REACTIVE PSYCHOSIS EVOLUTION OF

ACUTE AND TRANSIENTPSYCHOTIC DISORDER

SPEAKER: AMIT CHOUGULE

MBBS, DPMPG REGISTRAR

(MD PSYCHIATRY)CHRISTIAN MEDICAL COLLEGE,

VELLORE

LAYOUT 1. Introduction 2. History of reactive psychosis3. Concept of reactive psychosis4. Reactive Psychosis and ICD/DSM5. Reactivity as a etiology for psychosis6. Journey towards separate diagnostic category in

ICD7. Course and diagnostic stability of ATPD8. Future of ATPD9. Conclusion

Psychiatric sculptors and Psychiatric sculptures

The efforts to define homogenous groups of

mental disorders are very similar to the work

of a sculptor

The artist usually has to cut pieces of wood,

marble or clay in an attempt to give the

material an identifiable feature

But the material that has been cut continues

to exist as material left in the sculptor’s

workshop

CREATION OF PSYCHIATRIC DIAGNOSTIC GROUPS The history of psychiatry is full of the

efforts of scientists to create

identifiable diagnostic groups

Material of the psychiatric sculptor is

similar to clay

Psychiatrists usually change the form

of the diagnosis like the artist change

shape of the clay

While the volume remains the same

shape changes

THE UNDEFINED PSYCHOTIC MATERIAL

The separation schizophrenia from affective disorders left an

undefined group of psychotic disorders

Schizophrenia and affective disorders became more or less the

sculptures

But other psychoses that were difficult to define remained the

unformed and confused clay material left in the workshop of the

sculptor

Efforts to give this material a form by naming it ‘schizoaffective

disorders’ were only partially successful

(Marneros and Tsuang, 1986;Marneros et al., 1991b;Marneros, 1999, 2003; Marneros andAngst, 2000)

THE UNDEFINED PSYCHOTIC MATERIAL

Some material remained undefined, confused and unnamed

Many people are suffering from psychotic disorders that are: Not schizophrenia Not an affective disorder Not a schizoaffective disorder

Various Psychiatrist around the world have tried to define

this difficult part of the psychotic material

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

UNDEFINED PSYCHOTIC MATERIAL ACCORDING TO ICD 10 AND DSM IV

ICD-10 and DSM-IV recognise the area between

schizophrenia, affective and schizoaffective disorders

They tried to homogenise the various regional and

national concepts creating the group of :

1. Brief Psychoses (DSM-IV)

2. Acute and Transient Psychotic Disorders (ICD-10)

SYNONYMS FOR ATPD1. Acute (Undifferentiated) Schizophrenia2. Bouff´ee D´elirante3. Cycloid Psychoses4. Oneirophrenia5. Paranoid Reaction6. Psychogenic Psychosis7. Reactive Psychosis8. Schizophrenic Reaction9. Schizophreniform Attack Or Psychosis10. Remitting Schizophrenia11. Good Prognosis Schizophrenia

The existence of acute psychoses has been described by almost all important authors of the Pre-Kraepelinian period

Meynert in 1889 first described transient amentia (amnesia with a sad spirit) Psychotic confusional state Good prognosis

Emil Kraepelin’s dichotomy of dementia praecox and manic-depressive insanity

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

(Kraepelin, 1893, 1896, 1899)

HISTORY OF ACUTE PSYCHOSIS

KRAEPELIN’S DICHOTOMY

Kraepelin knew of Brief and Acute Psychoses

Could not be allocate it either to schizophrenia or to affective disorder

Such disorders could cause severe doubts regarding the reliability of

his dichotomy (Kraepelin, 1920)

Kraepelin allocated them either to manic-depressive insanity or to

dementia praecox

Majority of Brief and Acute Psychoses were allocated by Kraepelin to

the manic-depressive insanity group (Maj, 1984)

JUGGLE OF ACUTE PSYCHOSIS GROUP TO SCHIZOPHRENIA

Kraepelin’s dichotomic system was

reformed by Eugen Bleuler (1911)

Created the group of schizophrenias

Problem of the brief, acute, transient and

good prognosis psychoses persisted

Acute psychosis category was moved

from Kraepelin’s manic-depressive

insanity to Bleuler’s schizophrenia

A tradition which is still going on

OPPOSITION TO KRAPELINIAN DICHOTOMY

France: Bouffee DeliranteGermany: Motility Psychosis Cycloid PsychosisScandinavia: Psychogenic

psychosis Reactive Psychosis America: Schizophreniform

Psychosis Remitting

Schizophrenia

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

THE CYCLOID PSYCHOSES- GERMANY One of the main synonyms given by the WHO for ATPD

It was created and developed by three Karls’:1. Carl Wernicke2. Karl Kleist3. Karl Leonhard

Focused mainly on clinical and on genetic findings Demanded a separation from Kraepelin’s manic-depressive

insanity Fish (1964) introduced the concept of cycloid psychosis to

English speaking countries

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

BOUFFEE DELIRANTE- FRANCE1. Another important synonym given by the WHO for ATPD2. It can be regarded as the French root of ATPD and Brief

Psychoses3. The modern concept of bouffee delirante is based on

operational criteria like:1. Sudden onset2. Specific symptomatology3. Evolution of the disorder

4. French psychiatrists put more weight on course than on symptomatology

5. French psychiatric school has retained the category bouffee delirante as an independent mental disorder

(Pichot,1982)

ACUTE PSYCHOSIS - INDIA

Wig and Singh extracted psychiatric categories from the APA

DSM II relevant for use in India

They argued for the category of acute psychosis for brief

episodes precipitated by stress which does not fit into the

Kraepelinian dichotomy

They sub-classified acute psychosis into:

1. Confusional

2. Paranoid hallucinatory

3. Schizoaffective

4. Hysterical psychosis (K. S. Jacob, 2016)

Reactive or Psychogenic Psychoses

Synonym given by the WHO for Acute and

Transient Psychotic Disorders

Basic concept was developed by Karl Jaspers

The first monograph was written by August

Wimmer

The concept developed by Wimmer is based on

Jaspers General Psychopathology

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

Carl Jaspers Concept of Reactive states

Jaspers stressed that reactive states can be classified in different

ways:

1. According to what precipitates the reaction: Prison psychoses Psychoses due to earthquakes and catastrophe Reactions of homesickness Combat psychoses Psychoses of isolation due to linguistic barriers or deafness

2. According to the particular psychic structure of the reactive states

3. According to the type of psychic constitution that determines the

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

Reactive Psychosis Scandinavian countries use four concepts of

reactive psychoses: Two called Psychogenic psychoses:

1. Danish concept of purely psychogenic psychoses according to Wimmer and Strömgren

2. Norwegian concept of constitutional and psychogenic psychoses according to Langfeldt and Retterstøl

The other two considered as Reactive psychoses:

1. Functional psychoses with good outcome 2. Group of functional psychoses not clearly of

schizophrenic, chronic paranoid or manic depressive type

THREE VARIANTS OF REACTIVE PSYCHOSIS

1. Reactive psychosis as purely psychogenic psychosis:Psychological stress or conflict causes and shapes the

psychosisMental state normalizes on resolution of the conflict

2. Reactive psychosis due to an interaction between trauma and vulnerability:A predisposed person by personality or physical state is

overtaken by a stressful life event at a vulnerable momentHe can only react by psychotic decompensation

3. Reactive psychosis as simply a good outcome psychosis:This implies that the diagnosis cannot be made until the

course and outcome are known

REACTIVE/ PSYCHOGENIC PSYCHOSIS BY WIMMER

Wimmer stated that Psychogenic Psychoses were:

Clinically independent psychoses caused by mental

factors or traumas

Seen in predisposed individuals

Tendency to full recovery

In these cases trauma determines:

Time of onset

Course and the termination of the psychosis

Form and content of the psychosis

REACTIVE PSYCHOSIS BY ERIK STRÖMGREN

For Diagnosis psychogenic/Reactive psychoses he required:

1. Adequate mental trauma

2. Close temporal correlation between the trauma and the onset

of the psychosis

3. Determination of the content of the psychosis by trauma

4. Preoccupation with the traumatic experience

5. Course should have some relation to the traumatic situation

6. Remission in the course of days or few weeks

7. Good prognosis with complete recovery (Acute and transient psychosis by Andreas Marneros and Frank pillmann,2004)

THE TRAUMATIC FACTORS IN REACTIVE PSYCHOSIS

The traumatic factors:1. Experiences of impersonal character:

e.g natural catastrophes or war-like situations2. Experiences of personal character:

e.g economic loss, loss of job or imprisonment3. Conflicts within the family4. Experiences of verbal isolation: e.g refugees5. Experiences of inner conflicts:

Disagreements between parts of personalityConflicts of consciousness or blows to self-esteem

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

CLINICAL TYPES OF THE REACTIVE PSYCHOSIS

A. Emotional reactions: Reactive depression Anxiety Excitations Emotional paralysis

B. Disorders of consciousness: Delirious reactions States with clouded consciousness and amnestic states Depersonalization states

C. The Paranoid type: Paranoid psychoses associated with imprisonment, sensory

deprivation or lack of verbal communication Induced paranoid psychosis

DETERMINANTS OF CLINICAL FORMS OF REACTIVE PSYCHOSES PROPOSED BY STRÖMGREN

A. The emotional reactions were based on simple

situational traumas

B. Disorders of consciousness were caused by a sudden

disruption of the individual’s:

Image of environment

His ideas about other people and environment

C. The paranoid reactions were caused by:

Sudden blow to the self-esteem

Individual’s image of self

EPIDEMIOLOGY OF REACTIVE PSYCHOSIS

The diagnosis of reactive psychoses has been widely

used in the Scandinavian countries

The prevalence of reactive psychosis was:

1. Denmark 21%

2. Norway 30%

3. Sweden 13%

In 1979 half of all first admissions in Norway and Denmark

were labelled reactive psychosis

(M Taylor,1994)

Course of Reactive Psychosis

Faergeman followed up Wimmer's original 170 patients for 20

years

50% were diagnosed as schizophrenia

Retterstol found that 80% of his cases of reactive psychosis

relapsed over 15 years

This stability could be taken to validate the syndrome

(M Taylor,1994)

Course of Reactive Psychosis

Longitudinal studies from Norway indicated that:

1. Reactive psychosis can be differentiated from schizophrenia

and manic depressive illness

2. Outcome of reactive psychosis is intermediary between

schizophrenia and affective illness

3. 31% to 40% of reactive psychosis cohort became

schizophrenic eventually (Aksel bertelsen, reactive or psychogenic psychoses: the scandinavian concept)

SCANDINAVIAN BIAS TOWARDS REACTIVE PSYCHOSIS

Reasons for overgenerous initial diagnostic rate of reactive

psychosis in Scandinavia:

1. Unwillingness to diagnose schizophrenia on first admission

2. Scandinavians freely read their case-notes

3. Use of the schizophrenic category may be limited to chronic

forms

4. Diagnostic tradition established amongst Scandinavian

psychiatrists

(Aksel bertelsen, reactive or psychogenic psychoses: the scandinavian concept)

BRIEF REACTIVE PSYCHOSIS AS COMPOSITE SYNDROME

Guinness working in Swaziland (Africa) gave three broad

groupings for reactive psychosis:

1. Culturally sanctioned form of illness behaviour:

1. Depression presenting as a dissociative state

2. These cases react psychotically to minor life events

3. If they relapse they present as acute psychosis

than progressing to schizophrenia

(Aksel bertelsen, reactive or psychogenic psychoses: the scandinavian

concept)

2. Younger males presenting with repeated episodes of

transient psychosis:

○ Manifest as mania which can be years apart

○ Precipitated by major life events

○ The intervals between are normal

3. Cases that present as typical brief reactive psychosis but

who insidiously develop schizophrenia:

○ These individuals later exhibit formal thought disorder,

slower recovery and the social impairment as seen in

schizophrenia

REACTIVE PSYCHOSIS AND ICD

WHO ICD-8 reactive psychoses were included under the

category of “other psychoses” with five subcategories

In WHO ICD-9 reactive psychoses were included under

other non-organic psychoses

With a preliminary remark that they “should be restricted to

the small group of psychotic conditions that are largely or

entirely attributable to a recent life experience”

This allowed the wide use of the reactive psychoses in the

Scandinavian countries

(Aksel bertelsen, reactive or psychogenic psychoses: the scandinavian concept)

REACTIVE PSYCHOSIS AND ICD 10

ICD-10 had non-etiological or purely descriptive

approach

This did not allow nosological classification of the

reactive psychoses as a separate category

Reactive Psychosis was included under a new

category of Acute and Transient Psychotic Disorders

REACTIVE PSYCHOSIS AFTER ICD 10

Large difference were seen in prevalence of Reactive

Psychoses

Comparison between last two years of ICD-8 and of ATPD

in the first two years of ICD-10 in Denmark

In 1992 and 1993 Reactive Psychoses were diagnosed in

19.2% of non-organic psychoses

In 1994 and 1995 Acute and Transient Psychotic

Disorders were diagnosed in 8.7% of non-organic

psychoses

REACTIVE PSYCHOSIS AFTER ICD 10

Associated acute stress was recorded only in 5.3% in the patients with ATPD category

This was because the definition of associated acute stress was made too narrow

The distribution of ICD-10 diagnoses at readmissions in 1994 and 1995 of patients admitted in 1992 and 1993 with Reactive Psychoses showed:1. Only 20.1% in the category of ATPD2. 24% went to affective disorders3. 12% to schizophrenia4. 11% to chronic delusional disorders5. only few to stress-related disorders

REACTIVE PSYCHOSIS VS ICD 10 ATPD

CRITERION Reactive Psychosis ICD 10 ATPD

Psychosocial precipitant Must be present Not a prerequisite

Depressive, dissociative and other non-psychotic states

Can be present

Should not be present

1. The Psychogenic or reactive psychoses disappeared almost completely

2. The concept may have a future in the coming revision of ICD-11

3. More Focus on etiology in ICD-11 as compared to ICD-10

REACTIVE PSYCHOSIS AND DSM

In DSM-III category of Brief Reactive Psychosis:

Characterised by a sudden display of psychotic behaviour

that lasts at least several hours but less than 1 week

An acute and severe stressful event as a trigger mandatory

In DSM-III-R the maximum duration of Brief Reactive

Psychosis was changed to 1 month

Definition was more restrictive

Strict criteria were set for duration, character of symptoms

and severity of the mandatory stressor

REACTIVE PSYCHOSIS AND DSM

Brief Reactive Psychosis proved to be a very rare

condition even among high risk groups

The concept was dropped from DSM-IV

Category of Brief Psychotic Disorder was created in

DSM IV

Criterion of a severe stressor was moved from a

defining criterion to an optional specifier

REACTIVITY AS ETIOLOGICAL FACTOR FOR PSYCHOSIS

AIDS

STROKE, IHD

DIABETES

PSYCHOSIS

HIV

INFRACT

INSULIN

STRESS/ TRAUMA/ REACTIVITY AS A CAUSE FOR PSYCHOSIS

There is compelling epidemiological evidence

Two studies from the British National Psychiatric Morbidity

Survey reported that:

1. Adverse life events during the preceding 6 months were

associated with psychotic experiences in a sample of the

general population

2. Both cross-sectionally and longitudinally

Cumulative exposure to traumatic life events may increase risk

of psychosis

(Ruud van Winkel,2008)

STRESS/ TRAUMA/ REACTIVITY AS A CAUSE FOR PSYCHOSIS A first episode study in Iran found that:1. 75% of ATPD patients had experienced a significant life

event2. 4 weeks preceding the onset of their symptoms A first episode study in India reported:1. 69% of patients 2. Stress within two weeks of onset In a study from Chandigarh, India:1. Recent life events were more common in ATPD2. Recent life events studied were:

Job distress for menLeaving or returning to parental village for women (Ruud van Winkel,2008)

The role of stress may vary by gender and frequency of

episodes

Stressful events were more commonly reported among

female than male

In a study of cycloid psychoses:

1. 1/3 of first episode cases were precipitated by

somatic or psychic stressors

2. Impact of stress decreased in subsequent episodes

Migration is associated with increased risk for psychosis

Social defeat defined as a subordinate position or

outsider status is postulated as risk for psychosis

An important aspect of the social defeat hypothesis is

that it is a subjective phenomenon, ie, ‘‘defeat is in the

eye of the beholder”

STRESS REACTIVITY IN PSYCHOSIS

Increased risk for psychosis is associated with increased

emotional reactivity to the small stresses of daily life

The study sample of:

1. Psychotic patients in state of remission

2. First degree relatives of patients with psychosis

3. Healthy controls

Patients reported a greater decrease in positive affect and a

greater increase in negative affect than the healthy controls

when they encountered stress with the first degree relatives

displaying intermediate scores

(Ruud van Winkel,2008)

In a general population twin sample increased

psychometric risk for psychosis was associated with

increased emotional reactivity to stress

Cross trait cross-twin association between stress reactivity

and subclinical psychosis was found

Stress also increased the intensity of subtle psychosis-like

symptoms in the realm of daily life, both in patients and

their first-degree relatives

These findings suggest that the association between

stress and psychosis may be a consequence of an

underlying vulnerability, characterized by increased

emotional and psychotic reactions to stress

Behavioural Sensitization to Stress

Behavioural Sensitization is hypothesized to represent an

underlying mechanism for stress reactivity

Sensitization refers to the process whereby repeated

exposure to a certain event increases the behavioural and

biological response to later exposure to a similar event

even if the later exposure is not as severe

Increased emotional and psychotic reactions to stress may

be the result of such a process of behavioural sensitization

BIOLOGICAL MECHANISMS RELATING STRESS TO PSYCHOSIS

Need to understand sensitization and genetic underpinnings

of stress leading to psychosis

Two plausible hypothesis of the biological mechanisms

involved are:1. Hypothalamus-pituitary-adrenal (HPA) axis:

It mediates the principal adaptive response to perceived psychological or physiological stress

2. Dopamine system:This is considered to be important in the development of

psychosis

HPA DYSREGULATION AND PSYCHOSIS

An enhanced response to stress is mediated by activation

of the HPA axis

This is postulated to play an important role in the onset,

exacerbation and relapse of psychosis

Walker and Diforio proposed a Neural diathesis-stress

model:1. HPA axis may trigger a cascade of events resulting in

neural circuit dysfunction including alterations in dopamine signaling

2. This model is based on evidence regarding effects of cortisol on brain and behavior

The authors conclude that several lines of evidence suggest

a link between HPA activity and psychosis:

1. Cushing syndrome is associated with psychosis

2. Administration of corticosteroids can induce psychosis

3. Patients with schizophrenia and other psychotic disorders

manifest HPA dysregulation such as: Increased baseline cortisol and adenocorticotropic

hormone levels Increased cortisol response to a pharmacologic challenge Abnormalities in glucocorticoid receptors

Dopamine and Psychosis

Dopamine dysregulation is implicated in the development of

psychosis

A sensitization process involving dopaminergic dysregulation

of key brain areas has been proposed as the final common

pathway leading to psychosis

Stress and Dopamine Reactivity

Can Psychosocial stress affect dopaminergic reactivity??

The available literature relating stress to dopamine

reactivity can be divided into 3 complementary approaches:

1. Animal studies

2. Studies using experimental and metabolic stress models in

humans

3. Studies using true psychosocial stressors in humans

Dopamine and Psychosis in Humans: Dopaminergic Reactivity to Metabolic Stress To model the influence of stress on dopaminergic reactivity

2-deoxy-D-glucose (2DG) is used as a metabolic stressor

This induces a robust activation of the HPA axis

Also raises the plasma levels of homovanillic acid (HVA)

It has been consistently found that patients with psychosis

display an increased (HVA) response to metabolic stress

Unaffected siblings of patients with psychosis display an

increased HVA response to metabolic stress

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?

International pilot study of schizophreniaIPSS (1968-70) First major study to recognize the problem of acute

psychosis Agra was the center from India The main findings in relation to acute and transient

psychosis were:1. Course and outcome in developing world was better

than developed countries2. 25% of people diagnosed to have schizophrenia had

only one episode and good outcome These findings of the IPSS raised following questions:

1. Whether these subjects with good outcome had a separate psychosis?

2. Were they part of the schizophrenia group?

Determinants Of Outcome Of Severe Mental Health Disorders (Dosmed) (1978-80)

Designed to study:1. First onset psychosis2. Incidence of schizophrenia3. Findings related to acute and transient psychosis

Chandigarh was the Indian center

The incidence of broadly defined schizophrenia which

included non-affective, acute and remitting psychosis (ICD-9)

was 10 times higher in the developing world than in the

developed countries These patients also exhibited a benign course at two-year

follow-up

The cross-cultural study of acute psychosis (CAP) (1980-82)

The study aimed to:1. Differentiate ATPD from schizophrenia and manic depressive

psychosis2. Understand its relationship with psychological and physical

stress Sample size was 1004 patients with acute psychosis Main findings included:

1. 41.2% of patients had symptoms of schizophrenia2. 20% had Affective symptoms3. 41.7% reported stress at onset4. Two-thirds of the subjects remained without relapse at one

year follow-up

Indian Council of Medical Research’s Multicentre study of acute psychosis

Bikaner, Goa, Patiala and Vellore

Documented 52% of patients with acute psychotic

presentations who could not be classified as

schizophrenia or MDP

The findings of the Chandigarh Acute Psychosis Study

were similar with 40% receiving the label of acute

psychosis

RECOGNITION OF ACUTE PSYCHOSIS AS A SEPARATE CATEGORY

These studies provided evidence of a non-affective,

non schizophrenia psychosis with remission and good

outcome

Lead to the inclusion of acute and transient Psychosis

as a separate category in ICD-10

COURSE AND DIAGNOSTIC STABILITY OF ATPD

Recurrence of psychotic episodes is common

Not as common as in schizophrenia or bipolar disorder

Over 15 years of follow-up:

1. 30% of ATPD patients experienced a single episode

2. 50% had an episodic-remitting course

3. 20% had a chronic course

In the Chandigarh site of the DOSMeD study only one (6%)

out of 17 patients followed-up to 12 years had remaining

symptoms of illness at follow-up

DIAGNOSTIC STABILITY OF ATPD

Diagnostic stability differs widely by diagnosis and length of

follow-up

A small study of first-episode psychotic patients in Iran found

that 100% of those diagnosed with ICD-10 ATPD and DSM-

IV brief psychotic disorder maintained the same diagnosis

over 12 months of follow-up

In a 15-year follow-up of 197 patients diagnosed using both

the ICD-10 and DSM-IV the diagnoses of ATPD,

Schizophreniform and brief psychotic disorder were unstable

over time

DIAGNOSTIC STABILITY OF ATPD

A Danish study covering 15 years of register data found a 39%

stability rate of ATPD

Majority of patients transitioning to diagnoses of schizophrenia

or affective disorders

60% of the total ATPD sample developing another psychiatric

disorder by their third admission

DIAGNOSTIC STABILITY IN INDIAN STUDIES

Thangadurai et al. while analyzing the medical records of all patients with psychotic disorders found:

13.9% were diagnosed with acute psychosis Mean duration of follow-up was 13.2 months The diagnosis was revised to:1. Affective disorder in 9.2%

2. Schizophrenia in 26.4%

3. 11.5% presented with recurrent episodes of acute psychosis Four studies in India have evaluated the diagnostic stability of

ATPD for a follow up period from 12-36 months 63-100% of patients retained their diagnosis of ATPD at

follow-up

DIAGNOSTIC STABILITYDEVELOPING VS DEVELOPED NATIONS

In industrialized nations like Europe more than 50% of cases

with ATPD tend to change diagnosis into another category

schizophrenia and related disorders or affective disorders

Findings from developed countries have indicated that this

diagnosis changes to either schizophrenia or affective disorders

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 ATPD

1. Sudden onset

2. Female sex

3. Duration less than one month

4. Good premorbid functioning

5. Acute insomnia

Treatment No randomized clinical trials deal with these disorders

exclusively

In the Halle Study of brief and acute psychoses during

initial episode:

95% received an antipsychotic

21% an antidepressant

7% lithium

GENERAL TREATMENT RECOMMENDATIONS

1. Comprehensive assessment to evaluate comorbidities

and rule-out organic and substance induced causes

2. Atypical antipsychotics often at low initial doses as first

line of treatment

3. Continuation of treatment for a year

4. Coordination with the patients family and/or friends

5. Ensure treatment adherence and to education about

the disorder

FUTURE OF ATPD IN ICD-11 Working Group on the Classification of Psychotic Disorders (WGPD) is

recommending that the diagnostic focus be on its “polymorphic” clinical

presentation:

1. Sudden onset

2. Brief duration

3. High variability/fluctuation of psychotic and affective symptoms

WGPD is recommending that:

1. Subcategory F23.0 (Acute polymorphic psychotic disorder without

symptoms of schizophrenia) be retained as the clinical guideline for

ATPD

2. Delusional subtype (F23.3) be incorporated into the revised category

Delusional disorder

The (WGPD) also recommended that:

Present ICD-10 categories F23.1 (Acute polymorphic

psychotic disorder with symptoms of schizophrenia) and

F 23.2 (Acute schizophrenia-like psychotic disorder) be

collapsed into “Unspecified primary psychotic disorders”

if duration of disorder is less than 4 weeks

If duration is more than 4 weeks schizophrenia should

be diagnosed

Schizophreniform disorder is not recommended to be

introduced into ICD-11

ATPD IN ICD-11 VS DSM-5

The concept and clinical picture of ATPD in ICD-11 are

different from Brief psychotic disorder in DSM-5

DSM-5 uses 4 of the 5 clinical symptom criteria of

schizophrenia but not of a polymorphic and fluctuating nature

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

symptom duration compared to 1 month for brief psychotic

disorder in DSM-5

The rationale for this longer duration of symptoms is that the

modal duration of remitting psychoses with acute onset is

2–4 months

CONCLUSION Psychiatrists often subscribe to the Kraepelinian dichotomy

Attempt to label all functional psychosis as schizophrenia or

affective disorders

Clinical presentations of acute psychosis challenge such

categorisation

It is often difficult to recognise the classic Psychotic

syndromes at the onset of the illness

However these can be identified over time as they become

more obvious

Conclusion A useful diagnostic category needs to have

1. A central principle

2. Clear boundaries

3. Should be amenable to investigation, treatment and

prevention

There was uncertainty about the validity of reactive

psychosis and historical or national variations in nosology

With the publication of ICD 10 the concept appears to have

gained a permanent place in international classification

More work is necessary to tighten up the definition

Few concepts need to be defined:

1. What is an adequate precipitant

2. Its temporal relation to the psychosis

There is a need for greater precision in delineating

vulnerability, course and outcome in acute psychosis

Need for etiological/ dimensional classification system

Any classification that is only phenomenological-

descriptive in nature, as in the DSM system without a

validating biological criteria is far from ideal

The concept of ATPD has opened new vistas for further

research and theorization even about schizophrenias

and affective disorders

References 1. Acute and transient psychosis by Andreas Marneros and

Frank pillmann,20042. K. S. Jacob Indian Psychiatry and classification of psychiatric

disorders.Indian J Psychiatry 52, Supplement, January 20103. Savita Malhotra Acute and transient psychosis: A

paradigmatic approach.Indian J Psychiatry 49(4), Oct-Dec 2007 233

4. M Taylor Madness and Maastricht: a review of reactive psychoses from a European perspectiveJournal of the Royal Society of Medicine Volume 87 November 1994

5. Aksel Bertelsen Reactive or Psychogenic Psychoses: The Scandinavian Concept. Revista do Serviço de Psiquiatria do Hospital Fernando Fonseca

6. Ruud 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. 1095–1105, 2008

7. Wolfgang Gaebel*Status of Psychotic Disorders in ICD-11Schizophrenia Bulletin vol. 38 no. 5 pp. 895–898, 2012

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