AKT · Psychiatry/Psychotic

Schizophrenia

Overview

A psychotic disorder with ≥6 months of disturbance including ≥1 month of active symptoms: delusions, hallucinations (often 3rd-person auditory), disorganised speech, and negative symptoms (blunted affect, avolition, alogia).

Recognise

Positive: delusions, hallucinations, thought disorder, passivity
Negative: blunting, avolition, social withdrawal, alogia
Schneider first-rank symptoms (thought echo/insertion/withdrawal/broadcast, passivity, 3rd-person voices)

Red flags

Command hallucinations, risk to self/others, first episode → urgent EIP/specialist referral

Differentials & how to tell them apart

Schizoaffective disorderprominent mood episode concurrent, but psychosis ≥2 weeks WITHOUT mood symptoms

Drug-induced psychosistemporal link to stimulants/cannabis; urine screen

Delusional disordersingle fixed delusion, function otherwise preserved, no prominent hallucinations

Psychotic depression / bipolarmood-congruent psychosis within a mood episode

Investigations

Clinical. Exclude organic/substance psychosis: bloods, urine drug screen, consider neuroimaging if atypical/neuro signs. Baseline before antipsychotic: weight/BMI, waist, pulse/BP, fasting glucose/HbA1c, lipids, prolactin, ECG (QTc).

Management

1Oral antipsychotic + psychological intervention (CBT for psychosis) + family intervention. Early intervention in psychosis (EIP) service.
2Inadequate response/adherence: try a different antipsychotic (adequate dose, 4–6 weeks); consider depot if adherence is the issue.Gate: Clozapine ONLY after ≥2 antipsychotics (at least one atypical) have failed at adequate dose/duration
3Treatment-resistant: clozapine with mandatory FBC monitoring.

Oral atypical antipsychotic (e.g. olanzapine, risperidone, aripiprazole) — first-line; choose by side-effect profile

Clozapine — treatment-resistant (after 2 antipsychotics, ≥1 atypical, fail) — agranulocytosis/myocarditis risk

Key points

Clozapine: weekly FBC for 18 weeks then reducing frequency (neutropenia/agranulocytosis); also myocarditis, constipation/ileus, seizures, hypersalivation. Metabolic monitoring for all antipsychotics. Catatonia (mutism, posturing, waxy flexibility, stupor — in schizophrenia or severe mood disorder) responds to a benzodiazepine (lorazepam) and, if life-threatening, ECT.

Monitor & prognosis

Antipsychotic: weight/metabolic at baseline, 12 weeks, annually; prolactin; ECG/QTc; EPSE and NMS (fever, rigidity, ↑CK, autonomic instability).

Variable; better with early treatment and good premorbid function.

Source: NICE CG178 (psychosis & schizophrenia); StatPearls