Acute and transient psychotic disorders
Acute and transient psychotic episodes have been described since the end of the nineteenth century. Descriptions have varied from one country to another, so that the exact nosology has not yet been established. The links between acute psychoses (generally defined as having brief obvious psychotic symptomatology) and chronic psychoses (schizophrenic psychoses and psychoses with persistent delusions) are still under discussion.
For instance, Sections F20 and F21 in ICD-10(1) are devoted to ‘Schizophrenia, schizotypal and delusional disorders’. A specific diagnostic category named ‘Acute and transient psychotic disorders’ is included, distinct from Schizophrenia (F20), Schizotypal disorder (F21), Persistent delusional disorder (F22), Induced delusional disorder (also called folie à deux) (F24), and Schizoaffective disorder (F25).
In this textbook, the acute and transient psychotic disorders (Chapter 4.3.10) appear in the section dedicated to schizophrenia, which also includes schizotypal disorders and schizoaffective disorders (Chapter 4.3.9). However, this section is clearly distinguished from the chapter in which the persistent delusional disorders are discussed (Chapter 4.4). These taxonomic divergences are justified more by the history of acute psychoses than by scientific findings.
In the nineteenth century, German psychiatrists had already described akute primäre Verruckheit,(2) termed paranoia acuta by Karl Westphal. In 1876 (published in 1878), Westphal used this term to describe an acute form of paranoia with an outburst of perceptual hallucinations, consisting mostly of hallucinatory voices and delusions, with clouding of consciousness. In 1890, Meynert repeated the clinical description but named the condition amentia.(3) Sigmund Freud chose this type of acute delusion with hallucinations for his psychoanalytic conception of psychosis.(4)
In the sixth edition of his textbook, published in 1899, Kraepelin(5) included all the paranoias under dementia praecox, and in the eighth edition (1908–1915) he combined manic and melancholic periodic disorders in a single group, leaving acute psychosis with no place between these two diagnostic categories.
In 1911, Bleuler(6) replaced the single disease dementia praecox by the concept of a group of schizophrenias of various clinical forms. He noticed that schizophrenia often began with an acute excitatory episode lasting from a few hours to a few years. He described a wide variation of outcome of acute forms of psychosis, but he separated acute schizophrenias from simple schizophrenia as he believed that acute forms do not necessarily end in deterioration.
In 1916, based on Karl Jaspers’ psychopathology, the Danish psychiatrist Wimmer(7) described psychogenic psychosis as a reactive psychosis arising after psychosocial trauma. Mayer-Gross,(8) who proposed an organic aetiology for schizophrenia, described ‘oneiroid states’ consisting of acute psychotic symptomatology with no other specific organic features.
In 1961, Leonhard(9) used Kleist's concept of marginal psychosis (Randpsychosen) to develop his description of ‘cycloid psychoses’ as endogenous psychoses separate from schizophrenic psychoses and from manic and melancholic psychoses. These cycloid psychoses tend to have a benign and periodic course.
Earlier (1933), Kasanin(10) had described ‘acute schizoaffective psychoses’, raising questions about the links between schizophrenic and affective diseases.
Langfeldt(11) suggested that observation for 5 years was required to be able to distinguish schizophrenia and what he called schizophreniform psychosis. This long-term observation is a reminder of the Bleulerian concept of acute schizophrenias which could last for several years. Epidemiological studies have led to the presence in modern classifications of a group of acute schizophreniform psychoses under the rubric ‘Schizophreniform disorder’ (DSM-IV Section 295.40) or ‘Acute psychotic disorder schizophrenic-like’ (ICD-10 Section F23.2).
In France, the concept of bouffée délirante led naturally to a specific class of acute psychoses. In 1895, Magnan(12) and his disciple Legrain(13) described bouffée délirante or délire d'emblée (immediate delusion) within the polymorphic delusions of the chronic insane. This concept is based on Morel's theory of degeneration, commonly accepted in the nineteenth century. The question of whether there is a susceptibility or a predisposition to the occurrence of an acute psychosis remains unanswered.(14)
In 1954, Ey(15,16) described the development of the concept of bouffées délirantes and of acute psychoses with hallucinations from the time of Magnan to a symposium devoted to the clinical subdivision of schizophrenic psychoses held at the First World Congress of Psychiatry in 1950, where the various ideas were discussed by Langfeldt, Karl Leonhard, and Aubrey Lewis (Table 184.108.40.206).
Table 220.127.116.11 Historical development of the terminology of acute and transient psychotic disorders
1876 Westphal Akute primäre Verruckheit Paranoia acuta
F23.3 Other acute predominantly delusional psychotic disorder
1890 Meynert Amentia
1895 Magnan and Legrain Bouffées délirantes
F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia
1899 Kraepelin Dementia praecox
1909–1913 Kraepelin Paranoia
F22.0 Persistent delusional disorder
1911 Bleuler Acute-onset forms of schizophrenia
F23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia F23.2 Acute schizophrenia-like psychotic disorder
1916 Wimmer Psychogenic psychosis
F23.3 Other acute predominantly psychotic disorder
1924 Mayer-Gross Oneroide Erlebnisform
F23.3 Acute schizophrenia-like psychotic disorder
1933 Kasanin Acute schizoaffective psychoses
F25 Schizoaffective disorders
1939 Langfeldt Schizophreniform states
F23.2 Acute schizophrenia-like psychotic disorder
1954 Ey Bouffées délirantes et psychoses hallucinatoires aigues
F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia
1961 Leonhard Cycloid psychoses
F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia
Clinical description: psychopathology
The heterogeneous group of acute and transient psychotic disorders are characterized by three typical features, listed below in descending order of priority:
♦ 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). However, a small number of patients develop persistent and disabling states.
The general (G) criteria for these acute disorders in DCR-10 (Diagnostic Criteria Research of ICD) are as follows.
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).
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.)
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 and
♦ F23.x1 with associated acute stress.
For research purposes it is recommended that 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, and we shall discuss them in order.
F23.0 acute polymorphic psychotic disorder without symptoms of schizophrenia
The diagnostic criteria are based on the classical symptoms of the true bouffée délirante described by Magnan and Legrain.
(a) Suddenness of onset
Bouffée délirante occurs over a period of a few hours or days, usually to young adults and often women in their 30s. The onset of the delirious episode is ‘like a thunderbolt in a serene sky’. This aphorism from Legrain has the same meaning as the French classical expression délire d'emblée (immediate delusion).
Although premonitory symptoms, such as increasing perplexity and anxiety, may occur, the delusions start suddenly and are always accompanied by a break-up in the individual psychic life. If the onset is preceded by a stressful or traumatic event, such as resettlement or acculturation, this may take place some months previously and the outburst of the delirious episode is delayed. The fifth code character of category F23 is used to specify whether acute stress is associated with the onset of the disorder (e.g. F23.00 has no associated acute stress).
(b) Polymorphic psychotic symptoms
The delusional themes are varied and include grandeur, persecution, influence, possession, body transformation (depersonalization), derealization, or world alteration; these themes change with time and may combine. Other symptoms are also varied, including hallucinations, illusions, interpretations, and intuitions.
(c) The emotional state
As a consequence of the delusions the patient experiences mood change and emotional turmoil (happiness, ecstasy, anxiety, irritability). However, the criteria for manic episode, depressive episode, schizoaffective disorder, and schizophrenia are not satisfied.
Consciousness fluctuates with the delirious convictions and changes of emotion. There is a specific disorientation with respect to time and place—the passage of time (temps vécu according to Eugène Minkowski) and ‘temporality’ (Sein und Zeit according to Ludwig Binswanger) are disturbed. This disorientation, described by Karl Jaspers as a ‘first delirious experience’ (Erlebnisse), has to be understood as a dream-like state.
Ey(15,16) differentiated the acute psychoses in terms of the specific alteration in the perception of time rather than their transient course. According to Jacksonian ideas, the acute psychoses are the expression of a destructuring of consciousness to levels related to each acute psychosis.
(d) The duration of the delirious experience
In ICD-10, the criterion of a duration of less than a month distinguishes other categories from schizophrenia (F20) and manic or depressive episodes (F30 and F32).
(e) Short recovery time
In most cases recovery from the acute psychotic disorder occurs within a few weeks or months. However, long-term prognosis is difficult because of the risk of relapse into either a repeated episode or a more chronic disease. If resolution of the symptoms has not occurred after 3 months, the diagnosis should be changed to persistent delusional disorder (F22) or non-organic psychotic disorder (F28).
(f) Suggested criteria
Pull et al.(17) have suggested the following empirical criteria for bouffée délirante.
♦ Abrupt or acute onset, with no previous psychiatric disorder except other similar episodes.
♦ Absence of chronicity: the active stages disappear completely in a few weeks or months. Relapses can occur, but there is no psychiatric disorder between consecutive episodes.
♦ Specific symptoms: delusions and/or any type of hallucination, depersonalization and/or derealization with or without confusion, and affective disturbance manifesting as depression or euphoria. The symptoms change from day to day and even from hour to hour.
♦ There is insufficient evidence for organic mental disorder, alcoholism, or drug addiction. The exclusion clauses are less restrictive in ICD-10, since a moderate, continued, and unchanged use of alcohol or drugs in habituated individuals does not exclude the diagnosis.
♦ The true acute psychotic disorder occurs without any associated psychosocial stress factor. When psychosocial stress factors are found, there is only a temporal link with the so-called ‘reactive’ acute psychosis.
(g) Long-term evolution
Bleuler(6) described one-third of cases of acute schizophrenic psychoses as single episode, one-third as recurrent episodes with repetition of the same acute and transient psychoses (either manic or depressive), and one-third following a course which developed as schizophrenia.
Between 1976 and 1989, Metzger and Weiber(18) studied 885 cases of acute psychoses. Using the criteria of Pull et al.(17) they found group 303 cases of genuine bouffée délirante (two-thirds female, one-third male, average age of 32 years). They followed the course of 191 cases (over an average period of 6.2 years): 34 per cent did not relapse, 24 per cent had recurrent and transient episodes, 34 per cent developed schizophrenia, and over 7 per cent developed a periodic affective disorder (manic and depressive states). The relapse or chronic course rate was higher in the group without triggering factors (n = 92) than in the group with triggering factors (n = 99). The difference between true bouffée délirante (no triggering factors) and other acute and transient psychotic disorders raises questions about their pathogenesis.
F23.1 acute polymorphic disorder with symptoms of schizophrenia (bouffée délirante or cycloid psychosis with symptoms of schizophrenia)
This diagnostic category combines the symptoms of acute polymorphic psychotic disorder with some typical symptoms of schizophrenia (F20) present for most of the time. However, the schizophrenic symptoms are not precisely listed. F23.1 can be a provisional diagnosis, which is changed to schizophrenia if the criteria of F20 persist more than a month.
Acute polymorphic disorder with symptoms of schizophrenia satisfies the general criteria for acute and transient psychotic disorders:
♦ acute onset of less than 2 weeks
♦ polymorphic delusions and hallucinations or perceptual disturbances leading to incomprehensible or incoherent speech
♦ clouding of consciousness with impairment of attention or concentration, disorientation, perplexity, etc.
♦ emotional turmoil and affective symptoms (depressed mood, euphoria, anxiety, irritability) without the symptomatic criteria for manic–depressive or recurrent depressive disorders
♦ rapid changes of the type and intensity of symptoms
♦ no evidence of causation by organic or psychoactive substances.
It is also associated with some schizophrenic symptoms which are present most of the time:
♦ mental automatism (thought echo, insertion, withdrawal, or broadcasting)
♦ control, influence, passivity referred to body movements, thoughts, actions, or sensations
♦ hallucinations with commentary
♦ catatonic behaviour
♦ negative symptoms.
The ICD-10 clinical criteria give no information about psychotic or schizophrenic symptoms or about the action of antipsychotic drugs on these symptoms.
Leonhard(9) described cycloid psychosis as an episode with clouding of consciousness and a marked alteration of thinking. Many authors have reported follow-up studies of cycloid psychoses,(21–23) which confirm the better prognosis of cycloid psychoses than of schizophrenias and schizoaffective disorders.
F23.2 acute schizophrenia-like psychotic disorder (schizophreniform psychosis)
This acute psychotic disorder lasts for less than a month and is mostly schizophrenic. The polymorphic psychotic symptoms are stable (no rapid changes, no emotional turmoil or confusion), sometimes with emotional instability.
The duration criterion is the most important. This category is a provisional diagnosis and appears to include such disparate descriptions as oneirophrenia (oneiroid states or Erlebnisform(8)), schizophrenic reaction (DSM.IV 298.8, Brief reactive psychoses), and schizophreniform psychosis.(11) In ICD-10, if the first episode lasts for more than a month, it has to be considered as an acute onset of schizophrenia.
The Scandinavian psychiatric school(24) justify the retention of this category because of the very good and rapid recovery, and have tried to determine factors in the personal and family history predicting the onset of schizophrenia.
Schizophreniform disorder remains in DSM-IV (295.40) because the evidence linking it to typical schizophrenia remains unclear, but the duration criterion is less restrictive (up to 6 months). Features suggesting a good prognosis are onset within 4 weeks, confusion at the height of the psychotic episode, previously good social and occupational functioning, and absence of blunted or flat affect.
F23.3 other acute predominantly delusional psychotic disorders
The main clinical features of this category are delusions and hallucinations. The foreground delusions are mostly persecutory (delusions that the person or close relatives are being malevolently treated or are under external influence, with thought disturbances); auditory hallucinations are present in the background. Despite their stability, these psychotic features do not meet the criteria for schizophrenia (F20).
As for F23.0, the duration of this acute predominantly delusional psychotic episode must be less than 3 months. If the persecutory delusions persist for more than 3 months, the diagnosis changes to persistent delusional disorders (F22). This development from F23.3 to F22 is reminiscent of the classical paranoia acuta. Thus, both paranoid reaction and psychogenic paranoid psychosis are included in F23.3. Paranoid reaction must be distinguished from induced delusional disorder or folie à deux (F24), in which the delusions of the ‘dominated’ patient disappear when the two people are separated (see Chapter 4.4).
If the background auditory hallucinations persist for more than 3 months, the diagnosis is changed to other non-organic psychotic disorders (F28). This diagnostic category is defined by exclusion: the persistent hallucinatory disorder does not meet the criteria for schizophrenia (F20), persistent delusional disorders (F22), acute and transient psychotic disorders (F23), psychotic types of manic episode (F30.2), or severe depressive episode (F32.3). F28 also corresponds to chronic hallucinatory psychosis, as explicitly noted in ICD-10.
F23.8 other acute and transient psychotic disorders
This category includes any other acute and transient psychotic disorders with no evidence of organic cause that are not classifiable under previous F23 categories, such as ephemeral delusions or hallucinations and undifferentiated excitement.
F23.9 acute and transient psychotic disorder unspecified
Brief psychotic disorder (298.8) is defined in DSM-IV as an episode of acute and transient psychotic disorders (delusions and hallucinations with disorganized speech and behaviour) which lasts at least a day but less than a month with eventual full return to previous level of functioning. If the symptoms occur after stressful events in the person's life, brief psychotic disorder with marked stressor(s) has to be specified. If the symptoms occur within 4 weeks post-partum, brief psychotic disorder with post-partum onset has to be specified.
Other forms of acute psychoses have been observed in both traditional and developing countries, with high prevalence in Asia, Africa, and Latin America. These brief psychotic episodes are culture-bound syndromes, often with immediate precipitating stress or life events.(25) There is disorganized behaviour, delusions, thought disorders, confusion, and mood disorders, usually with full recovery and no relapse in a 1-year follow-up.
The culture-specific disorders(26) and their potentially related syndromes are often acute and transient. The status of these culture-reactive disorders is controversial and needs more clinical and epidemiological research. The mode of assignment to categories in ICD-10 does not suggest category F23.
Appendix I of DSM-IV (Outline for cultural formulation and glossary of culture-bound syndromes) lists 25 syndromes, with a glossary mostly using the local terms (seven in Hispanic languages, five in English, and one in French). Bouffée délirante, described only in West Africa and Haiti, is defined as episodes resembling brief psychotic disorder and classified in F23.0. Messich and Lin(25) 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).
ICD-10 includes the two Malaysian syndromes koro and latah as well as dhat (India) in F48.8, Other specified neurotic disorders.
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. These results probably explain the individualization of category F23 in ICD-10.
Some authors(27) have suggested that short-lived psychotic episodes are expressions of overcharged mechanisms of defence, or of individual psychological fragility. The brief psychosis is an understandable development of the psychic life of the subject and has a cathartic effect.
Culturally related syndromes are discussed further in Chapter 4.16.
Acute psychotic syndromes require early hospitalization in either an inpatient psychiatric unit or a crisis centre. These syndromes are to be considered as psychiatric emergencies. The decision to admit to hospital is taken in order to make a careful physical and mental examination clinical evaluation, to separate the patient from his or her environment, to provide a reassuring setting, and to prevent any suicidal or aggressive tendencies.(28)
The goals are to prevent auto or heteroagressivity (suicidal potential, affective symptoms, agitation, aggressive behaviour, command hallucinations, etc.), to reduce the acute psychotic symptoms, to suppress the causal factors and to establish an early therapeutic alliance with the patient and his family. Antipsychotic drugs medications are prescribed.(29) Some clinicians wait for a day or two before starting neuroleptic therapy in order to eliminate an organic cause (a general medical condition or substance abuse disorder can be present with acute and transient psychoticsymptoms) and prescribe benzodiazepines rather than neuroleptics. More often, however, antipsychotic treatment starts immediately after physical, electrophysical, radiological assessments, and laboratory tests (CBC, blood electrolytes, cholesterol, triglycerides, toxicology screen, etc.) to evaluate health status.
The choice of antipsychotic medication depends on the clinician's experience and the clinical features. Second-generation antipsychotic medications (amisulpride, aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone) are commonly prescribed as first-line treatment; clozapine is reserved to schizophrenia with high suicidal potential or to resistant schizophrenia. First-generation antipsychotic medications (chlorpromazine, haloperidol, etc.) are second choice or adjunctive medications.
In cases of major anxiety or agitated behaviour, short-acting sedative drugs neuroleptics such as first-generation antipsychotics chlorpromazine (100–500 mg/day), (loxapine: 50–300 mg/day), with or without benzodiazepines (lorazepam) can be prescribed or levomepromazine (25–300 mg/day) are chosen, or zuclopenthixol acetate (100–300 mg every 3 days by intramuscular injection) is used as a short-acting depot antipsychotic. Parenteral administration (standard intramuscular 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.
Benzodiazepines may be given to potentiate the action of the neuroleptics. Alprazolam (0.5–4 mg/day), clorazepate (50–200 mg/day), and lorazepam (2–5 mg/day) produce rapid sedation in acutely psychotic patients if they are used with a neuroleptic. Some clinicians prefer the combination of two neuroleptics (haloperidol–levomepromazine, haloperidol–cyamemazine).
New compounds with fewer adverse effects can be used (amisulpride, 800–1200 mg/day; olanzapine, 5–20 mg/day; quetiapine, 75–500 mg/day; risperidone, 2–10 mg/day).
In culture-bound syndromes the prescription of antidepressants is often recommended as primary treatment.
The dosage may be adjusted from low doses and gradually increased, or adjusted to the standard dose after a first loading dose. Frequent monitoring to assess drug response and adverse effects (extrapyramidal side-effects, orthostatic hypotension, anticholinergic effects, and temperature dysregulation) is essential, and corrections and prophylactic prescriptions (e.g. antiparkinsonian medications) may be necessary.
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.
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 may lead to the main indications for electroconvulsive therapy.
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.
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.
Advice about management
Patients are often hospitalized under constraint because they do not acknowledge the disorder. The initial non-compliance leads to the frequent use of first-generation antipsychotic medications classic intramuscular neuroleptics. After remission recovery, a switch to a second-generation antipsychotic medication newer antipsychotic drug, which is better tolerated, helps to ensure the acceptance of long-term treatment when the psychotic symptoms have disappeared.
In general, psychotherapy and psychosocial care are more effective in an outpatient setting after symptomatic remission recovery has started. A good relationship between patient and psychiatrist together with collaboration with the family practitioner and social workers improve the long-term prognosis. If resources allow, psychotherapy by a trained practitioner, behavioural therapy, or family therapy may be combined with a low-dose pharmacotherapy.(30)
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