ACUTE TRANSIENT
PSYCHOTIC DISORDER
Presented by :
ELIZA KOIRALA
A CASE OF BRIEF PSYCHOTIC DISORDER
• A 30 yrs old nurse sejal was brought to an emergency
room by family members because of visual hallucination
, referential thinking concerning colours and persecutory
delusions.
• The patient was well until one week before , when her
family noticed that she started to throw things away ,
including food for no apparent reason.
• She had been talking lot about the family problems including
being the sole support for the family but she was more upset
about her brother prison release , fearing that he is going to
harm her.
• On admission to hospital , she kept questioning staff
members to show identification cards , and she felt that she
was about to be harmed. .
• Her physical examination , laboratory examination and
finding of Brain MRI ,EEG were normal.
• After receiving haloperidol for several weeks her delusional
thinking and hallucinations were no more.
• She responded to ward milieu , individual and group therapies.
• In family meeting she was able to discuss her concerns and
develop effecting coping strategies.
• After her discharge she did well on her job and continued in
supportive psychotherapy without medication.
INTRODUCTION
• Acute transient psychotic disorder is one
of the less understood form of psychosis
— also known as brief reactive psychosis.
• Typically diagnosed in a person’s 20s or early 30s.
• Brief reactive psychosis can be thought of as time-limited
schizophrenia that is resolved within one month’s time and do
not need long treatment.
DEFINITION
• DSM-V defines brief psychotic
disorder as an illness lasting from one
day to one month, with eventual
return to premorbid levels of
functioning.
• Under DSM-V it comes under 298.8
• At least one or more of the
following symptoms is required:
Hallucinations,
delusions,
strange bodily movements or
lack of movements,
peculiar speech and
bizarre or markedly
inappropriate behavior.
There are three basic forms of brief psychotic
disorder:
• Brief psychotic disorder with obvious
stressor
• Brief psychotic disorder without obvious
stressor.
• Brief psychotic disorder with postpartum
onset.
EPIDEMIOLOGY
• appears to be uncommon condition.
• generally occurs in early adulthood (20s and 30s)
• more common in women than in men.
• People with personality disorder are more prone
ETIOLOGY
• exact cause not known.
• genetic link- disorder is more
common in people who have family
members with schizophrenia or
mood disorders.
• Biochemical abnormality- increase
in level f 5-HT and dopamine .
• Serotonin or 5-hydroxytryptamine (5-HT) is
a neurotransmitter.
• found in the gastrointestinal tract (GI tract),
blood platelets, and the central nervous system.
• Include the regulation of mood, appetite, and sleep.
Serotonin also has some cognitive functions.
• Dopamine is a neurotransmitter
released by the brain that plays a
number of roles like movement,
memory, pleasurable, cognition ,
thought, sleep, mood, learning.
• produced in the dopaminergic neurons
in the ventral area of the midbrain, the
substantia nigra , and nucleus of
the hypothalamus.
ETIOLOGY
• poor coping skills against
frightening or stressful situation.
• triggered by a major stress or
traumatic event (childbirth , severe
conflict e.t.c)
• People who have a personality
disorder are more prone to
developing brief psychotic disorder
SYMPTOMS
• Hallucinations
• Delusions
• Disorganized speech or incoherence.
• Catatonic behavior
Other symptoms of brief psychotic disorder
include:
• Disorganized thinking
• Affect may shift rapidly
• Impaired memory for recent events
• Disorientation or confusion
• Avolition
• Unusual behavior and dress
• Changes in eating or sleeping habits
• Violence
• Disorientation
• Rapidly changing mood
• confusion
• Insomnia
• Bizarre behaviour
• Loss of insight
DIAGNOISIS OF BRIEF PSYCHOTIC DISORDER
• Complete history with patient and
family members.
– precipitating stressful life events (loss
of the loved one or any kind of
psychological trauma)
– Duration of illness
– Past history
• MSE
DIAGNOSTIC CRITERIA FOR 298.8 BRIEF PSYCHOTIC DISORDER ACCORDING TO
DSM-V
A. Presence of one (or more) of the following
symptoms:
(1) Delusions
(2) hallucinations
(3) disorganized speech (e.g., frequent incoherence)
(4) grossly disorganized or catatonic behavior.
.
B. 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 is not better accounted for by a Mood
Disorder With Psychotic Features, Schizoaffective
Disorder, or Schizophrenia and is not due to the direct
physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition.
Specify if:
• With Marked Stressor(s) (brief reactive psychosis): if
symptoms occur shortly after and apparently in response to
events that, singly or together, would be markedly stressful to
almost anyone in similar circumstances in the person's culture
• Without Marked Stressor(s): if psychotic symptoms do not
occur shortly after, or are not apparently in response to events
that, singly or together, would be markedly stressful to almost
anyone in similar circumstances in the person's culture
• With Postpartum Onset: if onset within 4 weeks postpartum
MANAGEMENT
• hospitalization should be considered.
• quite, well structured environment with
reduced stimulation is usually helpful.
• physical or chemical restrains for
behavioural problem.
• Assess safety of patient.
Medication:
Antipsychotic medication
• Chlorpromazine – 50 mg to 100 mg
upto three times per day
• Haloperidol—2.5 to 5 mg upto three
times per day
Anti anxiety medication
• Lorazepam 1-2 mg upto 3 times per
day
• General maintenance antipsychotic :
no role in brief psychotic disorder.
• Once the acute episode has subsided,
clarify patient vulnerability to stress
and enhance their coping
mechanism.
• Minimize stress.
• Psychotherapy
– Individual therapy
– Group therapy
– Social skill training
– Family therapy
COURSE AND PROGNOSIS OF BRIEF
PSYCHOTIC DISORDER
• 50 % of the patient seems to be diagnosed with
schizophrenia later after.
• some experience significant psychological disability
and suggest the need for continued follow-up after
the treatment of brief psychotic disorder.
NURSING MANAGEMENT
ASSESSMENT
• Complete history and mental status
examination
• Lab investigation
• Present and past health status
• Physical functioning
• Nutritional assessment
Nursing Diagnosis
1) Disturbed though process related Inability
to trust, panic anxiety evidenced by
Delusional thinking or extreme
suspiciousness of others.
NURSING INTERVENTION
1. Convey acceptance of client’s need for the false
belief but indicate that you do not share the belief.
2. Do not argue or deny the belief.
3. Reinforce and focus on reality. Talk about real
events and real people.
NURSING INTERVENTION
4. If client is highly suspicious, the following
interventions may be helpful:
a. Use same staff as much as possible.
b. Avoid physical contact
c. Avoid laughing, whispering, or talking
d. Provide canned food if possible or tell patient to
serve by themselves .
Nursing Diagnosis
2) Disturbed sensory perception
Auditory/Visual related biochemical
alteration evidenced by Inappropriate
responses , hallucination , disorientation
etc.
NURSING INTERVENTION
1. Observe client for signs of hallucinations (listening
pose, laughing or talking to self).
2. Avoid touching the client without warning him or her
that you are about to do so.
3. An attitude of acceptance will encourage the client to
share the content of the hallucination with you.
NURSING INTERVENTION
4. Do not reinforce the hallucination. Use “the voices”
instead of words like “they” that imply validation. Let
client know that you do not share the perception.
5. Try to distract the client from the hallucination.
Listening to the radio or watching television helps
distract some clients from attention to the voices.
Nursing Diagnosis
3) Risk for violence: self-directed or other-
directed related to extreme suspiciousness,
command Hallucinations evidenced by self-
destructive behavior or active aggressive
suicidal acts.
NURSING INTERVENTION
1. Maintain low level of stimuli in client’s environment
(low lighting, few people, simple decor, low noise
level).
2. Observe client’s behaviour frequently.
3. Remove all dangerous objects from client’s
environment.
NURSING INTERVENTION
4.Offer empathetic response to the client’s feelings.
5 . Maintain a calm attitude toward the client. As the
client’s anxiety increases, offer some alternatives: to
participate in a physical activity (e.g., punching bag,
physical exercise).
NURSING INTERVENTION
6. Have sufficient staff available to indicate a show of
strength to the client if it becomes necessary.
7. If client is not calmed by “talking down” or by
medication, use of mechanical restraints may be
necessary.
8. If restraint is necessary, ensure to remove restraint at
a time while assessing the client’s response.
Nursing Diagnosis
4) Social isolation related to Inability to trust,
panic anxiety, delusional thinking evidenced
by Withdrawal, sad, expression of feelings
of rejection or of aloneness imposed by
others
NURSING INTERVENTION
1. Convey an accepting attitude by making brief,
frequent contacts.
2. Show unconditional positive regard.
3. Offer to be with client during group activities that he
or she finds frightening or difficult.
4. Give recognition and positive reinforcement for
client’s voluntary interactions with others.
Nursing Diagnosis
5) Impaired verbal communication related to:
panic anxiety, unrealistic thinking evidenced
by: loose association of ideas, poor eye
contact, delusional thinking.
NURSING INTERVENTION
1. Maintain staff assignments as consistently as
possible.
2. Orient client to reality as required. Call the
client by name
3. Explanations must be provided at the client’s
level of comprehension.
4. Involve patient in group activities.
Summary
QUESTIONS?
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