Download STRESS AND BRIEF PSYCHOTIC DISORDER

CLINICAL CASE
STRESS AND BRIEF PSYCHOTIC DISORDER
Andreea Ciornei1, Carmen Bumbu1, Ramona Spînu1
Abstract:
Brief Psychotic Disorder is a short-term illness with
psychotic symptoms. The symptoms often come on
suddenly, lasting from 1 day to 1 month, after which the
person can recover completely and return to the premorbid
level of functioning. Most cases of Brief Psychotic
Disorder occur as a reaction to a very disturbing event. We
reported a case of a 33 years old man, who presented to the
Clinical Hospital of Psychiatry with symptoms associated
with psychotic episode: hallucinations, delusions,
disorganized behavior. After excluded other possible
causes (organic, traumatic, drugs or other substance
abuse) and based on a full medical, personal, family
history and psychiatric evaluation, we concluded that a
high rate of stress may be associated with Brief Psychotic
Disorder.
Key words: psychosis, schizophrenia, legal drugs,
posttraumatic
Rezumat:
Tulburarea psihoticã scurtã este o boala ce dureazã o
perioadã scurtã de timp ºi este asociatã cu simptome
psihotice. Simptomele au de obicei un debut brusc ºi pot
dura între 1 zi si 1 lunã, dupã care pacientul se poate
recupera în totalitate ºi poate reveni la nivelul de
funcþionare anterior bolii. Cele mai multe cazuri de
tulburare psihoticã scurtã apar ca o reacþie la un
eveniment inoportun. Prezentãm cazul unui barbat în
vârstã de 33 de ani, care vine la Spitalul Clinic de
Psihiatrie cu simptome asociate episodului psihotic acut:
halucinaþii, idei delirante, comportament dezorganizat.
Dupa excluderea altor cauze ( organice, traumatice, abuz
de droguri sau alte substante) ºi pe baza unei anamneze
medicale, personale ºi heredo-colaterale, pacientul a fost
diagnosticat cu tulburare psihoticã acutã datoratã
stresului crescut.
Cuvinte cheie: psihozã, schizofrenie, droguri legale,
psttraumatic
Brief psychotic disorder is uncommon and is
difficult to diagnosis it because there are no laboratory test
to specifically diagnose psychotic disorder – except those
that accompany a physical illness, such brain tumors – and
there are no laboratory tests for some adverse drugs effects
prescribed or illicit or legal (eg ethnobotanics).
Brief psychotic disorder is a short- term disorder
that lasts for a limited period of time. An individual with
brief psychotic disorder must have experience at least one
of the major symptoms of psychosis for less than a month
such as hallucinations, delusions, lack of movement,
strange behavior or peculiar speech. Preexisting
personality disorders (eg paranoid, histrionic, narcissistic,
schizotypal, borderline) predispose to its development. A
major stressor may precipitate the disorder. (1)
The disorder is not diagnosed if a psychotic mood
disorder, a schizoaffective disorder, schizophrenia, a
physical disorder or an adverse drug effect (prescribed or
illicit) better accounts for the symptoms. Differentiating
between brief psychotic disorder and schizophrenia in a
patient without any prior psychotic symptoms is based on
duration of symptoms, if the duration of the symptoms
exceeds 1 month, the patient no longer meets required
diagnosis criteria for brief psychotic disorder. Since there
are several similarities between brief psychotic disorder
and schizophrenia, many researchers and clinicians think
that the former is an antecedent for the latter. (2)
We describe the case of a 33 year old man who
came to the Clinical Hospital of Psychiatry with an acute
psychotic picture: psychomotor restlessness, visual an
hearing hallucinations (”I saw and I heard my
parents in my room”, “I saw the cameras in my room, they
were fallowing me”), delusions - exterior influence ideas
(”they took my parents' and my friends' identities”),
prejudice ideas (“they what to take my room because is
more spacious and has better conditions”), bizarre
behavior (he stayed locked in his room and let nobody to
enter, because he was afraid they would occupy his
beautiful room), anxiety and mix insomnia.
From family history there were no psychiatric
disorders in his family. From his medical history there
was a cranial – cerebral trauma with loosing of conscience
for a short period of time (2-3 minutes) two years before
this episode.
He always was an eminent student (finished the
Military High School, he took his Degree on Automatic
and Computers College) and had no behavior problems.
He is a single child. He lives alone in a student's hall room.
He denies alcohol or drugs or other substances abuse
(family, friends, co-workers say he never took any kind of
drugs and there were no evidence of them in his room,
clothes, among his stuffs).
According to his family members and friends
another episode (with hearing hallucinations -”I heard my
parents in my room”, prejudice ideas –“someone from
one radio played an joke on me” and bizarre behavior)
happened 6 months ago, but the symptoms disappeared in
few days without treatment or any other psychiatric help.
The dates we gathered from the patient, family and friends
link these 2 episodes with very stressful events. First
1
Resident in Adult Psychiatry, Clinical Hospital of Psychiatry “Prof Dr. Alex Obregia” Bucharest, Romania, contact: [email protected]. tel:
+40726752399.
Received January 12, 2011, Revised April 04, 2011, Accepted May 30, 2011.
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Romanian Journal of Psychiatry, vol. XIII, No.2, 2011
episode – he had lost his scholarship for a short period of
time, because he had a lot of work to do and had a
disagreement with his tutor teacher, and before he manage
to find another teacher he had no money and no place to
stay. Second episode – a lot of work and many deadlines
(he works, he is a doctorand and he is also on his second
master).
Objective clinic examination and neurological
exam were in normal limits. Laboratory test revealed few
modifications in hepatic test with no clinical value.
Toxicology tests were negative. Psychological tests –
conclusions - supplementary sensibility trends, paranoid
trends, anxiety and depressive trends. Because he had a
cranial-cerebral traumatism we recommended to the
patient a native brain CT and there were no modifications
at this level.
Psychiatric examinations revealed a conscious
patient with proper hygiene,
cooperating,
psychomotor restlessness, little suspicious, with mimicry
and broad gestures easy hypo-mobility. Perception-visual
and hearing hallucinations. He was orientated in time,
place and person, with spontaneous and voluntary hypoprosexia. Memory within normal limits, anxiety,
suspicions. He had prejudice ideas, followings and
exterior influence ideas. He also had sleep problems.
He was diagnosed with Brief Psychotic Disorder.
We had to consider other problems such as
psychotic disorder secondary to general condition,
delirium and various other disorder, but history, physical
examination or laboratory tests ( which were normal)
helped us to differentiate. Our major problem was
substance – induced psychotic disorder (especially legal
drugs), because there are no specific laboratory tests to
help us identify the drugs (we exclude it on toxicological
tests and a history taken from the family, friends, coworkers and there were no evidence of drugs in his room,
clothes, among his stuffs and the that the onset is linked to
a obviously stressor).
Other problem to be considered – occurrence of a
psychotic episode during a full affective episode excludes
the diagnosis of brief psychotic disorder. If psychotic
symptoms persist longer than a month, the diagnoses of
schizophreniform disorder, schizoaffective disorder,
schizophrenia, delusional disorder, mood disorder with
psychotics features. In case of malingering, there is
usually some evidence indicating that the illness was
feigns for an understandable goal. In factitious disorder,
past history may reveal that the symptoms are
intentionally produced. Presence of a florid psychosis
makes the diagnosis of dissociative disorder unlikely. (3)
Treatment for brief psychotic disorder typically
includes medication and psychotherapy (a type of
counseling). Hospitalization is necessary if the symptoms
are severe or if there is a risk that the person may harm
himself or others. Antipsychotic drugs may be prescribed
to decrease or eliminate the symptoms and end the brief
psychotic disorder.
We initiated the treatment with Olanzapine 10
mg/day. The symptoms disappeared very quickly (in 2
days) and the patient had tolerated well the treatment. (4)
Generally brief psychotic disorder has a good
prognosis and its run its course in less than a month. A
good prognosis is usually associated with sudden onset of
symptoms,few premorbid schizoid traits, affective
symptoms, confusion and perplexity during psychosis,
short duration of symptoms,
absence of
schizophrenic relatives and good premorbid adjustment.
Although hospitalization and pharmacotherapy
are likely to control short-term situations, the difficult part
of the treatment is the psychological integration of the
experience into the lives of the patients and their family
It is important to educate the patient and the
patients family about the situation. (3)
DISCUSSION
Our days stress and the overcame are the causes
of many medical and psychiatric problems.
Brief psychotic disorder is not common,
generally occurs in adolescence or early adulthood, with
the average age at onset being in the late 20s or early 30s. It
is more common in women than men. People who have
personality disorders – such as paranoid personality
disorder or antisocial personality disorder- are more prone
to develop brief psychotic disorder.
The exact cause of this disorder in unknown. One
theory is based on genetic vulnerability (is more common
in people who have family members with mood disorders
such as bipolar disorder). Other theory suggests that the
disorder is caused by poor coping skills as a defense
against or escape from a particularly frightening or
stressful situation. It must be understood that the
individual perceives the stress as totally overwhelming.
Neither biological nor psychological theories have been
validated by carefully controlled studies. In most cases
the trigger is a major or traumatic stress event (traumatic
events, family conflict, employment problems, accidents,
severe illness, death of a love one, uncertain immigration
status). Childbirth may also trigger the disorder in women
(5)
A variety of general medical conditions can
present psychotic symptoms for a short period of time.
Delirium or psychotic disorder due general medical
condition is diagnosed when there is evidence in the
physical examination and laboratory test ( eg Cushing
Syndrome, brain tumor). Substance induced psychotic
disorder should be distinguished from brief psychotic
disorder ( eg a medication, exposure to a toxin, a drug
abuse). The diagnosis of brief psychotic disorder cannot
be made if the psychotic episode is better accounted by a
mood disorder. The differential diagnosis between brief
psychotic disorder and schizophreniform disorder is
difficult when the psychotic symptoms have remitted
before 1 month in response to medication. Because
recurrent episodes of brief psychotic disorder are rare,
careful attention should be given to the possibility that a
recurrent disorder could be responsible for that psychotic
episode (bipolar disorder, exacerbations of
schizophrenia).
An episode of factitious disorder could have the
appearance of brief psychotic disorder, but in such cases
there is evidence that the symptoms are intentionally
produced. Malingering can also look like brief psychotic
disorder, but usually there is evidence that the illness was
feiged for an understandable goal.
In personality disorders some psychosocial
stressors may precipitate brief periods of psychotic
symptoms, they are usually transient, but if they persist
more than a day an additional diagnosis of brief psychotic
disorder may be appropriate.
Patients with acute psychotic attack may need a
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Andreea Ciornei, Carmen Bumbu, Ramona Spînu: Stress And Brief Psychotic Disorder
brief hospitalization for evaluation and safety concerns.
Patients may be at risk of committing suicide during
psychotic episodes, especially when brief psychotic
disorder is associated with affective symptoms.
If the symptoms are only minimally impairing
the patient's function and a specific stressor is identified,
removing the stressor should be sufficient, in event that
symptoms are disabling an antipsychotic agent should be
used. The goals of pharmacotherapy are to reduce
morbidity and to prevent complications. Psychotherapy is
also need it because helps the person identify and cope
with the situation or event that triggered the disorder.
By definition a diagnosis of brief psychotic
disorder requires a full remission of all symptoms and a
return to the premorbid level of functioning within a
month of the onset disturbance. There are patients who
have a brief duration of psychotic symptoms (eg few
days), however some people may have others episodes of
psychotic symptoms in response to stress, but this
situations are rare. According to European studies, 5080% of all patients have no further major psychiatric
problems and some date indicate that brief psychotic
episode with an acute onset may be an early manifestation
of severe mental disorder (eg affective disorders or
schizophrenia).
Preventive and therapeutical stress management
may improve the evolution of psychosis. An important
component of vulnerability is environmental factors,
especially stress, which is essential in developing of
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psychoses. On the other hand, stress impairs
clinical features in psychotic and prepsychotic patients
(6).
Patients with no premorbid psychiatric history
have been associated with excellent prognosis. Therefore,
educating the patient and the patient's family about the
situation is essential. There is no way to prevent Brief
Psychotic Disorder, however early diagnosis and
treatment can help decrease the disruption of the person's
life, family and friends (7).
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