ACUTE & TRANSIENT PSYCHOSIS: AN OVERVIEW

Sandeep Grover
Introduction Acute psychosis has been described for more than a century. The occurrence of a non-organic, non-affective psychosis, which has an acute onset and is short lasting in course, has always been a problem in traditional classifications, which are based on Kraepelins dichotomy. Over the years it has been documented to be more common in developing countries. An important aspect of acute psychosis described around the globe is its divergent symptom profile and the impact of culture on the symptom profile. In this article, I will briefly review the literature on the historical concepts, inclusion of acute psychosis in the current nosological and research from India, which has provided credence to existence of this nosological entity. Historical Background In the later part of nineteenth century, Kraepelin1 for the first time attempted to classify the functional psychosis on the basis of longitudinal course and prognosis. He 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. They named it as acute or subacute polymorphic psychosis2, bouffee delirante3, Motility Psychosis 4, Confusional Psychosis, Cycloid Psychosis 5, Schizoaffective disorder 6, Schizophreniform Psychosis7, Anxiety-elation Psychosis 8, Reactive Psychosis9, Psychogenic Psychosis10, Hysterical Psychosis11, Atypical Psychosis12. As shown in table-1, when we look at the description of most of the authors, all of them described the existence of a third psychosis which had acute onset, was associated with stress, had changing symptomatology, and the subjects had complete recovery from the same. Some authors also pointed out that this psychosis could recur and was associated with abnormal premorbid personality, like histrionic personality disorder.

Table-1: Comparison of description of Acute Psychosis

Acute onset Stress Changing symptoms Complete recovery Recurr -ance Abnormal PMP

Legrain2 Magnan3 Leonhard8 Jasper9 Faergerman & Stromgren10 Langfeldt7 Kasanin6 Hollender & Hirsch11

3 3 3 3 3 3 3 3

3 3 3 3 3 3 3 3
14

3 3 3 3

3 3 3 3

The first observation regarding the existence of a separate nosological entity of acute psychosis from India was made by Wig and Singh 13 . They pointed out the existence of an acute onset psychosis with florid symptomatology, which had good prognosis and pointed out that the equivalent nosological entities in ICD were acute psychosis of uncertain origin and hysterical psychosis. In another study, Kapur & Pandurangi 14 considered the existence of 2 types of acute psychosis one which was associated with stress and other which was not associated with stress. Singh & Sachdeva 15, pointed out that acute schizophrenia episode should not be included under schizophrenia and said that it was different from schizophrenia and manic-depressive psychosis. Chavan & Kulhara 16 described reactive psychosis which had manifest psychopathology, personality traits, life events & family history. In another study conducted by ICMR 17 it is also reported that 40% of patients with acute onset psychosis dont fit into either the diagnosis of schizophrenia, MDP or depression. Nosological Status: Prior to ICD-10 18 there was no separate nosology for acute psychosis as a group and it was placed under the broad category of schizophrenia. As discussed above over the years, around the globe there was a growing consensus about the existence of a third psychosis, which had acute onset, florid and variable symptomatology and favourable outcome. All these efforts led to the inclusion of concept of acute psychosis as a separate nosological entity in ICD-10 under the heading of Acute and Transient Psychosis. Further research on acute psychosis continued across the world but most of the research has been limited to India and Scandinavian Countries. The ICD-10 (WHO, 1992) acute and transient psychotic disorders (ATPD) are defined by acute onset within 2 weeks, limited duration and complete recovery. Though mentioned in the criteria, presence of a stressor is not a must. The ICD10 offers four specific (acute polymorphic psychosis with symptoms of schizophrenia-F23.0; without symptoms of schizophrenia-F23.1; acute schizophrenia like psychosis- F23.2; and acute delusional psychosis-F23.3) and two non-specific (other acute psychosis-F23.8; and unspecified-F23.9) subcategories. This empirical categorization is based on the variability of clinical picture, presence of schizophrenic symptoms, and duration of the episode. The duration is limited to less than 1 month for the subcategories of acute schizophrenia-like disorder and acute polymorphic disorder with schizophrenic symptoms separating these from schizophrenia. Duration criterion of 3 months is used for the other subcategories of acute polymorphic disorder without schizophrenic symptoms, other acute predominantly delusional psychotic disorder, which delineate the latter from persistent delusional disorders.
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The DSM-IV 19 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. The BPD can be specified as with/without marked stressors and with postpartum onset. DSM-IV also has another category in the form of 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. The duration criterion of 6 months helps in differentiation of schizophreniform disorder from the categories of BPD and schizophrenia respectively. This distinction is based on the assumption that schizophrenia can be diagnosed by certain characteristic symptoms called as schizophrenia symptoms when these are present for a duration longer than 1 month. This reflects the dilemma inherent in the diagnosis where schizophrenia is seen as clinical syndromes for which there are no objective criteria. It is held that schizophrenic patients have a sufficient commonality of signs and symptoms to validly differentiate them from patients with other forms of psychosis. Diagnostic validity of Acute Psychosis In psychiatry to consider any entity as a valid diagnostic entity, we still follow the schema of Robin & Guze 20 , who considered that for any valid diagnosis to exist, it must have a specific clinical description which could be supported by laboratory studies, which could be separated from other entities and on followup must be stable and there must be familial aggregation. However over the years the scheme has been modified and the validity of any entity is based on the existence of separate antecedent, concurrent and predictive Validators (See table2). I will now discuss the research on acute psychosis from India and other parts of the world, which has tried to suggest that acute and transient psychosis a valid diagnostic entity. Table-2: Diagnostic Validators

Antecedent Demographic factors Premorbid personality Precipitating factors Family studies

Concurrent Physiological Neuropsychological Neurophysiological Neuroimaging Biological Genetics

Predictive Course and outcome Response to treatment

Clinical Features: Nosology In a study from PGIMER, Chandigarh, Malhotra et al 21 studied all cases of acute onset psychosis and reported that acute non-organic psychosis presents with wide variety of symptoms and when they attempted to classify acute psychosis
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using statistical method they found 6 symptom clusters, i.e, manic-depressive psychosis, confusional psychosis, schizophrenic psychosis, reactive hysteriform psychosis, reactive undifferentiated psychosis, hallucinatory psychosis. They also concluded that ICD-9 criteria of reactive psychosis were somewhat stringent and that of schizophrenia was very broad. In the same study, when they tried to classify the patients using ICD-9 22 & Catego criteria 23, they found that 40 % of subjects did not fit into either manic-depressive psychosis or schizophrenia. When attempt was made to classify the patients diagnosed as non-organic acute psychosis, they found support for existence of acute and transient psychosis as a separate entity. In the ICMR multicentric collaborative study 17 , also reported similar profile of acute psychosis, i.e., 40 % of patients with acute onset psychosis doesnt fit into schizophrenia, manic depressive psychosis or depression. They also reported that the core cases had less anxiety, less expansive mood, and less perplexity compared to other entities. Antecedent Validators Sociodemographic factors: No significant differences were observed between the age at onset or at hospitalization of acute psychoses and schizophrenia in the studies conducted in 1970s. Epidemiological findings of incidence of acute psychosis suggest that acute and transient psychosis is 10 times more common in developing countries as compared to the industrialized countries. Various studies have also shown it to be more common in females and in persons from rural background 24-28. However, there is no consensus in relation to existence of acute psychosis in any particular socioeconomic status, with some studies reporting it to be more common in subjects from lower socioeconomic status and others reporting it to be more common in subjects from middle socio-economic status. The age of onset of acute psychosis has been reported to be similar to schizophrenia in men, but Susser and Wanderling 24 , suggested that age of onset was slightly younger in females when compared to age of onset of schizophrenia. In another study, Chaturvedi & Sahu 29 reported that acute psychosis was more common in younger people compared to schizophrenia. Precipitating factors - Role of stress: Presence of acute stress was inbuilt in the older concepts of reactive psychoses, psychogenic psychoses, combat psychoses and hysterical psychoses. Various studies have reported higher frequency of stress prior to onset of acute psychosis compared to schizophrenia 21,25,26 . Chavan and Kulhara 16 reported that subjects with reactive psychosis have higher weighted stress scores. In their study of non-affective remitting psychosis, Varma et al 30 found that 34 % of the subjects experienced stress prior to onset, but when they evaluated the prevalence of stress in patients with reactive psychosis, all the subjects experienced stressful event prior to the onset of psychosis. Das et al 31 evaluated the stress vulnerability
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hypothesis in ATPD subjects and found support for the same. It was observed that ATPD patients with a positive family history of psychiatric disorder in their first degree relatives reported significantly less amount of stress prior to the onset of their acute psychotic illness. Collins et al 32 reported that departure from or return to parental village in female and job distress in males were the common precipitating events for ATP. Distinct gender roles in developing countries could explain these observations. Marriage in developing countries represents a young womans first separation from the family of origin and the village. Males in the developing world are traditionally meant to perform the role of providing an income to the family and therefore job distress could constitute a major stressor amongst them 33. It has also been reported that stress preceding acute psychosis is more commonly seen in females and is associated with a better prognosis 34 . Premorbid Personality: As with the role of stress the role of premorbid personality in development of acute psychosis has also been studied since its earlier description. Kapur and Pandurangi 14 reported that subjects with reactive psychosis have a vulnerable personality. Chavan & Kulhara 16 reported that subjects with acute psychosis have suspiciousness and cyclothymic traits. Studies have shown prevalence of personality disorders to the extent of 63 to 87 % in cases of acute psychosis 34,35. In their study Jorgensen et al 34 reported that the most common personality disorder was unspecified category of ICD-10 & DSM-IV with 87 % cases of brief reactive psychoses having PD. Family studies: Presence of family history is widely hypothesized as a constitutional vulnerability. Mitsuda 12 in a study of 16 twin pairs did not report any case in which one twin had schizophrenia and the other had atypical psychosis; and thereby suggested that there is a poor link between the two disorders. Kendler et al 36 did not find any significant difference in the risk of any psychiatric disorder between relatives of schizophrenic and schizophreniform patients. Their observations also suggested a significant familial relation of the non-schizophrenic non-affective psychoses with schizophrenia and schizotypal disorder 36 . In a study from India, Chavan & Kulhara 16 reported more family history of psychiatric illness in patients of reactive psychosis. In another comparative family study from India, family history of schizophrenia was found to be commoner in the subtypes of ATPD with schizophrenic symptomatology. The study also observed that the genetic risk of ATPD was 3 times higher in first degree relatives of ATPD patients than in those of schizophrenia. It was also observed that the risk of schizophrenia was 4 times lower than the risk of schizophrenia in first degree relatives of schizophrenic patients. The study suggested a genetic distinctiveness on the basis of familial
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aggregation in cases of ATPD and schizophrenia and also indicated the existence of a possible overlap between the concepts of ATPD and schizophrenia, which was particularly reflected in the subtype of ATPD with schizophrenic symptoms 37 . Biological /Concurrent Validators Over the years research have linked many biological factors with acute psychosis. Malhotra et al 25 reported that in comparison to schizophrenia, significantly higher proportion of females with acute psychosis give a history of child birth in the 3 months prior to the onset of the illness. They hypothesized that, childbirth could be viewed as both, a psychosocial stressor (life event, role change) as well as a biological factor (hormonal change). Studies have also reported a significant association of fever with onset of acute psychosis in developing country settings 25,32,38. Acute psychosis has also been described in patients with specific infections like the viral infection, meningoencephalitis and neurocysticercosis 39-43 . Further studies have also found relationship between the course of psychotic symptoms and changes in serum and CSF viral antibodies 44 . The association with fever assumes importance in view of common occurrence of acute brief psychotic states as well as fever in developing countries with greater prevalence of infectious diseases and various hypotheses are plausible with regards to this association. It is possible that the stress of recent illness and fever may lead to re-activation of the latent virus, resulting in an acute and short lived manifestation of psychotic symptoms. It could also be possible that the acute infection and fever initiate an auto-immune response, predisposing to the development of psychosis in the weeks after the fever itself subsides 38 . Fever could also act as a physiological stressor, leading to hormonal and biochemical changes in the brain resulting in psychosis (Malhotra et al, 1998) 25. However, this association may be confounded by the fact that poor nutrition or trauma may predispose to both high fever and psychosis and subtle premorbid manifestations of the illness may predispose towards fever prior to onset of acute psychosis 38 . Studies from India have also reported a summer peak, from May to September, in the acute psychosis group compared to the schizophrenic control group 25. However, it remains to be determined whether the association is attributable to the physical effects of the heat (temperature range 30 to 45 degree Celsius), temperature associated neuro-endocrine changes, endogenous circadian rhythms or activation of some viruses at a specific temperature range, predisposing to fever and subsequent acute psychosis. In a controlled study normal P300 topographies and latencies but significantly higher P300 amplitudes than normal controls were observed in patients of cycloid psychosis 45 . Higher than normal P300 amplitudes have not been described in any other psychiatric disorder and therefore such a finding assumes importance. In contrast, studies on schizophrenic patients have revealed
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low amplitudes and asymmetric topography with right hemispheric peaks of P300-evoked response 46,47 . It has also been observed that patients with cycloid psychosis have increased hemispheric blood flow levels 48 . As the P300 amplitudes correlate with attentional performance and with higher levels of norepinephrine metabolite in CSF, higher than normal amplitudes may be an indication of higher levels of arousal in the cycloid psychosis group. Predictive Validators: Researchers have utilized the parameters of recovery, relapses, readmissions, stability of diagnosis and socio-occupational functioning to study the course and outcome in acute psychosis. Most of the existing studies, on course and outcome of acute psychoses, point towards an excellent prognosis and distinctness of the group from other functional psychoses. Short-term and long-term (upto twenty years) follow-up data on acute brief psychosis is available. Studies have reported a favorable prognosis of acute psychosis16,27,49-51. In a one-year follow-up study of ATPD (defined as per ICD-10) revealed a diagnostic change in about half (48%) of the patients, most often to either schizophrenia (15%) or affective disorder (28%) 52 . Patients with an unchanged diagnosis of ATPD managed well with regard to psychosocial functioning. The authors suggested that acute onset brief psychosis could be an early manifestation of severe mental disorders. Interestingly a previous study by the same principal author, though on a small sample of patients, pointed towards diagnostic stability in 87% of ATPD and a high psychosocial functioning over an 8-year follow-up period 54 . In another western study of non-affective brief psychosis, on 2-year follow-up, none of the acute brief psychosis cases showed a change of diagnosis to either chronic psychotic or affective disorder. Six of the seven patients remained well following recovery from the first psychotic episode and remaining one had a recurrence of a similar episode. On the other hand, the more numerous nonacute brief psychoses were neither distinctive nor temporally stable, and despite remission of the index episode, generally relapsed during the 2-year follow-up and often did not show complete recovery from the subsequent episodes. The non-acute brief psychoses seemed to be etiologically similar to other non-affective psychoses, representing milder forms schizophrenia 54 . On the basis of duration of psychosis, Susser et al 26 also showed that the duration of psychotic illness episode in non-affective acute psychoses have a bimodal pattern of distribution, with a point of rarity between two symptom score clusters. In 80% of the cases the duration was less than 28 weeks and in the rest of the 20% cases it was more than a year. Although, treatment response could be a potential confounder in the study, the findings never-the-less suggest the probability of two different diagnostic
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entities, one with a better and the other with a poorer prognosis 26 . Coryell & Tsuang 55 repor ted that outcome of acute psychosis is best if the duration of admission is shor ter, i.e., between 2 weeks to a month. A long term follow-up study in a developing country setting has compared the course of acute brief psychosis with that of other remitting psychoses at five, seven and twelve years after onset 51 . In the study, the long term prognosis of acute brief psychosis was excellent and remarkably homogenous, with only one out of seventeen subjects developing a chronic psychotic illness at 12 year follow-up. Interestingly, none of the seventeen cases developed an affective syndrome. On the contrar y, the long ter m prognosis of other remitting psychoses was often poor, with frequent relapses and one half of cases being ill at 12-year follow-up, possibly schizophrenia. There is some data regarding the stability of diagnosis over time and studies have repor ted varying results. In another study, which followed up the cases for 2 years, no case of acute non-affective- non organic psychosis case evolved into chronic or affective disorders 54 . In another follow-up study of, unspecified non-organic psychosis, Chaturvedi & Sahu 30 reported change in diagnosis in 46 % (21% affective, 16 % reactive psychosis, 9 % schizophrenia) cases. Fur ther regarding the recur rence of acute psychosis, Wig & Narang 56 reported that majority of cases are non-recurrent. Conclusions From the above review it is evident that acute psychosis is characterised by acute onset, is of brief duration and have good prognosis. However, the role of stress in cases of acute psychosis has not been established equivocally. Fur ther with the available data, there is a need to refine the criteria of ATP, validate the subtypes and understand the etiology. In relation to refinement of criteria many authors have also given there suggestions. Mojtabai et al 57 made an observation that recurrent acute psychosis, both in developing as well as developed countries, has a modal distribution of 2-4 months, often longer than the 1-3 months duration specified in the ICD-10 diagnosis for ATPD 57 . It has therefore been felt that if the duration criteria of the cur rent ICD-10 system to diagnose ATP are followed, there is higher likelihood of excluding a large proportion of cases. Hence, the duration criteria must be modified in ICD-10 and expanded to about 6 months 38,51 . Susser et al 51 also suggested to use a shor t ter m prognosis criterion of no psychotic relapse upto 2 years after onset and an exclusion criteria of presence of affective syndromes at onset or up to 2 years after follow-up.

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Reference: 1. 2. 3. 4. 5. Kraepelin, E. (1893) Psychiatric, 4 th Edition, J.A, Barth, Leipzig. Legrain M. Delire chez les Degeneres. Paris: These., 1886. Magnan V (1886) cit. Ey H. Bernard P. Brisset C (1963) Manuel de Psychiatrie, 2nd.rev.edition. Masson, Paris Wernicke C. Grundriss der Psychiatrie in Klinischen Vorlesungen, Thieme, Leipzig., 1894. Kleist K. Iiber cykloide, paranoide und epileptoide psychosen und iiber die Frage der Degeneratious psychosen Schweiz. Archiives of Neurology and Psychiatry, 1929; 23: 3-37. Kasanin J. The acute schizoaffective psychoses. American Journal of Psychiatry, 1933; 13: 97-126. Langfeldt G. The prognosis in schizophrenia and the factors influencing the course of the disease. Acta Psychiatrica et. Neurologica.,1937; Suppl., 13. Leonhard K.Cycloid psychoses- Endogenous psychoses which are neither schizophrenic nor manic-depressive. Journal of Mental Science, 1961;107: 632-648. Jaspers K.General Psychopathology (J. Hhoenig and M.W. Hamilton Transl.). Manchester, U.K.: Manchester University Press.,1963.

6. 7. 8.

9.

10. Faergeman P.Psychogenic psychoses. A description and follow-up of psychoses following psychological stress. London: Butterworth, 1963. 11. Hollender MH & Hirsch SJ. Hysterical psychosis. American Journal of Psychiatry,1964; 120:1066-1077. 12. Mitsuda, H. The concept of atypical psychoses from aspects of clinical genetics. Acta Psychiatrica Scandinavica,1965;41: 372. 13. Wig NN & Singh G. A proposed classification of psychiatric disorders for use in India. Indian Journal of Psychiatry, 1967; 9: 158-171. 14. Kapur RL, Pandurangi AK. A comparative study of reactive posycyhosis and acute psychosis without precipitating stress. British Journal of Psychiatry, 1979;135: 544. 15. S i n g h G . & S a c h d e v a J S . A c u t e s c h i z o p h r e n i c e p i s o d e s : A r e t h e y schizophrenics? Indian Journal of psychiatry,1981; 23: 200-205. 16. Chavan BS & Kulhara P. A clinical study of reactive psychosis. Acta psychiatrica Scand-inavica, 1988; 78: 712-715. 17. Indian Council of Medical Research (1985) Final report of phenomenology and natural history of acute psychosis, ICMR, New Delhi. 18. World Health Organization. The ICD-10 classification of mental and behavioural disorders. Geneva, World Health Organization, 1992.
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19. American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders, 4 th edition. Washington, DC, American Psychiatric Association, 1994. 20. Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. American Journal of Psychiatry 1970; 126:107111. 21. Malhotra S, Varma VK, Malhotra A. Classification of acute non organic psychotic states in India. International Journal of Mental Health, 1992-93; 21: 6-32. 22. World Health Organization: The ICD-9 Classification of Mental Disorders. Geneva, WHO, 1978. 23. Wing, J.K., Cooper, J.E. and Sar torius,N. (1974) Measurement and classification of Psychiatric symptoms. Cambridge University Press, Cambridge. 24. Susser E & Wanderling J. Epidemiology of non-affective acute remitting psychosis: sex and socio-cultural setting. Archives of General Psychiatry, 1994;51: 294-301. 25. Malhotra S, Varma VK, Misra AK, et al. Onset of acute psychotic states in India: A study of sociodemographic, seasonal and biological factors. Acta Psychiatrica Scandinavica,1998; 97: 125-131. 26. Susser E, Varma VK, Malhotra S. et al.Delineation of acute and trasient psychotic disorders in a developing country setting. British Journal of Psychiatry, 1995; 167: 216-219. 27. Varma VK, Malhotra S, Yoo ES, et al. Course and outcome of acute non-organic psychotic states in India. Psychiatric Quarterly, 1996;67: 195-207. 28. Pillmann F Haring A, Balzuweit S, Bloink R,Marneros A. The concordance of ICD, 10 acute and transient psychosis and DSM-IV brief psychotic disorders. Psychological Medicine, 2002;32, 525-533. 29. Chaturvedi SK, Sahu RN. Clinical and follow-up study of unspecified non-organic psychosis. Indian Journal of Psychiatry,1986;28:73-77. 30. Varma VK, Malhotra S, Jiloha RC. Acute non-organic psychotic states in India: Symptomatology. Indian Journal of Psychiatry, 1992;34: 89-101. 31. Das SK, Malhotra S, Basu D. Testing the stress- vulnerability hypothesis in ICD-10diagnosed acute and transient psychotic disorders. Acta Psychiatrica Scandinavica, 2001;104: 56-58. 32. Collins P Wig NN, Varma VK, et al. Psychosocial and biological aspects of acute brief , psychoses in three developing country sites. Psychiatric Quarterly, 1996; 67:177193. 33. Malhotra S,Malhotra S.Acute and Transient Psychosis: conceptual understanding and current status. In Mental Health in India 1950-2000 (Ed R.S. Murthy), PAMH Bangalore, 2001:17-41.
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34. Jorgensen, P., Bennedsen, J.,Christensen, J., et al. Acute and transient psychotic disorder: comorbidity with personality disorder. Acta Psychiatrica Scandinavica, 1996; 94: 460-464. 35. Maffei C, Madeddu F, Fossati A, Brancato V, Di Rosa E, Riva E. DSM-III-R brief reactive psychosis and personality disorders. Psychopathology,1995;28:140-6. 36. Kendler KS, McGuire M, Guenberg AM, et al.The Roscommon family study 11: the risk of nonschizophrenic non-affective psychoses in relatives. Archives of General Psychiatry, 1993;50: 645-652. 37. Das SK, Malhotra S, Basu D. Family study of acute and transient psychotic disorders: comparison with schizophrenia. Social Psychiatry and Psychiatric Epidemiology,1999; 34: 328-332. 38. Collins PY, Varma VK, Wig NN, Mojtabai R, Day R, Susser E. Fever and acute brief psychosis in urban and rural settings in north India. British Journal of Psychiatry, 1999;174: 520-524. 39. Wise TN, Lebuffe FP, Granger ST. Meningo-encephalitis presenting as an acute paranoid psychosis. International Journal of Psychiatry,1977; 8: 405414. 40. Klein RF, Betts R, Hom R, et al.Acute psyshosis in a 45-year old man with bipolar disorder and primary Epstein-Barr virus infection: A case report. General Hospital Psychiatry, 1984;6:13-15. 41. Jar vis WR, Wasserman AL,Fodd RD.Acute psychosis in a patient with Epstein-Barr virus infection. Journal of American Academy of Child & Adolescent Psychiatry, 1990;29:468-469. 42. Shriqui CL & Mileltte PC. You drive me carzy: a case report of acute psychosis and neurocysticerosis. Canadian Journal of Psychiatry,1992; 37:121-124. 43. Frasca J, Kilpatrick TJ, Burns RJ.Protracted form of encephalitis with good outcome. Medical Journal of Australia,1993;158: 629-630. 44. Srikanth S, Ravi V, Poornima K, et al. Viral antibodies in recent-onset, nonorganic psychoses, correspondence with sympathetic severity. Biological Psychiatry,1994; 36: 517-521. 45. Strik WK, Fallgatter AJ, Stoeber G, et al. Specific P300 features in patients with cycloid psychosis. Acta Psychiatrica Scandinavica,1997; 95: 67-72. 46. Strik WK, Dierks T, Maurer K. Amplitudes of auditory P300 in remitted and residual schizophrenics: Correlations with clinical features. Neuropsychobiology, 1993; 27: 54-60. 47. Strik WK, Dierks T, Franzek E, et al. Differences in P300 amplitudes and topography between cycloid psychosis and schizophrenia in Leonhards classification. Acta Psychiatrica Scandinavica,1993; 87: 179-183.
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48. Warketin S, Nilsson A, Karlson S, et al. Cycloid psychosis: regional cerebral b l o o d f l o w c o r r e l a t e s o f a p s y c h o t i c e p i s o d e . A c t a Ps y c h i a t r i c a Scandinavica,1992; 85: 23-29. 49. Singh, G.The nature of acute psychoses and their management. In: Continuing Medical Education Programme of Indian Psychiatric Society,1986; 6:23-30. 50. Okasha A, el Dawla AS, Khalil AH, Saad A. Presentation of acute psychosis in an Egyptian sample: a transcultural comparison. Compr Psychiatr y, 1993;34:4-9. 51. Susser E, Varma VK, Mattoo SK, et al. Long-term course of acute brief psychosis in a developing country setting. British Journal of Psychiatry, 1998; 173: 226-230. 52. 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. 53. Jorgensen A. Long term course of acute reactive paranoid psychosis. Acta Psychiatrica Scandinavica, 1995;71: 30-37. 54. Susser EPH, Fennig S, Jandorf L, et al. Epidemiology, diagnosis and course of brief psychoses. American Journal of Psychiatry, 1995;152: 1743-1748. 55. Coryell W & Tsuang MT. DSM-III schizohreniform disorder: comparison with schizophrenia and affective disorder. Archives of General psychiatry, 1982;39: 66-69. 56. Wig NN & Narang RL. Hysterical psychosis. Indian Journal of Psychiatry, 1969;11: 93. 57. Mojtabai R, Varma VK, Susser E. Duration of remitting psychoses with acute onset: implications for ICD-10. British Journal of Psychiatry, 2000;176: 576580.

Dr Sandeep Grover
Assistant Professor, Department of Psychiatry PGIMER, Chandigarh 160012, India

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