Psicosis

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, Text Revision (DSM-IV-TR) 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.[1]

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 or an overwhelming stressful circumstance. 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.

Epidemiology

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.[2] 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.[3]

Sex

According to an international epidemiologic study, incidence of the disorder was 2-fold higher in women than in men.[2] 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.

DSM-IV-TR 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-TR, the diagnosis of brief psychotic disorder can be specified as with or without marked stressors or with postpartum onset.[4, 5] Some clinicians believe that persons with personality disorders (eg, narcissistic, paranoid, borderline, schizotypal) are more prone to develop brief psychotic disorder in stressful situations.[6]

• 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.

ifferentials

• Delirium

• Delusional Disorder

• Dissociative Disorders

• Factitious Disorder

• Malingering

• Mental Disorders Secondary to General Medical Conditions

• Schizoaffective Disorder

• Schizophrenia

Schizophreniform Disorder

Laboratory 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

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