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.

Lead Researcher: Renqiao Lan

Experts & Contributors: Ferry Dharsono

Editorial Panel: Core membership

Date reviewed: June 2021

Date Published: December 2025

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Neuroimaging can identify organic causes in patients with first episode psychosis (FEP) 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 FEP whereas the National Institute for Health and Care Excellence (NICE) does not. The latest Canadian Schizophrenia Guidelines and the American Psychiatric Association Practice Guideline changed their recommendations for routine neuroimaging for all patients with FEP to individualised case-by-case basis and when it is clinically indicated.
Patients with psychosis have been shown to have more structural abnormalities when compared to controls on imaging, but whether imaging alters clinical management/outcome is still debated.

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

Freudenreich O, Schulz SC, Goff DC. Initial medical work-up of first-episode psychosis: a conceptual review. Early Interv Psychiatry. 2009;3(1):10-8. (Level II Evidence)
Skikic M, Arriola JA. First Episode Psychosis Medical Workup: Evidence-Informed Recommendations and Introduction to a Clinically Guided Approach. Child Adolesc Psychiatr Clin N Am. 2020;29(1):15-28. (Level II Evidence)
Early Psychosis Guidelines Writing Group and EPPIC National Support Program. Australian Clinical Guidelines for Early Psychosis [Internet], 2nd edition update. Melbourne: the National Centre of Excellence in Youth Mental Health; 2016 [cited 28 June 2021]. 138 p. Available from: https://www.orygen.org.au/Campus/Expert-Network/Resources/Free/Clinical-Practice/Australian-Clinical-Guidelines-for-Early-Psychosis/Australian-Clinical-Guidelines-for-Early-Psychosis.aspx?ext (Evidence based guidelines)
Galletly C, Castle D, Dark F, Humberstone V, Jablensky A, Killackey E, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Aust N Z J Psychiatry. 2016;50(5):410-72. (Evidence based guidelines)
Addington D, Abidi S, Garcia-Ortega I, Honer WG, Ismail Z. Canadian Guidelines for the Assessment and Diagnosis of Patients with Schizophrenia Spectrum and Other Psychotic Disorders. Canadian Journal of Psychiatry. 2017;62(9):594-603. (Level II Evidence)
Keepers GA, Fochtmann LJ, Anzia JM, Benjamin S, Lyness JM, Mojtabai R, et al. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. Am J Psychiatry. 2020;177(9):868-72. (Evidence based guidelines)
Goulet K, Deschamps B, Evoy F, Trudel JF. Use of brain imaging (computed tomography and magnetic resonance imaging) in first-episode psychosis: review and retrospective study. Can J Psychiatry. 2009;54(7):493-501. (Level II Evidence)
Coentre R, Silva-Dos-Santos A, Talina MC. Retrospective study on structural neuroimaging in first-episode psychosis. PeerJ. 2016;4:e2069. (Level III Evidence)
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)
Forbes M, Stefler D, Velakoulis D, Stuckey S, Trudel JF, Eyre H, et al. The clinical utility of structural neuroimaging in first-episode psychosis: A systematic review. Aust N Z J Psychiatry. 2019;53(11):1093-104. (Level II 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 MRI from 1000 asymptomatic volunteers. JAMA. 1999;282(1):36-9. (Level III Evidence)
Strahl B, Cheung YK, Stuckey SL. Diagnostic yield of computed tomography of the brain in first episode psychosis. J Med Imaging Radiat Oncol. 2010;54(5):431-4. (Level III Evidence)
Falkenberg I, Benetti S, Raffin M, Wuyts P, Pettersson-Yeo W, Dazzan P, et al. Clinical utility of MRI in first-episode psychosis. Br J Psychiatry. 2017;211(4):231-7. (Level III Evidence)
Lubman DI, Velakoulis D, McGorry PD, Smith DJ, Brewer W, Stuart G, et al. Incidental radiological findings on brain MRI 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 3]. Available from: http://guidance.nice.org.uk/TA136/QuickRefGuide/pdf/English (Evidence based guidelines)
Degreef G, Bogerts B, Falkai P, Greve B, Lantos G, Ashtari M, et al. Increased prevalence of the cavum septum pellucidum in MRI 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)
Vita A, De Peri L, Silenzi C, Dieci M. Brain morphology in first-episode schizophrenia: a meta-analysis of quantitative MRI 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 MRI in first-episode schizophrenia, psychotic and severe non-psychotic depression and healthy controls. Br J Psychiatry Suppl. 2002;43:s58-65. (Level IV Evidence)

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The first time someone experiences psychotic symptoms or a psychotic episode

Evaluating patients presenting with First Episode of Psychosis (FEP) requires a comprehensive assessment including psychiatric assessment and physical health screening
Neuroimaging can identify organic causes of FEP and is indicated when there is clinical suspicion after specialist psychiatric assessment. Some reviews also recommend routine neuroimaging for people presenting with atypical features and aged 50 and over, as a higher number of organic lesions responsible for the psychosis have been identified in older people, even though in low rate
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, brain tumours, hippocampal changes suggesting epilepsy and 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 some studies found clinically important findings on MRI in 7.6–9.6% of FEP patients, this was not significantly different to normal controls and in less than 1.5% 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 (NICE) does not recommend neuroimaging as a routine part of initial investigations for FEP . In their latest editions, the Canadian Schizophrenia Guidelines and the American Psychiatric Association Practice Guideline no longer recommend neuroimaging as part of routine workup for patients presenting with FEP, unless indicated clinically.
However, the Australian Guidelines for Early Psychosis continues to recommend MRI for all people admitted to an early psychosis service. Likewise, the latest Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines for the management of schizophrenia and related disorders still include MRI as a recommended investigation for FEP but note divided expert opinion.
Patients with first episode psychosis have been shown more likely to have structural abnormalities compared with controls subjects including:

an increased prevalence of an abnormal (>6mm) cavum septum pellucidum
decreased cerebral volume
increased ventricular system volume, especially in the lateral and third ventricles
decreased hippocampal volumes

In addition, chronic schizophrenia has been shown to be associated with :

decreased volume of the amygdala
increased volume of the basal ganglia

Routine neuroimaging is controversial

Prevalence of potentially causal lesions in patients without neurological signs is <3%, similar to the normal population. RANZCP recommends baseline neuroimaging as part of optimal initial assessment, while NICE does not support routine neuroimaging. The latest APA and Canadian Practice Guidelines recommend neuroimaging on a case-by-case basis

Evaluating patients presenting with First Episode of Psychosis (FEP) requires a comprehensive assessment including psychiatric assessment and physical health screening
Neuroimaging can identify organic causes of FEP and is indicated when there is clinical suspicion after specialist psychiatric assessment. Some reviews also recommend routine neuroimaging for people presenting with atypical features and aged 50 and over, as a higher number of organic lesions responsible for the psychosis have been identified in older people, even though in low rate
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, brain tumours, hippocampal changes suggesting epilepsy and 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 some studies found clinically important findings on MRI in 7.6–9.6% of FEP patients, this was not significantly different to normal controls and in less than 1.5% 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 (NICE) does not recommend neuroimaging as a routine part of initial investigations for FEP . In their latest editions, the Canadian Schizophrenia Guidelines and the American Psychiatric Association Practice Guideline no longer recommend neuroimaging as part of routine workup for patients presenting with FEP, unless indicated clinically.
However, the Australian Guidelines for Early Psychosis continues to recommend MRI for all people admitted to an early psychosis service. Likewise, the latest Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines for the management of schizophrenia and related disorders still include MRI as a recommended investigation for FEP but note divided expert opinion.
Patients with first episode psychosis have been shown more likely to have structural abnormalities compared with controls subjects including:

an increased prevalence of an abnormal (>6mm) cavum septum pellucidum
decreased cerebral volume
increased ventricular system volume, especially in the lateral and third ventricles
decreased hippocampal volumes

In addition, chronic schizophrenia has been shown to be associated with :

decreased volume of the amygdala
increased volume of the basal ganglia

Psychosis (first episode)

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