Atpd

48
Acute and Transient Psychotic Disorders

description

ppt on ATPD

Transcript of Atpd

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Acute and Transient Psychotic Disorders

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History

• From several different parts of the world, there is occurrence of certain psychotic states other than schizophrenia and MDP

France : Bouffee Delirante 

Germany: Motility Psychosis, Cycloid Psychosis, Reactive PsychosisScandinavia : Psychogenic psychosis, Schizophreniform PsychosisAmerica : Remitting Schizophrenia; Good Prognosis Schizophrenia               Hysterical Psychosis,  Acute Schizoaffective PsychosisJapan : Atypical PsychosisAfrica : Acute Primitive Psychosis, Acute Paranoid Psychosis 

                 Transient Psychosis 

West Indies : Acute Psychotic Reaction 

India : Acute Psychoses of Uncertain Origin 

           Hysterical Psychosis          Acute Psychosis without Antecedent Stress          Acute Schizophrenic Episode

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History

Amentia-• Theodor Meynert (1833 to 1898),Emil Kraepelin (1856 to 1926) • a psychotic disorder with a remitting course and favorable outcome,

Cycloid psychosis-• Two variants - Karl Kleist (1879–1960):• Confusional insanity - contrasting phases of confused excitement and

stupor, and • motility psychosis - contrasting phases of hyperkinesis and akineses.• A 3rd variant, anxiety-elation psychosis - Karl Leonhard (1904–1988).• Still used by German, Scandinavian, & other European psychiatrists• Influential for the formulation of ATPDs in ICD-10.

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Bouffée délirante (Legrain, Magnan)• influential in formulating ICD-10 ATPDs. • Common in Africa and the Caribbean, so categorized as a

culture-bound syndrome in the DSM-IV-TR.

Psychogenic or reactive psychosis• A psychotic disorder with acute onset following external stress• popular among Scandinavian psychiatrists

Oneirophrenia• acute onset of confusion, nightmare, or dream-like quality of all

perceptions (hence the term “oneirophrenia”),• extreme fear and anxiety, delusions, and visual hallucinations.

Hysterical psychosis• sudden and dramatic onset related to a profoundly upsetting event

in the context of a “hysterical” personality

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• Descriptions similar and grew out of different psychiatric traditions separated by cultural and linguistic boundaries

• all portray a non-organic, non-affective psychotic condition with acute onset and remitting course, the multiplicity of descriptions

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Most of the research on ATPD has been limited to India and Scandinavian countries

Wig and Singh First pointed the existence of ATPD in India

Kapur and Pandurangi 2 types of acute psychosis, based on presence or absence of stress

Singh and Sachdeva pointed “acute schizophrenia episode” shouldn’t be included in schizophrenia

Chavan and Kulhara Reactive psychosis

ICMR 40% of patients with acute onset psychoses don’t fit into either diagnosis of schizophrenia, MDP or depression

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NOSOLOGICAL STATUS

Prior to ICD 10 – no separate nosology & placed under broad category of schizophrenia.

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DSM

• Scandinavian concept of reactive or psychogenic psychosis is influential in the formulation of the DSM-III “brief reactive psychosis”

• a psychotic condition lasting less than 2 weeks that • followed a significant psychosocial stressor and • that involved emotional turmoil and • one of the symptoms of loosening of associations, delusions,

hallucinations, or disorganized or catatonic behavior.

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• maintained in the DSM-III-R, but the allowable duration of symptoms was extended to 1 month.

• In DSM-IV and IV TR replaced by brief psychotic disorder, eliminating an identifiable psychosocial stressor as a diagnostic criterion.

• partly motivated by observation that many cases of brief psychosis are not precipitated by marked stressor & hence can’t be labeled ‘reactive’.

• DSM-III and DSM-III-R criterion of emotional turmoil was removed from the DSM-IV & DSM-IV-TR criteria for brief psychotic disorder.

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ICD 10

• F23 ACUTE AND TRANSIENT PSYCHOTIC DISORDERS• G1. An 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 fulfill the criteria for organically caused

clouding of consciousness as specified in F05 A.

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• G3. The disorder does not meet the symptomatic criteria for

manic episode (F30),

depressive episode (F32), or RDD (F33).• G4. No evidence of recent psychoactive substance use sufficient to

fulfil the criteria of

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 amounts or frequencies to which the subject is accustomed

does not necessarily rule out the use of F23;

this must be decided by clinical judgment.

• G5. Most commonly used exclusion criteria:

absence of organic brain disease (F0) or

serious metabolic disturbances affecting the central nervous

system (this does not include childbirth).

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• A fifth character should be used to specify whether the acute onset of the disorder is associated with

acute stress (occurring within two weeks prior to evidence of first psychotic symptoms).

• F23.x0 without associated acute stress• F23.x1 with associated acute stress

• For research purposes it is recommended to further specify the onset of the disorder from a non-psychotic to a clearly psychotic state as either:

• abrupt (onset within 48 hours), or• acute (onset in more than 48 hours but less than two weeks).

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CLASSIFICATION IN ICD 10

• The empirical classification in ICD 10 is based on the • course of clinical picture (polymorphic), • presence or absence of schizophrenic symptoms, and • duration of the episode.

ATPDAcute polymorphic PD

Without symptoms of schizophrenia

With symptoms of schizophrenia

Acute schizophrenia-like PD

Other acute predominantly delusional PD

Other ATPD

Unspecified ATPD

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F23.0 Acute polymorphic psychotic disorder without symptoms of schizophreniaICD 10 ICD 10 DCR

(a)the onset must be acute (from a nonpsychotic state to a clearly psychotic state within 2 weeks or less);

A. The general criteria for acute and transient psychotic disorders (F23) must be met.

(b)there must be several types of hallucination or delusion, changing in both type and intensity from day to day or within the same day;

B. The symptomatology is rapidly changing in both type and intensity from day to day or within the same day.C. The presence of any type of either hallucinations or delusions, for at least several hours, at any time since the onset of the disorder.

(c)there should be a similarly varying emotional state; and D. Symptoms from at least two of the following categories, occurring at the same time:(1) Emotional turmoil, characterized by intense feelings of happiness or ecstasy, or overwhelming anxiety or marked irritability;(2) Perplexity, or misidentification of people or places;(3) Increased or decreased motility, to a marked degree.

(d)in spite of the variety of symptoms, none should be present with sufficient consistency to fulfil the criteria for schizophrenia (F20.-) or for manic or depressive episode (F30.- or F32.-).

E. Any of the symptoms listed in Schizophrenia F20, G1.1 and G1.2 that are present, are only present for a minority of the time since the onset, i.e. criterion B of F23.1 is not fulfilled.

If the symptoms persist for more than 3 months, the diagnosis should be changed (F22.-) or (F28) is likely to be the most appropriate.

F. The total duration of the disorder does not exceed three months.

Includes: bouffée délirante without symptoms of schizophrenia or unspecified cycloid psychosis without symptoms of schizophrenia or unspecified

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F23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia

ICD10 ICD 10 DCR

For a definite diagnosis, criteria (a), (b), and (c) specified for acute polymorphic psychotic disorder (F23.0) must be fulfilled

A. Criteria A, B, C, and D of acute polymorphic psychotic disorder (F23.0) must be met.

in addition, symptoms that fulfil the criteria forschizophrenia (F20.-) must have been present for the majority of the time since the establishment of an obviously psychotic clinical picture.

B. Some of the symptoms specified for schizophrenia (F20.0 - F20.3) must have been present for the majority ofthe time since the onset of the disorder, but not necessarily meeting these criteria completely, i.e. at least any one of the symptoms in F20, G1.1a to G1.2g.

If the schizophrenic symptoms persist for more than 1 month, the diagnosis should bechanged to schizophrenia (F20.-).

C. The symptoms of schizophrenia in B above do not persist for more than one month.

Includes: bouffée délirante with symptoms of schizophreniacycloid psychosis with symptoms of schizophrenia

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F23.2 Acute schizophrenia-like psychotic disorder

ICD 10 ICD 10 DCR

(a)the onset of psychotic symptoms must be acute (2 weeks or less from a nonpsychotic to a clearly psychotic state);

A. The general criteria for acute and transient psychotic disorders (F23) must be met.

(b)symptoms that fulfil the criteria for schizophrenia (F20.-) must have been present for the majority of the time since the establishment of an obviously psychotic clinical picture;

B. The criteria for schizophrenia (F20.0 - F20.3) are met, with exception of the duration criterium.

(c)the criteria for acute polymorphic psychotic disorder are not fulfilled.

C. The disorder does not meet the criteria B, C and D for acute polymorphic psychotic disorder (F23.0).

If the schizophrenic symptoms last for more than 1 month, the diagnosis should be changed to schizophrenia (F20.-).

D. The total duration of the disorder does not exceed one month.

Includes: acute (undifferentiated) schizophreniabrief schizophreniform disorder, brief schizophreniform psychosisOneirophrenia, schizophrenic reactionExcludes: organic delusional [schizophrenia-like] disorder (F06.2)schizophreniform disorder NOS (F20.8)

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F23.3 Other acute predominantly delusional psychotic disorder

ICD 10 ICD 10 DCR

(a)the onset of psychotic symptoms must be acute (2 weeks or less from a nonpsychotic to a clearly psychotic state);

A. The general criteria for acute and transient psychotic disorders (F23) must be met.

(b)delusions or hallucinations must have been present for the majority of the time since the establishment of an obviously psychotic state;

B. Relatively stable delusions and/or hallucinations are present, but they do not fulfil the symptomatic criteria for schizophrenia (F20.0 - F20.3).

(c)the criteria for neither schizophrenia (F20.-) nor acute polymorphic psychotic disorder (F23.0) are fulfilled.

C. The disorder does not meet the criteria for acute polymorphic psychotic disorder (F23.0).

If delusions persist for more than 3 months, the diagnosis should be changed to persistent delusional disorder (F22.-). If only hallucinations persist for more than 3 months, the diagnosis should be changed to other nonorganic psychotic disorder (F28).

D. The total duration of the disorder does not exceed three months.

Includes: paranoid reactionpsychogenic paranoid psychosis

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F23.8 Other acute and transient psychotic disorders

ICD 10 ICD 10 DCR

Any other acute psychotic disorders that are unclassifiable under any other category in F23 (such as acute psychotic states in which definite delusions or hallucinations occur but persist for only small proportions of the time) should be coded here.

Any other acute psychotic disorders that are unclassifiable under any other category in F23 (such as acute psychotic states in which definite delusions or hallucinations occur but persist for only small proportions of the time) should be coded here.

States of undifferentiated excitement should also be coded here if more detailed information about the patient's mental state is not available, provided that there is no evidence of an organic cause.

States of undifferentiated excitement should also be coded here if more detailed information about the patient's mental state is not available, provided that there is no evidence of an organic cause.

F23.9 Acute and transient psychotic disorder, unspecified

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• Apart from diagnostic criteria, ICD-10  also provides diagnostic guidelines which include:

• Not meeting the criteria for manic or depressive episodes although affective symptoms may be prominent.

• Absence of organic causation although perplexity, confusion and inattention may be present.

• Absence of obvious intoxication by drugs or alcohol.

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DSM IV TR

• 298.8 Brief Psychotic Disorder• A. Presence of one (or more) of the following symptoms:• (1) delusions• (2) hallucinations• (3) disorganized speech (e.g frequent derailment or incoherence)• (4) grossly disorganized or catatonic behavior• Note: Do not include a symptom if it is a culturally sanctioned

response pattern.• B. Duration of an episode of the disturbance is at least 1 day but

less than 1 month, with eventual full return to premorbid level of functioning.

• C. The disturbance is not better accounted for by a

Mood Disorder With Psychotic Features,

Schizoaffective Disorder, or Schizophrenia and is not due to the

direct physiological effects of a substance or a GMC.

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• Specify if:• With Marked Stressor(s) (brief reactive psychosis): • if symptoms occur shortly after and apparently in response to

events that, singly or together,

would be markedly stressful to almost anyone in similar circumstances in the person's culture

• Without Marked Stressor(s):• if psychotic symptoms do not occur shortly after, or are not

apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture

• With Postpartum Onset: if onset within 4 weeks postpartum

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ICD vs DSM• ICD 10 for ATPD• (a) an acute onset (within 2 weeks); • (b) presence of typical syndromes, which are the

basis for the sub-categorization into specific disorders; and • (c) the presence of associated acute stress

(within about 2 weeks of onset).

• DSM includes only one disorder for psychotic presentations with a • duration of at least 1 day but less than 1 month, • regardless of type or course of the psychotic symptoms.

• Many cases of ICD-10 ATPDs would be categorized as schizophreniform disorder, BPD, or psychotic disorder NOS in DSM.

• acute onset is not a diagnostic criterion for any of the above DSM diagnoses, but a specifier for favorable prognosis.

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COMPARISION

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Epidemiology

• rare, especially in industrialized settings• 10 fold higher incidence in developing countries compared with

industrialized countries• Of all 1st contact non-affective psychoses • 35 % in developing countries compared to only • 6 % in industrialized countries.• Age of onset was also • younger (mid-20s) in the developing • than developed (mid-20s to 30s) countries• MC - polymorphic psychotic disorder without symptoms of

schizophrenia (1/3-1/2) > with symptoms of schizophrenia• more common among women than men

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Etiology

• Both biological and • Socio-cultural factors as possible causes.• BIOLOGICAL :• higher P300 amplitude over the left hemisphere in AEPs than

normal controls, suggesting a higher level of arousal.• increased hemispheric blood flow during the psychotic episode that

was directly related to symptom severity and that returned to a normal level after remission.

• febrile illness prior to the development of ATPD,

which may in part explain the higher incidence of these disorders in developing country settings where infectious diseases are common.

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• A study from India reported

a higher risk of ATPDs and

a lower risk of schizophrenia and mood disorders in the first-degree relatives of ATPD probands

compared with schizophrenia probands.• rapid cultural change and

modernization in the developing countries expose

individuals to loss of status and stress arising from role confusion,

making individuals vulnerable to psychotic reactions.

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• Among women in developing countries, • departure from or return to their parental village was a major

stressor in one study, • whereas among men , job-related problems were the main stressor• Proportion of patients who experience acute stress varies across

studies, ranging from 10–69%.• Association with pre-existing personality disorders• A psychodynamic formulation of brief reactive psychosis links this

condition to deficient ego strength.• intense emotionally stressful event

• absence of support in the environment,

• overwhelms the individual's ego defense mechanisms and

PSYCHOSIS

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Diagnosis and Clinical Features

• (a) an acute onset• (b) presence of typical syndromes, • (c) the presence of associated acute stress• Acute onset is defined as • “a change from a state without psychotic features to a clearly

abnormal psychotic state, within a period of 2 weeks or less.”• Time to onset should not be confused• with the time between symptom onset and peak illness severity, as

the maximum severity of symptoms may occur weeks after symptom onset

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• Similarly “prodromal periods of anxiety, depression, social withdrawal, or mildly abnormal behaviour” should not be counted in determining time to onset.

• Thus, the criterion for acute onset will still be met even if the individual reports weeks or months of these prodromal symptoms before the onset of illness.

• ICD-10 also suggests that a distinction be made between acute onset, and

• abrupt onset (i.e., onset within 48 hours), • noting that the latter may be associated with even better outcome.

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• ICD-10 describes two typical syndromes: • The polymorphic syndrome and • The typical schizophrenic syndrome.• The polymorphic syndrome consists of marked hallucinations,

delusions, and perceptual disturbances that change from day to day or even from hour to hour.

• This state is frequently associated with symptoms of emotional turmoil, “with intense transient feelings of happiness and ecstasy or anxieties and irritability.”

• Although mood symptoms might be present, the criteria for a manic or depressive episode are not met.

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• The schizophrenic syndrome requires that the ICD-10 symptom criteria for schizophrenia be met for the majority of the time since the onset, but less than 1 month.

• The schizophrenic syndrome might be associated• with the polymorphic syndrome as in “acute polymorphic psychotic

disorder with symptoms of schizophrenia” or • stand alone as in “acute schizophrenia-like psychotic disorder”.

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• The ICD-10 defines acute stress as• “events that would be regarded as stressful to most people in similar

circumstances, within the culture of the person concerned.” • ICD-10 mentions • “bereavement, unexpected loss of partner or job, marriage, or the

psychological trauma of combat, terrorism and torture” as typical examples of acute stress.

• A diagnosis of ATPD requires ruling out typical manic or depressive episodes, alcohol or drug intoxication, delirium, dementia, and mental disorders due to medical etiologies.

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DIAGNOSIS

• Detailed history :• From parents, relatives, spouse / friend regarding :

– Stressors, level of functioning before onset of illness,– history of response to similar stressors in past.

• H/o onset, delusion(s),hallucination(s) & its frequency & rapidity of change

• R/o medical & substance induced disorders.• Past history of similar illness which subsided with or without treatment.• Family history• Premorbid personality• Examination : MSE-

– rapidly changing/persistent delusion, hallucination, disorganised behaviour, emotional status, psychomotor activity,

– consciousness levels, cognitive functions.• GPE & Syst. Examination : R/O organic etiology,• Investigations

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Differential Diagnosis

• A definitive diagnosis of ATPD or BPD early in the first episode of illness is difficult if not impossible.

• Unless the psychosis has fully remitted, the duration of an episode of illness cannot be determined.

• Remission of psychotic symptoms within 1 month as a result of successful treatment also makes it difficult to distinguish BPD from other longer lasting disorders.

• In such instances, the presence of continued residual symptoms or impairment may be helpful in ruling out a diagnosis of BPD.

• DD: • delirium, dementia, • psychotic disorder due to medical illness, and • drug or alcohol intoxication or withdrawal.

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• The temporal relationship• b/w onset of psychosis & the pattern of substance abuse may be

helpful in differentiating a substance-induced psychotic episode from a nonsubstance-induced one.

• Acute psychotic episodes have been reported in a no of GMC including head trauma, cerebral anoxia, epilepsy, and endocrine disorders such as hyper- or hypothyroidism.

• Many of these episodes are associated with disturbances of consciousness.

• Differential diagnosis is often based on a thorough medical history and physical examination as well as laboratory investigations.

• Good prognosis of BPD and of ATPD, variability of symptoms, and the presence of mood symptoms sometimes make it difficult to differentiate these diagnoses from mood disorders.

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• Patients with personality disorders, especially borderline personality disorder, sometimes experience psychotic symptoms under stressful life circumstances.

• These symptoms are generally transient and do not require a separate diagnosis.

• If the symptoms last more than 1 day, an additional diagnosis of BPD may be warranted.

• A no of “culture-bound” syndromes with acute onset of psychotic and dissociative symptoms have been described in various cultural settings.

• Many of these syndromes are transient and resolve spontaneously without antipsychotic medication treatment.

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Course and Prognosis

• ATPDs have a favorable early course by definition: • Full remission within 1 to 3 months is a diagnostic criterion in ICD.• Recurrence rates of 39 – 47 % have been reported in 1st admission

samples followed for 3 to 4 years, but full recovery is common.• Only about 6 -18 % of patients have any residual symptoms at a

later point of time, • although some studies have shown that the duration of nonaffective

psychoses with acute onset and remitting course • may extend up to 6 months.

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GOOD PROGNOSIS

• Good Premorbid adjustment• Few premorbid schizoid traits• Severe precipitating stressor• Sudden onset of symptoms• Affective symptoms• Confusion, Perplexity during psychosis• Little affective blunting• Short duration of symptoms• Absence of schizophrenic relatives

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TREATMENT

• Short-term treatment• Acute psychotic syndromes require early hospitalization in inpatient

psychiatric unit. • They are psychiatric emergencies. • The decision to admit to hospital is taken in order to make• a careful clinical evaluation, • to separate the patient from his or her environment, • to provide a reassuring setting, and • to prevent any suicidal or aggressive tendencies.• Antipsychotic drugs are prescribed.• Some clinicians wait for a day or two before starting antipsychotic

therapy in order to eliminate an organic cause (a GMC or substance abuse disorder can present with ATP symptoms).

• The choice of antipsychotic drug depends on the clinician's experience and the clinical features.

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• Continuation treatment• The effectiveness of psychopharmacotherapy is usually manifested

in the first 6 weeks, • with improved sleep, • regression of agitation, • recovery from anxiety and delusion, and • finally disappearance of the psychotic features.• Worsening of the symptoms, serious side-effects, or a poor

response to pharmacotherapy are the main indications for ECT.

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• Prevention of recurrence• possibility that psychotic symptoms may re-emerge during the first 2

years of follow-up. • Low-dosage pharmacotherapy must be maintained for 1 or 2 years

after recovery.• During this long-term follow-up, periodic assessment and effective

clinical care with social and psychological therapy are essential.

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RESEARCH

• Research on ATP supports the notion that there is:(i) Genetic distinctiveness of ATP.

• Although the findings point towards genetic distinctiveness of ATPD, it is hypothesized that

• ATPD may be an environmentally induced psychotic condition superimposed upon an underlying vulnerability to psychosis.

• What type of psychosis the patient is likely to develop, could be related to:(ii) The timings of brain insult, e.g., early-life insult may lead more often to schizophrenia and later-life insult may lead to ATP.

(iii) The severity of brain insult where ATP may be associated with less severe insult. 

As there are also good outcome schizophrenias, ATP and schizophrenia may lie on a continuum of severity.

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• There may be a common genetic liability to psychosis and further distinction between schizophrenia, MDP and ATPD could lie on two dimensions:

a) Symptoms dimensions, where symptoms of schizophrenia → schizoaffective psychosis → ATPD → affective psychosis with psychotic symptoms → affective psychosis without psychotic symptoms lie on a continuum.

(b) Course dimension, which may vary from chronic deteriorating → recurrent with varying levels of recovery → single episode with full recovery.

Complex interplay between genetic, biological and environmental factors could produce different phenotypic variations recognized in contemporary literature as schizophrenia, MDP or ATPD.

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DSM V and ICD 11

• The DSM-5 diagnostic criteria for this disorder are similar to those  in DSM-IV, with very minor wording changes being proposed.

• The specifier With Catatonic Features is added.• 298.85 (Brief Psychotic Disorder)• Dimensions will be assessed on a 0-4 scale cross-sectionally, with

severity assessment based on past month.• ICD 11• A diagnostic classification of Nonaffective acute remitting

psychosis (NARP),also termed as acute brief psychosis • 4 criteria would be central to the diagnosis:

1) nonaffective

2) acute onset (over < two weeks),

3) recovery within a brief duration (< six months)

4) psychosis broadly defined.

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CONCLUSION

• Acute and Transient psychotic disorders have disproved Kraeplin’s dichotomy.

• ATPD disorders are eminently treatable and have a good long term course and favorable outcome

• Family, genetic and imaging studies are needed to firmly establish acute and transient psychotic disorders as a distinct clinical entity

• Research on ATPD in India has made a significant contribution and this is one area where Indian research has made a mark at the international level.

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THANK U