Oxford Textbook of Psychiatry
4.3 Schizophrenia and acute transient psychotic disorders 4.3.9 Acute and transient psychotic disorders J. Garrabé and F.-R. Cousin Historic introduction Clinical description: psychopathology F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia F23.1 Acute polymorphic disorder with symptoms of schizophrenia (bouffée délirante or cycloid psychosis with symptoms of schizophrenia) F23.2 Acute schizophrenia-like psychotic disorder (schizophreniform psychosis) F23.3 Other acute predominantly delusional psychotic disorders F23.8 Other acute and transient psychotic disorders F23.9 Acute and transient psychotic disorder unspecified Cultural variants Treatment Short-term treatment Continuation treatment Prevention of recurrence Advice about management Chapter References Historic introduction 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 psychoses (schizoph (schizophrenic renic psycho psychoses ses and psychoses psychoses with with persistent persistent delusion delusions) s) are still 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 4.3.9) appear in the section dedicated to schizophrenia, which also includes schizotypal disorders and schizoaffective disorders (Chapter 4.3.8). 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 psychiatists 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 perceptual hallucinations hallucinations,, consisting consisting mostly mostly of of hallucinatory hallucinatory voices voices and and delusions, 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 1) Table 1 Historical development of the terminology of acute and transient psychotic disorders 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 -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 F23.1 Acute polymorphic disorder with symptoms of schizophrenia (bouffée délirante or cycloid psychosis with symptoms of schizophrenia) F23.2 Acute schizophrenia-like psychotic disorder (schizophreniform psychosis) F23.3 Other acute predominantly delusional psychotic disorders 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 postpartum, brief psychotic disorder with postpartum onset has to be specified. Cultural variants 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. Mezzisch 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. Treatment 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.(28) Antipsychotic drugs 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 present with acute and transient psychotic symptoms) 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 (100–500 mg/day), loxapine (50–300 mg/day), 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. Predominance of delusions and hallucinations indicates a high-potency antipsychotic agent as haloperidol (5–15 mg/day) or flupenthixol (80–200 mg/day). 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. 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.
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 classic intramuscular neuroleptics. After recovery, a switch to a 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 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 practionioner, behavioural therapy, or family therapy may be combined with a low-dose pharmacotherapy.
