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.

Objectives:

• 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:

• 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 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.

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 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.

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 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.

Prognosis

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.