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Brief Psychotic Disorder

  • Author: Mohammed A Memon, MD; Chief Editor: David Bienenfeld, MD  more...
 
Updated: Nov 17, 2015
 

Practice Essentials

Brief psychotic disorder is currently classified with schizophrenia spectrum and other psychotic disorders. It is differentiated from other related disorders by its sudden onset, its relatively short duration (< 1 month), and the full return of functioning.

Signs and symptoms

Brief psychotic disorder is characterized by the abrupt onset of 1 or more of the following symptoms:

  • Delusions
  • Hallucinations
  • Bizarre behavior and posture
  • Disorganized speech

Associated symptoms may include the following:

  • Affective symptoms
  • Disorientation
  • Impaired attention
  • Catatonic behavior

The following are also commonly observed in brief psychotic disorder:

  • Emotional volatility
  • Outlandish dress or behavior
  • Screaming or muteness
  • Impaired memory for recent events

A psychiatric history may be helpful.

Symptoms of brief psychotic disorder must be distinguished from culturally sanctioned response patterns that may resemble such symptoms. Cultural and religious background must always be taken into account when a judgment is to be made about whether a given patient’s beliefs are delusional.

Routine physical examination is necessary to exclude medical causes of psychosis. A careful Mental Status Examination is vital.

See Presentation for more detail.

Diagnosis

Specific laboratory studies for brief psychotic disorder do not exist. The history, the physical examination, and laboratory tests can help differentiate this condition from psychotic disorder secondary to general medical condition, delirium, and various other disorders.

No imaging studies are required for diagnosis; though CT, MRI, and EEG may be considered for assessing possible medical causes of psychosis.

See Workup for more detail.

Management

Management considerations include the following:

Treatment is brief and focused on being as nonrestrictive as possible

It is clinically imperative to prevent patients from harming themselves or others; thus, brief hospitalization may be necessary, potentially including brief seclusion or restraint for aggressive or combative patients

If symptoms are only minimally impairing the patient’s function and a specific stressor is identified, removing the stressor should suffice for treatment

If symptoms are disabling, an antipsychotic agent should be given, but for no longer than 1 month. Antipsychotics include the following:

  • Haloperidol
  • Thiothixene
  • Olanzapine
  • Quetiapine
  • Ziprasidone
  • Risperidone
  • Paliperidone

Once the acute attack has ended, further inpatient care is unnecessary. Individual, family, and group psychotherapy may be considered to help cope with stressors, resolve conflict, and improve self-esteem and self-confidence.

See Treatment and Medication for more detail.

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Background

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), classifies brief psychotic disorder as belonging to the category of schizophrenia spectrum and other psychotic disorders.[1] These disorders are characterized by delusions, hallucinations, disorganized thinking, motor behavior abnormalities (including catatonia), and negative symptoms.

Brief psychotic disorder is distinguished from related disorders by the combination of sudden onset, relatively short duration (< 1 month) and full return of functioning. The diagnosis has been better appreciated and more completely studied in Scandinavia and other Western European countries than it has been in the United States.

Diagnostic criteria (DSM-5)

The specific DSM-5 criteria for brief psychotic disorder are as follows[1] :

  • The patient must have 1 or more of the following symptoms: delusions, hallucinations, disorganized speech (eg, frequent derailment or incoherence), and grossly disoriented or catatonic behavior; 1 or more of the first 3 symptoms must always be present; a symptom should not be included if it is a culturally sanctioned response
  • The duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning
  • The disturbance cannot be better explained by major depressive or bipolar disorder with psychotic features or by another psychotic disorder (eg, schizophrenia or catatonia), nor can it be attributed to the physiologic effects of a substance or medication or another medical condition

In addition, the following must be specified:

  • Presence of marked stressor(s) (brief reactive psychosis)
  • Absence of marked stressor(s)
  • Postpartum onset (if onset is during pregnancy or ≤4 weeks post partum) [2, 3]
  • Presence of catatonia

The severity of brief psychotic disorder can be specified on the basis of quantitative assessment of the primary symptoms (see above), though a diagnosis can be made without specifying severity in this manner. Each symptom is rated with respect to current severity on a 5-point scale that ranges from 0 (not present) to 4 (present and severe).

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Pathophysiology and Etiology

The causes of brief psychotic episodes are largely unknown. Patients with personality disorder may have biologic or psychological vulnerability toward the development of psychotic symptoms. One or more severe stress factors, such as traumatic events, family conflict, employment problems, accidents, severe illness, death of a loved one, and uncertain immigration status, can precipitate brief reactive psychosis.

Psychodynamic theories suggest that the psychotic symptoms occur because of inadequate coping mechanisms, as a defense against prohibited fantasy, or as an escape from a specific psychological situation or an overwhelming stressful circumstance. It must be understood that the individual perceives the stress as totally overwhelming. Neither biologic nor psychological theories have been validated by carefully controlled clinical studies.

Some studies support a genetic vulnerability to brief psychotic disorder. Some data suggest an increased incidence of mood disorders in families of patients with brief psychotic disorder.

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Epidemiology

United States statistics

Brief psychotic disorder is not common. In a follow-up study of 221 first-admission patients with affective and nonaffective psychoses, only 20 (9%) of the 221 experienced brief psychoses, and only 7 (3%) experienced acute brief psychoses.[4]

International statistics

According to an international epidemiologic study, the incidence of nonaffective acute remitting psychoses in contrast to that of schizophrenia, was 10-fold higher in developing countries than in industrialized countries.[5] Some clinicians believe that the disorder may occur most frequently in patients from lower socioeconomic classes, patients with preexisting personality disorders, and immigrants.

In nonindustrialized countries, such terms as yak, latah, koro, amok, and whitiligo have been used to describe psychotic states precipitated by stressful events. These and several similar cultural terms are now considered to be culture-bound syndromes.

Age- and sex-related demographics

The disorder is more common in patients late in the third to early in the fourth decade of life. Cases have also been recognized later in life. An international epidemiologic study found the incidence of the disorder to 2-fold higher in women than in men.[5] Study reports from the United States indicate an even preponderance in women.

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Prognosis

Generally, brief psychotic disorder has a good prognosis and runs its course in less than 1 month. A good prognosis is usually associated with sudden onset, short duration of symptoms, and good premorbid adjustment; the prognosis is especially favorable for patients with no premorbid psychiatric history. According to European studies, 50-80% of all patients have no further major psychiatric problems.

As with any other psychotic episode, the risk of harm to self or others increases with an acute episode of brief psychotic disorder.[6] Some data indicate that a brief psychotic episode with an acute onset may be an early manifestation of severe mental disorder (eg, an affective disorder).[7] Patients may be at risk for committing suicide during psychotic episodes, especially when brief psychotic disorder is associated with affective symptoms.

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Patient Education

Both the patient and the family must be educated about the illness and the potential adverse effects of the medications. Helpful Web sites include the following:

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Contributor Information and Disclosures
Author

Mohammed A Memon, MD Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Acknowledgements

Harold H Harsch, MD Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Michael F Larson, DO Clinical Instructor, Department of Child and Adolescent Psychiatry, Harvard Medical School; Psychiatrist, Harvard Vanguard Medical Associates and Private Practice

Michael F Larson, DO is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, and American Society of Addiction Medicine

Disclosure: Nothing to disclose.

Alan D Schmetzer, MD Professor Emeritus, Interim Chairman, Vice-Chair for Education, Associate Residency Training Director in General Psychiatry, Fellowship Training Director in Addiction Psychiatry, Department of Psychiatry, Indiana University School of Medicine; Addiction Psychiatrist, Midtown Mental Health Cener at Wishard Health Services

Alan D Schmetzer, MD is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Clinical Psychiatrists, American Academy of Psychiatry and the Law, American College of Physician Executives, American Medical Association, American Neuropsychiatric Association, American Psychiatric Association, and Association for Convulsive Therapy

Disclosure: Eli Lilly & Co. Grant/research funds Other

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013.

  2. Chaudron LH, Pies RW. The relationship between postpartum psychosis and bipolar disorder: a review. J Clin Psychiatry. 2003 Nov. 64(11):1284-92. [Medline].

  3. Valdimarsdottir U, Hultman CM, Harlow B, Cnattingius S, Sparen P. Psychotic illness in first-time mothers with no previous psychiatric hospitalizations: a population-based study. PLoS Med. 2009 Feb 10. 6(2):e13. [Medline].

  4. Susser E, Fennig S, Jandorf L, Amador X, Bromet E. Epidemiology, diagnosis, and course of brief psychoses. Am J Psychiatry. 1995 Dec. 152(12):1743-8. [Medline].

  5. Susser E, Wanderling J. Epidemiology of nonaffective acute remitting psychosis vs schizophrenia. Sex and sociocultural setting. Arch Gen Psychiatry. 1994 Apr. 51(4):294-301. [Medline].

  6. Jorgensen P, Mortensen PB. Reactive psychosis and mortality. Acta Psychiatr Scand. 1990 Mar. 81(3):277-9. [Medline].

  7. Correll CU, Smith CW, Auther AM, McLaughlin D, Shah M, Foley C, et al. Predictors of remission, schizophrenia, and bipolar disorder in adolescents with brief psychotic disorder or psychotic disorder not otherwise specified considered at very high risk for schizophrenia. J Child Adolesc Psychopharmacol. 2008 Oct. 18(5):475-90. [Medline].

  8. Jorgensen P, Bennedsen B, Christensen J, Hyllested A. Acute and transient psychotic disorder: comorbidity with personality disorder. Acta Psychiatr Scand. 1996 Dec. 94(6):460-4. [Medline].

  9. Karagianis JL, Dawe IC, Thakur A, et al. Rapid tranquilization with olanzapine in acute psychosis: a case series. J Clin Psychiatry. 2001. 62 Suppl 2:12-6. [Medline].

  10. Brook S, Lucey JV, Gunn KP. Intramuscular ziprasidone compared with intramuscular haloperidol in the treatment of acute psychosis. Ziprasidone I.M. Study Group. J Clin Psychiatry. 2000 Dec. 61(12):933-41. [Medline].

 
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