article.
Negative symptoms are NOT defining features of psychosis.
1. Delusions
Common types of delusion:
| Delusional theme | Description | Example vignette |
|---|---|---|
| Persecutory | Persecutory delusions are the most common type of delusion [Ref]
Belief that another person, group or organisation intends to harm, threaten, monitor or conspire against him/her |
A man believes MI5 is secretly monitoring him and has installed cameras in his home despite no evidence |
| Referential | Belief that neutral events, comments or media have a special personal meaning directed specifically at him/her | A woman believes a newsreader is sending coded messages specifically to her during television broadcasts |
| Grandiose | Belief that him/her has exceptional power, ability, status, identity or importance | A man believes he has been personally chosen by God to save the world |
| Erotomanic | Belief that another person is in love with them, despite little or no evidence or relationship | A woman believes a famous actor is secretly in love with her and communicates this through their social media posts |
| Somatic | Belief concerning an abnormality or change in the body or health despite contrary medical evidence | A man remains convinced that parasites are living underneath his skin despite repeated normal examinations |
| Nihilistic | Belief that oneself, part of the body or the world no longer exists, is dead or has been destroyed | A woman believes that she is already dead and her internal organs have stopped existing |
| Jealous | Belief that a partner is being unfaithful despite inadequate evidence | A man is convinced his wife is having an affair with a colleague despite there being no evidence |
Thought alienation and passivity phenomena:
| Phemonemon | Description | Example vignette |
|---|---|---|
| Thought insertion | Belief that thoughts have been placed into the person’s mind by an external force and are not their own | A man believes that the government is placing thoughts into his mind |
| Thought withdrawal | Belief that an external force is removing thoughts from the person’s mind | A woman believes that someone is taking thoughts out of her mind, causing her thoughts to suddenly disappear |
| Thought broadcasting | Belief that the person’s thoughts are being transmitted or are accessible to other people | A man believes that people on the bus can hear his thoughts even though he has not spoken |
| Passivity (delusions of control) | Belief that one’s actions, impulses, emotions or bodily experiences are being controlled by an external force | A woman believes that an outside force is controlling her arm movements and making her walk |
Some named delusional syndromes:
| Name | Meaning |
|---|---|
| De Clérambault syndrome | = Erotomanic delusion |
| Cotard syndrome | = Nihilistic delusion |
| Capgras syndrome | Belief that someone familiar has been replaced by an identical-looking impostor |
| Fregoli syndrome | Belief that different people are actually the same person appearing in different disguises |
2. Hallucinations
Definition: a perception-like experience that occurs without a corresponding external stimulus and is experienced as real rather than voluntarily imagined
| Hallucination type | Description | Example vignette |
|---|---|---|
| Auditory | Perception of sounds or voices without an external auditory stimulus | A man repeatedly hears two voices discussing his behaviour despite nobody else being present |
Specific patterns of auditory hallucinations:
|
||
| Visual | Perception of people, objects, shapes or scenes that are not actually present | An older woman with cognitive decline repeatedly sees unfamiliar children and animals walking around her home despite nobody being there |
| Tactile | False perception of touch or movement on the skin without an external stimulus | A man using stimulants repeatedly feels insects crawling underneath his skin despite nothing being present |
| Somatic | False perception of an internal bodily sensation or change without a corresponding physical cause | A woman describes feeling that her internal organs are moving around inside her abdomen despite normal examination and investigations |
Auditory hallucinations are more characteristic of primary psychotic disorders (e.g. schizophrenia) [Ref]
Prominent visual hallucinations should raise suspicion of a secondary / organic cause of psychosis [Ref]
Tactile hallucinations should particularly raise suspicion of a substance-related cause [Ref]
3. Disorganised Thoughts or Speech
| Type | Description | Example vignette |
|---|---|---|
| Derailment (loose associations) | Speech moves between ideas with weak or illogical connection | A man is asked why he stopped working and says, “My manager was difficult. Managers wear suits. Suits are made in factories. Factories control the weather” |
| Tangentiality | When asked a question, the person begins with a relevant response but moves progressively away from the question and never actually answers it | A woman is asked, “Have you been sleeping well?” She talks about her noisy neighbours, then the council, then local taxes and roadworks, but never says how she has been sleeping |
| Circumstantiality | When asked a question, the person gives excessive unnecessary detail and repeatedly digresses, but eventually returns to the point and answers the question | A man is asked where he lives and describes when he moved there, his neighbours, the nearby supermarket and his bus route before eventually giving his address |
| Word salad (incoherence) | Overall meaning of the speech cannot be understood, although individual words are recognisable | A man says, “Blue window Tuesday runs the television because shoes are sleeping tomorrow” |
| Neologisms | The person creates new words that have a particular meaning to them only | A woman repeatedly says that the doctors are using a “braincaster”, explaining that this is a machine that sends thoughts directly into her head |
| Clang associations | Words are chosen because they rhyme or sound similar, rather than because they are logically connected in meaning | A man says, “The train brings rain to my brain, causing pain again on the plain” |
| Thought blocking | The person’s chain of thought suddenly stops, often in the middle of a sentence, and they may be unable to recall what they were going to say | A woman says, “I came to hospital because yesterday I was…”, suddenly becomes silent for several seconds, then says she cannot remember what she was thinking about |
Most easily confused terms:
- Circumstantiality → gives lots of unnecessary detail but eventually answers the question
- Tangentiality → goes off-topic and never answers the question, although the sequence may still be understandable
- Derailment → jumps between topics that are only weakly or illogically connected
4. Disorganised or Abnormal Behaviour
| Category | Specific examples |
|---|---|
| Grossly disorganised / bizarre behaviour |
|
| Catatonic behaviour | Marked abnormalities of movement and responsiveness:
|
| Impaired goal-directed behaviour / self-care | May present with
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Psychosis Work Up
| Category | Assessment / investigation | Rationale |
|---|---|---|
| Clinical assessment |
|
|
| Blood tests |
|
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| Urine studies | Urine drug screen | Consider when substance-induced psychosis is suspected |
| Neuroimaging | CT / MRI brain | Not routinely required in uncomplicated first-episode psychosis but consider if there are neurological signs, atypical features or suspicion of structural brain disease |
Management
Management of first episode of psychosis:
- Oral antipsychotic monotherapy, PLUS
- Psychological interventions (both individual CBT and family intervention)
Choice of antipsychotic
- NICE did NOT recommend a single preferred 1st line antipsychotic
- Choice of antipsychotic should be guided by the side-effect profile and which side effect the patient is most willing to tolerate (including metabolic, extrapyramidal, cardiovascular and prolactin-related effects)
- Clozapine is reserved for treatment-resistant schizophrenia and is not a routine 1st line antipsychotic (see below for indications)
Antipsychotic depots are long-acting injectables (usually IM injections) that can be considered if:
- Patient prefers the method of administration, or
- To avoid non-adherence