A Moment of Insanity

How Brief Reactive Psychosis can turn a silent lamb into a menacing wolf

By LUCIO C VICTOR JR.  

Maria did not know what got into her when she drove a knife repeatedly into her husband’s abdomen. Her husband survived the episode, but he could not fathom how getting home 15 minutes later than promised would warrant such punishment. Apparently, Maria was reaching the end of her rope with her husband’s repeated philandering. When her husband broke his promise to come home before midnight one night, Maria’s thoughts went everywhere. She thought her husband was in another one of his escapades or was simply being irritating and taking her for granted—again.

The Real McCoy

     It is commonplace nowadays to hear news of a seemingly normal person going into a sudden burst of laughter, tears, or murderous rage and later return to previous mental state. Individuals committing crimes with devastating passion and later claiming innocence. But what can push a person into going berserk and later revert to normalcy?

     Dr. A. Efren B. Reyes, psychiatrist and training officer of the National Center for Mental Health (NCMH) offers an explanation.

     He says there are instances wherein normal people with no family history of psychotic disorders or emotional disturbance can suddenly lose all sense of reality momentarily, but later on regain their normal mental state. Called Brief Reactive Psychosis (BRP), these instances belong to the much larger classification of Brief Psychotic Disorders (BPD) and can last anywhere from a few hours to two weeks.

     The Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) says the main criterion for the condition is that it last at least 24 hours but less than one month. But in the clinical setting, a few hours to two weeks duration is mostly observed. If the symptoms last longer than one month, BRP is no longer considered. The differential diagnosis would be a low level of depressive illness or personality disorder, if not a pattern of drug or alcohol abuse.

     “The characteristic of the process are very florid psychiatric symptoms,” says Dr. Reyes. These can be delusions, hallucinations, disorganized speech and thoughts, and grossly disorganized catatonic behavior including the tendency for violence. There are also no established mood disorders with psychotic features, schizoaffective disorder or schizophrenia. Likewise, the symptoms should not be due to the effects of alcohol, substance, or drug use. Usually after the person has regained his mental capacity, he may have already forgotten the psychotic episode. And with the release of whatever aggressive feelings or painful affectations, the person may return to normal and manifest remorse and guilt.

The Breakdown

     Dr. Karl Jaspers in 1913 described many features of BRP, putting emphasis on the presence of an identifiable and extremely traumatic stressor that plays an important role in the development of BRP. This stressor, says Dr. Reyes, is psychosocial in nature but is not solely responsible for the development of BRP regardless of its gravity. Every individual has a coping capability to deal with the stressor.  “If the stressor is too much for the person’s coping strategies, and the defense mechanisms of the person are overwhelmed, then the individual can break down [and develop a BRP].”

     Dr. Reyes explains that the precipitating stressors are major life events that can cause significant emotional upset. However, the severity of the events must be weighed in relation to the person’s life. People who have experienced major disasters like losing their homes or loved ones in calamities or going through major cultural changes like migrating may be prone to suffer from BRP. Dr. Reyes cites other studies showing that the stressor as a series of modestly stressful events and the BRP episode as a response to the stressor when coping strategies and defense mechanisms previously employed break down.

     People respond to everyday stressors in a variety of ways. Normal, healthy people are armed with a wide repertoire of defense and coping mechanisms to deal with virtually any kind of stress. A pattern of healthy defenses can come in many forms like denial, rationalization, or suppression.  “But there is a limit [to] how far people can make use these coping mechanisms,” warns Dr. Reyes. “So the psychotic process would come in as a form of pathologic defense mechanism when all the other forms of defense mechanisms have been exhausted and when rational and logical thoughts have been overwhelmed and impaired.”

     Alcoholism, drug abuse or dependence, talking to family, friends or clergy about problems, and seeking professional help are forms of coping mechanisms. But when these are not sufficient to buffer the stressor, or other coping strategies have not been utilized, then a psychotic episode may take the place of a coping mechanism.

A Murderous Mind?

"When you lose the mens rea principle and with it, your will, volition, and the capacity to distinguish right from wrong then you have no liability for the crime you have committed" -- Dr. Reyes

     Although not everyone who goes through a BRP manifests violent or criminal behavior, many cases involving BRP have seen action in the courtroom. The charges can be anything from disturbance of the peace, destruction of property to homicide or manslaughter. Whatever the case, Dr. Reyes says: “When you lose the mens rea principle and with it, your will, volition, and the capacity to distinguish right from wrong then you have no liability for the crime you have committed.”

     In these situations the psychiatrist may be called as an expert witness to testify as to the accused’s state of mind. The psychiatrist will have to prove that at the time of the commission of the crime, the patient’s logical and rational thinking was taken over by the innate aggressive drives and need for release. However, Dr. Reyes points out that compounding factors like a secondary gain may actually put these cases in a different light.

     If cases simply involved a basic emotional need like jealousy being a driving factor for a woman to hurt her philandering husband, then it would not be too difficult to prove such patient innocent due to the psychotic condition. However, with secondary gain such as the acquisition of money, goods, or objects with the death of the victim then the whole case may take another convoluted turn. It would then be reckless to say that the crime was committed out of pure psychosis because the premeditation to kill or hurt should be negated first. Says Dr. Reyes: “Cases where there is a secondary gain are usually premeditated.”

The Long Road Home

     When a person has undergone BRP, acute or residual symptoms would last for a few days. These could be anything from depression to suicidal ideation, which have to be properly addressed. In any case, Dr. Reyes says the prognosis of persons who have suffered a BRP is good since there is a less than three percent chance for them to progress into frank psychosis and there is hardly any chance for recurrence in more than 96 percent of BRP sufferers.

     Therapy for BRP is centered on keeping the patient from inflicting harm on himself and others, immediate control of the psychotic episode, and utilizing pharmacotherapy and psychotherapy. Hospitalization is necessary not only for his protection, but that of the people around him. A quiet and structured atmosphere is suggested to enable the patient to regain their sense of reality faster.  Seclusion, use of restraints, and close monitoring are likewise essential.

     Antipsychotic agents are very useful in dealing with the psychotic manifestations. Most commonly used are benzodiazepines in conjunction with anticholinergics to control extrapyramindal symptoms. Sedative-hypnotics and newer antipsychotic medication are also available.

     Once the psychotic condition has subsided, helping the patient deal with the BRP and cope with the different stressors will prove useful. Psychotherapy individually or together with the patient’s immediate family helps in this regard. Therapy should address such issues as the patient’s loss of self-esteem and confidence because of the stigma attached to people who have experienced a psychotic episode.

     Dr. Reyes feels that it is unfair to tag BRP sufferers as mentally disturbed for the rest of their live when most persons who have gone through a BRP do not progress to another form of psychotic disturbance or have recurrence of BRP. In some form of mood disorder like depression, which develops due to coping difficulties, appropriate therapeutic measures have to be taken.