Long-term stability of acute and transient psychotic disorders

COVID-19-Associated Acute Psychotic Disorder-Longitudinal Case Report and Brief Review of Literature

Even though since the beginning of the COVID-19 pandemic, the literature became more and more abundant on data and hypotheses about the various consequences on people's lives, more clarity needs to be added to the existing information. Besides the stressful experiences related to the COVID-19 pandemic, SARS-CoV-2 infection has been proven to impact brain functioning through direct and indirect pathogenic mechanisms. In this context, we report a case of a patient presenting with a first episode of psychosis following COVID-19. In our case, a 28-year-old male patient with no personal or family psychiatric history developed psychotic symptoms (delusions, hallucinations, and disorganized behaviour) that required antipsychotic treatment and inpatient hospitalization one week after he was discharged from the hospital after COVID-19. At the six-month and one-year follow-up, the patient was in remission without any psychotic signs or symptoms. A brief review of the literature is also provided. The case presented in this article outlines the possibility that the post-COVD-19 recovery period might be a crucial time for the onset of acute psychotic disorder, and therefore, routine psychiatric assessments should be carried out during all phases of the disease. A clearer picture of the impact of the COVID-19 pandemic on mental health will most likely be revealed in the future as many consequences need long-term evaluation.

Mapping diagnostic trajectories from the first hospital diagnosis of a psychiatric disorder: a Danish nationwide cohort study using sequence analysis

BACKGROUND

A key clinical problem in psychiatry is predicting the diagnostic future of patients presenting with psychopathology for the first time. The objective of this study was to establish a comprehensive map of subsequent diagnoses after a first psychiatric hospital diagnosis.

METHODS

Through the Danish National Patient Registry, we identified patients aged 18 years or older with an inpatient or outpatient psychiatric hospital contact and who had received one of the 20 most common first-time psychiatric diagnoses (defined at the ICD-10 two-cipher level, F00-F99) between Jan 1, 1995, and Dec 31, 2008. For each first-time diagnosis, the 20 most frequent subsequent psychiatric diagnoses (F00-F99), and death, occurring during 10 years of follow-up were identified as outcomes. To assess diagnostic stability, we used social sequence analyses, assigning a subsequent diagnosis to each state with a length of 6 months following each first-time diagnosis. The subsequent diagnosis was defined as the last diagnosis given within each 6-month period. We calculated the normalised entropy of each sequence to show the uncertainty of predicting the states in a given sequence. Cox proportional hazards models were used to assess the risk of receiving a subsequent diagnosis (at the one-cipher level, F0-F9) after each first-time diagnosis.

FINDINGS

The cohort consisted of 184 949 adult patients (77 129 [41·7%] men and 107 820 [58·3%] women, mean age 42·5 years [SD 18·5; range 18 to >100). Ethnicity data were not recorded. Over 10 years of follow-up, 86 804 (46·9%) patients had at least one subsequent diagnosis that differed from their first-time diagnosis. Measured by mean normalised entropy values, persistent delusional disorders (ICD-10 code F22), mental and behavioural disorders due to multiple drug use and use of other psychoactive substances (F19), and acute and transient psychotic disorders (F23) had the highest diagnostic variability, whereas eating disorders (F50) and non-organic sexual dysfunction (F52) had the lowest. The risk of receiving a subsequent diagnosis with a psychiatric disorder from an ICD-10 group different from that of the first-time diagnosis varied substantially among first-time diagnoses.

INTERPRETATION

These data provide detailed information on possible diagnostic outcomes after a first-time presentation in a psychiatric hospital. This information could help clinicians to plan relevant follow-up and inform patients and families on the degree of diagnostic uncertainty associated with receiving a first psychiatric hospital diagnosis, as well as likely and unlikely trajectories of diagnostic progression.

FUNDING

Mental Health Services, Capital region of Denmark.

TRANSLATION

For the Danish translation of the abstract see Supplementary Materials section.

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.

Clinical characterization of brief psychotic disorders triggered by the COVID-19 pandemic: a multicenter observational study

This study aimed to characterize the clinical profile of patients with brief psychotic disorders (BPD) triggered by the psychosocial distress derived from the COVID-19 crisis. A multicenter study was conducted from March 14 to May 14, 2020 (the peak weeks of the pandemic in Europe). All consecutive patients presenting non-affective psychotic episodes with a duration of untreated psychosis of less than 1 month and whose onset was related to the COVID-19 crisis were recruited, but only those patients meeting Diagnostic Statistical Manual 5th edition (DSM-5) criteria for "BPD with marked stressors" (DSM-5 code: 298.8) during follow-up were finally included. Patients' sociodemographic and clinical characteristics were collected at baseline and summarized with descriptive statistics. During the study period, 57 individuals with short-lived psychotic episodes related to the emotional stress of the COVID-19 pandemic were identified, of whom 33 met DSM-5 criteria for "BPD with marked stressors". The mean age was 42.33 ± 14.04 years, the gender distribution was almost the same, and the majority were rated as having good premorbid adjustment. About a quarter of the patients exhibited suicidal symptoms and almost half presented first-rank schizophrenia symptoms. None of them were COVID-19 positive, but in more than half of the cases, the topic of their psychotic features was COVID-19-related. The coronavirus pandemic is triggering a significant number of BPD cases. Their risk of suicidal behavior, their high relapse rate, and their low temporal stability make it necessary to closely monitor these patients over time.

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.

Relapse risk after in-ward electroconvulsive therapy for acute polymorphic psychotic disorder

PURPOSE

Acute polymorphic psychotic disorder (APPD) without symptoms of schizophrenia is a serious psychiatric condition. APPD can be effectively treated with electroconvulsive therapy (ECT), but little is known about relapse prevention after ECT for APPD.

MATERIALS AND METHODS

This was a retrospective register-based study conducted with 97 patients with APPD (ICD-10 diagnosis F23.0). We estimated the rates of readmission and suicide, and the prognostic factors of these outcomes after ECT. We combined data from several national Swedish registers and used Cox's regression analysis to identify demographic factors, disease characteristics, and relapse preventive treatments that predicted time to readmission or suicide (relapse). Data registered between 2011 and 2016 were used in the study.

RESULTS

Twenty percent of cases relapsed within a year. Thereafter, relapse rate was low. Two cases died during follow-up, whereof one by suicide. Anxiolytic treatment, lamotrigine treatment, and having more than four previous psychiatric hospital admissions were associated with shorter time to relapse. The most robust of these associations was between anxiolytics and relapse risk.

CONCLUSIONS

The first year after discharge from APPD is the period associated with the highest risk of relapse. Having many previous admissions was associated to relapse risk after ECT for APPD. The associations between anxiolytics, lamotrigine, and relapse are uncertain and might be influenced by indication bias.

Predictors of diagnostic stability in acute and transient psychotic disorders: validation of previous findings and implications for ICD-11

Acute and transient psychotic disorders (ATPD) have moderate prospective diagnostic stability. Female gender, older age at onset, good premorbid adjustment, abrupt onset, shifting polymorphic symptomatology and absence of schizophrenic features have been found to be predictive factors of diagnostic stability in ATPDs. Nevertheless, most of these findings need to be replicated. The purpose of this study was to evaluate the diagnostic stability of patients with ATPD, and to determine whether previously accepted predictors of diagnostic stability for ATPD could be externally validated in our cohort. To that end, a prospective 2-year observational study was conducted on patients with first-episode ATPD. Multivariate analysis was performed to determine factors associated with ATPD diagnostic stability at the end of the follow-up period. The following prior knowledge variables were analyzed: female gender, older age at onset, good premorbid adjustment, abrupt onset, shifting polymorphic symptomatology and absence of schizophrenic features. Sixty-eight patients with first-episode ATPD completed the follow-up, of whom 55.9% (n = 38) retained their diagnosis of ATPD at the end of the study. Multivariate analysis revealed that diagnostic stability was independently significantly associated with the presence of shifting polymorphic symptomatology (OR = 7.42, 95% CI 1.65-33.30; p = 0.009) and the absence of schizophrenic features (OR = 6.37, 95% CI 1.47-27.54; p = 0.013) at the onset of the psychotic disorder. Our findings provide empirical support for the ICD-11 proposal restricting the new ATPD category to the acute polymorphic disorder without schizophrenia symptoms.

The prognostic role of catatonia, hallucinations, and symptoms of schizophrenia in acute and transient psychosis

OBJECTIVES

To examine the prospective temporal stability of acute and transient psychotic disorders (ATPDs) and analyze whether there are clinical, psychopathological, or sociodemographic characteristics that predict ATPD diagnostic stability.

METHOD

We conducted a prospective, 2-year, observational study of patients presenting a first-episode ATPD. A multivariate logistic regression model was developed to identify independent variables associated with ATPD diagnostic stability. Well-established predictive factors of diagnostic stability, as well as all the psychopathological features included in the ICD-10 Diagnostic Criteria for Research (DCR) descriptions of ATPD, were analyzed.

RESULTS

Sixty-eight patients with a first episode of ATPD completed the study with a diagnostic stability rate as high as 55.9% (n = 38) at the end of the follow-up period. Multivariate analysis revealed that diagnostic stability was independently significantly associated with the baseline presence of motility disturbances (OR = 6.86, 95% CI = 1.10-42.62; P = 0.039), the absence of hallucinations (OR = 5.75, 95% CI = 1.51-21.98; P = 0.010), and the absence of schizophrenic features (OR = 7.13, 95% CI = 1.38-36.90; P = 0.019).

CONCLUSION

A symptom checklist assessing these psychopathological features would enable early identification of those subjects whose initial ATPD diagnosis will remain stable over time.

Acute and Transient Psychotic Disorders: Newer Understanding

PURPOSE OF REVIEW

We review the ongoing research in the area of acute and transient psychotic disorders (ATPDs) with regard to their nosology, epidemiology, clinical description, genetics, and neurobiology, examining evidence for distinctiveness or otherwise of ATPDs. We further highlight the lacuna in research in ATPDs.

RECENT FINDINGS

Studies on ATPDs as defined in the ICD 10 have been reported from different parts of the world, more so from the developing countries. There is consistent evidence that there exist a group of ATPDs that occur more commonly among females, are often precipitated by stressful life events or exposure to physiological stresses like fever, child birth, are associated with well-adjusted premorbid personality, and show complete recovery in a short period. Although in some cases of ATPDs, there is symptomatic overlap with schizophrenic symptoms in the acute phase, they follow a completely different course and outcome, exhibit genetic distinctiveness, and do not share genetic relationship with schizophrenias or bipolar affective disorder (BPAD). Comparative studies on neurophysiology and neuroimaging in ATPDs and schizophrenias have demonstrated evidence of hyper arousal and hyper metabolism in ATPDs vs hypo arousal and hypo metabolism as noted in the P300 response and on FDG PET studies, respectively. Immune markers such as IL-6, TNF-alpha, and TGF-beta show higher levels in ATPDs as compared to healthy controls. Findings on the neurobiological mechanisms underlying ATPDs, so far, point towards significant differences from those in schizophrenia or BPAD. Although the studies are few and far between, nevertheless, these point towards the possibility of ATPDs as a distinct entity and underscore the need for pursuing alternate hypothesis such as neuro inflammatory or metabolic. Research on ATPDs is limited due to many reasons including lack of harmony between the ICD and DSM diagnostic systems and clinician biases. Available research data supports the validity of ATPDs as a distinct clinical entity. There is also evidence that ATPDs are different from schizophrenias or BPAD on genetic, neuroimaging, neurophysiological, and immunological markers and require further studies.

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.

Acute and transient psychoses: clinical and nosological issues

This article examines the clinical, epidemiological and nosological aspects of short-lived psychotic disorders as currently classified under ‘acute and transient psychotic disorders' in ICD-10 and ‘brief psychotic disorder’ in DSM-5. After describing earlier diagnostic concepts such as bouffée délirante, cycloid psychosis, reactive psychosis and schizophreniform psychosis, we present an overview of the literature and discuss implications for classification, diagnosis and treatment of these conditions, pointing out differences from longer-lasting psychotic disorders.

Improvement of cycloid psychosis following electroconvulsive therapy

BACKGROUND

The treatment of choice for cycloid psychosis has traditionally been electroconvulsive therapy (ECT), but there is a lack of studies on its effectiveness.

AIMS

The primary aim of this register study was to determine the rates of remission and response after ECT for cycloid psychosis. The secondary aim was to examine possible predictors of outcome.

METHODS

Data were obtained from the National Quality Register for ECT in Sweden. The study population was patients (n = 42) who received ECT for acute polymorphic psychotic disorder without symptoms of schizophrenia or for cycloid psychosis between 2011-2015 in 13 hospitals. Remission and response rates were calculated using Clinical Global Impression-Severity (CGI-S) and -Improvement scores, respectively. Variables with possible predictive value were tested using Chi-square and Fisher's exact test.

RESULTS

The response rate was 90.5%. The remission rate was 45.2%. Of 42 patients, 40 improved their CGI-S score after ECT (p < 0.001). The mean number of ECT treatments was 2.5 for non-responders and 7.0 for responders (p = 0.010). The mean number of ECT treatments did not differ significantly between remitters and non-remitters (7.2 vs 6.1, p = 0.31). None of the other investigated potential predictors was statistically significantly associated with outcome.

CONCLUSIONS

ECT is an effective treatment for cycloid psychosis. Future studies need to compare the outcome of ECT to that of other treatment strategies.

CLINICAL IMPLICATIONS

The high response rate with ECT indicates that cycloid psychosis is a clinically useful diagnosis.

Diagnostic validity of ICD-10 acute and transient psychotic disorders and DSM-5 brief psychotic disorder

BACKGROUND

Short-lived psychotic disorders are currently classified under "acute and transient psychotic disorders" (ATPDs) in ICD-10, and "brief psychotic disorder" (BPD) in DSM-5. This study's aim is to review the literature and address the validity of ATPDs and BPD.

METHOD

Papers published between January 1993 and December 2016 were identified through searches in Web of Science. Reference lists in the located papers provided further sources.

RESULTS

A total of 295 articles were found and 100 were included in the review. There were only a few studies about the epidemiology, vulnerability factors, neurobiological correlates and treatment of these disorders, particularly little interest seems to exist in BPD. The available evidence suggests that short-lived psychotic disorders are rare conditions and more often affect women in early to middle adulthood. They also are neither associated with premorbid dysfunctions nor characteristic family predisposition, while there seems to be greater evidence of environmental factors particularly in developing countries and migrant populations. Follow-up studies report a favourable clinical and functional outcome, but case identification has proved difficult owing to high rates of transition mainly either to schizophrenia and related disorders or, to a lesser extent, affective disorders over the short- and longer-terms.

CONCLUSIONS

Although the lack of neurobiological findings and little predictive power argue against the validity of the above diagnostic categories, it is important that they are kept apart from longer-lasting psychotic disorders both for clinical practice and research. Close overlap between ATPDs and BPD could enhance the understanding of these conditions.

Outcome of acute and transient psychotic disorder in an index episode: A study from a tertiary care centre in North India

BACKGROUND

Acute and Transient Psychotic Disorder (ATPD) is a psychotic disorder of brief duration with acute onset and uncertain diagnostic stability.

AIM

To study the diagnostic stability of ATPD during the index episode.

METHOD

140 patients diagnosed with ATPD as per ICD-10, attending a tertiary care hospital in North India were evaluated at follow ups.

RESULTS

Other acute and transient psychotic disorder (ICD10: F23.8) was the most common (69.3%) subtype of ATPD. In 14.28% patients, there was a past episode of ATPD. In our study, 66.3% patient's episodes resolved as ATPD, 32.7% patients converted into either a mood disorder or schizophrenia spectrum disorders.

CONCLUSION

The diagnostic stability of ATPD during the index episode was 66.3% during three months follow up period. Nearly two third of patients with ATPD evolve to either, schizophrenia or mood disorders during the index episode.

The clinical trajectory of patients with borderline personality disorder

OBJECTIVE

The epidemiological data on the diagnostic course of patients with borderline personality disorder (BPD) is limited. We used a nationwide register to investigate the diagnostic stability and changes over time.

METHOD

The Danish nationwide registers were used to follow all patients with a diagnosis of BPD and investigate their first-ever psychiatric diagnosis and their latest diagnosis in the time period of 1995-2012. From this, we found the diagnostic stability and described the diagnostic changes.

RESULTS

A total of 10 786 patients diagnosed with BPD were identified. The prospective diagnostic stabilities were 37% for females and 25% for males, and retrospective stabilities were 20% for females and 22% for males. More than 60% of patients received other diagnoses than BPD as their first-ever diagnosis. Stress-related (17%) and depressive disorders (14%) were most frequent as first-ever diagnosis. The latest diagnosis remained BPD in nearly half of females and one third of males, followed by schizophrenia, notably for those with longer follow-up and males.

CONCLUSION

This study gives a detailed display of complicated clinical trajectories. The low diagnostic stabilities demonstrate a heterogenous patient group diagnosed with many other psychiatric diagnoses over time. Copyright © 2016 John Wiley & Sons, Ltd.

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.

Psychosis post corona radiata and lentiform nucleus infarction

Complications of stroke can include neuropsychiatric symptoms. However, post-stroke psychosis is rare. We report a case where an acute presentation of psychosis, depression and fluctuating cognitive impairment in a middle-aged man turned out to be related to a silent brain infarction. The patient had a background of poorly controlled type 2 diabetes mellitus with glycated haemoglobin level of 9.0-11.0%, hypertension and ischaemic heart disease. His CT brain results showed multifocal infarct with hypodensities at bilateral lentiform nucleus and bilateral corona radiata. His strong genetic predisposition of psychosis and a history of brief psychotic disorder with complete remission 3 years prior to the current presentation might possibly contribute to his post-stroke atypical neuropsychiatric presentation, and posed diagnostic challenges. He showed marked improvement with risperidone 6 mg nocte, chlorpromazine 50 mg nocte and fluvoxamine of 200 mg nocte. The need of comprehensive treatments to modify his stroke risk factors was addressed.

A prospective follow-up study of first-episode acute transient psychotic disorder in Latvia

BACKGROUND

Acute and transient psychotic disorder (ATPD) has been described as an acute psychosis with brief onset and polymorphous symptomatology (WHO, 1993). The study of ATPD is growing increasingly relevant as scientists start an active discussion of the possibility of changing the ATPD classification in the next International Classification of Diseases (ICD-11). The aims of this study were to describe the clinical features of the index episode of ATPD in patients in Latvia, to analyse the stability and longitudinal changes of the diagnosis, to explore potential correlations between the sociodemographic and disease characteristics and to describe stressful life events before the first ATPD episode.

METHODS

A prospective follow-up study of all first-time admitted patients from the Riga Centre of Psychiatry and Addiction Disorders who fulfilled the ICD-10 criteria for ATPD (WHO, 1993) during the 15-month period from 9 January 2010 to 30 March 2011 and followed up until 31 October 2012. Stressful life events, demographics and clinical features during the index episode were assessed.

RESULTS

One hundred two patients were admitted with first-episode ATPD. The majority were females (60.7%). Over an average 26.5-month follow-up period, 59.8% of the patients were not readmitted. The overall stability rate of ATPD diagnosis in our sample was 67.4% (p = 0.0001). In the subgroup of patients who were readmitted, 70.7% had their diagnosis converted to schizophrenia in subsequent visits. Stressful life events before the first episode were found in 49.0% of first-episode ATPD patients. Thought disorder was found to be the strongest statistically significant predictor of ATPD diagnosis conversation to schizophrenia (odds ratio 4.3), with high Wald's criterion (9.435) in binary logistic regression.

CONCLUSIONS

ATPD is prevalent in Latvia, with rather high overall stability rate. Combining these data from first-episode ATPD patients in Latvia with data from other countries may help predict the development of the disease and provide a basis for potential changes to ICD-11.

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.

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.

Family psychiatric morbidity of acute and transient psychotic disorders and their relationship to schizophrenia and bipolar disorder

BACKGROUND

Although transient psychotic disorders are currently classified as a category separate from schizophrenia (SZ) and affective disorders, their distinctive features remain uncertain. This study examines the family psychiatric morbidity of the ICD-10 category of 'acute and transient psychotic disorders' (ATPDs), pointing out differences from SZ and bipolar disorder (BD).

METHOD

From a cohort of 2.5 million persons, we identified all patients enrolled in the Danish Psychiatric Register who were ever admitted with ATPDs (n=2537), SZ (n = 10639) and BD disorder (n=5292) between 1996 and 2008. The relative risk (RR) of ATPDs, SZ and BD associated with psychiatric morbidity in first-degree relatives (FDRs) was calculated as the incidence rate ratio using Poisson regression.

RESULTS

The RR of ATPDs [1.93, 95% confidence interval (CI) 1.76-2.11] was higher if patients with ATPDs had at least one FDR admitted with any mental disorder than patients without family psychiatric antecedents. An additional risk arose if they had FDRs admitted not only with ATPDs (RR 1.60, 95% CI 1.33-1.92) but also with SZ (RR 2.06, 95% CI 1.70-2.50) and/or BD (RR 1.55, 95% CI 1.23-1.96). Despite some overlap, the risk of SZ (RR 2.80, 95% CI 2.58-3.04) and BD (RR 3.68, 95% CI 3.29-4.12) was markedly higher if patients with SZ and BD had FDRs admitted with the same condition.

CONCLUSIONS

These findings suggest that family psychiatric predisposition has a relatively modest impact on ATPDs and argue against a sharp differentiation of ATPDs from SZ and BD.

Excess mortality of acute and transient psychotic disorders: comparison with bipolar affective disorder and schizophrenia

OBJECTIVE

To investigate mortality and causes of death of short-lived psychotic disorders, by carrying out a comparison with bipolar disorder and schizophrenia.

METHOD

Record linkage study to the official register of causes of death of all cases aged 15-64 years who were listed for the first time in the Danish Psychiatric Register between 1995 and 2008 with an ICD-10 diagnosis of 'acute and transient psychotic disorders' (ATPDs; n = 4157), bipolar disorder (n = 3200) and schizophrenia (n = 4576).

RESULTS

A total of 232 patients (5.6%) with ATPDs, 172 (5.4%) with bipolar disorder and 233 (5.1%) with schizophrenia had died over a mean follow-up period of 6.6 years. The standardized mortality ratio for all causes, natural causes and unnatural causes was significantly high for the three conditions. Mortality of ATPDs was greater in men, with about two-thirds of all deaths resulting from natural causes mainly cardiovascular, digestive, neoplastic and respiratory diseases. Suicide was the major cause of premature death in patients with ATPDs.

CONCLUSION

These findings suggest that ATPDs are associated with an increased mortality from both natural causes and suicide.