Acute and Transient Psychotic Disorders
J. Garrabé
F.-R. Cousin
Historic introduction
Acute and transient psychotic episodes have been described since the end of the nineteenth century. Descriptions have varied from one country to another, so that the exact nosology has not yet been established. The links between acute psychoses (generally defined as having brief obvious psychotic symptomatology) and chronic psychoses (schizophrenic psychoses and psychoses with persistent delusions) are still under discussion.
For instance, Sections F20 and F21 in ICD-10(1) are devoted to ‘Schizophrenia, schizotypal and delusional disorders’. A specific diagnostic category named ‘Acute and transient psychotic disorders’ is included, distinct from Schizophrenia (F20), Schizotypal disorder (F21), Persistent delusional disorder (F22), Induced delusional disorder (also called folie à deux) (F24), and Schizoaffective disorder (F25).
In this textbook, the acute and transient psychotic disorders (Chapter 4.3.10) appear in the section dedicated to schizophrenia,
which also includes schizotypal disorders and schizoaffective disorders (Chapter 4.3.9). However, this section is clearly distinguished from the chapter in which the persistent delusional disorders are discussed (Chapter 4.4). These taxonomic divergences are justified more by the history of acute psychoses than by scientific findings.
which also includes schizotypal disorders and schizoaffective disorders (Chapter 4.3.9). However, this section is clearly distinguished from the chapter in which the persistent delusional disorders are discussed (Chapter 4.4). These taxonomic divergences are justified more by the history of acute psychoses than by scientific findings.
In the nineteenth century, German psychiatrists had already described akute primäre Verruckheit,(2) termed paranoia acuta by Karl Westphal. In 1876 (published in 1878), Westphal used this term to describe an acute form of paranoia with an outburst of perceptual hallucinations, consisting mostly of hallucinatory voices and delusions, with clouding of consciousness. In 1890, Meynert repeated the clinical description but named the condition amentia.(3) Sigmund Freud chose this type of acute delusion with hallucinations for his psychoanalytic conception of psychosis.(4)
In the sixth edition of his textbook, published in 1899, Kraepelin(5) included all the paranoias under dementia praecox, and in the eighth edition (1908-1915) he combined manic and melancholic periodic disorders in a single group, leaving acute psychosis with no place between these two diagnostic categories.
In 1911, Bleuler(6) replaced the single disease dementia praecox by the concept of a group of schizophrenias of various clinical forms. He noticed that schizophrenia often began with an acute excitatory episode lasting from a few hours to a few years. He described a wide variation of outcome of acute forms of psychosis, but he separated acute schizophrenias from simple schizophrenia as he believed that acute forms do not necessarily end in deterioration.
In 1916, based on Karl Jaspers’ psychopathology, the Danish psychiatrist Wimmer(7) described psychogenic psychosis as a reactive psychosis arising after psychosocial trauma. Mayer-Gross,(8) who proposed an organic aetiology for schizophrenia, described ‘oneiroid states’ consisting of acute psychotic symptomatology with no other specific organic features.
In 1961, Leonhard(9) used Kleist’s concept of marginal psychosis (Randpsychosen) to develop his description of ‘cycloid psychoses’ as endogenous psychoses separate from schizophrenic psychoses and from manic and melancholic psychoses. These cycloid psychoses tend to have a benign and periodic course.
Earlier (1933), Kasanin(10) had described ‘acute schizoaffective psychoses’, raising questions about the links between schizophrenic and affective diseases.
Langfeldt(11) suggested that observation for 5 years was required to be able to distinguish schizophrenia and what he called schizophreniform psychosis. This long-term observation is a reminder of the Bleulerian concept of acute schizophrenias which could last for several years. Epidemiological studies have led to the presence in modern classifications of a group of acute schizophreniform psychoses under the rubric ‘Schizophreniform disorder’ (DSM-IV Section 295.40) or ‘Acute psychotic disorder schizophrenic-like’ (ICD-10 Section F23.2).
In France, the concept of bouffée délirante led naturally to a specific class of acute psychoses. In 1895, Magnan(12) and his disciple Legrain(13) described bouffée délirante or délire d’emblée (immediate delusion) within the polymorphic delusions of the chronic insane. This concept is based on Morel’s theory of degeneration, commonly accepted in the nineteenth century. The question of whether there is a susceptibility or a predisposition to the occurrence of an acute psychosis remains unanswered.(14)
In 1954, Ey(15,16) described the development of the concept of bouffées délirantes and of acute psychoses with hallucinations from the time of Magnan to a symposium devoted to the clinical subdivision of schizophrenic psychoses held at the First World Congress of Psychiatry in 1950, where the various ideas were discussed by Langfeldt, Karl Leonhard, and Aubrey Lewis (Table 4.3.10.1).
Table 4.3.10.1 Historical development of the terminology of acute and transient psychotic disorders | ||||||||||||||||||||||||||
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Clinical description: psychopathology
The heterogeneous group of acute and transient psychotic disorders are characterized by three typical features, listed below in descending order of priority:
suddenness of onset (within 2 weeks or less);
presence of typical syndromes with polymorphic (changing and variable) or schizophrenic symptoms;
presence of associated acute stress (stressful events such as bereavement, job loss, psychological trauma, etc.).
The onset of the disorder is manifested by an obvious change to an abnormal psychotic state. This is considered to be abrupt when it occurs within 48 h or less. Abrupt onset often indicates a better outcome. Full recovery occurs within 3 months and often in a shorter time (a few days or weeks). However, a small number of patients develop persistent and disabling states.
The general (G) criteria for these acute disorders in DCR-10 (Diagnostic Criteria Research of ICD) are as follows.
G1 There is acute onset of delusions, hallucinations, incomprehensible or incoherent speech, or any combination of these. The time interval between the first appearance of any psychotic symptoms and the presentation of the fully developed disorder should not exceed 2 weeks.
G2 If transient states of perplexity, misidentification, or impairment of attention and concentration are present, they do not fulfil the criteria for organically caused clouding of consciousness as specified for F05, criterion A.
G3 The disorder does not satisfy the symptomatic criteria for manic episode (F30), depressive episode (F32), or recurrent depressive disorder (F33).
G4 There is insufficient evidence of recent psychoactive substance use to satisfy the criteria for intoxication (F1x.0), harmful use (F1x.1), dependence (F1x.2), or withdrawal states (F1x.3 and F1x.4). The continued moderate and largely unchanged use of alcohol or drugs in the amounts or with the frequency to which the individual is accustomed does not necessarily exclude the use of F23; this must be decided by clinical judgement and the requirements of the research project in question.
G5 There must be no organic mental disorder (F00-F09) or serious metabolic disturbances affecting the central nervous system (this does not include childbirth). (This is the most commonly used exclusion clause.)
A fifth character should be used to specify whether the acute onset of the disorder is associated with acute stress (occurring 2 weeks or less before evidence of first psychotic symptoms):
F23.x0 without associated acute stress and
F23.x1 with associated acute stress.
For research purposes it is recommended that change of the disorder from a non-psychotic to a clearly psychotic state is further specified as either abrupt (onset within 48 h) or acute (onset in more than 48 h but less than 2 weeks).
Six categories of acute psychoses are presented in ICD-10, and we shall discuss them in order.
F23.0 acute polymorphic psychotic disorder without symptoms of schizophrenia
The diagnostic criteria are based on the classical symptoms of the true bouffée délirante described by Magnan and Legrain.
(a) Suddenness of onset
Bouffée délirante occurs over a period of a few hours or days, usually to young adults and often women in their 30s. The onset of the delirious episode is ‘like a thunderbolt in a serene sky’. This aphorism from Legrain has the same meaning as the French classical expression délire d’emblée (immediate delusion).
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