How to approach psychotic symptoms in a non-specialist setting

• Published in: BMJ (Online) Vol. 359; p. j4752
• Main Authors: Sami, Musa Basseer, Shiers, David, Latif, Saqib, Bhattacharyya, Sagnik
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group LTD 08.11.2017
• Subjects: Alcohol; Antipsychotics; General Practice - methods; General Practice - standards; Hallucinations; Humans; Marijuana; Mental disorders; Mental health care; Patients; Practice Guidelines as Topic; Primary care; Primary Health Care - methods; Primary Health Care - standards; Psychiatry; Psychosis; Psychotic Disorders - diagnosis; Referral and Consultation - standards; Risk Factors; Schizophrenia; Social networks; Social research; Symptom Assessment - methods; Symptom Assessment - standards; Verbal communication
• ISSN: 0959-8138; 1756-1833
• DOI: 10.1136/bmj.j4752

What you need to know Listen carefully to the patient: frank psychotic symptoms (positive or negative) may not be apparent initially-be alert to sub-threshold symptoms such as problems with mood or sleep; alteration in personality, and functional decline Take family concerns seriously and actively seek from them relevant information (or from school or university, as appropriate) Accompaniment by family or carers at appointments can be particularly helpful, but ask your patient whether they also want to be seen alone during the appointment Fig 1Puppet Schizophrene by Bryan Charnley (1949-1991), who had schizophrenia ( www.bryancharnley.info ). © The estate of Bryan Charnley, reproduced with permission Identification of psychotic symptoms in non-specialist settings is key to initiating timely pathways to care. A systematic review of 30 observational studies of pathways to care of first-episode psychosis showed that first contact was more usually through a physician than through emergency services. 1 This article is aimed at generalists, primary care physicians, and hospital doctors, who play a critical role and who require a low threshold for referral for specialist assessment, sometimes before diagnosis is certain. 2 Prompt intervention is key to improving outcome. Full blood count Urea and electrolytes Liver and thyroid function tests Urine sampling to rule out illicit drug use If organic differential suspected or neurological features (such as focal neurology or seizures), test for HIV, syphilis (VDRL test), vitamin B12, anti-NMDA receptor antibodies Consider neuroimaging (computed tomography of head or magnetic resonance imaging) particularly if neurological features (somnolence, seizures, recent head trauma) or abnormalities on neurological exam are present Baseline metabolic assessment before starting antipsychotic medication: First I was given an online CBT course, then drowsy anti-histamine tablets, then SSRIs.