Clinical outcomes in brief psychotic episodes: a systematic review and meta-analysis.

AIMS: Patients with brief psychotic episodes (BPE) have variable and fluctuating clinical outcomes which challenge psychiatric care. Our meta-analysis aims at providing a comprehensive summary of several clinical outcomes in this patient group. METHODS: A multistep systematic PRISMA/MOOSE-compliant literature search was performed for articles published from inception until 1st March 2021. Web of Science database was searched, complemented by manual search of original articles reporting relevant outcomes (psychotic recurrence, prospective diagnostic change or stability, remission, quality of life, functional status, mortality and their predictors) for patients diagnosed with acute and transient psychotic disorders (ATPD), brief psychotic disorders (BPD), brief intermittent psychotic symptoms (BIPS) and brief limited intermittent psychotic symptoms (BLIPS). Random-effects methods and Q-statistics were employed, quality assessment with Newcastle-Ottawa Scale, assessment of heterogeneity with I2 index, sensitivity analyses (acute polymorphic psychotic disorders, APPD) and multiple meta-regressions, assessment of publication bias with funnel plot, Egger's test and meta-regression (psychotic recurrence and sample size). RESULTS: A total of 91 independent articles (n = 94 samples) encompassed 37 ATPD, 24 BPD, 19 BLIPS and 14 BIPS samples, totalling 15 729 individuals (mean age: 30.89 ± 7.33 years, mean female ratio: 60%, 59% conducted in Europe). Meta-analytical risk of psychotic recurrence for all BPE increased from 15% (95% confidence interval (CI) 12-18) at 6 months, 25% (95% CI 22-30) at 12 months, 30% (95% CI 27-33) at 24 months and 33% (95% CI 30-37) at ⩾36 months follow-up, with no differences between ATPD, BPD, BLIPS and BIPS after 2 years of follow-up. Across all BPE, meta-analytical proportion of prospective diagnostic stability (average follow-up 47 months) was 49% (95% CI 42-56); meta-analytical proportion of diagnostic change (average follow-up 47 months) to schizophrenia spectrum psychoses was 19% (95% CI 16-23), affective spectrum psychoses 5% (95% CI 3-7), other psychotic disorders 7% (95% CI 5-9) and other (non-psychotic) mental disorders 14% (95% CI 11-17). Prospective diagnostic change within APPD without symptoms of schizophrenia was 34% (95% CI 24-46) at a mean follow-up of 51 months: 18% (95% CI 11-30) for schizophrenia spectrum psychoses and 17% (95% CI 10-26) for other (non-psychotic) mental disorders. Meta-analytical proportion of baseline employment was 48% (95% CI 38-58), whereas there were not enough data to explore the other outcomes. Heterogeneity was high; female ratio and study quality were negatively and positively associated with risk of psychotic recurrence, respectively. There were no consistent factor predicting clinical outcomes. CONCLUSIONS: Short-lived psychotic episodes are associated with a high risk of psychotic recurrences, in particular schizophrenia spectrum disorders. Other clinical outcomes remain relatively underinvestigated. There are no consistent prognostic/predictive factors.

Combined treatment with quetiapine and sertindole in therapy refractory insomnia after clozapine discontinuation.

Insomnia associated with chronic schizophrenia and after clozapine discontinuation represents a common, but mostly not predominant, complaint and often does not respond sufficiently to classical hypnotics. We report the case of a 46-year-old patient with schizophrenia who developed a rebound insomnia confirmed by polysomnography after discontinuation of long-term treatment with clozapine and changing to sertindole therapy. Zolpidem, zolpiclone and chloral hydrate only led to short-term improvement of subjective sleep quality. An add-on therapy with 300 mg quetiapine resulted in improved subjective quality of sleep regarding sleep latency and the number of nocturnal awakenings. The combination of the two neuroleptics did not lead to increased QTc intervals (normal QTc < 450 ms) or metabolic side effects. In conclusion, the combination of sertindole and quetiapine might be a safe and effective combination in therapy-refractory insomnia after clozapine discontinuation in schizophrenia.

Brief and acute psychoses: the development of concepts.

This paper reviews the conceptual history of brief and acute psychoses. As psychotic disorders of usually dramatic symptomatology but nevertheless with a usually benign course, brief and acute psychoses have the air of a paradox. Thus, they have posed specific problems in regard to nosology, diagnostics and aetiology. Despite a strong convergence of the descriptive elements, the historical concepts of brief and acute psychoses have yielded different answers to the questions raised. Kahlbaum and Kraepelin set the stage on which brief and acute psychoses appeared "atypical". The concept of "bouffée délirante" used degeneration theory as a background for nosological and aetiological allocation. Similarly, the concepts of cycloid psychoses, reactive (psychogenic) psychoses, emotional psychoses and atypical psychoses have provided diverging but interrelated ways to delineate brief and acute psychoses, to determine their nosological status and to explain the coexistence of severe disorder and favourable prognosis. Modern classifications, namely the acute and transient psychotic disorder of ICD-10 and the brief psychotic disorder of DSM-IV, reflect the varied history of the concept.

Features of acute and transient psychotic disorders.

BACKGROUND: Little is known about acute and transient psychotic disorders (ATPD), a diagnostic category introduced with ICD-10. AIMS: To determine the clinical and sociodemographic features, course and outcome of ICD-10 ATPD in a prospective and longitudinal study. METHOD: We recruited all consecutive inpatients fulfilling the ICD-10 criteria of ATPD during a 5-year period. Demographic and clinical features were systematically evaluated and follow-up investigations were carried out at an average of 10 years after onset of the disorder using standardized instruments. RESULTS: ATPD patients represented 8.5% of all inpatients with non-organic psychotic disorders. ATPD were characterized by female preponderance. In two-thirds of the cases a typical polymorphic symptomatology was found. In spite of the fact that the possibility of relapse within 5 years was high, the psychopathological and social outcome for most of the patients was very favourable. Schizophrenic episodes during follow-up were rare (7.7% of patients), but a strictly monomorphous course (ATPD episodes only) from index episode to the end of the prospective follow-up was found in only 53.9% of the patients. CONCLUSION: ATPD are not a sharply demarcated and unchanging nosological entity. Nevertheless, the present data support a delineation of ATPD as a diagnostic category with specific clinical features and with a usually favourable prognosis. Further research on the topic is necessary.

The concordance of ICD-10 acute and transient psychosis and DSM-IV brief psychotic disorder.

BACKGROUND: ICD-10 acute and transient psychotic disorder (ATPD; F23) and DSM-IV brief psychotic disorder (BPD; 298.8) are related diagnostic concepts, but little is known regarding the concordance of the two definitions. METHOD: During a 5-year period all in-patients with ATPD were identified; DSM-IV diagnoses were also determined. We systematically evaluated demographic and clinical features and carried out follow-up investigations at an average of 22 years after the index episode using standardized instruments. RESULTS: Forty-two (4.1%) of 1036 patients treated for psychotic disorders or major affective episode fulfilled the ICD-10 criteria of ATPD. Of these, 61.9% also fulfilled the DSM-IV criteria of brief psychotic disorder; 31.0%, of schizophreniform disorder; 2.4%, of delusional disorder; and 4.8%. of psychotic disorder not otherwise specified. BPD showed significant concordance with the polymorphic subtype of ATPD, and DSM-IV schizophreniform disorder showed significant concordance with the schizophreniform subtype of ATPD. BPD patients had a significantly shorter duration of episode and more acute onset compared with those ATPD patients who did not meet the criteria of BPD (non-BPD). However, the BPD group and the non-BPD group of ATPD were remarkably similar in terms of sociodemography (especially female preponderance), course and outcome, which was rather favourable for both groups. CONCLUSIONS: DSM-IV BPD is a psychotic disorder with broad concordance with ATPD as defined by ICD-10. However, the DSM-IV time criteria for BPD may be too narrow. The group of acute psychotic disorders with good prognosis extends beyond the borders of BPD and includes a subgroup of DSM-IV schizophreniform disorder.

The relation of "acute and transient psychotic disorder" (ICD-10 F23) to bipolar schizoaffective disorder.

The aim of this work is to investigate differences between acute and transient psychotic disorders (ATPD; F23 of ICD-10) and bipolar schizoaffective disorders (BSAD). In a controlled prospective and longitudinal study, we compared all inpatients with ATPD treated at Halle university hospital during a 5-year period with matched controls with BSAD. Sociobiographical data were collected using a semi-structured interview. Follow-up investigations were performed at a mean of 2.2-3.3 years after the index episode or 8.2-16.1 years after the first episode by means of standardized instruments. ATPD differs significantly from BSAD on various relevant levels, such as gender (more female), age at onset (older), development of the full symptomatology (more rapid), duration of the symptomatology (shorter), acuteness of onset (more acute), preceding stressful life-events (more frequent) and long-term prognosis (better). It is concluded that ATPD and BSAD are different nosological entities.

[Carl Wernicke: his impact past and present]. / Carl Wernicke: Wirkung und Nachwirkung.

From April 1904 until his premature death due to an accident in June 1905, Carl Wernicke was head of the Department of Psychiatric and Nervous Diseases at the University of Halle-Wittenberg, Germany. We report on Wernicke's work and activities during this short but influential period in the context of his biography and scientific development. Archive materials reveal some interesting details concerning Wernicke's appointment and his diagnostic practice in Halle. As the most outstanding representative of 19th century neuropsychiatry, Wernicke constantly strove to base his psychiatric doctrine on the brain research of the time. In Breslau, his former place of employment, his scientific working environment had dramatically deteriorated. In Halle, Wernicke found not only a well-functioning clinical institution but also an important neurobiological tradition inaugurated by Eduard Hitzig. He immediately resumed his research programme. Fields of interest included the implementation of his nosological system in clinical practice, the study of aetiological factors of mental diseases and the use of a new method of puncture for the localisation of brain tumours. Wernicke's biological research agenda was interrupted not only by his premature death but also by historical developments. Many aspects of this agenda, however, have been raised anew by today's psychiatry.

[Social rank and depression--an example of "evolutionary psychopathology"]. / Sozialer Rang und Depression--ein Beispiel "evolutionärer Psychopathologie".

Affective disorders are pathological alterations of phylogenetically old emotional mechanisms the adaptive function of which is still a matter of debate. According to the social competition hypothesis, depressive syndromes involve activation of a mechanism serving subordination in competitive situations. This mechanism protects the individual from the damaging consequences of an escalating agonistic encounter. The paper critically discusses supporting evidence culled from biological, clinical and psychological findings. Animal models show phenomenological similarities between subordination and depression. In primates affiliative behavior and social bonding are closely linked to rank-related behaviors. Common biochemical and pharmacological features of subordination and depression include an activation of the stress axis, diminished serotonergic neurotransmission and modification by antidepressants. However, the discrimination between a specific subordination reaction and an unspecific stress response is often controversial. Many clinical and psychological aspects of depressive syndromes may be understood as an--exaggerated--submissive behavior, but have rarely been studied in that light. Typical endogenous depression and bipolar disorders challenge the social competition hypothesis. While the manic syndrome, due to its similarity to dominance behavior, supports the link between social competition and affective disorders, the cyclic alteration of mood cannot be sufficiently explained by the social competition hypothesis alone.

Concordance of acute and transient psychoses and cycloid psychoses.

OBJECTIVE: We prospectively investigated a sample of 42 patients with acute and transient psychotic disorder (ATPD) as defined by the 10th revision of the International Classification of Diseases (ICD-10; F23) to determine the clinical and demographic features of this entity and its relationship to cycloid psychoses. METHODS: During a 5-year period, all in-patients with ATPD were identified. We systematically evaluated demographic and clinical features and carried out follow-up investigations on average 2 years after the index episode, using standardised instruments. RESULTS: We found 42 cases of ATPD (4.1%) among 1,036 patients treated for psychotic disorders or a major affective episode. There was a marked female preponderance in ATPD (79%). Fifty-five percent of cases concurrently met the criteria of cycloid psychosis according to Perris and Brockington [in Perris C, Struwe G, Jansson B (eds): Biological Psychiatry. Amsterdam, Elsevier, 1981, pp 447-450]. There was no difference in gender distribution between cycloid and non-cycloid ATPD. As expected, abrupt onset and polymorphic features were significantly more common in cycloid than in non- cycloid ATPD. At follow-up, patients with cycloid ATPD showed less persistent alterations and better social functioning. CONCLUSION: ATPD as defined by ICD-10 is a heterogeneous category. A diagnosis of cycloid psychosis is made in half of the cases of ATPD, and in these cases, the prognosis is more favourable.

[Acute effects of alcohol and chronic alcoholism as causes of violent crime]. / Akute Alkoholwirkung und chronische Alkoholabhängigkeit als Determinanten von Gewaltdelinquenz.

To study the influence of alcohol and psychosocial variables on delinquent behavior, we coded data from the psychiatric evaluation of 254 defendants using a standardized score sheet, analyzing correlations between acute intoxication at the time of the crime (ICD 10:F10.0), diagnosis of alcohol dependency according to ICD 10 (F10.2), psycho-biographical variables, criminal history, and parameters relating to the index offence. We found that 64.6% of all defendants studied were intoxicated when committing the crime and 25.6% suffered from alcohol dependency. Alcohol intoxication correlated to occurrence of violent crime, cruelty in committing the index offence, and earlier convictions. Logistic regression, with demographic and psychosocial variables entered as covariables, revealed acute alcohol intoxication but not alcohol dependency as a predictor of violent crime (odds ratio 2.3, P = 0.02). Alcohol intoxication and dependency were also independent predictors of earlier convictions (intoxication, odds ratio 4.4, P = 0.0001; dependency, odds ratio 3.6, P = 0.003). Our findings support the hypothesis that acute alcohol intoxication, not dependency, influences violent crime in a direct manner. However, alcohol dependency predicts criminal recidivism.

[Acute and transient psychotic disorders]. / Die akuten vorübergehenden psychotischen Störungen.

Psychotic disorders with acute onset, a dramatic and polymorphous symptomatology and rapid resolution have been described in different countries and by different psychiatric schools. They have been called cycloid psychosis, bouffée délirante, psychogenic psychosis or good prognosis schizophrenia. ICD-10 has given an operational definition under the name "acute and transient psychotic disorders" (F23). Their nosological status is unclear. The Halle-Study of acute and transient psychotic disorders (ATPD) has investigated in a prospective manner clinical, para-clinical features and course of illness in 42 patients with ATPD and matched controls with positive schizophrenia, bipolar schizoaffective disorders as well as mentally healthy patients with acute surgical conditions. First results of our study show that ATPD amount to 4% of psychotic in-patients, prefer female sex, show short prodromi, marked affective disturbances within the episode and much better outcome as schizophrenic psychoses according to psychopathological, social, psychological and biographical criteria. Though ATPD may still be an inhomogeneous group, their clinical delineation from schizophrenia seems justified.

Electroencephalogram alterations during treatment with olanzapine.

RATIONALE: Olanzapine is similar in structure and pharmacology to clozapine. An increased incidence of electroencephalogram (EEG) abnormalities and seizures has been associated with clozapine but not with olanzapine, although isolated cases of seizures under olanzapine have been observed in high-risk patients. OBJECTIVE: To evaluate the frequency of epileptic and non-epileptiform EEG abnormalities during treatment with olanzapine. METHODS: Using a rating scale of demonstrated reliability, 43 EEGs of patients receiving 10-25 mg/day olanzapine in routine treatment were blindly rated and compared with EEG registrations from the same 43 patients with a different medication. RESULTS: There was no difference in epileptiform activity between the conditions with and without olanzapine. However, EEG slowing was significantly more frequent with olanzapine than under the other condition. This difference could not be attributed to concomitant medication. CONCLUSIONS: Although epileptiform activity did not increase under olanzapine, unspecific EEG abnormalities may be more frequent than with use of other neuroleptics. Careful surveillance of patients with risk factors for seizures is advisable. Further studies addressing the frequency and clinical relevance of EEG changes under olanzapine are necessary.

[Ingestion of metals and factitious disorders. Impulse control disorder presenting on a background of situational conflicts]. / Metallingestion und Artefaktkrankheit. Gestörte Impulskontrolle vor interaktionellem Hintergrund.

We describe the case of a 27-year-old woman who in addition to the symptoms of factitious disorder showed deliberate ingestion of foreign objects. The relationship between secret and open self-destructive behavior is discussed. Analysis of situational factors highlights the importance of interactional background for the manifestation of impulsive self-harm. Parallels are pointed out to foreign body ingestion in institutionalized persons. Therapeutic issues are discussed.

[Homicides--the sociodemographic background of the offender and the behavioral symptoms]. / Tötungsdelikte--soziodemographischer Hintergrund der Täter und tatspezifische Merkmale.

The authors examined 261 forensic-psychiatric reports to determine whether persons convicted of criminal homicide differed from persons convicted of other crimes with regard to personal biography, sociodemographic milieu, and character traits. Both groups were found to come from similarly disadvantaged social backgrounds. Murderers could not be distinguished on the basis of biographical data alone. The parameters found to be distinctive of murderers were: site of the crime, criminal-victim relationship, motive for the act, intoxication at the time of the crime, and the perpetrator's opinion regarding the purpose and intent of the homicide. The present findings confirm some of the results obtained by other authors on this topic.

Violence, criminal behavior, and the EEG: significance of left hemispheric focal abnormalities.

The authors studies the relationship of EEG abnormalities and violent criminal behavior in 222 defendants referred for psychiatric evaluation. There was no connection between the number of violent offenses and EEG abnormalities in general. Focal abnormalities, however, especially of the left hemisphere, were related to a significantly higher number of violent offenses. In many cases these abnormalities were accompanied by mental retardation, epilepsy, or earlier brain damage. The findings suggest that impairment of left hemisphere functions may enhance the propensity for violent behavior in a subgroup of offenders.

[Habitual shoplifting in multi-infarct syndrome]. / Habitueller Ladendiebstahl bei Multiinfarktsyndrom.

The authors report on a 59-year-old male who repeatedly had been apprehended for shoplifting. The behavior only started after he had suffered multiple ischemic strokes. The deviant behavior is explained as a consequence of frontal lobe lesions leading to behavioral disinhibition. Criminal responsibility had to be denied.

[Transitory global amnesia--psychogenic origin of organic disease? Psychopathologic basis and pathogenetic considerations]. / Transitorische globale Amnesie--psychogene Auslösung einer organischen Störung? Psychopathologisches Bild und pathogenetische Uberlegungen.

Transient global amnesia (TGA) is an acute amnestic syndrome without neurological symptoms and remitting spontaneously. Though cerebral ischemia, epilepsy, and migraine have been implicated in some cases, non of these factors could be proven responsible for most, and etiology remains unclear. Of special interest is the induction of TGA by psychological and emotional stress in about 14-29% of all cases, which is illustrated by the clinical example of a 72-year-old women who suffered an attack of TGA after discovering a burglary in her home. Psychopathological and pathogenetic aspects are discussed in the context of recent neurobiological memory research. This suggests that TGA involves transient dysfunction of a specific memory subsystem associated with hippocampal structures. Neural network modelling explains the syndrome of TGA on a pathogenetic basis allowing for heterogeneous etiology and even for psychogenic release. Thus TGA serves as a model for pathogenetic explanation in the neuro-psychiatric borderland.

Responses of single cells in the cat inferior colliculus to binaural masking level difference signals.

Neurones with low best frequency (less than 2 kHz) and sensitive to interaural phase differences were recorded in the dorsal part of the central nucleus of the cat inferior colliculus. Best frequency tone (S) and noise (N) bursts were delivered binaurally via closed field sound systems either in phase (S0, N0) at both ears or inverted at one ear (SII, NII). The responses to tone + noise bursts in the stimulus configurations S0N0, SIINII and SIIN0 and noise bursts (N0 and NII) were compared. The latter two tone + noise configurations (S0NII and SIIN0) give a binaural masking level difference (BMLD) of up to 15 dB in psychophysical experiments, i.e. an increase in noise level is necessary to mask perception of the tone. Most cells responded better to in phase stimuli (here called 0 cells). A minority of cells responded better to out of phase stimuli (here called II cells). Each cell's response was correlated with the level of acoustic stimulus (tone or masker) in the preferred configuration and not with the BMLD situation: for the 0 cells, the responses were therefore maximal for S0N0 and minimal for SIINII. For II cells, the gradation was reversed: the response to SIINII was maximal and that to S0N0 minimal. For both populations, the responses to S0NII and SIIN0 were intermediate between the S0N0 and SIINII responses. Cells that responded best to S0NII or SIIN0, i.e. cells selectively coding BMLD, were not found. This was also true for the synchronized spike rates of those cells showing phase locked responses to the stimulus frequency. Some cells appeared to be strongly suppressed by the addition of an non-preferred masker (i.e. in the configuration that resulted in less response to a noise-alone burst; e.g. NII for the 0 cells). Other cells were more suppressed by the addition of a preferred masker (N0 for the 0 cells). The difference in the number of spikes evoked by the tone + noise and the noise burst was analyzed according to signal detection theory and neuronal masked threshold determined. Some 0 cells showed lower thresholds in the configuration S0NII whereas others had higher thresholds in this configuration. This correlated with the binaural suppression effects noted above: when the noise in the preferred configuration (N0) gave more suppression, the threshold was lower for S0NII; when NII gave more suppression the threshold was higher for S0NII. Over the whole population, these effects cancelled out and the neuronal threshold was not significantly affected by the BMLD configuration.(ABSTRACT TRUNCATED AT 400 WORDS)