Chapter 3 Jüergen Zielasek and Wolfgang Gaebel Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich Heine University, LVR-Clinics Düsseldorf, Düsseldorf, Germany “Brief Reactive Psychoses” is a designation for a group of transient psychotic disorders occurring after stressful events [1, 2]. Some issues of terminology and conceptualization arise: Different designations have been used over time to describe a transient psychotic state following a stressful event. Jauch and Carpenter [1] provided a succinct summary by describing “reactive psychosis” by its relation to a precipitating stressor, by the briefness in duration of the episode, by the absence of chronicity, and by a return to the previous level of functioning. This summary was derived from previous concepts developed by Jaspers on the reactive psychoses, which were characterized by rapid onset, full return to normal once the stressor was removed, and psychotic thoughts comprehensibly related to the nature of the stressor [3]. Other examples are Magnan’s “bouffée delirante,” Leonhardt’s “cycloid psychosis,” and Wimmer’s “psychogenic psychosis,” the latter basically reflecting Jaspers’s criteria [4] but also containing 33 percent schizophrenia cases [5]. The concept of a brief reactive psychosis had become increasingly used in Scandinavian countries in the second half of the last century and was also used to describe what are now considered culture-bound psychotic states precipitated by external events like “yak,” “latah,” “koro,” and others. In the Scandinavian tradition, it was important that the psychotic reaction bore a relation to acute mental trauma, that the content of the delusion reflected the traumatic experience, that the course was benign and that termination of the psychosis was expected upon “liquidation of the traumatic experience” [6]. Thus, Jaspers’s central features of reactive psychoses can be found in the Scandinavian conceptualization. Only the elements of the brief duration and of the immediate temporal relationship of the trauma and the psychotic reaction were retained in later international definitions. Faergeman’s monograph published in 1963 was the first English publication on this topic [5] and McCabe’s monograph [7] was the first detailed investigation of 40 cases, which—in 90 percent—fulfilled Jaspers’s criteria. The latter study, for example, showed that Jaspers’s criterion of a comprehensible relation of the psychotic contents to the traumatic event could be ascertained in 33 of the 40 cases. Only 12.5 percent of cases showed Schneiderian first-rank symptoms of schizophrenia. “Brief Reactive Psychoses” were first incorporated in the American Diagnostic and Statistical Manual in its second edition (DSM-II) in 1968, but no explicit diagnostic criteria were given. With DSM-III in 1980, a list of six criteria was introduced (described in detail in the section on “Diagnosis” in this chapter). This disorder was not included by this name in the various versions of the International Classification of Disorders (ICD) published by the World Health Organization (WHO). In ICD-10, the clinical picture of “brief reactive psychosis” can be classified under a different name (i.e., “acute and transient psychotic disorder,” or ATPD), but ATPD is a group of disorders among which the reactive psychoses only are a part. Therefore, ATPD (ICD-10) is not identical with the “brief psychotic disorder” (DSM-5), and neither ATPD nor “brief psychotic disorder” are identical with “brief reactive psychosis.” A brief overview of the history of the concept of “brief reactive psychoses” is given in Table 3.1 and a recent summary of the historic and conceptual issues can be found in a doctoral thesis by Krstev [8]. Table 3.1 History of the concept of brief reactive psychosis and classification of brief reactive psychoses. Given the different conceptualizations of “brief reactive psychoses” over time and in the different classification systems, a central issue is which clinical characteristics should be used to characterize brief reactive psychoses, what is known about their prevalence, and whether there are treatment guidelines that may be followed. Finally, open questions for future research need to be identified. This review will therefore focus on the following questions: (1) classification; (2) epidemiology; (3) treatment; (4) open questions for future research. DSM-III was the first and only classification system for mental disorders to explicitly operationalize “brief psychotic disorder” (diagnosis code 298.80 [9]). The definition included the sudden onset of a psychotic disorder of at least a few hours’ duration, with a maximum duration of 2 weeks. The psychotic symptoms had to follow “immediately” a recognizable psychosocial stressor “that would evoke significant symptoms of stress in almost everyone.” The loss of a loved one or the psychological trauma of combat were mentioned as examples of such stressors. According to DSM-III, invariably emotional turmoil ensues. Characteristic symptoms of psychosis were incoherence or loosening of associations, delusions, hallucinations, and behavior that was grossly disorganized or catatonic. Thus, “psychotic” was used in DSM-III not in Jaspers’s wider sense, but in a more narrow sense. DSM-III adds other associated features, including perplexity, a feeling of confusion, bizarre behavior, suicidality, and aggressiveness. Disturbances of affect and speech are also listed. Hallucinations and delusions were described as transient. Disorientation and memory impairment were considered to occur often. A return to the premorbid level of functioning would “usually” occur within a day or two. A maximum disease duration of 2 weeks was the upper limit. Of note, one of Jaspers’s original criteria, namely that the psychotic state must resolve quickly once the stressor was removed, was not included, but a maximum duration time criterion was introduced [2]. As exclusion criteria, DSM-III mentions that no period of increasing psychopathology may have preceded the psychosocial stressor and no organic mental disorder, manic episode, or factitious disorder with psychological symptoms may have been present. DSM-III-R introduced several changes, including that the maximum duration was prolonged to 1 month, the prodrome exclusion was specified as “the prodromal symptoms of schizophrenia,” overwhelming perplexity or confusion could substitute for a lack of emotional turmoil, schizotypal personality disorder and a psychotic mood disorder had to be excluded [1]. DSM-IV/DSM-IV-TR [10] added those brief psychotic disorders occurring without stressors (i.e., non-reactive brief psychotic disorders) into the diagnosis code 298.80, which had been used for the “brief reactive psychosis” in DSM-III, so that this code in DSM-IV was renamed “brief psychotic disorder” and included all brief psychotic disorders, that is, those with or without marked stressor(s). DSM-IV-TR explicitly states that the brief psychotic disorder with marked stressor(s) had been called “brief reactive psychosis” in DSM-III. The precipitating event was defined in DSM-IV-TR as “one or more events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in that person’s culture.” Disease duration was at least 1 day and not more than 1 month. Similarly to DSM-III, confusion and emotional turmoil are mentioned as associated features. Thus, compared to DSM-III, DSM-IV still included the “brief reactive psychotic disorders,” but not anymore as a separate mental disorder, and confirmed the longer duration criterion introduced in DSM-III-TR (1 month instead of 2 weeks). This may reflect the tendency of DSM-IV to deemphasize the putative causality of stressors for mental disorders. The reasons for the increase of the duration of symptoms are unclear. In DSM-5, a brief reactive psychosis was again not included as a unique mental disorder. However, DSM-5 retained the category of “Brief Psychotic Disorder” (298.8) [11], which still includes the specifier “with or without marked stressor(s).” Thus, a brief reactive psychosis would be classified as a “Brief Psychotic Disorder with marked stressor(s).” The key features are the sudden onset (i.e., within 2 weeks and usually without a phase of prodromal symptoms) of positive psychotic symptoms (i.e., delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior). In DSM-5, these symptoms must last at least 1 day, but not longer than 1 month. Eventually, there is a full return to the premorbid level of functioning within 1 month. Culturally sanctioned responses are excluded. The most striking difference compared to DSM-IV-TR is the introduction of a catatonia specifier and of a severity specifier, but this is a general new feature of the psychotic disorders in DSM-5 and does not particularly pertain to the brief psychotic disorders. The World Health Organization International Classification of Disorders (ICD) has a section on mental disorders, but currently does not contain a “brief reactive psychotic disorder.” Based upon requests from Scandinavia [12], the eighth edition (ICD-8) was the first to incorporate reactive psychosis as part of the nomenclature, and ICD-9 moved it into the category “other non-organic psychoses.” ICD-10 moved this disorder into the chapter of “acute and transient psychotic disorders” (ATPD) together with the other (nonreactive) acute and transient psychotic disorders (F23 [13]). ATPD is characterized by an acute onset (within 2 weeks) of a “polymorphic” (i.e., rapidly changing and variable) acutely psychotic state. A psychotic state is defined as “the presence of hallucinations, delusions, or a limited number of severe abnormalities of behavior, such as gross excitement and overactivity, marked psychomotor retardation, and catatonic behavior” (ICD-10, p. 3–4 [13]). “Associated acute stress” may be specified, but ICD-10 states that this condition may arise without associated stress. A stress-association requires that first psychotic symptoms occur within 2 weeks of one or more events that would be regarded stressful to most people in similar circumstances. ICD-10 mentions bereavement, unexpected loss of partner or job, marriage, or the psychological trauma of combat, terrorism, or torture. In ICD-10, complete recovery is expected to be reached within 2–3 months, but ICD-10 acknowledges that there may be cases with persistent symptoms. Six separate psychotic disorders belong to this chapter: Evaluating the index episode in ATPD patients, Marneros and coworkers [14] found delusions in 98 percent of all cases and hallucinations in 76 percent. Disturbances of drive and psychomotor disturbances were present in 86 percent, depressed mood in 74 percent, and maniform symptoms in 76 percent. Anxiety was found in 76 percent. Very characteristic was a fluctuating symptomatology, with rapidly changing delusions in 48 percent and rapidly changing mood in 69 percent. Of note, suicidality occurred in 36 percent during the acute episode [15] and is still the leading cause of excess mortality in acute and transient psychotic disorders besides cardiovascular diseases [16, 17]. In post-hoc analyses, only minor differences of the psychopathological features could be differentiated in the various ATPD disorders and as compared to other psychotic disorders, but the clinical characteristics best differentiating ATPD from schizophrenia were rapidly changing delusional topics, rapidly changing mood, and anxiety [14]. In ICD-10, a fifth character is used to indicate the presence or not of acute stress: Thus, ATPD is a group of disorders and the brief reactive psychotic disorders may be subsumed in this group. Category F23.x1 in ICD-10 would correspond to a “brief reactive psychotic disorder” of DSM-5, except for the different maximum duration criteria. ICD-10 is currently under revision and for ATPD the essential clinical features of acute onset, polymorphic and temporally variable clinical presentation, and short duration, will be retained. However, in order to better reflect a distinction between schizophrenic and purely delusional clinical types of these disorders, the original ICD-10 F23 categories will probably be reorganized: ICD-10 F23.0 “Acute polymorphic psychotic disorder without symptoms of schizophrenia” was chosen as the basis of the clinical guideline for 05 B 02 ATPD with a duration of up to 3 months, as it best reflects the polymorphic and varying clinical presentation typical of ATPD. The delusional subtype (F23.3) will be moved into the revised category 05 B 04 Delusional Disorder and the schizophrenic subtypes (F23.1 and F23.2) into 05 B 05 Other primary psychotic disorders [18] (Figure 3.1). Figure 3.1 Proposal for the revision of the classification of acute and transient psychotic disorders in ICD-11 [18]. The proposal mainly suggests subdividing the ICD-10 group of “acute and transient psychotic disorders” into a group of polymorphic brief psychotic disorders with symptoms of schizophrenia (ICD-11 B05), with primary delusional symptoms (ICD-11 B04) and in those without symptoms of schizophrenia (ICD-11 B02).
Brief reactive psychoses
Introduction
Time
Feature
Late 19th-early 20th century
Concepts of acute and transient, in some concepts also reactive psychoses developed
Examples:
Magnan’s “bouffée delirante”
Wimmer’s “psychogenic psychosis”
Leonhardt’s “cycloid psychosis”
1967
1968
ICD-8 includes “reactive psychosis”
DSM-II mentions “brief reactive psychosis”
1980
DSM-III lists explicit diagnostic criteria for “brief reactive psychoses”
ICD-9 moves “reactive psychosis” into the chapter “other non-organic psychoses”
1990
1992
DSM-IV puts reactive and non-reactive psychoses into one common category (“brief psychotic disorder”) and adds a specifier for the presence of “marked stressor(s)”
ICD-10 introduces “acute and transient psychotic disorders” including a specifier “with or without associated acute stress”
2013
DSM-5 retains the concept of “brief reactive psychosis” with or without marked stressor(s), and adds a catatonia and a severity specifier
ICD-11: suggestion to retain the diagnostic principles of ATPD, but to move the ATPD subtypes into different chapters to better differentiate between prototypical ATPD, brief schizophrenia-like psychoses, and brief purely delusional disorders
Classification
DSM
ICD
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