Brief Psychotic Disorder
Brief Psychotic Disorder
Brief psychotic disorder is a short-term psychiatric disorder lasting between one day and one month, with complete remission and return to full functioning following the episode. In brief psychotic disorder, the individual experiences at least one symptom of psychosis : incoherence, delusions, hallucinations, and/or grossly disorganized or catatonic behavior.
The cause of the symptoms helps to determine whether or not the person is described as having brief psychotic disorder. If the psychotic symptoms appear as a result of a physical disease, a reaction to medication, or intoxication with drugs or alcohol, then the unusual behaviors are not classified as brief psychotic disorder. If hallucinations, delusions, or other psychotic symptoms occur at the same time that an individual is experiencing major clinical depression or bipolar (manic-depressive) disorder, then the brief psychotic disorder diagnosis is not given. The decision rules that allow the clinician to identify this cluster of symptoms as brief psychotic disorder are outlined in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision, produced by the American Psychiatric Association. This manual is referred to by most mental health professionals as DSM-IV-TR.
The person experiencing brief psychotic disorder always has one or more “positive” psychotic symptoms. The psychotic symptoms are not positive in the everyday sense of something being good or useful. Positive in this context is used with the medical meaning: a factor is present that is not normally expected, or a normal type of behavior is experienced in its most extreme form. Positive symptoms of psychosis include hallucinations, delusions, strange bodily movements or lack of movements (catatonic behavior), peculiar speech, and bizarre or primitive behavior.
Hallucinations involve experiencing sensations that have no corresponding objective reality. Hallucinations can occur in various forms that parallel the human senses. Visual hallucinations involve the sense of sight, or “seeing things.” Auditory hallucinations generally involve hearing voices, and are the most common of the hallucinations. Sometimes, a hallucination can include both voices and some visual experience; mental health professionals describe this as an “auditory-visual hallucination.” Smelling nonexistent smells or feeling things on or under one’s skin that do not actually exist are forms of somatic hallucinations. Somatic comes from soma, the Greek word for body; thus, somatic hallucinations are bodily hallucinations.
Delusions are also a classic psychotic feature. Delusions are strongly held irrational and unrealistic beliefs that are extremely difficult to change, even when the person is exposed to evidence that contradicts the delusion. The layperson typically thinks of delusions as being paranoid, or persecutory, wherein the delusional person is excessively suspicious and continually feels at the mercy of conspirators who are “out to get” him or her. However, delusions can also be unjustified beliefs that are grandiose, involve elaborate love fantasies (called erotomanic delusions), or extreme and irrational jealousy. Grandiose delusions are persistent irrational beliefs that somehow exaggerate the person’s importance, such as believing oneself to be a famous person, or having an enviable position such as being the Prime Minister or President. Often grandiose delusions take on religious overtones; for instance, a person might become convinced that she is the Virgin Mary. Furthermore, delusions can also be somatic. Somatic delusions are erroneous but strongly held beliefs about the characteristics or functioning of one’s body; an example is a mental health consumer who refuses to eat because of a conviction that the throat muscles are completely paralyzed and that only liquids can be swallowed, when there is no actual physical reason to be unable to swallow.
OTHER PSYCHOTIC SYMPTOMS
Other psychotic symptoms that may occur in brief psychotic disorder are strange bodily movements or lack of movements (catatonic behavior), peculiar speech, and bizarre or childlike behavior. Catatonic behavior or catatonia involves both possible extremes related to movement. Catalepsy is the motionless aspect of catatonia—a person with catalepsy may remain fixed in the same position for hours on end. Rapid or persistently repeated movements, frequent grimacing and strange facial expressions, and unusual gestures are the opposite end of the catatonia phenomenon. Peculiar speech is also seen in some cases of brief psychotic disorder. Speech distortions can involve words mixed together in no coherent order, responses that are irrelevant and strange in the context of the conversation in which they occur, or echolalia, the repetition of another person’s exact spoken words, repeated either immediately after the speaker or after a delay of minutes or hours. Bizarre behavior can range from childlike behaviors such as skipping, singing, or hopping in inappropriate circumstances to unusual practices such as hoarding food or covering one’s head and clothing with aluminum foil wrappings.
Of course, not all of these psychotic symptoms will be observed simultaneously in the person with brief psychotic disorder. Any constellation of these positive psychotic symptoms that occurs for one entire day up to one month is considered to be brief psychotic disorder, unless there is some other syndrome or biological cause that caused the symptoms to appear.
Brief psychotic disorder is not a simple or consistent disorder with a single cause. Because many phenomena can prompt a short-term experience of psychotic symptoms, there are several ways of viewing the causes of the disorder.
AN EARLY PHASE OF SCHIZOPHRENIA
Because of the similarities between brief psychotic disorder, schizophreniform disorder, and schizophrenia, many clinicians have come to think of brief psychotic disorder as being the precursor to a lengthier psychotic disorder. Although this can only be identified retrospectively, brief psychotic disorder is often the diagnosis that was originally used when an individual (who later develops schizophrenia) experiences a first psychotic break from more typical functioning.
A STRESS RESPONSE
At times, under severe stress, temporary psychotic reactions may appear. The source of stress can be from typical events encountered by many people in the course of a lifetime, such as being widowed or divorced. The severe stress may be more unusual, such as being in combat, enduring a natural disaster, or being taken hostage. The person generally returns to a normal method of functioning when the stress decreases or more support is available, or better coping skills are learned.
In some susceptible women, dramatic hormonal changes in childbirth and shortly afterward can result in a form of brief psychotic disorder often referred to as postpartum psychosis. Unfortunately, postpartum conditions are often misidentified and improperly treated. In many cases of a mother killing her infant or committing suicide, postpartum psychosis is involved.
DEFENSE MECHANISM IN PERSONALITY DISORDER
Persons with personality disorders appear to be more susceptible to developing brief psychotic reactions in response to stress. Individuals with personality disorders have not developed effective adult mechanisms for coping with life. When life becomes more demanding and difficult than can be tolerated, the person may lapse into a brief psychotic state.
CULTURALLY DEFINED DISORDER
Culture is a very important factor in understanding mental health and psychological disturbance, and brief psychotic disorder is an excellent example. The types of behavior that occur during brief psychotic disorder are very much shaped by the expectations and traditions of the individual’s culture. In many cultures, there are some forms of mental disorders that meet criteria for brief psychotic disorder and manifest with symptoms that are peculiar to that culture or community. Individuals within the group exhibit similar behavior, which may be attributed to a particular cause or stimulus, such as cabin fever, witchcraft, or spiritual possession, or may be the result of a culturally specific phobia, such as the fear of sinning among religious communities or the fear of being cold in tropical climates. The DSM-IVTR terms disorders unique to certain societies or groups to be culture-bound. An example of a culture-bound syndrome is koro, a syndrome observed in Japan and some other areas of Asia but not elsewhere. Koro is an obsession to the point of delusion with the possibility that the genitals will retract or shrink into the body and cause death.
Conversely, while culture shapes the form a psychotic reaction may take, culture also determines what is not to be considered psychotic. Behaviors that in one culture would be thought of as bizarre or psychotic may be acceptable in another. For example, some cultural groups and religions view “speaking in tongues” as a valuable expression of the gifts of God, whereas viewed out of context, the unrecognizable speech patterns might be viewed as psychotic. If the behaviors shown are culturally acceptable in the person’s society or religion, and happen in an approved setting such as a religious service, then brief psychotic disorder would not be diagnosed.
The DSM-IV-TR provides three major criteria for brief psychotic disorder:
- At least one positive symptom of psychosis, from the following symptoms: delusions; hallucinations; disorganized speech which is strange, peculiar, difficult to comprehend; disorganized (bizarre or childlike) behavior; or catatonic behavior.
- Limited duration. The psychotic symptoms have occurred for at least one day but less than one month. There is an eventual return to normal level of functioning.
- The symptoms are not biologically influenced or attributable to another disorder. In other words, the symptoms cannot be occurring as part of a mood disorder, schizoaffective disorder, or schizophrenia, and they cannot be due to intoxication with drugs or alcohol. Further, the symptoms cannot be an adverse reaction to a medication, and they cannot be caused by a physical injury or medical illness.
The actual rate of brief psychotic disorder is unknown, although it appears to be fairly rare in the United States and other developed countries. While psychotic reactions that occur and subside in under a month are more common in developing nations, the mental disorders wherein psychotic symptoms last longer than one month are more prevalent in developed countries. The disorder appears to be more common in adolescents and young adults than in those of middle age or older.
Using the DSM-IV-TR criteria makes identification of the disorder relatively clear-cut. However, an unusual aspect to this diagnosis is the emphasis on the length of time that symptoms have been evident. Most mental health disorder diagnoses do not include the duration of the symptoms as part of their definitions. However, the length of time the person has had psychotic symptoms is one of the major distinctions among three different psychotic disorders. Brief psychotic disorder involves the shortest duration of suffering psychotic symptoms: one day to one month. Schizophreniform disorder also involves the individual showing signs of psychosis, but for a longer period (one month or more, but less than six months). Schizophrenia is diagnosed in individuals who have evidenced psychotic symptoms that are not associated with physical disease, mood disorder, or intoxication, for six months or longer. Another complicating factor in making the diagnosis is the context in which the psychotic symptoms are experienced. If the psychotic-like behaviors evidenced are acceptable in the person’s culture or religion and these behaviors happen in a traditionally expected context such as a religious service or meditation, then brief psychotic disorder would not be diagnosed.
The disorder is usually diagnosed by obtaining information in interview from the client and possibly from immediate family. Also, the diagnostician would be likely to perform a semistructured interview called a mental status examination, which examines the person ’s ability to concentrate, to remember, to realistically understand the situation, and to think logically.
Antipsychotic medications are very effective in ending a brief psychotic episode. A number of different antipsychotics are used for the purpose of terminating acute psychotic episodes. Haloperidol (Haldol) is most commonly used if the psychotic symptoms are accompanied by agitation. Agitation is a state of frantic activity that is often accompanied by anger or fearfulness; when in an agitated state, the client is more likely to cause harm to self or others. In agitated psychotic states, the haloperidol is often given as an injection, accompanied by other medications that decrease anxiety (lorazepam, also known as Ativan) and slow behavior (diphenhydramine, also known as Benadryl). If the client is not agitated, usually a newer-generation antipsychotic is used, given daily as tablets, capsules or liquid, for a lengthier period of time. The antipsychotic that would be used is likely to be one of the following: olanzapine (Zyprexa), quetiapine (Seroquel), or risperidone (Risperdal). Hormones may also be prescribed for postpartum psychosis. Supportive therapy may also prove helpful in some situations, in decreasing the client’s anxiety and educating the client about the psychiatric illness. In culture-bound syndromes, the most effective treatment is often the one that is societally expected; for example, bathing in a river viewed as sacred might be a usual method of curing the psychotic-like state, in a particular culture.
The prognosis is fairly positive in brief psychotic disorder because by its own definition, a return to normal functioning is expected. If there is a major life event as a stress or an unusual traumatic experience that initiated the episode, chances are very good that there will be no recurrence. If there is not a particular triggering event or if the episode occurred in an individual with a personality disorder, the likelihood of recurrence is higher. If an episode is a recurrence without a specific triggering event, then the beginnings of the development of schizophrenia or bipolar disorder may be at hand, in which case the prognosis is poor. In the individual with personality disorder, the pattern may recur in response to stress, so that there are intermittent experiences of brief psychotic disorder over the course of a lifetime.
In women who have experienced brief postpartum psychosis, one prevention option is to forgo having additional children. If a postpartum psychosis has occurred in the past, in subsequent pregnancies the physician may be proactive in prescribing an antipsychotic medication regimen to be taken in the postpartum period in order to prevent psychotic symptoms from recurring. In many cases severe stressors can be a trigger for brief psychotic disorder. Therefore, in response to identifiable extreme stressors, such as natural disasters or terrorist attacks, strong social support and immediate postcrisis counseling could possibly prevent the development of brief psychotic disorder in susceptible persons.
Catatonia —A state characterized by rigid muscles, sustained unresponsiveness with fixed body posture, strange bodily movements, extreme overactivity, or bizarre postures.
Delusion —An improbable or irrational belief or idea maintained in spite of evidence to the contrary. Delusions are often highly personal in nature.
Hallucination —A false sensory perception that appears real but which is not caused by an external stimulus. Although hallucinations may affect any of the senses, auditory hallucinations (hearing voices) and visual hallucinations (seeing things that are not there) are the most common.
Psychosis —Severe state that is characterized by loss of contact with reality and deterioration in normal social functioning; examples are schizophrenia and paranoia. Psychosis is usually one feature of an overarching disorder, not a disorder in itself. (Plural: psychoses)
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Deborah Rosch Eifert, PhD
Ruth A. Wienclaw, PhD