Psychiatry — Psychosis and Schizophrenia, NMC MBBS licence examination syllabus (Nepal Medical Council).
Psychosis: a syndrome before it is a diagnosis
The first job is not to name the illness. It is to find out what is causing it.
Psychosis means loss of contact with shared reality — delusions, hallucinations, disorganised thinking. It is a syndrome, in exactly the way that jaundice or breathlessness are syndromes, and it has a long list of causes. Schizophrenia is only one of them, and in an acute presentation it is rarely the first one to exclude.
That framing matters because the alternative — treating "psychotic" as a diagnosis and reaching for an antipsychotic — misses delirium, intoxication, withdrawal, hypoglycaemia and brain injury, all of which present this way and all of which need something different. A psychiatric label given to an organic illness is a serious and quite common error.
🩺 Where this lives: Duration of untreated psychosis is one of the few modifiable predictors of long-term outcome — the longer a first episode goes untreated, the worse people tend to do. In settings where psychosis is understood as spiritual affliction or moral failing, families often seek help elsewhere first and arrive after months or years. That delay is not a cultural curiosity; it is a clinical variable. Recognising psychosis early, and explaining it to families in terms they can accept, is part of the treatment.
💡 A note on scope. This chapter gives no doses and names no first-line agent — antipsychotic choice follows national formularies, and rapid tranquillisation is protocol-driven and carries real airway and cardiovascular risk. It also gives no diagnostic duration criteria, because the required duration differs between ICD and DSM and between their editions; use the classification system currently in force. Risk assessment is covered in the Delirium and Risk Assessment chapter, and mood disorder in the Depression and Anxiety chapter.
What psychosis is
Note the qualifier built into the definition of a delusion: a fixed false belief not explained by the person's culture, religion or community. This is not a technicality. Beliefs about spirit possession, witchcraft, karma or divine communication may be entirely normal within a community, and labelling them psychotic is a serious error — one that damages trust and drives families away from services. The test is whether the belief is shared by others in that community, and whether it is held in the same way they hold it.
Finding the cause
THE FEATURES THAT SHOULD MAKE YOU LOOK FOR AN ORGANIC CAUSE
CLOUDED OR FLUCTUATING CONSCIOUSNESS
Schizophrenia does not impair consciousness. If
attention and awareness wax and wane, think DELIRIUM
until proven otherwise — see the delirium chapter.
VISUAL HALLUCINATIONS
Auditory hallucinations predominate in schizophrenia.
Prominent VISUAL hallucinations point towards an
organic cause or a substance.
FIRST EPISODE IN LATER LIFE
Schizophrenia typically begins in adolescence or early
adult life. A first psychosis in an older person
demands an organic search.
RAPID ONSET IN HOURS, ABNORMAL VITAL SIGNS, FOCAL
NEUROLOGICAL SIGNS, or a history of head injury, seizures,
substance use or new medication.
MINIMUM WORK-UP FOR A FIRST EPISODE:
Full history — including from an INFORMANT, since the
patient may not be able to give one
Physical examination and vital signs
GLUCOSE — always
Basic blood tests, and a substance history
Further investigation guided by findings
ALCOHOL WITHDRAWAL deserves a specific mention: it can
produce florid hallucinations and is potentially fatal if
missed, and it is treated in an entirely different way
from a primary psychosis.
Positive and negative symptoms
💡 Exam angle: the positive/negative distinction is examined constantly, and the clinically important half is the one people forget. Negative symptoms — blunted expression, poverty of speech, loss of drive, withdrawal — respond poorly to medication and predict long-term function better than delusions and hallucinations do. They are also routinely misread by families and by staff as laziness, rudeness or depression. Recognising them as part of the illness changes how the person is treated in every sense of the word.
Treatment principles
WHAT TREATMENT INVOLVES
ANTIPSYCHOTIC MEDICATION is the mainstay for positive
symptoms. All available agents block dopamine to some
degree, and the adverse effects follow from that and from
the other receptors each drug touches.
BUT MEDICATION IS NOT THE WHOLE TREATMENT:
Psychological therapy · family education and support ·
help with housing, income and occupation · treatment of
substance use · attention to PHYSICAL HEALTH.
PHYSICAL HEALTH IS A GENUINE PRIORITY. People with severe
mental illness die substantially earlier than the general
population, and most of that gap is CARDIOVASCULAR AND
METABOLIC disease rather than suicide — driven by smoking,
antipsychotic metabolic effects, poverty and poorer access
to physical healthcare. Monitoring weight, glucose, lipids
and blood pressure is part of psychiatric care, not
somebody else's job.
ADHERENCE is the central practical problem, and side
effects are the commonest reason people stop. Akathisia in
particular is deeply unpleasant and easily mistaken for
agitation due to the illness — which leads to the dose
being increased, making it worse.
RELAPSE PREVENTION: stopping medication is the commonest
precipitant of relapse. Long-acting injectable preparations
exist partly for this reason. Discuss duration honestly
rather than implying a short course.
Neuroleptic malignant syndrome
Neuroleptic malignant syndrome is rare, but it is the reason that fever and rigidity in anyone taking an antipsychotic must be taken seriously rather than attributed to infection alone. The tetrad is fever, severe rigidity, altered consciousness and autonomic instability, usually with a raised creatine kinase. The immediate actions are to stop the antipsychotic, cool the patient, and give generous fluids to protect the kidneys from rhabdomyolysis.
Clinical reasoning: four presentations
🔍 Case 1 — an old man seeing things
PresentationA 76-year-old becomes agitated over two days, seeing animals in the room and accusing staff of theft. He is drowsy at times and lucid at others. An antipsychotic is prescribed for "new psychosis".
Three red flagsLater life onset, visual hallucinations, fluctuating consciousness.
ReasoningThis is delirium until proven otherwise. Schizophrenia does not begin at 76 and does not impair consciousness, and visual hallucinations point to an organic cause.
AnswerSearch for the precipitant — infection, drugs, retention, constipation, metabolic derangement, hypoxia. Check the glucose. Treat the cause; see the delirium chapter for management.
🔍 Case 2 — a belief the family share
PresentationA young woman brought to clinic explains her illness in terms of spirit affliction, a belief her whole family and community hold. She is otherwise coherent, functioning, sleeping and working normally, with no hallucinations or thought disorder.
Key questionIs the belief shared by her community?
ReasoningA delusion is a fixed false belief not explained by the person's culture or religion. A shared explanatory model is not psychosis, and labelling it as such damages trust and drives families away.
AnswerDo not diagnose psychosis on this basis. Assess for genuine psychotic features, functional decline and risk, and work with her explanatory model rather than against it.
🔍 Case 3 — restless on treatment
PresentationA man started on an antipsychotic a week ago cannot sit still, paces constantly and describes an unbearable inner restlessness. The team reads this as worsening agitation and increases the dose.
TrapMistaking a side effect for the illness.
ReasoningThis is akathisia — a distressing extrapyramidal effect. Increasing the dose makes it worse, and akathisia is a well-recognised cause of treatment refusal and of real distress.
AnswerRecognise it, review the dose and the agent, and manage per national guidance. Ask specifically about side effects at every review rather than waiting to be told.
🔍 Case 4 — fever and stiffness
PresentationA patient on an antipsychotic develops fever, marked muscle rigidity, confusion and labile blood pressure. Creatine kinase is markedly raised. He is treated for a presumed chest infection and the antipsychotic is continued.
DiagnosisNeuroleptic malignant syndrome.
ReasoningFever, rigidity, altered consciousness and autonomic instability with a raised creatine kinase in someone taking an antipsychotic is NMS until proven otherwise. Continuing the drug is the critical error.
AnswerStop the antipsychotic immediately. Cool, give generous intravenous fluids to protect against rhabdomyolysis-induced kidney injury, monitor intensively, and manage per protocol. Infection can be treated alongside if present.
Commonly confused
Confusion
The distinction
Why it matters
Psychosis vs schizophrenia
Psychosis is a syndrome with many causes
Prevents missing organic disease.
Delirium vs primary psychosis
Clouded, fluctuating consciousness
Schizophrenia does not impair consciousness.
Auditory vs visual hallucinations
Visual suggests an organic cause
Redirects the whole work-up.
Delusion vs cultural belief
Is it shared by the community?
Mislabelling destroys trust.
Positive vs negative symptoms
Added versus lost
Negative symptoms predict function and respond poorly.
Negative symptoms vs laziness
They are part of the illness
Changes how the person is treated.
Akathisia vs worsening agitation
A drug effect, not the illness
Raising the dose makes it worse.
NMS vs infection
Rigidity, raised CK, on an antipsychotic
The drug must be stopped.
Rapid revision
MUST-KNOW FACTS
1. Psychosis is a SYNDROME, not a diagnosis.
2. Features: DELUSIONS, HALLUCINATIONS, THOUGHT DISORDER.
3. A delusion is a FIXED FALSE belief held with total conviction.
4. A belief SHARED by the patient's community is NOT a delusion.
5. Hallucination = perception without a stimulus.
6. AUDITORY hallucinations predominate in schizophrenia.
7. VISUAL hallucinations suggest an ORGANIC cause.
8. Schizophrenia does NOT cloud consciousness.
9. Clouded or fluctuating consciousness = DELIRIUM until excluded.
10. A first episode in later life demands an organic search.
11. Always check the GLUCOSE.
12. Alcohol WITHDRAWAL can cause florid hallucinations and can be fatal.
13. Stimulants, cannabis, steroids and other drugs can cause psychosis.
14. Severe depression and mania can both be PSYCHOTIC.
15. Get an INFORMANT history — the patient may not be able to give one.
16. POSITIVE symptoms are things ADDED: delusions, hallucinations, thought disorder.
17. NEGATIVE symptoms are things LOST: blunting, poverty of speech, loss of drive.
18. Positive symptoms respond BETTER to medication.
19. NEGATIVE symptoms respond poorly and drive long-term disability.
20. Negative symptoms are misread as laziness, rudeness or depression.
21. Longer DURATION OF UNTREATED PSYCHOSIS predicts worse outcome.
22. Extrapyramidal effects: acute DYSTONIA, parkinsonism, AKATHISIA, tardive dyskinesia.
23. AKATHISIA is inner restlessness — do not mistake it for agitation.
24. Increasing the dose makes akathisia worse.
25. TARDIVE DYSKINESIA is late and often irreversible.
26. Metabolic effects: WEIGHT GAIN, diabetes, dyslipidaemia — monitor them.
27. Raised PROLACTIN causes galactorrhoea and menstrual disturbance.
28. People with severe mental illness die earlier, mostly of CARDIOVASCULAR disease.
29. Physical health monitoring is part of psychiatric care.
30. Side effects are the commonest reason patients stop medication.
31. Stopping medication is the commonest precipitant of relapse.
32. NMS TETRAD: fever, rigidity, altered consciousness, autonomic instability.
33. NMS: raised creatine kinase, risk of rhabdomyolysis and kidney injury.
34. NMS management: STOP the antipsychotic, cool, fluids, intensive monitoring.
35. Take duration criteria from the classification system currently in use.
💡 Exam angle: three questions recur. Is this organic? — answered by consciousness, visual hallucinations and age of onset. Is this a delusion or a cultural belief? — answered by whether the community shares it. And is this symptom the illness or the drug? — answered most often by akathisia. Each has a clean discriminator, which makes them dependable marks.
Syllabus points
Psychosis as a syndrome, not a diagnosis
Delusions, hallucinations and thought disorder
Why a shared cultural belief is not a delusion
Features pointing to an organic cause
Delirium, substances and withdrawal
The minimum first-episode work-up
Positive versus negative symptoms
Why negative symptoms drive disability
Duration of untreated psychosis
Extrapyramidal adverse effects
Akathisia mistaken for agitation
Metabolic effects and physical health
Neuroleptic malignant syndrome
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