Presented By : Dr. Karrar Husain

Moderator : Dr. M. Amir Usmani

In late 19th century, Kraepelin divided functional psychosisinto manic–depressive psychosis and dementia praecox.

However after Kraepelin’s dichotomous classification offunctional psychosis, many authors kept on showing theirdissatisfaction with such a classification and kept ondescribing an acute psychotic illness which was different frommanic-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

Amentia—a psychotic disorder with remitting course andfavorable outcome, originally described by Theodor Meynert(1833 to 1898).

A psychotic illness with acute onset characterized byconfusion and perplexity; agitation; rapidly changing, vividhallucinations and delusions; anxiety; and apprehension.

An association with physical illness and exhaustion was notedin some patients. Full recovery occurs in a few weeks ormonths

Cycloid psychosis

A psychotic disorder with acute onset and good prognosisbut frequent recurrences, characterized by confusion, mood-incongruent delusions, hallucinations, overwhelming anxiety,deep feelings of happiness or ecstasy, motility disturbancesof akinetic or hyperkinetic type, a particular concern withdeath, mood swings, and rapid change in symptoms within anepisode.

Two variants : confusional - contrasting phases of confusedexcitement and stupor

: motility psychosis - contrasting phases ofhyperkinesis and akinesis.

A third variant, anxiety-elation psychosis, was introduced byKarl Leonhard (1904–1988).

The diagnosis of cycloid psychosis is still used by German,Scandinavian, and other European psychiatrists and wasinfluential for the formulation of acute and transientpsychotic disorders in ICD-10.

Bouffée délirante

A psychotic disorder with acute onset without previouspsychiatric history. The episode remits completely with noresidual symptoms.

The episodes are characterized by delusions, hallucinations,depersonalization and derealization, confusion, moodchange, and changing symptoms during the course ofepisode.

Episodes are not due to organic or substance use.

The diagnosis is still used by French-speaking clinicians inEurope, West Africa, and the Caribbean.

The concept of bouffée délirante was influential informulation of the ICD-10 acute and transient psychoticdisorders.

Due to its common occurrence in Africa and the Caribbean, itis 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 beacute and later in life. Premorbid adjustment tends to bebetter than in schizophrenia. Prognosis is better thanschizophrenia.

There are more affective and confusional symptoms andfewer bizarre symptoms, and there is less family history ofschizophrenia.

Diagnoses of psychogenic or reactive psychoses were popularamong Scandinavian psychiatrists.

The reactive or psychogenic psychosis was especiallyinfluential in the formulation of the third edition of the DSM(DSM-III) brief reactive psychosis diagnosis, which, in DSM-IVand DSM-IV-TR, was replaced by brief psychotic disorder.

The change was partly motivated by the observation thatmany cases of brief psychosis are not precipitated by amarked stressor and, hence, are not “reactive.

Nonetheless, the DSM-IV and DSM-IV-TR distinguish betweenbrief psychotic disorder with and without marked stressorsand indicate that brief psychotic disorder with markedstressor is equivalent to the brief reactive psychosis.

Schizophreniform psychosis or disorder

Gabriel Langfeldt (1937–1966)

A condition with sudden onset after an identifiable precipitatingfactor and good outcome in an individual with well-adjustedpremorbid personality.

The patients often present disturbance of mood and clouding ofconsciousness.

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

The concept of schizophreniform in the latter sense wasperpetuated in the later editions of the DSM.

Oneirophrenia

Ladislas von Meduna (1896–1964) in 1939

A syndrome characterized by acute onset of confusion,nightmare or dream-like quality of all perceptions, extremefear and anxiety, delusions, and visual hallucinations.

The prognosis is generally good with full recovery.

Meduna proposed an endocrinological explanation for thesyndrome.

Hysterical psychosis

Marc Hollander and Steven Hirsch in 1964.

A psychotic episode with sudden and dramatic onset relatedto a profoundly upsetting event in the context of a“hysterical” personality.

Symptoms include hallucinations, delusions,depersonalization, and disorganized behavior.

The episode seldom lasts longer than 1–3 wks.

Common features of these historical entities were:

o – acute or sudden onset

o – unstable, variable, fluid and florid symptomatology

o – volatile polymorphic content

o – anxiety

o – fear or prominent affective symptoms

o – association with a clear precipitant

o – good premorbid adjustment

o – 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

ATP is a new entrant to psychiatric nosology and ICD-10concept 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 fromthe international initiatives in the form of WHO multi-centered collaborative studies IPSS(International Pilot-study ofschizophrenia), DOSMeD (Determinants of Outcome of SevereMental Health Disorders) and CAP(Cross-cultural study ofAcute Psychosis)

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.

WHO-led and -funded study done in 10 countries includingboth the developing and developed countries.

Salient findings relevant to the discussion on ATP were:

1. There were a group of patients who had non-affectivepsychosis and which remitted completely. These were calledas non-affective, acute, remitting psychosis (NARP).Incidence of such NARP cases was 10 times higher in thedeveloping countries in the DOSMeD data.

2. These patients from developing countries exhibited a benigncourse at 2 years follow-up.

This study was an off-shoot of DOSMeD study done in 14centers and 7 countries.

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

(i) Acute psychotic states that can be defined, which aredescriptively different from schizophrenia and MDP? And

(ii) How are acute psychoses related to psychological andphysical 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 WHOstudies provided strong evidence in favour of occurrence ofacute onset psychotic disorders that were different from bothschizophrenia as well as MDP and formed the basis for theICD-10 category ATP (F23).

Sources of uncertainty in the nomenclature and nosology ofATP lied in the issue of the relationship of ATPs withschizophrenia and manic-depressive psychosis.

RELATIONSHIP OF ATPS WITH SCHIZOPHRENIA AND AFFECTIVEDISORDERS

Quest to separate ATP from schizophrenia and MDP wascomplicated as there were questions about the biologicaldistinctiveness of schizophrenias and MDP.

While the relationship of ATP to schizophrenia or MDP wasunder question, the relationship between schizophrenia andaffective disorders, the two major psychotic conditions, itselfhas been a matter of debate. “It is becoming increasinglyclear that we cannot distinguish satisfactorily between thesetwo 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 aprototypical syndrome of ATP, have yielded varying results. Ithas been considered to be closely related to affective illnessin some studies and to Schizophrenias in other group ofstudies.

According to some family genetics study ATP is geneticallydistinct from MDP and that there is genetic overlap betweenATP and schizophrenia and schizophrenic symptoms.

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.

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: Comparison with schizophrenia. Soc Psy Psychiatr Epidem1999;34:328-32.

Some studies also suggested that there is poor link betweenshizophrenia and ATP.

ATPD differs significantly from BSAD on various relevantlevels, 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 ATPDand BSAD are different nosological entities.

Chavan BS & Kulhara P. A clinical study of reactive psychosis. Acta psychiatricaScand-inavica, 1988; 78: 712-715.

The relation of ‘‘acute and transient psychotic disorder’’(ICD-10 F23) to bipolar schizoaffective disorder, Journal of Psychiatric Research 36 (2002) 165

ATP and DSM ATPD do not have a designated place in the DSM.

Many of the cases of ICD-10 acute and transient psychoticdisorder would be categorized as schizophreniform disorder,brief psychotic disorder, or psychotic disorder not otherwisespecified (NOS) in DSM.

Brief psychotic disorder’ (BPD), which is characterized bypresence of psychotic symptoms for less than 1 month duration,is equivalent to the ICD-10 ATPD of less than one monthduration.

‘Schizophreniform disorder’, which requires minimum of 1month for active symptoms to appear after the first noticeablechange in behavior or functioning and allows a duration limit forthe symptoms to a maximum of 6 months.

psychotic disorder NOS includes presentations of psychoticsymptoms for which there is inadequate information to makea specific diagnosis or symptoms that do not meet full criteriafor a specific psychotic disorder.

DSM-III and DSM-III-R had a diagnosis of the brief reactivepsychosis diagnosis, defined as a psychotic episode lastingless than 1 month that was preceded by a marked stressor

Acute and transient psychotic disorders are rare inindustrialized settings.

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 and0.88 in women in developing countries and 0.04 in men and0.10 in women in industrialized countries.

Age of onset is in the early to mid-20s in the developingcountries and in the mid-20s to mid-30s in industrializedcountries.

CTP 9th edition,

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.

The most common specific disorder in the group of ICD-10 isacute polymorphic psychotic disorder without symptoms ofschizophrenia(2/3 -1/2 cases).

ATP cases are reported to be more frequently belonging tolower socio-economic status and rural areas.

Stress preceding the onset was seen in about 60% of ATPpatients and stress was more common among female.

History of non-specific, short-lasting fever.

A summer peak

Malhotra S, Varma VK, Misra AK, Das S, Wig NN, Santosh PJ. Onset of acute psychotic states in India: A study of sociodemographic, seasonal and biological factors. Acta Psychiatr Scand 1998;97:125-31.

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.

Little is known about the etiology of acute and transientpsychotic disorders.

Higher risk of acute transient psychotic disorders and a lowerrisk of schizophrenia and mood disorders in the first-degreerelatives of probands, compared with schizophrenia probands.

It is hypothesized that ATP may be an environmentally inducedpsychotic condition superimposed upon an underlyingvulnerability to psychosis.

Early-life brain insult may lead more often to schizophrenia andlater-life insult may lead to ATP. The severity of brain insultwhere ATP may be associated with less severe brain insult.

Acute and transient psychotic disorders are characterized bythree typical features

1. suddenness of onset (within 2 weeks or less)

2. presence of typical syndromes with polymorphic (changingand variable) or schizophrenic symptoms

3. presence of associated acute stress (stressful events such asbereavement, job loss, psychological trauma, etc.).

The onset of the disorder is manifested by an obvious changeto an abnormal psychotic state. This is considered to beabrupt when it occurs within 48 h or less. Abrupt onset oftenindicates a better outcome. Full recovery occurs within 3months 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 combinationof these. The time interval between the first appearance ofany psychotic symptoms and the presentation of the fullydeveloped disorder should not exceed 2 weeks.

G2 If transient states of perplexity, misidentification, orimpairment of attention and concentration are present, theydo not fulfil the criteria for organically caused clouding ofconsciousness as specified for F05, criterion A.

G3 The disorder does not satisfy the symptomatic criteria formanic episode (F30), depressive episode (F32), or recurrentdepressive disorder (F33).

G4 There is insufficient evidence of recent psychoactivesubstance 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 largelyunchanged use of alcohol or drugs in the amounts or with thefrequency to which the individual is accustomed does notnecessarily exclude the use of F23; this must be decided byclinical judgement and the requirements of the researchproject in question.

G5 There must be no organic mental disorder (F00–F09) orserious metabolic disturbances affecting the central nervoussystem (this does not include childbirth). (This is the mostcommonly used exclusion clause.)

A fifth character should be used to specify whether the acuteonset of the disorder is associated with acute stress(occurring 2 weeks or less before evidence of first psychoticsymptoms):

F23.x0 without associated acute stress

F23.x1 with associated acute stress.

The change of the disorder from a non-psychotic to a clearlypsychotic state is further specified as either abrupt (onsetwithin 48 h) or acute (onset in more than 48 h but less than 2weeks).

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 symptomsof schizophrenia

A. Criteria A, B, C, and D of acute polymorphic psychoticdisorder (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 timesince the onset of the disorder, but not necessarily meetingthese criteria completely, i.e. at least any one of thesymptoms in F20, G1.1a to G1.2g.

C. The symptoms of schizophrenia in B above do not persistfor more than one month.

F23.2 Acute schizophrenia-like psychotic disorder

A. The general criteria for acute and transient psychoticdisorders (F23) must be met.

B. The criteria for schizophrenia (F20.0 - F20.3) are met, withexception of the duration criterium.

C. The disorder does not meet the criteria B, C and D for acutepolymorphic psychotic disorder (F23.0).

D. The total duration of the disorder does not exceed onemonth.

F23.3 Other acute predominantly delusional psychoticdisorder

A. The general criteria for acute and transient psychoticdisorders (F23) must be met.

B. Relatively stable delusions and/or hallucinations are present,but they do not fulfil the symptomatic criteria forschizophrenia (F20.0 - F20.3).

C. The disorder does not meet the criteria for acutepolymorphic psychotic disorder (F23.0).

D. The total duration of the disorder does not exceed threemonths.

F23.8 Other acute and transient psychotic disorders

Any other acute psychotic disorders that are unclassifiableunder any other category in F23 (such as acute psychoticstates in which definite delusions or hallucinations occur butpersist for only small proportions of the time) should becoded here. States of undifferentiated excitement should alsobe coded here if more detailed information about thepatient's mental state is not available, provided that there isno evidence of an organic cause.

F23.9 Acute and transient psychotic disorder, unspecified

Other forms of acute psychoses have been observed in bothtraditional and developing countries, with high prevalence inAsia, Africa, and Latin America.

Mezzisch and Lin have suggested that the whole group ofculture-bound syndromes should be classified as acute andtransient psychotic disorders, although this is justified onlyfor a very few such as amok (dissociative episode withpersecutory ideas and aggressive behaviour from Malaysia),shin-byung (Korean dissociation and possession), and spell(trance state in southern United States).

There are no laboratory tests for acute and transient psychoticdisorders or brief psychotic disorder.

Auditory evoked potential studies in patients with cycloidpsychosis recorded P300 peaks over the left hemisphere, similarto normal controls. In contrast, in patients with residualschizophrenia, P300 peaks are located over the righthemisphere. A higher P300 amplitude, compared with normalcontrols, was noted in the cycloid psychosis patients, suggestinga higher level of arousal.

Increased hemispheric blood flow during the psychotic episodewith return to normal after remission. There was a directrelationship between the severity of symptoms and arousal, andthe degree of increase in blood flow, on the other.

Studies of schizophrenia have consistently shown evidence ofenlarged ventricles and dilated cerebral fissures, patients withcycloid psychosis show little or no evidence of such deficits

Hypothalamic-pituitary axis abnormalities in subsets offemale patients with recurrent atypical psychoses who aremore likely to experience episodes at the time ofmenstruation and parturition

persistent delusional disorder: acute polymorphic psychoticdisorder without symptoms of schizophrenia is changed to adiagnosis of persistent delusional disorder or other nonorganicpsychotic disorder if the illness lasts more than 3 months.

Schizophrenia: acute polymorphic psychotic disorder withsymptoms of schizophrenia is changed to ICD-10schizophrenia if the episode lasts more than 1 month.

mood disorders: Presence of a full mood syndrome that meetsthe ICD-10 criteria for a manic or a depressive episodeexcludes diagnosis of acute and transient psychotic disorders

Delirium: acute and transient psychotic disorders may beassociated with confusion and perplexity, making it difficult todistinguish these disorders froms.

Drug or alcohol intoxication or withdrawal: The temporalrelationship between the onset of psychosis and thesubstance use may be helpful in differentiating a substance-induced psychotic episode from a non-substance-inducedone. Symptoms that persist for many days after all traces ofthe substance are eliminated from blood and urine supportdiagnoses of acute and transient psychotic disorders or briefpsychotic disorder.

Psychotic disorder due to medical illness: Acute psychoticepisodes have been reported in a number of medicalconditions, including head trauma, cerebral anoxia, epilepsy,and endocrinological disorders such as hyper- orhypothyroidism

Acute and transient psychotic disorders, by definition, have a favorable early course—full remission within 1 to 3 months.

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.

acute remitting psychosis had a modal distribution of 2-4 months which is larger than 1-3 months given in ICD-10 for ATP.

CTP 9th edition

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.

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 ofATP episodes which is upto 28 weeks and that is definitelylonger than was recognized in the ICD-10.

In a short-term (5 years) follow-up study of ICD-10 ATPcases, it was found that majority (75%) had good outcome inthe form of complete recovery and no residual symptoms.

Female gender, presence of stress at onset and absence ofschizophrenic symptoms predicted good outcome.

In a long-term 20-year follow-up study of WHO CAP study upto 82% patients had an excellent outcome with no relapse andno residual symptoms.

Rozario A, Malhotra S, Basu D. Acute and Transient Psychotic disorders: A follow-up 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 diagnosticchange in about half (48%) of the patients, most often toeither schizophrenia (15%) or affective disorder (28%).

diagnostic change was seen from ATP to schizophrenia in15% and from ATP to affective disorder in 28% cases.

Diagnosis was stable in 87% cases

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.

Jorgensen A. Long term course of acute reactive paranoid psychosis. ActaPsychiatrScand 1995;71:30-7..

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 ATPDdevelop a severe social impairment after three to seven years.

Patients with a severe social impairment at follow-up werecharacterized by higher means in the total score of thenegative syndrome and the depressive syndrome at dischargefrom the first hospitalization. Therefore, persisting “negative”and/or “depressive” symptoms in patients with ATPD maypredict an unfavorable outcome in terms of a chronicschizophrenic disorder.

Course and outcome of first-admitted patients with acute and transient psychotic disorders (ICDFocus on relapses and social adjustment; Eur Arch Psychiatry Clin Neurosci (2003) 253 : 209–215

recurrence rate was found to be of 46.6% on 8-year follow-up study, and 35% on 5-year follow-up study.

Recurrence in the DOSMeD cohort of ATP cases was 22% at 5 years and 11.76% at 12-year follow-up.

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

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 culturalfactors can influence the course and prognosis of acutepsychotic disorders.

In 1979, the World Health Organization compared the courseof schizophrenia (295), psychotic depression, mania, andother psychoses in different cultures, using the ICD-9 criteriafor the diagnoses. The outcome for the schizophrenic groupwas better in emerging countries than in the industrializedworld

Short-term treatment

Acute psychotic syndromes require early hospitalization ineither an inpatient psychiatric unit or a crisis centre. They arepsychiatric emergencies.

The decision to admit to hospital is taken in order to make acareful clinical evaluation, to separate the patient from his orher environment, to provide a reassuring setting, and toprevent any suicidal or aggressive tendencies.

Antipsychotic drugs are prescribed. Some clinicians wait for aday or two before starting neuroleptic therapy in order toeliminate an organic cause and prescribe benzodiazepinesrather than neuroleptics. More often, however, antipsychotictreatment starts immediately.

The choice of antipsychotic drug depends on the clinician'sexperience and the clinical features.

In cases of major anxiety or agitated behaviour, sedativeneuroleptics such as chlorpromazine, loxapine, orlevomepromazine are chosen, or zuclopenthixol acetate isused as a short-acting depot antipsychotic.

Parenteral administration may be required if the patientrefuses oral medication, or if a rapid effect is requiredbecause the patient is seriously uncooperative or is toodangerously disturbed.

Predominance of delusions and hallucinations indicates ahigh-potency antipsychotic agent as haloperidol orflupenthixol.

In patients experiencing first-episode psychosis, olanzapinehad a risk-benefit profile significantly superior to that ofhaloperidol.

Olanzapine Versus Haloperidol Treatment in First-Episode Psychosis(Am J Psychiatry 1999; 156:79–87)

Benzodiazepines may be given to potentiate the action of theneuroleptics.

Sociotherapy (occupational or intensive) and psychotherapy(reality–adaptive–supportive) are indicated depending on thestate of the patient and his environment, with individual,family or rehabilitation care.

Continuation treatment

The effectiveness of psychopharmacotherapy is usuallymanifested 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 anotherantipsychotic drug should be used or the dosage of the firstincreased.

Worsening of the symptoms, serious side-effects, or a poorresponse to pharmacotherapy are the main indications forelectroconvulsive therapy.

If mood disorders or cyclic episodes occur, treatment withantidepressants, mood stabilizers (lithium or valproate), or ananticonvulsant drug (carbamazepine) may be indicated.

Care must be taken to distinguish between a post-neurolepticdepression and the development of a (schizo)affectivedisorder.

Prevention of recurrence

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

Most guidelines recommended antipsychotic maintenancetreatment 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.

New Oxford Textbook of Psychiatry

ICD-11 is currently scheduled for presentation to the WorldHealth Assembly, WHO’s governing body, in 2015.

The Working Group on the Classification of PsychoticDisorders (WGPD) is recommending that the diagnostic focusbe on its sudden onset, brief duration, and highvariability/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 ofschizophrenia) be retained as the clinical guideline for ATPD,and the delusional subtype (F23.3) be incorporated into therevised category “Delusional disorder.”

The WGPD is recommending that the present ICD-10categories F 23.1 (Acute polymorphic psychotic disorder withsymptoms of schizophrenia) and F 23.2 (Acuteschizophrenia-like psychotic disorder) be collapsed into“Unspecified primary psychotic disorders” if duration ofdisorder is less than 4 weeks.

If duration is more than 4 weeks, schizophrenia should bediagnosed.

ATPD in ICD-11 as in ICD-10 allows up to 3 months ofsymptom duration.

ATP is a descriptively valid entity on the basis of onset,duration, course and outcome. ATP presents with crosssectionally prominent psychotic, affective, confusionalsymptoms.

Diagnostic criteria particularly duration of episode given inICD-10 is short and needs to be changed to 6 months atleast.

There is suggestive evidence of genetic distinctiveness ofATP.

Schizophrenia symptoms in ATP and in schizophrenia appearto have shared genetic liability.

Environmental factors such as fever, childbirth, seasonality,low SES, stress, rural living, seem to be involved in triggeringATP.

Course and outcome of ATP is different from that ofschizophrenia or of affective disorder.

Except for recurrent course, there seems to be minimaloverlap of ATP with affective disorder.

CTP 9th edition

Oxford textbook of psychiatry

Status of Psychotic Disorders in ICD-11, Schizophrenia Bulletin vol. 38no. 5 pp. 895–898, 2012doi:10.1093/schbul/sbs104

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