Assessment of psychosis

may have family history of schizophrenia; ≥2 of the following, each present for a significant portion of time during a 1-month period: delusions, hallucinations, disorganised speech, disorganised or catatonic behaviour, negative symptoms (at least one must be delusions, hallucinations, or disorganised speech); social/occupational dysfunction; continuous signs of the disturbance persist for at least 6 months; exclusion of schizoaffective, mood disorder, or effects of a substance[2]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition, text revision (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022.

speech disorganised or pressurised, may jump from one subject to another with minimal connection, prolonged time elapsing between queries and answers (evidence of internal preoccupation), verbal responses to internal stimuli (evidence of hallucinations), may be possible to identify delusional thought, affect may be incongruent or flat, anxious, behaviour may be grossly disorganised or catatonic, may be bizarre, repetitive movements that appear goal directed but are carried out in a stiff fashion; no findings suggestive of secondary cause of psychosis

may have family history of psychiatric disorder; an uninterrupted period of illness, with an episode of mood disorder (manic or major depressive disorder) concurrent with ≥2 of the following: delusions, hallucinations, disorganised speech, disorganised or catatonic behaviour, and negative symptoms (at least one must be delusions, hallucinations, or disorganised speech); during the lifetime period of illness, delusions or hallucinations should occur for at least 2 weeks in the absence of prominent major mood symptoms[2]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition, text revision (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022.

speech disorganised or pressurised, may jump from one subject to another with minimal connection, prolonged time elapsing between queries and answers (evidence of internal preoccupation), verbal responses to internal stimuli (evidence of hallucinations), may be possible to identify delusional thought, affect reflects associated mood disorder and may be decreased (with anhedonia and suicidal ideation) or increased, behaviour may be grossly disorganised or catatonic, may be bizarre, repetitive movements that appear goal directed but are carried out in a stiff fashion; no findings suggestive of secondary cause of psychosis

may have family history of psychiatric disorder; may have history of childbirth within last 4 weeks, or recent stress and trauma; history of ≥1 of delusions, hallucinations, disorganised speech, or disorganised or catatonic behaviour (at least one of these symptoms must be delusions, hallucinations, or disorganized speech), lasting at least 1 day but not >1 month, with eventual full return to premorbid level of functioning[2]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition, text revision (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022.

speech disorganised or pressurised, may jump from one subject to another with minimal connection, prolonged time elapsing between queries and answers (evidence of internal preoccupation), verbal responses to internal stimuli (evidence of hallucinations), delusions are generally very unstable and have rapidly changing topics, affect may be incongruent or flat, anxious, behaviour may be grossly disorganised or catatonic, changing moods are more common than in schizophrenia, may be bizarre, repetitive movements that appear goal directed but are carried out in a stiff fashion; no findings suggestive of secondary cause of psychosis

history of ≥2 of the following for a significant portion of time during a 1-month period but <6 months: delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour, and negative symptoms (at least one of the symptoms must be delusions, hallucinations, or disorganised speech)[2]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition, text revision (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022.

speech disorganised or pressurised, may jump from one subject to another with minimal connection, prolonged time elapsing between queries and answers (evidence of internal preoccupation), verbal responses to internal stimuli (evidence of hallucinations), may be possible to identify delusional thought, affect may be incongruent or flat, anxious, behaviour may be grossly disorganised or catatonic, may be bizarre, repetitive movements that appear goal directed but are carried out in a stiff fashion; no findings suggestive of secondary cause of psychosis

may have family history of psychiatric disorder, trouble falling asleep, waking too early, or sleeping excessively without feeling rested, reports that thoughts come more slowly, reduced interest and ability to enjoy usual activities

flat affect, speech may be slowed, and thought blocking may be present; no findings suggestive of secondary cause of psychosis

may have family history of psychiatric disorder; history of alternating episodes of mania, hypomania, and depression (although, despite being common, major depressive episode is not required for diagnosis of bipolar I disorder); requires fewer hours of sleep to feel rested, reports thoughts coming too fast to keep up with, distractible, increased goal-directed activities, excessive involvement in activities with high chance of painful consequences[2]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition, text revision (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022.

speech may be pressured with racing thoughts and flight of ideas during manic episodes; flat affect, speech may be slowed, and thought blocking may be present during depressive episodes; no findings suggestive of secondary cause of psychosis

may have family history of psychiatric disorder; history of stroke; delusions of at least 1 month's duration; diagnostic criteria for schizophrenia not met; normal functioning aside from the impact of the delusions, mood disturbances are brief or absent[2]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition, text revision (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022.

delusions may be identified; no findings suggestive of secondary cause of psychosis

history of high levels of alcohol intake; describes prominent hallucinations (may be predominantly visual) or delusions; evidence that the psychotic symptoms develop within 1 month of substance intoxication or withdrawal, or that the substance is aetiologically related to the psychosis; psychotic symptoms not better accounted for by another mental disorder; psychotic symptoms do not occur exclusively during the course of a delirium

may be evidence of prominent hallucinations or delusions, may be agitated; general appearance may be of state of malnourishment, poor hygiene, smell of alcohol

history of high levels of alcohol intake or benzodiazepine or barbiturate use followed by abrupt cessation, tremors, nausea, confusion, hallucinations, including tactile hallucinations

may be evidence of prominent hallucinations or delusions, may be agitated; general appearance may be of state of malnourishment, poor hygiene, smell of alcohol, tremulous, irregular vital signs consistent with alcohol withdrawal

history of cocaine use; describes prominent hallucinations or delusions; evidence that the psychotic symptoms develop within 1 month of substance intoxication or withdrawal, or that the substance is aetiologically related to the psychosis; psychotic symptoms not better accounted for by another mental disorder; psychotic symptoms do not occur exclusively during the course of a delirium; may have chest pain, palpitations

may be evidence of prominent hallucinations or delusions, may be agitated; general appearance may be of state of malnourishment, poor hygiene, track marks, tremulous; signs of acute intoxication include: hyperthermia, tachycardia, hypertension, mydriasis, diaphoresis, psychomotor stimulation, seizure, signs of acute coronary syndrome or stroke

history of cannabis use; describes prominent hallucinations or delusions; evidence that the psychotic symptoms develop within 1 month of substance intoxication or withdrawal, or that the substance is aetiologically related to the psychosis; psychotic symptoms not better accounted for by another mental disorder; psychotic symptoms do not occur exclusively during the course of a delirium

may be evidence of prominent hallucinations or delusions, may be agitated; general appearance may be of state of malnourishment, poor hygiene, tremulous, cannabis use may be associated with a distinctive odour

history of amfetamine use; describes prominent hallucinations or delusions; evidence that the psychotic symptoms develop within 1 month of substance intoxication or withdrawal, or that the substance is aetiologically related to the psychosis; psychotic symptoms not better accounted for by another mental disorder; psychotic symptoms do not occur exclusively during the course of a delirium; may have palpitations, chest pain, abdominal pain, headache

may be evidence of prominent hallucinations or delusions, rushed speech, may be agitated; general appearance may be of state of malnourishment, poor hygiene, tremulous; signs of intoxication include: tachycardia, hypertension, hyperthermia, confusion, dyspnoea, may be agitated with violent behaviour, seizures, dilated pupils, muscle rigidity

history of phencyclidine use; describes prominent hallucinations or delusions; evidence that the psychotic symptoms develop within 1 month of substance intoxication or withdrawal, or that the substance is aetiologically related to the psychosis; psychotic symptoms not better accounted for by another mental disorder; psychotic symptoms do not occur exclusively during the course of a delirium

may be evidence of prominent hallucinations or delusions, may be agitated; general appearance may be of state of malnourishment, poor hygiene, tremulous; signs of intoxication include: agitation and violent behaviour, tachycardia and hypertension, miosis and nystagmus

acute intoxication in a young adolescent, older teen, or young adult; often impoverished; symptoms of confusion and psychosis are very short lived; associated loss of appetite, slurred speech, dizziness, or unsteady gait

paint or oil stains on clothing, face, or hands; chemical odour on breath or clothes; oral lesions or ulcerations; rhinorrhoea; bloodshot eyes with nystagmus; dazed appearance; hallucinations; anxiety, irritability, or excitability

more commonly teenagers; mild inebriation at low doses, increasing amounts produce intoxication similar to alcohol followed by a dissociative experience; history of misuse of cough/cold medications is often present; symptoms include blurred vision, body itching, sweating, diarrhoea, vomiting, some preparations also contain paracetamol, chlorphenamine, and guaifenesin; large doses of guaifenesin cause vomiting

rash, fever, hypertension, shallow respiration, coma, tachycardia; large doses of chlorphenamine can cause tachycardia, lack of coordination, seizures, and coma

chronic decline in recent and long-term memory associated with cognitive decline; personality changes, and progressive decline in social relationships, work, and activities of daily life; new onset psychosis associated with cognitive impairment in older people

primitive reflexes, rigidity, bradykinesia, abnormal speech and posture in Alzheimer's dementia; focal neurological deficits in vascular dementia; muscle rigidity, stooped posture, cog-wheeling, well-formed visual hallucinations, and cognitive fluctuations in Lewy body dementia patients; resting tremor, bradykinesia, hypokinesia, and rigidity in dementia associated with Parkinson's disease

history of alcohol misuse/dependence; symptoms include memory loss, confusion, amnesia, personality change, and confabulation

psychomotor slowing, nystagmus, ataxia, and oculomotor dysfunction in Wernicke's encephalopathy

intermittent abdominal pain, vomiting, seizures, acute neuropathy, psychiatric symptoms include hallucinations, paranoia, depression, and anxiety

dark urine, tachycardia, arrhythmias may be present

history of the development of a delusion in the context of a close relationship with another person or people who have an already established similar delusion

no findings suggestive of secondary cause of psychosis

history of exposure to organophosphates (e.g., insecticides, herbicides, nerve gases, and ophthalmic agents); symptoms of toxicity depend on the specific chemical; may be acute cholinergic symptoms

clinical signs variable depending on the specific chemical, route, and amount of exposure; often an acute cholinergic crisis initially, intermediate phase of respiratory paralysis (24-96 hours) and delayed neuropathy (1-3 weeks); hypotension or hypertension; bradycardia or tachycardia; bronchospasm; nausea and vomiting; blurred vision; diaphoresis; confusion, anxiety; respiratory paralysis; extrapyramidal symptoms

history of use of anticholinergic medications, symptoms more likely at toxic doses

fever, dry skin and mucous membranes; mydriasis with loss of accommodation, sinus tachycardia, decreased bowel sounds, functional ileus, urinary retention, hypertension, tremulousness, myoclonic jerking

history of use of dopamine agonist medications, symptoms more likely at toxic doses

signs are variable

history of use of other prescription or over-the-counter medications, particularly phenylpropanolamine, antihistamines, or centrally acting herbal medications such as ma huang

usually normal

history of exposure to heavy metal (arsenic, mercury, and lead) through environmental sources, hobbies, or industrial work

a wide range of physical (cardiovascular, renal, reproductive, gastrointestinal, neurological, dermatological) and psychiatric sequelae, depending on the type of exposure

moderate to severe head trauma, or multiple events of mild brain injury; timing of onset of symptoms is variable and can occur long after the initial injury; personality or behavioural change may precede psychosis; behavioural changes include impulsivity, aggressiveness, loss of social graces, moodiness

evidence of head trauma or other physical injuries

psychosis (rare), seizures, headaches, focal neurological deficits, such as leg or arm weakness or loss of vision; personality change may also occur; history of malignancy, particularly in the lung, breast, skin, kidney, and gastrointestinal tract

focal neurological signs, altered level of consciousness

history of previous seizures present; symptoms classified as ictal if they are an expression of the seizure activity, postictal when they occur within 7 days of a seizure, and interictal when they occur independently of seizures; alternative psychosis due to antiepileptic drug treatment or following surgery for epilepsy

usually normal; may reveal focal neurological signs if a focal brain lesion is present

weakness and fatigue; numbness, paraesthesias; bladder problems; vision impairment; depression, personality change

optic neuritis, bilateral internuclear ophthalmoplegia; paralysis, spasticity, and hyperreflexia; abnormal movement and gait;decreased pain and temperature sensation; poor coordination, cranial nerve palsies; dysphasia

catatonia or psychosis may appear before any clear-cut neurological symptoms

delirium, fever, autonomic dysfunction, seizures, rash, focal neurological signs

history of testing HIV-positive; psychosis includes delusions, hallucinations, and cognitive impairment, but anxiety and affective symptoms are less frequent; risk factors such as advanced infection, severe immunosuppression, previous psychiatric history may be present; lower cognitive performance; higher lifetime use of stimulant and sedative misuse; central nervous system opportunistic infection; stressful life events

weight loss and/or wasting; lymphadenopathy; HIV-associated rashes and scars; papular pruritic eruptions, fungal infections, Kaposi's sarcoma, oral thrush, oral hairy leukoplakia; periodontal disease; hepatosplenomegaly; genital warts

risk factors are usually present (sexual contact with an infected person, men who have sex with men, illicit drug users, sex workers, those with multiple sexual partners, and people infected with HIV or other STIs); onset of psychosis varies; may be physical symptoms of headache, dizziness, seizures, ataxia, stroke, blurred vision, bladder incontinence, hearing loss; personality change may occur

primary disease: painless macule evolves into a papule and then a chancre; secondary disease: multisystemic presentation with fever, malaise, myalgia, arthralgia, lymphadenopathy, generalised symmetrical macular, papular, or maculopapular, diffuse rash, typically affecting the palms of the hands and plantar aspects of the feet; tertiary disease: ataxia, wide-based gait, trophic degenerative joint disease, sudden-onset abdominal pain with vomiting, urinary retention, optic atrophy, and Argyll Robertson pupils

an acute confusional state, most often in older and medically ill people; acute or subacute deterioration in behaviour, cognition, or function; change in cognition (e.g., memory deficit, disorientation, language disturbance, perceptual disturbance) that is not better accounted for by a pre-existing, established, or evolving dementia; disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day; may have blurred vision, dry mouth

impaired concentration, confusion, and changes in level of consciousness; psychosis often takes the form of visual hallucinations and persecutory delusions; dilated pupils; increased heart rate; decreased sweating causing fever; constipation, bowel obstruction; urinary retention with distended bladder

vegan diet or known inability to absorb B12 from diet; acute or chronic psychosis, delirium, mood or personality changes

peripheral neuropathy, weakness, decreased positional and vibration sense, cognitive impairment

may have history of high alcohol use accompanied by poor diet, central nervous system symptoms, irritability, forgetfulness, psychosis; may be a sore tongue or oral lesions; nausea, vomiting, abdominal pain, and diarrhoea

low-grade fever is common

complaints of memory impairment, confusion, confabulation, disorientation, psychosis; may be associated history of malnutrition, cirrhosis, diarrhoea, or pyridoxine-inactivating drug use (e.g., anticonvulsants, isoniazid cycloserine, corticosteroids, or penicillamine); may be history of a diet lacking niacin and tryptophan; physical symptoms include poor appetite, nausea, epigastric discomfort, abdominal pain, diarrhoea, increased salivation

may appear malnourished and kwashiorkor may be seen in severe cases; erythematous skin lesions associated with burning sensation, distributed bilaterally in areas exposed to the sun; affected skin may be thick and hyperpigmented; pellagra

may have history of corticosteroid use, weakness, easy bruising, amenorrhoea, decreased libido, history of new-onset diabetes, depression, cognitive dysfunction, emotional lability, increased infections, fractures

truncal obesity, proximal muscle weakness, hirsutism, hypertension, moon facies, supraclavicular fat pads, dorsocervical fat pad

hyperthyroidism: anxiety, heat intolerance, weight loss with increased appetite, oligomenorrhoea; affective psychosis with either depressive or manic components; hypothyroidism: more common in women, weight increase, sensitivity to cold, coarse features, thinning hair, depression, memory impairment, decreased attentiveness, apathy, psychosis; hallucinations, seizures, confusion in adolescents

hyperthyroidism: tachycardia, weight loss, excessive sweating, muscle weakness and tremor; hypothyroidism: coarse dry skin, eyelid oedema, thick tongue, facial oedema, and bradycardia

most patients are >40 years of age; associated with paraneoplastic diseases, commonly with myasthenia gravis; in addition to hallucinations, deja vu, altered consciousness, and changes in taste and smell

cough, shortness of breath

headaches, fatigue, anorexia, nausea, kidney stones, paraesthesias, weakness, and long-standing depression; psychosis (rare); usually occurs in women >50 years; bone fractures suggestive of osteopenia or osteoporosis; history of pancreatitis or peptic ulcers

no specific physical findings; hypertension and signs of congestive heart failure may be present

headache, seizure, stroke, chest pain, arthralgia, myalgia, dyspnoea, haematuria, psychosis (rare); use of corticosteroids

may have any of the physical manifestations of systemic lupus erythematosus, including malar rash, photosensitivity, discoid rash, alopecia, arthritis, fever, pleural effusion, hypertension, oral ulcers

may have family history; may have personality change, inappropriate behaviour, mania, depression, abrupt onset psychosis, sleep disturbances; neurological symptoms include tremor, mild dysarthria, spastic gait, dystonia

liver disease onset usually between ages 8 and 16; jaundice, liver tenderness, spider angiomata, gynaecomastia, ascites, encephalopathy, and easy bruising; Kayser-Fleischer rings on slit-lamp examination of eyes are usually present when patient has neuropsychiatric symptoms

family history may be present; many of these diseases are evident in infancy and are fatal, but some milder forms may not be evident until adulthood; symptoms characteristic to the specific inherited disorders

Niemann-Pick disease: vertical supranuclear gaze palsy, ataxia, myoclonic jerks, spasticity; Tay-Sachs disease: "cherry red spot" on ophthalmoscopy; Fabry's disease: angiokeratoma, hypohidrosis, anhidrosis, slit-lamp examination reveals cornea verticillata (whirl-like white-to-golden-brown opacities extending from the central to peripheral cornea)

developmental delay, 30% to 70% increase in risk of psychosis compared with the general population

dislocation of the lens and/or severe myopia; skeletal abnormalities; signs of thromboembolism

late adolescence or adulthood: predominantly psychiatric symptoms, including auditory hallucinations and bizarre delusions in 50% of patients

gait disturbance and peripheral neuropathy

developmental delay in infants, learning disabilities and behavioural problems in school; gynaecomastia and small testes in adolescent males; infertility; hypospadias, small phallus

tall adult male with disproportionately long arms and legs

psychosis is common, occurring in 10% to 30% of patients; learning difficulties in 70% to 90%

signs of congenital heart disease (74%); palatal abnormalities (69%); hearing loss; seizures; skeletal abnormalities; renal abnormalities

often diagnosed in infancy or early childhood because of hypotonicity, delayed developmental milestones, and insatiable appetite

obesity; hypotonicity; hypogonadism; scoliosis