Brief Psychotic Disorder


Article Author:
Anu Stephen


Article Editor:
Forshing Lui


Editors In Chief:
Bonnie Franckowiak


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
6/3/2019 4:22:57 PM

Introduction

Brief psychotic disorder (BPD) according to DSM-5 is the sudden onset of psychotic behavior that lasts less than 1 month followed by complete remission with possible future relapses.[1] It is differentiated from schizophreniform disorder and schizophrenia by the duration of the psychosis. The diagnosis is often anticipatory or retrospective due to the diagnostic requirement of complete remission within 1 month. Brief psychotic disorder is an acute but transient disorder with onset of one or more of the following psychotic symptoms:

  • Delusions
  • Hallucinations
  • Disorganized speech
  • Grossly disorganized or catatonic behavior

At least one of these symptoms must be delusions, hallucinations, or disorganized speech. The symptoms in BPD last between one day to one month, with a complete return to premorbid level of functioning after the disease course in response to antipsychotic medications. The disturbance in behavior cannot be better accounted by schizophrenia, schizoaffective disorder, mood disorder with psychotic features, or be a direct result of a drug, medication, or medical condition like thyrotoxicosis, sarcoidosis, or syphilis.

Etiology

Although unclear, the underlying etiology of brief psychotic disorder can be a stressful event or trauma. There may be a genetic, neurological, or environmental component to BPD as well. The specific trigger of BPD, if present, must be specified as follows[2][3]:

  • Brief psychotic disorder with marked stressor(s) is also referred to as brief reactive psychosis. It is the onset of psychotic symptoms that occur in response to a traumatic event that would be stressful for anyone in similar circumstances in the same culture
  • Brief psychotic disorder without marked stressor(s) is the onset of psychotic symptoms that occur in the absence of a traumatic event that would be stressful for anyone in similar circumstances in the same culture
  • Brief psychotic disorder with postpartum onset is defined as the onset of psychotic symptoms that occur within four weeks postpartum

Epidemiology

Reliable data on the frequency of brief psychotic disorder are not available, mostly because of its low incidence and variation based on the population under study. However, increased frequency of the disorder generally occurs in populations known to be under high stress such as immigrants, refugees, earthquake victims, etc.[4][5] A study researching the Finnish population found the prevalence of brief psychotic disorder to be 0.05%.[6] Another study in rural Ireland found 10 cases of BPD among 196 first-admission psychosis cases.[7]

Compared to developed countries, reports show a higher incidence of brief psychotic disorder in developing countries. Data drawn from the World Health Organization Determinants of Outcome Study also found that the incidence of BPD in developing countries was ten times as much as that in industrialized countries.[8] BPD is also thought to be more common in women and those with a personality disorder.[6][7][9][10]

Pathophysiology

The pathophysiology of BPD is not known, especially given the extremely low incidence of the disorder. Its higher prevalence among patients with personality or mood disorders may suggest underlying biological or psychological susceptibility which may some genetic influence.

History and Physical

Three essential elements of the history and physical in an individual with suspected brief psychotic disorder are:

  1. The presence of at least one positive psychotic symptom such as delusions, hallucinations, disorganized speech, or disorganized or catatonic behavior
  2. Establishing that the symptoms have not been present for less than one day or more than one month
  3. Investigating if the disturbance in behavior is otherwise explainable by another mood disorder, medical condition, or substance/medication use

In order to further classify individual cases of brief psychotic disorder, it becomes essential to recognize if the triggering of psychotic symptoms were from a stressful event or if it is postpartum. Common stressors are death, environmental disaster, military activity, recent immigration.[11] Acknowledging patient characteristics such presence of a personality disorder that can limit coping skills will also be crucial to identifying individuals at a greater risk of developing disorders like BPD. It is also important to keep in mind that the presenting symptoms of BPD may occasionally be highly severe and mimic the presentation of delirium as a result.

Evaluation

There are no particular lab studies or psychological testing that are performable to make the diagnosis of a brief psychotic disorder.

The most appropriate tests and imaging to be done would rule out other potential diagnoses or causes for the behavioral disturbances. Hence, it would be apt to do a serum pregnancy test in women to evaluate any underlying triggers for the patient's behavioral disturbances. Other potential tests to consider ordering would be ECG, electrolytes, glucose level, liver function tests, thyroid function tests, and urinalysis. Urine toxicology tests can help exclude any potential drug or medication intoxication or withdrawal. CT and MRI of the brain may also be performed to evaluate for any underlying structural causes for the symptoms.

Treatment / Management

It is important to first and foremost decide the appropriate level of care and whether the patient should be hospitalized or treated on an outpatient basis. The basis for decisions regarding treatment should be on multiple factors such as the patient's presenting symptoms, socioeconomic stability, the presence of supporting individuals or family, and the presence of homicidal or suicidal ideation. Because of the limited number of clinical trials evaluating the efficacy of specific treatment modalities in patients with brief psychotic disorder, current recommendations for treatment of BPD relies on pharmacological and psychotherapeutic interventions known to be effective in patients with other psychotic disorders.[12][13]

Pharmacotherapy: Antipsychotics, especially second-generation, are the first-line treatment for brief psychotic disorder. Although BPD characteristically shows complete resolution of symptoms within one month of symptom onset, it is suggested to continue treatment with antipsychotics for one to three months after symptom remission. Although oral formulations are preferable as first-line treatment for BPD, intramuscular formulations may have to be used in patients during immediate assessments and treatment, especially in emergency settings.

  1. Second-generation or atypical antipsychotics: Quetiapine, paliperidone, olanzapine, risperidone, aripiprazole, ziprasidone, and clozapine are the medications that are classified as second-generation and preferred because of their better side effect profile in terms of extrapyramidal symptoms. Olanzapine may be more favorable in lactating mothers as compared to the other drugs from the same class.[14] Metabolic symptoms such as weight gain, dyslipidemia, and hyperglycemia are the most common side effects seen with this drug class that would necessitate obtaining a baseline and periodic waist circumference, BMI, HbA1c, fasting lipid panel, and fasting blood glucose. Clozapine, in particular, is used in treatment-resistant individuals and requires weekly full blood count monitoring for any blood dyscrasias because of its possibility of inducing neutropenia and agranulocytosis.
  2. First-generation or typical antipsychotics: Trifluoperazine, fluphenazine, haloperidol, chlorpromazine, and thioridazine are the medications that are classified as first-generation. Extrapyramidal symptoms (EPS) such as acute dystonia, akathisia, cogwheel rigidity, and tardive dyskinesia are some of the more prominent side effects to keep in mind within this drug class. Anticholinergic medications such as benztropine and biperiden may be added to the treatment regimen to treat the EPS.
  3. Benzodiazepines: Medications within the benzodiazepine class may prove helpful to ameliorate symptom manifestation in acutely combative or agitated individuals.[15]

Psychotherapy: As expected, a brief yet major psychotic episode can be highly disruptive to the livelihood and functioning of an individual and his/her family and friends. Psychotherapeutic management of BPD would involve medically informing the patient and his/her family about the condition and treatment modalities employed for the particular patient. Along with emphasizing reintegration into the societal milieu, it is essential to focus on managing comorbid disorders or stressors and improving overall coping skills.

During the treatment process, the patient should be monitored on a long-term basis to assess for relapse or presence of residual symptoms that may necessitate referral to a specialist. It is essential to support the patient to maintain medication adherence as a lack of adherence may facilitate symptom relapse. The overall treatment plan for BPD should ideally include both pharmacological and psychosocial interventions. The biological, psychological, and social dimensions of the patient's life should in unison dictate the eventual treatment decisions made.

Differential Diagnosis

It is essential to consider other possible etiologies before determining a final diagnosis of the brief psychotic disorder. A diagnosis of brief psychotic disorder can only be made retrospectively after the symptoms have remitted within one month of presentation, as the symptoms of psychosis may otherwise be an early manifestation of another disorder with a psychotic component. Prior to symptomatic remission, a diagnosis of ‘psychotic disorder, not otherwise specified' may be given. Primary differential diagnoses to consider are psychotic affective disorder, schizophrenia-spectrum disorders, personality disorders, delusional disorder, substance use disorder (including withdrawal), substance-induced psychosis, and psychosis secondary to medical conditions.

Psychotic affective disorder is diagnosed in the presence of a major mood component with symptoms of depression or mania. Even with treatment, a patient with affective disorder with psychosis is not expected to return to baseline in 30 days, unlike patients with BPD. Schizophrenia-spectrum disorders such as schizophreniform disorder and schizophrenia are distinguished from BPD based mainly on the presence of symptoms for longer than 30 days. Schizoaffective disorder is diagnosed in a patient who meets the criteria for major depressive disorder or manic disorder who also has psychotic symptoms consistent with schizophrenia concurrently with the mood symptoms and for at least 2 weeks in the absence of mood symptoms. Patients with personality disorder, especially borderline personality disorder, may also have transient episodes of psychosis mostly induced by stress that may only last for 1 day or less. Substance intoxication, substance withdrawal, or medical conditions such as syphilis, neurosarcoidosis, metastasis likely secondary to lung cancer, thyrotoxicosis, and head trauma may occasionally present with symptoms that mimic that of BPD, however, a comprehensive history and physical examination in addition to necessary laboratory testing and imaging will help elucidate the underlying condition.

Prognosis

Given the nature of this condition, the prognosis is considerably well with a complete remission of symptoms within a month per definition based on DSM-5 criteria. However, the symptoms may recur especially in the setting of a stressful psychosocial milieu. Some positive prognostic indicators for the brief psychotic disorder are the absence of genetically-related individuals with schizophrenia or brief psychotic disorder, sudden symptom onset, the presence of stressful triggers, and short duration of symptoms.

Prognosis is notably worse for individuals diagnosed with BPD who have then been able to meet criteria for other disorders characterized by psychosis. A study conducted in Suffolk County, New York in 2000 found that only 2% of the first-admission psychosis patients met the criteria for BPD at the six-month mark. Per the Suffolk County study consisting of 11 patients initially given the diagnosis of brief psychotic disorder, three retained the diagnosis of BPD while the remaining nine received diagnoses of mood disorder, schizophrenia, schizophreniform disorder, and other disorders involving psychosis.[16]

Complications

The most significant complication associated with brief psychotic disorder is the sudden onset of symptoms and accompanying loss in functioning. It is crucial to make special note of predisposing stressors and comorbid disorders and manage them appropriately as that may have precipitated this episode and may result in similar manifestations in the future. Although pharmacotherapy may help curb the presenting symptoms of BPD, it is psychotherapy that will empower the patient with the skills and techniques to cope with this disorder during and after the symptoms have remitted.

Deterrence and Patient Education

Patient and family education is an imperative aspect of the psychotherapeutic interventions used to manage brief psychotic disorder. Experiencing one or more psychotic symptoms including delusions, hallucinations, disorganized speech, or grossly disorganized/catatonic behavior can be extremely unsettling to the individual and family likewise. As a result, adequate education about treatment options and psychotherapy are necessary, in addition to facilitating a strong support system for the patient.

Enhancing Healthcare Team Outcomes

As with most other psychiatric pathologies, the diagnosis, treatment, and management of brief psychotic disorder require the coordinated efforts of a strong multidisciplinary team that includes the primary care provider, mental health nurse, psychologist, and a psychiatrist. It is paramount to develop and follow a patient-centered approach with a particular focus on psychotherapy and pharmacotherapy, given how disruptive such a disease process can be to the patient and his/her family. Working on the biopsychosocial aspect of well-being will ensure that the patient is well supported all-around and help curtail the overall negative impact of this disorder on the life and functioning of the individual.


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Brief Psychotic Disorder - Questions

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A 28-year-old male is brought to the emergency department by police. The patient was found in a parking lot yelling at passing cars. The patient is partially cooperative, has fair hygiene and appears anxious upon evaluation. He states that he has been hearing voices telling him that the world is ending for the past two weeks. He denies any current medical problems or recent drug use, which is corroborated by a negative drug screen and normal labs. He denies any history of medical or psychiatric illness. What is the most likely diagnosis?



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A 22-year-old female is brought by her parents for bizarre behavior. The patient's parents report that the patient has been high functioning her entire life, but over the past one week she has been isolating herself in her room and has been seen speaking to herself. Upon questioning, the patient admits to hearing the voices of five different people, none of whom she recognizes. She remarks that humankind is coming to an end and that she must go on a mission to save everyone. She denies any history of drug use or any medical problems. A urine toxicology screen and medical workup are all normal. The patient is started on risperidone and her auditory hallucinations and delusion resolve one week later. When should the antipsychotic be discontinued?



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A 17-year-old male with daily marijuana use for the past 6 months suddenly believes he can read people's minds. He increasingly spends time alone. At the onset of symptoms, he describes his new beliefs to a friend, and the friend encourages him to stop using marijuana. After about 2 weeks of abstinence, the patient no longer thinks he can read minds. He feels like he has returned to his old self. What would be the diagnosis for this patient?



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A 35-year-old man loses his job and can no longer afford to pay his bills. He moves back home with his parents, who note that their son seems "down" but is still functioning normally. After several months, he remarks one day that there are invisible military bases around the city and that the government is sending spies for him. He then accuses his father of being a spy and runs away from home. He is picked up by the police and brought to the emergency department. He is given intramuscular olanzapine, after which he is admitted and placed on an enforced medication schedule. After 3, days he stops endorsing his previous delusions. Which of the following statements is true?



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A 38-year-old woman’s husband dies in a motor vehicle collision, leaving her with two small children. For the next 3 weeks, the patient stops bathing and isolates herself in her room while relatives look after her children. They hear the woman pacing in her bedroom and talking to herself in a disorganized manner. Which of the following statements is true?



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A 17-year-old recent immigrant is brought to the clinic. Her parents describe a bizarre incident where she became unresponsive and stayed in bed for 2 days shortly after arriving in the United States. The patient was breathing and her eyes would open, but she would not talk and refused all food and liquids. If they moved her, she would maintain the position she was put in, even if it looked uncomfortable. After 2 days, she seemed to return to her normal level of activity and engagement. The family has brought her to the clinic a week later. In the office, the patient confesses that she feels very depressed about leaving her home country. Which of the following statements is true?



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A 26-year-old female who is 2 weeks postpartum tells her husband that the baby is sending her messages to hurt herself. The next day, her husband comes home to find the baby crying in the crib and his wife passed out next to a bottle of pills. He brings them both to the emergency department for evaluation. Which of the following statements is true?



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A patient was recently brought in to the office by her sister and husband after she began screaming that her twin daughters needed her help. The patient was crying hysterically and was yelling, “They are alive.” Her husband then remarked that the couple’s 4-month-old twin daughters were killed in a car accident two weeks ago while returning from the grocery store and the patient had been disorganized, incoherent, and disturbed since then. She had not slept for the three days and was often seen pacing at home while mumbling to herself. She had no recent drug or medication use, and her medical workup and urine toxicology screen were negative. She now returns two weeks later and is back to her baseline. What was the most likely management following the patient's last visit?



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A 45-year-old is brought to the emergency department for 'seeing people' that are actually not there. He was in good health three weeks back when he suddenly started acting strangely. He was seen to be talking to people who were not present, and his speech became jittery over time. On further probing, it becomes clear that the patient was laid off from his job 4 weeks back. On physical examination, the patient is irritable and disheveled. His family history is nonsignificant. Which one of the following is considered to be a positive prognostic factor in this condition?



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Brief Psychotic Disorder - References

References

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Pfuhlmann B,Stöber G,Franzek E,Beckmann H, Cycloid psychoses predominate in severe postpartum psychiatric disorders. Journal of affective disorders. 1998 Sep;     [PubMed]
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Jørgensen P,Bennedsen B,Christensen J,Hyllested A, Acute and transient psychotic disorder: comorbidity with personality disorder. Acta psychiatrica Scandinavica. 1996 Dec;     [PubMed]
Beighley PS,Brown GR,Thompson JW Jr, DSM-III-R brief reactive psychosis among Air Force recruits. The Journal of clinical psychiatry. 1992 Aug;     [PubMed]
Pillmann F,Haring A,Balzuweit S,Blöink R,Marneros A, The concordance of ICD-10 acute and transient psychosis and DSM-IV brief psychotic disorder. Psychological medicine. 2002 Apr;     [PubMed]
Hultsjö S,Berterö C,Hjelm K, Perceptions of psychiatric care among foreign- and Swedish-born people with psychotic disorders. Journal of advanced nursing. 2007 Nov;     [PubMed]
Usher K,Foster K,McNamara P, Antipsychotic drugs and pregnant or breastfeeding women: the issues for mental health nurses. Journal of psychiatric and mental health nursing. 2005 Dec;     [PubMed]
Thomas P,Alptekin K,Gheorghe M,Mauri M,Olivares JM,Riedel M, Management of patients presenting with acute psychotic episodes of schizophrenia. CNS drugs. 2009;     [PubMed]
Schwartz JE,Fennig S,Tanenberg-Karant M,Carlson G,Craig T,Galambos N,Lavelle J,Bromet EJ, Congruence of diagnoses 2 years after a first-admission diagnosis of psychosis. Archives of general psychiatry. 2000 Jun;     [PubMed]
Regier DA,Kuhl EA,Kupfer DJ, The DSM-5: Classification and criteria changes. World psychiatry : official journal of the World Psychiatric Association (WPA). 2013 Jun     [PubMed]

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