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

1. Presented By : Dr. Karrar Husain
Moderator : Dr. M. Amir Usmani

2.  In late 19th 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.

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:
o – acute or sudden onset
o – unstable, variable, fluid and florid symptomatology
o – volatile polymorphic content
o – anxiety
o – fear or prominent affective symptoms
o – association with a clear precipitant
o – good premorbid adjustment
o – 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)

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.

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:
1. 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.
2. These patients from developing countries exhibited a benign
course at 2 years follow-up.

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.

21.  Main findings showed that:
a) 41.2% patients showed schizophrenic symptoms, whereas
20% showed affective symptoms and 35.3% exhibited other
psychoses.
b) 41.7% showed stress close to onset.
c) There was marked prevalence of patients from below
average socio-economic status.
d) 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:

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

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.
CTP 9th 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
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
1. suddenness of onset (within 2 weeks or less)
2. presence of typical syndromes with polymorphic (changing
and variable) or schizophrenic symptoms
3. 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).

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 (F1x.0),
harmful use (F1x.1), dependence (F1x.2), or withdrawal states
(F1x.3 and F1x.4). The continued moderate and largely
unchanged use of alcohol or drugs in 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.x0 without associated acute stress
F23.x1 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).

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.

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.

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.
CTP 9th 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 (I
Focus on relapses and social adjustment; Eur Arch Psychiatry Clin Neurosci (2003) 253 : 209–2

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.

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.”

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.

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 9th edition
 Oxford textbook of psychiatry
 Status of Psychotic Disorders in ICD-11, Schizophrenia Bulletin vol. 38
no. 5 pp. 895–898, 2012doi: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, 5th edition.

64.  World Health Organization. Report of the International pilot study of
schizophrenia. WHO: Geneva; 1973.
 Sartorius N, Jablensky A, Korten A, Ernberg G, Anker M, Cooper JE, et al.
Early manifestations and first-contact incidence of schizophrenia in
different cultures: A preliminary report on the initial evaluation phase of
the WHO Collaborative Study on determinants of outcome of severe
mental disorders. Psychol. Med 1986;16:909-28.
 Cooper JE, Jablensky A, Sarotrius N. WHO collaborative studies on acute
psychoses using the SCAAP schedule. In: Psychiatry: A world perspective,
Volume 1. Stefanis CN, Rabavilas AD, Saldatos CR, editors. Pub Elsevier:
1990. p. 185-92.