Acute and transient psychotic disorders

acute and transient psychotic disorder its history phenomenology, etiology, diagnosis and managment

1. Acute and Transient Psychotic Disorders Presented By : Karrar Husain Moderator : Dr. M. Amir Usmani

2. In late 19 th century, Kraepelin divided functional psychosis into manic–depressive psychosis and dementia praecox. However after Kraepelin’s dichotomous classification of functional psychosis, many authors kept on showing their dissatisfaction with such a classification and kept on describing an acute psychotic illness which was different from manic-depressive psychosis and dementia praecox. HISTORICAL BACKGROUND

3. There were several reports, from several different parts of the world, of occurrence of certain psychotic states other than schizophrenia and MDP described by different names. France : Bouffee Delirante Germany : Motility Psychosis Cycloid Psychosis Reactive Psychosis Scandinavia : Psychogenic psychosis Schizophreniform Psychosis

4. 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

5. Amentia —a psychotic disorder with remitting course and favorable outcome, originally described by Theodor Meynert (1833 to 1898). A psychotic illness with acute onset characterized by confusion and perplexity; agitation; rapidly changing, vivid hallucinations and delusions; anxiety; and apprehension. An association with physical illness and exhaustion was noted in some patients. Full recovery occurs in a few weeks or months

6. Cycloid psychosis A psychotic disorder with acute onset and good prognosis but frequent recurrences, characterized by confusion, mood-incongruent delusions, hallucinations, overwhelming anxiety, deep feelings of happiness or ecstasy, motility disturbances of akinetic or hyperkinetic type, a particular concern with death, mood swings, and rapid change in symptoms within an episode. Two variants : confusional - contrasting phases of confused excitement and stupor : motility psychosis - contrasting phases of hyperkinesis and akinesis .

7. A third variant, anxiety-elation psychosis, was introduced by Karl Leonhard (1904–1988). The diagnosis of cycloid psychosis is still used by German, Scandinavian, and other European psychiatrists and was influential for the formulation of acute and transient psychotic disorders in ICD-10.

8. Bouffée délirante A psychotic disorder with acute onset without previous psychiatric history. The episode remits completely with no residual symptoms. The episodes are characterized by delusions, hallucinations, depersonalization and derealization , confusion, mood change, and changing symptoms during the course of episode. Episodes are not due to organic or substance use.

9. The diagnosis is still used by French-speaking clinicians in Europe, West Africa, and the Caribbean. The concept of bouffée délirante was influential in formulation of the ICD-10 acute and transient psychotic disorders. Due to its common occurrence in Africa and the Caribbean, it is also categorized as a culture-bound syndrome in the DSM-IV-TR.

10. Psychogenic or reactive psychosis A psychotic disorder with acute onset after external stress. Compared with schizophrenia, the onset is more likely to be acute and later in life. Premorbid adjustment tends to be better than in schizophrenia. Prognosis is better than schizophrenia. There are more affective and confusional symptoms and fewer bizarre symptoms, and there is less family history of schizophrenia. Diagnoses of psychogenic or reactive psychoses were popular among Scandinavian psychiatrists.

11. The reactive or psychogenic psychosis was especially influential in the formulation of the third edition of the DSM (DSM-III) brief reactive psychosis diagnosis, which, in DSM-IV and DSM-IV-TR, was replaced by brief psychotic disorder. The change was partly motivated by the observation that many cases of brief psychosis are not precipitated by a marked stressor and, hence, are not “reactive. Nonetheless, the DSM-IV and DSM-IV-TR distinguish between brief psychotic disorder with and without marked stressors and indicate that brief psychotic disorder with marked stressor is equivalent to the brief reactive psychosis.

12. Schizophreniform psychosis or disorder Gabriel Langfeldt (1937–1966) A condition with sudden onset after an identifiable precipitating factor and good outcome in an individual with well-adjusted premorbid personality. The patients often present disturbance of mood and clouding of consciousness. The term, but not the concept, was adopted by the DSM-III as a nonaffective psychotic syndrome with schizophrenic symptoms but a duration of less than 6 mos. The concept of schizophreniform in the latter sense was perpetuated in the later editions of the DSM.

13. Oneirophrenia Ladislas von Meduna (1896–1964) in 1939 A syndrome characterized by acute onset of confusion, nightmare or dream -like quality of all perceptions, extreme fear and anxiety, delusions, and visual hallucinations. The prognosis is generally good with full recovery. Meduna proposed an endocrinological explanation for the syndrome.

14. Hysterical psychosis Marc Hollander and Steven Hirsch in 1964. A psychotic episode with sudden and dramatic onset related to a profoundly upsetting event in the context of a “hysterical” personality. Symptoms include hallucinations, delusions, depersonalization, and disorganized behavior. The episode seldom lasts longer than 1–3 wks.

15. Common features of these historical entities were: – acute or sudden onset – unstable, variable, fluid and florid symptomatology – volatile polymorphic content – anxiety – fear or prominent affective symptoms – association with a clear precipitant – good premorbid adjustment – rapid and complete recovery These syndromes did not fit into descriptions of affective or schizophrenic disorders.

16. Historical development of the terminology of acute and transient psychotic disorders

17. ATP is a new entrant to psychiatric nosology and ICD-10 concept of ATP has limited validity. ATP came to be recognized as a disorder in ICD-10 in 1992. The confirmatory evidence for the validity of ATP came from the international initiatives in the form of WHO multi-centered collaborative studies IPSS(International Pilot-study of schizophrenia), DOSMeD (Determinants of Outcome of Severe Mental Health Disorders) and CAP(Cross-cultural study of Acute Psychosis) NOSOLOGICAL ISSUES

18. This was a nine-country study on schizophrenia Aims: ( i ) Whether schizophrenia existed in different parts of the world? (ii) What were the common/differing clinical presentations? (iii) What was the course and outcome among different cultures? This study yielded certain findings that were important for discussion on ATP: ( i ) That a substantial proportion (26%) of schizophrenic subjects had good outcome in the form of only one episode; and (ii) That patients from developing countries had better outcome. IPSS (International Pilot-study of schizophrenia (1968- 1970):

19. WHO-led and -funded study done in 10 countries including both the developing and developed countries. Salient findings relevant to the discussion on ATP were: There were a group of patients who had non-affective psychosis and which remitted completely. These were called as non-affective, acute, remitting psychosis (NARP). Incidence of such NARP cases was 10 times higher in the developing countries in the DOSMeD data. These patients from developing countries exhibited a benign course at 2 years follow-up. DOSMeD (Determinants of Outcome of Severe Mental Health Disorders) (1978-1980):

20. This study was an off-shoot of DOSMeD study done in 14 centers and 7 countries. Main objectives of this study were to know if there are: ( i ) Acute psychotic states that can be defined, which are descriptively different from schizophrenia and MDP? And (ii) How are acute psychoses related to psychological and physical stress? 1004 were included and data was analyzed. CAP (Cross-cultural study of Acute Psychosis) (1980- 1982):

21. Main findings showed that : 41.2 % patients showed schizophrenic symptoms, whereas 20% showed affective symptoms and 35.3% exhibited other psychoses . 41.7 % showed stress close to onset . There was marked prevalence of patients from below average socio-economic status . 2/3 patients remained well with no relapse at 1 year . e) Outcome in patients of acute psychosis with schizophrenic symptom was similar to those with only affective symptoms.

22. Taken together, the findings of these three major WHO studies provided strong evidence in favour of occurrence of acute onset psychotic disorders that were different from both schizophrenia as well as MDP and formed the basis for the ICD-10 category ATP (F23). Sources of uncertainty in the nomenclature and nosology of ATP lied in the issue of the relationship of ATPs with schizophrenia and manic-depressive psychosis.

23. RELATIONSHIP OF ATPS WITH SCHIZOPHRENIA AND AFFECTIVE DISORDERS Quest to separate ATP from schizophrenia and MDP was complicated as there were questions about the biological distinctiveness of schizophrenias and MDP. While the relationship of ATP to schizophrenia or MDP was under question, the relationship between schizophrenia and affective disorders, the two major psychotic conditions, itself has been a matter of debate. “It is becoming increasingly clear that we cannot distinguish satisfactorily between these two illnesses. Rudin E. To inheritance and Neuentslehung of Dementia Praecox. Berlin: Springer; 1916. Powell A, Thomson N, Hall DJ, Wilson L. Parent-child concordance with respect to sex and diagnosis in schizophrenia and manic-depressive psychosis. Br J psychiatry 1973;123:653-8. Abrams R, Taylor MA. The genetics of schizophrenia: A reassessment using modern research criteria. Am J Psychiatry 1983;140:171-5.

24. Several studies on schizophreniform disorder, which is a prototypical syndrome of ATP, have yielded varying results. It has been considered to be closely related to affective illness in some studies and to Schizophrenias in other group of studies. According to some family genetics study ATP is genetically distinct from MDP and that there is genetic overlap between ATP and schizophrenia and schizophrenic symptoms. Fogelson DL, Cohen BM, Pope HG Jr. A study of DSM III schizophreniforM disorder. Am J Psychiatry 1982;139:1281-5. Taylor MA. Schizo -affective and allied disorders. In: Post RM, Ballenger JC, editors. The Neurobiology of Manic-Depressive Illness. Williams and Wilkins: Baltimore; 1984. Makanjuola RO, Adedapo SA. The DSM-III concepts of schizophrenic disorders and schizophreniform disorder. Br J Psychiatry 1987;151:611-8. Coryell W, Tsuang MT. DSM-III schizohreniform disorder:comparison with schizophrenia and affective disorder. Arch Gen Psychiatry 1982;39:66-9. Beiser M, Fleming JAE, Iacono WG, Lin T. Redefi ning the diagnosis of schizophreniform disorder. Am J Psychiatry 1988;145:695-700. Das SK, Malhotra S, Basu D. Family study of acute and transient psychoticdisorders : Comparison with schizophrenia. Soc Psy Psychiatr Epidem1999;34:328-32.

25. Some studies also suggested that there is poor link between shizophrenia and ATP. ATPD differs significantly from BSAD on various relevant levels, such as gender (more female), age at onset (older), development of the full symptomatology (more rapid), duration of the symptomatology (shorter), acuteness of onset (more acute), preceding stressful life-events (more frequent) and longterm prognosis (better). It is concluded that ATPD and BSAD are different nosological entities. Chavan BS & Kulhara P. A clinical study of reactive psychosis. Acta psychiatrica Scand- inavica , 1988; 78: 712-715. The relation of ‘‘acute and transient psychotic disorder’’ (ICD-10 F23) to bipolar schizoaffective disorder, Journal of Psychiatric Research 36 (2002) 165–171

26. ATP and DSM ATPD do not have a designated place in the DSM. Many of the cases of ICD-10 acute and transient psychotic disorder would be categorized as schizophreniform disorder, brief psychotic disorder, or psychotic disorder not otherwise specified (NOS) in DSM. Brief psychotic disorder’ (BPD), which is characterized by presence of psychotic symptoms for less than 1 month duration, is equivalent to the ICD-10 ATPD of less than one month duration. ‘ Schizophreniform disorder’, which requires minimum of 1 month for active symptoms to appear after the first noticeable change in behavior or functioning and allows a duration limit for the symptoms to a maximum of 6 months.

27. psychotic disorder NOS includes presentations of psychotic symptoms for which there is inadequate information to make a specific diagnosis or symptoms that do not meet full criteria for a specific psychotic disorder. DSM-III and DSM-III-R had a diagnosis of the brief reactive psychosis diagnosis, defined as a psychotic episode lasting less than 1 month that was preceded by a marked stressor

28. Acute and transient psychotic disorders are rare in industrialized settings. Incidence was ten times higher in developing countries, compared with industrialized countries Two times higher in women, compared with men. The annual incidence rates per 10,000 were 0.49 in men and 0.88 in women in developing countries and 0.04 in men and 0.10 in women in industrialized countries. Age of onset is in the early to mid-20s in the developing countries and in the mid-20s to mid-30s in industrialized countries. EPIDEMIOLOGY and ETIOLOGY CTP 9 th edition, Susser E, Varma VK, Malhotra S, Conover S, Amador XF. Delineation of acute and transient psychotic disorders in a developing country setting. BrJ Psychiatry 1995a;167:216-9. Susser E, Fennig S, Jandorf L, Amador X, Bromet E. Epidemiology, diagnosis and course of brief psychoses. Am J Psychiatry 1995b;152:1743- 8.

29. The most common specific disorder in the group of ICD-10 is acute polymorphic psychotic disorder without symptoms of schizophrenia(2/3 -1/2 cases). ATP cases are reported to be more frequently belonging to lower socio-economic status and rural areas. Stress preceding the onset was seen in about 60% of ATP patients and stress was more common among female. History of non-specific, short-lasting fever. A summer peak Malhotra S, Varma VK, Misra AK, Das S, Wig NN, Santosh PJ. Onset of acute psychotic states in India: A study of sociodemographic , seasonal and biological factors. Acta Psychiatr Scand 1998;97:125-31. Susser E, Varma VK, Malhotra S, Conover S, Amador XF. Delineation of acute and transient psychotic disorders in a developing country setting. BrJ Psychiatry 1995a;167:216-9. Susser E, Fennig S, Jandorf L, Amador X, Bromet E. Epidemiology, diagnosis and course of brief psychoses. Am J Psychiatry 1995b;152:1743- 8.

30. Little is known about the etiology of acute and transient psychotic disorders. Higher risk of acute transient psychotic disorders and a lower risk of schizophrenia and mood disorders in the first-degree relatives of probands , compared with schizophrenia probands . It is hypothesized that ATP may be an environmentally induced psychotic condition superimposed upon an underlying vulnerability to psychosis. Early-life brain insult may lead more often to schizophrenia and later-life insult may lead to ATP. The severity of brain insult where ATP may be associated with less severe brain insult.

31. Acute and transient psychotic disorders are characterized by three typical features suddenness of onset (within 2 weeks or less) presence of typical syndromes with polymorphic (changing and variable) or schizophrenic symptoms presence of associated acute stress (stressful events such as bereavement, job loss, psychological trauma, etc.). The onset of the disorder is manifested by an obvious change to an abnormal psychotic state. This is considered to be abrupt when it occurs within 48 h or less. Abrupt onset often indicates a better outcome. Full recovery occurs within 3 months and often in a shorter time (a few days or weeks). CLINICAL DESCRIPTION

32. The general (G) criteria G1 There is 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 fulfil the criteria for organically caused clouding of consciousness as specified for F05, criterion A. G3 The disorder does not satisfy the symptomatic criteria for manic episode (F30), depressive episode (F32), or recurrent depressive disorder (F33).

33. G4 There is insufficient evidence of recent psychoactive substance use to satisfy the criteria for intoxication (F1 x .0), harmful use (F1 x .1), dependence (F1 x .2), or withdrawal states (F1 x .3 and F1 x .4). The continued moderate and largely unchanged use of alcohol or drugs in the amounts or with the frequency to which the individual is accustomed does not necessarily exclude the use of F23; this must be decided by clinical judgement and the requirements of the research project in question. G5 There must be no organic mental disorder (F00–F09) or serious metabolic disturbances affecting the central nervous system (this does not include childbirth). (This is the most commonly used exclusion clause.)

34. A fifth character should be used to specify whether the acute onset of the disorder is associated with acute stress (occurring 2 weeks or less before evidence of first psychotic symptoms): F23. x 0 without associated acute stress F23. x 1 with associated acute stress. The change of the disorder from a non-psychotic to a clearly psychotic state is further specified as either abrupt (onset within 48 h) or acute (onset in more than 48 h but less than 2 weeks). Six categories of acute psychoses are presented in ICD-10

35. F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia A . The general criteria for acute and transient psychotic disorders (F23) must be met. B. The symptomatology is rapidly changing in both type and intensity from day to day or 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 .

36. 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. E. Any of the symptoms listed in Schizophrenia F20, G1.1 and G1.2 that are present, are only present for a minority of the time since the onset, i.e. criterion B of F23.1 is not fulfilled. F . The total duration of the disorder does not exceed three months.

37. F23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia A. Criteria A, B, C, and D of acute polymorphic psychotic disorder (F23.0) must be met. 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.

38. F23.2 Acute schizophrenia-like psychotic disorder 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 duration criterium . C. The disorder does not meet the criteria B, C and D for acute polymorphic psychotic disorder (F23.0). D. The total duration of the disorder does not exceed one month.

39. F23.3 Other acute predominantly delusional psychotic disorder A. The general criteria for acute and transient psychotic disorders (F23) must be met. B. Relatively stable delusions and/or hallucinations are present, but they do not fulfil the symptomatic criteria for schizophrenia (F20.0 - F20.3). C. The disorder does not meet the criteria for acute polymorphic psychotic disorder (F23.0). D. The total duration of the disorder does not exceed three months.

40. F23.8 Other acute and transient psychotic disorders Any other acute psychotic disorders that are unclassifiable under any other category in F23 (such as acute psychotic states in which definite delusions or hallucinations occur but persist for only small proportions of the time) should be coded here. States of undifferentiated excitement should also be coded here if more detailed information about the patient's mental state is not available, provided that there is no evidence of an organic cause. F23.9 Acute and transient psychotic disorder, unspecified

41. Other forms of acute psychoses have been observed in both traditional and developing countries, with high prevalence in Asia, Africa, and Latin America. Mezzisch and Lin have suggested that the whole group of culture-bound syndromes should be classified as acute and transient psychotic disorders, although this 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), and spell (trance state in southern United States). CULTURAL VARIANTS

42. There are no laboratory tests for acute and transient psychotic disorders or brief psychotic disorder. Auditory evoked potential studies in patients with cycloid psychosis recorded P300 peaks over the left hemisphere, similar to normal controls. In contrast, in patients with residual schizophrenia, P300 peaks are located over the right hemisphere. A higher P300 amplitude, compared with normal controls, was noted in the cycloid psychosis patients, suggesting a higher level of arousal. Increased hemispheric blood flow during the psychotic episode with return to normal after remission. There was a direct relationship between the severity of symptoms and arousal, and the degree of increase in blood flow, on the other. PATHOLOGY AND LABORATORY EXAMINATION

43. Studies of schizophrenia have consistently shown evidence of enlarged ventricles and dilated cerebral fissures, patients with cycloid psychosis show little or no evidence of such deficits Hypothalamic-pituitary axis abnormalities in subsets of female patients with recurrent atypical psychoses who are more likely to experience episodes at the time of menstruation and parturition

44. persistent delusional disorder: acute polymorphic psychotic disorder without symptoms of schizophrenia is changed to a diagnosis of persistent delusional disorder or other nonorganic psychotic disorder if the illness lasts more than 3 months. Schizophrenia: acute polymorphic psychotic disorder with symptoms of schizophrenia is changed to ICD-10 schizophrenia if the episode lasts more than 1 month. mood disorders: Presence of a full mood syndrome that meets the ICD-10 criteria for a manic or a depressive episode excludes diagnosis of acute and transient psychotic disorders Delirium: acute and transient psychotic disorders may be associated with confusion and perplexity, making it difficult to distinguish these disorders froms . DIFFERENTIAL DIAGNOSIS

45. Drug or alcohol intoxication or withdrawal: The temporal relationship between the onset of psychosis and the substance use may be helpful in differentiating a substance-induced psychotic episode from a non-substance-induced one. Symptoms that persist for many days after all traces of the substance are eliminated from blood and urine support diagnoses of acute and transient psychotic disorders or brief psychotic disorder. Psychotic disorder due to medical illness: Acute psychotic episodes have been reported in a number of medical conditions, including head trauma, cerebral anoxia, epilepsy, and endocrinological disorders such as hyper- or hypothyroidism

46. Acute and transient psychotic disorders, by definition, have a favorable early course—full remission within 1 to 3 months. Duration of episode among non-affective acute psychoses had a bimodal distribution with a point of rarity between the cluster of symptoms where 80% patients had a duration less than 28 weeks and 20% had a duration of more than 1 year. acute remitting psychosis had a modal distribution of 2-4 months which is larger than 1-3 months given in ICD-10 for ATP. COURSE AND PROGNOSIS CTP 9 th edition Susser E, Varma VK, Malhotra S, Conover S, Amador XF. Delineation of acute and transient psychotic disorders in a developing country setting. BrJ Psychiatry 1995a;167:216-9. Susser E, Fennig S, Jandorf L, Amador X, Bromet E. Epidemiology, diagnosis and course of brief psychoses. Am J Psychiatry 1995b;152:1743-8. Mojtabai R, Varma VK, Susser E. Duration of remitting psychoses with acute onset: Implications for ICD-10. Br J Psychiatry 2000;176:576-80.

47. Findings of these studies provide data for typical duration of ATP episodes which is upto 28 weeks and that is definitely longer than was recognized in the ICD-10. In a short-term (5 years) follow-up study of ICD-10 ATP cases, it was found that majority (75%) had good outcome in the form of complete recovery and no residual symptoms. Female gender, presence of stress at onset and absence of schizophrenic symptoms predicted good outcome. In a long-term 20-year follow-up study of WHO CAP study up to 82% patients had an excellent outcome with no relapse and no residual symptoms. Rozario A, Malhotra S, Basu D. Acute and Transient Psychotic disorders: A follow-up study. Unpublished MD thesis: PGIMER, Chandigarh; 1999. Malhotra S. Twenty year follow up of WHO CAP study cohort. Unpublished 2000

48. In a one-year follow-up study of ATPD revealed a diagnostic change in about half (48%) of the patients, most often to either schizophrenia (15%) or affective disorder (28%). diagnostic change was seen from ATP to schizophrenia in 15% and from ATP to affective disorder in 28% cases. Diagnosis was stable in 87% cases Jorgensen P, Bennedsen B, Christensen J, et al. Acute and transient psychotic disorder: A one-year follow up study. Acta Psychiatrica Scandinavica , 1997;96: 150-154. Jorgensen A. Long term course of acute reactive paranoid psychosis. ActaPsychiatr Scand 1995;71:30-7. . Jorgensen P, Bennedsen B, Christensen J, Hyllested A. Acute and transient psychotic disorder: A one-year follow up study. Acta Psychiatr Scand 1997;96:150-4

49. Only a minority of first-hospitalized patients with ATPD develop a severe social impairment after three to seven years. Patients with a severe social impairment at follow-up were characterized by higher means in the total score of the negative syndrome and the depressive syndrome at discharge from the first hospitalization. Therefore, persisting “negative” and/or “depressive” symptoms in patients with ATPD may predict an unfavorable outcome in terms of a chronic schizophrenic disorder. Course and outcome of first-admitted patients with acute and transient psychotic disorders (ICD-10:F23) Focus on relapses and social adjustment; Eur Arch Psychiatry Clin Neurosci (2003) 253 : 209–215

50. recurrence rate was found to be of 46.6% on 8-year follow-up study, and 35% on 5-year follow-up study. Recurrence in the DOSMeD cohort of ATP cases was 22% at 5 years and 11.76% at 12-year follow-up. Rozario A, Malhotra S, Basu D. Acute and Transient Psychotic disorders: A follow-up study. Unpublished MD thesis: PGIMER, Chandigarh; 1999. Malhotra S, Gupta N, Gill S. Recurrence in acute and transient psychosis: Paper presented at the 13th World Congress of Psychiatry. Cairo, Egypt;2005 Sept. 10-15 Susser E, Fennig S, Jandorf L, Amador X, Bromet E. Epidemiology, diagnosis and course of brief psychoses. Am J Psychiatry 1995b;152:1743-8. Mojtabai R, Varma VK, Susser E. Duration of remitting psychoses with acute onset: Implications for ICD-10. Br J Psychiatry 2000;176:576-80.

51. International follow-up studies have shown that cultural factors can influence the course and prognosis of acute psychotic disorders. In 1979, the World Health Organization compared the course of schizophrenia (295), psychotic depression, mania, and other psychoses in different cultures, using the ICD-9 criteria for the diagnoses. The outcome for the schizophrenic group was better in emerging countries than in the industrialized world

52. Short-term treatment Acute psychotic syndromes require early hospitalization in either an inpatient psychiatric unit or a crisis centre. They are psychiatric emergencies. The decision to admit to hospital is taken in order to make a careful clinical evaluation, to separate the patient from his or her environment, to provide a reassuring setting, and to prevent any suicidal or aggressive tendencies. TREATMENT

53. Antipsychotic drugs are prescribed. Some clinicians wait for a day or two before starting neuroleptic therapy in order to eliminate an organic cause and prescribe benzodiazepines rather than neuroleptics . More often, however, antipsychotic treatment starts immediately. The choice of antipsychotic drug depends on the clinician's experience and the clinical features. In cases of major anxiety or agitated behaviour , sedative neuroleptics such as chlorpromazine, loxapine , or levomepromazine are chosen, or zuclopenthixol acetate is used as a short-acting depot antipsychotic.

54. Parenteral administration may be required if the patient refuses oral medication, or if a rapid effect is required because the patient is seriously uncooperative or is too dangerously disturbed. Predominance of delusions and hallucinations indicates a high-potency antipsychotic agent as haloperidol or flupenthixol . In patients experiencing first-episode psychosis, olanzapine had a risk-benefit profile significantly superior to that of haloperidol. Olanzapine Versus Haloperidol Treatment in First-Episode Psychosis (Am J Psychiatry 1999; 156:79–87)

55. Benzodiazepines may be given to potentiate the action of the neuroleptics . Sociotherapy (occupational or intensive) and psychotherapy (reality–adaptive–supportive) are indicated depending on the state of the patient and his environment, with individual, family or rehabilitation care.

56. Continuation treatment The effectiveness of psychopharmacotherapy is usually manifested in the first 6 weeks, with improved sleep, regression of agitation, recovery from anxiety and delusion, and finally disappearance of the psychotic features. When there is no recovery or improvement either another antipsychotic drug should be used or the dosage of the first increased. Worsening of the symptoms, serious side-effects, or a poor response to pharmacotherapy are the main indications for electroconvulsive therapy.

57. If mood disorders or cyclic episodes occur, treatment with antidepressants, mood stabilizers (lithium or valproate ), or an anticonvulsant drug ( carbamazepine ) may be indicated. Care must be taken to distinguish between a post- neuroleptic depression and the development of a ( schizo )affective disorder.

58. Prevention of recurrence The possibility that psychotic symptoms may re-emerge has to be borne in mind during the first 2 years of follow-up. 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. Most guidelines recommended antipsychotic maintenance treatment to be continued for at least 1 year. Gaebel W, Weinmann S, Sartorius N, Rutz W, McIntyre JS. Schizophrenia practice guidelines: international survey and comparison. Br J Psychiatry. 2005;187(3):248. New Oxford Textbook of Psychiatry

59. ICD-11 is currently scheduled for presentation to the World Health Assembly, WHO’s governing body, in 2015. The Working Group on the Classification of Psychotic Disorders (WGPD) is recommending that the diagnostic focus be on its sudden onset, brief duration, and high variability/fluctuation of psychotic and affective symptoms ( ie , “polymorphic” clinical presentation). The WGPD is recommending that the subcategory F23.0 (Acute polymorphic psychotic disorder without symptoms of schizophrenia) be retained as the clinical guideline for ATPD, and the delusional subtype (F23.3) be incorporated into the revised category “Delusional disorder.” STATUS OF ATPD IN ICD-11

60. The WGPD is recommending that the present ICD-10 categories F 23.1 (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. ATPD in ICD-11 as in ICD-10 allows up to 3 months of symptom duration.

61. ATP is a descriptively valid entity on the basis of onset, duration, course and outcome. ATP presents with cross sectionally prominent psychotic, affective, confusional symptoms. Diagnostic criteria particularly duration of episode given in ICD-10 is short and needs to be changed to 6 months at least. There is suggestive evidence of genetic distinctiveness of ATP. Schizophrenia symptoms in ATP and in schizophrenia appear to have shared genetic liability. SUMMARY

62. Environmental factors such as fever, childbirth, seasonality, low SES, stress, rural living, seem to be involved in triggering ATP. Course and outcome of ATP is different from that of schizophrenia or of affective disorder. Except for recurrent course, there seems to be minimal overlap of ATP with affective disorder.

63. CTP 9 th edition Oxford textbook of psychiatry Status of Psychotic Disorders in ICD-11, Schizophrenia Bulletin vol. 38 no. 5 pp. 895–898, 2012 doi:10.1093/ schbul /sbs104 Malhotra S. Acute and transient psychosis: A paradigmatic approach. Indian J Psychiatry 2007;49:233-43. World Health Organization The ICD-10 classifi cation of mental and behavioral disorders. World Health Organization: Geneva; 1992. schizophrenics? Indian J psychiatry 1981;23:200-5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5 th edition. REFERENCES

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65. Thank you