Please provide a structured psychosis assessment script for a psychiatric nurse practitioner.

Psychosis Assessment Script for Psychiatric Nurse Practitioners

Initial Presentation and Chief Concern

Begin by documenting the reason for evaluation, the patient's goals for treatment, and their treatment preferences, as this collaborative approach is essential for effective psychiatric care. 1

• Ask directly: "What brings you in today?" and "What are you hoping to get from this evaluation?" 1
• Document whether this is a self-referral, family-initiated, or mandated evaluation 1
• Clarify the timeline: When did symptoms first appear, and what has changed recently? 1

Psychotic Symptom Assessment

Systematically evaluate all positive psychotic symptoms including hallucinations, delusions, formal thought disorder, and bizarre behaviors. 1

Hallucinations

• Auditory: "Do you hear voices or sounds that others don't hear?" If yes: How many voices? What do they say? Are they commanding you to do things? 1
• Visual: "Do you see things others don't see?" (Visual hallucinations suggest medical causes over primary psychiatric illness) 2
• Other sensory modalities: tactile, olfactory, gustatory 1

Delusions

• Persecutory: "Do you feel people are trying to harm you or plot against you?" 1
• Grandiose: "Do you have special powers or abilities others don't have?" 1
• Referential: "Do you feel the TV, radio, or internet is sending you special messages?" 1
• Thought insertion/withdrawal/broadcasting: "Do thoughts that aren't yours get put into your head? Can others hear your thoughts?" 1

Thought Disorder

• Assess during interview for: tangentiality, loose associations, circumstantiality, word salad, neologisms 1
• Note speech patterns: fluency, articulation, coherence 1

Phase of Illness Identification

Determine which phase of psychotic illness the patient is experiencing, as this guides treatment intensity. 1

• Acute phase: Dominated by active positive symptoms (hallucinations, delusions, disorganization) with functional deterioration 1
• Prodromal phase: Social isolation, bizarre preoccupations, unusual behaviors, academic/occupational decline without frank psychosis 1
• Recovery phase: Active psychosis remitting but ongoing symptoms with confusion or dysphoria 1
• Residual phase: Minimal positive symptoms but prominent negative symptoms (flat affect, avolition, social withdrawal) 1

Mental Status Examination

Conduct a comprehensive mental status examination focusing on appearance, behavior, cognition, thought process, and perception. 1

• Appearance: General presentation, nutritional status, hygiene, signs of self-neglect 1, 3
• Behavior: Coordination, gait, involuntary movements, abnormal motor tone, psychomotor agitation or retardation 1, 3
• Mood and affect: Stated mood, observed affect (flat, blunted, inappropriate, labile) 1
• Thought process: Linear vs. tangential, goal-directed vs. circumstantial, flight of ideas 1, 3
• Thought content: Delusions, obsessions, suicidal/homicidal ideation, preoccupations 1
• Perception: Hallucinations across all sensory modalities 1, 3
• Cognition: Orientation, attention, memory, executive function 1, 3
• Insight and judgment: Does patient recognize they are ill? Can they make safe decisions? 1

Critical Safety Assessment

Every psychosis evaluation must include systematic assessment of suicide and violence risk with documentation of specific influencing factors. 1, 3

Suicide Risk

• Current ideation: "Are you having thoughts of hurting yourself or ending your life?" 1, 3
• Specific plans: "Have you thought about how you would do it?" 1
• Access to means: Firearms, medications, other lethal methods 1, 3
• Intent: "How likely are you to act on these thoughts?" 1
• Motivations: Command hallucinations, delusional guilt, shame, humiliation, desire for attention 1
• Protective factors: Reasons for living, responsibility to children, religious beliefs 1
• Past attempts: Number, methods, lethality, circumstances 1, 3
• Family history: Suicide in biological relatives 1, 3

Violence/Aggression Risk

• Current aggressive ideation: "Are you having thoughts of hurting someone else?" 1
• Specific targets: Identified individuals, access to potential victims 1
• Homicidal thoughts: Plans, intent, means 1
• Past violence: History of physical or sexual aggression, legal consequences 1
• Triggers: Situations that provoke aggression, command hallucinations 1
• Family history: Violence in biological relatives 1

Medical Rule-Out Assessment

Medical causes of psychosis must be systematically excluded before attributing symptoms to primary psychiatric illness. 1, 2

Vital Signs and Physical Examination

• Vital signs: Temperature, blood pressure, heart rate, respiratory rate 1
  • Tachycardia or severe hypertension suggests drug toxicity or thyrotoxicosis 2
  • Fever suggests encephalitis or porphyria 2
• Physical exam: Height, weight, BMI 1
• Neurological exam: Focal deficits, abnormal reflexes, tremor, increased muscle tone 1
• Skin: Stigmata of trauma, self-injury, or drug use (track marks) 1

Red Flags for Medical Causes

• Recent head injury or trauma 2
• New or worsening headaches 2
• Seizures or seizure history 2
• Cerebrovascular disease symptoms 2
• Cognitive changes with abnormal vital signs (suggests medical over psychiatric cause) 2
• Visual hallucinations predominating (more common in medical causes) 2
• Subacute onset (raises suspicion for oncologic cause) 2

Substance Use Assessment

Illicit drug use is the most common medical cause of acute psychosis and must be thoroughly evaluated. 2

• Current use: Stimulants (methamphetamine, cocaine), cannabis, hallucinogens, synthetic cannabinoids 1, 2
• Alcohol: Amount, frequency, withdrawal symptoms 1, 3
• Tobacco: Cigarettes per day (important for treatment planning) 1, 3
• Prescription medications: Corticosteroids, anticholinergics, dopaminergic agents 2
• Recent intoxication or withdrawal: Timeline relative to symptom onset 2

Laboratory and Diagnostic Testing

• Urine toxicology screen (essential) 2
• Complete blood count 2
• Comprehensive metabolic panel (renal, hepatic function) 1, 2
• Thyroid function tests 2
• Calcium and parathyroid hormone 2
• Vitamin B12, folate, niacin 2
• HIV and syphilis testing (consider based on risk factors) 2
• Neuroimaging (CT or MRI if focal neurological signs, head trauma, new-onset psychosis in older adults, or atypical presentation) 1
• EEG (if seizure disorder suspected) 1

Psychiatric History

Document comprehensive psychiatric history including all prior diagnoses, treatments, hospitalizations, and treatment response patterns. 1, 3

• Prior psychiatric diagnoses: Schizophrenia, schizoaffective disorder, bipolar disorder, major depression with psychotic features 1, 3
• Previous psychiatric hospitalizations: Number, dates, reasons, outcomes 3
• Past treatments: Medications tried, doses, duration, response, side effects 3
• Treatment adherence: History of medication compliance or non-compliance 4, 3
• Prior psychotic episodes: Frequency, triggers, duration, recovery 3

Differential Diagnosis Considerations

The differential diagnosis must systematically exclude mood disorders, developmental disorders, trauma-related disorders, and substance-induced psychosis. 1

• Bipolar disorder with psychotic features: Assess for manic or mixed episodes (decreased need for sleep, grandiosity, pressured speech, increased goal-directed activity) 1
• Major depression with psychotic features: Assess for depressive symptoms (anhedonia, guilt, psychomotor changes, mood-congruent delusions) 1
• Schizoaffective disorder: Prominent mood episodes concurrent with psychotic symptoms 1
• Pervasive developmental disorders: Autism spectrum, intellectual disability 1
• Post-traumatic stress disorder: Flashbacks, hypervigilance, trauma history 1
• Substance-induced psychotic disorder: Temporal relationship to substance use 1, 2
• Psychotic disorder due to medical condition: Identified medical etiology 1, 2

Trauma and Psychosocial History

Assess trauma history and psychosocial stressors, as these influence presentation, treatment planning, and prognosis. 1, 3

• Trauma exposure: Childhood abuse (physical, sexual, emotional), combat exposure, domestic violence 1
• Current stressors: Financial problems, housing instability, legal issues, occupational difficulties, relationship conflicts 1, 3
• Social support: Family involvement, friendships, community connections 1
• Medical illness: Chronic pain, disfiguring conditions, terminal illness 1

Family Psychiatric History

Document family history of psychotic disorders, mood disorders, suicide, and violence in biological relatives. 1, 3

• Psychotic disorders: Schizophrenia, schizoaffective disorder in first-degree relatives 1
• Mood disorders: Bipolar disorder, major depression 1
• Suicide: Completed suicides or serious attempts in family 1, 3
• Violence: History of violent behaviors in relatives 1, 3

Developmental and Premorbid Functioning

Assess developmental history and premorbid functioning to understand baseline and degree of deterioration. 1

• Developmental milestones: Any delays in childhood 1
• Academic history: School performance, learning disabilities, behavioral problems 1
• Social functioning: Peer relationships, social isolation, ability to maintain friendships 1
• Occupational history: Work history, job stability, reasons for job loss 1
• Highest level of functioning: When did patient last function well? 1

Cultural and Linguistic Factors

Assess cultural beliefs about mental illness and need for interpreter services, as these impact diagnosis and treatment engagement. 1, 3

• Cultural explanations of illness: How does patient/family understand these symptoms? 1, 3
• Language barriers: Need for interpreter services 1
• Cultural factors in social environment: Immigration status, acculturation stress, discrimination 1
• Religious/spiritual beliefs: Influence on symptom interpretation and treatment acceptance 1

Quantitative Symptom Measurement

Use validated rating scales to quantify symptom severity and establish baseline for treatment monitoring. 1, 4, 3

• PANSS (Positive and Negative Syndrome Scale): Comprehensive assessment of positive, negative, and general psychopathology symptoms 1
• BPRS (Brief Psychiatric Rating Scale): Shorter alternative for symptom tracking 1
• CGI (Clinical Global Impressions): Overall severity and improvement ratings 1

Documentation Requirements

Document all required elements including risk assessment, treatment rationale, and patient preferences. 1, 3

• Estimated suicide risk with specific influencing factors 1, 3
• Estimated violence risk with specific influencing factors 1, 3
• Differential diagnosis with rationale 1
• Treatment plan with evidence-based rationale 1
• Patient's treatment preferences and goals 1, 3
• Rationale for any ordered tests 1

Treatment Planning and Patient Collaboration

Develop a comprehensive, person-centered treatment plan through shared decision-making with the patient. 1, 3

• Explain differential diagnosis to patient in understandable terms 1, 3
• Discuss risks of untreated illness: Functional decline, suicide risk, violence risk, medical complications 1, 3
• Review treatment options: Antipsychotic medications, psychosocial interventions, hospitalization if needed 1, 3
• Explain benefits and risks of each treatment option 1, 3
• Incorporate patient preferences into final treatment plan 1, 3
• Document specific rationale for chosen treatments 1

Common Pitfalls to Avoid

• Do not assume dangerousness based on race or culture—assess actual risk factors systematically 1
• Do not overlook medical causes—psychosis from medical conditions requires different treatment than primary psychiatric illness 2
• Do not attribute psychosocial reactions to biological illness—irritability from life stressors may need counseling, not medication adjustment 5
• Do not skip collateral information—family input is crucial for establishing timeline and baseline functioning 2
• Do not forget to assess negative symptoms—flat affect, avolition, and social withdrawal are often more disabling than positive symptoms 1