Other Psychotic Disorders

Other Psychotic Disorders
University of Massachusetts, Amherst
Nursing 690
Donna Petko, MSN, RN, APN, FNP-BC
March 30, 2015

Objective
• prevalence
• diagnostic criteria
• development
• functional
consequences
• cultural issues
• measurements
• diagnostic features
• specifiers
• severity levels
• differential diagnoses
• ICD-10 coding
To increase understanding of Other Psychotic Disorders
listed in the DSM-5 (APA, 2013):

Other Psychotic Disorders
Consist of the following (APA, 2013):
• Brief Psychotic Disorder
• Substance/Medication-Induced Psychotic Disorder
• Psychotic Disorder d/t Another Medical Condition

Brief Psychotic Disorder
Prevalence (APA, 2013):
• may account for 9% of cases of first-onset psychosis (US)
• more common in developing countries
• more common in females than males: 2 to 1

Brief Psychotic Disorder cont.
Diagnostic Criteria (APA, 2013):
• Presence of 1 or more of the following:
• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behaviors
• Duration ≥1 day to < 1 month
• Not better explained by:
• Major depressive, bipolar disorder with psychotic features
• Another psychotic disorder (schizophrenia or catatonia)
• Not attributable to substance use, another medical condition

Development and course (APA, 2013):
• May appear in adolescence/early adulthood
• Onset can occur throughout lifespan
• Average age of onset mid 30s
• Diagnosis requires full remission of all symptoms and
eventual return to premorbid level of functioning within
1 month of onset

Functional Consequences (APA, 2013):
• Despite high rates of relapse, outcome is excellent in
social functioning and symptomatology, for most
individuals
Cultural Issues (APA, 2013):
• Cultural and religious backgrounds must be considered
• E.g., some individuals report hearing voices in religious
ceremonies but these do not persist and are not perceived as
abnormal by the individual’s community

Measurements:
• Clinician-Rated Dimensions of Psychosis Symptom
Severity (APA, 2013)
• 5-point scale
• Covers 8 domains:
• delusions, hallucinations, disorganized speech, abnormal
psychomotor behavior, negative symptoms, impaired cognition,
depression, and mania
• Useful in treatment planning, prognostic decision-making, and
research on pathophysiological mechanisms
• Use at regular intervals; the higher the score, the worse the
functioning

Diagnostic Features (APA, 2013):
• Sudden onset of at least one positive symptom:
delusions, hallucinations, disorganized speech, or grossly
abnormal psychomotor behavior, including catatonia
• ≥ 1 day to < 1 month
Specifiers:
• with marked stressors
• without marked stressors
• with postpartum onset
• with catatonia

Severity Levels (APA, 2013):
• Severity is rated by quantitative assessment:
• Clinician-Rated Dimensions of Psychosis Symptom Severity
Differential Diagnoses (APA, 2013):
• Other medical conditions
• Substance-related disorders
• Depressive/bipolar disorders
• Other psychotic disorders
• Malingering/factitious disorders
• Personality disorders

ICD-10 Coding (APA, 2013):
• 298.8 (F23)

Substance/Medication-Induced
Psychotic Disorder
• Unknown in general population
• Between 7-25% of individuals presenting with first
episode in various settings are reported to have SMIPD

Psychotic Disorder cont.
Diagnostic Criteria (APA, 2013):
• Presence of 1 or both of the following:
• Delusions
• Hallucinations
• Evidence from Hx, PE, or labs of both 1 & 2:
• Symptoms in criterion A developed during/soon after
substance/medication intoxication, exposure or withdrawal
• Involved substance/medication capable of producing symptoms
in criterion A

Diagnostic Criteria cont. (APA, 2013):
The disturbance:
• not better explained by other psychotic disorder that is
not substance/medication-induced
• does not occur exclusively during the course of a
delirium
• causes clinically significant distress/impairment in social,
occupational, or other areas of functioning

• Onset may vary based on substance
• E.g., smoking a high dose of cocaine may induce psychosis within
minutes
• Substance/medication-induced psychotic disorder may
persist even when offending agent is removed
• E.g., amphetamines may induce psychotic states lasting weeks or
longer
• Polypharmacy may cause psychosis

• Typically severely disabling and seen more in ER
• Disability is typically self-limited and resolves when
offending agent is removed
Cultural Issues (ISMP, 2003):
• Some cultures/races respond differently to medications
based on genetic differences
• Practices such as fasting may alter medication levels

Measurements:
• 5-point scale
• 8 domains:
functioning

• Prominent delusions/hallucinations (Criterion A)
• d/t physiological effects of substance/medication
• must be evidence in Hx, PE, or labs of both:
• symptoms in criterion A developed during or soon after use
• involved substance/medication is capable of producing symptoms in
criterion A
• Not better explained by a psychotic disorder that is not
substance/medication-induced
• Does not occur exclusively during course of a delirium
• Causes clinically significant distress/impairment

Specifiers (APA, 2013):
• with onset during intoxication
• with onset during withdrawal
• Substance intoxication or substance withdrawal
• Primary psychotic disorder
• Psychotic disorder due to another medical condition

ICD-10 (APA, 2013, p. 111):

Psychotic Disorder d/t Another
Medical Condition
• Estimated lifetime prevalence 0.21-0.54%
• Ages 65+ have > prevalence 0.74%
• More common in untreated endocrine, metabolic,
autoimmune disorders; temporal lobe epilepsy
• Among older individuals, may be higher in females, but
unclear

Medical Condition cont.
Diagnostic Criteria (APA, 2013:
• Prominent hallucinations or delusions
• Evidence from Hx, PE, or labs indicating direct
pathophysiological consequence of another medical
condition
• The disturbance:
• not better explained by another mental disorder
• does not occur exclusively during course of delirium
• causes clinically significant distress/impairment in social,

• May be a single transient state or recurrent
• Treatment of underlying medical condition usually
rectifies, but not always:
• E.g., psychotic symptoms may persist after brain injury
• Condition may be long term in chronic conditions like MS
• Older adults have higher prevalence of the disorder
• d/t increasing medical burden, advanced age, cumulative effects
of age-related processes
• Younger age groups more affected by epilepsy, head
trauma, autoimmune, and neoplastic events

• Typically severe due to another medical condition
• Varies considerably by the type of condition
• Likely to improve with successful resolution of condition
Cultural Issues (ISMP, 2003):
• Some cultures/races respond differently to medications
based on genetic differences
• Practices such as fasting may alter medication levels
• Individuals may not take medications to treat medical
conditions d/t cultural norms/expectations

Measurements:
• 5-point scale
• Covers 8 domains:
functioning

• Prominent delusions/hallucinations
• Evidence from Hx, PE, labs that disturbance is result of
pathophysiological consequence of another medical
condition
• Not better explained by another mental disorder
• Doe not occur exclusively during course of delirium
• Causes clinically significant stress or impairment in social,

Specifiers (APA, 2013):
• Based on predominant symptom:
• With delusions
• With hallucinations
• Delirium
• Substance/medication-induced psychotic disorder
• Psychotic disorder

ICD-10 (APA, 2013):
• Code based on predominant symptom:
• 293.81 (F06.2) with delusions
• 293.82 (F06.0) with hallucinations
• Coding note:
• Include the name of the other medical condition in the name of
the mental disorder; the other medical condition should be
coded and listed separately immediately before the psychotic
disorder

Case Study
A 50-year-old man, nonalcoholic, with uncontrolled diabetes mellitus
and hypertension was admitted to the hospital with history of high-
grade fever and cough with scanty expectoration, of 2 days’ duration;
and burning micturition and ulcer over left foot. Clinically the patient
was febrile and diagnosed to have community-acquired left lower lobe
pneumonia with urinary tract infection and cellulites of left foot.
Investigations revealed Hb was 10.4 g/dl, total leukocyte count was
9,500 cells/mm3 with neutrophilia, E.S.R. was 60 mm at one hour,
random blood sugar was 250 mg/dl, blood urea was 25 mg/dl, serum
creatinine was 1.3 mg/dl with normal creatinine clearance, and serum
electrolytes were within normal limits. Peripheral smear for malarial
parasite was negative. Urine microscopy showed 15-18 pus cells/high
power field. However, urine culture was sterile and urine ketone
bodies were negative. Blood and sputum culture did not grow any
organisms (Moorthy, Raghavendra, & Venkatarathnamma, 2008, para.
3).

Case Study cont.
• Final diagnosis of type 2 diabetes mellitus with hypertension with
community-acquired pneumonia and urinary tract infection and
cellulites of left foot with ulcer was made. In view of multiple
infections, intravenous amoxicillin (1 g) and clavulanic acid (200 mg)
every 8th hour were started and continued for 10 days. His general
condition improved, and repeat chest x-ray showed resolution of
pneumonia with better lung aeration. Cellulitis and urinary tract
infection also showed improvement, and blood sugar and
hypertension were under control. After 10 days, oral levofloxacin
(500 mg/day) was started as a sequential therapy in view of
persisting foot ulcer. On the third day of therapy, he became restless
and speech became irrelevant and incoherent. Later he became
abusive, violent and experienced visual hallucinations of people in
his hospital room. Gradually his confusion worsened and he became
more violent in nature. He slept very little (Moorthy et al., 2008,
para. 3).

What do you think is causing the
psychosis?

Case Study cont.
Psychiatric evaluation was suggestive of acute psychosis. The diagnosis
of acute psychosis cannot be attributed to the clinical diagnosis as the
patient had good improvement following 10 days of intravenous
amoxicillin and clavulanic acid therapy. Other conditions like
hypoglycemia, dyselectrolytemia, diabetic ketoacidosis, and meningitis
were ruled out. Other drugs the patient was receiving were insulin,
enalapril, atorvastatin, which are not known to result in such
psychosis. So the likely possibility of levofloxacin-induced acute
psychosis was considered and levofloxacin was stopped. Within 48 h of
stopping levofloxacin, repeat psychiatric evaluation revealed him to be
alert and oriented with no further hallucinations. His speech was
normal in flow and content, and his concentration and recall were
intact. He did not require any antipsychotic medications (Moorthy et
al., 2008, para. 3).

References
American Psychiatric Association. (2013). Clinician-rated
dimensions of psychosis symptom severity. Retrieved
from http://www.psychiatry.org /File%20Library/
Practice/DSM/DSM-5/ClinicianRatedDimensionsOf
PsychosisSymptomSeverity.pdf
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.).
Washington D.C.: Author.
Institute for Safe Medical Practices. (2003). Cultural diversity and
medication safety. Retrieved from http://www.ismp.org/
newsletters/acutecare/articles/20030904.asp

References cont.
Moorthy, M. Raghavendra, N, & Venkatarathnamma, P.N. (2008).
Levofloxacin-induced acute psychosis. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2745871

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Editor's Notes