case study brief psychotic disorder

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Wandering in brief psychotic disorders: a case study.

Published online by Cambridge University Press: 16 April 2020

Wandering is a symptom present in a variety of psychiatric disorders.

A case of a patient manifesting wandering in the scope of a brief psychotic disorder is described in this presentation.

A 28-year-old male patient was transferred in the Acute Ward of the Psychiatric Hospital of Petra Olympus from the emergency ward of the General Hospital of Katerini.

He was exhausted, filthy, and full of scratches, mentioning that while being with his girlfriend in a remote area, they were verbally attacked by strangers. Panicked, he ran away (this being the last thing he could clearly recall). from that point on, he was wandering in the forest disorientated and feeling threatened. He accidentally approached his village and sought for help.

Upon his admission he had a good self, place orientation but he was disorientated in time and couldn't define the time period he had been wandering. (His relatives mentioned that he was missing for three days, confirming the incident he described). He presented persecutory ideas, auditory hallucinations and he was extremely anxious since he strongly believed that his life was in danger.

He was free of psychiatric history, being functional till the day of the incident. His lab results were normal as well as his neurological examination, EEG and brain-CT. the test for substance use was also negative. He received medication with risperidone (3mg/day) and diazepam (15mg/day). Few days upon his admission he was free of symptoms and was dismissed within 10 days with diagnosis: Brief Psychotic Disorder on risperidone (2mg/day).

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Volume 24, Issue S1
K. Papanikolaou (a1) , L. Stilopoulos (a2) and N. Voura (a1)
DOI: https://doi.org/10.1016/S0924-9338(09)71416-6

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http://orcid.org/0000-0002-5758-4698 Colin M Smith 1 , 2 ,
Jonathan R Komisar 1 , 2 ,
http://orcid.org/0000-0002-3149-597X Ahmad Mourad 2 and
Brian R Kincaid 1 , 2
1 Department of Psychiatry and Behavioral Sciences , Duke University Medical Center , Durham , North Carolina , USA
2 Department of Medicine , Duke University Medical Center , Durham , North Carolina , USA
Correspondence to Dr Colin M Smith; colin.smith{at}duke.edu

A 36-year-old previously healthy woman with no personal or family history of mental illness presented with new-onset psychosis after a diagnosis of symptomatic COVID-19. Her psychotic symptoms initially improved with antipsychotics and benzodiazepines and further improved with resolution of COVID-19 symptoms. This is the first case of COVID-19-associated psychosis in a patient with no personal or family history of a severe mood or psychotic disorder presenting with symptomatic COVID-19, highlighting the need for vigilant monitoring of neuropsychiatric symptoms in these individuals.

psychotic disorders (incl schizophrenia)
infectious diseases

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

https://doi.org/10.1136/bcr-2020-236940

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Contributors CMS wrote the draft of the introduction and discussion of the manuscript, while JRK and AM wrote the draft of the case presentation, while participating in clinical care and clinical data extraction for the case. CMS, JRK, AM and BRK reviewed the literature and participated in data interpretation. BRK oversaw the clinical care of the patient. All authors contributed to the final writing, analysis and revising of the article, gave approval for the final version to be published and agree to be accountable for all aspects of the work.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Disclaimer The views expressed in the article are solely the opinions of the authors and do not necessarily reflect the official policies of the U.S. Department of Health and Human Services or the Indian Health Service.

Competing interests None declared.

Patient consent for publication Obtained.

Provenance and peer review Not commissioned; externally peer reviewed.

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COVID-19 Induced Brief Psychotic Disorder: A Case Report and Review of Literature

Affiliations.

1 Virginia Tech Carilion School of Medicine, 2017 S Jefferson St, Roanoke, VA 24014, USA.
2 Children's Health, 1935 Medical District Drive, Dallas, TX 75235, USA.
PMID: 35036019
PMCID: PMC8754596
DOI: 10.1155/2022/9405630

The COVID-19 pandemic has significantly impacted people around the world, with asymptomatic infection to severe diseases and death. There is an increasing incidence of mental health problems in patients diagnosed with COVID-19. There are some studies that discuss possible mechanisms responsible for psychotic disorders due to coronavirus as well as risk factors for developing psychosis in patients infected with the virus. We report the case and a review of the literature in a 29-year-old female with no past psychiatric history who was diagnosed with a brief psychotic disorder following infection with COVID-19.

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Brief psychotic disorder during COVID-19 pandemic

A case series.

Sunbul, Esra Aydin; Cavusoglu, Emine Cengiz; Gulec, Huseyin

Department of Psychiatry, University of Health Sciences Erenkoy Mental Health and Neurological Diseases Training and Research Hospital, Istanbul, Turkey

Address for correspondence: Dr. Esra Aydin Sunbul, Sahrayicedid Mah, Bayar Cad, Bahceli Sok, Cagri Apt, No: 3/8, Kadikoy, Istanbul 34734, Turkey. E-mail: [email protected]

Received September 19, 2020

Received in revised form June 22, 2021

Accepted July 01, 2021

INTRODUCTION

The COVID-19 pandemic is a virus outbreak that was first reported on December 1, 2019, in Wuhan and spread all over the world in a short time. Restrictions on freedom, such as curfew and quarantine, school closures, flexible shifts of working which were implemented as control strategies for the COVID-19 pandemic, and boredom, inadequate information, and virus-related fears related to the control strategies can lead to various psychiatric disorders in susceptible individuals.[ 1 ]

While many studies examine the relationship between COVID-19 pandemic with depression, anxiety, posttraumatic stress disorder, suicide, psychological stress, and somatic symptoms, few cases of new-onset psychosis have been reported.[ 2 3 ] Considering that biological, environmental, and social events play a role in the pathophysiology of psychotic disorders, it is important to examine psychotic disorders during the pandemic period.[ 4 ] Here, we described three clinical cases of patients with a brief psychotic disorder (BPD) admitted to the psychiatry service. All three admissions occurred <1 month after the initiation of strict societal restrictions in the country.

CASE REPORTS

This case was a 43-year-old unmarried man with a high-school education. The second of the three siblings, he had neither physical nor psychiatric history prior to the pandemic. He had good job performance.

As the first COVID-19 cases emerged in the country, the patient began to experience unhappiness, introversion, indifference, sleep, and appetite disruption. He worked at home for 15 days due to flexible working conditions. He developed feelings of being infected by the virus and visited multiple health centers for COVID-19 test. However, he did not believe the negative test results. He had delusions that he was infected with COVID-19, and it caused damage to his internal organs. One day, he removed all of his clothes, including his underwear in the street. The patient was found by the police and taken to the emergency department.

The physical examination, biochemical blood, and urine analysis for substance use were normal. Structural injury was not shown by computerized tomography axial. The COVID-19 polymerase chain reaction (PCR) sample taken during hospitalization was negative.

He was awake, disoriented in time and space, and experienced poor insight, circumstantial thinking, delusions of persecution, marked psychotic anxiety, a sense of sadness, frustration, self-undervaluation, and insomnia. The treatment consisted of 10 mg of olanzapine. During the 2 nd week of his hospitalization, he showed a rapid improvement in his psychotic and depressive symptoms, and his sleep improved as well. A best-estimate BPD diagnosis was made. The symptoms of psychosis did not seem to be better explained by a depressive episode. Depressive and psychotic symptoms started in the same period, and the patient improved dramatically in the 2 nd week of the antipsychotic treatment dramatically. The patient was discharged after 20 days with a clinical remission, confirmed by a brief psychotic rating scale (BPRS) total score (90 upon admission and 23 at discharge).

This case was a 53-year-old unmarried man with a secondary-school education. He had hypertension and chronic renal failure under control. He performed well at work.

After the appearance of the first COVID-19 cases in the country, the patient started to worry that the virus would be transmitted to him, and he left his job. The patient's appetite decreased, and he experienced significant weight loss and severe insomnia. He frequently visited the internal medicine department for a COVID-19 test and had negative test results. The patient was brought to the internal medicine department by his family due to syncope. A low sodium level related to a decrease in food and drink was detected, and he was treated by a one-night hospital stay until his biochemical values were normal. In the following days, the patient continued to say that he had got the COVID-19, but it had not been detected in the tests. He developed bizarre behaviors, including plucking out his head and body hair. The patient was brought to the emergency department by his family.

All physical and laboratory examinations performed during hospitalization were normal. He was awake with delusions of persecution and marked psychotic anxiety during the mental examination. After approximately 2 weeks of the olanzapine treatment, psychiatric symptoms including sleep and diet improved markedly (BPRS score went from 86 to 25). BPD seemed to be the best explanation for the symptoms of psychosis. Delirium diagnosis was not considered due to the absence of impaired consciousness, impaired orientation, and also the absence of any organic pathology. Mood disorders were also not considered either, as the patient's mood symptoms did not reach a level that would meet the episode criteria.

This was a 31-year-old unmarried man working as a moto courier before the pandemic. He did not have any physical or psychiatric history prior to the pandemic. The economic concerns caused by the loss of his job due to the pandemic caused him severe anxiety, leading to intense distress and interrupted sleep. He developed delusions about COVID-19, believing that he was being followed, as he had found the treatment for it. The patient said that he needed to reach a doctor before he was harmed. He felt the need to escape from his house and went to the post office to try to find doctors’ phone numbers. He settled in a hotel but left after one night, as he thought there were cameras in his room. The police were informed by the people who passed him walking the streets while shredding his clothes and shouting. The patient was brought to the psychiatry emergency room by police and ambulance.

His physical and laboratory examinations and PCR were normal. After approximately 3 weeks in hospital, an improvement in his mood and a progressive reduction of psychotic symptoms, with the development of initial insight, was observed. A BPD diagnosis was made because the symptoms of psychosis were not deemed to be better explained by any other psychiatric disorder. The patient was discharged after 17 days with a clinical remission, confirmed by a BPRS total score (from 93 to 26).

None of the three patients had a history of psychiatric disorders before the pandemic. They were treated with olanzapine and experienced complete remission of psychotic symptoms within a few days. Our diagnosis was BPD, according to DSM-5 criteria, in all three cases.

The COVID-19 pandemic caused fearful reactions and psychological stress in the general population because of the high infection rate of the virus and the catastrophic consequences of the infection.[ 5 ] Harmless bodily sensations can be interpreted as symptoms of a COVID-19 infection due to anxiety and fear. Increasing anxiety in our cases interfered with the patients’ capability to make rational decisions, which can lead to maladaptive behavior, such as going often to medical centers to rule out the disease.[ 6 ] Our patients had also gone to many hospitals to be tested, but they did not believe negative test results.

Recently, there have been case reports of the onset of psychotic symptoms triggered by the fear of COVID-19. A cohort of six cases with first-episode psychosis was reported in the 2 nd month of national lockdown in Italy.[ 7 ] In that study, cases had a negative psychiatric history and normal premorbid psychosocial adjustment; none of their first-degree relatives had a known mental disorder, and no shared risk factor other than pandemic-related stress could be identified similar to our cases. The mean age of our cases was 42.3 years, although other recently reported cases of pandemic-reactive psychoses revealed a relatively younger age, confirming available evidence on BPD first episodes, which tend to peak in early adulthood for males and the mid-30 s for females.[ 8 ]

Among older people and those who have chronic medical conditions, previous history of mental disorder, the presence of a family with a history of mental disorders, and having poor psychosocial supports were hypothesized either to provoke or exacerbate the existing mental problems during the COVID-19 pandemic.[ 9 ]

All three of our cases were not married and lived alone. The feeling of loneliness may have increased their stress during the pandemic process. The first case stayed at home for 15 days due to flexible working hours. The second case had to quit his job for fear of the pandemic. Moreover, the last one's workplace was closed related to the pandemic. These changes in their lives may have reduced their psychosocial support. One of the cases had chronic illnesses such as hypertension and chronic renal failure that may have caused the fear of getting COVID-19 infection and hospitalization.

Psychotic disorders that develop during the pandemic may increase the risk of suicidal behavior. In a case report, the first episode of psychosis that resulted in suicide was mentioned.[ 10 ] Patients with psychotic symptoms are also hazardous for the rapid spread of COVID-19. Disturbances in the content of thought and decision-making mechanism may prevent them from taking precautions against coronavirus.

Clinical implications

There is much to speculate regarding the consequences of the COVID-19 pandemic on individuals with psychosis. Sufficient attention has not been shown to these patients. Mental health professionals should be aware of the possible increase in the BPDs related to pandemics.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

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Brief Psychotic Disorder

Reviewed by Psychology Today Staff

A brief psychotic disorder is a psychiatric condition characterized by sudden and temporary periods of psychotic behavior, such as delusions, hallucinations, and confusion. Symptoms can endure for only one day or for as long as one month, but they may be severe enough to put the person at increased risk of violent behavior or suicide . Although onset can occur at any age, the majority of cases present for the first time when an individual is in their 20s or 30s. Brief psychotic disorder is differentiated from other disorders in which psychosis occurs by its limited duration, and it is not triggered by drugs or alcohol abuse . In most cases, brief psychotic disorder does not indicate the presence of a chronic mental health condition.

According to the DSM-5 , symptoms of brief psychotic disorder may include:

Delusions and hallucinations
Sudden and extreme mood changes
Nonsensical or disordered speech
Disorganized behavior

Other signs may include:

Memory problems
Beliefs that may seem bizarre
Indecisiveness
Changes in sleep, eating, hygiene

Women are more likely than men to develop brief psychotic disorder, especially postpartum . The DSM-5 classifies one subtype of brief psychotic disorder as psychosis with onset within one month of giving birth. Most people who develop brief psychotic disorder experience only one episode and are able to resume all activities with no permanent symptoms or impairment. People with certain personality disorders have an elevated risk of experiencing a brief psychotic episode , as are those who have experienced trauma or severe stress . It is important to understand that the prognosis for brief psychotic disorder is generally good. However, an initial psychotic episode may be the first sign of a chronic mental health condition such as schizoaffective disorder, schizophrenia, or a mood disorder with psychotic symptoms. The diagnosis of brief psychotic disorder is generally reevaluated if symptoms persist for more than one month.

Brief psychotic disorder does not normally recur. Certainly, if the symptoms last longer than a month, health professionals may assess if there is another illness or disorder, such as schizophrenia.

Brief limited intermittent psychotic symptoms, known as BLIPS, are moderate to severe manifestations of psychosis. The symptoms can happen before the onset of severe mental illness. Symptoms for brief and limited psychosis last no more than one week. There are also brief intermittent psychosis symptoms, or BIPS, where symptoms last less than three months.

The cause of brief psychotic disorder is unclear, but major stress or trauma—such as the death of a loved one, assault, or natural disaster—can trigger an episode. As with other disorders on the psychotic spectrum, there may be a genetic, biologic, environmental, or neurological basis for this episode. Neurological abnormalities have been found in people with psychotic disorders; some appear to be present before symptoms first appear, while other abnormalities have been recorded after the onset of symptoms. Brief psychotic disorder tends to run in families.

Extreme or intense stress can cause brief psychosis that lasts for less than one month. The person normally has no other mental illness or medical condition.

Stress, drugs, and other substances can indeed exacerbate brief psychosis. People with a family history of psychosis are particularly at higher risk.

Generally, a medical or psychiatric professional will interview the person to rule out any other physical or mental health condition that exists simultaneously or could be causing the symptoms. Antipsychotic medications and, if necessary, antidepressants may be prescribed to help manage symptoms, and the person may need to be supervised at all times to ensure they don’t harm themselves or others. Short-term psychotherapy can help a person understand and recover from brief psychotic disorder, manage their medications, and learn to cope with stress. Those who fail to seek treatment after a first psychotic episode are more likely to see a future recurrence of brief psychotic disorder or to subsequently be diagnosed with a chronic disorder on the psychotic spectrum.

Brief psychotic disorder generally has a good prognosis. It concludes its course in a short period of time, within a month. It is normally sudden-onset and symptoms are not lasting. People with no previous history of psychiatric illness tend to have better outcomes.

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Brief psychotic disorder, learning objectives.

Describe the symptoms, etiology, and management of 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:

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.

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).

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]

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.

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]

In this video, Chris speaks about his experience and recovery from brief psychotic disorder.

You can view the transcript for “Chris talks about his experience of psychosis and his recovery journey” here (opens in new window) .

Key Takeaways: Brief Psychotic Disorder

brief psychotic disorder: : the sudden onset of psychotic behavior that lasts less than one month followed by complete remission with possible future relapses

brief psychotic disorder with postpartum: the onset of psychotic symptoms that occur within four weeks postpartum

brief reactive psychosis: brief psychotic disorder with marked stressor(s)

postpartum: period of time following the birth of a new baby

Nolen-Hoeksema, Susan (2014). Abnormal Psychology (6th ed.). New York, NY: McGraw-Hill Education. pp. 230–231. ISBN 9780078035388. ↵
Stephen A, Lui F. Brief Psychotic Disorder. [Updated 2020 Jul 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539912/ ↵
"eMedicine - Brief Psychotic Disorder: Article by Mohammed A Memon". 2019-11-09. ↵
Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY-SA: Attribution-ShareAlike
Brief Psychotic Disorder . Authored by : Stephen Anu and Lui Forshing. Provided by : StatPearls. Located at : https://www.ncbi.nlm.nih.gov/books/NBK539912/ . Project : NIH. License : CC BY: Attribution
Brief Psychotic Disorder. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Brief_psychotic_disorder . License : CC BY-SA: Attribution-ShareAlike
Chris talks about his experience of psychosis and his recovery journey. Provided by : Time to Change. Located at : https://www.youtube.com/watch?v=7BHKV2_wiik . License : Other . License Terms : Standard YouTube License

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Brief psychotic disorder.

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Last Update: June 25, 2023 .

Continuing Education Activity

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. 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. This activity describes the presentation and pathophysiology of brief psychotic disorder and highlights the role of the interprofessional team in its management.

Review the presentation of a patient with brief psychotic disorder.
Summarize the treatment of brief psychotic disorder.
Describe the DSM 5 criteria for brief psychotic disorder.
Explain the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients with a brief psychotic disorder.
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 the onset of one or more of the following psychotic symptoms:

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 for 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.

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:

The presence of at least one positive psychotic symptom such as delusions, hallucinations, disorganized speech, or disorganized or catatonic behavior
Establishing that the symptoms have not been present for less than one day or more than one month
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.

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 rely 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.

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.
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.
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 the 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.

Given the nature of this condition, the prognosis is considerably well with 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 a 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 interprofessional team that includes the primary care provider, mental health nurse, psychologist, and 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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Disclosure: Anu Stephen declares no relevant financial relationships with ineligible companies.

Disclosure: Forshing Lui declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Cite this Page Stephen A, Lui F. Brief Psychotic Disorder. [Updated 2023 Jun 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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