What are psychotic features and what is the clinical picture of a patient presenting with them?

Definition of Psychotic Features

Psychotic features are defined by the presence of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and/or negative symptoms (such as affective flattening or poverty of speech), with the critical distinguishing characteristic being that awareness and level of consciousness remain intact, unlike in delirium. 1, 2, 3

Core Diagnostic Components

Positive Symptoms (Reality Distortion)

At least two of the following must be present for a significant period during a 1-month timeframe 1, 3:

• Delusions: Fixed false beliefs that represent the second cardinal feature of psychotic symptomatology 2
• Hallucinations: Perceptual experiences without external stimuli (visual, auditory, tactile, olfactory, or gustatory) 1, 2
• Disorganized speech: Incoherent communication patterns, tangentiality, or circumstantiality 1, 2
• Grossly disorganized or catatonic behavior: Inability to follow commands, unpredictable agitation, or motor abnormalities 1, 3

Only one symptom is required if: (1) delusions are bizarre, (2) hallucinations include a running commentary on the person's behavior, or (3) two or more voices are conversing with each other 1, 3

Negative Symptoms (Deficit Features)

These include 1, 2:

• Affective flattening: Diminished expression of emotions 2
• Alogia: Poverty of speech or speech content 1
• Avolition: Lack of motivation or goal-directed behavior 1
• Anergia and social withdrawal: These become more prominent as symptoms shift from positive to negative over time 2

Clinical Picture and Presentation

Temporal Course

The illness unfolds in distinct phases 1:

• Prodromal phase: Deterioration in functioning before overt psychotic symptoms, including marked social isolation, peculiar behavior (food hoarding, poor hygiene), blunted affect, odd beliefs, and poverty of speech 1
• Active phase: Lasts 1 to 6 months with predominance of positive symptoms and significant functional deterioration 1, 2
• Residual phase: Follows the active phase with persistence of negative symptoms such as lack of social interest or amotivation 1

Functional Deterioration

For a significant portion of time since onset, there must be marked deterioration in social, occupational, and self-care functioning below the level achieved before onset. In children and adolescents, this includes failure to achieve age-appropriate levels of interpersonal, academic, or occupational development 1, 3

Critical Distinguishing Feature: Intact Consciousness

The most important clinical distinction is that psychotic patients maintain intact awareness and level of consciousness, unlike patients with delirium who exhibit fluctuating consciousness, disorientation, and inattention. 4, 2, 3 Missing this distinction is a critical pitfall that doubles mortality 4

Age-Specific Presentations

Children and Adolescents

• True psychotic symptoms must be differentiated from psychotic-like phenomena due to idiosyncratic thinking, developmental delays, exposure to traumatic events, or overactive imaginations 1
• The emergence of psychotic symptoms usually results in a marked change in both mental status and level of functioning, even in severely developmentally disabled children 1
• Most children who report hallucinations are not schizophrenic, and many do not have psychotic disorders 1
• Bipolar disorder with psychotic features is frequently misdiagnosed as schizophrenia in this age group, as manic episodes often present with florid psychosis including hallucinations, delusions, and thought disorder 1, 4

Elderly Patients (≥65 years)

In elderly patients, secondary medical causes of psychosis are more prevalent, with delirium being the most common cause of psychotic symptoms in those presenting to emergency departments. 4, 2 Secondary causes include endocrine disorders, autoimmune diseases, neoplasms, neurologic disorders, infections, metabolic disorders, nutritional deficiencies, and medication-induced psychosis 4

Associated Behavioral Features

Patients may exhibit 2:

• Combativeness: Complicates examination and imaging procedures 2
• Inability to follow commands: Due to disorganized thought and behavior 2
• Agitation or catatonia: Ranging from extreme motor activity to complete immobility 1

Duration Criteria

Symptoms must be present for at least 6 months, including an active phase with or without prodromal or residual phases, to distinguish from brief psychotic episodes. 1, 3 If the 6-month duration criterion is not met, a diagnosis of schizophreniform disorder is made 1

Essential Exclusion Criteria

Before diagnosing a primary psychotic disorder 1, 3:

• Rule out schizoaffective disorder and mood disorders with psychotic features: Approximately 50% or more of bipolar patients experience mania with psychotic features 1, 2
• Rule out substance-induced psychosis: Including intoxication, withdrawal states, and medication side effects 1, 4
• Rule out general medical conditions: Other medical conditions must be systematically excluded 1, 3
• Rule out delirium: Symptoms should not be better explained by delirium 3

Common Diagnostic Pitfalls

• Do not assume all psychotic symptoms indicate schizophrenia: Psychotic depression and bipolar disorder commonly present with psychotic features 2, 5, 6
• Do not overlook secondary causes: Particularly in elderly patients where medical conditions and drug-related causes are more common 4, 2
• Do not miss withdrawal states: These require immediate benzodiazepine treatment to prevent seizures 4
• Cultural and developmental factors: Cultural or religious beliefs may be misinterpreted as psychotic symptoms when taken out of context, and developmental and intellectual factors must be considered 1

Physical Examination Red Flags Requiring Immediate Neuroimaging

4, 2:

• Focal neurological deficits
• Recent head trauma history
• Atypical features or new-onset psychosis in elderly patients
• First episode psychosis with neurological signs
• Fever and altered mental status suggesting CNS infection