Questionnaire/history: Prodromal period (a few days to around 18 months) (critical treatment window to delay or prevent transition to frank psychosis)? Emotional and behavioural changes (eg suspicion, mistrust or perceptual changes) leading to a deterioration in personal functioning and social withdrawal? - Increasing distress? - Decline in personal and social functioning? - Transient, low-intensity psychotic symptoms (intermittent, self-limiting episodes, typically lasting less than a week, may include hallucinations or unusual thoughts (including preoccupation with mystical or religious themes, concerns about being under surveillance etc)), which may manifest as unusual or uncharacteristic behaviour? - Reduced interest in daily activities, which may manifest as poor personal hygiene and/or reduced performance at school or work? - Problems with ----- Sleep? ----- Memory? ----- Concentration? ----- Communication? ----- Affect? ----- Motivation? - Anxiety, irritability or depressive features? - Incoherent or illogical speech (suggestive of thought disturbance)? Frank psychosis? Positive symptoms? - Hallucinations (perceptions in the absence of stimulus)? ----- Auditory (in which voices are heard and may provide a running commentary on actions, discussing the person among themselves, argue, command or echo thoughts)? ----- Visual? ----- Smell? ----- Taste? ----- Tactile? - Delusions (fixed or falsely-held beliefs)? ----- Delusions of reference (belief that ordinary events, objects or the behaviour of others has a meaning specifically for the person (eg that people on the radio are talking to, or about, them))? ----- Delusions of control (belief that thoughts, feelings or behaviour are being controlled by others)? ---------- Thought insertions? ---------- Thought withdrawal? ---------- Thought broadcasting? ----- Delusions of persecution (belief that other people are plotting against the person)? - Disorganised behaviour, speech and/or thoughts (thought disturbance)? Negative symptoms? - Emotional blunting/affective flattening (lack of spontaneity or reactivity of mood)? - Lack of drive (avolition)? - Lack of pleasure (anhedonia)? - Attention deficit? - Reduced speech (impoverishment of speech and language)? - Loss of motivation? - Self-neglect? - Social withdrawal? Screening questions for Hallucinations: Are you feeling, seeing or hearing things that other people cannot? Delusional thoughts: Are you feeling that you are being talked about, watched, or given a hard time for no reason, suspecting you are being externally controlled, or having thoughts inserted or removed from your mind or others being aware or your thoughts? ICD-10 diagnostic criteria fulfilled? At least two of the following symptoms present (by the individual’s report or through observation by the clinician or other informants) most of the time for ≥ 1 month (with at least one of the qualifying symptoms from item a) through d) below: a. Persistent delusions (eg grandiose delusions, delusions of reference, persecutory delusions)? b. Persistent hallucinations (most commonly auditory, although they may be in any sensory modality)? c. Disorganised thinking (formal thought disorder) (eg tangentiality and loose associations, irrelevant speech, neologisms) (when severe, speech may be so incoherent as to be incomprehensible (‘word salad’))? d. Experiences of influence, passivity or control (i.e. the experience that one’s feelings, impulses, actions or thoughts are not generated by oneself, are being placed in one’s mind or withdrawn from one’s mind by others, or that one’s thoughts are being broadcast to others)? d. Negative symptoms such as affective flattening, alogia or paucity of speech, avolition, asociality and anhedonia? e. Grossly disorganised behaviour that impedes goal-directed activity (eg behaviour that appears bizarre or purposeless, unpredictable or inappropriate emotional responses that interferes with the ability to organise behaviour)? f. Psychomotor disturbances such as catatonic restlessness or agitation, posturing, waxy flexibility, negativism, mutism or stupor? Symptoms not a manifestation of another medical condition (eg brain tumour) and are not due to the effects of a substance or medication (eg corticosteroids) on the central nervous system, including withdrawal effects (eg from alcohol)? Other psychotic disorders? Schizoaffective disorder (where symptoms of schizophrenia and a mood disorder are equally prominent? Drug-induced psychosis (usually remits within a month)? Persistent delusional disorder (where the most pervasive symptom is delusion)? Risk factors? Past medical history? Family history (first-degree relative with psychosis or schizophrenia)? Current medication? Drug allergies? Management: Risk of self-harm? - History of self-harm? - Suicidal ideation and plans, any previous attempts? ----- Do you ever think about suicide? ----- Do you hear voices commanding you to harm yourself? ----- Have you made any plans for ending your life? ----- Do you have the means for doing this available to you? ----- Have you made any preparations? ----- What has kept you from acting on these thoughts? - Feelings of hopelessness? - Misuse of recreational drugs and/or alcohol? - Likelihood of accidental or non-accidental injury? - ‘Command’ hallucinations and feeling compelled to act upon them? - Level of family/support? - Timing (highest risk around the psychotic episode and shortly after hospital discharge)? - Risk of unintentional harm to themselves caused by disorganised behaviour or poor judgement of risk due to absorption with psychotic experiences and beliefs? Risk of harm to others? - Potential for neglect of individuals dependent on the person for care? - Any risk to the public? - Delusions focused on a particular individual? Risk from others including any adult safeguarding issues? Judged at high risk of harm to themselves or others? - Same-day specialist MH assessment by the early intervention in psychosis service or this service is not available or cannot provide urgent intervention for people in crisis referral to crisis resolution and home treatment team? - If hospital admission needed, every attempt should be made to persuade to go voluntarily? - If admission is necessary, but declined, compulsory admission may be necessary under sections 2 or 4 of the MH Act? Not judged at high risk of harm to themselves or others? Psychosis? - Referral without delay to early intervention in psychosis service or if not available to the crisis resolution and home treatment team (with support from early intervention in psychosis services)? Prodromal phase of psychosis? - Referral without delay to early intervention in psychosis service or if not available a specialist mental health service with a consultant psychiatrist or a trained specialist with experience in at-risk mental states to carry out the assessment Reference(s): NICE CKS: Psychosis and schizophrenia