Psychosis (First Episode)
Population Covered By The Guidance
This pathway provides guidance on the imaging of adult patients with first presentation of psychosis, to exclude an intracranial organic cause.
Date reviewed: July 2014
Date of next review: May 2023
Published: November 2014
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- Neuroimaging can identify organic causes in patients with first episode psychosis and enhance diagnostic certainty
- Routine neuroimaging in FEP patients without neurological signs is controversial and has a very low yield for potentially causal lesions (<3%), similar to healthy volunteers. Local practice is consensus-based
- The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recommends neuroimaging as part of the optimal initial assessment for patients presenting with first episode of psychosis where as NICE (National Institute for Health and Care Excellence) does not
- Patients with psychosis have been shown to have structural abnormalities when compared to controls on imaging, but whether imaging alters clinical management/outcome is still debated
First Episode Psychosis
- Neuroimaging can identify organic causes of First Episode Psychosis (FEP) and is indicated when there is clinical suspicion after specialist psychiatric assessment
- MRI is comparable to CT in detecting structural causes of FEP but MRI is generally preferred due to higher sensitivity for areas of interest; e.g. white matter changes, hippocampal changes suggesting epilepsy, vascular problems
- The usefulness of routine imaging in FEP where intracranial pathology is not suspected clinically is debatable. In the absence of neurological signs the prevalence of potentially causal brain lesions on neuroimaging is 0-3%, far outweighed by incidental findings, similar to healthy volunteers and unlikely to alter management
- While one Australian study found clinically important findings on MRI in 7.9% of FEP patients, this was not significantly different to normal controls and in only 1.3% of cases were lesions potentially accountable
- Due to the lack of evidence on clinical and cost-effectiveness, the National Institute for Health and Care Excellence does not recommend neuroimaging as a routine part of initial investigations for FEP ,
- However, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) recommends neuroimaging as part of the optimal initial assessment of FEP. It can enhance the confidence of the diagnosis and provide information that is relevant to treatment planning and prognosis
- Patients with first episode psychosis have been shown more likely to have structural abnormalities compared with controls subjects including
- In addition, chronic schizophrenia has been shown to be associated with
- decreased volume of the amygdala
- increased volume of the basal ganglia
- Information for consumers on CT InsideRadiology
- Information for consumers on MRI InsideRadiology
Date of literature search: June 2014
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Khandanpour N, Hoggard N, Connolly DJ. The role of MRI and CT of the brain in first episodes of psychosis. Clin Radiol. 2013;68(3):245-50. (Level III evidence)
- Ebdrup BH, Lublin H, Akeson P, Glenthoj B. Patients with first-episode psychosis should not be scanned routinely. Ugeskr Laeger. 2011;173(7):484-9. (Level II evidence)
- Bain BK. CT scans of first-break psychotic patients in good general health. Psychiatr Serv. 1998;49(2):234-5. (Level IV evidence)
- Agzarian MJ, Chryssidis S, Davies RP, Pozza CH. Use of routine computed tomography brain scanning of psychiatry patients. Australas Radiol. 2006;50(1):27-8. (Level III evidence)
- McKay D, Gorrell J, Cornish A, Tennant C, Rosen A, Moss B, et al. Let's get physical: an audit of medical practice in first episode psychosis. Australas Psychiatry. 2006;14(2):146-9. (Level IV evidence)
- Katzman GL, Dagher AP, Patronas NJ. Incidental findings on brain magnetic resonance imaging from 1000 asymptomatic volunteers. JAMA. 1999;282(1):36-9. (Level III evidence)
- Lubman DI, Velakoulis D, McGorry PD, Smith DJ, Brewer W, Stuart G, et al. Incidental radiological findings on brain magnetic resonance imaging in first-episode psychosis and chronic schizophrenia. Acta Psychiatr Scand. 2002;106(5):331-6. (Level III evidence)
- Albon E, Tsourapas A, Frew E, Davenport C, Oyebode F, Bayliss S, et al. Structural neuroimaging in psychosis: a systematic review and economic evaluation. Health Technol Assess. 2008;12(18):iii-iv, ix-163. (Level II evidence)
- National Institute for Health and Care Excellence (NICE). TA136 Structural neuroimaging in first-episode psychosis. 2008 [updated 2011 December 12; cited 2013 Aug 3rd]. (Evidence based guidelines). View the reference
- Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders. Aust N Z J Psychiatry. 2005;39(1-2):1-30. (Evidence based guidelines)
- Lehman AF, Lieberman JA, Dixon LB, McGlashan TH, Miller AL, Perkins DO, et al. Practice guideline for the treatment of patients with schizophrenia, second edition. Am J Psychiatry. 2004;161(2 Suppl):1-56. (Consensus statement)
- Degreef G, Bogerts B, Falkai P, Greve B, Lantos G, Ashtari M, et al. Increased prevalence of the cavum septum pellucidum in magnetic resonance scans and post-mortem brains of schizophrenic patients. Psychiatry Res. 1992;45(1):1-13. (Level IV evidence)
- Galarza M, Merlo AB, Ingratta A, Albanese EF, Albanese AM. Cavum septum pellucidum and its increased prevalence in schizophrenia: a neuroembryological classification. J Neuropsychiatry Clin Neurosci. 2004;16(1):41-6. (Level III evidence)
- Kasai K, McCarley RW, Salisbury DF, Onitsuka T, Demeo S, Yurgelun-Todd D, et al. Cavum septi pellucidi in first-episode schizophrenia and first-episode affective psychosis: an MRI study. Schizophr Res. 2004;71(1):65-76. (Level III evidence)
- Wright IC, Rabe-Hesketh S, Woodruff PW, David AS, Murray RM, Bullmore ET. Meta-analysis of regional brain volumes in schizophrenia. Am J Psychiatry. 2000;157(1):16-25. (Level II evidence). View the reference
- Vita A, De Peri L, Silenzi C, Dieci M. Brain morphology in first-episode schizophrenia: a meta-analysis of quantitative magnetic resonance imaging studies. Schizophr Res. 2006;82(1):75-88. (Level II evidence)
- Salokangas RK, Cannon T, Van Erp T, Ilonen T, Taiminen T, Karlsson H, et al. Structural magnetic resonance imaging in patients with first-episode schizophrenia, psychotic and severe non-psychotic depression and healthy controls. Results of the schizophrenia and affective psychoses (SAP) project. Br J Psychiatry Suppl. 2002;43:s58-65. (Level IV evidence)
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