Brief Psychotic Disorder

Brief psychotic disorder according to DSM-5 is the sudden onset of psychotic behavior that lasts at least one day but less than one month followed by complete remission with possible future relapses. It is differentiated from schizophreniform disorder and schizophrenia by the duration of the psychosis. Brief psychotic disorder is an acute, often very intense, but transient disorder with the 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 brief psychotic disorder last between one day to one month, with a complete return to previous level of functioning after the disease course in response to antipsychotic medications. The disturbance in behavior cannot be better accounted for by schizophrenia, schizoaffective disorder, mood disorder with psychotic features, or be a direct result of a drug, medication, or medical condition like thyrotoxicosis (excessive levels of thyroid hormone in the blood), sarcoidosis (strong immune system inflammatory response), or syphilis (sexually transmitted bacterial infection). Other relevant medical conditions include brain tumors and head injury. The term sudden onset in this case refers to symptoms appearing within two weeks of a major stressful event.

Etiology

Although unclear, the underlying etiology of brief psychotic disorder is often a severely stressful event or trauma. There may be a genetic, neurological, or environmental component to brief psychotic disorder as well. The specific trigger of brief psychotic disorder, if present, must be specified as follows:

• 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, such as the sudden loss of a loved one.
• Brief psychotic disorder without marked stressor(s) is the onset of psychotic symptoms that occur in the absence of a traumatic event.
• 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 is 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. A study researching the Finnish population found the prevalence of brief psychotic disorder to be 0.05%. Another study in rural Ireland found 10 cases of brief psychotic disorder among 196 first-admission psychosis cases.

Compared to developed countries, reports show a higher incidence of brief psychotic disorder in developing countries. Data drawn from the World Health Organization (WHO) Determinants of Outcome Study also found that the incidence of brief psychotic disorder in developing countries was ten times as much as that in industrialized countries. Brief psychotic disorder is also thought to be more common in women and those with a personality disorder (such as schizotypal or borderline personality disorders).

Etiology

The exact cause of brief psychotic disorder is not known. One theory suggests a genetic link, because the disorder is more common in people who have family members with mood disorders, such as depression or bipolar disorder. Another theory suggests that the disorder is caused by poor coping skills as a defense against or escape from a particularly frightening or stressful situation. These factors may create a vulnerability to develop brief psychotic disorder. In most cases, the disorder is triggered by a major stress or traumatic event.

In females, a low estrogen state (which may occur premenstrual, postpartum, or perimenopausal) can trigger sudden, short-lived psychosis. The psychosis is often linked to an underlying bipolar or schizophrenic condition. Such psychosis (when diagnosed as such) is often considered premenstrual exacerbation, menstrual psychosis, or postpartum psychosis. Childbirth may trigger the disorder in some women. Approximately one in 10,000 women experience brief psychotic disorder shortly after childbirth.^[1]

Evaluation

There are no particular lab studies or psychological testing instruments that are useful in diagnosing 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 scans and brain MRIs 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 brief psychotic disorder relies on pharmacological and psychotherapeutic interventions known to be effective in patients with other psychotic disorders.

Antipsychotics, especially second-generation (e.g., Clozaril, Zyprexa, Seroquel), are the first-line treatment for brief psychotic disorder. Although brief psychotic disorder 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 brief psychotic disorder, intramuscular formulations may have to be used in patients during immediate assessments and treatment, especially in emergency settings.

Pharmacotherapy

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 brief psychotic disorder 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.

Prognosis

Given the nature of this condition, the prognosis is considerably good, as symptoms subside within a month. However, the symptoms may reoccur especially in the setting of a stressful psychosocial environment. Some positive 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 a short duration of symptoms.

Prognosis is notably worse for individuals diagnosed with brief psychotic disorder 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 brief psychotic disorder 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 brief psychotic disorder while the remaining nine received diagnoses of mood disorder, schizophrenia, schizophreniform disorder, and other disorders involving psychosis.^[2]