Historical and conceptual features of acute polymorphic psychosis: a myth of European psychiatry from bouffée délirante to ICD-11 acute and transient psychotic disorder.

This paper deals with the history and epistemology of acute polymorphic psychosis. We undertook a comparative study of short-lived psychotic disorders used in different European countries since the late nineteenth century. The theory of degeneration offered a speculative basis to conceptualization of conditions such as bouffée délirante, cycloid psychosis and reactive psychosis, but it seems likely that different factors contributed to the profusion of clinical concepts with adverse effects on both nomenclature and classification. The resulting picture suggests that earlier nosological concepts tend to converge on common descriptive features and challenge the diagnostic categories for short-lived psychotic disorders listed in modern symptom-based psychiatric classifications.

Reactive Psychosis: Discrepancy Between Nosological Concepts and Descriptive Categories.

ABSTRACT: Reactive psychosis (RP) is a trauma-induced category whose meaning has varied in relation to the role attributed to lived experiences or vulnerable personality. It has long been described in different countries, but seldom investigated under the influence of symptom-based psychiatric classifications. This article aims to examine the development of RP since the early 20th century, outline how it has been incorporated in modern diagnostic classifications, and set out empirical findings. It is likely that variations in terminology and diagnostic practice have affected estimates of the frequency and hampered the validity of RP in earlier studies. To enhance reliability, RP underwent several changes in successive Diagnostic and Statistical Manual of Mental Disorders and ICD versions and was eventually replaced with descriptive categories for short-lived psychotic disorders. Clinical observations during the COVID-19 pandemic attest the durability of RP, but the current categories prove unhelpful in identifying it and have failed to encourage research.

The predictive validity and outcome of ICD-10 and DSM-5 short-lived psychotic disorders: a review and meta-analysis.

The ICD-10 Classification of Mental and Behavioural Disorders introduced the category of 'acute and transient psychotic disorders' (ATPDs) encompassing polymorphic, schizophrenic and predominantly delusional subtypes, and the forthcoming ICD-11 revision has restricted it to polymorphic psychotic disorder, while the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) listed 'brief psychotic disorder' (BPD). To assess the predictive validity and outcome of ATPDs and BPD, relevant papers in English, French and German were searched in PubMed and Web of Science. Where possible meta-analysis of prognostic validators (diagnostic stability, course, outcome and response to treatment) was conducted. Fifty studies published between January 1993 and July 2019 were found. The clinical and functional outcome of ATPDs proved better than in schizophrenia and related disorders, but mortality risk is high, particularly suicide, and treatment trials provide little evidence. Meta-analysis of 25 studies (13,507 cases) revealed that 55% (95% CI 49-62) do not change diagnosis, 25% (95% CI 20-31) converted into schizophrenia and related disorders, and 12% (95% CI 7-16) into affective disorders on average over 6.3 years. Subgroup meta-analysis estimated prospective consistency of polymorphic psychotic disorder (55%; 95% CI 52-58) significantly greater than that of the ATPD subtypes with schizophrenic (OR 1.7; 95% CI 1.4-2.0) and predominantly delusional (OR 1.3; 95% CI 1.1-1.5) symptoms. Moreover, the diagnostic stability of BPD (13 studies; 294 cases) was 45% (95% CI 32-50) over a mean 4.2 years. Although these findings indicate that short-lived psychotic disorders have little predictive validity, significant differences among the ATPD subtypes support the revised ICD-11 ATPD category.

Conceptual Issues in Acute and Transient Psychotic Disorders.

Short-lived psychotic disorders as currently listed under "acute and transient psychotic disorder," ICD-11 Classification of Mental, Behavioural, and Neurodevelopmental Disorders, and "brief psychotic disorder," Diagnostic and Statistical Manual of Mental Disorders (DSM-5), constitute a point of divergence in the classification of psychotic disorders between the 2 diagnostic systems, which reveals the lack of knowledge about these conditions. Whether this is due to conceptual shortcomings inherent to the categories themselves and which spill over onto research or reflects a mismatch between the diagnostic criteria used and research techniques needs clarification. This study aimed to examine conceptual issues involved in the development of the above categories and shows that little continuity exists between earlier nosological concepts such as bouffée délirante, cycloid psychosis, and reactive psychosis and modern descriptive categories used to classify short-lived psychotic disorders. It seems likely that shortcomings in terms of symptom completeness, specificity, and heterogeneity, in addition to changes in definition and diagnostic criteria in successive DSM and ICD versions, have hampered empirical research, making it difficult to enhance the understanding of these conditions and achieve a closer concordance between the 2 classificatory systems.

Acute Polymorphic Psychotic Disorder: Concepts, Empirical Findings, and Challenges for ICD-11.

The ICD-11 International Classification of Diseases and Related Health Problems will move toward a narrower concept of "acute and transient psychotic disorders" (ATPD) characterized by the remnant "polymorphic psychotic disorder" (APPD) of the current ICD-10 category, also including schizophrenic and predominantly delusional subtypes. To assess the validity of APPD, relevant articles published between January 1993 and September 2017 were found through searches in PubMed and Web of Science. APPD is a rare mental disorder and affects significantly more women than men in early-middle adulthood. Its diagnostic reliability is relatively low, and its consistency reaches just 53.8% on average over 8.8 years, but is significantly greater than either of ATPD subtypes, which are more likely to progress to schizophrenia and related disorders. Although APPD has distinctive features and higher predictive power, its rarity and the fleeting and polymorphic nature of its symptoms could reduce its usefulness in clinical practice and discourage research.

'Paranoia and its historical development (systematized delusion)', by Eugenio Tanzi (1884).

This was the first paper by the Italian alienist Eugenio Tanzi (1856-1934). It surveyed existing works and provided an analysis of clinical categories such as monomania, sensory madness, moral insanity, Wahnsinn, Verrücktheit and systematized delusions, which had been used in France, Germany, Britain and Italy since the early nineteenth century to deal with paranoia. As pointed out by Tanzi, discrepancies and discontinuities in diagnostic concepts affected both psychiatric nosology and practice. Paranoia (from the Greek παρά and νοια) made for greater clarity in psychiatric terminology, and denoted a broad category, including both acute and chronic delusional states which were considered to be distinct from mania and melancholia, and usually not to lead to mental deterioration.

Continuity of care from child and adolescent to adult mental health services: evidence from a regional survey in Northern Italy.

To examine clinical and demographic factors associated with continuity of care from child-adolescent (CAMHS) to adult mental health services (AMHS), we undertook a record-linkage study to the Adult Mental Health Information System including all those 16 years old and over who were listed between 2010 and 2013 in the Child and Adolescent Neuropsychiatry Information System in Emilia-Romagna, an Italian region of nearly 4.5 million residents. From a cohort of 8239 adolescents attending CAMHS (population at risk about 144,000), 821 (19.4 %) moved to AMHS, excluding cases with specific developmental disorders, whose conditions were not managed by adult psychiatrists, and those with mental retardation who attended usually social services. Young people referred for treatment to AMHS were more likely to receive a discharge diagnosis of schizophrenia and related disorders (Odds Ratio [OR] 3.92; 95 % confidence interval [CI] 2.17-7.08), personality disorders (OR 2.69; 95 % CI 1.89-3.83), and pervasive developmental disorders (OR 2.13; 95 % CI 1.51-2.99). Further factors predicting transfer to AMHS were not living with parents, inpatient psychiatric admission, and being on medication in the previous 24 months. These findings suggest that a relatively small number of adolescents moved to AMHS and are likely to reflect the configuration of local mental health services and alternative care available, mainly for those with less-severe mental disorders.

Epidemiology, course and outcome of acute polymorphic psychotic disorder: implications for ICD-11.

BACKGROUND: The proposed revision of the ICD-10 category of 'acute and transient psychotic disorders' (ATPDs), subsuming polymorphic, schizophrenic or predominantly delusional syndromes, would restrict their classification to acute polymorphic psychotic disorder, reminiscent of the clinical concepts of bouffée délirante and cycloid psychosis. SAMPLING AND METHODS: We selected all subjects aged 15-64 years (n = 5,426) who were listed in the Danish Psychiatric Central Register with a first-admission diagnosis of ATPDs in 1995-2008 and estimated incidence rates, course and outcome up to 2010. RESULTS: Although about half of ATPD patients tended to experience transition to another category over a mean follow-up period of 9.3 years, acute polymorphic psychotic disorder fared better in terms of cases with a single episode of psychosis and temporal stability than the subtypes featuring schizophrenic or predominantly delusional symptoms. Acute polymorphic psychotic disorder was more common in females, while cases with acute schizophrenic features predominated in younger males and evolved more often into schizophrenia and related disorders. CONCLUSIONS: These findings suggest that acute polymorphic psychotic disorder exhibits distinctive features and challenge the current approach to the classification of ATPDs.

Long-term stability of acute and transient psychotic disorders.

OBJECTIVE: To examine the temporal stability of the category 'acute and transient psychotic disorders' (ATPDs), ICD-10 Classification of Mental and Behavioural Disorders, including subtypes characterised by polymorphic, schizophrenic and predominantly delusional features. METHOD: We checked the readmission patterns of all patients aged 15-64 years (n = 5426), whether admitted to hospital or treated as outpatients, who were enrolled for the first time in the Danish Psychiatric Register with a diagnosis of ATPDs between 1995 and 2008. RESULTS: An increasing number of cases with ATPDs changed diagnosis in subsequent admissions after 1, 2 and 5 years, mainly either to schizophrenia and related disorders or affective disorders. In their last admission, on average after 7.3 years, there were 2429 patients listed with ATPDs, accounting for an overall stability of 44.8%. Females were less likely than males to develop another diagnosis. Among the ATPD subtypes, polymorphic psychotic disorder without schizophrenic symptoms had a higher stability than those featuring schizophrenic or predominantly delusional features. CONCLUSIONS: The low diagnostic stability of ATPDs reflects the lack of clearly defining features and argues against their validity as a distinct category.

Variations in incidence and age of onset of acute and transient psychotic disorders.

PURPOSE: To determine incidence and age of onset of the ICD-10 category of 'acute and transient psychotic disorders' (ATPDs) characterised by subtypes with polymorphic, schizophrenic and predominantly delusional symptoms, pointing out differences from schizophrenia (SZ) and bipolar affective disorder (BD). METHODS: We identified all subjects aged 15-64 years who were listed for the first time in the Danish Psychiatric Register with a diagnosis of ATPDs (n = 3,350), SZ (n = 4,576) and BD (n = 3,200) in 1995-2008. Incidence rates and rate ratios (IRR; 95 % confidence interval) by gender and age were calculated. RESULTS: The incidence of ATPDs was 6.7 per 100,000 person-years, similarly high for both genders (IRR 1.0; 0.9-1.1). Among the ATPD subtypes, polymorphic psychotic disorder was more common in females (IRR 1.4; 1.2-1.6) as opposed to those featuring schizophrenic symptoms, which tended to occur in younger males (IRR 1.4; 1.2-1.7). No significant gender difference was found for acute predominantly delusional disorder (IRR 1.0; 0.9-1.2), which had a later onset than any ATPD subtypes. SZ had an incidence twice as high in males (IRR 2.0; 1.9-2.2), and an earlier age of onset than ATPDs. A different pattern was observed for BD in terms of a slightly greater incidence in females (IRR 1.1; 1.0-1.1), and a later age of onset than both ATPDs and SZ. CONCLUSION: These findings are likely to reflect the heterogeneity of the clinical features encompassed by ATPDs, and contribute to building a case for their revision in ICD-11.

Mortality and causes of death of acute and transient psychotic disorders.

BACKGROUND: Little is known about mortality associated with acute transient psychoses. This paper examines mortality and causes of death of ICD-10 F23 'Acute and transient psychotic disorders' (ATPD). METHOD: Data from all subjects aged over 15 years who were enrolled in 1996 in the Danish psychiatric register with a first-admission diagnosis of ATPD were linked to the national register of causes of death. The standardized mortality ratio (SMR) for overall mortality and specific categories were calculated. RESULTS: Over the period 1996-2001, 87 (17.3%) of 503 patients with ATPD had died, accounting for a mortality rate of 35.3 per 1,000 person/years. The SMR for all causes (2.9), natural causes (2.5), and unnatural causes (9.2) were significantly increased. Suicide had the greatest SMR (30.9). CONCLUSIONS: These findings argue for excess mortality of ATPD particularly from suicide.

Wimmer's concept of psychogenic psychosis revisited.

In the early twentieth century the Danish psychiatrist August Wimmer (1872-1937) developed the concept of psychogenic psychosis (PP) as a category of mental disorders separate from schizophrenia and manic depression. It subsumed a variety of clinical conditions with affective, confusional and paranoid features typically triggered by a psychical trauma.Wimmer's work has established itself as one of the classic texts in Scandinavian psychiatry but, for linguistic reasons, long remained almost unknown in other European countries.Translated into English in 2003, it is now available for historical and psychopathological analyses. This paper describes the original meaning of PP and sets it in context, then discusses the implications arising from the usage of the diagnostic categories introduced to replace PP in modern international classifications.

Acute and transient psychotic disorders (ICD-10 F23): a review from a European perspective.

The tenth revision of the International Classification of Mental and Behavioural Disorders (ICD-10) introduced the category F23 'Acute and transient psychotic disorders' (ATPD) to incorporate clinical concepts such as the French bouffée délirante, cycloid psychosis (Germany), and the Scandinavian reactive and schizophreniform psychoses. The aim of this paper is to review the literature on ATPD and to examine how it has been differentiated from the other categories of F2 group 'schizophrenia and related disorders'. Papers published between 1993 and 2007 were found through searches in Medline, PsychInfo and Google Scholar. Further references were identified from book chapters and comprehensive reviews of the topic. ATPD is reported as being prevalent in females and as having onset in early-middle adulthood. Although follow-up studies suggest that its outcome is more favourable than other disorders in the F2 group, ATPD tends to recur and half of cases convert mainly into either schizophrenia or affective disorders. No evidence supports the view that the traditional conditions subsumed under ATPD all refer to this diagnostic category. The lack of defining features and poor prognostic validity argue against the separation of ATPD from borderland categories.

Diagnostic and Prognostic Significance of Brief Limited Intermittent Psychotic Symptoms (BLIPS) in Individuals at Ultra High Risk.

BACKGROUND: Brief Limited Intermittent Psychotic Symptoms (BLIPS) are key inclusion criteria to define individuals at ultra high risk for psychosis (UHR). Their diagnostic and prognostic significance is unclear. OBJECTIVES: To address the baseline diagnostic relationship between BLIPS and the ICD-10 categories and examine the longitudinal prognostic impact of clinical and sociodemographic factors. METHODS: Prospective long-term study in UHR individuals meeting BLIPS criteria. Sociodemographic and clinical data, including ICD-10 diagnoses, were automatically drawn from electronic health records and analyzed using Kaplan-Meier failure function (1-survival), Cox regression models, bootstrapping methods, and Receiver Operating Characteristics (ROC) curve. RESULTS: Eighty BLIPS were included. At baseline, two-thirds (68%) of BLIPS met the diagnostic criteria for ICD-10 Acute and Transient Psychotic Disorder (ATPD), most featuring schizophrenic symptoms. The remaining individuals met ICD-10 diagnostic criteria for unspecified nonorganic psychosis (15%), mental and behavioral disorders due to use of cannabinoids (11%), and mania with psychotic symptoms (6%). The overall 5-year risk of psychosis was 0.54. Recurrent episodes of BLIPS were relatively rare (11%) but associated with a higher risk of psychosis (hazard ratio [HR] 3.98) than mono-episodic BLIPS at the univariate analysis. Multivariate analysis revealed that seriously disorganizing or dangerous features increased greatly (HR = 4.39) the risk of psychosis (0.89 at 5-year). Bootstrapping confirmed the robustness of this predictor (area under the ROC = 0.74). CONCLUSIONS: BLIPS are most likely to fulfill the ATPD criteria, mainly acute schizophrenic subtypes. About half of BLIPS cases develops a psychotic disorder during follow-up. Recurrent BLIPS are relatively rare but tend to develop into psychosis. BLIPS with seriously disorganizing or dangerous features have an extreme high risk of psychosis.

Short-term course and outcome of acute and transient psychotic disorders: Differences from other types of psychosis with acute onset.

BACKGROUND: The category of 'acute and transient psychotic disorders' (ATPDs) appeared in the ICD-10 Classification of Mental and Behavioural Disorders (ICD-10), but its distinctive features remain uncertain. AIM: To examine the course and outcome of ATPDs, pointing out differences from other types of psychosis. METHODS: A one-year follow-up investigation of patients enrolled at the former World Health Organization (WHO) Centre for Research and Training in Mental Health in Aarhus (Denmark) for the WHO collaborative study on acute psychoses. RESULTS: Of 91 patients aged 15-60 years presenting with acute psychosis, 47 (51.6%) were diagnosed with ATPD, and it occurred more commonly in females; yet, the other acute psychoses featured mainly mood disorders and affected equally both genders. After 1 year, the ATPD diagnosis did not change in 28 cases (59.6%); the remaining developed either affective psychoses (27.7%), or schizophrenia and schizoaffective disorder (12.8%). Nearly, all patients with unchanged diagnosis of ATPD enjoyed full recovery, while those with other types of acute psychosis had significantly higher rates of recurrence or incomplete remission. Duration of illness within 4 weeks and stressful events in the 3 months before symptom onset predicted 1-year favourable clinical outcome for acute psychoses. CONCLUSION: Although ATPDs fared better over the short-term than other acute psychoses, their diagnostic stability is relatively low.

Integration of a psychiatric service in a long-term charitable facility for people with intellectual disabilities: a 5-year medication survey.

Since the implementation of a psychiatric service in a long-term facility for people with intellectual disability, the usage of psychotropic and anti-convulsant drugs has been surveyed over the 5-year period 1994-1999. At that time, although the overall prevalence rate of residents on medication was not declining significantly, a decrease in number, dosage and polypharmacy of those receiving neuroleptic drugs occurred than 1994. A reduction also resulted among the in-patients prescribed anxiolytic preparations, despite a relative increase in their mean daily intake. Anti-convulsant drugs climbed slightly during the same interval with a parallel increase in the mean daily dosage. A retrospective comparison of current findings to prevalence, dosage and type of psychoactive medications dispensed 10 years previously in 1989 revealed no trend towards drug rationalisation. Until interdisciplinary training programmes as well as effective community services combining disability and mental health needs are forthcoming, a therapeutic approach involving early psychiatric inputs may contribute to ensure a more rational prescribing practice for long-stay adults with intellectual disability who are referred for neuro-psychiatric consultation.

Incidence and diagnostic stability of ICD-10 acute and transient psychotic disorders.

OBJECTIVE: The 10th Revision of the International Classification of Diseases (ICD-10) introduced a new diagnostic category, F23 acute and transient psychotic disorders (ATPD) to embrace clinical concepts such as the French bouffée délirante, Kleist and Leonhard's cycloid psychoses, and the Scandinavian reactive and schizophreniform psychoses. The relative rarity of these disorders and insufficient follow-up studies with adequate numbers of patients makes ATPD classification as uncertain as their validity. The aim of this study was to evaluate incidence and validity of ATPD in terms of diagnostic stability. METHOD: A 6-year analysis of readmission patterns of all subjects listed in the Danish psychiatric central register as having been first-ever admitted to hospital or treated in outpatient services with a diagnosis of ATPD from January 1 to December 31, 1996, was conducted. RESULTS: The incidence of ATPD was 9.6 per 100 000 population, with a higher rate of females than males (9.8 vs 9.4). Incidence rates by age group were higher for males than for females, with a marked reversal of this pattern above 50 years. This contrasted with incidence of schizophrenia that was almost twice as high in males as in females, particularly in the 20-29 year age group. Of 416 cases with a first-admission diagnosis of ATPD, an increasing number tended to change on subsequent admissions, nearly half to another F2 category schizophrenia and related disorders. The overall stability rate reached only 39%. CONCLUSIONS: Although demographic differences from schizophrenia are topics that deserve further research, poor diagnostic stability argues against attempts to separate ATPD from borderland disorders.

The relationship of reactive psychosis and ICD-10 acute and transient psychotic disorders: evidence from a case register-based comparison.

BACKGROUND: ICD-10 introduced a new diagnostic category, F23 'acute and transient psychotic disorders' (ATPD), to embrace clinical concepts such as bouffée délirante, cycloid psychosis, psychogenic (reactive) psychosis and schizophreniform psychosis. The purpose of this study was to examine the relationship between the concept of reactive psychosis (RP), equivalent to the ICD-8 298 category of 'other psychoses', and ATPD. SAMPLING AND METHOD: Since January 1, 1994, ICD-10 has replaced ICD-8 as official classification in Denmark. Patients given an ICD-8 298 diagnosis on their last admission in 1992-1993 were identified from the Danish Psychiatric Central Register, and the ICD-8 diagnoses assigned were compared with their ICD-10 diagnoses when readmitted in 1994-1995. RESULTS: Diagnosis of RP was recorded in 19.2% of patients with functional psychoses in 1992-1993, whereas ATPD overall prevalence accounted for 8.7% of those with non-organic psychotic and affective disorders in 1994-1995. Thirty-eight per cent of patients with an ICD-8 298 diagnosis were readmitted during the years 1994-1995. Schizophrenia and related disorders (F2) and affective disorders (F3) accounted for three quarters of ICD-10 diagnoses. The most frequently used ATPD subcategories were F23.3 'other acute delusional psychotic disorders', F23.0 'acute polymorphic psychotic disorder without symptoms of schizophrenia' and F23.9 'acute and transient psychotic disorder unspecified'. A significant majority were female and associated acute stress was recorded only in 5.3% of cases. CONCLUSIONS: ICD-8 298 register diagnosis of RP showed little empirical continuity to ATPD and conformed more to F23.3 acute delusional disorder among ATPD subtypes.