Can you provide a concise (<10‑minute) psychosis screening script for a psychiatric nurse practitioner?

Rapid 10-Minute Psychosis Screening Script for Psychiatric Nurse Practitioners

Use this structured 10-minute assessment to systematically screen for psychosis while simultaneously ruling out life-threatening medical causes that require immediate intervention. 1

Part 1: Immediate Safety & Delirium Screen (2 minutes)

First, distinguish delirium from psychosis—missing delirium doubles mortality. 1, 2

Consciousness & Orientation Assessment

• Ask: "What is today's date? Where are we right now? What time of day is it?"
• Observe: Is the patient's level of alertness fluctuating during your conversation? 1, 2
• Key distinction: Delirium shows fluctuating consciousness and disorientation over hours-to-days; psychosis maintains intact awareness. 1, 2

Attention Testing

• Ask: "Can you spell 'WORLD' backwards?" or perform serial 7s (100-7,93-7, etc.)
• Marked inattention with acute onset suggests delirium, not primary psychosis. 1, 2

Vital Signs Red Flags

• Check: Temperature, heart rate, blood pressure
• Fever suggests encephalitis or systemic infection; tachycardia/severe hypertension may indicate drug toxicity or thyrotoxicosis. 3

If delirium is present (fluctuating consciousness, acute onset, inattention): STOP—this is a medical emergency requiring immediate workup for infection, metabolic causes, or intoxication. 1, 2

Part 2: Core Psychotic Symptom Documentation (3 minutes)

Document observable phenomena, not just patient reports—this prevents misdiagnosis of pseudo-psychosis. 1

Hallucinations

• Ask: "Have you been hearing voices when no one is around? What do they say?"
• Ask: "Have you been seeing things others don't see?"
• Critical distinction: Auditory hallucinations favor primary psychiatric psychosis; visual hallucinations raise suspicion for delirium or medical causes. 1, 3

Delusions

• Ask: "Do you feel people are trying to harm you or control you?"
• Ask: "Do you have special powers or abilities others don't have?"
• Document whether delusions are bizarre (impossible) or non-bizarre (plausible but false). 1

Observable Thought Disorder

• Assess during conversation: Is speech disorganized, tangential, or impossible to follow?
• Look for: Loose associations, word salad, or abrupt topic changes without logical connection. 1

Observable Behavior

• Document: Bizarre behavior, catatonia, or grossly disorganized actions
• Observe: Responding to internal stimuli (talking to unseen persons, looking at empty spaces). 1

Negative Symptoms

• Assess: Flat affect, reduced speech (alogia), diminished emotional expression, social withdrawal
• True psychosis typically shows negative symptoms; their absence suggests pseudo-psychosis or other diagnoses. 1

Part 3: Critical Medical Exclusion Questions (3 minutes)

Systematically exclude secondary causes—especially in patients ≥65 years or without prior psychiatric history. 1

Substance Use (Most Common Medical Cause)

• Ask: "What substances have you used in the past week—alcohol, marijuana, cocaine, methamphetamine, hallucinogens, prescription stimulants?"
• Ask: "When did you last use? Have you recently stopped drinking or using drugs?"
• Substance-induced psychosis is the most common medical trigger; symptoms persisting >1 week post-detoxification suggest primary psychosis. 1, 3

Neurological Red Flags

• Ask: "Have you had recent head injury, seizures, or new/worsening headaches?"
• Ask: "Any weakness, numbness, vision changes, or difficulty walking?"
• These features mandate neuroimaging before psychiatric diagnosis. 4, 1

Infection Screening

• Ask: "Do you have fever, burning with urination, cough, or other infection symptoms?"
• Urinary tract infection and pneumonia are the most common infectious precipitants in elderly patients. 1, 2

Medication Review

• Ask: "What medications are you taking? Any recent changes or new prescriptions?"
• Corticosteroids, stimulants, and anticholinergics commonly cause psychosis. 1

Age-Specific Risk Assessment

• If ≥65 years: Secondary medical causes are significantly more prevalent; delirium and dementia-related psychosis are most common. 1, 2
• If <30 years without prior psychiatric history: Still perform full medical exclusion, but primary psychiatric disorders become more probable after exclusions. 1

Part 4: Mood & Temporal Pattern Assessment (2 minutes)

Determine whether psychosis occurs within a mood episode—this changes diagnosis and treatment. 1

Mood Episode Screening

• Ask: "Over the past weeks, have you felt extremely high, energized, or needed much less sleep?"
• Ask: "Have you felt extremely depressed, hopeless, or lost interest in everything?"
• Cyclical mood episodes with psychosis suggest bipolar disorder or schizoaffective disorder. 1, 5

Temporal Course

• Ask: "When did these symptoms start? Hours, days, weeks, or months ago?"
• Ask: "Have symptoms been constant or do they come and go?"
• Acute onset over hours-to-days favors delirium or substance-induced; episodic course suggests mood disorder; chronic progressive course suggests schizophrenia or dementia. 1, 2

Relationship Pattern (Especially in Youth)

• Ask: "How do you get along with family and friends—isolated and withdrawn, or lots of conflict and drama?"
• Isolated/awkward relationships indicate true psychosis; chaotic/tumultuous relationships suggest pseudo-psychosis or personality pathology. 1

Trauma History (If Time Permits)

• Ask: "Have you experienced significant trauma or abuse?"
• Maltreated youth may report psychotic-like symptoms that are actually dissociative phenomena (intrusive thoughts, derealization). 1

Part 5: Risk Assessment & Disposition (1 minute)

Suicide & Violence Risk

• Ask: "Are you having thoughts of hurting yourself or others?"
• Psychosis carries a 10% lifetime suicide risk. 6

Functional Impairment

• Ask: "Can you care for yourself—eating, hygiene, safety?"

Collateral Information

• Obtain from family/friends: Baseline functioning, timeline of symptom onset, substance use, medication adherence
• Collateral history is essential for accurate diagnosis. 3, 6

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Immediate Next Steps Based on Findings

If delirium suspected: Urgent medical workup (CBC, CMP, urinalysis, chest X-ray, toxicology screen). 1, 2

If substance-induced psychosis: Document detoxification status; observe for ≥1 week post-detox before diagnosing primary psychosis. 1

If neurological signs present: Obtain brain MRI (preferred) or CT head without contrast. 4, 1

If primary psychosis suspected after medical exclusion: Initiate low-dose atypical antipsychotic (risperidone 2 mg/day or olanzapine 7.5–10 mg/day) and refer to psychiatry or early intervention service. 1, 5

If mood episode with psychosis: Add mood stabilizer (lithium or valproate) alongside antipsychotic. 5

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Critical Pitfalls to Avoid

• Do not diagnose primary psychosis without excluding delirium, substance use, and medical causes—especially in elderly patients or those with visual hallucinations. 1, 2, 3
• Do not rely solely on patient-reported symptoms; document observable psychotic phenomena (thought disorder, negative symptoms, bizarre behavior). 1
• Do not miss withdrawal states (alcohol, benzodiazepines)—these require immediate benzodiazepine treatment to prevent seizures. 1, 2
• Do not delay neuroimaging when focal neurological signs, head trauma history, or atypical features are present. 4, 1, 2