Psychogenic (reactive) and hysterical psychoses: a cross-system reliability study

The aim of this study was to investigate the concepts of reactive and hysterical psychoses and how they are classified in standardized diagnostic Systems. To this end we identified all of the patients who had been admitted to a psychiatric in-patient unit and diagnosed as suffering from psychogenic psychosis, reactive psychosis, hysterical psychosis or hysteria, using ICD-9 criteria. The case notes of these patients were then re-examined and diagnoses reached using DSM-III-R, DSM-IV and ICD-10 criteria and the Present State Examination (PSE)/catego computer program. The objective of this study was to evaluate the agreement between the diagnoses of reactive and hysterical psychosis obtained using ICD-9 criteria with those obtained using the DSM-III-R, DSM-IV, ICD-10 and PSE diagnostic Systems. A total of 67 case notes were identified in which the above diagnoses had been made: 27 cases with ICD-9 ‘hysteria’ and 26 cases with ‘other reactive and not otherwise specified psychoses’. Using the DSM-III-R criteria, 27 cases were diagnosed as psychotic disorder NOS, 12 as brief reactive psychosis and 11 as bipolar disorder. Using the DSM-IV criteria, 21 cases were diagnosed as psychotic disorder NOS, 11 as mood disorder, 7 as brief disorder without stressor, and 12 as brief disorder with stressor. Using the ICD-10 criteria, 18 cases were diagnosed as unspecified non-organic psychosis, 12 as mood disorder, 10 as acute and transient psychotic disorder without stressor and 13 as acute and transient psychotic disorder with stressor. Using the PSE/catego program, the most common diagnoses were class ‘S’ schizophrenia (17), class ‘P?’ uncertain psychosis (16) and class ‘M+’ mixed and manic affective disorder (11). Using the kappa coefficient a very low level of agreement was found between ICD-9 ‘hysteria’ and ‘other reactive and non-specified psychoses’ and the corresponding categories of DSM-III-R and the PSE/catego program. We concluded that, although DSM-III-R provides operational criteria for brief reactive psychosis, and DSM-IV and ICD-10 provide such criteria for brief or acute psychotic disorder, these bear little relationship to the original concept of the disorder. The PSE/catego program provides a very systematic approach to symptomatology, but the diagnostic classes have little clinical usefulness.     

Categorical and dimensional diagnostic approach to acute psychosis in view of operational diagnostic criteria

"Acute psychosis" is the tentative diagnosis made for the patients presenting acute onset of delusion, hallucination, confusion and emotional instability. "Acute psychosis" was focused in view of operational diagnostic criteria, ie, DSM-IV-TR and ICD-10. The diagnostic categories in the DSM-IV-TR corresponding to "acute psychosis" were brief psychotic disorder, schizophreniform disorder, schizo-affective disorder and mood disorder with psychotic features. Although brief psychotic disorder is representative of "acute psychosis" in the DSM-TR, it lacks in clinical usefulness, because its diagnostic criteria, based on no historical background, lack clinical validity in terms of symptom definition and duration (1 month>). On the other hand, in the ICD-10, a diagnostic category of acute transient psychotic disorder was based on the traditional "acute psychosis" concept that has been bred in the European Psychiatry. Among the acute transient psychotic disorders, acute polymorphic psychotic disorder is the diagnostic category made according to traditional concept of "bouffées délirantes" and cycloid psychosis. It is a clinically useful diagnostic category, because it could predict favorable episode outcome, if a person with fairly good premorbid social adaptation presents acute onset of polymorphic psychotic symptoms. One of the most prominent points of the revision of DSM-IV-TR to DSM-5 is the adoption of dimensional approach evaluation (diagnosis) in a disorder-crossing fashion. In addition to insomnia, depressive mood and anxiety, symptomatic domain such as acute onset, bipolarity, polymorphism of psychotic symptoms, and furthermore such domain as premorbid social adaptation, life event and episode outcome should be evaluated in the course of treatment, contributing to the clinical practice of the patients with acute psychosis.     

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.     

Nonschizophrenic psychotic disorders: the case of cycloid psychoses

BACKGROUND: Cycloid psychosis is a psychiatric disorder known for about 100 years. This disorder is at present partly and simplified represented in the ICD-10. SAMPLING AND METHODS: Over a period of 15 months, 139 consecutively acutely admitted psychotic patients were assessed, by means of different diagnostic instruments, in order to investigate the prevalence and the symptom profile of cycloid psychoses. In addition, the concordance between the diagnoses cycloid psychosis, brief psychotic disorder, and acute polymorphic psychotic disorder with or without symptoms of schizophrenia was calculated. RESULTS: Cycloid psychoses were present in 13% of the patients. There was a significant but small overlap with the DSM brief psychotic disorder and the ICD acute polymorphic psychotic disorder. CONCLUSIONS: This study demonstrates that cycloid psychoses can be identified with the proper diagnostic instruments in a proportion that is also found in other studies. Since this type of psychosis entails a distinct prognosis and may require a specific treatment, its identification is of clinical importance. Limitations are the nature of the psychiatric facility with an inherent bias in the selection of patients and the lack of a long-term evaluation.     

The late-onset psychoses. Clinical and diagnostic features

Psychoses of late onset are poorly understood due to a limited number of inconsistent studies. The authors conducted this study to determine the clinical characteristics of a clearly defined group of patients with onset of psychosis after age 65 years and to test the usefulness of DSM-III criteria in diagnosing the condition of these patients. Late-onset psychosis occurred in 8% of the patients admitted to the geropsychiatry unit during the study period. More than three quarters of these patients suffered from either an organic mental disorder or major affective disorder, the remainder having primary psychotic disorder. The diagnoses of the psychotic patients were much less reliable than those of a comparable group of nonpsychotic patients, with more than 5 times as many patients in the psychosis group changing diagnostic categories between the time of their admission and their discharge. DSM-III diagnostic criteria were not well suited for the categorization of many of these patients. For patients with primary psychotic disorder, the criteria artificially subdivided groups of similar patients. For patients with organic mental disorder, the criteria did not provide sufficient guidance for the diagnosis of psychosis in the presence of dementia. All three groups of patients responded to somatic therapies. A subgroup of patients with affective disorder improved without neuroleptic treatment, and several patients with primary psychotic disorder benefited from antidepressant treatment. These results highlight the difficulty inherent in the treatment of patients with late-onset psychosis. Further research is needed to develop adequate diagnostic criteria and to determine which patients will benefit from neuroleptic and/or antidepressant therapy.     

Prospective study of adolescents with subsyndromal psychosis: characteristics and outcome

OBJECTIVE: The aim of this study was to examine the characteristics and outcome of adolescents with psychotic disorder not otherwise specified (PsyNOS) and brief psychotic disorder (BrPsy), two neglected subsyndromal diagnostic entities. METHODS: As part of an ongoing, naturalistic study investigating adolescents considered to be prodromal for schizophrenia, 29 youngsters (mean age, 16.2 +/- 2.7 years) with PsyNOS or BrPsy were identified as theoretically at highest risk for schizophrenia and followed for over 6 (mean, 22.8 +/- 19.4) months. RESULTS: Contrary to our expectations, only 7 of the 26 individuals (27.0%) with follow-up data developed schizophrenia or schizoaffective disorder, and only 2 subjects (7.7%) retained their diagnosis of BrPsy/PsyNOS. The most frequent other diagnoses at follow-up were mood disorders (34.6%), personality disorders (11.5%), and obsessive-compulsive disorder (7.7%). Regarding severity of outcome, 38.5% of the patients progressed to a syndromal psychotic disorder, 23.1% continued to have attenuated positive symptoms, and 38.4% improved to having attenuated negative symptoms only, or no positive or negative symptoms. BrPsy was associated with lower maximum levels of negative symptoms (p = 0.02) and higher likelihood of symptom remission (p = 0.02). CONCLUSIONS: This study indicates that psychotic symptoms not fulfilling criteria for schizophrenia or a psychotic mood disorder are unreliable predictors of a syndromal psychotic disorder outcome at 2 years. Long-term studies of PsyNOS and BrPsy are needed to clarify where these disorders fall in the developmental course of schizophrenia.     

Schizoaffective disorder merges schizophrenia and bipolar disorders as one disease--there is no schizoaffective disorder

PURPOSE OF REVIEW: Schizoaffective disorder was named as a compromise diagnosis in 1933, and remains popular as judged by its place in the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders, its frequent use in clinical practice, and its extensive discussion in the literature. Some, however, have questioned the validity of schizoaffective disorder as separate from psychotic mood disorder. We examined the literature to assess the rationale for the continuation of schizoaffective disorder as a legitimate diagnostic category. RECENT FINDINGS: The diagnosis of schizoaffective disorder depends on the disease specificity of the diagnostic criteria for schizophrenia; however, the psychotic symptoms for schizophrenia, traditionally held as specific, can be accounted for by psychotic bipolar. Further, the interrater reliability for diagnosing schizoaffective disorder is very low. A recent and expanding body of comparative evidence from a wide range of clinical and basic science studies, especially genetic, reveals multiple similarities between schizoaffective disorder, schizophrenia and psychotic bipolar. SUMMARY: Schizoaffective disorder unifies schizophrenia and bipolar, blurring the zones of rarity between them and suggesting that schizoaffective disorder is not a separate, 'bona-fide' disease. Patients diagnosed with schizoaffective disorder likely suffer from a psychotic mood disorder. The diagnosis of schizoaffective disorder, which can result in substandard treatment, should be eliminated from the diagnostic nomenclature.     

Does operational diagnosis of schizophrenia significantly impact intellectual deficits in psychotic disorders?

Background Evidence suggests that, as a group, patients with schizophrenia have intellectual deficits that may precede the manifestation of psychotic symptoms; however, how successfully intelligence tests are able to discriminate schizophrenia from other psychotic disorders has yet to be investigated in detail. Methods Using Wechsler Adult Intelligence Scale – Revised (WAIS‐R) data for 55 inpatients with schizophrenia and 28 inpatients with non‐schizophrenic psychotic disorders (NSPD) (schizophreniform disorder, brief psychotic disorder, delusional disorder, psychotic disorder due to a general medical condition, and psychotic disorders not otherwise specified), intelligence performance was compared between schizophrenia and NSPD and among different subtypes of schizophrenia. Results There were no significant differences in intelligence quotient (IQ), verbal IQ (VIQ) and performance IQ (PIQ) discrepancy, and subtest scores of WAIS‐R between the patients with schizophrenia and those with NSPD. These diagnostic groups were not discriminated well by any WAIS‐R variables. Schizophrenia patients with prominent negative symptoms, on the other hand, had a significantly larger IQ discrepancy (VIQ > PIQ) than those without prominent negative symptoms and NSPD patients. Intelligence performance in schizophrenia did not differ with respect to diagnostic subtypes and longitudinal courses. Conclusions The current study failed to show diagnostic usefulness of WAIS‐R in discriminating schizophrenia and other psychoses. A diagnosis of schizophrenia does not significantly impact intellectual deficits in psychotic disorders.     

Antisocial personality disorder and anxiety disorder: A diagnostic variant?

Antisocial personality disorder (ASPD) with co-morbid anxiety disorder may be a variant of ASPD with different etiology and treatment requirements. We investigated diagnostic co-morbidity, ASPD criteria, and anxiety/affective symptoms of ASPD/anxiety disorder. Weighted analyses were carried out using survey data from a representative British household sample. ASPD/anxiety disorder demonstrated differing patterns of antisocial criteria, co-morbidity with clinical syndromes, psychotic symptoms, and other personality disorders compared to ASPD alone. ASPD criteria demonstrated specific associations with CIS-R scores of anxiety and affective symptoms. Findings suggest ASPD/anxiety disorder is a variant of ASPD, determined by symptoms of anxiety. Although co-morbid anxiety and affective symptoms are the same as in anxiety disorder alone, associations with psychotic symptoms require further investigation.     

Bipolar disorder,schizophrenia, and other psychotic disorders in adults with childhood onset AD/HD and/or autism spectrum disorders

Summary. Individuals with attention-deficit/hyperactivity disorder (AD/HD) and autism spectrum disorders (ASD) often display symptoms from other diagnostic categories. Exclusion criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) impede the use of categorical diagnoses to describe the particular problem constellation in a patient. In this study, we describe the prevalence and patterns of comorbid bipolar and psychotic disorders in 241 consecutively referred adult patients with AD/HD and/or ASD. Thirty per cent of patients with AD/HD had comorbid ASD and 38% of patients with ASD had comorbid AD/HD. Of the subjects with ASD, 7% had bipolar disorder with psychotic features, and 7.8% had schizophrenia or another psychotic disorder. The corresponding figures for the patients with AD/HD were 5.0% and 5.0%, respectively. Current diagnostic criteria have to be revised to acknowledge the comorbidity of bipolar and/or psychotic disorders in AD/HD and ASD.     

ADD psychosis: treatment with antipsychotics and methylphenidate?

Two patients with a psychotic disorder who also met the diagnostic criteria for attention deficit hyperactivity disorder ADHD were treated with antipsychotics and methylphenidate. The first patient remained stable for many years with this combination treatment, whereas the second became psychotic several months after he had increased the dose of methylphenidate and had started to use cocaine. In the light of these two case studies, we have reviewed the literature on ADD psychosis, and we formulate recommendations regarding the specialised treatment needed for this uncommon disorder.     

The Community Assessment of Psychic Experiences: Optimal cut‐off scores for detecting individuals with a psychotic disorder

ObjectivesThe need for a brief screening tool for psychosis is widely recognized. The Community Assessment of Psychic Experiences (CAPE) is a popular self‐report measure of psychosis, but a cut‐off score that can detect those most likely to fulfill diagnostic criteria for psychotic disorder is not established.MethodsA case–control sample from the Genetic Risk and Outcome of Psychosis Project study (N = 1375, healthy individuals, n = 507, and individuals with a psychotic disorder, n = 868), was used to examine cut‐off scores of the CAPE with receiver operating curve analyses. We examined 27 possible cut‐off scores computed from a combination of scores from the frequency and distress scales of the various factors of the CAPE.ResultsThe weighted severity positive symptom dimension was most optimal in detecting individuals with a psychotic disorder (>1.75 cut‐off; area under the curve = 0.88; sensitivity, 75%; specificity, 88%), which correctly identified 80% of the sample as cases or controls with a diagnostic odds ratio of 22.69.ConclusionsThe CAPE can be used as a first screening tool to detect individuals who are likely to fulfill criteria for a psychotic disorder. The >1.75 cut‐off of the weighted severity positive symptom dimension provides a better prediction than all alternatives tested so far.     

DSM-III and the diagnosis of borderline

In order to achieve more understanding of the diagnosis of borderline personality, particularly as it relates to DSM-III, a historical review of influential diagnostic approaches is undertaken. DSM-III defines the borderline personality disorder in a simple way, enhancing reliability and research value. In comparison to other influential approaches, however, there is an overemphasis on affective disturbance, plus an obvious omission amongst the diagnostic criteria of the vulnerability to brief psychotic regressions under stress. The checklist approach of DSM-III greatly takes away from dynamic understanding and makes potentially valuable items such as defensive organization difficult to include. The DSM-III concept of the borderline personality as one of many distinct personality disorders seems unfounded. The concept of the borderline as a superordinate diagnosis under which more specific personality disorders would fall, appears more reasonable.     

Diagnostic stability 2 years after treatment initiation in the early psychosis intervention programme in Singapore

OBJECTIVE: To evaluate the diagnostic stability of psychotic disorders over a 2 year period in patients presenting with first-episode psychosis. METHODS: One hundred and fifty-four patients were recruited from an early psychosis intervention programme (EPIP). They were diagnosed by the attending psychiatrist using the Structured Clinical Interview for DSM-IV Axis I at first contact (baseline) and after 24 months. The diagnoses were classified into the following categories: schizophrenia spectrum disorders (schizophrenia, schizophreniform disorder and schizoaffective disorder), affective psychosis (bipolar and major depressive disorders with psychotic symptoms), and other non-affective psychosis (delusional disorder, psychosis not otherwise specified and brief psychotic disorder). Two measures of stability, the prospective and the retrospective consistency were determined for each diagnosis. RESULTS: The diagnoses with the best prospective consistency were schizophrenia (87.0%) and affective psychosis (54.5%). The shift into schizophrenia spectrum disorder was the most frequent diagnostic change. Duration of untreated psychosis was found to be the only significant predictor of shift. CONCLUSION: It is difficult to make a definitive diagnosis at first contact. The clinical need to review the diagnosis throughout the period of follow up is emphasized.     

The dexamethasone suppression test in affective illnesses and schizophrenia: relationship with psychotic symptoms

The authors studied the dexamethasone suppression test (DST) on a series of 112 inpatients including 65 patients with major depressive disorder (21 bipolars: 4 with, 17 without psychotic symptoms; 44 unipolars: 13 with, 31 without psychotic symptoms), 15 patients with depressive disorder, 10 schizoaffective and 22 schizophrenic patients. Using different diagnostic criteria, they confirm the best performances of the DST in depression for the diagnosis of a major depressive disorder, primarily endogenous. They also examined the potential influence of psychotic symptoms, suicidal behavior and family history of affective illness on the DST. The only significant difference found is in the cortisol plasma level at 4 p.m. in bipolar patients with psychotic symptoms. That fact and the high rate of abnormality of the DST in schizoaffective and schizophrenic patients indicate that psychotic symptoms per se may play a role in a dysregulation of the hypothalamo-pituitary adrenal axis.     

Evaluating clinicians' representations of schizoaffective disorder

BackgroundSchizoaffective disorder (SAD) has routinely exhibited poor diagnostic accuracy and reliability. In addition to phenomenological problems with the definition of SAD, the way in which clinicians represent the symptoms of the disorder could contribute to its poor diagnostic outcomes.PurposeThe present study sought to examine clinicians' representations of SAD compared to schizophrenia (SCZ), bipolar disorder with psychotic features (BiPD-PSY), and major depressive disorder with psychotic features (MDD-PSY).MethodParticipants (N = 113) were clinicians recruited via email as part of a larger study. They were randomly assigned to either select symptoms from a predetermined criteria list or freely list features of the disorders based on their own mental representations.ResultsParticipants' conceptualizations of SAD were not entirely congruent with DSM-5 criteria; they conceptualized it as less psychotic than SCZ and less affective than the two mood disorder tasks. SAD was conceptualized as significantly more depressive than manic.ConclusionsThis study's findings support the notion that clinicians' conceptualizations of SAD are not entirely congruent with its DSM-5 criteria, which could contribute to diagnostic difficulties.     

Cycloid psychotic disorder: validation of the concept by means of a follow-up and a family study

A 3-year prospective follow-up investigation and a family study were carried out in patients fulfilling the diagnostic criteria for cycloid psychotic disorder proposed by Perris and Brockington in 1981. The results show that cycloid psychosis differs in several respects from schizoaffective disorders as defined by current diagnostic criteria used in the United States. Furthermore, they seem to suggest that most cases of cycloid psychosis are not variants of either schizophrenia or major affective disorders.     

Acute and transient psychotic disorder: a 1-year follow-up study

A study sample consisting of 51 patients suffering from acute and transient psychotic disorder (ATPD) (ICD-10) on initial examination was evaluated at 1-year follow-up. The findings show a diagnostic change in half of the patients (48%), most often to schizophrenia (15%) and affective disorder (28%). From index admission to follow-up, patients with an unchanged diagnosis of ATPD manage fairly well with regard to psychosocial functioning, and no deteriorating development is observed. In the majority of cases no personality disorder (PD) (ICD-10, 54%; DSM-IV, 71%) is apparent, and the ATPD is not related to any specific PD. With regard to diagnostic stability, no significant demographic, social or clinical predictors were found. The findings highlight the need for validation of the concept of ATPD, and point to the fact that brief psychotic episodes with an acute onset may be an early manifestation of severe mental disorder (schizophrenia and affective disorder).     

Children and adolescents with psychotic disorder not otherwise specified: a 2- to 8-year follow-up study.

Although psychotic phenomena in children with disruptive behavior disorders are more common than expected, their prognostic significance is unknown. To examine the outcome of pediatric patients with atypical psychoses, a group of 26 patients with transient psychotic symptoms were evaluated with clinical and structured interviews at the time of initial contact (mean age, 11.6 +/- 2.7 years) and at follow-up 2 to 8 years later. Measures of functioning and psychopathology were also completed at their initial assessment. Risk factors associated with adult psychotic disorders (familial psychopathology, eyetracking dysfunction in patients and their relatives, obstetrical complications, and premorbid developmental course in the proband) had been obtained at study entry. On follow-up examination (mean age, 15.7 +/- 3.4 years), 13 patients (50%) met diagnostic criteria for a major axis I disorder: three for schizoaffective disorder, four for bipolar disorder, and six for major depressive disorder. The remaining 13 patients again received a diagnosis of psychotic disorder not otherwise specified (NOS), with most being in remission from their psychotic symptoms. Among this group who had not developed a mood or psychotic disorder, disruptive behavior disorders were exceedingly common at follow-up and were the focus of their treatment. Higher initial levels of psychopathology, lower cognitive abilities, and more developmental motor abnormalities were found in patients with a poor outcome. Obstetrical, educational, and family histories did not differ significantly between the groups. Through systematic diagnostic evaluation, children and adolescents with atypical psychotic disorders can be distinguished from those with schizophrenia, a difference with important treatment and prognostic implications. Further research is needed to delineate the course and outcome of childhood-onset atypical psychoses, but preliminary data indicate improvement in psychotic symptoms in the majority of patients and the development of chronic mood disorders in a substantial subgroup.     

A comparison of borderline with depressed and schizophrenic patients on a new diagnostic interview

Recent advances in the scientific study of borderline disorders have produced reliable diagnostic criteria and an objective interview assessment method. To prove validity, however, the diagnostic criteria must discriminate the borderline syndrome from closely related disorders. In an effort to identify such distinguishing features, we have compared criteria—defined borderline patients with schizophrenic and depressed controls using Gunderson's Diagnostic Interview for Borderlines. In contrast to controls, borderline patients were characterized by patterns of impulsive, self destructive behavior, angry and depressive mood states, brief psychotic episodes, and unstable interpersonal relationships. These findings provide a data base for future tests of concurrent and construct validity of the diagnostic criteria for borderline disorders.