Southern Philippines Medical Center

Institute of Psychiatry and Behavioral Medicine

Davao City

BRIEF PSYCHOTIC DISORDER

Submitted by:

Davao Regional Medical Center (DRMC)

Post-Graduate Interns

BUMA-AT, LOVELY JANE

CELO, KENETH JEAN

ESCALANTE, MICHAEL JOHN

February 28, 2017

 PSYCHIATRIC INTERVIEW

I. Identifying Data:

This is a case of patient M.A., 16 years old, female, common law, Filipino and a resident
of Arakan, North Cotabato. She was admitted last February 17, 2017 at two in the morning.

II. Source and Reliability:

The informants were her mother and her common law partner with 90% and 80%
reliability, respectively.

III. Chief Complaint:

Violent behavior

Patients words: Ambot nila. Wala ko kabalo.

Companions words: Dili na siya gakaon. Gapanumbag na siya.

IV. Premorbid Personality:

Patient M.A. was known to be talkative and friendly. She has good interpersonal
relationship with her cousins as well as their neighbors. She was described as responsible and
hard-working. She loves to do household chores and taking care of her 2 year old child. She
usually shares her problems with her common law partner. Patient M.A. rarely gets angry. If she
does, she verbally expresses her feelings towards the person.

V. History of Present Illness:

Two weeks prior to admission, patient was noted to have sudden onset of change in
behavior. She was noted to be laughing boisterously alone and sometimes crying incessantly.
She had difficulty falling asleep and was noted to be restless during the night, walking back and
forth their house. She was also seen talking and arguing to herself. There was no consult done.
No medications taken.
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One week prior to admission, there was persistence of above signs and symptoms. This
time, the patient had loss of appetite, poor hygiene and was noted to have decrease interaction
with her family members. Still no consult was done and no medications were taken.
 Five hours prior to admission, the patient exhibited violent behavior. She was seen
shouting and throwing stones at their neighbors house with no reason at all. She was
reprimanded by her partner and mother causing her to throw several punches to them. Because
of this, they immediately sought consult to this institution. Hence, advised for admission.

VI. Past Illness:

A. Past Psychiatric Illness

The patient had no history of any psychiatric illness.

B. Past Medical Illness

Patient M.A. is nonhypertensive, nondiabetic and non-asthmatic. She has no

history of thyroid disease, trauma, previous hospitalization or surgery.

VII. Family History:

The patient has a strong family history of mental illness on the maternal side (cousin,
uncle and aunt). She also has genetic predisposition to hypertension in both maternal and
paternal side with no family history of Diabetes Mellitus, Bronchial Asthma and Thyroid Disease.

VIII. Developmental and Social History:

A. Prenatal and perinatal

Patient M.A.s mother and father were married. She was the youngest of the 8 siblings. It
was an unplanned but wanted pregnancy. Her mother did not have prenatal check-ups and
cannot recall any history of fever or illness during pregnancy. The patient was delivered via
normal spontaneous vaginal delivery at home, attended by a hilot. There were no complications
or birth trauma reported.

B. Infancy

The patient was breastfed. Circumstances of weaning unrecalled. Her primary caregiver
was her mother. The patient had no delay in speech and motor activity as claimed. The patients
mother cannot recall other information regarding this period.

C. Childhood
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She was described as friendly and playful to girls of the same age as her. She was also
close to her cousins and other relatives. She started Grade 1 at the age of 7. She was an
average student and denied history of bullying or trauma at school. After school, she helped her
mother clean their house and cook food. Mode of discipline during these years was physical
punishment using a piece of stick, a slipper and belt. The disciplinarian was her mother.

D. Adulthood

Occupational history

The patient started working as a dish washer and waitress at a carinderia at the age of
13. She had no reported history of work-related conflicts and had satisfying relationships with
her co-workers. Currently, she has no job and serves as a housewife and caregiver to her child.

Marital and relationship history

The patient engaged in heterosexual relationship starting at the age of 14. She had a
total of 3 boyfriends. She was impregnated by her last boyfriend at the age of 15. After which,
she cohabited with him until then. Her common law partner verbalized that they did not have
any serious family problems or conflicts that may precipitate the patients condition.

Educational history

The patient graduated from elementary school and did not proceed to high school
because of financial constraints. Other family members have more or less the same academic
achievement.

Religion

The patient is a Protestant (Evangelical). She was not raised in a particularly religious
family. She rarely goes to church. She was not involved in charismatic activity or organizations.

Social activity

The patient has friends among her neighbors and relatives. She enjoyed singing
(Karaoke) with them during special occasions like birthdays, reunions and fiestas.

Current living situation

She lives with her common law partner and her 1 year old child in a rural community.
The house is made of mixed materials. The breadwinner was her partner who worked as a
farmer.

Legal history

The patient is not and has never been involved in any legal dispute. She has never been
arrested.
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Sexual history

The patient vehemently denies sexual activities aside from her husband. She started
engaging in premarital sex at the age of 15 years old as claimed.
IX. Substance Use/ Abuse

Patient M.A. denies cigarette smoking, alcohol intake and use of illicit drugs.

X. Review of Systems:

General: She had no history of fever, trauma or any illnesses. She had weight loss from 60kg to
55.6kg in a span of 1 week.

Skin: She reported no changes in the size and color of moles.

Head, Eyes, Ears, Nose, Throat (HEENT):

Head: No history of head trauma.

Eyes: No history of frequent tearing, eye discharge and redness was reported.

Ears: Patient has no ear infection, pain or discharge reported.

Nose and Sinuses: No nasal discharge or epistaxis noted and the sinuses were not inflamed.

Throat/Mouth: She has no bleeding gums or mouth ulcers.

Neck: No goiter or stiffness in the neck reported.

Respiratory: She has no fast breathing, cough or difficulty of breathing. No hemoptysis or

audible wheezing noted.

Cardiovascular: No loud, audible murmurs noted. No complains of chest pain, orthopnea or

exertional dyspnea.

Gastrointestinal: She has decreased appetite. She has no problems with defecation. She has
no milk intolerance, no diarrhea, constipation or rectal bleeding.

Peripheral vascular: No edema noted.

Urinary: No gross hematuria noted. No dysuria or urinary incontinence.

Hematologic: No easy bruising or bleeding reported.

Endocrine: No known thyroid trouble or heat or cold intolerance. No excessive sweating noted.

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XI. Physical Examination:

General Survey:
Patient was seen awake, ambulatory and not in respiratory distress.

Vital Signs:
BP - 120/80 mmHg RR - 18 cpm Weight - 55.6 kg BMI - 21.99 kg/m2
CR - 84 bpm Temp- 36.70C Height - 159 cm

Skin
She has brown complexion, dry and warm to touch with good skin turgor. No rashes,
clubbing and lesions noted. Her fingers and fingernails were dirty.

Head, Eyes, Ears, Nose, Throat (HEENT)

Head is atraumatic. She has anicteric sclerae with pupils equally round and reactive to
light and accommodation. Ears are symmetrical and no mass, lesions and discharges noted.
Hearing acuity is good to normal tone voice. Nasal septum is in the midline with no nasal flaring
or rhinorrhea. Oral mucosa is pink with no inflamed tonsils. Drooling of saliva was noted.

Neck
She has supple neck with no cervical lymphadenopathy.

Chest and Lungs

Breathing pattern is normal with symmetrical chest expansion and clear breath sounds.

Cardiovascular
Precordium is adynamic. Normal rate and regular rhythm with no murmurs noted.

Abdomen
She has flat abdomen, with normoactive bowel sounds, soft and nontender.

Extremities
Both extremities are symmetrical with full range of motion (5/5). No edema or deformity
noted.

Genitalia and Rectum

Not assessed

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XII. Neurologic Examination:

Sensorium
Patient was awake; GCS 15, RLS 1

Cerebellum
Patient was ambulatory with normal gait and no difficulty walking or imbalance

Cerebrum
She was coherent to some questions but uncooperative to others; oriented to person
but not oriented to time and place.

Reflexes
Deep tendon reflexes normal, 2+
No pathologic reflexes such Babinski reflex

Cranial Nerves:

Cranial Nerve Findings

1 Olfactory Able to identify the smell of toothpaste
2 Optic Able to read the text with font size of 12
Isocoric pupils 4mm constricting to 2mm with intact
3 Oculomotor
direct and consensual reflex
Oculomotor,
3, 4, 6 No deviations, nystagmus or lid lag noted
Trochlear, Abducens
Able to sense light touch on the forehead, cheeks,
5 Trigeminal
and jaw. Corneal reflex intact.
Able to raise both eyebrows, frown, show both upper
and lower teeth, smile and puff out both cheeks
7 Facial
symmetrically with no face lag noted. No tics or any
other abnormal facial movements noted.
8 Vestibulocochlear Hearing acuity is good to normal and whispered voice
Glossopharyngeal, No difficulty of swallowing noted. Able to say ah with
9, 10
Vagus soft palate rises symmetrically
No atrophy or fasciculations of the trapezius muscle
11 Spinal Accessory noted. Able to shrug shoulders against the resistance
of the hands.
Able to move tongue from side to side. No
12 Hypoglossal
asymmetry, atrophy or fasciculations noted

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XIII. Mental Status Examination:

General Description

A. Appearance
Patient was poorly groomed wearing t-shirt, shorts and slippers with dirty
untrimmed nails. She had disheveled hair and looks older than her stated age.

B. Behavior and Psychomotor Activity

She was noted to be agitated during the interview.

Mood and Affect

A. Mood -Angry mood Nasuko ko ngano gidala ko nila diri.

B. Affect -Blunted affect

Neurovegetative Function

A. Sleep - (+) Early insomnia

B. Appetite - decreased appetite
C. Weight - (+) weight loss- from 60kg to 55.6kg in 1 week
D. Diurnal Variation - usually low energy the entire day
E. Libido - no change
F. Attention - poor attention, easily distracted, poor eye contact

Speech: Deliberate
(+) whispered voice

Perception

Type: (+) Auditory and visual hallucinations; noted to have hallucinatory gestures like
talking and whispering to someone
Description: Patient will not elaborate when asked.

Thought process: (+) looseness of association

(+) tangentiality
(+) thought blocking

Thought content: (+) Paranoid delusion - gihiluan nila akong pagkaon

Sensorium and Cognition:

A. Orientation
Patient was not oriented to time and place. She answered ambot lang when asked
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about the time and place. Oriented to person, Akong banaSi mama.
B. Memory (remote, recent past, recent, immediate)
Patient was uncooperative.
C. Concentration and Attention
1. Serial Subtraction - uncooperative
 2. Spelling - uncooperative
3. Abstract Thought - uncooperative
4. Information and intelligence - uncooperative

Judgment and Insight

A. Judgment - Test judgment- uncooperative

- Social judgment - impaired
B. Insight - No insight Ambot lang ngano gidala ko diri.

SUMMARY OF MSE:

A. Disturbance in: General Description

Mood and Affect
Neurovegetative Function
Speech and Perception
Thought content and process
Sensorium
Judgment and Insight

B. Diagnostic Category: Psychotic

Functional

C. Diagnosis DSM V- Brief Psychotic Disorder

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 ADMITTING IMPRESSION

Brief Psychotic Disorder

DIFFERENTIAL DIAGNOSES

DIAGNOSIS RULE IN RULE OUT

Presence of auditory and

visual hallucinations; paranoid
delusion, disorganized The symptoms occurred not
Schizophreniform Disorder
speech, grossly disorganized later than 1 month.
behavior (violent behavior)
and affective blunting

Presence of auditory and

visual hallucinations; paranoid
delusion, disorganized The symptoms occurred not
Schizophrenia
speech, grossly disorganized later than 6 months.
behavior (violent behavior)
and affective blunting

There was no history of fever,

Psychotic Disorder due to
another medical condition
Sudden onset; Presence of
hallucinations and delusion
trauma or any medical illness.
The patient is
nonhypertensive, nondiabetic,
non-asthmatic and with no
history of thyroid disease

COURSE IN THE WARD

SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

Day of Poorly groomed; Brief Psychotic Admit patient to CIU

admission: agitated; blunted affect; Disorder Psychoeducation done to
whispered voice; with family
Nasuko ko hallucinatory gesture; VS q 4 hours
ngano gidala disoriented; Labs: CBC, U/A, serum
ko nila diri. uncooperative; poor eye electrolytes (s. Na, s. K),
contact SGPT, SGOT, Creatinine,
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BUN
Meds: Olanzapine
10mg/ODT 1/4 ODT at
bedtime
 Strict homicidal/ suicidal
and escape precautions
1st Hospital Hair unkempt; Brief Psychotic Increase Olanzapine
Day: disorganized behavior Disorder 10mg/ODT to 1/2 ta ODT
(raises hand, shakes at bedtime
(no verbal hand); labile mood;
output) blunted affect; (+)
muteness,
uncooperative, with
noticeable body odor

2nd Hospital Patient was seen Brief Psychotic For 4-point restraint on
Day: jumping on bed; does not Disorder bed x 2 hours
follow verbal commands; Ensure adequate limb
(no verbal possible risk for injury, circulation q 30min
output) (+) drooling, (+) Monitor patient q hourly
muteness while on restraint
Elevate head of bed at
30o
Strict aspiration
precaution
3rd Hospital Patient still Brief Psychotic Increase Olanzapine
Day: uncooperative; will not Disorder 10mg/ODT to 1/2 tab BID
respond when called;
(no verbal good hygiene (+)
output) muteness

4th Hospital Patient was calm, Brief Psychotic Continue medication

Day: euthymic mood, Disorder
responded when called,
Okay na. well groomed, good
appetite, enough
uninterrupted sleep, (+)
auditory and visual
hallucination, (+) thought
blocking, uncooperative
to some questions,
oriented to person, not
oriented to time and
place, fair concentration,
impaired judgment, no
insight

5th Hospital Patient was well Brief Psychotic Continue medication

Day: groomed, euthymic Disorder
11 mood, appropriate affect,
Okay ra ko. good appetite, good
Gusto nako sleep, fair attention,
mouli. easily distracted, good
eye contact, , still
refused to answer serial
 subtraction and spelling,
oriented to time, place
and person, unimpaired
memory, unimpaired test
judgment, no insight

6th Hospital Patient was well Brief Psychotic Continue medication

Day: groomed, euthymic Disorder Possible MGH tomorrow
mood, appropriate affect,
Okay naman good appetite, good
ko. sleep, good attention,
good eye contact, good
concentration in serial
subtraction and spelling,
oriented to time, place
and person, unimpaired
memory, unimpaired test
judgment, no insight

7th Hospital Patient was well Brief Psychotic MGH today

Day: groomed, euthymic Disorder Home medication:
mood, appropriate affect, Olanzapine 10mg/ODT,
Okay lang. Uli good appetite, good 1/2 ODT BID
nako. sleep, good attention, Psychoeducation done
good eye contact, good Follow-up after 2 weeks
concentration in serial Advised
subtraction and spelling,
oriented to time, place
and person, unimpaired
memory, unimpaired
judgment, no insight

DISCUSSION

BRIEF PSYCHOTIC DISORDER

I. Diagnostic Criteria

The specific DSM-5 criteria for brief psychotic disorder are as follows:

A. The patient must have 1 or more of the following symptoms: delusions, hallucinations,
disorganized speech (eg, frequent derailment or incoherence), and grossly disoriented or
12 catatonic behavior; 1 or more of the first 3 symptoms must always be present; a symptom
should not be included if it is a culturally sanctioned response

B. The 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 cannot be better explained by major depressive or bipolar disorder with
psychotic features or by another psychotic disorder (eg, schizophrenia or catatonia), nor
can it be attributed to the physiologic effects of a substance or medication or another
medical condition

In addition, the following must be specified:

1. Presence of marked stressor(s) (brief reactive psychosis)

2. Absence of marked stressor(s)
3. Postpartum onset (if onset is during pregnancy or 4 weeks post partum) [2, 3]
4. Presence of catatonia

II. Pathophysiology

The causes of brief psychotic episodes are largely unknown. Patients with personality
disorder may have biologic or psychological vulnerability toward the development of psychotic
symptoms. One or more severe stress factors, such as traumatic events, family conflict,
employment problems, accidents, severe illness, death of a loved one, and uncertain
immigration status, can precipitate brief reactive psychosis.

Psychodynamic theories suggest that the psychotic symptoms occur because of

inadequate coping mechanisms, as a defense against prohibited fantasy, or as an escape from
a specific psychological situation or an overwhelming stressful circumstance. It must be
understood that the individual perceives the stress as totally overwhelming. Neither biologic nor
psychological theories have been validated by carefully controlled clinical studies.

III. Epidemiology

According to an international epidemiologic study, the incidence of nonaffective acute

remitting psychoses in contrast to that of schizophrenia, was 10-fold higher in developing
countries than in industrialized countries. Some clinicians believe that the disorder may occur
most frequently in patients from lower socioeconomic classes, patients with preexisting
personality disorders, and immigrants.
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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.
Age- and sex-related demographics

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. An international epidemiologic study found
the incidence of the disorder to 2-fold higher in women than in men.

IV. Clinical Presentation

Brief psychotic disorder is characterized by the abrupt onset of 1 or more of the following
symptoms:
1) Delusions - Rapidly changing delusional topics
2) Hallucinations
3) Bizarre behavior and posture
4) Disorganized speech

Patients may present with a variety of associated symptoms, including the following:
1. Affective symptoms - Rapidly changing mood
2. Disorientation
3. Impaired attention
4. Catatonic behavior (in some cases)
The following are also commonly observed in brief psychotic disorder:
1) Emotional volatility
2) Outlandish dress or behavior
3) Screaming or muteness
4) Impaired memory for recent events

V. Management

Because of the short duration of brief psychotic disorder, treatment is brief and focused
on being as nonrestrictive as possible. However, it remains clinically imperative to prevent
patients from harming themselves or others. Accordingly, patients experiencing an acute
psychotic attack may have to be hospitalized briefly so that they can be evaluated and their
safety ensured. If a patient becomes aggressive and combative, brief seclusion or restraint
may be necessary.
If symptoms are only minimally impairing the patients function and a specific stressor is
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identified, removing the stressor should suffice for treatment of the brief psychotic episode.
 If, however, symptoms are disabling, an antipsychotic agent should be given, but for
no longer than 1 month. Commonly used typical (first-generation) antipsychotics include the
following:
1. Haloperidol
2. Thiothixene
3. Thioridazine
4. Fluphenazine
5. Chlorpromazine
If adverse effects are intolerable, it may be helpful to use one of the following atypical
(second-generation) antipsychotics:
1) Olanzapine
2) Quetiapine
3) Ziprasidone
4) Risperidone
5) Paliperidone

Once the acute attack has ended, further inpatient care is unnecessary. Individual,
family, and group psychotherapy may be considered to help cope with stressors, resolve
conflict, and improve self-esteem and self-confidence.

VI. Prognosis

Generally, brief psychotic disorder has a good prognosis and runs its course in less than
1 month. A good prognosis is usually associated with sudden onset, short duration of symptoms,
and good premorbid adjustment; the prognosis is especially favorable for patients with no
premorbid psychiatric history. According to European studies, 50-80% of all patients have no
further major psychiatric problems.

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 CLINICAL PRACTICE GUIDELINES

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines
for the management of schizophrenia and related disorders (2016)

Prescribing considerations. A treatment algorithm for pharmacological treatment for first

episode non-affective psychosis is provided in Figure 1.

Young people are particularly sensitive to the side effects of psychotropic medicines. A
low starting dose with gradual titration up to an effective level is recommended, unless the
young person is acutely mentally ill and requires urgent treatment. Second-generation
antipsychotic agents (SGAs) are recommended in preference to first-generation antipsychotic
agents (FGAs) due to their better tolerability and extrapyramidal side-effect profile. There is
some evidence of improved relapse prevention with SGAs, compared with FGAs, although this
meta-analysis included only oral medications, and the most common FGA comparator was
haloperidol.

There are high levels of non-adherence to medication among people with psychotic
disorders. Adherence should be proactively and sensitively addressed. There is a need for
careful ongoing monitoring of medication in this stage of illness, combined with a willingness to
decrease dosages. This is likely to work better in the presence of a multi-dimensional
psychosocial programme to assist recovery. Attempting to avoid relapse has been a rationale for
medication in the management of FEP. Many researchers have emphasised the need for
ongoing treatment to prevent relapse and the negative impact of relapse on the long-term
course of the disorder. However, a recent study observed that compared with a standard
maintenance treatment regimen, dose reduction or supervised discontinuation of antipsychotic
medication during the early phases of FEP led to a higher relapse rate initially, but improved
long-term outcomes. This study has been criticised for its unequal distribution across diagnostic
groups, high attrition rate, failure to separate the dose reduction and discontinuation groups,
and the fact that most patients in each arm of the study did receive medication. These findings
have not been replicated.

For people with FEP, as for all people with psychotic illness, medication is only a part of
the required treatment. Studies have shown that an early functional recovery is more predictive
of a long-term full recovery than early symptomatic recovery alone. This finding also aligns with
the goals of young people with FEP. The top five goals, in order, are employment, education,
housing, relationships and health. Therefore, it is imperative to provide psychosocial
interventions designed to achieve these goals. Compared with standard treatment,
comprehensive FEP services have demonstrated greater family satisfaction and lower family
burden. In addition, the provision of family psychoeducation and family group therapy can help
reduce relapse and readmission rates.
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 (PLS PRINT THE DIAGRAM)

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 REFERENCES

Kaplan and Sadocks Synopsis of Psychiatry, 11th edition

Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the
management of schizophrenia and related disorders (2016)

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