Recommendations
Urgent
Risk assess the situation to ensure the safety of the patient and yourself.[60]
Find out about the patient’s background before seeing them.[60]
What led to their presentation today?
Do they have any physical health issues?
Are they disorientated, suspicious, or distressed at the moment?[61]
Take a chaperone if there are any concerns.[61]
Assess the patient’s suicide risk carefully and sensitively.[62] See Suicide risk mitigation.
If the patient wants to leave before further assessment and treatment, consider assessing their mental capacity to make this decision. Always assume the patient has capacity, unless there is evidence to suggest an assessment is required.[63][64] Seek help from a senior colleague if needed.
Apply the principles of the Mental Capacity Act 2005 and its Code of Practice.[63] Mental Capacity Act 2005: Code of Practice Opens in new window
In Scotland, the Adults with Incapacity Act 2000 is used. Adults with Incapacity Act Opens in new windowIn Northern Ireland, the Mental Capacity Act (Northern Ireland) 2016 is used. Mental Capacity Act (Northern Ireland) 2016 Opens in new window
Give the patient the opportunity to make informed decisions about their care and treatment and take into account their needs and preferences.[65]
Always ensure there is appropriate follow-up in place if the patient leaves.
Consider whether your patient may need help from the mental health team; contact the team urgently if you suspect an acute mental illness and think the patient may require urgent treatment.[66]
In practice, many patients may have acute treatment in the community. Consider this, with support from the crisis resolution and home treatment teams if necessary, before admission to an inpatient unit.[1]
Key Recommendations
Schizophrenia should be diagnosed by a specialist; diagnosis is based on clinical assessment, as well as by ruling out an organic cause of symptoms.[67][68] See Assessment of psychosis.
Important features of schizophrenia include:[3][4]
Hallucinations in any sensory modality, but most often auditory
Delusions (which also include thought withdrawal, insertion, block, and broadcast, and delusional perception)
Passivity phenomena (feelings or actions experienced by the patient as being influenced or created by external agents)
Negative symptoms such as apathy or lack of motivation
Disorganised thinking (formal thought disorder).
Include a full psychiatric history in your assessment and identify any risk factors for schizophrenia. If possible, obtain a collateral history (e.g., from a relative or partner) to establish the presentation and course of symptoms.[67]
Other key features to ask the patient about are:
Personal history
Family history
Premorbid personality
Social history and current social circumstances
Cultural history
Forensic history
Past medical history (e.g., cardiometabolic disease, autoimmune conditions), current and past medications (including any allergies)
Drug and alcohol history
Assessment of insight.
Risk assess the situation to ensure the safety of the patient and yourself before reviewing the patient.
Find out about the patient’s background before seeing them.[60]
What led to their presentation today?
Are there any physical health concerns?
Are they disorientated, suspicious, or distressed at the moment?[61]
If there are concerns, take a chaperone with you who is not associated with the patient (e.g., security personnel, nurse, healthcare assistant).[61]
Assess the patient’s suicide risk carefully and sensitively.[62] See Suicide risk mitigation.
Practical tip
You may need to contact mental health services to access a patient’s mental health records if based in the UK, as access to patient records may vary between different services. Gaining background information is essential, however, especially out of hours.
If the patient wants to leave before further assessment and treatment, consider assessing their mental capacity to make this decision. Always assume the patient has capacity, unless there is evidence to suggest an assessment is required.[63][64] Seek help from a senior colleague if needed.
Apply the principles of the Mental Capacity Act 2005 and its Code of Practice if based in England or Wales.[63] Mental Capacity Act 2005: Code of Practice Opens in new window
In Scotland, the Adults with Incapacity Act 2000 is used. Adults with Incapacity Act Opens in new window In Northern Ireland, the Mental Capacity Act (Northern Ireland) 2016 is used. Mental Capacity Act (Northern Ireland) 2016 Opens in new window
Give the patient the opportunity to make informed decisions about their care and treatment and take into account their needs and preferences.[65]
Always ensure there is appropriate follow up in place if the patient leaves.
Consider whether your patient may need help from the mental health team; contact the team urgently if you suspect an acute mental illness and think that the patient may require urgent treatment.[66]
In practice, many patients may have acute treatment in the community. Consider this, with support from crisis resolution and home treatment teams if necessary, before admission to an inpatient unit.[1]
Practical tip
If the patient needs to be admitted to an inpatient unit, they may agree to this voluntarily or it may be necessary to use legal procedures to admit the patient involuntarily. The Mental Health Act 1983 is used in England and Wales.[69] Mental Health Act 1983: Code of Practice Opens in new window In Scotland, the Mental Health (Scotland) Act 2015 is used.[70] Mental Health (Scotland) Act 2015 Opens in new window In Northern Ireland, the Mental Capacity Act (Northern Ireland) 2016 is used.[71] Mental Capacity Act Code of Practice (Northern Ireland) Opens in new window
Patients may present with symptoms or signs of psychosis, or an ‘at-risk mental state’ - for more information, see Prevention.
Be aware of organic causes of acute psychosis that can mimic schizophrenia.[67][68] See Assessment of psychosis.
Refer any patient with psychosis for a specialist assessment (e.g., an early intervention in psychosis or community mental health team) as soon as possible if they do not already have a diagnosis of psychosis or schizophrenia.[72]
Practical tip
Schizophrenia is a mental health condition with specific diagnostic criteria.[3][4] See Criteria.
Psychosis refers to the presence of one or more psychotic symptoms that can be caused by a range of physical and mental illnesses.
It is important to recognise that not all patients with psychosis will develop schizophrenia.[5] Most people make a good recovery following a first episode of psychosis. Data vary, but it is estimated that up to 20% of patients will make a full recovery.[5] Many people who have subsequent episodes of psychosis maintain a good quality of life despite symptoms.
Evidence: Predicting outcome following first-episode psychosis
Despite the development of many different prediction models for first-episode psychosis, none are validated for clinical use.
There are no validated clinical tools to assess individual risk of further episodes of psychosis following first-episode psychosis (FEP); however, there have been multiple attempts to identify independent risk factors and develop prediction models.
A systematic review of prediction models (search date January 2021) included 13 studies covering 31 models.[73]
Only two studies were at low risk of bias. Issues included small sample sizes, lack of external validation of the model, and inappropriate handling of missing data. All studies were in high-income countries and only three included non-European populations.
Two studies were in an outpatient setting only, and four were in both inpatients and outpatients; the rest did not specify the setting. Follow-up ranged from 1-10 years.
The 13 studies between them considered 258 candidate predictors. The majority focused on sociodemographic and clinical factors, with only one study also considering environmental and genetic factors.
Outcomes included symptom remission, global functioning (e.g., employment, education, or training status; Global Assessment of Functioning score; Disability Assessment Schedule score), treatment resistance, hospital readmission, and quality of life.
All of the models were research tools only with none being used in clinical practice.
The majority of cohorts used to develop the models only included people with non-affective psychosis; this might limit their generalisability to people with FEP in clinical settings.
Most of the prediction models in the systematic review were developed using logistic regression; however, machine learning is increasingly being used, which may help with the complexity and degree of individuality required in predicting outcomes following FEP.[73][74]
Biomarkers are emerging as a potential area of interest in predicting the outcome of a first episode of psychosis, and in the future they may improve the performance of prediction models. However, the evidence is very limited and they are not being used currently in clinical practice.[73][75][76]
Perform a mental state examination looking particularly for symptoms of psychosis associated with schizophrenia.[66] BMJ: how to approach the mental state examination Opens in new window
Start by assessing the patient’s appearance and behaviour; they may:
Appear poorly kempt due to poor self-care
Be observed responding to hallucinations if these are present
Show signs of catatonia.
Identify features of psychosis associated with schizophrenia; these may include:
Hallucinations[77]
Hallucinations are perception-like experiences that occur without an external stimulus. They are vivid and clear, with the full force and impact of normal perceptions, and not under voluntary control.[3]
These are typically auditory but may involve any sensory modality. The patient may hear their own thoughts spoken aloud (thought echo) or hear voices referring to themself, typically in the third person or in the form of a commentary.
Tactile hallucinations involve the perception of a physical experience within the patient’s body (e.g., electrical pulses, crawling sensation).[77][78]
Less common hallucinations include visual, olfactory, and gustatory hallucinations.
Delusions[77]
Delusions refer to fixed beliefs that are not reality based and cannot be explained as part of the patient's cultural background.[3] They are not amenable to change in light of conflicting evidence.[3]
Persecutory/paranoid delusions are most common.
The most characteristic delusion of schizophrenia is 'delusional perception', in which the delusion arises at the same time as, and apparently out of, a normal perception.[77]
Interpret delusional symptoms in the context of the patient’s culture and also what is normal for the patient.[67] Be aware that there can be significant differences in beliefs within a single culture; it is important to establish the patient’s previous beliefs. If indicated, psychosis should be assessed through interpreters or in a second or third language to avoid the misunderstanding of unfamiliar metaphors as delusions.[3]
Passivity phenomena[77]
The patient may feel that their thoughts or actions are controlled by an outside agency. Examples include feeling that thoughts are: removed (thought withdrawal), inserted (thought insertion), or known to others (thought broadcast).
Sudden pauses in the patient’s speech may indicate thought withdrawal.[79]
Negative symptoms
These include flattened affect, apathy, anergia, social withdrawal, and anhedonia (these can be difficult to differentiate from comorbid depression - see Depression in adults).
Disorganised thinking (formal thought disorder), which includes:
Tangentiality
Loosening of association (derailment)
Circumstantiality
Distractible speech
Word salad
Catatonia
Signs of catatonia include stupor, waxy flexibility, mutism, catalepsy, negativism, posturing, mannerisms, stereotypy, echolalia, and echopraxia.
Altered cognition
Schizophrenia affects all cognitive domains, including attention, language, memory, executive function, and processing speed.[3]
Cognitive deficits in schizophrenia are common and are strongly linked to vocational and functional impairments.[3]
Some people with schizophrenia show social cognition deficits, including deficits in the ability to infer the intentions of other people (theory of mind).[3]
Consider using a formal test such as the Abbreviated Mental Test Score to assess this. Abbreviated Mental Test Score Opens in new window
Practical tip
Be aware that these symptoms are not exclusively seen in schizophrenia. ‘First-rank’ symptoms of schizophrenia (these include auditory or somatic hallucinations, thought withdrawal, thought insertion, thought interruption, thought broadcasting, delusional perception, and passivity phenomena) occur in about one quarter of people with mania so are not specific for schizophrenia.[77][80]
Always assess the patient’s insight (the extent of their understanding of their experience).[66] Useful questions to ask include:
‘What do you feel are your difficulties at the moment?’
‘What do you think might be causing how you’re feeling?’
‘Do you think medical treatment or therapies would help?’
Loss of insight is the most common predictor of non-adherence to treatment, and it predicts higher relapse rates, increased number of involuntary treatments, poorer psychosocial functioning, aggression, and an unfavourable course.[3]
Practical tip
Comorbid depression and anxiety are common in patients with schizophrenia but are commonly missed; always assess the patient’s mood.[81][82] See Depression in adults and Generalised anxiety disorder.
Assess the patient’s suicide risk carefully and sensitively.[85] See Suicide risk mitigation.
Practical tip
Around 5% of patients with schizophrenia die by suicide.[86] However, poor physical health is the main cause of premature death in patients with schizophrenia.[87] Patients with auditory hallucinations, delusions, substance misuse, comorbid depression, or a history of suicide attempts are at higher risk for suicide.[86][88][89] Risk of suicide is highest in the year after the first presentation of psychosis.[88]
Assess the patient’s risk to others. Royal College of Psychiatrists: assessment and management of risk to others Opens in new window
Sometimes, patients may understandably become very agitated or distressed by psychosis. They may use aggression as a defence against apparent persecutors, which can increase the risk of harm to themselves and others.
Past psychiatric history
Ask about previous:
Diagnosis of mental illness[1]
Contact with psychiatric services and admissions
Treatments and response of symptoms to these treatments, plus any adverse effects[1]
Risk, including previous harm to self (i.e., self-harm, neglect), from others (i.e., vulnerability), or to others.[1]
Review current treatment and consider the possibility of non-adherence with prescribed medication.[1][90]
Explore reasons behind non-adherence (e.g., adverse effects, problems picking up prescriptions).
Assess for post-traumatic stress disorder and other reactions to trauma.[1] See Post-traumatic stress disorder.
Patients with psychosis or schizophrenia are likely to have experienced previous adverse events or trauma that is associated with the development of the psychosis, as a result of the psychosis, or related to previous treatment, admissions, or experience of health care (especially if they were previously detained under the Mental Health Act).[5][91]
Risk factors
Assess risk factors for schizophrenia. Ask about:
Family history of schizophrenia
This is the strongest single indicator of individual risk of developing schizophrenia.[92]
The closer the family relationship to an affected relative, the higher the risk.[23][24][37] People with an affected first-degree relative (e.g., parent, child, sibling) have an approximate lifetime incidence of 6% to 17% of schizophrenia.[38]
Environmental factors
Developmental factors
Social factors
Recent stressors or significant changes in the patient's life, such as job loss, death of a significant other, educational stress, or other traumatic event.[67]
Substance misuse.
Practical tip
Be aware that many patients who have risk factors for schizophrenia never develop the illness, and conversely some patients with schizophrenia may have no risk factors for it. Presence of risk factors should not be used as evidence for the diagnosis of schizophrenia.
Practical tip
Comorbid substance misuse is very common in schizophrenia and is not necessarily the cause of psychotic symptoms (e.g., some people may misuse substances to cope with symptoms of psychosis, or develop psychosis that is independent of substance misuse).[101]
Other useful information
Ask about the patient’s personal history, premorbid personality, social and cultural history, forensic history, past medical history (e.g., cardiometabolic disease, autoimmune conditions), family history, current and past medications (including any allergies), and drug and alcohol history.
Interpret delusional symptoms in the context of the patient’s culture and also what is normal for the patient.[67] Be aware that there can be significant differences in beliefs within a single culture; it is important to establish the patient’s previous beliefs. If indicated, psychosis should be assessed through interpreters or in a second or third language to avoid the misunderstanding of unfamiliar metaphors as delusions.[3]
Family history should include physical disorders that might increase the risk of harm from antipsychotic medication, such as a myocardial infarction or sudden cardiac death in a first-degree relative before the age of 60 years, type 2 diabetes, or epilepsy.[68]
Ask about other features that may not be directly related to the presenting complaint but may guide management, including social factors such as smoking, housing, employment history, and financial situation.
Always check whether the patient could be pregnant. Pregnancy is not covered in this topic; discuss pregnant patients with a senior colleague.
Collateral history
Take a collateral history from friends or family where possible, with the patient’s consent and respecting confidentiality. Establish the presentation and course of the symptoms.[67]
Cultural considerations
Consider cultural and socio-economic factors when interpreting symptoms and, if indicated, carry out your assessment through interpreters or in a second or third language to avoid the misunderstanding of unfamiliar metaphors as delusions.[3][9]
Ideas that appear to be delusional in one cultural context (e.g., evil eye, causing illness through curses, influences of spirits) may be commonly held in others.
Visual or auditory hallucinations with a religious content (e.g., hearing God’s voice) may be an expected component of some religious experiences.
If the assessment is conducted in a language that is different from the patient’s primary language, care must be taken to ensure that alogia (paucity of speech) is not related to linguistic barriers.
In certain cultures, distress might take the form of hallucinations and overvalued ideas; although presentation may be clinically similar to true psychosis, these manifestations might be a product of the patient’s cultural or social group.[9]
Misdiagnosis of schizophrenia in patients with other psychiatric disorders is more likely to occur in certain racial groups. This may be attributable to clinical bias, racism, or discrimination leading to misinterpretation of symptoms.[9]
Perform a full physical examination and consider investigations to rule out an organic cause of psychosis.[67][68] Soft neurological signs (minor abnormalities in motor performance on clinical examination: for example, rigidity, gait imbalance, tremor, smooth pursuit eye movement deficit, a sensory integration deficit, and right-left disorientation) are common in patients with schizophrenia.[3][51][52] These signs are related to the severity of negative symptoms.[53][54][55] See Assessment of psychosis.
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