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SPEAKER: AMIT CHOUGULE

ACUTE AND TRANSIENT PSYCHOTIC DISORDER

LAYOUT Introduction History and evolution of ATPD ICD-10 diagnostic criteria Epidemiology of ATPDCourse and outcomeTreatment of ATPDIssues with nosologyFuture of ATPD as a diagnostic criteria Conclusion

INTRODUCTIONAcute and transient Psychotic Disorder (ATPD) as a descriptive entity was recognized in ICD-10 in 1992Included under psychotic disorder (F23) as a three-digit codeNomenclature of these acute disorders is as uncertain as their nosological statusPsychotic disorder is used as a term of convenienceThe fact remains that systematic clinical information that would guide the classification of acute psychotic states is not yet available

HISTORY AND EVOLUTION OF ATPD 1876 German Psychiatist Karl westphal described paranoia acuta 1890 Meynert repeated the clinical description but named the condition amentiaSigmund Freud chose this type of acute delusion with hallucinations for his psychoanalytic conception of psychosis100 Years

The existence of acute psychoses has been described by almost all important authors of the Pre-Kraepelinian periodMeynert in 1889 first described transient amentia (amnesia with a sad spirit)Psychotic confusional stateGood prognosisEmil Kraepelins dichotomy of dementia praecox and manic-depressive insanityKraepelin based this dichotomy mainly on symptomatology, course and longitudinal outcome (Kraepelin, 1893, 1896, 1899)

HISTORY OF ACUTE PSYCHOSIS

KRAEPELINS DICHOTOMYKraepelin knew of Brief and Acute PsychosesCould not be allocate it either to schizophrenia or to affective disorderSuch disorders could cause severe doubts regarding the reliability of his dichotomy (Kraepelin, 1920)Kraepelin allocated them either to manic-depressive insanity or to dementia praecoxMajority of Brief and Acute Psychoses were allocated by Kraepelin to the manic-depressive insanity group (Maj, 1984)

JUGGLE OF ACUTE PSYCHOSIS GROUP TO SCHIZOPHRENIAKraepelins dichotomic system was reformed by Eugen Bleuler (1911) Created the group of schizophreniasProblem of the brief, acute, transient and good prognosis psychoses persistedAcute psychosis category was moved from Kraepelins manic-depressive insanity to Bleulers schizophrenia A tradition which is still going on

Kraepelin based this dichotomy mainly on symptomatology, course and longitudinal outcome

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OPPOSITION TO KRAPELINIAN DICHOTOMYFrance: Bouffee DeliranteGermany: Motility PsychosisCycloid PsychosisScandinavia:Psychogenic psychosisReactive Psychosis America:Schizophreniform PsychosisRemitting SchizophreniaJapan : Atypical Psychosis

Africa :Acute Primitive PsychosisAcute Paranoid PsychosisTransient Psychosis

West Indies : Acute Psychotic Reaction

India : Acute Psychoses of Uncertain OriginHysterical PsychosisAcute Psychosis without Antecedent StressAcute Schizophrenic Episode

THE CYCLOID PSYCHOSES- GERMANYIt was created and developed by three Karls:Carl WernickeKarl KleistKarl Leonhard Focused mainly on clinical and on genetic findingsDemanded a separation from Kraepelins manic-depressive insanityFish (1964) introduced the concept of cycloid psychosis to English speaking countries

(Acute and transient psychosis by Andreas Marneros and Frank pillmann,2004)

BOUFFEE DELIRANTE- FRANCEIt can be regarded as the French root of ATPD and Brief PsychosesValentin Magnan (18351916)The modern concept of bouffee delirante is based on operational criteria like:Sudden onsetSpecific symptomatologyEvolution of the disorderRetained the category bouffee delirante as an independent mental disorder

ACUTE PSYCHOSIS - INDIAWig and Singh extracted psychiatric categories from the APA DSM II relevant for use in IndiaThey argued for the category of acute psychosis for brief episodes precipitated by stress which does not fit into the Kraepelinian dichotomyThey sub-classified acute psychosis into:ConfusionalParanoid hallucinatorySchizoaffectiveHysterical psychosis (K. S. Jacob, 2016)

REACTIVE/PSYCHOGENIC PSYCHOSESBasic concept was developed by Karl JaspersVery strong tradition mainly in ScandinaviaThe first monograph was written by August WimmerThe concept developed by Wimmer is based on Jaspers General Psychopathology

(Acute and transient psychosis by Andreas Marneros and Frank pillmann,2004)

TOWARDS A PERMANENT PLACE IN INTERNATIONAL CLASSIFICATION What happened to individual national concepts of acute psychosis?How did they find a permanent place in international classification?Which landmark studies identified them as a separate category?

Although this evidence was highly suggestive, there was need for confirmation using standardized methodology

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INTERNATIONAL PILOT STUDY OF SCHIZOPHRENIA (IPSS) (1968-70)This was a nine-country study on schizophrenia led and funded by WHO, with the main aims:Whether schizophrenia existed in different parts of the world?What were the common/differing clinical presentations?What was the course and outcome among different cultures?

INTERNATIONAL PILOT STUDY OF SCHIZOPHRENIA (IPSS) (1968-70)Agra was the center from IndiaThe main findings:Course and outcome in developing world was better than developed countries25% of people diagnosed to have schizophrenia had only one episode and good outcomeIPSS raised questions like whether these subjects with good outcome had a:Separate psychosis?Were they part of the schizophrenia group?

Determinants Of Outcome Of Severe Mental Health Disorders (DOSMED) (1978-80)Designed to study:First onset psychosisIncidence of schizophreniaFindings related to acute psychosisChandigarh was the Indian center The incidence of broadly defined schizophrenia was 10 times higher in the developing world than in the developed countries as compared to narrowly defined schizophreniaThese patients also exhibited a benign course at two-year follow-upPossibility of psychotic states that were not yet clearly identified

THE CROSS-CULTURAL STUDY OF ACUTE PSYCHOSIS (CAP) (1980-82)The study aimed to:Differentiate ATPD from schizophrenia and manic depressive psychosisUnderstand its relationship with psychological and physical stressMain findings included:41.2% of patients had symptoms of schizophrenia20% had Affective symptoms 35.3% had other psychoses41.7% reported stress at onsetTwo-thirds of the subjects remained without relapse at one year follow-up

INDIAN COUNCIL OF MEDICAL RESEARCHS MULTICENTRE STUDY OF ACUTE PSYCHOSISBikaner, Goa, Patiala and VelloreIt was found that:35% of were Schizophrenia25% were MDP40% as non-organic psychosis as per ICD-952% of cases of acute psychosis could not be categorized into any of the categorical diagnosis

RECOGNITION OF ACUTE PSYCHOSIS AS A SEPARATE CATEGORYThese studies provided evidence of a non-affective, non schizophrenia psychosis with remission and good outcomeInclusion of acute and transient Psychosis as a separate category in ICD-10 in 1992

CLINICAL DESCRIPTION: PSYCHOPATHOLOGYThe heterogeneous group of acute and transient psychotic disordersCharacterized by three typical features in the descending order of priority:An acute onset (within 2 weeks) as the defining feature of the whole groupPresence of typical syndromesPresence of associated acute stress

ACUTE ONSETAcute onset is defined as a change from a state without psychotic features to a clearly abnormal psychotic state, within a period of 2 weeks or lessThere is some evidence that acute onset is associated with a good outcomeMore abrupt the onset better the outcomeIt is therefore recommended that whenever appropriate, abrupt onset (within 48 hours or less) be specified

THE TYPICAL SYNDROMESRapidly changing and variable state called "polymorphicTypical schizophrenic symptomsDifferentiated on the basis of first rank Symptoms of schizophrenia

ASSOCIATED ACUTE STRESSTraditional linkage of stress with acute psychosisSubstantial proportion of acute psychotic disorders arise without associated stressFirst psychotic symptoms should occur within about 2 weeks of one or more events that would be regarded as stressful to most peopleTypical events would be bereavement, unexpected loss of partner or job, marriage or the psychological trauma of combat, terrorism, and tortureLong-standing difficulties or problems should not be included

F23.0 Acute polymorphic psychotic disorder without symptoms of schizophreniaThe delusional themes are varied and include grandeur, persecution, influence, possession, body transformation (depersonalization), derealization or world alterationThese themes change with time and may combineConsciousness fluctuates with the delirious convictions and changes of emotionKarl Jaspers - first delirious experience which is a dreamlike stateThe criteria for manic episode, depressive episode or schizophrenia are not fulfilled

F23.0 Acute polymorphic psychotic disorder without symptoms of schizophreniaDuration of less than a month In most cases recovery occurs within a few weeks or monthsIf resolution of the symptoms has not occurred after 3 months, the diagnosis should be changed to persistent delusional disorder (F22) or non-organic psychotic disorder (F28)

F23.1 Acute polymorphic disorder with symptoms of schizophrenia

This diagnostic category combines the symptoms of acute polymorphic psychotic disorder with some typical symptoms of schizophrenia (F20) present for most of the timeIt can be a provisional diagnosis, which is changed to schizophrenia if the criteria of schizophrenia persist more than a month

F23.2 Acute schizophrenia-like psychotic disorder This acute psychotic disorder lasts for less than a month and is mostly schizophrenicThe polymorphic psychotic symptoms are stable The duration criterion is the most importantThis category is a provisional diagnosis In ICD-10 if the first episode lasts for more than a month, it has to be considered as an acute onset of schizophrenia

F23.3 Other acute predominantly delusional psychotic disordersThe main clinical features of this category are delusions and hallucinationsDo not meet the criteria for schizophrenia The duration of this psychotic episode must be less than 3 monthsIf the persecutory delusions persist for more than 3 months, the diagnosis changes to persistent delusional disorders (F22)Auditory hallucinations persist for more than 3 months, the diagnosis is changed to other non-organic psychotic disorders (F28)

F23.8 Other acute and transient psychotic disordersAny other acute psychotic disorders that are unclassifiable under any other category in F23States of undifferentiated excitement should also be coded here if more detailed information about the patient's mental state is not availableF23.9 Acute and transient psychotic disorder unspecified (brief) reactive psychosis NOS

SYNONYMS FOR ATPD IN ICD 10Acute (Undifferentiated) Schizophrenia Bouffee Delirante Cycloid Psychoses Oneirophrenia Paranoid Reaction Psychogenic Psychosis/ Reactive Psychosis Schizophrenic Reaction Schizophreniform Attack Or Psychosis Remitting Schizophrenia Good Prognosis Schizophrenia

YearTerm Given ByHistoric TermCurrent Terminology1876Westphal Akute primare Verruckheit paranoia acutaOther acute predominantly delusional psychotic disorder1890MeynertAmentia1895Magnan and LegrainBouffee DeliranteAcute polymorphic psychotic disorder without symptoms of schizophrenia1899KraepelinDementia praecoxSchizophrenia1909- 1913KraepelinParanoiaPersistent delusional disorder1911BleulerAcute onset schizophreniaAcute Polymorphic psychotic disorder with symptoms of schizophrenia Acute schizophrenia like psychotic disorder

YearTerm Given ByHistoric TermCurrent Terminology1916WimmerPsychogenic psychosisOther acute predominantly psychotic disorder1924Mayer- GrossOneroide erlebnisformAcute Schizophrenia like psychotic disorder1933KasaninAcute schizoaffective psychosesSchizoaffective disorder1939LangfeldtSchizophreniform statesAcute schizophrenia like psychotic disorder1954EYBouffees Delirante et psychoses hallucinatoires aiguesAcute polymorphic psychotic disorder without symptoms of schizophrenia1961LeonhardCycloid psychosesAcute polymorphic psychotic disorder without symptoms of schizophrenia

CULTURAL VARIANTSOther forms of acute psychoses have been observed with high prevalence in Asia, Africa, and Latin AmericaThese brief psychotic episodes are culture-bound syndromesImmediate precipitating stress or life eventsThere is disorganized behaviour, delusions, thought disorders, confusion, and mood disordersFull recovery and no relapse in a 1-year follow-upICD-10 does not suggest category of ATPD

CULTURE BOUND SYNDROME VS PSYCHOTIC DISORDERCulture-bound syndromes should be classified as acute and transient psychotic disorders (Mezzisch and Lin)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)spell (trance state in southern United States)

CULTURE BOUND SYNDROME AS NEUROSISICD-10 includes the two Malaysian syndromes koro and latah as well as Dhat (India) in (F48.8) Other specified neurotic disordersShort-lived psychotic episodes are expressions of overcharged mechanisms of defence or of individual psychological fragilityThe brief psychosis is an understandable development of the psychic life of the subject and has a cathartic effect

BRIEF PSYCHOTIC DISORDER OF DSM-5 ANDATPD OF ICD-10Brief Psychotic DisorderATPDDuration from onset to full remission of psychotic episode 1 day to 1 Monthup to 3 monthsexceptionsWith Symptoms of Schizophrenia andAcute Schizophrenia-like PsychoticDisorderIn these cases less than 1 monthFull developmentOf the SyndromeNot SpecifiedWithin 2 weeksDefining SymptomatologyPositive Psychotic SymptomsPsychotic symptoms + Polymorphic Symptoms

EPIDEMIOLOGY OF ATPDThe Halle Study on Brief and Acute Psychoses (HASBAP) by Andreas Marneros and Frank PillmannThe Cairo study by Okasha and co-workers (1993)The cohort study of Pondicherry, India by Sajith and co-workers (2002) at JIPMER, Pondicherry, IndiaThe cohort study of Chandigarh at PGIThe Danish Cohort Study

THE FREQUENCY OF ATPDThe frequency of Brief and Acute Psychoses is considerably higher in developing countriesFrequency of subtypes of ATPD according to ICD-10:Acute Polymorphic Psychoses- 67%Acute Schizophrenia-like Psychoses - 26%Other Acute Predominantly Delusional Psychoses - 2%Other Acute and Transient Psychoses (F23.8) - 5%Frequency of Subtypes of Acute Polymorphic:Without Symptoms of Schizophrenia-50%With Symptoms of Schizophrenia-50%

GENDER DISTRIBUTIONMore frequent in women than in menThis constitutes an important difference to schizophrenia and to schizoaffective disordersAGE AT ONSETAcute and Transient Psychotic Disorders may occur at any agePeak in the mid thirtiesAge at onset is higher than in schizophrenia

MENTAL DISORDERS IN THE FAMILYIn a major case control study found family history of ATP was three times greater in first degree relatives(FDRS) of ATPHistory of schizophrenia was seen in FDRs of those ATP patients who had schizophrenic symptomsThese findings gave evidence that ATP is genetically distinct from MDPThere is genetic overlap between ATP and schizophrenia and schizophrenic symptoms

PREMORBID PERSONALITYAssessment by Big Five personality dimensions No significant difference between ATPD patients and healthy controlsBipolar Schizoaffective Disorder patients differ from mentally healthy controls on two of five subscales-neuroticism and extraversionSchizophrenia patients show pronounced differences from the mentally healthy controls on three of five subscales: neuroticism, extraversion and conscientiousness

ONSET AND DURATION OF EPISODENeither abrupt nor acute onset are specific for ATPDSchizophrenia can have an acute onset and rarely an abrupt onsetThe duration of the psychotic period as well as the duration of inpatient treatment is significantly shorter in ATPDInsidious onset tends to have a longer duration of the psychotic periodTendency for patients with a precipitating life event to show a more acute onset

PSYCHOPATHOLOGICAL ASPECTS OF ATPDThe most crucial differences in phenomenology of ATPD:Rapidly changing delusional topicsRapidly changing moodAnxietySignificantly more frequently represented in ATPD

LONGITUDINAL COURSE OF ATPDRelapse rates in ATPD are similar to those in controls with Schizophrenia and BPADAfter 2.3 years one-half of the ATPD patients will experience a relapsePatients with ATPD who experience a relapse usually have ATPD episodes againAffective and schizoaffective episodes during follow-up are also common (HALLE STUDY)

COURSE AND DIAGNOSTIC STABILITY OF ATPDRecurrence of psychotic episodes is commonNot as common as in schizophrenia or bipolar disorderOver 15 years of follow-up:30% of ATPD patients experienced a single episode50% had an episodic-remitting course20% had a chronic courseFour studies in India have evaluated the diagnostic stability of ATPD for a follow up period from 12-36 months63-100% of patients retained their diagnosis of ATPD at follow-up

DIAGNOSTIC STABILITY IN INDIAN STUDIESThangadurai et al. while analyzing the medical records of all patients with psychotic disorders found:13.9% were diagnosed with acute psychosisMean duration of follow-up was 13.2 monthsThe diagnosis was revised to:Affective disorder in 9.2%Schizophrenia in 26.4%11.5% presented with recurrent episodes of acute psychosis

DIAGNOSTIC STABILITY OF ATPDA Danish study covering 15 years of register data found a 39% stability rate of ATPDMajority of patients transitioning to diagnoses of schizophrenia or affective disorders60% of the total ATPD sample developing another psychiatric disorder by their third admission

DIAGNOSTIC STABILITY OF ATPDDiagnostic stability differs widely by diagnosis and length of follow-upA small study of first-episode psychotic patients in Iran found that 100% of those diagnosed with ICD-10 ATPD maintained the same diagnosis over 12 months of follow-upIn a 15-year follow-up the diagnoses of ATPD, Schizophreniform and brief psychotic disorder were unstable over time

DIAGNOSTIC STABILITYDEVELOPING VS DEVELOPED NATIONSIn industrialized nations like Europe more than 50% of cases with ATPD tend to change diagnosis into another category In a review of 13 follow-up studies of ATPD:Castagnini and Berrios noted that studies in developing settings tend to show higher diagnostic stability and lower rates of relapse than studies in western settings

PREDICTORS OF DIAGNOSTIC STABILITY AND FAVOURABLE OUTCOME IN ATPDSudden onsetFemale sexDuration less than one monthGood premorbid functioningAcute insomnia

DIAGNOSTIC STABILITY OF ATPDSyndrome stability of ATPD is found to be located in the middle between the high stability of schizophrenia and the low stability of schizoaffective disorderAfter exclusion of the Acute Schizophrenia-like Psychotic Disorders from the group of ATPD 50% of the ATPD patients have a monosyndromal course during the prospective follow-up of five years

OUTCOMEAfter 10 years of illness patients with ATPD in comparison to controls with schizophrenia show:Better global functioningLess social disabilityFewer persisting alterationsFewer negative and positive symptomsHigher rates of heterosexual relationships

MANAGEMENT OF ATPDEarly hospitalization in order to make:Careful clinical evaluationTo separate the patient from environmentTo provide a reassuring settingTo prevent any suicidal or aggressive tendenciesAntipsychotic drugs are indicated The choice of antipsychotic drug depends on the clinician's experience and the clinical featuresBenzodiazepines may be given to potentiate the action of the neuroleptics

CONTINUATION OF TREATMENT AND PREVENTION OF RECURRENCEThe effectiveness of psychopharmacotherapy is usually manifested in the first 6 weeksIf mood disorders or cyclic episodes occur treatment with antidepressants or mood stabilizers is warrantedLow-dosage pharmacotherapy must be maintained for 1 or 2 years after recoveryDuring this long-term follow-up, periodic assessment and effective clinical care with social and psychological therapy are essential

ISSUES OF NOSOLOGYTHE BOUNDARIES OF HOMOGENEITY:Various sub-classifications of ATPD leads to an inhomogeneous group of psychotic disordersICD-10 differentiates Acute Polymorphic Psychoses with and without symptoms of schizophrenia based on first-rank symptomsWHO defines Acute Schizophrenia-like Psychotic Disorder based on:Presence of first-rank symptomsAbsence of polymorphic symptomatologyNo significant differences between the Polymorphic Psychotic Disorders with or without schizophrenic symptoms was found

THE BOUNDARIES OF HOMOGENEITYFirst-rank symptoms cannot distinguish the Acute Polymorphic Disorders into subgroupsThe polymorphism of the symptomatology has a much more discriminating power than the presence of first-rank symptomsThe WHO distinction of Acute Polymorphic Disorder into the two categories with and without schizophrenic symptoms is unwarranted and unnecessaryICD-10 subtype F23.0 (with schizophrenic symptoms) and F23.1 (without schizophrenic symptoms) can be put together

Is the Acute Schizophrenia-like Psychosis simply schizophreniaMain difference between Acute Schizophrenia-like Disorders and schizophrenia concerns is duration (1 month)Is this criterion valid enough to combine with ATPD ??Patients with Acute Schizophrenia-like Psychoses are more similar to patients with schizophreniaThe category ATPD can be much more homogeneous if the Acute Polymorphic Psychotic Disorders are not combined with the Acute Schizophrenia-like Psychotic Disorders

FUTURE OF ATPD IN ICD-11Working Group on the Classification of Psychotic Disorders (WGPD) Diagnostic focus should be Polymorphic clinical presentation:High variability/fluctuation of psychotic and affective symptomsWGPD recommends that:Subcategory F23.0 (Acute polymorphic psychotic disorder without symptoms of schizophrenia) be retained as the clinical guideline for ATPDDelusional subtype (F23.3) be incorporated into the revised category Delusional disorder

EXPECTED CHANGES IN ICD-113. Present ICD-10 categories:F23.1 (Acute polymorphic psychotic disorder with symptoms of schizophrenia)F23.2 (Acute schizophrenia-like psychotic disorder) be combined into:Unspecified primary psychotic disorders if duration of disorder is less than 4 weeksIf duration is more than 4 weeks schizophrenia should be diagnosed

CONCLUSION Psychiatrists often subscribe to the Kraepelinian dichotomyAttempt to label all functional psychosis as schizophrenia or affective disordersClinical presentations of acute psychosis challenge such categorisationMore work is necessary to tighten up the definitionFew concepts need to be defined:What is an adequate precipitantIts temporal relation to the psychosisThere is a need for greater precision in delineating vulnerability, course and outcome in acute psychosis

NEED FOR ETIOLOGICAL/ DIMENSIONAL CLASSIFICATION SYSTEMAny classification that is only phenomenological/descriptive in nature without a validating biological criteria is far from idealThe concept of ATPD has opened new vistas for further research and theorization even about schizophrenias and affective disorders

References Acute and transient psychosis by Andreas Marneros and Frank pillmann,2004K. S. Jacob Indian Psychiatry and classification of psychiatric disorders.Indian J Psychiatry 52, Supplement, January 2010Savita Malhotra. Acute and transient psychosis: A paradigmatic approach. Indian J Psychiatry 49(4), Oct-Dec 2007 233M Taylor Madness and Maastricht: a review of reactive psychoses from a European perspectiveJournal of the Royal Society of Medicine Volume 87 November 1994Aksel Bertelsen Reactive or Psychogenic Psychoses: The Scandinavian Concept. Revista do Servio de Psiquiatria do Hospital Fernando FonsecaRuud van Winkel, Nicholas C. Stefanis, Inez Myin-Germeys Psychosocial Stress and Psychosis. A Review of the Neurobiological Mechanisms and the Evidence for Gene-Stress InteractionSchizophrenia Bulletin vol. 34 no. 6 pp. 10951105, 2008Wolfgang Gaebel*Status of Psychotic Disorders in ICD-11Schizophrenia Bulletin vol. 38 no. 5 pp. 895898, 2012

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