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379

Section 4

Related concepts

31Acutebriefpsychosis–anorganic

syndrome?

Anand K. Pandurangi

Facts box

unclear. APDs are characterized by sudden (acute)
r

onset and florid psychotic symptoms that resolve in
Acute Psychotic Disorders (APDS) have been
days to weeks
[1]
. They are reportedly more preva-described for more than a hundred years.

lent in developing countries than developed coun-r
APDs may represent 8%–20% of
tries
[2]
, thereby receiving greater recognition in the
nonaffective, nonorganic psychotic
International Classification of Diseases (ICD) than the
presentations.

Diagnostic and Statistical Manual of Mental Disorders
r
APDs are more prevalent in developing
(DSM) of the American Psychiatric Association.

countries.

The ICD provides many terms to capture the var-r
Most or all APDs resolve in 12 weeks or less.

ious presentations, whereas the DSM has only two
r

categories for this group. For example, in the ICD-9

In 50% of patients, there is recurrence of one
[3]
these conditions were conceptualized as reactions
or more psychotic episode.

r

to emotional and environmental stress and subcate-Long-term prognosis is good, both from
gorized into syndromes, such as depressive, excita-symptom and functional points of view.

r

tive, paranoid, confusional and mixed
[3].
In ICD-10,
APDs often occur after fever, during
however, the conditions were renamed as Acute Tran-puerperium, concomitant with systemic
sient Psychotic Disorders (ATPDs), and any associ-infections, and in association with many
ation with a psychological stressor was less empha-medical and neurological disorders.

sized. The current subtypes are ATPD with and ATPD

r
There is modest evidence linking APDs to
without schizophrenia symptoms, and ATPD with
demonstrable pathology, including changes
prominent delusions
[1].
Classic schizophrenia symp-in EEG, brain scan, viral antibody titers, and
toms such as prominent auditory hallucinations, well-so on.

formed delusions, and formal thought disorder may
r
APDs may be a result of a genetic or
be present or absent depending on the subtype. Often
developmental vulnerability interacting with
the symptoms and signs are unstable, changing con-physiological or psychological stress.

siderably even during the short course. To highlight
r
APDs are best treated with low-to
this aspect of the disorders, the term “polymorphic”

medium-dose antipsychotics in combination
has been used within the voluminous diagnostic terms,
with supportive therapy and

i.e., “acute transient polymorphic psychosis with (or
psychoeducation of patient and family.

without) schizophrenia-like symptoms.” Nonspecific
psychotic symptoms may include regressed behaviors such as withdrawal, posturing, mutism, and poor
self-care, or dramatic behaviors such as hyperactiv-

Current description of acute psychotic

ity, stereotypy, emotional volatility, anxiety, paranoia,
disorders in ICD and DSM

dysphoria, fleeting delusions, fleeting hallucinations.

There are many more possible presentations and some
Acute Psychotic Disorders (APDs) are a group of
are culture specific. All these subtypes are conceived
“functional” disorders with unknown etiology catego-to be brief or transient – typically lasting from a few
rized separately from schizophrenia and bipolar dis-days to about 2 weeks, although they may last as long
380

orders. Their relation to the latter disorders remains
as 12 weeks. When a condition diagnosed as APD

Chapter 31 – Acute brief psychosis – an organic syndrome?

outlasts this duration, the diagnosis is revised to a
psychosis may appropriately be diagnosed as APD
[2,

chronic condition such as schizophrenia, delusion dis-

19, 20, 21].
There is typically a female preponder-order, or a mood disorder with psychosis.

ance in contrast to schizophrenia and bipolar disorIn DSM-IV, the equivalent terms are Brief Psy-der where the gender distribution (over time) is more
chotic Disorder (BPD) and Schizophreniform Disor less equal. Onset is typically in the third or fourth
order
[4]
. These terms are self-explanatory and the
decade but may be at any age. A psychological or envi-underlying concepts are very similar to those in the
ronmental stress factor is frequently but not always
ICD. Disorders presenting with classic schizophrenia
present. Acute psychotic disorders are more common
symptoms but of short duration are to be diagnosed
in immigrants. Both ICD and DSM consider APD to
as Schizophreniform Disorder, whereas all other psy-have good prognosis for the episode with virtually
chotic presentations are referred to as Brief Psychotic
complete recovery, but neither comment definitively
Disorder or Psychosis NOS.

on the course such as recurrence rates nor on the long-term outcome and prognosis. It is known from various
Brief history of acute psychotic

studies that a full resolution of the psychosis occurs
in almost all cases within 12 weeks, with most cases
disorders

resolving in 2–6 weeks, and in some cases the psy-Acute psychotic disorders
[5]
have a rather interest-chosis may even resolve in days. About 50% of the cases
ing history. Although Kraepelin formulated Demen-relapse within 2–3 years
[2, 22, 23, 24].

tia Praecox and Manic-Depressive Illness as the two
Differential diagnoses of APDs include schizo-major psychoses
[6]
, it is well known that other terms
phrenia, psychotic depression, mania, substance-continued to be used for various acute psychotic dis-induced psychosis, delirium, psychosis due to general
orders, such as Bouffeé Delirante
[7],
Cycloid Psy-medical condition, and dissociative disorders. Rapid
chosis
[8],
Manic Delirium
[9],
Atypical Psychosis
changes in delusions and mood have been found to dis-

[10],
Schizophreniform Psychosis
[11],
and so on. Ear-tinguish APD from schizophrenia and bipolar disorlier, the Scandinavians led by Wimmer had recognized
der
[25].
Malhotra and colleagues
[26, 27]
found APD,
a “Third Psychosis” based largely on Jaspers’ descrip-in comparison to schizophrenia, to be more common
tion of criteria for psychogenic psychoses
[12, 13].
The
in females, more frequently associated with stress,
term Reactive Psychosis was used for these conditions
such as childbirth and fever, and to have a more fre-for many years
[14, 15].
The term Hysterical Psychosis
quent family history of APD but not schizophrenia. In
was also used to describe similar psychoses in England
contrast to mood disorders, sustained mood changes
and the United States
[16].
As noted earlier, the ICD-are infrequent in APD
[28].
The long-term progno-9 included Reactive Psychosis with depressive, excite-sis is considered very good, in relation to schizophre-ment, paranoid, confusional, and mixed subtypes
[3].