Acute and Transient Psychotic Disorders

History
From several different parts of the world, there is occurrence of certain psychotic states other than schizophrenia and MDP 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

History
Amentia Theodor Meynert (1833 to 1898),Emil Kraepelin (1856 to 1926) a psychotic disorder with a remitting course and favorable outcome, Cycloid psychosis Two variants - Karl Kleist (18791960): Confusional insanity - contrasting phases of confused excitement and stupor, and motility psychosis - contrasting phases of hyperkinesis and akineses. A 3rd variant, anxiety-elation psychosis - Karl Leonhard (19041988). Still used by German, Scandinavian, & other European psychiatrists Influential for the formulation of ATPDs in ICD-10.

Bouffe dlirante (Legrain, Magnan) influential in formulating ICD-10 ATPDs. Common in Africa and the Caribbean, so categorized as a culture-bound syndrome in the DSM-IV-TR. Psychogenic or reactive psychosis A psychotic disorder with acute onset following external stress popular among Scandinavian psychiatrists Oneirophrenia acute onset of confusion, nightmare, or dream-like quality of all perceptions (hence the term oneirophrenia), extreme fear and anxiety, delusions, and visual hallucinations. Hysterical psychosis sudden and dramatic onset related to a profoundly upsetting event in the context of a hysterical personality

 Descriptions similar and grew out of different psychiatric traditions separated by cultural and linguistic boundaries all portray a non-organic, non-affective psychotic condition with acute onset and remitting course, the multiplicity of descriptions

Wig and Singh

First pointed the existence of ATPD in India

Kapur and Pandurangi

2 types of acute psychosis, based on presence or absence of stress pointed acute schizophrenia episode shouldnt be included in schizophrenia Reactive psychosis

Singh and Sachdeva

Chavan and Kulhara

ICMR

40% of patients with acute onset psychoses dont fit into either diagnosis of schizophrenia, MDP or depression

Most of the research on ATPD has been limited to India and Scandinavian countries

NOSOLOGICAL STATUS
Prior to ICD 10 no separate nosology & placed under broad category of schizophrenia.

DSM
Scandinavian concept of reactive or psychogenic psychosis is influential in the formulation of the DSM-III brief reactive psychosis a psychotic condition lasting less than 2 weeks that followed a significant psychosocial stressor and that involved emotional turmoil and one of the symptoms of loosening of associations, delusions, hallucinations, or disorganized or catatonic behavior.

 maintained in the DSM-III-R, but the allowable duration of symptoms was extended to 1 month. In DSM-IV and IV TR replaced by brief psychotic disorder, eliminating an identifiable psychosocial stressor as a diagnostic criterion. partly motivated by observation that many cases of brief psychosis are not precipitated by marked stressor & hence cant be labeled reactive. DSM-III and DSM-III-R criterion of emotional turmoil was removed from the DSM-IV & DSM-IV-TR criteria for brief psychotic disorder.

ICD 10
F23 ACUTE AND TRANSIENT PSYCHOTIC DISORDERS G1. An 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 fulfill the criteria for organically caused clouding of consciousness as specified in F05 A.

 G3. The disorder does not meet the symptomatic criteria for manic episode (F30), depressive episode (F32), or RDD (F33). G4. No evidence of recent psychoactive substance use sufficient to fulfil the criteria of 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 amounts or frequencies to which the subject is accustomed does not necessarily rule out the use of F23; this must be decided by clinical judgment.

G5. Most commonly used exclusion criteria: absence of organic brain disease (F0) or serious metabolic disturbances affecting the central nervous system (this does not include childbirth).

 A fifth character should be used to specify whether the acute onset of the disorder is associated with acute stress (occurring within two weeks prior to evidence of first psychotic symptoms). F23.x0 without associated acute stress F23.x1 with associated acute stress For research purposes it is recommended to further specify the onset of the disorder from a non-psychotic to a clearly psychotic state as either: abrupt (onset within 48 hours), or acute (onset in more than 48 hours but less than two weeks).

CLASSIFICATION IN ICD 10
The empirical classification in ICD 10 is based on the course of clinical picture (polymorphic), presence or absence of schizophrenic symptoms, and duration of the episode.
Without symptoms of schizophrenia Acute polymorphic PD With symptoms of schizophrenia Acute schizophrenia-like PD Other acute predominantly delusional PD

ATPD

Other ATPD

Unspecified ATPD

F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia

ICD 10 (a)the onset must be acute (from a nonpsychotic state to a clearly psychotic state within 2 weeks or less); ICD 10 DCR A. The general criteria for acute and transient psychotic disorders (F23) must be met.

(b)there must be several types of hallucination or delusion, B. The symptomatology is rapidly changing in both type changing in both type and intensity from day to day or and intensity from day to day or within the same day. 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. (c)there should be a similarly varying emotional state; and 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. (d)in spite of the variety of symptoms, none should be E. Any of the symptoms listed in Schizophrenia F20, G1.1 present with sufficient consistency to fulfil the criteria for and G1.2 that are present, are only present for a minority schizophrenia (F20.-) or for manic or depressive episode of the time since the onset, i.e. criterion B of F23.1 is not (F30.- or F32.-). fulfilled. If the symptoms persist for more than 3 months, the F. The total duration of the disorder does not exceed three diagnosis should be changed (F22.-) or (F28) is likely to be months. the most appropriate. Includes: bouffe dlirante without symptoms of schizophrenia or unspecified cycloid psychosis without symptoms of schizophrenia or unspecified

F23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia

ICD10

ICD 10 DCR

For a definite diagnosis, criteria (a), (b), and (c) specified for acute polymorphic psychotic disorder (F23.0) must be fulfilled

A. Criteria A, B, C, and D of acute polymorphic psychotic disorder (F23.0) must be met.

in addition, symptoms that fulfil the criteria for schizophrenia (F20.-) must have been present for the majority of the time since the establishment of an obviously psychotic clinical picture.

If the schizophrenic symptoms persist for more than 1 month, the diagnosis should be changed to schizophrenia (F20.-).

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.

Includes: bouffe dlirante with symptoms of schizophrenia cycloid psychosis with symptoms of schizophrenia

F23.2 Acute schizophrenia-like psychotic disorder

ICD 10 (a)the onset of psychotic symptoms must be acute (2 weeks or less from a nonpsychotic to a clearly psychotic state); (b)symptoms that fulfil the criteria for schizophrenia (F20.-) must have been present for the majority of the time since the establishment of an obviously psychotic clinical picture; (c)the criteria for acute polymorphic psychotic disorder are not fulfilled. If the schizophrenic symptoms last for more than 1 month, the diagnosis should be changed to schizophrenia (F20.-). Includes: acute (undifferentiated) schizophrenia brief schizophreniform disorder, brief schizophreniform psychosis Oneirophrenia, schizophrenic reaction Excludes: organic delusional [schizophrenia-like] disorder (F06.2) schizophreniform disorder NOS (F20.8)

ICD 10 DCR 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

ICD 10 (a)the onset of psychotic symptoms must be acute (2 weeks or less from a nonpsychotic to a clearly psychotic state); (b)delusions or hallucinations must have been present for the majority of the time since the establishment of an obviously psychotic state; (c)the criteria for neither schizophrenia (F20.-) nor acute polymorphic psychotic disorder (F23.0) are fulfilled. If delusions persist for more than 3 months, the diagnosis should be changed to persistent delusional disorder (F22.-). If only hallucinations persist for more than 3 months, the diagnosis should be changed to other nonorganic psychotic disorder (F28). Includes: paranoid reaction psychogenic paranoid psychosis ICD 10 DCR 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

ICD 10

ICD 10 DCR

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.

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

 Apart from diagnostic criteria, ICD-10 also provides diagnostic guidelines which include: Not meeting the criteria for manic or depressive episodes although affective symptoms may be prominent. Absence of organic causation although perplexity, confusion and inattention may be present. Absence of obvious intoxication by drugs or alcohol.

DSM IV TR
298.8 Brief Psychotic Disorder A. Presence of one (or more) of the following symptoms: (1) delusions (2) hallucinations (3) disorganized speech (e.g frequent derailment or incoherence) (4) grossly disorganized or catatonic behavior Note: Do not include a symptom if it is a culturally sanctioned response pattern. B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning. C. The disturbance is not better accounted for by a Mood Disorder With Psychotic Features, Schizoaffective Disorder, or Schizophrenia and is not due to the direct physiological effects of a substance or a GMC.

 Specify if: With Marked Stressor(s) (brief reactive psychosis): if symptoms occur shortly after and apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture Without Marked Stressor(s): if psychotic symptoms do not occur shortly after, or are not apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture With Postpartum Onset: if onset within 4 weeks postpartum

ICD vs DSM
ICD 10 for ATPD (a) an acute onset (within 2 weeks); (b) presence of typical syndromes, which are the basis for the sub-categorization into specific disorders; and (c) the presence of associated acute stress (within about 2 weeks of onset).
DSM includes only one disorder for psychotic presentations with a duration of at least 1 day but less than 1 month, regardless of type or course of the psychotic symptoms. Many cases of ICD-10 ATPDs would be categorized as schizophreniform disorder, BPD, or psychotic disorder NOS in DSM. acute onset is not a diagnostic criterion for any of the above DSM diagnoses, but a specifier for favorable prognosis.

COMPARISION

Epidemiology
rare, especially in industrialized settings 10 fold higher incidence in developing countries compared with industrialized countries Of all 1st contact non-affective psychoses 35 % in developing countries compared to only 6 % in industrialized countries. Age of onset was also younger (mid-20s) in the developing than developed (mid-20s to 30s) countries MC - polymorphic psychotic disorder without symptoms of schizophrenia (1/3-1/2) > with symptoms of schizophrenia more common among women than men

Etiology
Both biological and Socio-cultural factors as possible causes. BIOLOGICAL : higher P300 amplitude over the left hemisphere in AEPs than normal controls, suggesting a higher level of arousal. increased hemispheric blood flow during the psychotic episode that was directly related to symptom severity and that returned to a normal level after remission. febrile illness prior to the development of ATPD, which may in part explain the higher incidence of these disorders in developing country settings where infectious diseases are common.

 A study from India reported a higher risk of ATPDs and a lower risk of schizophrenia and mood disorders in the first-degree relatives of ATPD probands compared with schizophrenia probands. rapid cultural change and modernization in the developing countries expose individuals to loss of status and stress arising from role confusion, making individuals vulnerable to psychotic reactions.

 Among women in developing countries, departure from or return to their parental village was a major stressor in one study, whereas among men , job-related problems were the main stressor Proportion of patients who experience acute stress varies across studies, ranging from 1069%. Association with pre-existing personality disorders A psychodynamic formulation of brief reactive psychosis links this condition to deficient ego strength. intense emotionally stressful event absence of support in the environment, overwhelms the individual's ego defense mechanisms and PSYCHOSIS

Diagnosis and Clinical Features

(a) an acute onset (b) presence of typical syndromes, (c) the presence of associated acute stress Acute 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 less. Time to onset should not be confused with the time between symptom onset and peak illness severity, as the maximum severity of symptoms may occur weeks after symptom onset

 Similarly prodromal periods of anxiety, depression, social withdrawal, or mildly abnormal behaviour should not be counted in determining time to onset. Thus, the criterion for acute onset will still be met even if the individual reports weeks or months of these prodromal symptoms before the onset of illness. ICD-10 also suggests that a distinction be made between acute onset, and abrupt onset (i.e., onset within 48 hours), noting that the latter may be associated with even better outcome.

ICD-10 describes two typical syndromes: The polymorphic syndrome and The typical schizophrenic syndrome. The polymorphic syndrome consists of marked hallucinations, delusions, and perceptual disturbances that change from day to day or even from hour to hour. This state is frequently associated with symptoms of emotional turmoil, with intense transient feelings of happiness and ecstasy or anxieties and irritability. Although mood symptoms might be present, the criteria for a manic or depressive episode are not met.

 The schizophrenic syndrome requires that the ICD-10 symptom criteria for schizophrenia be met for the majority of the time since the onset, but less than 1 month. The schizophrenic syndrome might be associated with the polymorphic syndrome as in acute polymorphic psychotic disorder with symptoms of schizophrenia or stand alone as in acute schizophrenia-like psychotic disorder.

 The ICD-10 defines acute stress as events that would be regarded as stressful to most people in similar circumstances, within the culture of the person concerned. ICD-10 mentions bereavement, unexpected loss of partner or job, marriage, or the psychological trauma of combat, terrorism and torture as typical examples of acute stress. A diagnosis of ATPD requires ruling out typical manic or depressive episodes, alcohol or drug intoxication, delirium, dementia, and mental disorders due to medical etiologies.

DIAGNOSIS
Detailed history : From parents, relatives, spouse / friend regarding : Stressors, level of functioning before onset of illness, history of response to similar stressors in past. H/o onset, delusion(s),hallucination(s) & its frequency & rapidity of change R/o medical & substance induced disorders. Past history of similar illness which subsided with or without treatment. Family history Premorbid personality Examination : MSE rapidly changing/persistent delusion, hallucination, disorganised behaviour, emotional status, psychomotor activity, consciousness levels, cognitive functions. GPE & Syst. Examination : R/O organic etiology, Investigations

Differential Diagnosis
A definitive diagnosis of ATPD or BPD early in the first episode of illness is difficult if not impossible. Unless the psychosis has fully remitted, the duration of an episode of illness cannot be determined. Remission of psychotic symptoms within 1 month as a result of successful treatment also makes it difficult to distinguish BPD from other longer lasting disorders. In such instances, the presence of continued residual symptoms or impairment may be helpful in ruling out a diagnosis of BPD. DD: delirium, dementia, psychotic disorder due to medical illness, and drug or alcohol intoxication or withdrawal.

 The temporal relationship b/w onset of psychosis & the pattern of substance abuse may be helpful in differentiating a substance-induced psychotic episode from a nonsubstance-induced one. Acute psychotic episodes have been reported in a no of GMC including head trauma, cerebral anoxia, epilepsy, and endocrine disorders such as hyper- or hypothyroidism. Many of these episodes are associated with disturbances of consciousness. Differential diagnosis is often based on a thorough medical history and physical examination as well as laboratory investigations. Good prognosis of BPD and of ATPD, variability of symptoms, and the presence of mood symptoms sometimes make it difficult to differentiate these diagnoses from mood disorders.

 Patients with personality disorders, especially borderline personality disorder, sometimes experience psychotic symptoms under stressful life circumstances. These symptoms are generally transient and do not require a separate diagnosis. If the symptoms last more than 1 day, an additional diagnosis of BPD may be warranted. A no of culture-bound syndromes with acute onset of psychotic and dissociative symptoms have been described in various cultural settings. Many of these syndromes are transient and resolve spontaneously without antipsychotic medication treatment.

Course and Prognosis

ATPDs have a favorable early course by definition: Full remission within 1 to 3 months is a diagnostic criterion in ICD. Recurrence rates of 39 47 % have been reported in 1st admission samples followed for 3 to 4 years, but full recovery is common. Only about 6 -18 % of patients have any residual symptoms at a later point of time, although some studies have shown that the duration of nonaffective psychoses with acute onset and remitting course may extend up to 6 months.

GOOD PROGNOSIS
Good Premorbid adjustment Few premorbid schizoid traits Severe precipitating stressor Sudden onset of symptoms Affective symptoms Confusion, Perplexity during psychosis Little affective blunting Short duration of symptoms Absence of schizophrenic relatives

TREATMENT
Short-term treatment Acute psychotic syndromes require early hospitalization in inpatient psychiatric unit. 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 antipsychotic therapy in order to eliminate an organic cause (a GMC or substance abuse disorder can present with ATP symptoms). The choice of antipsychotic drug depends on the clinician's experience and the clinical features.

 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. Worsening of the symptoms, serious side-effects, or a poor response to pharmacotherapy are the main indications for ECT.

 Prevention of recurrence possibility that psychotic symptoms may re-emerge during the first 2 years of follow-up. 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.

RESEARCH
Research on ATP supports the notion that there is: (i) Genetic distinctiveness of ATP. Although the findings point towards genetic distinctiveness of ATPD, it is hypothesized that ATPD may be an environmentally induced psychotic condition superimposed upon an underlying vulnerability to psychosis. What type of psychosis the patient is likely to develop, could be related to: (ii) The timings of brain insult, e.g., early-life insult may lead more often to schizophrenia and later-life insult may lead to ATP.

(iii) The severity of brain insult where ATP may be associated with less severe insult.
As there are also good outcome schizophrenias, ATP and schizophrenia may lie on a continuum of severity.

 There may be a common genetic liability to psychosis and further distinction between schizophrenia, MDP and ATPD could lie on two dimensions: a) Symptoms dimensions, where symptoms of schizophrenia schizoaffective psychosis ATPD affective psychosis with psychotic symptoms affective psychosis without psychotic symptoms lie on a continuum. (b) Course dimension, which may vary from chronic deteriorating recurrent with varying levels of recovery single episode with full recovery. Complex interplay between genetic, biological and environmental factors could produce different phenotypic variations recognized in contemporary literature as schizophrenia, MDP or ATPD.

DSM V and ICD 11

The DSM-5 diagnostic criteria for this disorder are similar to those in DSM-IV, with very minor wording changes being proposed. The specifier With Catatonic Features is added. 298.85 (Brief Psychotic Disorder) Dimensions will be assessed on a 0-4 scale cross-sectionally, with severity assessment based on past month. ICD 11 A diagnostic classification of Nonaffective acute remitting psychosis (NARP),also termed as acute brief psychosis 4 criteria would be central to the diagnosis: 1) nonaffective 2) acute onset (over < two weeks), 3) recovery within a brief duration (< six months) 4) psychosis broadly defined.

CONCLUSION
Acute and Transient Kraeplins dichotomy. psychotic disorders have disproved

ATPD disorders are eminently treatable and have a good long term course and favorable outcome Family, genetic and imaging studies are needed to firmly establish acute and transient psychotic disorders as a distinct clinical entity Research on ATPD in India has made a significant contribution and this is one area where Indian research has made a mark at the international level.

THANK U