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Very Late-Onset Psychosis Characteristics — MRCPsych Paper B MCQ

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HardOld Age PsychiatryVery Late-Onset Psychosis CharacteristicsMRCPsych Paper B

A 72-year-old woman develops a first episode of persistent non-affective psychosis. Assessment has excluded delirium, a major neurocognitive disorder, substance-induced psychosis and a primary mood disorder. Which clinical profile is most characteristic of very late-onset schizophrenia-like psychosis?

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Correct answer: B — Persecutory or partition delusions with auditory or other hallucinations, but relatively little formal thought disorder or negative symptom burden

Very late-onset schizophrenia-like psychosis begins after age 60 and typically has a predominantly positive-symptom presentation. Persecutory delusions, partition delusions—such as believing that people or forces pass through walls—and auditory or multimodal hallucinations are characteristic, while formal thought disorder and negative symptoms are generally less prominent than in early-onset schizophrenia. Mild cognitive deficits may occur, so cognition should not be described as invariably preserved. Option D better resembles an early-onset schizophrenia phenotype. Option A suggests dementia with Lewy bodies, particularly when hallucinations accompany cognitive fluctuations and parkinsonism. Option E describes psychotic depression, while option C is more consistent with delusional disorder. Female sex, sensory impairment and social isolation are associated with VLOSLP but are risk correlates rather than defining symptoms.

Reference: Regala J, et al. Very Late-Onset Schizophrenia-Like Psychosis: A Case Report and Critical Literature Review. Annals of Geriatric Medicine and Research. 2023. https://www.rcpsych.ac.uk/docs/default-source/members/faculties/old-age/old-age-newsletter-jan-18.pdf?sfvrsn=82e1b4ef_4