Approach
Brief psychotic disorder (BPD) cannot be officially diagnosed until the person has returned to pre-morbid functioning after ≤1 month of exhibiting at least 1 positive psychotic symptom. Nevertheless, a thorough evaluation and differential diagnosis need to take place at the time of symptom onset. Target symptoms should be treated.
Importantly, the International Classification of Diseases (ICD)-11 criteria for acute and transient psychotic disorders (ATPD) vary slightly from the BPD criterion of a duration of <1 month in DSM-5-TR.[20] Some sub-categories of ATPD may have a criterion of 3 months of symptoms that differentiate from persistent psychotic symptoms.[17] This led to suggestions that the criterion of 1 month's duration for BPD may be too narrow.[21]
Diagnosis
BPD can only be diagnosed after the individual has recovered within 1 month of developing the psychotic symptom(s). Otherwise, it is difficult to determine at presentation whether the disturbance is an early form of schizophrenia or delusional disorder or whether it is a mood disorder (e.g., major depressive disorder with psychotic features). Therefore, the appropriate diagnosis to give before the symptoms have remitted is 'other specified psychotic disorder' or 'unspecified psychotic disorder'.[1][22] Delusions associated with BPD are generally highly unstable and have rapidly changing topics compared with those in schizophrenia. Additionally, changing moods are more common in BPD than in schizophrenia.[23]
Obtaining collateral information from family members and friends may be helpful in establishing the timeline of the psychotic episode. It may be necessary in complex cases to refer patients to a psychiatrist or psychiatric clinical team for further evaluation and treatment options.
Patients should also be assessed for risk factors for suicide as well as any homicidal impulses. The most common risk factors for suicide in BPD are a higher education level and impulsivity, measured as the negative side of 'conscientiousness' on the NEO Five-Factor Inventory. This inventory is designed to give a valid and reliable measure of the five domains of adult personality: Extroversion, Agreeableness, Conscientiousness, Neuroticism, and Openness to Experience.[24] The most common risk factors for suicide in postnatal women are a history of psychiatric disorders and family history of psychiatric disorders.[25]
Differential diagnosis
Any person presenting for the first time with psychotic symptoms requires a comprehensive assessment and broad differential diagnosis consideration. In addition to the psychiatric disorders, psychosis can be associated with a wide array of neurological and general medical conditions. Seizure disorder, syphilis, substance abuse, sarcoidosis, lung cancer, thyrotoxicosis, and head trauma have been found as the cause in about 6% of 268 patients presenting with first-time psychotic symptoms.[26] As people generally present with a short history of psychopathology and have problems recalling historical information accurately, the most important clinical data for differential diagnosis are often not readily available. Substance abuse, co-morbid medical illnesses, and psychosocial factors often confound the case assessment.
Medical evaluation
All patients presenting with psychotic symptoms should have a thorough medical evaluation, including a review of all systems and a physical examination that includes a neurological evaluation. According to the American Psychiatric Association Practice Guidelines, patients should receive laboratory assessments including electrolytes, urea, creatinine, glucose, liver function profile, thyroid function tests, syphilis serology, serum pregnancy test, urinalysis, weight/height measurement for BMI assessment, and urine toxicology.[27] Laboratory tests are needed to rule out other underlying medical illnesses and to create a baseline of medical function prior to treatment. Additionally, an ECG is recommended, particularly in people with cardiac risk factors or a family history of cardiac conduction defects. Neuroimaging techniques (e.g., brain MRI or CT scan) do not have the sensitivity or specificity to be applied in the diagnosis of psychotic disorders. They may be used as a secondary assessment to exclude neurological lesions. This is indicated if neurological signs and symptoms such as asymmetry, weakness, or altered sensorium are present.
BMI should also be assessed, as selecting antipsychotic treatment may depend on cardiac risk factors. Certain antipsychotics can cause weight gain and other metabolic adverse effects.
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