INTRODUCTION
Brief psychotic disorder incorporates disorders occurring in response to markedly stressful events and is defined as an illness lasting from 1 day to 1 month followed by full return to the premorbid level of functioning (American Psychiatric Association, 1994). Patients with brief psychotic disorder show at least one of the following clinical symptoms indicative of impaired reality perception: delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. When symptoms occur shortly after and apparently in response to events that, singly or together, would be markedly stressful to almost anyone under similar circumstances in that person's culture, then the further designation of “brief psychotic disorder with marked stressors” is appropriate (Kaplan & Sadock, 1995).
Because of differences in diagnostic criteria and methodological differences, the prevalence, incidence and etiology of brief psychotic disorder varies in different studies (Jorgensen, 1985; Beighley et al., 1992). It is most frequently reported in young adults, and is reported to be a rare condition (annual incidence is 1.43 per 100,000; Beighley et al., 1992).
Psychological distresses in terminally ill cancer patients are recognized. This is illustrated by a report that 60% of terminally ill cancer patients have a psychiatric diagnosis (Minagawa et al., 1996; Akechi et al., 2004). However, only one case of brief psychotic disorder in terminally ill cancer patients has been reported to date (Onishi et al., 2003). Therefore, little is known about brief psychotic disorders in terminally ill cancer patients, although having cancer is commonly perceived as a life-threatening, universally stressful event (Stiefel & Razavi, 1994).
In this communication, we report a terminally ill patient with stomach cancer who developed brief psychotic disorder after an event that, for the patient, symbolized deterioration of the general condition and death, even though the event was common, usually not markedly stressful to almost anyone, and is not generally life-threatening in medical settings.
CASE REPORT
A 77-year-old male had been diagnosed as having stomach cancer 2 years previously and had received gastrectomy. Recurrence of cancer was recognized and chemotherapy was performed. However, his conditions deteriorated and he was admitted to the palliative care unit.
Six weeks after admission to the palliative care unit, the patient developed nasal bleeding, which was soon stopped. However, tremor of the upper limb developed thereafter and he could not respond to questions promptly. When a physician in charge was called, the patient laid down on the bed, opening his eyes. Blood pressure was 136/76 mmHg. Neurological examinations demonstrated tremor in both upper limbs. Laboratory data were unremarkable. On psychiatric examination, responses to verbal stimuli were very slow, but the patient could answer the question very slowly and he understood what was happening around him. He said to the nursing staff, “I have only a short time to live.”
The next day, psychiatric symptoms became apparent. He turned around on the bed and tried to get out of the bed at night. Because grossly disorganized and catatonic behaviors were prominent, the patient was given 5 mg of intravenous haloperidol. On the following day, his grossly disorganized and catatonic behavior disappeared and he returned to the previous level of functioning. Medication was discontinued without recurrence of symptoms.
His wife explained that during hospitalization as an in-patient he had seen a patient whose general condition deteriorated and then died after an episode of nasal bleeding. Thereafter, he believed that nasal bleeding was a sign of deterioration in general condition leading to death and became afraid of nasal bleeding.
He did not recall well what happened during the psychotic period but said that nasal bleeding was a dreadful experience for him and said that he thought he might die when he developed nasal bleeding. He also said that he had nasal bleeding and cutting of his forehead 2 weeks earlier and thereafter he had been afraid of dying.
His psychiatric features fulfilled the DSM-IV criteria for brief psychotic disorder with marked stressors (code no. 298.8). One month later, he died.
MEDICAL HISTORY
The patient had worked as a patent lawyer, and he had no medical history of psychiatric illness or alcohol or drug abuse. He was normally cooperative in character and was kind to others.
DISCUSSION
The patient developed a brief psychotic disorder after nasal bleeding. The short interval between the nasal bleeding and the onset of the brief psychotic disorder also makes it seem unlikely that the brief psychotic disorder in this case occurred without stressors. His statements further confirmed that nasal bleeding was the stressor that caused the psychiatric symptoms. Nasal bleeding is common in medical settings and is usually not markedly stressful to almost anyone. However, in this patient, nasal bleeding was a stressful event that induced brief psychotic disorder.
The patient had seen another patient whose condition deteriorated after nasal bleeding, leading to death. Thereafter, the patient thought that nasal bleeding was a dreadful event that would lead to death and became afraid of nasal bleeding. We speculated that when he saw the patient whose general condition deteriorated after nasal bleeding, nasal bleeding became a symbol of impending death in the patients receiving palliative care.
In the differential diagnosis of brief psychotic disorder, delirium due to cerebrovascular attack was considered. However, close psychiatric examination demonstrated that the patient did not show a decreased level of consciousness, although he showed catatonic stupor.
In considering why the patient developed a brief psychotic disorder, preexisting psychopathology and/or defense mechanisms are also thought to be predisposing factors (Kaplan & Sadock, 1995).
In this patient, there were no past medical history of psychiatric illness recognized in the psychiatric interview. Therefore, a possible explanation is defense mechanism. We speculated that as a defense mechanism the patient used denial, which is frequently applied when facing major stressors (Hughes, 1986; Thomas & Marks, 1995). However, the patient's own nasal bleeding, which had already come to symbolize death, made him intensely aware of his own fragile condition, breaking down his denial and inducing psychotic symptoms. Nasal bleeding and cutting the forehead 2 weeks before might have predisposed the patient to the onset of brief psychotic disorder. The number of stressful life events during a period of stress is related to developing psychiatric symptoms (Tjemsland et al., 1998).
In our pervious report (Onishi et al., 2003), we speculated that brief psychotic disorder might be a defense mechanism that emerges to protect the patient from the most destructive effects of depression, as is also postulated in mania (Amberas, 1979). In this case, a similar mechanism might be considered. Brief psychotic disorder appeared as a temporary shield to help make the traumatic events less emotionally painful.
Nasal bleeding is not uncommon, usually not markedly stressful to almost anyone, and is not generally life-threatening in medical settings. In this case, we could not detect the fear of the patient when he developed nasal bleeding for the first time. We should keep in mind that an event or symptom that often occurs in a palliative care unit and is not severe enough to affect the general condition may still symbolize impending death for the patient and might evoke fear, becoming a stressor that breaks the defense mechanism usually employed by the patient. We must communicate with patients and detect the psychological distress that patients have.
ACKNOWLEDGMENTS
We would like to thank the patient and families for giving us kind suggestions.
