Prodromal psychosis and the at-risk mental state: early signs, assessment and support

The NHS describes psychosis as when people lose some contact with reality, which may involve seeing or hearing things that other people cannot (hallucinations), believing things that are not true (delusions) and confused thinking and speech. Prodromal psychosis refers to the period before this becomes a full psychotic episode, when experiences are milder, briefer or less certain.

NICE does not use the word prodromal in its psychosis guideline. It describes a group of people who may be at increased risk of developing psychosis, with an at-risk mental state, and sets out how they should be assessed and supported. The label is a description of risk, not a diagnosis of psychosis, and many people with these experiences do not go on to develop psychosis.

Because the changes can be gradual and overlap with ordinary teenage or young adult problems such as stress, low mood, anxiety or substance use, the period before a first episode is often recognised only in hindsight.

NICE refers to transient or attenuated psychotic symptoms, meaning brief or weaker versions of hallucinations, unusual beliefs or odd thinking, together with distress and a decline in social functioning. Other experiences or behaviour suggestive of possible psychosis are also taken seriously. In practice, families and friends often notice some of the following.

• Withdrawing from friends, school, work or usual activities.

• A drop in performance, concentration or motivation that is out of character.

• Sleep disturbance, anxiety, irritability or low mood.

• Unusual perceptions, such as fleeting voices, sounds or sensations, or a sense that things are strange or unreal.

• New suspiciousness, unusual ideas or difficulty explaining thoughts clearly.

The NHS says to see a GP immediately if you are experiencing symptoms of psychosis, because treating it as soon as possible matters. Most people who are at risk will not need emergency services, but a GP appointment should be arranged promptly. If you are worried about someone else, you can contact a GP on their behalf or their mental health worker if they have one.

If someone appears to be at risk because of their symptoms, the NHS suggests taking them to the nearest A&E if they agree, calling their GP or out-of-hours GP, or calling 999 and asking for an ambulance. Suicidal thoughts, self-harm or threats to others need urgent help the same day, through NHS 111, A&E or 999.

NICE identifies a first-degree relative with psychosis or schizophrenia as one of the factors that, together with distress and a decline in functioning, should prompt referral. The NHS lists possible triggers of psychosis more widely: a traumatic experience, stress, drug misuse, alcohol use disorder, side effects of prescribed medicine, a physical condition such as a brain tumour, head injury and childbirth, as well as conditions such as schizophrenia, bipolar disorder and severe depression.

No single cause explains who becomes unwell. Genetic vulnerability, stressful experiences and substance use, especially cannabis, can interact. This is why the assessment looks at the whole picture rather than at one symptom alone.

NICE recommends that a person who is distressed, has a decline in social functioning and has transient or attenuated psychotic symptoms, other suggestive experiences or a first-degree relative with psychosis, is referred without delay to a specialist mental health service or an early intervention in psychosis service. The assessment should be carried out by a consultant psychiatrist or a trained specialist with experience in at-risk mental states.

The assessment explores the experiences, their frequency and distress, mood, anxiety, substance use, risk and physical health. Because physical illnesses and medicines can mimic or trigger psychotic symptoms, a physical check and blood tests are usually part of the work-up.

For people considered at increased risk, NICE says to offer individual cognitive behavioural therapy (CBT) with or without family intervention, and to offer the interventions recommended in NICE guidance for any anxiety disorders, depression, emerging personality disorder or substance misuse that are present. It is explicit that antipsychotic medication should not be offered to people at increased risk of developing psychosis, or with the aim of decreasing the risk of or preventing psychosis.

If after treatment the person still has symptoms, impaired functioning or distress, but a clear diagnosis of psychosis cannot be made, NICE says to monitor them regularly for changes in symptoms and functioning for up to 3 years using a structured and validated tool. If a person asks to be discharged, they should be offered follow-up and the option to self-refer in future.

If a psychotic episode does develop, the NHS says treatment usually combines antipsychotic medicine, talking therapies including CBT and family interventions, and social support with education, employment or accommodation.

Keeping routine, sleep and activity, avoiding cannabis and other drugs and limiting alcohol, and having someone to talk to all help. Families benefit from clear information and from being involved in care where the person agrees. NICE recommends giving carers written and verbal information and offering carer-focused education and support.

People often feel frightened or ashamed of unusual experiences, so a calm, non-judgemental response matters more than arguing about what is real. Encourage a GP visit, and offer to go along.