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Acute and Transient

Psychotic Disorders
Presented By : Dr. Karrar
Husain
Moderator : Dr. M. Amir
Usmani

HISTORICAL BACKGROUND

In late 19th century, Kraepelin divided functional psychosis


into manicdepressive psychosis and dementia praecox.

However after Kraepelins dichotomous classification of


functional psychosis, many authors kept on showing their
dissatisfaction with such a classification and kept on
describing an acute psychotic illness which was different
from manic-depressive psychosis and dementia praecox.

There were several reports, from several different parts of


the world, of occurrence of certain psychotic states other
than schizophrenia and MDP described by different names.
France
: Bouffee Delirante
Germany
: Motility Psychosis
Cycloid Psychosis
Reactive Psychosis
Scandinavia : Psychogenic psychosis
Schizophreniform Psychosis

America : Remitting Schizophrenia


Good Prognosis Schizophrenia
Hysterical Psychosis
Acute Schizoaffective Psychosis
Japan : Atypical Psychosis
Africa : Acute Primitive Psychosis
Acute Paranoid Psychosis
Transient Psychosis
West Indies : Acute Psychotic Reaction
India : Acute Psychoses of Uncertain Origin
Hysterical Psychosis
Acute Psychosis without Antecedent Stress
Acute Schizophrenic Episode

Amentiaa psychotic disorder with remitting course and


favorable outcome, originally described by Theodor
Meynert (1833 to 1898).

A psychotic illness with acute onset characterized by


confusion and perplexity; agitation; rapidly changing, vivid
hallucinations and delusions; anxiety; and apprehension.

An association with physical illness and exhaustion was


noted in some patients. Full recovery occurs in a few weeks
or months

Cycloid psychosis
A psychotic disorder with acute onset and good prognosis
but frequent recurrences, characterized by confusion,
mood-incongruent delusions, hallucinations, overwhelming
anxiety, deep feelings of happiness or ecstasy, motility
disturbances of akinetic or hyperkinetic type, a particular
concern with death, mood swings, and rapid change in
symptoms within an episode.
Two variants : confusional - contrasting phases of confused
excitement and stupor
: motility psychosis - contrasting phases
of hyperkinesis and akinesis.

A third variant, anxiety-elation psychosis, was introduced


by Karl Leonhard (19041988).

The diagnosis of cycloid psychosis is still used by German,


Scandinavian, and other European psychiatrists and was
influential for the formulation of acute and transient
psychotic disorders in ICD-10.

Bouffe dlirante
A psychotic disorder with acute onset without previous
psychiatric history. The episode remits completely with no
residual symptoms.

The episodes are characterized by delusions, hallucinations,


depersonalization and derealization, confusion, mood
change, and changing symptoms during the course of
episode.

Episodes are not due to organic or substance use.

The diagnosis is still used by French-speaking clinicians in


Europe, West Africa, and the Caribbean.

The concept of bouffe dlirante was influential in


formulation of the ICD-10 acute and transient psychotic
disorders.

Due to its common occurrence in Africa and the Caribbean,


it is also categorized as a culture-bound syndrome in the
DSM-IV-TR.

Psychogenic or reactive psychosis


A psychotic disorder with acute onset after external stress.

Compared with schizophrenia, the onset is more likely to be


acute and later in life. Premorbid adjustment tends to be
better than in schizophrenia. Prognosis is better than
schizophrenia.

There are more affective and confusional symptoms and


fewer bizarre symptoms, and there is less family history of
schizophrenia.

Diagnoses of psychogenic or reactive psychoses were


popular among Scandinavian psychiatrists.

The reactive or psychogenic psychosis was especially


influential in the formulation of the third edition of the DSM
(DSM-III) brief reactive psychosis diagnosis, which, in DSMIV and DSM-IV-TR, was replaced by brief psychotic disorder.

The change was partly motivated by the observation that


many cases of brief psychosis are not precipitated by a
marked stressor and, hence, are not reactive.

Nonetheless, the DSM-IV and DSM-IV-TR distinguish


between brief psychotic disorder with and without marked
stressors and indicate that brief psychotic disorder with
marked stressor is equivalent to the brief reactive
psychosis.

Schizophreniform psychosis or disorder

Gabriel Langfeldt (19371966)

A condition with sudden onset after an identifiable


precipitating factor and good outcome in an individual with
well-adjusted premorbid personality.

The patients often present disturbance of mood and clouding


of consciousness.

The term, but not the concept, was adopted by the DSM-III as
a nonaffective psychotic syndrome with schizophrenic
symptoms but a duration of less than 6 mos.

The concept of schizophreniform in the latter sense was


perpetuated in the later editions of the DSM.

Oneirophrenia

Ladislas von Meduna (18961964) in 1939

A syndrome characterized by acute onset of confusion,


nightmare or dream-like quality of all perceptions, extreme
fear and anxiety, delusions, and visual hallucinations.

The prognosis is generally good with full recovery.

Meduna proposed an endocrinological explanation for the


syndrome.

Hysterical psychosis

Marc Hollander and Steven Hirsch in 1964.

A psychotic episode with sudden and dramatic onset


related to a profoundly upsetting event in the context of a
hysterical personality.

Symptoms
include
hallucinations,
depersonalization, and disorganized behavior.

The episode seldom lasts longer than 13 wks.

delusions,


o
o
o
o
o
o
o
o

Common features of these historical entities were:


acute or sudden onset
unstable, variable, fluid and florid symptomatology
volatile polymorphic content
anxiety
fear or prominent affective symptoms
association with a clear precipitant
good premorbid adjustment
rapid and complete recovery
These syndromes did not fit into descriptions of affective or
schizophrenic disorders.

Historical development of the terminology of acute and transient


psychotic disorders

NOSOLOGICAL ISSUES

ATP is a new entrant to psychiatric nosology and ICD-10


concept of ATP has limited validity.

ATP came to be recognized as a disorder in ICD-10 in 1992.

The confirmatory evidence for the validity of ATP came


from the international initiatives in the form of WHO multicentered collaborative studies IPSS(International Pilot-study
of schizophrenia), DOSMeD (Determinants of Outcome of
Severe Mental Health Disorders) and CAP(Cross-cultural
study of Acute Psychosis)

IPSS (International Pilot-study of


schizophrenia (1968- 1970):

This was a nine-country study on schizophrenia

Aims:
(i) Whether schizophrenia existed in different parts of the world?
(ii) What were the common/differing clinical presentations?
(iii) What was the course and outcome among different cultures?

This study yielded certain findings that were important for


discussion on ATP:
(i) That a substantial proportion (26%) of schizophrenic subjects
had good outcome in the form of only one episode; and
(ii) That patients from developing countries had better outcome.

DOSMeD (Determinants of Outcome of Severe Mental


Health Disorders) (1978-1980):

WHO-led and -funded study done in 10 countries including


both the developing and developed countries.

Salient findings relevant to the discussion on ATP were:


There were a group of patients who had non-affective
psychosis and which remitted completely. These were
called as non-affective, acute, remitting psychosis (NARP).
Incidence of such NARP cases was 10 times higher in the
developing countries in the DOSMeD data.
These patients from developing countries exhibited a
benign course at 2 years follow-up.

1.

2.

CAP (Cross-cultural study of Acute Psychosis) (19801982):

This study was an off-shoot of DOSMeD study done in 14


centers and 7 countries.

Main objectives of this study were to know if there are:


(i) Acute psychotic states that can be defined, which are
descriptively different from schizophrenia and MDP? And
(ii) How are acute psychoses related to psychological and
physical stress?

1004 were included and data was analyzed.

Main findings showed that:

a)

41.2% patients showed schizophrenic symptoms, whereas


20% showed affective symptoms and 35.3% exhibited
other psychoses.

b)

41.7% showed stress close to onset.

c)

There was marked prevalence of patients from below


average socio-economic status.

d)

2/3 patients remained well with no relapse at 1 year.

e) Outcome in patients of acute psychosis with


schizophrenic symptom was similar to those with only
affective symptoms.

Taken together, the findings of these three major WHO


studies provided strong evidence in favour of occurrence of
acute onset psychotic disorders that were different from
both schizophrenia as well as MDP and formed the basis for
the ICD-10 category ATP (F23).

Sources of uncertainty in the nomenclature and nosology of


ATP lied in the issue of the relationship of ATPs with
schizophrenia and manic-depressive psychosis.

RELATIONSHIP OF ATPS WITH SCHIZOPHRENIA AND


AFFECTIVE DISORDERS
Quest to separate ATP from schizophrenia and MDP was
complicated as there were questions about the biological
distinctiveness of schizophrenias and MDP.

While the relationship of ATP to schizophrenia or MDP was


under question, the relationship between schizophrenia and
affective disorders, the two major psychotic conditions,
itself has been a matter of debate. It is becoming
increasingly clear that we cannot distinguish satisfactorily
between these two illnesses.

Rudin E. To inheritance and Neuentslehung of Dementia Praecox. Berlin:


Springer; 1916.
Powell A, Thomson N, Hall DJ, Wilson L. Parent-child concordance with respect
to sex and diagnosis in schizophrenia and manic-depressive psychosis. Br J
psychiatry 1973;123:653-8.
Abrams R, Taylor MA. The genetics of schizophrenia: A reassessment using
modern research criteria. Am J Psychiatry 1983;140:171-5.

Several studies on schizophreniform disorder, which is a


prototypical syndrome of ATP, have yielded varying results.
It has been considered to be closely related to affective
illness in some studies and to Schizophrenias in other group
of studies.
Fogelson DL, Cohen BM, Pope HG Jr. A study of DSM III schizophreniforM disorder.
Am J Psychiatry 1982;139:1281-5.
Taylor MA. Schizo-affective and allied disorders. In: Post RM, Ballenger JC,
editors. The Neurobiology of Manic-Depressive Illness. Williams and Wilkins:
Baltimore; 1984.

According to some family genetics study ATP is genetically


distinct from MDP and that there is genetic overlap
between ATP and schizophrenia and schizophrenic
symptoms.
Makanjuola RO, Adedapo SA. The DSM-III concepts of schizophrenic disorders and
schizophreniform disorder. Br J Psychiatry 1987;151:611-8.
Coryell W, Tsuang MT. DSM-III schizohreniform disorder:comparison with schizophrenia and
affective disorder. Arch Gen Psychiatry 1982;39:66-9.
Beiser M, Fleming JAE, Iacono WG, Lin T. Redefi ning the diagnosis of schizophreniform
disorder. Am J Psychiatry 1988;145:695-700.
Das SK, Malhotra S, Basu D. Family study of acute and transient psychoticdisorders:

Some studies also suggested that there is poor link


between shizophrenia and ATP.
Chavan BS & Kulhara P. A clinical study of reactive psychosis. Acta psychiatrica
Scand-inavica, 1988; 78: 712-715.

ATPD differs significantly from BSAD on various relevant


levels, such as gender (more female), age at onset (older),
development of the full symptomatology (more rapid),
duration of the symptomatology (shorter), acuteness of
onset (more acute), preceding stressful life-events (more
frequent) and longterm prognosis (better). It is concluded
that ATPD and BSAD are different nosological entities.

The relation of acute and transient psychotic disorder


(ICD-10 F23) to bipolar schizoaffective disorder, Journal of Psychiatric Research 36 (2002) 1651

ATP and DSM


ATPD do not have a designated place in the DSM.

Many of the cases of ICD-10 acute and transient psychotic


disorder would be categorized as schizophreniform disorder, brief
psychotic disorder, or psychotic disorder not otherwise specified
(NOS) in DSM.

Brief psychotic disorder (BPD), which is characterized by


presence of psychotic symptoms for less than 1 month duration,
is equivalent to the ICD-10 ATPD of less than one month duration.

Schizophreniform disorder, which requires minimum of 1 month


for active symptoms to appear after the first noticeable change
in behavior or functioning and allows a duration limit for the
symptoms to a maximum of 6 months.

psychotic disorder NOS includes presentations of psychotic


symptoms for which there is inadequate information to
make a specific diagnosis or symptoms that do not meet
full criteria for a specific psychotic disorder.

DSM-III and DSM-III-R had a diagnosis of the brief reactive


psychosis diagnosis, defined as a psychotic episode lasting
less than 1 month that was preceded by a marked stressor

EPIDEMIOLOGY and ETIOLOGY

Acute and transient psychotic


industrialized settings.

disorders

are

rare

in

Incidence was ten times higher in developing countries,


compared with industrialized countries

Two times higher in women, compared with men.

The annual incidence rates per 10,000 were 0.49 in men


and 0.88 in women in developing countries and 0.04 in men
and 0.10 in women in industrialized countries.

Age of onset is in the early to mid-20s in the developing


countries and in the mid-20s to mid-30s in industrialized
countries.
CTP 9 edition,
th

Susser E, Varma VK, Malhotra S, Conover S, Amador XF. Delineation of acute and
transient psychotic disorders in a developing country setting. BrJ Psychiatry
1995a;167:216-9.
Susser E, Fennig S, Jandorf L, Amador X, Bromet E. Epidemiology, diagnosis and course

The most common specific disorder in the group of ICD-10


is acute polymorphic psychotic disorder without symptoms
of schizophrenia(2/3 -1/2 cases).

ATP cases are reported to be more frequently belonging to


lower socio-economic status and rural areas.

Stress preceding the onset was seen in about 60% of ATP


patients and stress was more common among female.

History of non-specific, short-lasting fever.

A summer peak
Susser E, Varma VK, Malhotra S, Conover S, Amador XF. Delineation of acute and
transient psychotic disorders in a developing country setting. BrJ Psychiatry
1995a;167:216-9.
Susser E, Fennig S, Jandorf L, Amador X, Bromet E. Epidemiology, diagnosis and course
of
brief psychoses.
Am Misra
J Psychiatry
1995b;152:17438. PJ. Onset of acute psychotic
Malhotra
S, Varma VK,
AK, Das
S, Wig NN, Santosh
states in India: A study of sociodemographic, seasonal and biological factors. Acta

Little is known about the etiology of acute and transient


psychotic disorders.

Higher risk of acute transient psychotic disorders and a lower


risk of schizophrenia and mood disorders in the first-degree
relatives of probands, compared with schizophrenia probands.

It is hypothesized that ATP may be an environmentally induced


psychotic condition superimposed upon an underlying
vulnerability to psychosis.

Early-life brain insult may lead more often to schizophrenia


and later-life insult may lead to ATP. The severity of brain insult
where ATP may be associated with less severe brain insult.

CLINICAL DESCRIPTION

1.
2.

3.

Acute and transient psychotic disorders are characterized


by three typical features
suddenness of onset (within 2 weeks or less)
presence of typical syndromes with polymorphic (changing
and variable) or schizophrenic symptoms
presence of associated acute stress (stressful events such
as bereavement, job loss, psychological trauma, etc.).
The onset of the disorder is manifested by an obvious
change to an abnormal psychotic state. This is considered
to be abrupt when it occurs within 48 h or less. Abrupt
onset often indicates a better outcome. Full recovery occurs
within 3 months and often in a shorter time (a few days or
weeks).

The general (G) criteria


G1 There is acute onset of delusions, hallucinations,
incomprehensible or incoherent speech, or any combination
of these. The time interval between the first appearance of
any psychotic symptoms and the presentation of the fully
developed disorder should not exceed 2 weeks.
G2 If transient states of perplexity, misidentification, or
impairment of attention and concentration are present,
they do not fulfil the criteria for organically caused clouding
of consciousness as specified for F05, criterion A.
G3 The disorder does not satisfy the symptomatic criteria for
manic episode (F30), depressive episode (F32), or recurrent
depressive disorder (F33).

G4 There is insufficient evidence of recent psychoactive


substance use to satisfy the criteria for intoxication (F1x.0),
harmful use (F1x.1), dependence (F1x.2), or withdrawal
states (F1x.3 and F1x.4). The continued moderate and
largely unchanged use of alcohol or drugs in the amounts
or with the frequency to which the individual is accustomed
does not necessarily exclude the use of F23; this must be
decided by clinical judgement and the requirements of the
research project in question.
G5 There must be no organic mental disorder (F00F09) or
serious metabolic disturbances affecting the central
nervous system (this does not include childbirth). (This is
the most commonly used exclusion clause.)

A fifth character should be used to specify whether the


acute onset of the disorder is associated with acute stress
(occurring 2 weeks or less before evidence of first psychotic
symptoms):
F23.x0 without associated acute stress
F23.x1 with associated acute stress.
The change of the disorder from a non-psychotic to a
clearly psychotic state is further specified as either abrupt
(onset within 48 h) or acute (onset in more than 48 h but
less than 2 weeks).
Six categories of acute psychoses are presented in ICD-10

F23.0 Acute polymorphic psychotic disorder without


symptoms of schizophrenia
A. The general criteria for acute and transient psychotic
disorders (F23) must be met.
B. The symptomatology is rapidly changing in both type and
intensity from day to day or within the same day.
C. The presence of any type of either hallucinations or
delusions, for at least several hours, at any time since the
onset of the disorder.

D. Symptoms from at least two of the following categories,


occurring at the same time:
(1) Emotional turmoil, characterized by intense feelings of
happiness or ecstasy, or
overwhelming anxiety or
marked irritability;
(2) Perplexity, or misidentification of people or places;
(3) Increased or decreased motility, to a marked degree.
E. Any of the symptoms listed in Schizophrenia F20, G1.1
and G1.2 that are present, are only present for a minority of
the time since the onset, i.e. criterion B of F23.1 is not
fulfilled.
F . The total duration of the disorder does not exceed three
months.

F23.1 Acute polymorphic psychotic disorder with


symptoms of schizophrenia
A. Criteria A, B, C, and D of acute polymorphic psychotic
disorder (F23.0) must be met.
B. Some of the symptoms specified for schizophrenia (F20.0 F20.3) must have been present for the majority of the time
since the onset of the disorder, but not necessarily meeting
these criteria completely, i.e. at least any one of the
symptoms in F20, G1.1a to G1.2g.
C. The symptoms of schizophrenia in B above do not persist
for more than one month.

F23.2 Acute schizophrenia-like psychotic disorder


A. The general criteria for acute and transient psychotic
disorders (F23) must be met.
B. The criteria for schizophrenia (F20.0 - F20.3) are met, with
exception of the duration criterium.
C. The disorder does not meet the criteria B, C and D for
acute polymorphic psychotic disorder (F23.0).
D. The total duration of the disorder does not exceed one
month.

F23.3
Other
acute
predominantly
delusional
psychotic disorder
A. The general criteria for acute and transient psychotic
disorders (F23) must be met.
B.
Relatively stable delusions and/or hallucinations are
present, but they do not fulfil the symptomatic criteria for
schizophrenia (F20.0 - F20.3).
C.
The disorder does not meet the criteria for acute
polymorphic psychotic disorder (F23.0).
D. The total duration of the disorder does not exceed three
months.

F23.8 Other acute and transient psychotic disorders


Any other acute psychotic disorders that are
unclassifiable under any other category in F23 (such as
acute psychotic states in which definite delusions or
hallucinations occur but persist for only small proportions of
the time) should be coded here. States of undifferentiated
excitement should also be coded here if more detailed
information about the patient's mental state is not
available, provided that there is no evidence of an organic
cause.
F23.9 Acute and transient psychotic disorder,
unspecified

CULTURAL VARIANTS

Other forms of acute psychoses have been observed in


both traditional and developing countries, with high
prevalence in Asia, Africa, and Latin America.

Mezzisch and Lin have suggested that the whole group of


culture-bound syndromes should be classified as acute and
transient psychotic disorders, although this is justified only
for a very few such as amok (dissociative episode with
persecutory ideas and aggressive behaviour from
Malaysia), shin-byung (Korean dissociation and possession),
and spell (trance state in southern United States).

PATHOLOGY AND LABORATORY


EXAMINATION

There are no laboratory tests for acute and transient psychotic


disorders or brief psychotic disorder.

Auditory evoked potential studies in patients with cycloid


psychosis recorded P300 peaks over the left hemisphere,
similar to normal controls. In contrast, in patients with residual
schizophrenia, P300 peaks are located over the right
hemisphere. A higher P300 amplitude, compared with normal
controls, was noted in the cycloid psychosis patients,
suggesting a higher level of arousal.

Increased hemispheric blood flow during the psychotic episode


with return to normal after remission. There was a direct
relationship between the severity of symptoms and arousal,
and the degree of increase in blood flow, on the other.

Studies of schizophrenia have consistently shown evidence


of enlarged ventricles and dilated cerebral fissures, patients
with cycloid psychosis show little or no evidence of such
deficits

Hypothalamic-pituitary axis abnormalities in subsets of


female patients with recurrent atypical psychoses who are
more likely to experience episodes at the time of
menstruation and parturition

DIFFERENTIAL DIAGNOSIS

persistent delusional disorder: acute polymorphic psychotic


disorder without symptoms of schizophrenia is changed to a
diagnosis of persistent delusional disorder or other nonorganic
psychotic disorder if the illness lasts more than 3 months.

Schizophrenia: acute polymorphic psychotic disorder with


symptoms of schizophrenia is changed to ICD-10 schizophrenia
if the episode lasts more than 1 month.

mood disorders: Presence of a full mood syndrome that meets


the ICD-10 criteria for a manic or a depressive episode excludes
diagnosis of acute and transient psychotic disorders

Delirium: acute and transient psychotic disorders may be


associated with confusion and perplexity, making it difficult to
distinguish these disorders froms.

Drug or alcohol intoxication or withdrawal:


The
temporal relationship between the onset of psychosis and
the substance use may be helpful in differentiating a
substance-induced psychotic episode from a nonsubstance-induced one. Symptoms that persist for many
days after all traces of the substance are eliminated from
blood and urine support diagnoses of acute and transient
psychotic disorders or brief psychotic disorder.
Psychotic disorder due to medical illness:
Acute
psychotic episodes have been reported in a number of
medical conditions, including head trauma, cerebral anoxia,
epilepsy, and endocrinological disorders such as hyper- or
hypothyroidism

COURSE AND PROGNOSIS

Acute and transient psychotic disorders, by definition, have a


favorable early coursefull remission within 1 to 3 months.
CTP 9th edition

Duration of episode among non-affective acute psychoses had


a bimodal distribution with a point of rarity between the
cluster of symptoms where 80% patients had a duration less
than 28 weeks and 20% had a duration of more than 1 year.
Susser E, Varma VK, Malhotra S, Conover S, Amador XF. Delineation of acute and transient
psychotic disorders in a developing country setting. BrJ Psychiatry 1995a;167:216-9.
Susser E, Fennig S, Jandorf L, Amador X, Bromet E. Epidemiology,diagnosis and course of
brief psychoses. Am J Psychiatry 1995b;152:1743-8.

acute remitting psychosis had a modal distribution of 2-4


months which is larger than 1-3 months given in ICD-10 for
ATP.
Mojtabai R, Varma VK, Susser E. Duration of remitting psychoses with acute onset:
Implications for ICD-10. Br J Psychiatry 2000;176:576-80.

Findings of these studies provide data for typical duration of


ATP episodes which is upto 28 weeks and that is definitely
longer than was recognized in the ICD-10.

In a short-term (5 years) follow-up study of ICD-10 ATP


cases, it was found that majority (75%) had good outcome
in the form of complete recovery and no residual symptoms.

Female gender, presence of stress at onset and absence of


schizophrenic symptoms predicted good outcome.

In a long-term 20-year follow-up study of WHO CAP study up


to 82% patients had an excellent outcome with no relapse
and no residual symptoms.
Rozario A, Malhotra S, Basu D. Acute and Transient Psychotic disorders: A followup study. Unpublished MD thesis: PGIMER, Chandigarh; 1999.
Malhotra S. Twenty year follow up of WHO CAP study cohort. Unpublished 2000

In a one-year follow-up study of ATPD revealed a diagnostic


change in about half (48%) of the patients, most often to
either schizophrenia (15%) or affective disorder (28%).
Jorgensen P, Bennedsen B, Christensen J, et al. Acute and transient
psychotic disorder: A one-year follow up study. Acta Psychiatrica
Scandinavica, 1997;96: 150-154.

diagnostic change was seen from ATP to schizophrenia in


15% and from ATP to affective disorder in 28% cases.
Jorgensen A. Long term course of acute reactive paranoid psychosis. ActaPsychiatr
Scand 1995;71:30-7.
.

Diagnosis was stable in 87% cases


Jorgensen P, Bennedsen B, Christensen J, Hyllested A. Acute and transient
psychotic disorder: A one-year follow up study. Acta Psychiatr Scand
1997;96:150-4

Only a minority of first-hospitalized patients with ATPD


develop a severe social impairment after three to seven
years.

Patients with a severe social impairment at follow-up were


characterized by higher means in the total score of the
negative syndrome and the depressive syndrome at
discharge from the first hospitalization. Therefore,
persisting negative and/or depressive symptoms in
patients with ATPD may predict an unfavorable outcome in
terms
of and
a chronic
schizophrenic
disorder.
Course
outcome of first-admitted
patients with
acute and transient psychotic disorders (ICD-10:F
Focus on relapses and social adjustment; Eur Arch Psychiatry Clin Neurosci (2003) 253 : 209215

recurrence rate was found to be of 46.6% on 8-year followup study, and 35% on 5-year follow-up study.
Rozario A, Malhotra S, Basu D. Acute and Transient Psychotic disorders: A
follow-up study. Unpublished MD thesis: PGIMER, Chandigarh; 1999.
Malhotra S, Gupta N, Gill S. Recurrence in acute and transient psychosis:
Paper presented at the 13th World Congress of Psychiatry. Cairo,
Egypt;2005 Sept. 10-15

Recurrence in the DOSMeD cohort of ATP cases was 22% at


5 years and 11.76% at 12-year follow-up.
Susser E, Fennig S, Jandorf L, Amador X, Bromet E. Epidemiology, diagnosis
and course of brief psychoses. Am J Psychiatry 1995b;152:1743-8.
Mojtabai R, Varma VK, Susser E. Duration of remitting psychoses with acute
onset: Implications for ICD-10. Br J Psychiatry 2000;176:576-80.

International follow-up studies have shown that cultural


factors can influence the course and prognosis of acute
psychotic disorders.

In 1979, the World Health Organization compared the


course of schizophrenia (295), psychotic depression, mania,
and other psychoses in different cultures, using the ICD-9
criteria for the diagnoses. The outcome for the
schizophrenic group was better in emerging countries than
in the industrialized world

TREATMENT

Short-term treatment
Acute psychotic syndromes require early hospitalization in
either an inpatient psychiatric unit or a crisis centre. They
are psychiatric emergencies.
The decision to admit to hospital is taken in order to make a
careful clinical evaluation, to separate the patient from his
or her environment, to provide a reassuring setting, and to
prevent any suicidal or aggressive tendencies.

Antipsychotic drugs are prescribed. Some clinicians wait for


a day or two before starting neuroleptic therapy in order to
eliminate an organic cause and prescribe benzodiazepines
rather
than
neuroleptics.
More
often,
however,
antipsychotic treatment starts immediately.

The choice of antipsychotic drug depends on the clinician's


experience and the clinical features.

In cases of major anxiety or agitated behaviour, sedative


neuroleptics such as chlorpromazine, loxapine, or
levomepromazine are chosen, or zuclopenthixol acetate is
used as a short-acting depot antipsychotic.

Parenteral administration may be required if the patient


refuses oral medication, or if a rapid effect is required
because the patient is seriously uncooperative or is too
dangerously disturbed.

Predominance of delusions and hallucinations indicates a


high-potency antipsychotic agent as haloperidol or
flupenthixol.

In patients experiencing first-episode psychosis, olanzapine


had a risk-benefit profile significantly superior to that of
haloperidol.
Olanzapine Versus Haloperidol Treatment in First-Episode Psychosis(Am J
Psychiatry 1999; 156:7987)

Benzodiazepines may be given to potentiate the action of


the neuroleptics.

Sociotherapy
(occupational
or
intensive)
and
psychotherapy (realityadaptivesupportive) are indicated
depending on the state of the patient and his environment,
with individual, family or rehabilitation care.

Continuation treatment
The effectiveness of psychopharmacotherapy is usually
manifested in the first 6 weeks, with improved sleep,
regression of agitation, recovery from anxiety and delusion,
and finally disappearance of the psychotic features.

When there is no recovery or improvement either another


antipsychotic drug should be used or the dosage of the first
increased.

Worsening of the symptoms, serious side-effects, or a poor


response to pharmacotherapy are the main indications for
electroconvulsive therapy.

If mood disorders or cyclic episodes occur, treatment with


antidepressants, mood stabilizers (lithium or valproate), or
an anticonvulsant drug (carbamazepine) may be indicated.

Care must be taken to distinguish between a postneuroleptic depression and the development of a
(schizo)affective disorder.

Prevention of recurrence
The possibility that psychotic symptoms may re-emerge
has to be borne in mind during the first 2 years of followup. Low-dosage pharmacotherapy must be maintained for 1
or 2 years after recovery. During this long-term follow-up,
periodic assessment and effective clinical care with social
and psychological therapy are essential.
New Oxford Textbook of Psychiatry

Most guidelines recommended antipsychotic maintenance


treatment to be continued for at least 1 year.
Gaebel W, Weinmann S, Sartorius N, Rutz W, McIntyre JS. Schizophrenia practice
guidelines: international survey and comparison. Br J Psychiatry.
2005;187(3):248.

STATUS OF ATPD IN ICD-11

ICD-11 is currently scheduled for presentation to the World


Health Assembly, WHOs governing body, in 2015.

The Working Group on the Classification of Psychotic


Disorders (WGPD) is recommending that the diagnostic
focus be on its sudden onset, brief duration, and high
variability/fluctuation of psychotic and affective symptoms
(ie, polymorphic clinical presentation).

The WGPD is recommending that the subcategory F23.0


(Acute polymorphic psychotic disorder without symptoms of
schizophrenia) be retained as the clinical guideline for
ATPD, and the delusional subtype (F23.3) be incorporated
into the revised category Delusional disorder.

The WGPD is recommending that the present ICD-10


categories F 23.1 (Acute polymorphic psychotic disorder
with symptoms of schizophrenia) and F 23.2 (Acute
schizophrenia-like psychotic disorder) be collapsed into
Unspecified primary psychotic disorders if duration of
disorder is less than 4 weeks.

If duration is more than 4 weeks, schizophrenia should be


diagnosed.

ATPD in ICD-11 as in ICD-10 allows up to 3 months of


symptom duration.

SUMMARY

ATP is a descriptively valid entity on the basis of onset,


duration, course and outcome. ATP presents with cross
sectionally prominent psychotic, affective, confusional
symptoms.

Diagnostic criteria particularly duration of episode given in


ICD-10 is short and needs to be changed to 6 months at
least.

There is suggestive evidence of genetic distinctiveness of


ATP.

Schizophrenia symptoms in ATP and in schizophrenia


appear to have shared genetic liability.

Environmental factors such as fever, childbirth, seasonality,


low SES, stress, rural living, seem to be involved in
triggering ATP.

Course and outcome of ATP is different from that of


schizophrenia or of affective disorder.

Except for recurrent course, there seems to be minimal


overlap of ATP with affective disorder.

REFERENCES

CTP 9th edition

Oxford textbook of psychiatry

Status of Psychotic Disorders in ICD-11, Schizophrenia Bulletin vol.


38 no. 5 pp. 895898, 2012doi:10.1093/schbul/sbs104

Malhotra S. Acute and transient psychosis:


approach. Indian J Psychiatry 2007;49:233-43.

World Health Organization The ICD-10 classifi cation of mental and


behavioral disorders. World Health Organization: Geneva; 1992.
schizophrenics? Indian J psychiatry 1981;23:200-5.

American Psychiatric Association. Diagnostic and Statistical Manual


of Mental Disorders, 5th edition.

paradigmatic

World Health Organization. Report of the International pilot study of


schizophrenia. WHO: Geneva; 1973.

Sartorius N, Jablensky A, Korten A, Ernberg G, Anker M, Cooper JE, et


al. Early manifestations and first-contact incidence of schizophrenia in
different cultures: A preliminary report on the initial evaluation phase
of the WHO Collaborative Study on determinants of outcome of severe
mental disorders. Psychol. Med 1986;16:909-28.

Cooper JE, Jablensky A, Sarotrius N. WHO collaborative studies on


acute psychoses using the SCAAP schedule. In: Psychiatry: A world
perspective, Volume 1. Stefanis CN, Rabavilas AD, Saldatos CR,
editors. Pub Elsevier: 1990. p. 185-92.

Thank you