Synopsis
Assess possible first-episode psychosis urgently and collaboratively, establish phenomenology, risk and function, exclude medical and substance-related causes, and connect the person promptly with age-appropriate early-intervention and physical-health care.
- Possible psychosis includes hallucinations, delusions, marked thought disorganisation, catatonia or sustained behavioural change with impaired reality testing; describe the experience before naming a diagnosis.
- Ask about onset, evolution, mood, sleep, function, trauma, development, substances, prescribed medicines and physical or neurological symptoms using a dated timeline.
- Assess suicide, harm to others, command content, self-neglect, exploitation, driving, dependants, access to means and protective arrangements through specific scenarios.
- Check observations, glucose and physical state and complete targeted neurological examination and investigations when the phenotype suggests an organic cause.
- Seek consented collateral and records because fear, disorganisation or lack of recall can obscure baseline, duration, substance exposure and recent danger.
- Refer without delay to an early-intervention-in-psychosis service or age-appropriate specialist team; primary care should not start antipsychotic treatment unless working with a consultant psychiatrist.
- Before antipsychotic prescribing, record weight, waist, pulse, blood pressure, glucose or HbA1c, lipids, movement findings, nutrition, activity and relevant ECG indications where feasible.
- Offer information, psychological support and family involvement with consent while maintaining diagnostic uncertainty; a first episode does not automatically equal schizophrenia.
Key red flags
Abrupt onset with altered attention, consciousness or orientation suggests delirium and requires urgent identification of infection, hypoxia, metabolic disturbance, toxicity or withdrawal.
Seizure, dyskinesia, catatonia, autonomic instability, new cognitive decline or focal signs raises encephalitis, epilepsy or structural neurological disease.
Commands, persecutory plans, weapon access, inability to delay action or rapidly escalating distress requires a scenario-based suicide and violence response.
Pregnancy, recent childbirth, inability to care for a child or vulnerable adult, exploitation or unsafe accommodation changes urgency and safeguarding arrangements.
Severe thirst, polyuria, weight change, rigidity, fever or collapse after treatment may signal metabolic decompensation or a serious antipsychotic reaction.
Investigation priorities
Define phenomenology, mood, course, function, trauma, development, substances, risk and social context.
Management branches
A person presents with possible hallucinations, delusions, disorganisation or major behavioural change.
- Check physiological stability, attention, consciousness, immediate suicide or violence scenarios, essential intake, dependants and access to means.
- Describe experiences and mood neutrally, build an onset timeline and ask about medicines, substances, sleep, trauma and neurological symptoms.
- Arrange urgent or routine specialist assessment according to danger and physical findings, with a named handover and escalation advice.