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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

HistoryAmentia 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


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 STATUSPrior 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


Other ATPD

Unspecified ATPD

F23.0 Acute polymorphic psychotic disorder without symptoms of schizophreniaICD 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



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 dur