First Episode Psychosis

FEP Fundamentals - Psychosis Unveiled

• FEP: First manifestation of a psychotic disorder (e.g., schizophrenia, schizoaffective, bipolar with psychosis).
• Key features:
  • Positive symptoms: Hallucinations (auditory common), delusions, disorganized thought/speech/behavior.
  • Negative symptoms: Avolition, alogia, anhedonia, affective flattening.
  • Cognitive deficits: Attention, memory, executive function.
• Early, prompt intervention is critical for improved prognosis.

⭐ Duration of Untreated Psychosis (DUP) > 6 months is linked to poorer long-term outcomes.

Symptom Spotlight - Reading the Mind

• Core: Disturbed thought possession & boundary.
• Schneiderian First-Rank Symptoms (FRS) are classic:
  • Thought Broadcasting: Belief one's thoughts are audible to others.
  • Thought Insertion: Belief external thoughts are implanted.
  • Thought Withdrawal: Belief thoughts are being removed.
• Delusions of Reference: Events misinterpreted as directly relating to oneself, implying others know one's thoughts.
• Auditory Hallucinations: Voices may echo thoughts or discuss patient.

⭐ Thought echo (Gedankenlautwerden), hearing one's thoughts spoken aloud, is a specific Schneiderian First-Rank Symptom.

Etiology Explored - Roots of Reality's Rift

• Genetic Vulnerability: Strong family history; polygenic inheritance.
• Neurobiological Factors:
  • Dopamine dysregulation (mesolimbic ↑, mesocortical ↓).
  • Glutamate, serotonin also involved.
  • Brain structural changes (e.g., ventricular enlargement).
• Environmental Stressors:
  • Early life adversity (trauma, infections).
  • Urban upbringing, migration.
  • Substance misuse (esp. cannabis).
• Gene-Environment Interaction: Stress-vulnerability model.

⭐ Adolescent cannabis use, particularly high-potency strains, is a significant, modifiable risk factor for developing psychosis.

Diagnostic Detective - Cracking the Case

• Assessment: Thorough history (patient, collateral), Mental Status Exam (MSE) for positive, negative, cognitive symptoms.
• Key Exclusions:
  • Organic causes: Essential bloods (CBC, U&Es, LFTs, TFTs, glucose), urine toxicology. Neuroimaging if new onset, atypical, or focal signs.
  • Substance-induced psychosis: Clear temporal link to substance use or withdrawal.
• Critical Differentials:
  • Mood disorders with psychotic features: Mood symptoms are primary and often precede psychosis.
  • Brief Psychotic Disorder: Symptoms <1 month.
  • Schizophreniform Disorder: Symptoms 1-6 months.

⭐ Early identification and reducing Duration of Untreated Psychosis (DUP) are crucial for better long-term prognosis.

Treatment Toolkit - Charting Recovery

• Antipsychotics (ASAP):
  • Low-dose SGAs (e.g., Risperidone, Olanzapine). Titrate slowly.
  • Goal: Remission. Duration: ≥1-2 years post-remission.
• Psychosocial Therapies (Essential):
  • CBTp, family psychoeducation, vocational support (SEE).
• Early Intervention Services (EIS):
  • Multidisciplinary team for holistic care.
• Key Monitoring:
  • Metabolic syndrome, EPS, prolactin.
• Overall Focus:
  • Relapse prevention, remission, functional recovery.

⭐ Combining low-dose SGAs with psychosocial therapies is key for optimal FEP recovery and relapse prevention.

High‑Yield Points - ⚡ Biggest Takeaways

• First Episode Psychosis (FEP): Initial psychotic illness, typically 15-25 years.
• Shorter Duration of Untreated Psychosis (DUP) is critical for better outcomes.
• Prodromal symptoms (social withdrawal, functional decline) often precede overt psychosis.
• Core features: hallucinations (auditory), delusions, disorganized thought, negative symptoms.
• Early intervention with low-dose antipsychotics and psychosocial support is paramount.
• Rule out substance-induced psychosis and medical conditions first.
• Good prognosis: acute onset, good premorbid function, older age at onset.