Brief Psychotic Disorder is a transient but intense period of psychosis that has intrigued clinicians and researchers alike. This phenomenon is characterised by an acute onset of various psychotic symptoms, including delusions, hallucinations, disorganised thinking and impaired reality testing.

Brief Psychotic Disorder (BPD) is different from other psychotic disorders due to its time-limited nature, typically lasting from a few days to less than a month. Individuals experiencing BPD often struggle with a profound disruption in their perception of reality, which can be extremely distressing for the individual affected and their loved ones.

In this article we delve deeper into the intricacies and defining features of Brief Psychotic Disorders, explore the diagnostic criteria used by mental health professionals, and examine some psychological models that theorise its origins. As we uncover the latest research on this disorder and evaluate the challenges facing its identification and treatment,  you will gain a comprehensive understanding on this captivating subject that lies at the intersection of psychology, neuroscience, and clinical care.

Introduction

Brief Psychotic Disorder is described as the sudden onset of psychotic behaviour that lasts from a day to less than a month, leading to complete remission with the possibility of relapse. It is currently classified under schizophrenic and other psychotic disorders, with the main differentiation being its transient nature.¹

Understanding the intricacies of a Brief Psychotic Episodes (BPEs) provides insights not only into the complexities of the human mind but also about the nature of psychosis, the brain's response to stressors, and the potential for recovery.

Characteristics of Brief Psychotic Episodes

BPD is characterised by the abrupt onset of one or more of the following symptoms:

• Delusions: False beliefs that are based on incorrect inferences about reality, that are unable to change despite conflicting evidence² 
• Hallucinations: Hallucinations occur when your brain experiences a false perception of objects involving one or more of your senses: sight, sound, smell, taste or touch²
• Disorganized thinking and/or,speech: Frequent derailment, incoherent and irrational speech, or language that is strangely out of character² 
• Catatonic behaviour: Sufferers may experience a repetitive, unresponsive stupor characterised by catatonic behaviour²
• Impaired reality testing:A deficit in reality testing is an inability to distinguish between your internal thoughts, imagery and feelings, and the external reality i.e. perceptions, and an inability to assign the most suitable meaning to experiences, usually with a lack of insight regarding this impairment²

BPD differentiates from other psychotic disorders in that there is a full remission of all symptoms and a full return to normal functioning within one month of its onset.

Comparison with other psychotic disorders

There are several key differences between BPD and other psychotic disorders, most notably, other schizophreniform disorders last 1-6 months with schizophrenia lasting at least 6 months, compared to the temporary nature of BPD.³ Individuals with BPD usually make a full recovery within a month, however, a large number of patients with brief psychotic disorder experience a change in diagnosis to another psychotic disorder or a mood disorder over time. BPD is also distinguished from other psychotic disorders by its lack of a prodrome- meaning the absence of early warning signs or symptoms that precede the onset of a disorder.³ In the case of BPD, individuals typically experience a sudden onset of symptoms without any prodromal phase, which makes early detection and prompt management of the disorder challenging.³

Diagnostic criteria

The Diagnostic and Statistical Manual of Mental Disorders (DSM) contains details of the numerous mental health conditions. The DSM-5 defines BPD as a thought disorder in which an individual will experience a transient, but gross deficit in reality testing with at least one of the following symptoms;Delusions, hallucinations, disorganised speech or thinking and catatonic behaviour.

To fulfil the criteria for BPD, the symptoms must be present for a day but resolved in less than a month. A complete remission of all symptoms is necessary for a BPD diagnosis.⁴

For BPD to be diagnosed, the psychotic episode cannot be a result of other psychiatric or medical conditions,substance use or fever and delirium.⁵ Additionally, the individual must not fit the diagnostic criteria for major depressive disorder and/or bipolar disorder with psychotic features, or schizophrenia.⁵

Prevalence and demographics

Frequency of occurrence

There is not enough reliable data on the frequency of BPD, mostly due to its low incidence and different studies observing different populations. However, the disorder is more common in populations that are known to be under stress, such as immigrants, refugees, earthquake victims, and so on.⁵ BPD is a relatively rare representation of psychotic disorders and may account for up to 7% of cases of first-episode psychosis.⁶ 

Age, gender, and cultural considerations

The annual incidence rate for BPD ranges from 4-10 per 100,000 and the average age at onset is usually mid-30s.⁷  The World Health Organisation’s Determinants of Outcome Study found that the incidence of BPD was ten times higher in developing countries than in industrialised countries.⁴  BPD is also thought to be more prevalent in women and people who have a personality disorder.⁸ The gender differences may be attributed to hormonal and genetic factors as well as socio environmental influences, however, it is important to note that the overall prevalence of BPD is low in general, and further research is needed to better understand the differences. 

Aetiology and risk factors

Stress and triggering events

The underlying cause of BPD is primarily a stressful, traumatic event, though the exact cause is unknown. The disorder is typically a reaction to a severe stressor or a series of stressors that the individual finds difficult to cope with. Psychological factors such as emotional turmoil, anxiety, and confusion can contribute to the onset of brief psychotic disorder.⁵ 

Genetics and hereditary factors

There may be a genetic and neurological component to BPD as well. Genome-wide association studies have provided insight into psychosis, however, its exact pathophysiology is unknown due to the low incidence of the disorder. Because BPD is more common in people with personality and mood disorders, which do have a genetic influence, the biological or psychological susceptibility may have a genetic component. 

Theories and Models

Psychodynamic theories

Psychodynamic theory is a psychological approach that focuses on the unconscious processes and childhood experiences that shape an individual's thoughts, feelings, and behaviours.⁹ 

The main psychodynamic theories of psychosis include the use of metacognition (thinking about thinking) to understand and promote recovery and self-integration.⁹  The psychodynamic approach to psychosis focuses on defining experiences that the person has found overwhelming and that have been dispensed with or altered through the psychosis rather than contained.⁹ 

Neurodevelopmental theories

The main neurodevelopmental theories of psychosis include the trauma model, the developmental risk factor model (DRFM), and the traumagenic neurodevelopmental model. The trauma model suggests that exposure to trauma increases the risk of psychosis, particularly in individuals with neurodevelopmental risks.¹⁰  

The DRFMl is a theoretical framework that aims to explain the development of psychosis by considering a range of developmental and environmental risk factors.¹⁰  It suggests that the interaction between these factors across a person's lifespan contributes to the emergence of psychotic symptoms and disorders. The traumagenic neurodevelopmental model integrates biological and psychological research, highlighting the similarities between structural and functional abnormalities in the brains of abused children and adults diagnosed with schizophrenia. This model suggests that the interaction between genetic vulnerability and early childhood trauma can contribute to the onset of psychotic symptoms and disorders, such as schizophrenia.¹⁰ 

Neurotransmitter dysregulation hypotheses

The neurotransmitter dysregulation hypothesis for psychosis suggests that dysregulated dopamine function and altered neurotransmitter systems, such as the dopamine system, play a central role in the development of psychotic symptoms.¹¹  Additionally, specific mechanisms underlying psychotic symptoms, such as hallucinations, have been linked to dopamine-dependent processes.¹²   

Diagnosis and Differential Diagnosis

Challenges in diagnosing BPEs

There are difference forms of BPD, a form that has specific triggers, is referred to as BPD with marked stressor(s), if however the trigger is non-specific then the condition is known as  BPD with unmarked stressor(s).¹³  The types of BPD are outlined below:

• BPD with marked stressor(s): Also known as brief reactive psychosis. This is defined by symptoms that occur in response to events that would be stressful for anyone in similar circumstances in the same culture.¹³ 
• BPD with unmarked stressor(s): This is where symptoms do not occur in response to events that would be stressful for anyone in a similar circumstance in the same culture.¹³ 
• Brief psychotic disorder with postpartum onset: Is defined as the onset of psychotic symptoms that occur within four weeks postpartum or during pregnancy.¹³ 

The difficulty in distinguishing BPD from other psychotic disorders presents diagnostic difficulties. BPD is differentiated from schizophreniform disorder and schizophrenia by the duration of the psychosis, with BPD lasting less than 1 month. BPD symptoms, like delusions, hallucinations, and disorganised speech, can overlap with those of other emotional, behavioural, and developmental disorders, which causes a high rate of misdiagnosis, particularly at the time of onset. The evaluation of BPD is based on feedback from patients, parents, and teachers, which can occasionally result in conflicting perceptions. ¹³ 

Treatment

Antipsychotic medications

Second generation, or atypical antipsychotics are usually the first line of treatment for BPD. Although this disorder characteristically shows full recovery within a month, it is still advised to continue antipsychotic treatment for 1-3 months after remission. These antipsychotics include olanzapine, risperidone and clozapine amongst others. These are preferred over first generation antipsychotics due to their less severe side effects.⁵ 

Psychotherapy and supportive interventions

A brief yet intense psychotic episode can be extremely disruptive to the lives of an individual and their family and friends. Cognitive Behavioural Therapy is often used to develop coping skills and ways to reduce stress to lower the possibility of relapses. Psychotherapeutic management would also involve encouraging the patient to continue their medication as  a lack of adherence can result in relapses, and overall the patient should be monitored on a long-term basis to assess the risk of relapse, presence of any residual symptoms and signs of co-morbidity that may require referral to a specialist. The ideal treatment plan for BPD should include both pharmacological and psychosocial interventions.⁵

Summary

In conclusion, Brief Psychotic Disorder (BPD) is a time-limited period of psychosis, marked by acute symptoms like delusions, hallucinations, and disorganized thinking. Its transient nature, typically lasting less than a month, sets it apart from other psychotic disorders. This article has delved into the defining features of BPD, explored its diagnostic criteria, and examined various psychological models that offer insights into its origins. We've also discussed the challenges in diagnosis and highlighted treatment approaches, such as antipsychotic medications and psychotherapy. Understanding BPD not only sheds light on the complexities of the human mind but also offers valuable insights into the broader nature of psychosis, stress responses, and recovery.