AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

In 1913, Karl Jaspers described specific criteria for the diagnosis of reactive psychosis, including the presence of an identifiable and extremely traumatic stressor, a close relation between the stressor and the development of psychosis, and a generally benign course for the psychotic episode.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) describes brief psychotic disorder based primarily on duration of symptoms. DSM-IV defines brief psychotic disorder as an illness lasting from 1 day to 1 month, with an eventual return to the premorbid level of functioning.

The diagnosis has been better appreciated and more completely studied in Scandinavia and other western European countries than in the United States.

Pathophysiology

Some data suggest increased incidence of mood disorders in families of patients with brief psychotic disorder. 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. It must be understood that the individual perceives the stress as totally overwhelming. Neither biological nor psychological theories have been validated by carefully controlled clinical studies.

Frequency

United States

Brief psychotic disorder is not common. According to one 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.

International

According to an international epidemiologic study, in contrast to schizophrenia, incidence of nonaffective acute remitting psychoses was 10-fold higher in developing countries than in industrialized countries. Some clinicians believe that the disorder may most frequently occur in patients from low 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.

Mortality/Morbidity

As with any other psychotic episode, the risk of harm to self and/or others increases with an acute episode of brief psychotic disorder.

Sex

According to an international epidemiologic study, incidence of the disorder was 2-fold higher in women than in men. Study reports in the United States indicate even higher incidence in women than in men.

Age

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.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

DSM-IV diagnostic criteria require presence of one or more of the following: delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior. These criteria also require an episodic duration of the disturbance for at least 1 day but less than 1 month, with eventual return to the premorbid level of functioning. According to the DSM-IV, the diagnosis of brief psychotic disorder can be specified as with or without marked stressors or with postpartum onset. Some clinicians believe that persons with personality disorders (eg, narcissistic, paranoid, borderline, schizotypal) are more prone to develop brief psychotic disorder in stressful situations.

• Patients with brief psychotic disorder have an abrupt onset of one 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 (for some patients)
• Characteristic symptoms in brief psychotic disorder
• • Emotional volatility
  • Outlandish dress or behavior
  • Screaming or muteness
  • Impaired memory for recent events

Physical

• Routine physical examination is necessary to exclude medical causes of psychosis.
• Mental Status Examination: Patients usually present with severe psychotic agitation that may be associated with strange or bizarre behavior, uncooperativeness, physical or verbal aggression, disorganized speech, screaming or muteness, labile or depressed mood, suicidal and/or homicidal thoughts or behaviors, restlessness, hallucinations, delusions, disorientation, impaired attention, impaired concentration, impaired memory, poor insight, and poor 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.

Causes

Causes are largely unknown.

• Patients with personality disorder may have biological 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.
• Some studies support a genetic vulnerability to brief psychotic disorder.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Substance-induced psychotic disorder
Psychotic disorder secondary to general medical condition
Mood disorder with psychotic features
Psychotic disorder not otherwise specified (NOS)
Psychosis associated with personality disorders
Epilepsy
Ganser syndrome

History, physical examination, or laboratory tests can help to differentiate brief psychotic disorder from psychotic disorder secondary to general medical condition, delirium, and various other disorders. Consider further testing with modalities such as CT scan, MRI, or EEG.

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

Occurrence of a psychotic episode during a full affective episode excludes the diagnosis of brief psychotic disorder. If psychotic symptoms persist longer than a month, the diagnoses of schizophreniform disorder, schizoaffective disorder, schizophrenia, delusional disorder, mood disorder with psychotic features, or psychotic disorder NOS are the most important disorders to be considered. Rapidly changing delusions and rapidly changing mood also help differentiate it from schizophrenia, schizoaffective disorder, and delusional disorder.

In the case of malingering, there is usually some evidence indicating that the illness was feigned for an understandable goal. In factitious disorder, past history may reveal that the symptoms are intentionally produced. Presence of a florid psychosis makes the diagnosis of dissociative disorder unlikely.

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

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Specific laboratory studies for brief psychotic disorder do not exist.
• History, physical examination, or laboratory tests can help to 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 are distinguished from brief psychotic disorder by considering onset, course, urine drug screening, and blood alcohol levels.

Imaging Studies

• No imaging studies are required to diagnose brief psychotic disorder.
• Consider further testing with modalities such as CT scan, MRI, or EEG.
• The usefulness of such studies is only in diagnosing medical causes of the psychosis.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• Patients with acute psychotic attack may need a brief hospitalization for evaluation and safety concerns. If a patient becomes aggressive and combative, brief seclusion or restraint may be necessary to ensure safety of the patient and/or others.
• Because of the short duration of brief psychotic disorder, the treatment is brief and focused on being least restrictive. However, since it is rapid in onset and quick in course, it remains clinically imperative to protect the patient from self-injury or harm to others. Hence, a brief hospitalization may be in order.
• If symptoms are only minimally impairing the patient's function and a specific stressor is identified, removing the stressor should suffice.
• In the event that symptoms are disabling, an antipsychotic agent should be used for no longer than a month. If adverse effects are intolerable, the use of atypical antipsychotics may be helpful. Unfortunately, not enough information is available in the literature to support the use of atypical antipsychotics for the treatment of brief psychotic disorder. A case series suggests that rapid tranquilization with olanzapine can achieve symptom relief in acute psychosis. A study involving intramuscular ziprasidone showed greater efficacy and tolerability than intramuscular haloperidol in treating acute psychosis. In the authors' experience, intramuscular ziprasidone is the most effective treatment of acute severe psychotic agitation.
• After the acute episode is resolved, individual, family, and group therapy may be considered to help cope with stressors, resolve conflict, and improve self-esteem and self-confidence.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Drug Category: Antipsychotics

Are high-potency agents (eg, haloperidol, droperidol) that provide rapid, predictable, and effective sedation in the management of patients who are acutely psychotic. They are less sedating and more easily titrated but are more likely to cause extrapyramidal syndrome (EPS) than lower-potency agents. They are often combined in the same syringe with a benzodiazepine (eg, lorazepam, diazepam) for better sedation and anxiolysis and for less dystonia or akathisia. For prophylaxis of extrapyramidal adverse effects, temporary use of a serotonin-dopamine antagonist may be needed. Administered IM or IV. (In a less emergent setting, administered PO [haloperidol only]). Haloperidol also has a monthly depot form (Haldol Decanoate). Depot antipsychotics are not intended for use in the emergent setting.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Further inpatient care is unnecessary once the acute attack has ended.

Further Outpatient Care

• Individual, family, and group psychotherapy may be considered to help cope with stressors and to help resolve conflict.

Prognosis

• Generally, brief psychotic disorder has a good prognosis and runs its course in less than a month. A good prognosis is usually associated with sudden onset, short duration of symptoms, and good premorbid adjustment.
• • According to European studies, 50-80% of all patients have no further major psychiatric problems.
  • Patients with no premorbid psychiatric history have been associated with excellent prognosis. Therefore, educating the patient and the patient's family about the situation is essential.
• Patients may be at risk of committing suicide during psychotic episodes, especially when brief psychotic disorder is associated with affective symptoms.
• Some data indicate that brief psychotic episode with an acute onset may be an early manifestation of severe mental disorder (eg, affective disorders).

Patient Education

• Both the patient and the family must be educated about the illness and potential adverse effects of the medications.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Missing an underlying medical etiology of psychosis is a potential medicolegal problem. General recommendations include serious consideration of medical causes in any acute onset new psychosis. This does not necessarily mean ordering every possible test, but history and physical examination often alert the clinician to the need for additional medical evaluation.
• Physical or chemical restraints may be necessary in cases of severe, uncontrolled agitation to provide safety to self and/or others.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington DC:. American Psychiatric Press;2000.
• Beighley PS, Brown GR, Thompson JW Jr. DSM-III-R brief reactive psychosis among Air Force recruits. J Clin Psychiatry. Aug 1992;53(8):283-8. [Medline].
• 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. Dec 2000;61(12):933-41. [Medline].
• Chaudron LH, Pies RW. The relationship between postpartum psychosis and bipolar disorder: a review. J Clin Psychiatry. Nov 2003;64(11):1284-92. [Medline].
• Jablensky A, Sartorius N, Ernberg G, et al. Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychol Med Monogr Suppl. 1992;20:1-97. [Medline].
• Jauch DA, Carpenter WT Jr. Reactive psychosis. II. Does DSM-III-R define a third psychosis?. J Nerv Ment Dis. Feb 1988;176(2):82-6. [Medline].
• Jauch DA, Carpenter WT Jr. Reactive psychosis. I. Does the pre-DSM-III concept define a third psychosis?. J Nerv Ment Dis. Feb 1988;176(2):72-81. [Medline].
• Johnson FA. African perspective on mental disorder. In: Mezzich JE, Honda Y, Kastrup MC, eds. Psychiatric Diagnosis: A World Perspective. New York, NY:. Springer Verlag;1994.
• Jorge MR, Mezzich JE. Latin American contributions to psychiatric nosology and classification. In: Mezzich JE, Honda Y, Kastrup MC, eds. Psychiatric Diagnosis: A World Perspective. New York, NY:. Springer Verlag;1994.
• Jorgensen P, Mortensen PB. Reactive psychosis and mortality. Acta Psychiatr Scand. Mar 1990;81(3):277-9. [Medline].
• Jorgensen P, Bennedsen B, Christensen J, Hyllested A. Acute and transient psychotic disorder: comorbidity with personality disorder. Acta Psychiatr Scand. Dec 1996;94(6):460-4. [Medline].
• Jorgensen P, Jensen J. An attempt to operationalize reactive delusional psychosis. Acta Psychiatr Scand. Nov 1988;78(5):627-31. [Medline].
• 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].
• Karno M, Jenkins JH. Cultural considerations in the diagnosis of schizophrenia and related disorders and psychotic disorders not otherwise classified. In: TA Widiger, ed. DSM-IV Source Book. Washington DC:. American Psychiatric Press;1994.
• Lin KM. Cultural influences on the diagnosis of psychotic and organic disorders. In: Mezzich JE, Kleinman A, Horacio F, Parron DL, eds. Culture and Psychiatric Diagnosis: A DSM-IV Perspective. Washington DC:. American Psychiatric Press;1996.
• Mezzich JE, Lin KM. Acute and transient psychotic disorders and culture-bound syndromes. In: Sadock BJ, Sadock VA, eds. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 6th ed. Baltimore, Md:. Lippincott Williams & Wilkins;1995:1049.
• Pull CB, Chaillet G. The nosological views of French-speaking psychiatry. In: Mezzich JE, Honda Y, Kastrup MC, eds. Psychiatric Diagnosis: A World Perspective. New York, NY:. Springer Verlag;1994.
• Susser E, Wanderling J. Epidemiology of nonaffective acute remitting psychosis vs schizophrenia. Sex and sociocultural setting. Arch Gen Psychiatry. Apr 1994;51(4):294-301. [Medline].
• Vanderhart O, Witztum E, Friedman B. From hysterical psychosis to reactive dissociative psychosis. J Trauma Stress. 1993;6:43.

Article Last Updated: Jan 19, 2007