Brief Psychotic Disorder DSM-5 298.8 (F23)

Brief Psychotic Disorder DSM-5 298.8 (F23)

DSM-5 Category: Schizophrenia Spectrum and Other Psychotic Disorders

Introduction

The DSM-5 identifies Brief Psychotic Disorder as a recurrent, transient thought disorder, which typically occurs in adolescence or young adulthood. By definition, it is of short duration, although it can result in increased risk of suicidality, or inability to perform self care (American Psychiatric Association, 2013). .

Symptoms of Brief Psychotic Disorder

According to the DSM-5, (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) Brief Psychotic Disorder is a thought disorder in which a person will experience short term, gross deficits in reality testing, manifested with at least one of the the following symptoms:

  • Delusions- strange beliefs and ideas which are resistant to rational/logical dispute or contradiction from others.
  • Hallucinations- auditory, or visual.
  • Disorganized Speech- incoherence, or irrational content.
  • Disorganized or Catatonic behavior- repetitive, senseless movements, or adopting a pose which may be maintained for hours. The individual may be resistant to efforts to move them into a different posture, or will assume a new posture they are placed in (American Psychiatric Association, 2013).

To fulfill the diagnostic criteria for Brief Psychotic Disorder, the symptoms must persist for at least one day, but resolve in less than one month. The psychotic episode cannot be attributed to substance use (ethanol withdrawal, cocaine abuse) or a medical condition (fever and delirium) and the person does not fit the diagnostic criteria for Major Depressive disorder with psychotic features, Bipolar disorder with psychotic features, or Schizophrenia (American Psychiatric Association, 2013). .

There are five specifiers that can be used to further describe the disorder:

  • With marked stressors- the psychotic episode appears following an acute stressor, or series of stressors, which would overtax the coping skills of most individuals.
  • Without marked stressors- there is no apparent stressor preceding the psychotic episode.
  • Post-partum- this disorder can appear during pregnancy or within one month following childbirth.
  • With catatonia.
  • Severity - The clinician can rate the severity of the psychotic episode during the last seven days using a five point scale- Zero ( Absent ) to Four ( Present and severe) (American Psychiatric Association, 2013).

This disorder will manifest over a period of about two weeks or less, resolve in less than one month, and the person will return to their pre-morbid level of functioning prior to the psychotic state. (American Psychiatric Association, 2013).

Onset

This disorder is typically a response to an extreme stressor, (American Psychiatric Association, 2013) such as combat, (Umbrasas, 2010) or a series of stressors, which overwhelm the individual's coping skills. The DSM-5 indicates Brief Psychotic Disorder tends to resolve within one month, and the individual typically returns to their former level of functioning (American Psychiatric Association, 2013).

Prevalence

The DSM-5 notes Brief psychotic disorder is two times more likely to occur in women than men, and is most commonly seen in adolescents, and young adults in their 20's and 30's. (American Psychiatric Association, 2013) .

Risk Factors and Risk Markers

Given that Brief psychotic disorder can precipitated by stressors which overwhelm the individual's coping skills, it can be inferred that acute or chronic stress, underdeveloped coping skills, isolation, and lack of social supports, are risk factors. Individuals in environments such as combat or domestic violence may be prone to brief psychotic episodes. Trauma has been identified as a precipitant of brief psychotic episodes (Freeman & Fowler, 2009 ; Umbrasas, 2010). The DSM-5 reports that the presence of a Personality Disorder is also recognized as a risk factor. A discrete diagnosis of Brief Psychotic Disorder is not warranted if the psychotic episode is transient in one diagnosed with a personality disorder. A distinct diagnosis of Brief Psychotic may be indicated if the episode persists for more than one day. (American Psychiatric Association, 2013).

Co-Morbidity

Brief psychotic disorder can occur in conjunction with Borderline Personality Disorder, or Paranoid Personality Disorder (American Psychiatric Association, 2013).

Brief Psychotic Disorder Treatment

Crisis evaluation and short term hospitalization and stabilization on anti-psychotic meds may be required (American Psychiatric Association, 2013). CBT ( Cognitive Behavioral therapy) to learn coping and stress reduction skills may be useful to prevent further episodes.

Impact of Disorder on Functioning

It can be speculated that a brief psychotic episode could precipitate anxiety in the individual over re-occurrence, or change self image. The individual may develop the perception there is something very wrong with them, or that they are weak or defective. They may experience social stigma, especially if they have a history of high functioning and therefore high expectations from others. This may be especially true if the psychotic episode cannot be rationalized in terms of a response to stress or childbirth, but was of the Without Marked Stressors type. The DSM-5 notes high rates of re-occurrence are typical (American Psychiatric Association, 2013).

Differential Diagnosis

The DSM-5 notes that the clinician must rule out several other conditions to make an accurate diagnosis (American Psychiatric Association, 2013). Extended abuse of sympathiomimetic agents ( e.g., cocaine and methamphetamine) can result in an acute psychotic break, as can withdrawal from ethanol ( Delirium Tremens) and the use of psychedelic agents ( e.g., LSD and psilocybin mushrooms). (Kuzenko, et al 2009). Familiarity with the specific effects of substance use and respective withdrawal syndromes will assist the clinician in making an appropriate differential diagnosis. Enzyme immunoassay urine toxicology screening can also provide an objective measure of recent substance use. Perceptual changes and delirium can also occur as a result of dehydration or prolonged sleep deprivation. Their are numerous medical conditions, including TBI ( Traumatic Brain Injury), which can produce psychotic symptoms as well, which must be ruled out (Umbrasas, 2010).

It has been found that Schizophrenia can be reliably differentiated form Brief Psychotic Disorder ( Korver-Neiberg, Quee, Boos, & Simmons, 2011). Schizophrenia may initially present a similar diagnostic picture, but will typically not completely resolve within less than a month, although an acute psychotic episode may be of relatively short duration. The onset of Schizophrenia will also typically involve negative symptoms. It should be noted that the psychotic symptoms are of a positive presentation in the symptom dichotomy applied to psychotic disorders, and that negative symptoms ( e.g., amotivation, anergia,) are not part of the diagnostic criteria. A history from both the patient and collateral reports from family or friends may be useful in determining if there have been prior psychotic episodes. Both unipolar depression and bipolar disorder can present with psychotic features, but again, a history can determine if there have been previous episodes. The delusional content is noteworthy, as depressed persons are likely to have mood congruent delusions (I am dead and rotting) and the delusional content of bipolar disorders tend to be of a grandiose nature. The astute clinician must be aware of malingering as well, especially in a forensic setting. There may be secondary gains for feigning mental illness, such as diminishing criminal culpability. Cultural norms must also be considered. What appears to be a brief psychotic state may be a within normal limits response in some cultures, and is socially approved of and not regarded as unusual.

References:

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders.

(5th Edition). Washington, DC.

Freeman, D. and Fowler, D., (2009). Routes to psychotic symptoms: Trauma, anxiety and psychosis-like experiences. Psychiatry Res. 169 (2).107–112. doi: 10.1016/j.psychres.2008.07.009 PMCID: PMC2748122

Korver-Neiberg, N. , Quee, J.P, Boos, H..B., & Simmons, C.J. (2011). The validity of the DSM-IV diagnostic classification system of non-affective psychoses Australia and New Zealand Journal of Psychiatry. (45). 1061-1068. DOI: 10.3109/00048674.2011.620562

Kuzenko, N. ,Sareen, J., Beesdo-Baum, K., Perkonigg, A., Höfler,M., Simm, J., Lieb,R., & Wittchen, H.U. (2011). Associations Between Cocaine, Amphetamine or Psychedelic Use and Psychotic Symptoms in a Community Sample. Acta Psychiatrica Scandinavica. (123). 6. 466- 474. DOI: 10.1111/j.1600-0447.2010.01633.x.

Umbrasas, K. (2010). Keeping the diagnostic lens polished. Psychological reactions to stress. Annals of American Psychotherapy. (13).2. 68-69. Retrieved February 19, 2014, from: www.americanpsychotherapy.com


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