Mental Health · Full case
Psychosis & Schizophrenia
Psychosis & Schizophrenia · Clinical Reasoning Framework v2
GP & SCA · NICE CG178 · First-episode psychosis · Early Intervention (EIP) · exclude organic/drugs · risk · antipsychotics & physical health · families
Refer early — don't treat aloneSuspected first-episode psychosis should be referred urgently to a community mental health team / Early Intervention in Psychosis (EIP) service. In primary care, do NOT start antipsychotics for a first episode without specialist assessment (unless advised) — refer
DUP mattersA shorter duration of untreated psychosis (DUP) predicts better outcomes — which is why early recognition and urgent referral matter. EIP services support 14–65-year-olds with a first episode and reduce relapse, admission and self-harm
Exclude organic & drug causesPsychosis is not always "psychiatric": exclude delirium, substance misuse/withdrawal (cannabis, stimulants, alcohol), prescribed drugs (steroids, dopaminergics), and organic disease (temporal lobe epilepsy, encephalitis, thyroid, B12, SLE, tumour, dementia). New psychosis in the older patient is delirium until proven otherwise
Positive vs negative symptomsPositive: hallucinations (often auditory), delusions, thought disorder, passivity. Negative: blunted affect, apathy, social withdrawal, poverty of speech — often the most disabling and easily mistaken for depression or "drifting"
Risk — to self, from others, to othersAssess suicide/self-harm (markedly raised in psychosis), risk from command hallucinations/delusions, self-neglect, vulnerability/exploitation, and risk to others (less common than feared but must be assessed) — and safeguarding of any dependents
Antipsychotics need monitoringAntipsychotics carry metabolic (weight, glucose, lipids), cardiac (QTc), prolactin and extrapyramidal effects. NICE mandates baseline + ongoing physical-health monitoring; GPs play a central role. Clozapine (for treatment-resistant schizophrenia) needs mandatory blood monitoring (agranulocytosis)
People with SMI die youngerPeople with severe mental illness die ~15–20 years earlier, largely from cardiovascular disease — proactive annual physical-health checks (BP, weight, lipids, glucose, smoking) and treatment are a core GP responsibility, not an afterthought
Involve family & carersWith consent, involve family/carers — they aid history, support engagement and adherence, and need support themselves. Family intervention and CBT for psychosis are NICE-recommended alongside medication. Watch the Mental Health Act threshold where risk/refusal endangers safety
📋 Clinical Stem — Psychosis & Schizophrenia
A 21-year-old student brought by his worried mother — withdrawn for months, now convinced his housemates are spying on him and hearing voices commenting on him
Daniel Osei, 21, a university student, is brought in by his mother, who is frightened by how he has changed. Over 4–5 months he has become increasingly withdrawn, stopped attending lectures and seeing friends, and neglected his self-care. In the last few weeks he has become convinced his housemates are spying on him and have "bugged" his room, and he hears two voices commenting on what he is doing. He is guarded and suspicious in the consultation, sleeps poorly, and has been smoking high-potency cannabis daily. There is a family history of schizophrenia in an uncle. He has had fleeting thoughts that he might be "better off dead" but denies any plan. He has no fever or confusion and is physically well.
This stem tests the ability to: recognise a first episode of psychosis (positive symptoms — persecutory delusions, third-person auditory hallucinations — on a background of months of negative symptoms/decline), and to assess it sensitively in a guarded patient; to assess RISK thoroughly (suicide/self-harm, command hallucinations, self-neglect, vulnerability, risk to/from others, safeguarding); to exclude organic and drug causes (cannabis, delirium, organic disease) with history, examination and baseline investigations; to refer URGENTLY to the community mental health team / Early Intervention in Psychosis service rather than starting antipsychotics alone in primary care; to engage and support the family with consent; and to understand the longer-term GP roles (physical-health monitoring, relapse prevention). The SCA challenge is building enough rapport with a suspicious young man to assess risk and facilitate referral, while supporting a frightened parent and being honest within the limits of confidentiality.
Scenario A — First-episode psychosis (this stem) Young person, positive + negative symptoms, cannabis use, family history. Risk assessment; exclude organic/drug causes; urgent EIP/CMHT referral; engage family (consent); don't start antipsychotics alone; safety-net.
Scenario B — Acute risk / crisis Command hallucinations to harm self/others, active suicidality, severe self-neglect, or refusal endangering safety. Crisis team / urgent psychiatric assessment; consider Mental Health Act.
Scenario C — Organic psychosis / delirium Older patient, acute onset, fluctuating, clouded consciousness, fever, focal signs. Treat as delirium — find and treat the cause; admit/medical work-up, not a psychiatric label.
Scenario D — Drug-induced psychosis Stimulants/cannabis/withdrawal. Manage substance use; may resolve, but new psychosis still warrants assessment; comorbid SMI common.
Scenario E — Established schizophrenia (GP role) Known patient on antipsychotics: physical-health monitoring, relapse signs, adherence, clozapine bloods, comorbidity, carer support, shared-care.
Key variables to adapt for First episode vs established vs crisis; positive/negative symptoms; organic/drug causes (age, onset, confusion); risk (self/others/neglect/vulnerability/safeguarding); cannabis/substances; family history & involvement; antipsychotic monitoring & physical health; Mental Health Act threshold; confidentiality with families.
Steps:
1
Step 1
History — Engage the Guarded Patient · Symptoms · Risk · Organic/Drug Causes · ICE
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The history has to do several hard things at once: build enough trust with a suspicious young man to explore his experiences; characterise the psychotic symptoms (positive and the often-missed negative); conduct a thorough risk assessment; and screen for the organic and drug causes that must not be mislabelled as schizophrenia. Rapport is not a nicety here — without it, Daniel discloses nothing and the risk assessment fails.
🎓 SCA framing — gentle, non-confronting, curious
"Thanks for coming in — I can see this is hard. I'm not here to judge or to catch you out; I just want to understand what life's been like for you lately. Can you tell me how things have been?"
Don't challenge delusions or argue with them; explore them with curiosity ("that sounds frightening — tell me more about it"). A non-confronting, validating stance is what allows a guarded, paranoid patient to talk, and is the gateway to assessing risk.
1A — Symptoms, risk and causes
1B — Red flags
🚨
Red Flags — risk and the organic mimics
| Red flag | Why dangerous | Action |
|---|---|---|
| Active suicidality / command hallucinations to harm self or others | Suicide risk is markedly raised in psychosis; command hallucinations can drive acts. | Urgent psychiatric/crisis assessment; safety plan; consider Mental Health Act if refusing & at risk |
| Severe self-neglect / inability to care for self / vulnerability & exploitation | Risk to health and safety; safeguarding of patient and any dependents. | Urgent assessment; safeguarding; consider admission |
| Delirium / organic psychosis — acute onset, fluctuating, clouded consciousness, fever, focal neurology, older age | A medical emergency mislabelled as "psychiatric"; encephalitis, metabolic, structural causes. | Treat as delirium — medical assessment/admission; find & treat the cause |
| First-episode psychosis (any) | Shorter duration of untreated psychosis improves outcomes; needs specialist assessment, not GP-alone treatment. | Urgent EIP/CMHT referral; do not start antipsychotics alone |
| Neuroleptic malignant syndrome (in treated patients) — rigidity, fever, autonomic instability, ↑CK | Life-threatening reaction to antipsychotics. | Stop antipsychotic; emergency admission |
| Clozapine patient with fever/sore throat (neutropenia) or new illness | Agranulocytosis / myocarditis — life-threatening. | Urgent FBC; liaise with the clozapine service; emergency assessment |
1C — ICE
💭 Ideas
"What do you make of what's been happening to you — what do you think is going on?"
Daniel may have little insight, or a frightening explanation (the housemates are real to him). Understanding his model lets you meet him where he is — neither colluding with nor flatly contradicting the delusion — and frame help in terms he can accept (stress, sleep, the distress of the voices).
😟 Concerns
"What's been the hardest or most frightening part of all this for you?"
His concern may be fear of the voices, of being watched, or of being "mad"/sectioned. Naming it builds trust, reduces threat, and lets you offer help framed around reducing his distress rather than labelling him.
🎯 Expectations
"What were you hoping might come from today — and what would feel like help to you?"
He may not want help, or fear hospital. Naming this lets you explain the supportive, non-coercive role of the specialist team, address fears about being sectioned, and negotiate engagement — central to a successful, consensual referral.
1D — Psychosocial context
🤝 Engagement over confrontation
Don't argue with delusions; build trust around shared goals (sleep, less distress).
"I can't fully know what you're experiencing, but I can see it's distressing and exhausting. Whatever's behind it, I'd like to help you feel safer and sleep better — can we work on that together?"👪 The frightened family
Support the mother; seek consent to involve her; signpost carer support.
"I can see how worried you are, and bringing him in was the right thing. With Daniel's permission I'd like to keep you involved — and there's support for families going through this too."😨 Fear of being "sectioned"
Address the fear of hospital/coercion honestly.
"Most people get help without ever going into hospital — the team I want to involve work with you in the community. My aim is to support you, not to take control away from you."🌱 Hope & early help
Convey realistic hope — early treatment helps.
"Getting help early genuinely makes a difference to how things go. There are effective treatments and a specialist team for exactly this — you don't have to manage it alone."🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills
Key phrases that score
"Tell me about the voices — what do they say?" + "Do they ever tell you to do things?" — characterises symptoms and command-hallucination risk.
"Have you had thoughts of harming yourself?" — explicit risk assessment.
"I'm not here to judge or take control — I want to help you feel safer." — engagement.
Deductions
- Arguing with / challenging delusions; confrontational stance
- Not assessing risk (suicide, command hallucinations, neglect, to others)
- Not screening drugs/organic causes
- Breaching confidentiality with family without consent (outside risk)
🔴 Red
No risk assessment; confronts delusions; organic/drug causes missed; starts antipsychotic alone; no referral
🟠 Amber
Recognises psychosis; partial risk assessment; some cause screen; referral vague; family/consent partly handled
🟢 Green
Engages without confrontation; characterises positive & negative symptoms; full risk assessment; excludes drug/organic; urgent EIP/CMHT referral; supports family with consent; ICE all three
2
Step 2
Triage — Crisis/MHA · Urgent EIP/CMHT · Medical (Organic)
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The triage hinge is risk and cause: acute risk or refusal endangering safety needs the crisis team and possibly the Mental Health Act; suspected organic psychosis/delirium needs medical assessment; and a first episode without acute risk needs urgent EIP/CMHT referral. Daniel — first episode, passive suicidal thoughts, no immediate plan, physically well — needs urgent EIP referral with a safety plan, not (yet) the crisis team.
🔴 Emergency
Same day / crisis
Immediate- Acute risk to self/othersActive suicidality, command hallucinations, violence → crisis team / urgent psychiatry; MHA if needed
- Severe self-neglect / refusal endangering safetyUrgent assessment; consider MHA
- Suspected delirium / organic causeMedical assessment/admission
🟠 Urgent
Days
EIP / CMHT- First-episode psychosis (no acute risk)Urgent EIP/CMHT referral; safety plan
- Relapse of known psychosisCMHT/care coordinator
- Significant substance-induced psychosisMH + substance services
🟢 Routine
GP / shared care
Ongoing role- Stable established schizophreniaPhysical-health monitoring; relapse vigilance; adherence
- Clozapine shared careBloods; liaise clozapine service
- Carer supportFamily intervention; carer's assessment
🎓 SCA Checkpoint — Step 2Tasks
Triage rationale
"You're not in immediate danger today, which is good — so rather than hospital, I want to get you seen urgently by a specialist team that helps young people with exactly these experiences, and we'll make a safety plan in the meantime."
Deductions
- Missing acute risk / not escalating to crisis/MHA when needed
- Treating organic psychosis as psychiatric
- Routine (non-urgent) referral for a first episode
3
Step 3
Assessment — Mental State · Risk Formulation · Physical/Cognitive Screen
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"Examination" is the mental state examination and risk formulation, plus a physical and cognitive screen to exclude organic causes — clouded consciousness, fever or focal signs point away from primary psychosis.
🎓 SCA Checkpoint — Step 3TasksGlobal Skills
Demonstrating the formulation
"My assessment is a likely first episode of psychosis — persecutory beliefs and voices on a background of months of withdrawal — with current risk of self-harm low but present, no signs of a physical cause, and heavy cannabis use as a factor. That needs urgent specialist assessment."
Deductions
- No explicit risk formulation
- No cognitive/physical screen to exclude organic cause
4
Step 4
Investigations — Exclude Organic · Drug Screen · Antipsychotic Baseline
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Investigations exclude organic causes, screen for substances, and establish a physical-health baseline before antipsychotic treatment — much of this is initiated in primary care or shared with the specialist team.
🎓 SCA Checkpoint — Step 4Tasks
Key reasoning
"I'll do some blood tests to rule out physical causes like thyroid or infection, and to get a baseline before any medication the specialist might start — and we'll factor in the cannabis use."
Deductions
- No organic screen / drug screen
- Not establishing a physical-health baseline
5
Step 5
Diagnosis — Psychosis · Schizophrenia · Organic/Drug · Affective · Differentials
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In primary care the working diagnosis is "first-episode psychosis" — the formal diagnosis (schizophrenia vs other) is the specialist's job after assessment over time. The GP's task is to recognise psychosis, exclude organic/drug causes, and refer; not to apply the schizophrenia label prematurely.
🚩 Recognise and refer — don't over-label or under-treat
The GP's job is not to diagnose schizophrenia but to recognise psychosis, exclude organic/drug causes, assess risk, and get specialist help quickly. For Daniel the formulation is a likely first episode of psychosis with heavy cannabis use and a family history, current self-harm risk low but present, no organic red flags — requiring urgent EIP referral, a safety plan, family support with consent, and physical-health baseline, but NOT a GP-initiated antipsychotic or a premature schizophrenia label.
🎓 SCA Checkpoint — Step 5Tasks
Explaining it plainly
"I think you're having experiences doctors call psychosis — the mind can start to perceive threats and voices that feel completely real. It's treatable, and there's a specialist team for young people I want to involve quickly. I won't put a bigger label on it now — that's something they'll work out with you over time."
Deductions
- Diagnosing "schizophrenia" prematurely
- Not excluding drug/organic causes before labelling
6
Step 6
Referral — Crisis/MHA · EIP/CMHT · Medical · Substance · Carer Support
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Referral is the core action: urgent Early Intervention in Psychosis / community mental health team for a first episode; the crisis team (and Mental Health Act) for acute risk; medical services for organic causes; substance services where relevant; and carer support for the family.
🎓 SCA Checkpoint — Step 6Tasks
The key action
"The most important thing today is to get you seen quickly by the Early Intervention team — they specialise in helping young people through exactly this, in the community. I'll make that referral urgently and we'll agree what to do if things feel worse before they see you."
Deductions
- Starting an antipsychotic alone instead of referring
- Not escalating acute risk to crisis/MHA
7
Step 7
Management — Safety Plan · Specialist Treatment · GP Physical-Health Role · Family
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Immediate primary-care management is a safety plan and an urgent referral, not GP-initiated antipsychotics. Longer term, the GP's roles are central: physical-health monitoring (people with SMI die younger), supporting adherence and relapse prevention, clozapine shared care, and supporting the family — alongside the specialist treatments (antipsychotics, CBT for psychosis, family intervention).
7A — Now and ongoing
🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills
A plan that scores
"Here's the plan: an urgent referral to the Early Intervention team today, some blood tests, and a clear plan for if things feel worse — including who to call. With your permission I'll keep your mum involved. I won't start medication myself; the specialists will discuss that with you. We'll also look after your physical health along the way."
Deductions
- Starting an antipsychotic alone for a first episode
- No safety plan / no physical-health consideration
- Excluding the family entirely, or breaching confidentiality without consent (outside risk)
Psychosis & Schizophrenia — SCA Consultation Scorecard
Engage · risk · exclude organic/drug · urgent EIP referral · family · physical health
0/ 33 pts
Global Skills
Structure, language, responsiveness
0/7
Tasks
Clinical reasoning, diagnosis, management
0/15
Relating to Others
Communication, rapport, shared decisions
0/11
RAG Self-Assessment
🔴 Red
No risk assessment; confronts delusions; organic/drug not excluded; antipsychotic started alone; no referral; family mishandled
🟠 Amber
Recognises psychosis; partial risk assessment/cause screen; referral made but not clearly urgent; family/safety partial; ICE partial
🟢 Green
Engages without confrontation; full risk assessment; excludes organic/drug; urgent EIP referral (no GP-alone antipsychotic); family with consent; safety plan; physical-health awareness; ICE all three
Complete the checklist to see your score and feedback
(Guarded, arms folded, glancing at the door) "I don't really want to be here — my mum made me come. There's nothing wrong with me. I just want people to leave me alone."
Who you are
Daniel Osei, 21, university student, brought by your worried mum. Over 4–5 months you've withdrawn — stopped lectures, stopped seeing friends, stopped looking after yourself. In the last few weeks you've become convinced your housemates are spying on you and have bugged your room, and you hear two voices commenting on what you're doing (talking about you in the third person). You sleep badly and smoke strong cannabis every day. An uncle has schizophrenia. You've had fleeting thoughts you'd be "better off dead" but no plan. You're guarded and suspicious; you'll only open up if the doctor is calm, patient and clearly not trying to trap or judge you. You don't think you're ill and you're scared of being "locked up".
Hidden concerns (reveal if explored, slowly)
Fear of the voices / being watched (main): it's frightening and exhausting; if the doctor is gentle, you admit how distressing it is.
Fear of being sectioned: you worry that admitting things means hospital. Reassurance about community help lowers your guard.
Passive suicidal thoughts: you'll disclose these only if asked directly and kindly; no current plan.
Cannabis: you don't connect it to how you feel; defensive if lectured.
Clinical details if asked (and trust is built)
- Persecutory beliefs (housemates spying/bugging); third-person auditory hallucinations commenting on you
- 4–5 months of withdrawal, stopping studies/friends, self-neglect (negative symptoms)
- Daily high-potency cannabis; poor sleep; family history (uncle with schizophrenia)
- Passive thoughts of being better off dead; no plan/intent; voices don't (currently) command harm
- No fever, confusion, head injury, fits; physically well; not on medications
Reactions at key moments
- If confronted/contradicted ("that's not real"): you shut down, become more guarded.
- If explored gently ("that sounds frightening — tell me more"): you slowly open up.
- On risk questions asked kindly: you admit the dark thoughts.
- On "community team, not hospital": you relax a little and become more willing.
- Challenge line: "You think I'm crazy, don't you? Are you going to lock me up?"
"You think I'm mad, don't you? Is that what this is — you're going to get me sectioned and locked away?"
Resolution: Daniel engages if the GP: (1) builds rapport with a calm, non-judgmental, non-confronting manner and explores his experiences without arguing; (2) characterises the positive and negative symptoms and conducts a thorough risk assessment (suicide, command hallucinations, neglect, to/from others); (3) excludes organic/drug causes (cannabis, delirium) with history and baseline bloods/drug screen; (4) refers him urgently to the Early Intervention in Psychosis team rather than starting an antipsychotic in primary care, and makes a safety plan; (5) supports his mother with his consent, addresses his fear of being sectioned, and instils hope. He disengages and discloses nothing if confronted, judged, or threatened with hospital.
Clinic Quick Reference
Psychosis & Schizophrenia — Clinical Decision Framework
CG178 · recognise · risk · exclude organic · refer EIP
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🚦 1 — Recognise & triage
Suspected psychosis
▼
🔴 Emergency
- Acute risk self/others; severe neglect; refusal + risk
- Delirium / organic cause
🟠 Urgent
- First-episode psychosis (no acute risk)
- Relapse
🟢 GP role
- Stable SMI: physical-health checks
- Clozapine shared care; carers
💊 2 — Act
Don't start antipsychotics for a first episode in primary care — refer urgently to EIP/CMHT (shorter DUP = better outcomes). Exclude organic/drug causes (delirium, cannabis/stimulants, thyroid/B12/encephalitis). Assess risk (self/others/neglect/safeguarding); safety plan. Involve family (consent). Ongoing GP role: annual physical-health monitoring (SMI mortality), antipsychotic adverse effects, clozapine bloods, relapse prevention, carer support; CBT & family intervention alongside medication.
SCA Quick Reference
Psychosis & Schizophrenia — Consultation Playbook
Engage · assess risk · exclude organic · refer EIP · don't treat alone
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🎯 The three pivots that pass this case
1 · Engage & assess risk
Build rapport, don't confront delusions; assess suicide, command hallucinations, neglect, risk to/from others.
2 · Exclude organic/drug
Cannabis/stimulants, delirium, thyroid/B12/encephalitis — new psychosis in the older/confused = delirium.
3 · Refer, don't treat alone
Urgent EIP/CMHT (shorter DUP = better); safety plan; involve family (consent); GP does physical-health monitoring.
⛔ Don't argue with or challenge delusions · Don't skip the risk assessment (self/others/neglect/safeguarding) · Don't miss organic/drug causes or call delirium "psychiatric" · Don't start antipsychotics for a first episode in primary care — refer urgently (EIP) · Don't breach confidentiality with family without consent (unless risk requires); do support them · Remember physical-health monitoring (SMI mortality) and clozapine bloods