ACUTE AND TRANSIENT PSYCHOTIC DISORDER, REACTIVE PSYCHOSIS, ACUTE PSYCHOSIS, CYCLOID PSYCHOSIS, BOUFEE DELIRANTE

SPEAKER:
AMIT CHOUGULE
MBBS, DPM
PG REGISTRAR
(MD PSYCHIATRY)
CHRISTIAN MEDICAL COLLEGE,
VELLORE

LAYOUT
1. Introduction
2. History of reactive psychosis
3. Concept of reactive psychosis
4. Reactive Psychosis and ICD/DSM
5. Reactivity as a etiology for psychosis
6. Journey towards separate diagnostic category in
ICD
7. Course and diagnostic stability of ATPD
8. Future of ATPD
9. Conclusion

Psychiatric sculptors and Psychiatric sculptures
 The efforts to define homogenous groups of
mental disorders are very similar to the work
of a sculptor
 The artist usually has to cut pieces of wood,
marble or clay in an attempt to give the
material an identifiable feature
 But the material that has been cut continues
to exist as material left in the sculptor’s
workshop

CREATION OF PSYCHIATRIC
DIAGNOSTIC GROUPS
 The history of psychiatry is full of
the efforts of scientists to create
identifiable diagnostic groups
 Material of the psychiatric sculptor is
similar to clay
 Psychiatrists usually change the
form of the diagnosis like the artist
change shape of the clay
 While the volume remains the
same shape changes

THE UNDEFINED PSYCHOTIC MATERIAL
 The separation schizophrenia from affective disorders left an
undefined group of psychotic disorders
 Schizophrenia and affective disorders became more or less
the sculptures
 But other psychoses that were difficult to define remained the
unformed and confused clay material left in the workshop of
the sculptor
 Efforts to give this material a form by naming it
‘schizoaffective disorders’ were only partially successful
(Marneros and Tsuang, 1986;Marneros et al., 1991b;Marneros, 1999, 2003; Marneros andAngst, 2000)

THE UNDEFINED PSYCHOTIC MATERIAL
 Some material remained undefined, confused and unnamed
 Many people are suffering from psychotic disorders that are:
 Not schizophrenia
 Not an affective disorder
 Not a schizoaffective disorder
 Various Psychiatrist around the world have tried to define
this difficult part of the psychotic material
(Acute and transient psychosis by Andreas Marneros and Frank pillmann,2004)

UNDEFINED PSYCHOTIC MATERIAL ACCORDING
TO ICD 10 AND DSM IV
 ICD-10 and DSM-IV recognise the area between
schizophrenia, affective and schizoaffective disorders
 They tried to homogenise the various regional and
national concepts creating the group of :
1. Brief Psychoses (DSM-IV)
2. Acute and Transient Psychotic Disorders (ICD-10)

SYNONYMS FOR ATPD
1. Acute (Undifferentiated) Schizophrenia
2. Bouff´ee D´elirante
3. Cycloid Psychoses
4. Oneirophrenia
5. Paranoid Reaction
6. Psychogenic Psychosis
7. Reactive Psychosis
8. Schizophrenic Reaction
9. Schizophreniform Attack Or Psychosis
10. Remitting Schizophrenia
11. Good Prognosis Schizophrenia

 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

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)

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

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

THE CYCLOID PSYCHOSES- GERMANY
 One of the main synonyms given by the WHO for ATPD
 It was created and developed by three Karls’:
1. Carl Wernicke
2. Karl Kleist
3. 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

BOUFFEE DELIRANTE- FRANCE
1. Another important synonym given by the WHO for ATPD
2. It can be regarded as the French root of ATPD and Brief
Psychoses
3. The modern concept of bouffee delirante is based on
operational criteria like:
1. Sudden onset
2. Specific symptomatology
3. Evolution of the disorder
4. French psychiatrists put more weight on course than on
symptomatology
5. French psychiatric school has retained the category
bouffee delirante as an independent mental disorder
(Pichot,1982)

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:
1. Confusional
2. Paranoid hallucinatory
3. Schizoaffective
4. Hysterical psychosis (K. S. Jacob, 2016)

Reactive or Psychogenic
Psychoses
 Synonym given by the WHO for Acute and
Transient Psychotic Disorders
 Basic concept was developed by Karl Jaspers
 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)

Carl Jaspers Concept of Reactive states
 Jaspers stressed that reactive states can be classified in different
ways:
1. According to what precipitates the reaction:
 Prison psychoses
 Psychoses due to earthquakes and catastrophe
 Reactions of homesickness
 Combat psychoses
 Psychoses of isolation due to linguistic barriers or deafness
2. According to the particular psychic structure of the reactive states
3. According to the type of psychic constitution that determines the
reactivity

Reactive Psychosis
 Scandinavian countries use four concepts of
reactive psychoses:
 Two called Psychogenic psychoses:
1. Danish concept of purely psychogenic
psychoses according to Wimmer and
Strömgren
2. Norwegian concept of constitutional and
psychogenic psychoses according to
Langfeldt and Retterstøl
 The other two considered as Reactive
psychoses:
1. Functional psychoses with good outcome
2. Group of functional psychoses not clearly of
schizophrenic, chronic paranoid or manic
depressive type

THREE VARIANTS OF REACTIVE PSYCHOSIS
1. Reactive psychosis as purely psychogenic psychosis:
 Psychological stress or conflict causes and shapes the
psychosis
 Mental state normalizes on resolution of the conflict
2. Reactive psychosis due to an interaction between trauma
and vulnerability:
 A predisposed person by personality or physical state is
overtaken by a stressful life event at a vulnerable moment
 He can only react by psychotic decompensation
3. Reactive psychosis as simply a good outcome psychosis:
 This implies that the diagnosis cannot be made until the
course and outcome are known

REACTIVE/ PSYCHOGENIC PSYCHOSIS BY
WIMMER
 Wimmer stated that Psychogenic Psychoses were:
 Clinically independent psychoses caused by mental
factors or traumas
 Seen in predisposed individuals
 Tendency to full recovery
 In these cases trauma determines:
 Time of onset
 Course and the termination of the psychosis
 Form and content of the psychosis

REACTIVE PSYCHOSIS
BY ERIK STRÖMGREN
For Diagnosis psychogenic/Reactive psychoses he required:
1. Adequate mental trauma
2. Close temporal correlation between the trauma and the onset
of the psychosis
3. Determination of the content of the psychosis by trauma
4. Preoccupation with the traumatic experience
5. Course should have some relation to the traumatic situation
6. Remission in the course of days or few weeks
7. Good prognosis with complete recovery

THE TRAUMATIC FACTORS IN REACTIVE
PSYCHOSIS
The traumatic factors:
1. Experiences of impersonal character:
e.g natural catastrophes or war-like situations
2. Experiences of personal character:
e.g economic loss, loss of job or imprisonment
3. Conflicts within the family
4. Experiences of verbal isolation:
e.g refugees
5. Experiences of inner conflicts:
 Disagreements between parts of personality
 Conflicts of consciousness or blows to self-esteem

CLINICAL TYPES OF THE REACTIVE PSYCHOSIS
A. Emotional reactions:
 Reactive depression
 Anxiety
 Excitations
 Emotional paralysis
B. Disorders of consciousness:
 Delirious reactions
 States with clouded consciousness and amnestic states
 Depersonalization states
C. The Paranoid type:
 Paranoid psychoses associated with imprisonment, sensory
deprivation or lack of verbal communication
 Induced paranoid psychosis

DETERMINANTS OF CLINICAL FORMS OF REACTIVE
PSYCHOSES PROPOSED BY STRÖMGREN
A. The emotional reactions were based on simple
situational traumas
B. Disorders of consciousness were caused by a sudden
disruption of the individual’s:
 Image of environment
 His ideas about other people and environment
C. The paranoid reactions were caused by:
 Sudden blow to the self-esteem
 Individual’s image of self

EPIDEMIOLOGY OF REACTIVE PSYCHOSIS
 The diagnosis of reactive psychoses has been widely
used in the Scandinavian countries
 The prevalence of reactive psychosis was:
1. Denmark 21%
2. Norway 30%
3. Sweden 13%
 In 1979 half of all first admissions in Norway and Denmark
were labelled reactive psychosis
(M Taylor,1994)

Course of Reactive Psychosis
 Faergeman followed up Wimmer's original 170 patients for 20
years
 50% were diagnosed as schizophrenia
 Retterstol found that 80% of his cases of reactive psychosis
relapsed over 15 years
 This stability could be taken to validate the syndrome
(M Taylor,1994)

Course of Reactive Psychosis
 Longitudinal studies from Norway indicated that:
1. Reactive psychosis can be differentiated from schizophrenia
and manic depressive illness
2. Outcome of reactive psychosis is intermediary between
schizophrenia and affective illness
3. 31% to 40% of reactive psychosis cohort became
schizophrenic eventually
(Aksel bertelsen, reactive or psychogenic psychoses: the scandinavian concept)

SCANDINAVIAN BIAS TOWARDS
REACTIVE PSYCHOSIS
Reasons for overgenerous initial diagnostic rate of reactive psychosis
in Scandinavia:
1. Unwillingness to diagnose schizophrenia on first admission
2. Scandinavians freely read their case-notes
3. Use of the schizophrenic category may be limited to chronic
forms
4. Diagnostic tradition established amongst Scandinavian
psychiatrists

BRIEF REACTIVE PSYCHOSIS AS COMPOSITE
SYNDROME
Guinness working in Swaziland (Africa) gave three broad
groupings for reactive psychosis:
1. Culturally sanctioned form of illness behaviour:
1. Depression presenting as a dissociative state
2. These cases react psychotically to minor life events
3. If they relapse they present as acute psychosis
than progressing to schizophrenia

2. Younger males presenting with repeated episodes of
transient psychosis:
○ Manifest as mania which can be years apart
○ Precipitated by major life events
○ The intervals between are normal
3. Cases that present as typical brief reactive psychosis but
who insidiously develop schizophrenia:
○ These individuals later exhibit formal thought disorder,
slower recovery and the social impairment as seen in
schizophrenia

REACTIVE PSYCHOSIS AND ICD
 WHO ICD-8 reactive psychoses were included under the
category of “other psychoses” with five subcategories
 In WHO ICD-9 reactive psychoses were included under
other non-organic psychoses
 With a preliminary remark that they “should be restricted to
the small group of psychotic conditions that are largely or
entirely attributable to a recent life experience”
 This allowed the wide use of the reactive psychoses in the
Scandinavian countries

REACTIVE PSYCHOSIS AND ICD 10
 ICD-10 had non-etiological or purely descriptive
approach
 This did not allow nosological classification of the
reactive psychoses as a separate category
 Reactive Psychosis was included under a new
category of Acute and Transient Psychotic Disorders

REACTIVE PSYCHOSIS AFTER ICD 10
 Large difference were seen in prevalence of Reactive
Psychoses
 Comparison between last two years of ICD-8 and of ATPD
in the first two years of ICD-10 in Denmark
 In 1992 and 1993 Reactive Psychoses were diagnosed in
19.2% of non-organic psychoses
 In 1994 and 1995 Acute and Transient Psychotic
Disorders were diagnosed in 8.7% of non-organic
psychoses

REACTIVE PSYCHOSIS AFTER ICD 10
 Associated acute stress was recorded only in 5.3% in the
patients with ATPD category
 This was because the definition of associated acute stress
was made too narrow
 The distribution of ICD-10 diagnoses at readmissions in
1994 and 1995 of patients admitted in 1992 and 1993 with
Reactive Psychoses showed:
1. Only 20.1% in the category of ATPD
2. 24% went to affective disorders
3. 12% to schizophrenia
4. 11% to chronic delusional disorders
5. only few to stress-related disorders

REACTIVE PSYCHOSIS VS ICD 10 ATPD
CRITERION
Reactive
Psychosis
ICD 10 ATPD
Psychosocial precipitant
Must be
present
Not a prerequisite
Depressive, dissociative and
other non-psychotic states
Can be
present
Should not be
present
1. The Psychogenic or reactive psychoses disappeared
almost completely
2. The concept may have a future in the coming revision of
ICD-11
3. More Focus on etiology in ICD-11 as compared to ICD-10

REACTIVE PSYCHOSIS AND DSM
In DSM-III category of Brief Reactive Psychosis:
 Characterised by a sudden display of psychotic behaviour
that lasts at least several hours but less than 1 week
 An acute and severe stressful event as a trigger mandatory
In DSM-III-R the maximum duration of Brief Reactive Psychosis
was changed to 1 month
 Definition was more restrictive
 Strict criteria were set for duration, character of symptoms
and severity of the mandatory stressor

REACTIVE PSYCHOSIS AND DSM
 Brief Reactive Psychosis proved to be a very rare
condition even among high risk groups
 The concept was dropped from DSM-IV
 Category of Brief Psychotic Disorder was created in
DSM IV
 Criterion of a severe stressor was moved from a
defining criterion to an optional specifier

REACTIVITY AS ETIOLOGICAL FACTOR FOR
PSYCHOSIS
 AIDS
 STROKE, IHD
 DIABETES
 PSYCHOSIS
HIV
INFRACT
INSULIN

STRESS/ TRAUMA/ REACTIVITY AS A
CAUSE FOR PSYCHOSIS
 There is compelling epidemiological evidence
 Two studies from the British National Psychiatric
Morbidity Survey reported that:
1. Adverse life events during the preceding 6 months
were associated with psychotic experiences in a
sample of the general population
2. Both cross-sectionally and longitudinally
 Cumulative exposure to traumatic life events may
increase risk of psychosis
(Ruud van Winkel,2008)

STRESS/ TRAUMA/ REACTIVITY AS A CAUSE
FOR PSYCHOSIS
 A first episode study in Iran found that:
1. 75% of ATPD patients had experienced a significant life
event
2. 4 weeks preceding the onset of their symptoms
 A first episode study in India reported:
1. 69% of patients
2. Stress within two weeks of onset
 In a study from Chandigarh, India:
1. Recent life events were more common in ATPD
2. Recent life events studied were:
 Job distress for men
 Leaving or returning to parental village for women

 The role of stress may vary by gender and frequency of
episodes
 Stressful events were more commonly reported among
female than male
 In a study of cycloid psychoses:
1. 1/3 of first episode cases were precipitated by
somatic or psychic stressors
2. Impact of stress decreased in subsequent episodes

 Migration is associated with increased risk for psychosis
 Social defeat defined as a subordinate position or
outsider status is postulated as risk for psychosis
 An important aspect of the social defeat hypothesis is
that it is a subjective phenomenon, ie, ‘‘defeat is in the
eye of the beholder”

STRESS REACTIVITY IN PSYCHOSIS
 Increased risk for psychosis is associated with increased
emotional reactivity to the small stresses of daily life
 The study sample of:
1. Psychotic patients in state of remission
2. First degree relatives of patients with psychosis
3. Healthy controls
 Patients reported a greater decrease in positive affect and a
greater increase in negative affect than the healthy controls
when they encountered stress with the first degree relatives
displaying intermediate scores

 In a general population twin sample increased
psychometric risk for psychosis was associated with
increased emotional reactivity to stress
 Cross trait cross-twin association between stress reactivity
and subclinical psychosis was found
 Stress also increased the intensity of subtle psychosis-like
symptoms in the realm of daily life, both in patients and
their first-degree relatives

 These findings suggest that the association between
stress and psychosis may be a consequence of an
underlying vulnerability, characterized by increased
emotional and psychotic reactions to stress

Behavioural Sensitization to Stress
 Behavioural Sensitization is hypothesized to represent an
underlying mechanism for stress reactivity
 Sensitization refers to the process whereby repeated
exposure to a certain event increases the behavioural and
biological response to later exposure to a similar event
even if the later exposure is not as severe
 Increased emotional and psychotic reactions to stress may
be the result of such a process of behavioural sensitization

BIOLOGICAL MECHANISMS RELATING
STRESS TO PSYCHOSIS
 Need to understand sensitization and genetic underpinnings
of stress leading to psychosis
 Two plausible hypothesis of the biological mechanisms
involved are:
1. Hypothalamus-pituitary-adrenal (HPA) axis:
 It mediates the principal adaptive response to perceived
psychological or physiological stress
2. Dopamine system:
 This is considered to be important in the development of
psychosis

HPA DYSREGULATION AND PSYCHOSIS
 An enhanced response to stress is mediated by activation
of the HPA axis
 This is postulated to play an important role in the onset,
exacerbation and relapse of psychosis
 Walker and Diforio proposed a Neural diathesis-stress
model:
1. HPA axis may trigger a cascade of events resulting in
neural circuit dysfunction including alterations in
dopamine signaling
2. This model is based on evidence regarding effects of
cortisol on brain and behavior

The authors conclude that several lines of evidence suggest
a link between HPA activity and psychosis:
1. Cushing syndrome is associated with psychosis
2. Administration of corticosteroids can induce psychosis
3. Patients with schizophrenia and other psychotic disorders
manifest HPA dysregulation such as:
 Increased baseline cortisol and adenocorticotropic
hormone levels
 Increased cortisol response to a pharmacologic
challenge
 Abnormalities in glucocorticoid receptors

Dopamine and Psychosis
 Dopamine dysregulation is implicated in the development of
psychosis
 A sensitization process involving dopaminergic dysregulation
of key brain areas has been proposed as the final common
pathway leading to psychosis

Stress and Dopamine Reactivity
 Can Psychosocial stress affect dopaminergic reactivity??
 The available literature relating stress to dopamine
reactivity can be divided into 3 complementary approaches:
1. Animal studies
2. Studies using experimental and metabolic stress models in
humans
3. Studies using true psychosocial stressors in humans

Dopamine and Psychosis in Humans:
Dopaminergic Reactivity to Metabolic Stress
 To model the influence of stress on dopaminergic reactivity
2-deoxy-D-glucose (2DG) is used as a metabolic stressor
 This induces a robust activation of the HPA axis
 Also raises the plasma levels of homovanillic acid (HVA)
 It has been consistently found that patients with psychosis
display an increased (HVA) response to metabolic stress
 Unaffected siblings of patients with psychosis display an
increased HVA response to metabolic stress

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?

International pilot study of schizophrenia
IPSS (1968-70)
 First major study to recognize the problem of acute
psychosis
 Agra was the center from India
 The main findings in relation to acute and transient
psychosis were:
1. Course and outcome in developing world was better
than developed countries
2. 25% of people diagnosed to have schizophrenia had
only one episode and good outcome
 These findings of the IPSS raised following questions:
1. Whether these subjects with good outcome had a
separate psychosis?
2. Were they part of the schizophrenia group?

Determinants Of Outcome Of Severe Mental Health
Disorders (Dosmed) (1978-80)
 Designed to study:
1. First onset psychosis
2. Incidence of schizophrenia
3. Findings related to acute and transient psychosis
 Chandigarh was the Indian center
 The incidence of broadly defined schizophrenia which
included non-affective, acute and remitting psychosis (ICD-9)
was 10 times higher in the developing world than in the
developed countries
 These patients also exhibited a benign course at two-year
follow-up

The cross-cultural study of acute psychosis (CAP)
(1980-82)
 The study aimed to:
1. Differentiate ATPD from schizophrenia and manic depressive
psychosis
2. Understand its relationship with psychological and physical
stress
 Sample size was 1004 patients with acute psychosis
 Main findings included:
1. 41.2% of patients had symptoms of schizophrenia
2. 20% had Affective symptoms
3. 41.7% reported stress at onset
4. Two-thirds of the subjects remained without relapse at one
year follow-up

Indian Council of Medical Research’s Multicentre
study of acute psychosis
 Bikaner, Goa, Patiala and Vellore
 Documented 52% of patients with acute psychotic
presentations who could not be classified as
schizophrenia or MDP
 The findings of the Chandigarh Acute Psychosis Study
were similar with 40% receiving the label of acute
psychosis

RECOGNITION OF ACUTE PSYCHOSIS AS
A SEPARATE CATEGORY
 These studies provided evidence of a non-affective,
non schizophrenia psychosis with remission and good
outcome
 Lead to the inclusion of acute and transient Psychosis
as a separate category in ICD-10

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:
1. 30% of ATPD patients experienced a single episode
2. 50% had an episodic-remitting course
3. 20% had a chronic course
 In the Chandigarh site of the DOSMeD study only one (6%) out
of 17 patients followed-up to 12 years had remaining symptoms
of illness at follow-up

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 and DSM-
IV brief psychotic disorder maintained the same diagnosis
over 12 months of follow-up
 In a 15-year follow-up of 197 patients diagnosed using both
the ICD-10 and DSM-IV the diagnoses of ATPD,
Schizophreniform and brief psychotic disorder were unstable
over time

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

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:
1. Affective disorder in 9.2%
2. Schizophrenia in 26.4%
3. 11.5% presented with recurrent episodes of acute
psychosis
 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

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
schizophrenia and related disorders or affective disorders
 Findings from developed countries have indicated that this
diagnosis changes to either schizophrenia or affective disorders
 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

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

Treatment
 No randomized clinical trials deal with these disorders
exclusively
 In the Halle Study of brief and acute psychoses during
initial episode:
 95% received an antipsychotic
 21% an antidepressant
 7% lithium

GENERAL TREATMENT RECOMMENDATIONS
1. Comprehensive assessment to evaluate comorbidities
and rule-out organic and substance induced causes
2. Atypical antipsychotics often at low initial doses as
first line of treatment
3. Continuation of treatment for a year
4. Coordination with the patients family and/or friends
5. Ensure treatment adherence and to education about
the disorder

FUTURE OF ATPD IN ICD-11
 Working Group on the Classification of Psychotic Disorders (WGPD)
is recommending that the diagnostic focus be on its “polymorphic”
clinical presentation:
1. Sudden onset
2. Brief duration
3. High variability/fluctuation of psychotic and affective symptoms
 WGPD is recommending that:
1. Subcategory F23.0 (Acute polymorphic psychotic disorder without
symptoms of schizophrenia) be retained as the clinical guideline
for ATPD
2. Delusional subtype (F23.3) be incorporated into the revised
category Delusional disorder

 The (WGPD) also recommended that:
 Present ICD-10 categories F23.1 (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
 Schizophreniform disorder is not recommended to be
introduced into ICD-11

ATPD IN ICD-11 VS DSM-5
 The concept and clinical picture of ATPD in ICD-11 are
different from Brief psychotic disorder in DSM-5
 DSM-5 uses 4 of the 5 clinical symptom criteria of
schizophrenia but not of a polymorphic and fluctuating nature
 ATPD in ICD-11 as in ICD-10 allows up to 3 months of
symptom duration compared to 1 month for brief psychotic
disorder in DSM-5
 The rationale for this longer duration of symptoms is that the
modal duration of remitting psychoses with acute onset is
2–4 months

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
 It is often difficult to recognise the classic Psychotic
syndromes at the onset of the illness
 However these can be identified over time as they become
more obvious

Conclusion
 A useful diagnostic category needs to have
1. A central principle
2. Clear boundaries
3. Should be amenable to investigation, treatment and
prevention
 There was uncertainty about the validity of reactive
psychosis and historical or national variations in nosology
 With the publication of ICD 10 the concept appears to have
gained a permanent place in international classification

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

Need for etiological/ dimensional
classification system
 Any classification that is only phenomenological-
descriptive in nature, as in the DSM system 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

References
1. Acute and transient psychosis by Andreas Marneros and
Frank pillmann,2004
2. K. S. Jacob Indian Psychiatry and classification of
psychiatric disorders.Indian J Psychiatry 52, Supplement,
January 2010
3. Savita Malhotra Acute and transient psychosis: A
paradigmatic approach.Indian J Psychiatry 49(4), Oct-Dec
2007 233
4. M Taylor Madness and Maastricht: a review of reactive
psychoses from a European perspectiveJournal of the
Royal Society of Medicine Volume 87 November 1994
5. Aksel Bertelsen Reactive or Psychogenic Psychoses: The
Scandinavian Concept. Revista do Serviço de Psiquiatria
do Hospital Fernando Fonseca

6. 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 InteractionSchizophrenia Bulletin vol. 34 no. 6 pp.
1095–1105, 2008
7. Wolfgang Gaebel*Status of Psychotic Disorders in ICD-
11Schizophrenia Bulletin vol. 38 no. 5 pp. 895–898, 2012

ACUTE AND TRANSIENT PSYCHOTIC DISORDER, REACTIVE PSYCHOSIS, ACUTE PSYCHOSIS, CYCLOID PSYCHOSIS, BOUFEE DELIRANTE

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