brief psychotic disorder

**DSM-5 definition:** Presence of ≥1 of the following, with at least one being delusions, hallucinations, or disorganized speech: (1) delusions, (2) hallucinations, (3) disorganized speech, (4) grossly disorganized or catatonic behavior. Duration is ≥1 day but <1 month, with eventual full return to premorbid level of functioning. Not better explained by a mood disorder with psychotic features, schizophrenia, schizoaffective disorder, or catatonia, and not attributable to a substance or another medical condition.

**Specifiers:** - With marked stressor(s) (formerly "brief reactive psychosis"): occurs in response to events that would be markedly stressful to almost anyone (e.g., death of a loved one, disaster, trauma). - Without marked stressor(s). - With peripartum onset: onset during pregnancy or within 4 weeks postpartum. - With catatonia.

**Epidemiology and risk factors:** - Typically presents in late adolescence to the 30s. - More common in women. - More common in patients with preexisting personality disorders (borderline, schizotypal, histrionic, paranoid), in those with a low socioeconomic status or recent immigration, and in those with a family history of psychotic or mood disorders.

**Pathophysiology:** Not well understood. Proposed mechanisms include stress-related dopaminergic hyperactivity (mesolimbic pathway) on a background of genetic vulnerability.

**Clinical features:** Abrupt onset of positive symptoms (delusions, hallucinations, disorganized speech or behavior), often with emotional turmoil, confusion, or labile affect. Negative symptoms are uncommon. Because the episode is time-limited, the patient returns to baseline.

**Diagnosis:** Clinical. Rule out the following: - Substance-induced psychosis (urine drug screen) - Delirium and other medical or neurologic causes (e.g., CNS infection, seizures, thyroid disease, autoimmune encephalitis, and metabolic derangements) - Mood disorders with psychotic features - Other psychotic disorders by duration

**Duration is the key to the differential diagnosis:** - Brief psychotic disorder: ≥1 day to <1 month - Schizophreniform disorder: ≥1 month to <6 months - Schizophrenia: ≥6 months (including prodromal/residual phases, with ≥1 month of active symptoms) - Delusional disorder: ≥1 month of non-bizarre delusions, with functioning relatively preserved

**Management:** - Ensure safety, since there is a risk of suicide and of harm to self or others. Hospitalization may be needed. - Use short-term antipsychotics (e.g., second-generation agents such as olanzapine, risperidone, or quetiapine). Benzodiazepines can help with agitation, insomnia, and catatonia. - Provide supportive psychotherapy and stress management. - Taper and discontinue medication after resolution. - Follow up closely, since some patients later develop a mood disorder or schizophrenia-spectrum illness.

**Prognosis:** Generally good. Most patients fully recover. Good prognostic factors include acute onset, a clear stressor, good premorbid functioning, and a short episode.

**High-yield pearl:** On boards, a vignette with psychotic symptoms lasting less than 1 month after a stressor (e.g., the death of a spouse or a postpartum state) with full recovery is brief psychotic disorder. If symptoms last 1–6 months, think schizophreniform disorder.