Synopsis
Distinguish positive, negative and cognitive manifestations of psychosis, describe their functional consequences accurately, and avoid mistaking depression, medication effects, neurodevelopmental difference or social adversity for primary negative symptoms.
- Positive symptoms add experiences or behaviours, including hallucinations, delusions and disorganised speech or behaviour; the term does not mean beneficial or pleasant.
- Negative symptoms reduce ordinary motivation, expression, speech, pleasure or social engagement and are described as avolition, blunted affect, alogia, anhedonia and asociality.
- Cognitive difficulties commonly affect attention, processing speed, working memory, learning, executive planning and social cognition, often determining everyday disability more than florid psychosis.
- Primary negative symptoms must be separated from depression, fear, sedation, extrapyramidal effects, substance use, poverty, isolation, autism, learning disability and active paranoid avoidance.
- Describe hallucination modality, frequency, control, distress and commands, and record a belief's content, conviction, preoccupation, cultural context and influence on behaviour.
- Assess function directly through self-care, meals, medicines, money, travel, relationships, education and work rather than inferring capability from a short interview.
- Symptom domains overlap but do not move together; hallucinations may improve while motivation, cognition and social recovery remain substantially impaired.
- Use shared language and collaborative goals because labels such as lack of insight or non-compliance can conceal understandable fear, adverse effects and unmet practical needs.
Key red flags
A voice directing immediate suicide or violence, a delusional belief driving confrontation, or accessible weapons makes the content, conviction and intended response an emergency.
Fever, fluctuating attention, altered arousal, seizure, focal neurology, autonomic instability or abrupt late-life onset suggests delirium, encephalitis, toxicity or another medical cause.
Mutism, stupor, posturing, marked negativism, purposeless excitement or new refusal of fluids can indicate catatonia with dehydration, thrombosis and pressure-injury risk.
Profound withdrawal with malnutrition, exposure, unsafe housing, exploitation or inability to manage essential treatment requires active safeguarding and physical-health intervention.
Investigation priorities
Describe perception, belief, thought form, motivation, expression, cognition, mood and current behaviour separately.
Management branches
A person reports unusual experiences, reduced function or cognitive difficulty.
- Explore hallucinations, beliefs and thought form using neutral phenomenological questions and assess distress, commands, conviction and resulting action.
- Ask about motivation, pleasure, expression, speech, attention, memory and planning with examples from ordinary tasks and a clear baseline.
- Summarise positive, negative, cognitive, mood and functional findings separately, recording uncertainty and the person's preferred explanation.
Symptoms are stable enough for collaborative rehabilitation and follow-up planning.
- Identify the functional outcomes the person values and the specific symptoms, cognitive barriers and environmental obstacles affecting each outcome.
- Offer guideline-aligned psychological, family, occupational, educational and physical-health support alongside medication review and shared decision making.
- Measure progress through distress, participation, safety and function as well as positive-symptom change, revising support when domains diverge.