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ATPD Nosology: These conditions do not have a designated place in the DSM-IV-TR.

Many of the cases of ICD-10 acute and transient psychotic disorders would be categorized as schizophreniform disorder, brief psychotic disorder, or psychotic disorder not otherwise specified (NOS) in DSM-IV-TR. Brief psychotic disorder is defined by DSM-IV-TR as a psychotic condition that involves the sudden onset of psychotic symptoms and lasts 1 day or more but less than 1 month. In the DSM-IV field trial for schizophrenia and other psychotic disorders, of all individuals meeting the ICD-10 criteria for acute and transient psychotic disorders, 42 percent also met the DSM-III-R criteria for schizophreniform disorder, 21 percent for psychotic disorder NOS, and only 13 percent for brief reactive psychosis. In contrast, in a study from Germany, 62 percent of patients with acute and transient psychotic disorders also met the DSM-IV criteria for brief psychotic disorder, 31 percent for schizophreniform disorder, and 5 percent for psychotic disorder NOS

ICD-10 DSM-IV ATPD Brief Psychotic Disorder o Onset within 2 weeks & full Schizophreniform disorder remission within within 1-3 months o Acute onset not specified in o Acute stress specified diagnostic criteria (bereavement, unexpected loss of o Acute stress not specified partner or job,marriage,psychological o Specified if postpartum onset trauma of combat, terrorism & o Schizophreniform disorder torture) o 1-6 month prodromal,active and o No specification for postpartum residual phases onset o >6months with functional o Acute schizophrenia like psychotic impairment-schizophrenia disorder >1 month-schizophrenia Epidemiology o About 10 times common in developing countries o The annual incidence ranges from 3.9 to 9.6 per 100,000 population o The overall annual incidence rate for the true 3-year diagnosis of ATPDs 1.36 per 100000 with a female preponderance o 89% of all psychotic disorders o 35%(Vs 6%) of all first contact non-affective psychosis in developing countries vs developed o 4.1% of all non-organic psychotic and affective disorders o 8.5% of all non-organic psychotic disorders

o Younger onset in developing countries. Age of onset was also younger (mid-20s) in the developing than developed (mid-20s to 30s) countries. o Male/female ratio 0.037 o Brief psychotic disorder less common than ATPD: 1.43-2.5% in different studies o Most common: (1/3-1/2) polymorphic without symptoms of schizophrenia Research to date suggests that the Scandinavian concept of RP bears little continuity to ATPD and conformed more to predominantly delusional disorder among ATPD subtypes o (F23.1&F23.2) reverse gender distribution being prevalent in males & earlier age at onset than mean age of patients with ATPD (31.8 and 27.8 years vs.42.2 years) indicating a close kinship with schizophrenia Neurobiological mechanisms Disturbance of amino acid metabolism proposed esp. low plasma concentration of serine level for acute polymorphic psychotic disorder EEG : No increased pattern of cerebral activity was observed Elevated hemispheric blood flow levels in Cycloid Psychosis patients P300 topography-Higher amplitude than normal control in cycloid psychosis Clinical features: Interview: o Recording presenting complaints first o listening empathically to their accounts of troubling symptoms o Open questions (How have things been for you lately?) should be followed by progressively more closed questions (Do you think something funny has been going on? Have you heard unusual noises or voices? Could someone be behind this? o Symptoms in other systems, especially neurological and endocrine systems o h/o substance use-esp. cannabis o Collateral h/o o Age-mid 20s in developing(Vs 20s-30s & even more) & a second peak occurs in people over 60 years o Sex-female>male o Occupation-higher among employed persons (both skilled (32%) and unskilled workers (31%) o Residence-developing>developed ; Rural >urban o SES : below Avg. SES o Onset- abrupt >acute: Time to onset should not be confused with the time between symptom onset and peak illness severity, as the maximum severity of symptoms may occur weeks after symptom onset. Similarly prodromal periods of anxiety, depression, social withdrawal, or mildly abnormal behaviour should not be counted in determining time to onset. Thus, the criterion for acute onset will still be met even if the individual reports weeks or months of these prodromal symptoms before the onset of illness. o Stressor-within 2 weeks of onset (9.5-11%)


F>M departure from or return to village(F) give birth to child 3mon. Prior(5 fold ) Job related stress(M) Broken home situation h/o recent fever (about 1/5th)

o Prodrome-anxiety,depression,social with drawl or mild abnormal behavior o Marked hallucination, delusions & perceptual disturbances that change from day to day or even hour to hour o Symptoms of Emotional turmoil o Mood symptoms o Schizophrenic symptoms

Treatment h/o: Allergies and adverse drug reactions(EPS,NMS....) Medical h/o: specific infections, such as viral infection, meningoencephalitis, and neurocysticercosis Family h/o: o broken home before age of 15 o fewer life events & scored less cumulative stress before illness among those with fam. h/o mental disorder o h/o ATPD 3 times more frequent in 1st degree relatives of patients with ATPD than family members of schizophrenics o Risk of schizophrenia was significantly increased in first-degree relatives of schizophrenic patients

o Risk of affective disorders did not exceed that expected in the general population o 20.3% -1stdegree relatives with any mental disorder o 3.4% -first-degree relatives with psychotic PMP o cases with ATPD do not have significant premorbid dysfunctions o 2/3 of have concomitant diagnosis of personality disorder & this rate dropped significantly 1 year later GPE :febrile: In one study from India, for example, a history of antecedent fever was reported in 47 percent of individuals with an acute and transient psychotic disorder. In all patients, the fever had resolved before the onset of psychotic symptoms, making it unlikely that the psychosis was the direct effect of an acute infection. Similar reports from other developing country settings and classic European psychiatric literature also note high rates of febrile illness prior to the development of acute and transient psychotic disorders, which may in part explain the higher incidence of these disorders in developing country settings where infectious diseases are common. MSE Disorganised speech, overarousal,hostility, confusion & perplexity DIAGNOSIS- Provisional DD A definitive diagnosis of acute and transient psychotic disorders or brief psychotic disorder early in the first episode of illness is difficult if not impossible. Unless the psychosis has fully remitted, the duration of an episode of illness cannot be determined. Therefore, during the first few days or weeks of an episode, the diagnosis is usually provisional.

A provisional ICD-10 diagnosis of acute polymorphic psychotic disorder without symptoms of schizophrenia would be changed to a diagnosis of ICD-10 persistent delusional disorder or other nonorganic psychotic disorder if the illness lasts more than 3 months. Similarly, a diagnosis of acute polymorphic psychotic disorder with symptoms of schizophrenia would be changed to ICD-10 schizophrenia if the episode lasts more than 1 month Similarly DSM-IV-TR brief psychotic disorder, in which the duration of an episode is defined as less than 1 month. If the duration of illness (from prodrome through recovery) exceeds 1 month, the diagnosis would need to be changed to schizophreniform disorder, schizophrenia, delusional disorder, or psychotic disorder NOS, depending on other symptoms and the duration of the illness. Remission of psychotic symptoms within 1 month as a result of successful treatment also makes it difficult to distinguish brief psychotic disorder from other longer lasting disorders.

Drug induced: The temporal relationship between onset of psychosis and the pattern of substance abuse may be helpful in differentiating a substance-induced psychotic episode from

a nonsubstance-induced one. Symptoms that persist for many days after all traces of the substance are eliminated from blood and urine would support a diagnosis of acute and transient psychotic disorder or brief psychotic disorder Delirium Dementia Medical illness(head trauma, cerebral anoxia, epilepsy & hyper/hypothyroidism schizophrenia; and other non-affective psychotic disorders Bipolar affective disorder: manic or depressed episode: Presence of a full mood syndrome that meets the criteria for a manic or a depressive episode excludes diagnosis of brief psychotic disorder in DSM-IV-TR and excludes diagnosis of acute and transient psychotic disorders in ICD-10. Schizoaffective disorder Severe depressive episode with psychotic features Delusional disorder Post-traumatic stress disorder Obsessive compulsive disorder Schizotypal or paranoid personality disorder: the symptoms last more than 1 day, an additional diagnosis of brief psychotic disorder may be warranted. Attention deficit hyperactivity disorder

Diagnostic Stability o Depends on: Clinical features & Gender o Acute and brief psychoses were consistently shown to be diagnostically unstable and frequently changed to schizophrenia and affective disorder at follow-up o 60% of cases tended to change diagnosis on subsequent admissions o In developing countries, ATPD has a relatively high diagnostic stability (5473%) and low rates of relapse o Recurrence rates of 39 to 47 percent have been reported in first-admission samples followed for 3 to 4 years, but full recovery is common. o Only about 6 to 18 percent of patients have any residual symptoms at a later point of time, although some studies have shown that the duration of nonaffective psychoses with acute onset and remitting course may extend up to 6 months. o A 12-year follow-up study from India also reported favorable long-term outcome. o In studies from India and Denmark, 27 to 48 percent of patients had a different diagnosis 1 to 3 years after their index episodes o A study from Germany found differences between the acute schizophrenia-like psychotic disorder subtype, of whom only 30 percent maintained their original

diagnosis at follow-up, and other subtypes of acute and transient psychotic disorders, of whom 67 percent maintained their original diagnosis. o In a retrospective long-term study from Japan, 63 percent of patients with acute polymorphic psychotic disorder without symptoms of schizophrenia maintained their original diagnosis for an average follow-up period of 20 years o In a British study, the diagnoses of acute and transient psychotic disorders remained unchanged in 73 percent of women, but only 14 percent of men at the 3-year followup. Most changes were into the schizophrenia or mood disorder categories BPD: o In a study of consecutive psychotic admissions in Germany, 83 percent of the patients initially diagnosed with brief psychotic disorder maintained this diagnosis when reevaluated 2 years later, and 70 percent experienced relapses during the 2-year followup o In a prospective epidemiologic study of a first-admission cohort from Suffolk County, New York, only 27 percent of those receiving a consensus research diagnosis of brief psychotic disorder at 6-month follow-up maintained this diagnosis when re-evaluated at the 24-month follow-up, with 9 percent rediagnosed with schizophreniform disorder and 18 percent with psychotic disorder NOS. The remainder were rediagnosed with mood disorders (27 percent), schizophrenia (9 percent), or other conditions (9 percent). o A Brazilian study of first-episode patients admitted to an emergency psychiatric unit also found that only about 23 percent of patients with a clinical discharge diagnosis of brief psychotic disorder maintained this diagnosis 1 year later Course Full remission Shift to another diagnosis Episodic with longer remissions Recurrence ATPD should be associated with a benign course and the absence of social impairment o 80% of the patients with cycloid psychosis had complete recovery o 53.0% of the patients with first episode; psychosis were admitted into inpatient care within the first week of contact with the care system o The patients with manic symptomatology were more at the risk for rapid admission o 80% of the symptoms resolving within 28 weeks and the rest lasting for more than 1 year Prognosis

Abrupt/acute onset good social adjustment in adolescence being married prior to onset women setting developing country

insidious-onset Personality disorder cognitive impairment negative symptoms Residual symptoms

o Outcome o Social function better than schizophrenia >90% living independently >50% employed o Patients with a diagnosis of cycloid psychosiso better global functioning at follow up o better social adaptation and less psychological impairment . o Disability Assessment Schedule and the Positive and Negative Syndrome Scales were low, indicating minimal dysfunction and thus validating the general concept of ATPD as a benign disorder Management Guideline:

Difficulties in clinical & research o o o o o o No meta-analysis of pooled data was made till date Validity of Diagnosis? Diagnostic influences that may have affected recognition of ATPD Lack of information about its defining features Different definition of onset & shorter duration criteria DSM-IV BPD only partially overlaps with ATPD

o Failed to encourage research . o Little continuity to traditional categories o Variance in course and outcome -? prospective studies Indian Studies Acute psychosis-extensively studied in India Indian studies-add better understanding of ATPD Professor N.N.Wig first ever paper in India in this field (1967) International o IPSS INDIA(Agra) one among 9 countries o DOSMED-Agra, Urban & Rural Chandigarh o CAPS-Agra,Chandigarh,Delhi National o ICMR Sponsored Multi collaborative study-Patiala,Bikaner,Vellore & Goa Summary: o Literacy & employment rate better than schizophrenia o Stress score more & esp. in Reactive psychosis o Psycho social stress varies with gender o Summer-peak o No much prominent mood symptoms (only Msym- >10% irritability &Dsym>10% social with drawl, Ideas of reference o ATPD Descriptively valid entity in contrast with other views Economics of ATPD o Avg. cost of a hosp. admission episode -- 2,830.29- 3,624.95 euros o 94.3% - fixed costs (medical, nursing and other staff, room and catering, allocated common services costs, etc.) o 3.4% to diagnostic tests & 2.4% to drug treatment o Length of hospital stay vary from 14-28 days o longer stay implies: longer duration of treatment & the presence of aggressiveness/agitation o Atypical antipsychotics are more expensive than the conventional ones o In long-term studies, the treatment with atypical antipsychotics tends to reduce costs by reducing relapse rates and re-admissions