Acute and transient Psychotic Disorder

Seminar on acute and transiet psychotic disorders covering historical aspects, evoultion of concept, prevalence, clinical features, future of ATPD

1. SPEAKER: AMIT CHOUGULE ACUTE AND TRANSIENT PSYCHOTIC DISORDER

2. LAYOUT Introduction History and evolution of ATPD ICD-10 diagnostic criteria Epidemiology of ATPD Course and outcome Treatment of ATPD Issues with nosology Future of ATPD as a diagnostic criteria Conclusion

3. INTRODUCTION Acute and transient Psychotic Disorder (ATPD) as a descriptive entity was recognized in ICD-10 in 1992 I ncluded under psychotic disorder ( F23) as a three-digit code “Nomenclature of these acute disorders is as uncertain as their nosological status” “Psychotic disorder” is used as a term of convenience” The fact remains that systematic clinical information that would guide the classification of acute psychotic states is not yet available ”

4. HISTORY AND EVOLUTION OF ATPD 1876 German Psychiatist Karl westphal described paranoia acuta 1890 Meynert repeated the clinical description but named the condition “ amentia” Sigmund Freud chose this type of acute delusion with hallucinations for his psychoanalytic conception of psychosis 100 Years

5. 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

6. 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 )

7. 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

8. OPPOSITION TO KRAPELINIAN DICHOTOMY France: Bouffee Delirante Germany: Motility Psychosis Cycloid Psychosis Scandinavia : 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

9. THE CYCLOID PSYCHOSES- GERMANY It was created and developed by three Karls ’: Carl Wernicke Karl Kleist 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)

10. BOUFFEE DELIRANTE- FRANCE It can be regarded as the French root of ATPD and Brief Psychoses Valentin Magnan (1835–1916 ) The modern concept of bouffee delirante is based on operational criteria like: Sudden onset Specific symptomatology Evolution of the disorder R etained the category bouffee delirante as an independent mental disorder

11. 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: Confusional Paranoid hallucinatory Schizoaffective Hysterical psychosis ( K . S. Jacob, 2016)

12. REACTIVE/PSYCHOGENIC PSYCHOSES Basic concept was developed by Karl Jaspers Very strong tradition mainly in Scandinavia 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)

13. 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?

14. INTERNATIONAL PILOT STUDY OF SCHIZOPHRENIA (IPSS) (1968-70) This was a nine-country study on schizophrenia led and funded by WHO, with the main aims: Whether schizophrenia existed in different parts of the world? What were the common/differing clinical presentations ? What was the course and outcome among different cultures ?

15. INTERNATIONAL PILOT STUDY OF SCHIZOPHRENIA (IPSS) (1968-70) Agra was the center from India The main findings: Course and outcome in developing world was better than developed countries 25% of people diagnosed to have schizophrenia had only one episode and good outcome IPSS raised questions like whether these subjects with good outcome had a: Separate psychosis? Were they part of the schizophrenia group?

16. Determinants Of Outcome Of Severe Mental Health Disorders (DOSMED) (1978-80) Designed to study: First onset psychosis Incidence of schizophrenia Findings related to acute psychosis Chandigarh was the Indian center The incidence of “broadly defined schizophrenia” was 10 times higher in the developing world than in the developed countries as compared to “narrowly defined schizophrenia” These patients also exhibited a benign course at two-year follow-up Possibility of psychotic states that were not yet clearly identified

17. THE CROSS-CULTURAL STUDY OF ACUTE PSYCHOSIS (CAP) (1980-82) The study aimed to: Differentiate ATPD from schizophrenia and manic depressive psychosis Understand its relationship with psychological and physical stress Main findings included: 41.2 % of patients had symptoms of schizophrenia 20% had Affective symptoms 35.3 % had “other psychoses” 41.7 % reported stress at onset Two-thirds of the subjects remained without relapse at one year follow-up

18. INDIAN COUNCIL OF MEDICAL RESEARCH’S MULTICENTRE STUDY OF ACUTE PSYCHOSIS Bikaner , Goa, Patiala and Vellore It was found that: 35 % of were Schizophrenia 25 % were MDP 40 % as non-organic psychosis as per ICD-9 52 % of cases of acute psychosis could not be categorized into any of the categorical diagnosis

19. RECOGNITION OF ACUTE PSYCHOSIS AS A SEPARATE CATEGORY These studies provided evidence of a non-affective, non schizophrenia psychosis with remission and good outcome Inclusion of acute and transient Psychosis as a separate category in ICD-10 in 1992

20. CLINICAL DESCRIPTION: PSYCHOPATHOLOGY The heterogeneous group of acute and transient psychotic disorders Characterized by three typical features in the descending order of priority: An acute onset (within 2 weeks) as the defining feature of the whole group Presence of typical syndromes Presence of associated acute stress

21. ACUTE ONSET Acute onset is defined as a change from a state without psychotic features to a clearly abnormal psychotic state, within a period of 2 weeks or less There is some evidence that acute onset is associated with a good outcome M ore abrupt the onset better the outcome It is therefore recommended that whenever appropriate, abrupt onset (within 48 hours or less) be specified

22. THE TYPICAL SYNDROMES R apidly changing and variable state called "polymorphic“ T ypical schizophrenic symptoms Differentiated on the basis of first rank Symptoms of schizophrenia

23. ASSOCIATED ACUTE STRESS T raditional linkage of stress with acute psychosis S ubstantial proportion of acute psychotic disorders arise without associated stress First psychotic symptoms should occur within about 2 weeks of one or more events that would be regarded as stressful to most people Typical events would be bereavement , unexpected loss of partner or job, marriage or the psychological trauma of combat , terrorism, and torture Long-standing difficulties or problems should not be included

24. F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia The delusional themes are varied and include grandeur, persecution , influence, possession, body transformation (depersonalization), derealization or world alteration These themes change with time and may combine Consciousness fluctuates with the delirious convictions and changes of emotion Karl Jaspers - ‘first delirious experience‘ which is a “dreamlike state” The criteria for manic episode, depressive episode or schizophrenia are not fulfilled

25. F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia D uration of less than a month In most cases recovery occurs within a few weeks or months If resolution of the symptoms has not occurred after 3 months , the diagnosis should be changed to persistent delusional disorder (F22) or non-organic psychotic disorder (F28 )

26. F23.1 Acute polymorphic disorder with symptoms of schizophrenia This diagnostic category combines the symptoms of acute polymorphic psychotic disorder with some typical symptoms of schizophrenia (F20) present for most of the time It can be a provisional diagnosis, which is changed to schizophrenia if the criteria of schizophrenia persist more than a month

27. F23.2 Acute schizophrenia-like psychotic disorder This acute psychotic disorder lasts for less than a month and is mostly schizophrenic The polymorphic psychotic symptoms are stable The duration criterion is the most important This category is a provisional diagnosis In ICD-10 if the first episode lasts for more than a month , it has to be considered as an acute onset of schizophrenia

28. F23.3 Other acute predominantly delusional psychotic disorders The main clinical features of this category are delusions and hallucinations D o not meet the criteria for schizophrenia T he duration of this psychotic episode must be less than 3 months If the persecutory delusions persist for more than 3 months , the diagnosis changes to persistent delusional disorders ( F22) A uditory hallucinations persist for more than 3 months , the diagnosis is changed to other non-organic psychotic disorders ( F28)

29. F23.8 Other acute and transient psychotic disorders Any other acute psychotic disorders that are unclassifiable under any other category in F23 States of undifferentiated excitement should also be coded here if more detailed information about the patient's mental state is not available F23.9 Acute and transient psychotic disorder unspecified ( brief) reactive psychosis NOS

30. SYNONYMS FOR ATPD IN ICD 10 Acute (Undifferentiated) Schizophrenia Bouff´ee D´elirante Cycloid Psychoses Oneirophrenia Paranoid Reaction Psychogenic Psychosis/ Reactive Psychosis Schizophrenic Reaction Schizophreniform Attack Or Psychosis Remitting Schizophrenia Good Prognosis Schizophrenia

31. Year Term Given By Historic Term Current Terminology 1876 Westphal Akute primare Verruckheit paranoia acuta Other acute predominantly delusional psychotic disorder 1890 Meynert Amentia 1895 Magnan and Legrain Bouffee Delirante Acute polymorphic psychotic disorder without symptoms of schizophrenia 1899 Kraepelin Dementia praecox Schizophrenia 1909- 1913 Kraepelin Paranoia Persistent delusional disorder 1911 Bleuler Acute onset schizophrenia Acute Polymorphic psychotic disorder with symptoms of schizophrenia Acute schizophrenia like psychotic disorder

32. Year Term Given By Historic Term Current Terminology 1916 Wimmer Psychogenic psychosis Other acute predominantly psychotic disorder 1924 Mayer- Gross Oneroide erlebnisform Acute Schizophrenia like psychotic disorder 1933 Kasanin Acute schizoaffective psychoses Schizoaffective disorder 1939 Langfeldt Schizophreniform states Acute schizophrenia like psychotic disorder 1954 EY Bouffees Delirante et psychoses hallucinatoires aigues Acute polymorphic psychotic disorder without symptoms of schizophrenia 1961 Leonhard Cycloid psychoses Acute polymorphic psychotic disorder without symptoms of schizophrenia

33. CULTURAL VARIANTS Other forms of acute psychoses have been observed with high prevalence in Asia, Africa, and Latin America These brief psychotic episodes are culture-bound syndromes I mmediate precipitating stress or life events There is disorganized behaviour, delusions, thought disorders, confusion, and mood disorders F ull recovery and no relapse in a 1-year follow-up ICD-10 does not suggest category of ATPD

34. CULTURE BOUND SYNDROME VS PSYCHOTIC DISORDER C ulture-bound syndromes should be classified as acute and transient psychotic disorders ( Mezzisch and Lin) T his is justified only for a very few such as: amok (dissociative episode with persecutory ideas and aggressive behaviour from Malaysia) shin- byung ( Korean dissociation and possession) spell (trance state in southern United States )

35. CULTURE BOUND SYNDROME AS NEUROSIS ICD-10 includes the two Malaysian syndromes koro and latah as well as D hat (India) in ( F48.8) Other specified neurotic disorders S hort-lived psychotic episodes are expressions of overcharged mechanisms of defence or of individual psychological fragility The brief psychosis is an understandable development of the psychic life of the subject and has a cathartic effect

36. BRIEF PSYCHOTIC DISORDER OF DSM-5 AND ATPD OF ICD-10 Brief Psychotic Disorder ATPD Duration from onset to full remission of psychotic episode 1 day to 1 Month up to 3 months exceptions ‘With Symptoms of Schizophrenia’ and ‘Acute Schizophrenia-like Psychotic Disorder’ In these cases less than 1 month Full development Of the Syndrome Not Specified Within 2 weeks Defining Symptomatology Positive Psychotic Symptoms Psychotic symptoms + Polymorphic Symptoms

37. EPIDEMIOLOGY OF ATPD The Halle Study on Brief and Acute Psychoses (HASBAP) by Andreas Marneros and Frank Pillmann The Cairo study by Okasha and co-workers ( 1993) The cohort study of Pondicherry, India by Sajith and co-workers ( 2002) at JIPMER, Pondicherry , India The cohort study of Chandigarh at PGI The Danish Cohort Study

38. THE FREQUENCY OF ATPD The frequency of Brief and Acute Psychoses is considerably higher in developing countries Frequency of subtypes of ATPD according to ICD-10: Acute Polymorphic Psychoses- 67% Acute Schizophrenia-like Psychoses - 26% Other Acute Predominantly Delusional Psychoses - 2% Other Acute and Transient Psychoses (F23.8) - 5% Frequency of Subtypes of Acute Polymorphic: Without Symptoms of Schizophrenia-50% With Symptoms of Schizophrenia-50%

39. GENDER DISTRIBUTION M ore frequent in women than in men This constitutes an important difference to schizophrenia and to schizoaffective disorders AGE AT ONSET Acute and Transient Psychotic Disorders may occur at any age Peak in the mid thirties Age at onset is higher than in schizophrenia

40. MENTAL DISORDERS IN THE FAMILY In a major case control study found family history of ATP was three times greater in first degree relatives(FDRS) of ATP History of schizophrenia was seen in FDRs of those ATP patients who had schizophrenic symptoms These findings gave evidence that ATP is genetically distinct from MDP There is genetic overlap between ATP and schizophrenia and schizophrenic symptoms

41. PREMORBID PERSONALITY A ssessment by ‘Big Five’ personality dimensions No significant difference between ATPD patients and healthy controls Bipolar Schizoaffective Disorder patients differ from mentally healthy controls on two of five subscales-neuroticism and extraversion Schizophrenia patients show pronounced differences from the mentally healthy controls on three of five subscales: neuroticism , extraversion and conscientiousness

42. ONSET AND DURATION OF EPISODE Neither abrupt nor acute onset are specific for ATPD Schizophrenia can have an acute onset and rarely an abrupt onset The duration of the psychotic period as well as the duration of inpatient treatment is significantly shorter in ATPD Insidious onset tends to have a longer duration of the psychotic period Tendency for patients with a precipitating life event to show a more acute onset

43. PSYCHOPATHOLOGICAL ASPECTS OF ATPD The most crucial differences in phenomenology of ATPD: Rapidly changing delusional topics Rapidly changing mood Anxiety Significantly more frequently represented in ATPD

44. LONGITUDINAL COURSE OF ATPD Relapse rates in ATPD are similar to those in controls with Schizophrenia and BPAD After 2.3 years one-half of the ATPD patients will experience a relapse Patients with ATPD who experience a relapse usually have ATPD episodes again Affective and schizoaffective episodes during follow-up are also common (HALLE STUDY)

45. 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: 30 % of ATPD patients experienced a single episode 50 % had an episodic-remitting course 20 % had a chronic course 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

46. 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: Affective disorder in 9.2% Schizophrenia in 26.4% 11.5 % presented with recurrent episodes of acute psychosis

47. 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

48. 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 maintained the same diagnosis over 12 months of follow-up In a 15-year follow-up the diagnoses of ATPD, Schizophreniform and brief psychotic disorder were unstable over time

49. DIAGNOSTIC STABILITY DEVELOPING VS DEVELOPED NATIONS In industrialized nations like Europe more than 50% of cases with ATPD tend to change diagnosis into another category 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

50. PREDICTORS OF DIAGNOSTIC STABILITY AND FAVOURABLE OUTCOME IN ATPD Sudden onset Female sex Duration less than one month Good premorbid functioning Acute insomnia

51. DIAGNOSTIC STABILITY OF ATPD S yndrome stability of ATPD is found to be located in the middle between the high stability of schizophrenia and the low stability of schizoaffective disorder A fter exclusion of the Acute Schizophrenia-like Psychotic Disorders from the group of ATPD 50 % of the ATPD patients have a ‘monosyndromal’ course during the prospective follow-up of five years

52. OUTCOME After 10 years of illness patients with ATPD in comparison to controls with schizophrenia show: B etter global functioning L ess social disability F ewer persisting alterations F ewer negative and positive symptoms H igher rates of heterosexual relationships

53. MANAGEMENT OF ATPD Early hospitalization in order to make: C areful clinical evaluation T o separate the patient from environment T o provide a reassuring setting T o prevent any suicidal or aggressive tendencies Antipsychotic drugs are indicated The choice of antipsychotic drug depends on the clinician's experience and the clinical features Benzodiazepines may be given to potentiate the action of the neuroleptics

54. CONTINUATION OF TREATMENT AND PREVENTION OF RECURRENCE The effectiveness of psychopharmacotherapy is usually manifested in the first 6 weeks If mood disorders or cyclic episodes occur treatment with antidepressants or mood stabilizers is warranted Low-dosage pharmacotherapy must be maintained for 1 or 2 years after recovery During this long-term follow-up, periodic assessment and effective clinical care with social and psychological therapy are essential

55. ISSUES OF NOSOLOGY THE BOUNDARIES OF HOMOGENEITY: Various sub-classifications of ATPD leads to an inhomogeneous group of psychotic disorders ICD-10 differentiates Acute Polymorphic Psychoses ‘with’ and ‘ without” symptoms of schizophrenia based on first-rank symptoms WHO defines ‘Acute Schizophrenia-like Psychotic Disorder” based on: Presence of first-rank symptoms A bsence of polymorphic symptomatology No significant differences between the Polymorphic Psychotic Disorders with or without schizophrenic symptoms was found

56. THE BOUNDARIES OF HOMOGENEITY F irst-rank symptoms cannot distinguish the Acute Polymorphic Disorders into subgroups The polymorphism of the symptomatology has a much more discriminating power than the presence of first-rank symptoms The WHO distinction of ‘Acute Polymorphic Disorder’ into the two categories ‘with ’ and ‘ without’ schizophrenic symptoms is unwarranted and unnecessary ICD-10 subtype F23.0 (‘with’ schizophrenic symptoms) and F23.1 (‘without’ schizophrenic symptoms) can be put together

57. Is the ‘Acute Schizophrenia-like Psychosis’ simply schizophrenia M ain difference between Acute Schizophrenia-like Disorders and schizophrenia concerns is duration (1 month) Is this criterion valid enough to combine with ATPD ?? Patients with Acute Schizophrenia-like Psychoses are more similar to patients with schizophrenia T he category ‘ATPD’ can be much more homogeneous if the ‘Acute Polymorphic Psychotic Disorders’ are not combined with the ‘Acute Schizophrenia-like Psychotic Disorders

58. FUTURE OF ATPD IN ICD-11 Working Group on the Classification of Psychotic Disorders (WGPD) Diagnostic focus should be “Polymorphic ” clinical presentation: “”High variability/fluctuation of psychotic and affective symptoms” WGPD recommends that: Subcategory F23.0 (Acute polymorphic psychotic disorder without symptoms of schizophrenia) be retained as the clinical guideline for ATPD Delusional subtype (F23.3 ) be incorporated into the revised category Delusional disorder

59. EXPECTED CHANGES IN ICD-11 3. Present ICD-10 categories: F23.1 ( Acute polymorphic psychotic disorder with symptoms of schizophrenia) F23.2 (Acute schizophrenia-like psychotic disorder) be combined 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

60. 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 More work is necessary to tighten up the definition Few concepts need to be defined: What is an adequate precipitant Its temporal relation to the psychosis There is a need for greater precision in delineating vulnerability, course and outcome in acute psychosis

61. NEED FOR ETIOLOGICAL/ DIMENSIONAL CLASSIFICATION SYSTEM Any classification that is only phenomenological/descriptive in nature 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

62. References Acute and transient psychosis by Andreas Marneros and Frank pillmann,2004 K. S. Jacob Indian Psychiatry and classification of psychiatric disorders.Indian J Psychiatry 52, Supplement, January 2010 Savita Malhotra. Acute and transient psychosis: A paradigmatic approach. Indian J Psychiatry 49(4), Oct-Dec 2007 233 M Taylor Madness and Maastricht: a review of reactive psychoses from a European perspective Journal of the Royal Society of Medicine Volume 87 November 1994 Aksel Bertelsen Reactive or Psychogenic Psychoses: The Scandinavian Concept. Revista do Serviço de Psiquiatria do Hospital Fernando Fonseca 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 Interaction Schizophrenia Bulletin vol. 34 no. 6 pp. 1095–1105, 2008 Wolfgang Gaebel *Status of Psychotic Disorders in ICD-11 Schizophrenia Bulletin vol. 38 no. 5 pp. 895–898, 2012

63. THANK YOU