Essential Questions for Evaluating Psychosis
When evaluating a patient presenting with psychosis, a structured assessment focusing on hallucinations, delusions, thought disorders, and potential medical causes is essential for accurate diagnosis and effective treatment.
Core Psychotic Symptom Assessment
Hallucinations
- What type of hallucinations are you experiencing? (Visual, auditory, tactile, olfactory, gustatory) 1, 2
- How frequently do these hallucinations occur? (Daily, weekly, etc.)
- What is the content of these hallucinations? 1
- Do the hallucinations occur outside of mood episodes? (Important for differentiating schizoaffective disorder from mood disorders with psychotic features) 3
- Do the hallucinations command you to harm yourself or others?
- How do you react emotionally to these hallucinations?
Delusions
- What beliefs do you hold that others tell you are not true?
- How convinced are you that these beliefs are true?
- Are these beliefs related to your mood (guilt, punishment, nihilism)? 3
- Do you believe others are trying to harm you or control your thoughts?
- Do you believe you have special powers or a special mission?
- How long have you held these beliefs?
Thought Process and Content
- Assessment for disorganized speech or thought patterns 3
- Presence of thought insertion, withdrawal, or broadcasting
- Evaluation of unusual thought content
- Assessment of conceptual disorganization 4
Medical and Substance-Related Causes
Substance Use History
- What substances have you used recently (including prescription medications, over-the-counter drugs, alcohol, and illicit substances)? 2, 5
- When was your last use of these substances?
- Have you recently stopped taking any medications or substances?
- Have you experienced withdrawal symptoms from any substances?
Medical History
- Recent head injury or trauma 2
- History of seizures or epilepsy
- Cerebrovascular disease
- New or worsening headaches
- History of autoimmune disorders
- Metabolic disorders (thyroid dysfunction, electrolyte abnormalities)
- Infections (HIV, syphilis, encephalitis) 2
- Neurological conditions (dementia, Parkinson's disease, multiple sclerosis) 1
Onset and Course of Symptoms
- When did you first notice these symptoms?
- Was the onset sudden or gradual?
- Have you experienced similar symptoms in the past?
- How have these symptoms affected your daily functioning?
- Have you noticed any decline in educational or occupational functioning? 6
- Have you experienced changes in sleep patterns? 6
- Have you noticed decreased motivation or social withdrawal? 6
Risk Assessment
- Do you have thoughts of harming yourself or others?
- Have you made any suicide attempts in the past? 4
- Do you have specific plans to harm yourself or others?
- Do you feel hopeless about the future?
- Have you been hospitalized to prevent suicide attempts? 4
Treatment History
- Have you been treated for psychiatric conditions before?
- What medications have you taken previously?
- How did you respond to previous treatments?
- Did you experience side effects from previous medications?
- Have you had any previous hospitalizations for psychiatric reasons?
Family History
- Is there a family history of psychosis, schizophrenia, bipolar disorder, or other mental health conditions?
- How were these family members treated, and what was their response?
Collateral Information
- Obtaining information from family members or caregivers about:
Physical Examination Focus
- Vital signs (tachycardia or severe hypertension may indicate drug toxicity or thyrotoxicosis; fever may suggest encephalitis) 2
- Complete neurological examination
- Mental status examination (appearance, behavior, speech patterns, mood, affect, thought content and process, perceptual disturbances, cognitive function, insight) 6
Laboratory and Diagnostic Testing
- Complete blood count
- Metabolic profile
- Thyroid function tests
- Urine toxicology
- Parathyroid hormone, calcium, vitamin B12, folate, and niacin levels
- HIV and syphilis testing 2
- Consider neuroimaging (CT or MRI) in cases with atypical presentation, abnormal neurological examination, or first-episode psychosis 1
Insight and Treatment Planning
- How do you understand what is happening to you?
- Do you believe you need treatment?
- What are your goals for treatment?
- What support systems do you have in place?
By systematically addressing these questions, clinicians can differentiate between primary psychiatric disorders (which typically present with auditory hallucinations and complex delusions) and secondary causes of psychosis (which more commonly present with visual hallucinations, cognitive changes, and abnormal vital signs) 2, leading to appropriate treatment decisions and improved outcomes.