Acute and transient psychotic disorder: comorbidity with personality disorder

A study sample of 51 patients with acute and transient psychotic disorder (ATPD) (ICD-10) is presented. The findings suggest that, in hospital settings, ATPD is a non-frequent condition with onset in early adult life and most often associated with female sex, good premorbid social functioning and no or minor/moderate psychosocial stressors. The DSM-IV criteria distribute the patients into three diagnostic categories: schizophreniform disorder (41%), brief psychotic disorder (33%) and psychotic disorder not otherwise classified (25%). A high prevalence (63%) of personality disorders (PD) is revealed after recovery from the psychotic episode. The ATPD is not related to any specific PD, and in a substantial minority (37%) of cases no PD is found. The unspecified category is by far the most frequent PD in patients with ATPD. The sample will be followed up and reassessed.     

The relationship of reactive psychosis and ICD-10 acute and transient psychotic disorders: evidence from a case register-based comparison

BACKGROUND: ICD-10 introduced a new diagnostic category, F23 'acute and transient psychotic disorders' (ATPD), to embrace clinical concepts such as bouffée délirante, cycloid psychosis, psychogenic (reactive) psychosis and schizophreniform psychosis. The purpose of this study was to examine the relationship between the concept of reactive psychosis (RP), equivalent to the ICD-8 298 category of 'other psychoses', and ATPD. SAMPLING AND METHOD: Since January 1, 1994, ICD-10 has replaced ICD-8 as official classification in Denmark. Patients given an ICD-8 298 diagnosis on their last admission in 1992-1993 were identified from the Danish Psychiatric Central Register, and the ICD-8 diagnoses assigned were compared with their ICD-10 diagnoses when readmitted in 1994-1995. RESULTS: Diagnosis of RP was recorded in 19.2% of patients with functional psychoses in 1992-1993, whereas ATPD overall prevalence accounted for 8.7% of those with non-organic psychotic and affective disorders in 1994-1995. Thirty-eight per cent of patients with an ICD-8 298 diagnosis were readmitted during the years 1994-1995. Schizophrenia and related disorders (F2) and affective disorders (F3) accounted for three quarters of ICD-10 diagnoses. The most frequently used ATPD subcategories were F23.3 'other acute delusional psychotic disorders', F23.0 'acute polymorphic psychotic disorder without symptoms of schizophrenia' and F23.9 'acute and transient psychotic disorder unspecified'. A significant majority were female and associated acute stress was recorded only in 5.3% of cases. CONCLUSIONS: ICD-8 298 register diagnosis of RP showed little empirical continuity to ATPD and conformed more to F23.3 acute delusional disorder among ATPD subtypes.     

Acute and transient psychotic disorders

Psychotic disorders with acute onset, a dramatic and polymorphous symptomatology and rapid resolution have been described in different countries and by different psychiatric schools. They have been called cycloid psychosis, bouffée délirante, psychogenic psychosis or good prognosis schizophrenia. ICD-10 has given an operational definition under the name "acute and transient psychotic disorders" (F23). Their nosological status is unclear. The Halle-Study of acute and transient psychotic disorders (ATPD) has investigated in a prospective manner clinical, para-clinical features and course of illness in 42 patients with ATPD and matched controls with positive schizophrenia, bipolar schizoaffective disorders as well as mentally healthy patients with acute surgical conditions. First results of our study show that ATPD amount to 4% of psychotic in-patients, prefer female sex, show short prodromi, marked affective disturbances within the episode and much better outcome as schizophrenic psychoses according to psychopathological, social, psychological and biographical criteria. Though ATPD may still be an inhomogeneous group, their clinical delineation from schizophrenia seems justified.     

Acute and transient psychotic disorders: An overview of studies in Asia

Abstract

Acute and transient psychotic disorders (ATPD), introduced in the International Classification of Diseases (ICD-10) diagnostic system, have not received much attention in Asia. As the World Health Organization (WHO) is in the process of revising the ICD-10 and ICD-11 is expected to be published in the near future, it seems appropriate to review the status of ATPD in this region. A PubMed search using appropriate keywords was conducted to identify literature describing samples from Asian countries with the diagnosis of ATPD for evidence of ATPD as a distinct diagnostic group. A total of 103 papers were found, but only nine publications were specifically related to ATPD and the ICD-10 criteria. The total number of patients receiving a diagnosis of ATPD in these studies was 390. Immigrants appear prone to ATPD, especially foreign domestic workers. When compared to schizophrenia, ATPD as a group had a different family history, course and outcome. However, ATPD was diagnostically unstable over time. A range of 35.5% to 73.3% in Asian patients with baseline ATPD retained their diagnoses over 3–12 years. Most individuals with polymorphic subtypes of ATPD in India and Hong Kong were rediagnosed with bipolar disorder after 3–5 years. In Japan, 31.2% of polymorphic cases were diagnosed as schizophrenia after 12 years of follow-up. This review supports the ICD-10 concept of separating ATPD into its own group; however, polymorphic subtypes may need revision in ICD-11. Before firm suggestions are submitted to the WHO, further research and data review from other regions is necessary.     

Features of acute and transient psychotic disorders

Background Little is known about acute and transient psychotic disorders (ATPD), a diagnostic category introduced with ICD-10. Aims To determine the clinical and sociodemographic features, course and outcome of ICD-10 ATPD in a prospective and longitudinal study. Method We recruited all consecutive inpatients fulfilling the ICD-10 criteria of ATPD during a 5-year period. Demographic and clinical features were systematically evaluated and follow-up investigations were carried out at an average of 10 years after onset of the disorder using standardized instruments. Results ATPD patients represented 8.5% of all inpatients with non-organic psychotic disorders.ATPD were characterized by female preponderance. In two-thirds of the cases a typical polymorphic symptomatology was found. In spite of the fact that the possibility of relapse within 5 years was high, the psychopathological and social outcome for most of the patients was very favourable.Schizophrenic episodes during follow-up were rare (7.7% of patients), but a strictly monomorphous course (ATPD episodes only) from index episode to the end of the prospective follow-up was found in only 53.9% of the patients. Conclusion ATPD are not a sharply demarcated and unchanging nosological entity. Nevertheless, the present data support a delineation of ATPD as a diagnostic category with specific clinical features and with a usually favourable prognosis. Further research on the topic is necessary.     

Neuropsykiatriska Föreningen i Finland: Dess 97:nde möte, 2. oktober 1948

Abstract

Background: Acute and transient psychotic disorder (ATPD; F23, ICD-10) is an acute, short-lived psychosis, which has variable prevalence worldwide and has not been extensively studied. Aims: To explore the first episode of ATPD in patients in Latvia by describing the clinical features, analyzing the longitudinal changes of diagnosis and associated socio-demographic characteristics. Material and Methods: Retrospective chart review of all first-time hospitalized patients fulfilling the ICD-10 criteria for ATPD treated at the Riga Centre of Psychiatry and Addiction Disorders, Latvia, during a 3-year period. Patients were followed-up and assessed using standardized instruments. Results: During a 3-year period, 294 patients were first-time hospitalized with a ATPD diagnosis; 54% were women. The average age at first psychotic episode was 35.7 ± 12.3 years for women, and 30.0 ± 10.8 years for men (P < 0.0001). Over an average of 5.6 years follow-up period, 51% of patients were not re-hospitalized. Later diagnosis was changed to schizophrenia in 73% of the re-hospitalized patients, mostly within the first 2 years of illness. The overall stability rate of ATPD diagnosis reached 58%. Typical polymorphic symptomatology, abrupt onset (i.e. within 48 h), less frequent anxiety, but more frequent hallucinations were observed in ATPD patients that later developed schizophrenia (P < 0.05). Stressful life events in the 6 months prior to the first episode were found in 44% of patients. Conclusions: Combining these assessments from first-episode ATPD patients in Latvia, with data from other countries may help to predict the development of disease and provide the possible basis for potential changes to ICD-11.     

Concordance of acute and transient psychoses and cycloid psychoses

OBJECTIVE: We prospectively investigated a sample of 42 patients with acute and transient psychotic disorder (ATPD) as defined by the 10th revision of the International Classification of Diseases (ICD-10; F23) to determine the clinical and demographic features of this entity and its relationship to cycloid psychoses. METHODS: During a 5-year period, all in-patients with ATPD were identified. We systematically evaluated demographic and clinical features and carried out follow-up investigations on average 2 years after the index episode, using standardised instruments. RESULTS: We found 42 cases of ATPD (4.1%) among 1,036 patients treated for psychotic disorders or a major affective episode. There was a marked female preponderance in ATPD (79%). Fifty-five percent of cases concurrently met the criteria of cycloid psychosis according to Perris and Brockington [in Perris C, Struwe G, Jansson B (eds): Biological Psychiatry. Amsterdam, Elsevier, 1981, pp 447-450]. There was no difference in gender distribution between cycloid and non-cycloid ATPD. As expected, abrupt onset and polymorphic features were significantly more common in cycloid than in non- cycloid ATPD. At follow-up, patients with cycloid ATPD showed less persistent alterations and better social functioning. CONCLUSION: ATPD as defined by ICD-10 is a heterogeneous category. A diagnosis of cycloid psychosis is made in half of the cases of ATPD, and in these cases, the prognosis is more favourable.     

Is the psychopathology of acute and transient psychotic disorder different from schizophrenic and schizoaffective disorders?

OBJECTIVE: This study explores psychopathological aspects of acute and transient psychotic disorders (ATPD), a diagnostic category introduced with ICD-10, to elucidate its relationship with schizophrenia and schizoaffective psychoses. METHODS: We recruited all consecutive inpatients fulfilling the ICD-10 criteria of ATPD (F23) during a 5-year period as well as control groups with "positive" schizophrenia (PS) and bipolar schizoaffective disorder (BSAD) matched for gender and age at index episode. For the evaluation of psychopathological parameters during index episode a standardized symptom list was used. Prepsychotic (prodromal) symptoms were also assessed. RESULTS: During the prepsychotic period few differences between the groups were detected. The most important difference between ATPD and the other two other psychotic disorders regarding phenomenology of the full-blown episodes was a higher frequency of "rapidly changing delusional topics", "rapidly changing mood" and anxiety in ATPD. CONCLUSION: ATPD show a characteristic psychopathological picture consistent with earlier concepts such as cycloid psychoses and bouffée délirante. Nevertheless, psychopathology alone is not enough to establish ATPD as an independent nosological entity.     

Suicidal behavior in acute and transient psychotic disorders

The aim of the study was to investigate the frequency and characteristics of suicidal behavior in a cohort of patients with acute transient psychotic disorder (ATPD), diagnosed according to ICD-10 (F23). In a longitudinal study, 42 patients fulfilling the ICD-10 criteria of ATPD were investigated in comparison to matched control groups with 'positive schizophrenia' (PS) and bipolar schizoaffective disorder (BSAD). Suicidal behavior was studied in the index episode and during the long-term course, including a 5-year prospective follow-up. The prevalence of suicidal behavior during the entire course of illness in ATPD was 35.7% compared to 57.1% in BSAD and 40.5% in PS. The difference was not significant when the duration of the illness was taken into account. Suicidal behavior in ATPD was associated with the acute episode, while in PS, suicidal behavior mainly occurred during the longitudinal course. In logistic regression models, suicidal behavior was associated with a higher educational level and lower conscientiousness in the NEO Five-Factor Inventory for patients with PS, but not ATPD. Suicidal behavior in ATPD is frequent, in particular during the acute episode. It seems to be associated with the dramatic psychotic symptomatology during the acute episode.     

The effect of the menstruation cycle on manifestations of pychiatric diseases

In the present study we investigated whether a correlation exists between menstrual cycle phase on the day of an acute psychiatric admission and diagnostic entities. Therefore we assessed the menstrual cycle phase in 155 women at the time of acute admission for any non-organic psychiatric disorder. A specific diagnosis according to ICD-10-criteria and to Leonhard's nosology was established without knowledge of the menstrual cycle phase. Independent of diagnosis and classification, the majority of patients (57%) was admitted during the pre-menstrual/menstrual period. Comparing the frequencies of admission before (increasing blood-estrogen-level) and after ovulation (decreasing blood-estrogen-level) we found using ICD-10 criteria there were no significant differences between affective psychoses (F3), acute polymorphous psychotic disorder (F23), schizophrenia/schizoaffective psychoses (F20 and F25) and patients suffering from neuroses or personality disorders (F4-F6). Applying Leonhard's criteria we found no significant differences between endogeneous psychoses and personality disorders and no significant differences between cycloid psychoses and affective psychoses or affective psychoses and schizophrenias as well. However, patients with cycloid psychoses were significantly more frequently admitted to hospital during the luteal-/menstrual phase than patients with schizophrenia (chi 2-Test, p = 0.02). These findings do not confirm a specificity of a pre-menstrual exacerbation of psychotic symptoms for schizophrenia. Rather we found cycloid psychoses to be significantly more frequently associated with premenstrual exacerbation of symptoms.     

Bouffée délirante and ICD-10 acute and transient psychoses: a comparative study

OBJECTIVE: ICD-10 acute and transient psychotic disorder (ATPD; F23) has one of its historical roots in the French concept of bouffée délirante. This study explores the empirical relationship of the two concepts. METHOD: During a 5-year period, all inpatients with ATPD were identified; the diagnosis of bouffée délirante was also determined. We systematically evaluated demographic and clinical features and carried out follow-up investigations at an average of 2.2 years after the index episode using standardized instruments. RESULTS: Forty-two (4.1%) of 1036 patients treated for psychotic disorders or major affective episode fulfilled the ICD-10 criteria of ATPD. Of these, only 28.6% also fulfilled the criteria of bouffée délirante. Patients with bouffée délirante were significantly younger than the remaining ATPD patients. Outcome parameters were generally more favourable for patients diagnosed with bouffée délirante than for ATPD patients without a concurrent diagnosis of bouffée délirante, but the difference was statistically significant only for occupational status. CONCLUSIONS: There are indications that a diagnosis of bouffée délirante carries a somewhat better prognosis than ATPD in general. However, the low frequency of operationally diagnosed bouffée délirante suggests that the criteria might be too narrow.     

Incidence and diagnostic stability of ICD-10 acute and transient psychotic disorders

OBJECTIVE: The 10th Revision of the International Classification of Diseases (ICD-10) introduced a new diagnostic category, F23 acute and transient psychotic disorders (ATPD) to embrace clinical concepts such as the French bouffée délirante, Kleist and Leonhard's cycloid psychoses, and the Scandinavian reactive and schizophreniform psychoses. The relative rarity of these disorders and insufficient follow-up studies with adequate numbers of patients makes ATPD classification as uncertain as their validity. The aim of this study was to evaluate incidence and validity of ATPD in terms of diagnostic stability. METHOD: A 6-year analysis of readmission patterns of all subjects listed in the Danish psychiatric central register as having been first-ever admitted to hospital or treated in outpatient services with a diagnosis of ATPD from January 1 to December 31, 1996, was conducted. RESULTS: The incidence of ATPD was 9.6 per 100 000 population, with a higher rate of females than males (9.8 vs 9.4). Incidence rates by age group were higher for males than for females, with a marked reversal of this pattern above 50 years. This contrasted with incidence of schizophrenia that was almost twice as high in males as in females, particularly in the 20-29 year age group. Of 416 cases with a first-admission diagnosis of ATPD, an increasing number tended to change on subsequent admissions, nearly half to another F2 category schizophrenia and related disorders. The overall stability rate reached only 39%. CONCLUSIONS: Although demographic differences from schizophrenia are topics that deserve further research, poor diagnostic stability argues against attempts to separate ATPD from borderland disorders.     

Outcome of first-episode acute and transient psychotic disorder in Hong Kong Chinese: a 20-year retrospective follow-up study

Background: ‘Acute and transient psychotic disorder’ (ATPD) is a category in ICD-10 marked by psychosis with acute onset and early remission. It remains relatively under-researched, despite controversies over its nosological status in the current classification system.

Aims: (1) To assess the changes in diagnosis over time in patients initially diagnosed as ATPD. (2) To identify factors predicting changes in diagnosis, and compare the long-term outcomes of various patterns of diagnostic shift. (3) To make recommendations on the classification and treatment of ATPD based on the findings of the study.

Methods: This was a retrospective longitudinal study based on review of medical records of patients first admitted to a regional hospital in Hong Kong for ATPD during the period from 1990–2000.

Results: Of the 87 subjects initially diagnosed as ATPD, 64.4% had their diagnoses revised over an average of 20 years, mostly to bipolar disorder and schizophrenia. Among those with diagnosis of ATPD unchanged, 54.8% had one single episode, while the remaining 45.2% had recurrence. Subjects with diagnostic shift had significantly younger age of onset, more first-degree relatives with a history of mental illness, and more subsequent psychiatric admissions.

Conclusions: ATPD is likely a composite category consisting of clinically distinct outcome groups, for which further research is warranted to identify diagnostic features that distinguish them at initial presentation and revise the current nosological status of ATPD. Long-term follow-up, judicial use of antipsychotics, and education on prognosis are of paramount importance in managing patients diagnosed with ATPD.     

Predicting features of later development of schizophrenia among patients with acute and transient psychotic disorder

It is acknowledged that a considerable proportion of patients who have an episode of acute and transient psychotic disorder (ATPD), will develop schizophrenia after the episode is remitted. If features discriminating the patients who later developed schizophrenia from those who underwent a monomorphous ATPD-only course are discerned, they may be useful for predicting the prognosis. The authors performed a chart review study of those who were hospitalized with the diagnosis of ATPD and followed up thereafter for >5 years and compared two subject groups: 10 later-schizophrenia-developing (SD) patients and 15 non-schizophrenia-developing (non-SD) patients. Assessment of the subjects, conducted by two psychiatrist raters blind to the subject groups, included frequency of ATPD episodes, adaptation levels and life events before admission, and psychiatric symptoms before and after admission. The interrater reliability of the assessment proved to be favorable. As a result, early recurrence of psychotic episodes in the follow-up period, lack of acute upsurge of insomnia in an early phase of the episode and poor premorbid heterosexual relations characterized the SD patients. The result indicated heterogeneity of ATPD episodes.     

Acute and transient psychotic disorders (ICD-10 F23): a review from a European perspective

The tenth revision of the International Classification of Mental and Behavioural Disorders (ICD-10) introduced the category F23 ‘Acute and transient psychotic disorders’ (ATPD) to incorporate clinical concepts such as the French bouffée délirante, cycloid psychosis (Germany), and the Scandinavian reactive and schizophreniform psychoses. The aim of this paper is to review the literature on ATPD and to examine how it has been differentiated from the other categories of F2 group ‘schizophrenia and related disorders’. Papers published between 1993 and 2007 were found through searches in Medline, PsychInfo and Google Scholar. Further references were identified from book chapters and comprehensive reviews of the topic. ATPD is reported as being prevalent in females and as having onset in early-middle adulthood. Although follow-up studies suggest that its outcome is more favourable than other disorders in the F2 group, ATPD tends to recur and half of cases convert mainly into either schizophrenia or affective disorders. No evidence supports the view that the traditional conditions subsumed under ATPD all refer to this diagnostic category. The lack of defining features and poor prognostic validity argue against the separation of ATPD from borderland categories.     

What is schizophrenic in acute and transient psychotic disorder?

Acute and transient psychotic disorder (ATPD) is supposed to differ from schizophrenia, but little research has been done on the subject. In a prospective longitudinal case control study we compared all inpatients with ATPD (ICD-10 F23) treated at Halle University Hospital during a 5-year period with matched controls with "positive" schizophrenia (PS) and with mentally healthy controls. Followup investigations were performed at a mean of 2.2 years after the index episode or 8.2 years after the first episode. Female preponderance in ATPD was marked (78.6%). ATPD and PS patients were similar to each other (but different from healthy controls) in the prevalence of a "broken home" situation and a family history for mental disorders. Compared with PS patients, ATPD patients showed better premorbid social adaptation, and they more often displayed rapidly changing symptoms in the index episode and a negative life event preceding the episode. Despite comparable relapse rates, at followup ATPD patients showed better social adaptation, less psychological impairment, and better global functioning than PS patients. These data support the delineation of ATPD from schizophrenia.     

Nosological status of the intermediate area between schizophrenia and affective disorder]

Non-organic psychoses diagnosed with neither schizophrenia nor affective disorder are an aggregation of heterogeneous psychotic disorders including major groups such as acute polymorphic psychotic disorders and schizoaffective disorders. Historically, similar psychotic pictures have been reported in various cultures. However, their slightly different definition hindered comparative studies. Even after the establishment of an operational diagnostic guideline such as ICD-10, epidemiological studies on this intermediate area between schizophrenia and affective disorder have brought different findings, making the reliability of diagnosis of this area questionable. Moreover, the situation is further complicated that there exists not only cases which have repeated the same episode as the first, but also cases whereby the diagnosis has been changed to schizophrenia or affective disorder over a long-term course. K. Schneider, who suggested not differential diagnosis but differential typology in the area of endogenous psychoses, is right in thinking of the existence of this intermediate area. We should be satisfied with making a provisional diagnosis, should take a flexible attitude towards changes in diagnosis between episodes. And during diagnosis, we should not differentiate schizophrenia from affective disorders rigidly, nor define the intermediate area strictly.     

Schizophreniform disorder,delusional disorder and psychotic disorder not otherwise specified: clinical features,outcome and familial psychopathology

The relationship between DSM-III-R schizophreniform disorder, delusional disorder (DD) and psychotic disorder not otherwise specified (PD-NOS) and schizophrenia and affective illness (AI) remains uncertain. We explore this question in the Roscommon Family Study by examining symptoms, outcome and patterns of psychopathology in relatives. Probands were selected from a population-based case registry in the west of Ireland with an ICD-9 diagnosis of schizophrenia or AI. Personal interviews were conducted with 88% of traceable, living probands, a mean of 16 years after onset, and 86% of traceable, living first-degree relatives. Best-estimate diagnoses were made at follow-up. Schizophreniform disorder, DD and PD-NOS constituted 6.4%, 2.8% and 7.5%, respectively, of all probands with a registry diagnosis of schizophrenia. Probands with schizophreniform disorder had prominent positive psychotic symptoms, negligible negative symptoms and a good outcome, comparable to that seen in AI probands. Their relatives had an excess risk of schizophrenia spectrum illness but not AI. Probands with DD had prominent delusions but no other psychotic symptoms, few negative symptoms, fair to good outcome and an increased risk in relatives for alcoholism. Probands with PD-NOS had both moderate positive and negative psychotic symptoms, a poor to fair outcome and a substantially elevated risk in relatives of schizophrenia and schizophrenia spectrum disorders but not AI. These results suggest that i) DSM-III-R criteria for schizophreniform disorder define a good outcome disorder with prominent positive psychotic symptoms that probably has a familial relationship to schizophrenia, but not AI; ii) DD is a rare, monosymptomatic psychosis that may have a modest etiologic relationship with alcoholism, but probably not with schizophrenia or AI and iii) PD-NOS is probably heterogeneous but, of these 3 disorders, most closely resembles schizophrenia with respect to symptoms, outcome and familial psychopathology. These results should be seen as tentative given the small number of probands and relatives evaluated.     

Acute and transient psychotic disorders (ICD-10: F23). Empirical data and implications for therapy

The defining clinical features of acute and transient psychotic disorders (ICD-10: F23) are an acute onset and a duration of psychotic symptoms not exceeding 1-3 months. Previous empirical investigations show that patients with this diagnosis have a favourable prognosis, but also a high risk of relapses (58-77%). The diagnostic stability in the further course of illness seems to be low (34-73%) with a frequent diagnostic change to schizophrenia and affective disorders being observed. As yet, data from controlled clinical trials regarding therapy do not exist. The implications for the treatment of acute and transient psychotic disorders are discussed with this background.     

Acute polymorphic psychotic disorder: diagnostic stability over 3 years

OBJECTIVE: Acute polymorphic psychotic disorder without symptoms of schizophrenia (APPD) in ICD-10 is unique in many characteristics. This study aimed at investigating the diagnostic stability of APPD over 3 years. METHOD: Forty-five patients with first episode APPD were followed up and assessed at regular intervals over a period of 3 years. RESULTS: Thirty-two patients were females. Average age of the sample was 26.9 years. Thirty-three cases retained their index diagnosis of APPD, while 12 cases required diagnostic revision: 10 to bipolar affective disorder and the rest to unspecified non-organic psychosis. Shorter duration of illness (<1 month) and abrupt onset (<48 h) predicted a stable diagnosis of APPD. CONCLUSION: APPD is a relatively stable diagnosis and argues for a distinct diagnostic entity.