LICEO DE CAGAYAN UNIVERSITY
R.N.P. Blvd., Carmen, Cagayan de Oro City
COLLEGE OF NURSING
As Partial Requirement for Graduate Studies PN303
Brief Psychotic Disorder
Mrs. Ma. Dolores Mercado, RN MAN
Ann Pryam Bagongon, RN
May 8, 2011
Brief Psychotic Disorder
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. Brief Psychotic Disorder is short-term, timelimited disorder. An individual with brief psychotic disorder has experienced at least one of the major symptoms of psychosis for less than one month. Hallucinations , delusions , strange bodily movements or lack of movements (catatonic behavior), peculiar speech and bizarre or markedly inappropriate behavior are all classic psychotic symptoms that may occur in brief psychotic disorder. The cause of the symptoms helps to determine whether or not the sufferer 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 . Diagnostic criteria for 298.8 Brief Psychotic Disorder A. Presence of one (or more) of the following symptoms: (1) delusions (2) hallucinations (3) disorganized speech (e.g., frequent derailment or incoherence) (4) grossly disorganized or catatonic behavior Note: Do not include a symptom if it is a culturally sanctioned response pattern. B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning. C. The disturbance is not better accounted for by a Mood Disorder With Psychotic Features, Schizoaffective Disorder, or Schizophrenia and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
With Marked Stressor(s) (brief reactive psychosis): if symptoms occur shortly after and apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture Without Marked Stressor(s): if psychotic symptoms do not occur shortly after, or are not apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture With Postpartum Onset: if onset within 4 weeks postpartum As the name suggests, brief psychotic disorder is a short-term illness with psychotic symptoms. The symptoms often come on suddenly, but last for less than one month, after which the person usually recovers completely. There are three basic forms of brief psychotic disorder:
Brief psychotic disorder with obvious stressor (also called brief reactive psychosis): This type, also called brief reactive psychosis, occurs shortly after and often in response to a trauma or major stress, such as the death of a love one, an accident or assault, or a natural disaster. Most cases of brief psychotic disorder occur as a reaction to a very disturbing event. Brief psychotic disorder without obvious stressor: With this type, there is no apparent trauma or stress that triggers the illness. Brief psychotic disorder with postpartum onset: This type occurs in women, usually within 4 weeks of having a baby.
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.
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.
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.
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. POSTPARTUM PSYCHOSIS. 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. Many cultures have some form of mental disorder that would meet criteria for brief psychotic disorder the features of which are unique to that culture, wherein most sufferers have similar behaviors that are attributed to causes that are localized to that community. The DSMIV-TR calls disorders unique to certain societies or groups "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.
Symptoms of Brief Psychotic Disorder The most obvious symptoms include: y Hallucinations: Hallucinations are sensory perceptions of things that aren't actually present, such as hearing voices, seeing things that aren't there or feeling sensations on your skin even though nothing is touching your body.
Delusions: These are false beliefs that the person refuses to give up, even in the face of contradictory facts. Other symptoms of brief psychotic disorder include: y Disorganized thinking
Speech or language that doesn't make sense
y y y y y
Unusual behavior and dress Problems with memory Disorientation or confusion Changes in eating or sleeping habits, energy level, or weight Inability to make decisions
Using the DSM-IV-TR criteria previously listed 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 semi-structured 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.
Treatment for brief psychotic disorder typically includes psychotherapy (a type of counseling) and/or medication. Hospitalization may be necessary if the symptoms are severe or if there is a risk that the person may harm him or herself, or others.
Medication: Antipsychotic drugs may be prescribed to decrease or eliminate the symptoms and end the brief psychotic disorder. Conventional antipsychotics include: Thorazine, Prolixin, Haldol, Navane, Stelazine, Trilafon and Mellaril. Newer medications, called atypical antipsychotic drugs, include: Risperdal, Clozaril, Seroquel, Geodon and Zyprexa. Tranquilizers such as Ativan or Valium
may be used if the person has a very high level of anxiety (nervousness) and/or problems sleeping.
Psychotherapy: Psychotherapy helps the person identify and cope with the situation or event that triggered the disorder.
Prognosis 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. Severe stressors can be a trigger for brief psychotic disorder in many cases. Therefore, in response to identifiable extreme stressors, such as natural disasters or terrorist attacks, strong social support and immediate post-crisis counseling could possibly prevent the development of brief psychotic disorder in susceptible persons.
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