INTRODUCTION — Brief psychotic disorder is defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as the presence of one or more psychotic symptoms with a sudden onset and full remission within one month [1].
Brief psychotic disorder is often a provisional or retrospective diagnosis with a substantial rate of recurrence and subsequent diagnosis of another psychotic disorder or affective disorder with psychosis. Symptom duration is one factor distinguishing brief psychotic disorder from schizophreniform disorder (one to six months) and schizophrenia (at least six months). Other disorders with psychotic features in the differential diagnosis include affective disorders, substance-induced disorders, psychosis due to a general medical condition, and psychotic disorder, not otherwise specified.
This topic discusses brief psychotic disorder. The epidemiology, pathogenesis, course, clinical manifestations, diagnosis, and treatment of other psychotic disorders are described separately.
●(See "Psychosis in adults: Epidemiology, clinical manifestations, and diagnostic evaluation".)
●(See "Schizophrenia in adults: Clinical manifestations, course, assessment, and diagnosis".)
●(See "Schizophrenia in adults: Epidemiology and pathogenesis".)
●(See "Schizophrenia in adults: Maintenance therapy and side effect management".)
●(See "Psychosocial interventions for schizophrenia in adults".)
●(See "Evaluation and management of treatment-resistant schizophrenia".)
TERMINOLOGY — Brief psychotic disorder is defined in DSM-5 as the presence of one or more psychotic symptoms with a sudden onset lasting more than one day and with full remission within one month [1]. An ICD-10 (International Classification of Diseases, 10th edition) criterion for overlapping conditions, acute and transient psychotic disorders, applies to psychoses with an acute onset and a duration of one to three months depending on subtype [2]. (See 'Diagnosis' below.)
Other terms have been used by European authors to describe psychotic syndromes which have an acute onset and remitting course, including bouffée delirantés (in French-speaking countries) and cycloid psychosis (in German-speaking countries) [3].
EPIDEMIOLOGY — Brief psychotic disorder is uncommon; community studies suggest the six-month to lifetime prevalence ranges from 0.05 to 2 percent. Little is known about the disorder’s epidemiology due to a very low incidence and variations in the disorder’s classification across countries. Available epidemiologic data are described below.
●The incidence of brief psychotic disorder was 1.8 per 100,000 person-years (95% CI 1.2-2.7) in the 15 years old or older population in two rural Irish communities [4]. Similarly, in a three-year follow-up study in the United Kingdom, the incidence of acute and transient psychotic disorder was 1.4 per 100,000 person-years [5].
●In the Suffolk County Study (United States), only 11 out of 547 (2.0 percent) of patients with first-admission psychosis met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria brief psychotic disorder at six months [6].
●The prevalence of brief psychotic disorder in first episode psychosis cohorts range from 2.1 (15 out of 722) in a 44-month Australian study [7] to 5.1 percent (10 cases out of 196) in a six-year follow-up study in two rural communities in Ireland [8].
Risk factors — There are little systematic data on risk factors for brief psychotic disorder. There is more information regarding risk factors for other psychotic conditions with remitting course and acute onset.
●Brief psychotic disorder is more common in women compared with men [4,8]. Transient psychotic disorders, some of which would meet the criteria for DSM-5 brief psychotic disorder, have also been found to be more common in women than in men [5,9,10].
●A higher incidence of acute and transient psychotic disorders has been reported in resource-limited countries compared with resource-rich countries [10,11]. In the World Health Organization Determinants of Outcome Study based on 444 first-onset nonaffective psychosis cases drawn from sites in eight countries, the incidence of nonaffective acute remitting psychoses were approximately 10 times higher in the two resource-limited country sites than the six resource-rich sites. The nonaffective acute remitting psychoses in that study were diagnosed based on the criteria introduced by the authors that required an acute onset (within one week) and complete remission of psychotic episode [10].
●Educational level and relationship status were not associated with brief psychotic disorder in a small case-control study [12].
Comorbidity — Anecdotal evidence and diagnostic taxonomy have linked psychotic disorders with remitting course and acute onset with premorbid personality disorders. DSM-5 described “mini-psychotic” episodes as a potential feature of borderline personality disorder [1]. Research studies of the association between personality disorders and remitting psychoses with acute onset have produced mixed findings:
●In a sample of 51 patients with an acute, transient psychotic disorder in Denmark, 63 percent were diagnosed with a co-occurring personality disorder based on ICD-10 (International Classification of Diseases, 10th edition) or DSM-IV criteria shortly after remission of psychotic symptoms [13]. The proportion of the sample diagnosed with a personality disorder decreased at one-year reassessment to 46 percent using ICD-10 criteria and 29 percent using DSM-IV criteria [14].
●A sample of 42 inpatients diagnosed with ICD-10 acute and transient psychotic disorders was compared with a matched control group of 42 surgical inpatients with acute illnesses who were free from mental health problems on the NEO five-factor personality inventory [15]. No difference between the groups was seen on any of the five personality subscales [16].
PATHOGENESIS — The causes of brief psychotic disorder are not known. Limited research data and more extensive research on other psychotic disorders with remitting course and acute onset implicate:
●Stressful life events – Stressful life events in the period immediately preceding onset have been implicated in cases of brief psychotic disorder and in other descriptions of brief psychosis [13,17-20]. The actual prevalence of such events in the life histories of patients with DSM-IV brief psychotic disorder has not been systematically investigated. It is sometimes unclear in individual patients whether a stressor was a precipitant or consequence of the illness, or if it was unrelated. Case series have also described tentative links between the social and economic stresses of the coronavirus disease 2019 (COVID-19) pandemic and brief psychotic disorder [21].
●Immigration – Higher incidences of psychotic disorders with remitting course and acute onset have been found among immigrants to several resource-rich countries [22-24]. This finding may be related to higher prevalence rates of the disorder observed in resource-limited countries (described above). Another hypothesized contributing factor is heightened stress associated with discrimination and social adversity that many immigrants experience. (See 'Epidemiology' above.)
●Genetics – There are little systematic data on possible contribution of genetic factors to the etiology of brief psychotic disorder. Most of the available data on the genetic risk factors are from studies of other psychotic disorders with remitting course and acute onset [12,25,26]. Implications of these findings for brief psychotic disorder remain unclear.
●Postpartum period – Many cases of psychosis in the postpartum period meet diagnostic criteria for brief psychotic disorder [27]. DSM-5 criteria allow for specification of a subtype “with postpartum onset” [1]. (See "Postpartum psychosis: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Pathogenesis' and "Treatment of postpartum psychosis".)
CLINICAL MANIFESTATIONS — Brief psychotic disorder is characterized by symptoms of psychosis lasting, by definition, between one day and one month.
Symptoms of psychosis seen in the disorder include one or more of the following:
●Hallucinations – The perception of a sensory process in the absence of an external source. Hallucinations can be auditory, visual, somatic, olfactory, or gustatory.
●Delusions – A fixed, false belief. Delusions can be bizarre or nonbizarre.
●Disorganized speech – Disorganized speech patterns reflect disruption in the organization of person’s thoughts. Commonly observed forms of disorganized speech include tangentiality and circumstantiality.
●Disorganized behavior – A patient with grossly disorganized behavior is often recognized by their inability to complete daily, normative tasks (eg, dressing and cleaning oneself, belongings in order).
COURSE — Symptoms of brief psychotic disorder, by definition, remit within a month based on DSM-5 criteria.
There are little systematic data on the age of onset of brief psychotic disorder though small studies suggest it may be somewhat higher than the onset of schizophrenia (eg, late teens and early 20s) [10,12,28,29]. As an example, in one study of patients with first-episode psychosis, the mean ages at presentation for brief psychotic disorder and schizophrenia were 34.7 and 30.4 years, respectively [4].
Assessment of duration of the natural history of brief psychotic disorder is often complicated by early treatment which can lead to remission of psychotic symptoms.
Many individuals who initially met criteria for a brief psychotic disorder have gone on to meet criteria for other psychotic disorders or affective disorders with psychosis. In the Suffolk County Study of first-admission psychosis, only 3 of the 11 patients who met the DSM-5 diagnostic criteria for brief psychotic disorder at six months maintained the diagnosis at two-year follow-up [6]. Three other patients received diagnoses of a mood disorder, two with schizophrenia or schizophreniform disorder, and three others with other disorders including psychotic disorder, not otherwise specified. In a study of first episode psychosis in Ireland, only 2 of 10 patients initially diagnosed with brief psychotic disorder maintained this diagnosis six years later [8].
A study based on registry data from Denmark identified evidence of excess mortality both from natural causes and suicide in patients initially recorded as having acute and transient psychotic disorder [30].
ASSESSMENT — A comprehensive clinical assessment of a patient presenting with new onset of psychosis includes a detailed history and physical examination, exclusion of general medical and substance-related causes of psychosis, assessment for co-occurring conditions, review of prior psychiatric and family history, and assessment of recent stressors and psychosocial functioning [31]. Additionally, obtaining collateral information from the patient’s family and other supports is recommended. (See "Psychosis in adults: Epidemiology, clinical manifestations, and diagnostic evaluation" and "Unipolar major depression with psychotic features: Epidemiology, clinical features, assessment, and diagnosis", section on 'Assessment' and "Bipolar disorder in adults: Clinical features", section on 'Psychosis'.)
In addition to the symptoms comprising diagnostic criteria for brief psychotic disorder assessment, the patient should be evaluated for other features suggestive of brief psychotic disorder:
●Presence of marked stressors preceding symptom onset
●Lack of negative symptoms
●Confusion during the early course of illness
Diagnosis of brief psychotic disorder requires ongoing, longitudinal assessment of the patient’s clinical status. Because the DSM-5 diagnostic criteria require remission within one month, the diagnosis is initially provisional or made retrospectively. Psychotic symptoms often recur subsequent to remission, in some cases leading to a final diagnosis of schizophrenia or other psychotic disorders.
DIAGNOSIS — DSM-5 diagnostic criteria for brief psychotic disorder are as follows [1]:
●Presence of one or more of the following symptoms:
•Delusions
•Hallucinations
•Disorganized speech
•Grossly disorganized or catatonic behavior
●Duration of an episode of the disturbance is at least a day but less than a month, with eventual full return to premorbid level of functioning.
●Absence of symptoms comprising a bipolar or depressive disorder, or psychosis resulting from substance use/withdrawal or a general medical condition.
Subtypes of the disorder include:
●With marked stressor – Symptoms are preceded by and apparently in response to a markedly stressful experience. This subtype was described as brief reactive psychosis in an earlier edition of the DSM.
●Without marked stressor.
●With postpartum onset – Within four weeks of delivery.
Differential diagnosis — Distinguishing brief psychotic disorder from other affective and nonaffective psychotic conditions is often difficult. An algorithm describes the diagnostic differentiation of psychoses (algorithm 1). The paragraphs that follow describe the principle features distinguishing these disorders.
Bipolar and depressive disorders — The main diagnostic challenge is to distinguish brief psychotic disorder from affective disorders, especially bipolar disorder with psychotic features. Patients with both affective disorders and brief psychotic disorder may present with psychosis, irritability, and disorganized behavior. In some cases, only continued observation of the patient’s response to treatment and long-term course will clarify the diagnosis.
Nonaffective psychotic disorders — Longitudinal follow-up can be necessary to differentiate brief psychotic disorder from other nonaffective psychotic disorders, which typically last longer and are associated with greater long-term deficits in functioning.
Schizophreniform disorder — Schizophreniform disorder is distinguished from brief psychotic disorder in DSM-5 by the following differences in diagnostic criteria:
●Psychotic symptoms are present for more than one month but less than six months.
●Two or more types of psychotic symptoms are present for a significant proportion of a one-month period if the patient is untreated.
●Negative symptoms may constitute one of the characteristic types of symptoms that are present.
Schizophrenia — Schizophrenia is distinguished from brief psychotic disorder by the following differences in diagnostic criteria (see "Schizophrenia in adults: Clinical manifestations, course, assessment, and diagnosis", section on 'Clinical manifestations'):
●Psychotic symptoms are present for at least six months.
●Two or more types of psychotic symptoms must be present for a significant proportion of a one-month period if the patient is untreated.
●Negative symptoms may constitute one of the characteristic types of symptoms that are present.
●Functioning in one or more major areas (eg, interpersonal relationships, work, self-care) is markedly below the level achieved prior to onset.
Substance-induced psychoses — Intoxication with or withdrawal from a number of substances (including hallucinogens, cocaine, and amphetamines) are associated with acute onset of psychotic symptoms. Toxicological examination of patients presenting with psychotic symptoms of acute onset is necessary, especially in younger patients.
Psychosis due to general medical conditions — A number of neurologic (eg, seizure disorders), endocrine (eg, thyroid disease), and infectious diseases (eg, viral encephalitis) are associated with psychotic symptoms. A thorough physical examination is necessary, with laboratory testing or neuroimaging based on the findings.
TREATMENT — The approach to individuals with brief psychotic disorder is the same as the general initial management of psychosis, regardless of cause. This includes antipsychotic medications and adjunctive supportive therapy. Management of psychosis is briefly discussed here. (See "Psychosis in adults: Initial management", section on 'Initial management'.)
●Ensuring safety/determining site of care – The initial treatment decisions should be guided by the patient’s ability to maintain safety. This should be assessed by direct questioning about homicidal or suicidal ideation (see "Suicidal ideation and behavior in adults"). Other considerations include assessing patient’s ability to secure basic needs such as food and shelter. It is essential to consider collateral information obtained from family members, psychosocial supports, and other providers during the safety risk assessment and site of care determinations. (See "Psychosis in adults: Initial management", section on 'Safety risk and level of care'.)
●Antipsychotic therapy – For most patients with psychosis, we suggest a second-generation antipsychotic medication. Even though some patients with brief psychotic disorder recover with supportive care only, we are unable to identify these patients at the time the decision to treat with medications needs to be made. (See 'Course' above.)
The choice of antipsychotic is based on presenting symptoms (eg, agitation or need for sedation), patient comorbidities, and side effect profile of the medication. As examples, risperidone starting at 1 mg twice daily and titrating to therapeutic range or aripiprazole starting at 10 mg per day and titrating to therapeutic range are often good choices due to their favorable side effect profiles (table 1 and table 2). (See "Psychosis in adults: Initial management", section on 'Preference for second-generation agents'.)
Some patients with severe anxiety and agitation also warrant adjunctive treatment with short-acting benzodiazepines. This is discussed elsewhere. (See "Assessment and emergency management of the acutely agitated or violent adult" and "Psychosis in adults: Initial management", section on 'Psychiatric symptoms'.)
There are no clinical trials or case series examining the efficacy of treatments for brief psychotic disorder. Our recommendations for treatment are based on clinical experience and evidence of effective treatment for other psychotic disorders [31]. (See "Psychosis in adults: Epidemiology, clinical manifestations, and diagnostic evaluation" and "Schizophrenia in adults: Maintenance therapy and side effect management" and "Evaluation and management of treatment-resistant schizophrenia" and "Management of neuropsychiatric symptoms of dementia" and "Unipolar major depression with psychotic features: Acute treatment".)
For patients who we suspect could have brief psychotic disorder (eg, psychosis improves within a month, no prior history of psychosis, and no premorbid characteristics that are concerning for chronic psychosis), we suggest continuing antipsychotic treatment for one to three months before discontinuing. As there are no widely accepted guidelines on the duration of treatment, this recommendation is based on our clinical experience. Medication should be tapered over two to four weeks, and during this time, the patient should be monitored weekly for signs of relapse.
Longer treatment is needed if residual psychotic symptoms persist beyond one month or if the patient experiences a relapse of symptoms after stopping medication. For these patients, further evaluation and reconsideration of the diagnosis of brief psychotic disorder is warranted. (See "Psychosis in adults: Epidemiology, clinical manifestations, and diagnostic evaluation".)
●Supportive psychotherapy – We recommend psychotherapy as an adjunct to antipsychotic therapy. No psychosocial interventions have been tested in brief psychotic disorder. Based on clinical experience, we suggest the use of supportive psychotherapy techniques such as reassurance and validation of realistic concerns. This may be particularly helpful in patients who are confused or frightened by the onset of psychotic symptoms. (See "Overview of psychotherapies", section on 'Supportive psychotherapy'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Psychotic disorders".)
SUMMARY AND RECOMMENDATIONS
●Brief psychotic disorder is defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as the presence of one or more psychotic symptoms with a sudden onset, absence of a mood or substance-induced disorder, and remission within one month. An overlapping category of syndromes in the ICD-10 (International Classification of Diseases, 10th edition), acute and transient psychotic disorders, applies to psychoses with an acute onset and a duration of one to three months depending on subtype. (See 'Terminology' above.)
●Brief psychotic disorder is rare. Limited epidemiologic data suggest an incidence of 1.8 per 100,000 person-years. Approximately 2 to 5 percent of patients with first episode psychosis have brief psychotic disorder. (See 'Epidemiology' above.)
●Symptoms seen in brief psychotic disorder include one or more of the following: hallucinations, delusions, disorganized speech, or grossly disorganized behavior. Symptoms may appear following a stressful life event. Negative symptoms may be less likely to be present than in other psychotic disorders. (See 'Clinical manifestations' above.)
●A comprehensive clinical assessment of a patient presenting with new onset of psychosis includes a detailed history and physical examination, and assessment for co-occurring conditions. Diagnosis of brief psychotic disorder requires the presence of one or more psychotic symptoms lasting more than a day and less than one month, and exclusion of an affective disorder or a general-medical or substance-related cause of psychosis. (See 'Assessment' above and 'Diagnosis' above.)
●Antipsychotic medications are an effective symptomatic treatment of psychosis, regardless of underlying cause, and are the standard initial treatment for most cases. Supportive psychotherapy that offers reassurance and validation of realistic concerns may be a helpful adjunct to medication. (See 'Treatment' above and "Psychosis in adults: Initial management", section on 'Initial management'.)
●Patients with brief psychotic disorder do not require long-term antipsychotic treatment. Thus, for patients who we suspect could have brief psychotic disorder (eg, psychosis improves within a month, no prior history of psychosis, and no premorbid characteristics that are concerning for chronic psychosis), we typically treat for at least one to three months and then discontinue the medication. Weekly monitoring of symptoms and functioning during and in the early months after stopping treatment is recommended. (See 'Treatment' above.)
