Brief Psychotic Disorder

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

Use additional code 293.89 (F06.1) when catatonia is associated with brief psychotic disorder to indicate the presence of the comorbid 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).

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.

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

Although this disorder may appear in adolescence or early adulthood it can occur accross the life span. 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.

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.

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:

• MedlinePlus, Brief reactive psychosis

• WebMD, Schizophrenia and Brief Psychotic Disorder

• MedicineNet.com, Brief Psychotic Disorder

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

• Delusions - Rapidly changing delusional topics

• Hallucinations

• Bizarre behavior and posture

• Disorganized speech

Patients may present with a variety of associated symptoms, including the following:

• Affective symptoms - Rapidly changing mood

• Disorientation - A careful Mental Status Examination can distinguish this from delirium, dementia, or other organic brain syndromes

• Impaired attention

• Catatonic behavior (in some cases)

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. Some clinicians believe that persons with personality disorders (eg, narcissistic, paranoid, borderline, schizotypal) are more prone to develop brief psychotic disorder in stressful situations.[8]

DSM-5 stresses that symptoms of brief psychotic disorder must be distinguished from culturally sanctioned response patterns that may resemble such symptoms.[1] For instance, hearing voices may be a component of some religious ceremonies; this generally would not be considered abnormal by most members of the religious community, and the voices typically would not persist into daily life. 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. Patients usually present with severe psychotic agitation that may be associated with the following:

• Strange or bizarre behavior

• Uncooperativeness

• Physical or verbal aggression

• Disorganized speech

• Screaming or muteness

• Labile or depressed mood

• Suicidal or homicidal thoughts or behaviors

• Restlessness

• Hallucinations

• Delusions

• Disorientation

• Impaired attention, concentration, or memory

• Poor insight or judgment

Psychological stressors in individuals with personality disorders may precipitate brief periods of psychotic symptoms. In such cases, if symptoms persist longer than 1 day, an additional diagnosis of brief psychotic disorder may be considered.

Specific laboratory studies for brief psychotic disorder do not exist. Comprehensive neuropsychiatric assessment, physical examination, and laboratory tests can help differentiate brief psychotic disorder from psychotic disorder secondary to general medical condition, delirium, and various other disorders. Routine and specific laboratory work may be needed to exclude other causes of psychoses.

Substance-induced psychotic disorder, substance-induced delirium, and substance intoxication can be distinguished from brief psychotic disorder by considering onset, course, urine drug screening, and blood alcohol levels.

No imaging studies are required to diagnose brief psychotic disorder. Further testing with modalities such as computed tomography (CT), magnetic resonance imaging (MRI), and electroencephalography (EEG) may be considered, but such studies are useful only for diagnosing possible medical causes of the psychosis.

It is important to evaluate weight, metabolic state, cardiac, sexual and neurologic functions along with hematologic health as well as periodic monitoring for changes in these areas during the treatment is recomended.[9]

Because of the short duration of brief psychotic disorder, treatment is brief and focused on being as nonrestrictive as possible. However, it remains clinically imperative to prevent patients from harming themselves or others. Accordingly, patients experiencing an acute psychotic attack may have to be hospitalized briefly so that they can be evaluated and their safety ensured. If a patient becomes aggressive and combative, brief seclusion or restraint may be necessary.

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

If, however, symptoms are disabling, an antipsychotic agent should be given, but for no longer than 1 month. Commonly used typical (first-generation) antipsychotics include the following:

• Haloperidol
• Thiothixene
• Thioridazine
• Fluphenazine
• Chlorpromazine

If adverse effects are intolerable, it may be helpful to use one of the atypical (second-generation) antipsychotics, for example:

• Olanzapine
• Quetiapine
• Ziprasidone
• Risperidone
• Paliperidone
• Lurasidone
• Aripiprazole

At present, the available evidence is not sufficient to support the use of atypical antipsychotics to treat brief psychotic disorder. A case series suggests that rapid tranquilization with olanzapine can achieve symptom relief in acute psychosis.[10] A study involving intramuscular (IM) ziprasidone showed this agent to be more effective and better tolerated than IM haloperidol for treating acute psychosis.[11] In the authors’ experience, IM ziprasidone is the most effective treatment for acute severe psychotic agitation.

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.

The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Both typical and atypical antipsychotic agents have been used in the treatment of brief psychotic disorder.

Class Summary

Antipsychotics are high-potency agents that provide rapid, predictable, and effective sedation in the management of patients who are acutely psychotic. They are less sedating and more easily titrated than lower-potency agents but more likely to cause extrapyramidal syndrome (EPS). They are often combined in the same syringe with a benzodiazepine to improve sedation and anxiety and reduce dystonia or akathisia. For prophylaxis of EPS, temporary use of a serotonin-dopamine antagonist may be needed.

Antipsychotics may be administered intramuscularly (IM) or intravenously (IV). In a nonemergency setting, haloperidol may be given orally. Haloperidol also has a monthly depot form (haloperidol decanoate), but this is not useful for brief psychotic disorder, because of the short duration of the psychotic episode.

Haloperidol (Haldol)

Haloperidol controls psychosis and provides rapid tranquilization. It can be administered with a benzodiazepine to protect against a lowered seizure threshold. IV haloperidol can be used effectively to treat acute psychotic agitation in a low dosage of 1-2 mg every 8 hours for 2-3 days, and the drug can be continued orally for the next several days until symptoms completely subside. In cases where it is difficulty to differentiate brief psychotic disorder and delirium, it should be kept in mind that IV haloperidol is also effective for delirium.

Thiothixene

Thiothixene blocks postsynaptic blockade of central nervous system (CNS) dopamine receptors, inhibiting dopamine-mediated effects. It provides rapid tranquilization in both oral and IM forms.

Risperidone (Risperdal)

Unlike haloperidol, risperidone has serotonergic blocking effects that alleviate negative symptoms of psychosis (eg, anhedonia, avolition, amotivation, and flat affect). It is well tolerated and has fewer extrapyramidal adverse effects than typical antipsychotics do. Dosages higher than 6 mg/day increase the risk of extrapyramidal effects.

Olanzapine (Zyprexa)

Olanzapine may inhibit serotonin, muscarinic, and dopamine effects. Its efficacy is similar to that of risperidone; it has fewer dose-dependent adverse effects but is more likely to be associated with weight gain.

Quetiapine (Seroquel)

Quetiapine may act by antagonizing dopamine and serotonin effects. Its efficacy is similar to those of risperidone and olanzapine; it has fewer dose-dependent adverse effects and poses less of a concern with regard to weight gain.

Paliperidone (Invega)

Paliperidone is the major active metabolite of risperidone and the first oral agent that can be given once daily. It is indicated for treatment of acute schizophrenia. The mechanism of action is not completely understood but is thought to involve mediation of central receptor antagonism of dopamine type 2 (D2) and serotonin type 2 (5-HT2A). It also elicits antagonist activity at alpha1- and alpha2-adrenergic receptors and histamine-1 receptors. It has no affinity for cholinergic, muscarinic, or beta-adrenergic receptors.