Table 12.17-3. ICD-10 Diagnostic Criteria for Research for Acute and Transient Psychotic Disorders

F23 Acute and transient psychotic disordersG1There 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 two weeks.

G2If 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 for F05.-, criterion A.

G3The disorder does not meet the symptomatic criteria for manic episode(F30.-), depressive episode (F32.-), or recurrent depressive disorder (F33.-).

G4There is insufficient evidence of recent psychoactive substance use to fulfill 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 amounts or with the frequency to which the individual is accustomed does not necessarily rule out the use of F23; that must be decided by clinical judgment and the requirements of the research project in question.

G5Most commonly used exclusion clause. There must be no organic mental disorder (F00–F09) or serious metabolic disturbances affecting the central nervous system (not including childbirth). A fifth character should be used to specify whether the acute onset of the disorder is associated with acute stress (occurring two weeks or less before evidence of first psychotic symptoms): F23.x0 Without associated acute stress, F23.x1 With associated acute stress. For research purposes it is recommended that change of the disorder from a nonpsychotic to a clearly psychotic state is further specified as either abrupt (onset within 48 hours) or acute (onset in more than 48 hours but less than two weeks).

F23.0 Acute polymorphic psychotic disorder without symptoms of schizophreniaA. The general criteria for acute and transient psychotic disorders (F23) must be met. B. Symptoms change rapidly in both type and intensity from day to day or within the same

day. C. Any type of either hallucinations or delusions occurs, for at least several hours, at any

time from the onset of the disorder. D. Symptoms from at least two of the following categories occur 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.

E. If any of the symptoms listed for schizophrenia (F20.0–F20.3), criteria G(1) and (2), are present, they are present only for a minority of the time from the onset (i.e., criterion B of F23.1 is not fulfilled).

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

F23.1 Acute polymorphic psychotic disorder with symptoms of schizophreniaA. Criteria A, B, C, and D of acute polymorphic psychotic disorder (F23.0) must be met. B. Some of the symptoms specified for schizophrenia (F20.0–F20.3) must have been present

for the majority of the 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.

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

F23.2 Acute schizophrenia-like psychotic disorderA. The general criteria for acute and transient psychotic disorders (F23) must be met. B. The criteria for schizophrenia (F20.0–F20.3) are met, with the exception of the criterion

for duration. C. The disorder does not meet criteria B, C, and D for acute polymorphic psychotic disorder

(F23.0). D. The total duration of the disorder does not exceed one month.

F23.3 Other acute predominantly delusional psychotic disordersA. The general criteria for acute and transient psychotic disorders (F23) must be met. B. Relatively stable delusions or hallucinations are present but do not fulfill the symptomatic

criteria for schizophrenia (F20.0–F20.3). C. The disorder does not meet the criteria for acute polymorphic psychotic disorder (F23.0). D. The total duration of the disorder does not exceed three months.

F23.8 Other acute and transient psychotic disorders  Any other acute psychotic disorders that are not classifiable 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.

F23.9 Acute and transient psychotic disorder, unspecified(From World Health Organization: The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. 10th revision. Geneva: World Health Organization; 1992, with permission.)There is no specific section for acute and transient psychotic disorders in the DSM-IV-TR. As a result, patients who meet these ICD-10 criteria are classified under a number of different diagnostic categories in the DSM-IV-TR. The large majority meet the DSM-IV-TR criteria for schizophreniform disorder, brief psychotic disorder, or psychotic disorder NOS, although the actual proportion that receive each diagnosis varies considerably across studies. In the DSM-IV field trial for schizophrenia and other psychotic disorders, of all individuals meeting the ICD-10 criteria for acute and transient psychotic disorders, 42 percent also met the DSM-III-R criteria for schizophreniform disorder, 21 percent for psychotic disorder NOS, and only 13 percent for brief reactive psychosis. In contrast, in a study from Germany, 62 percent of patients with acute and transient psychotic disorders also met the DSM-IV criteria for brief psychotic disorder, 31 percent for schizophreniform disorder, and 5 percent for psychotic disorder NOS. Part of the difference in the results of the two studies may be due to differences in the criteria of DSM-III-R brief reactive psychosis and DSM-IV brief psychotic disorder.Although acute onset is described in the text of the DSM-IV-TR as an essential feature of brief psychotic disorder and, in the criteria for schizophreniform disorder, as a specifier for favorable prognosis, it is not a diagnostic criterion for any of the above DSM-IV-TR diagnoses. As a result, many patients with nonacute onset remitting psychoses also meet the criteria for these diagnoses.

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EpidemiologyAcute and transient psychotic disorders are rare, especially in industrialized settings. As a result, data on their incidence or prevalence are limited with a particular paucity of research on their occurrence in developing countries. Much of the present knowledge of these disorders has come from clinical samples, but their brief nature means that many individuals with acute and transient psychoses will never come to the attention of mental health services. Additional information about the epidemiology of these conditions is the result of international studies in developing and industrialized settings in the 1980s and 1990s. For example, a first-episode psychosis study from Nottingham, England, estimated the incidence rate of cases that remained diagnostically stable for 3 years to be 1.36 per 100,000 (0.74 per 100,000 for men and 1.99 for women). Another epidemiological study reported a ten fold higher incidence in developing countries compared with industrialized countries. These psychoses comprised 35 percent of all first contact nonaffective psychoses in developing countries compared to only 6 percent in industrialized countries. Age of onset was also younger (mid-20s) in the developing than developed (mid-20s to 30s) countries. Age of onset was even higher (30s to 50s) in a German clinical sample.The most common specific disorder in the group of ICD-10 acute and transient psychotic disorders is likely polymorphic psychotic disorder without symptoms of schizophrenia, comprising between a third to a half of all cases of acute and transient psychotic disorders, followed in frequency of occurrence by polymorphic psychotic disorder with symptoms of schizophrenia.Brief psychotic disorder is perhaps even less common than acute and transient psychotic disorders, although the two disorders overlap considerably. In a sample of over 1,000 patients with nonorganic psychotic or major affective disorder hospitalized in a German hospital, individuals with brief psychotic disorder comprised only 2.5 percent of the cases. Similarly, in the Suffolk County, New York, first-admission cohort, a primary diagnosis of brief psychotic disorder was found in only 2 percent of individuals. A study of U.S. air force recruits during basic training reported a 6-week incidence rate of 1.43 cases of DSM-III-R brief reactive psychosis per 100,000 recruits. However, this number may be an overestimate of general population rates because basic training is a particularly stressful period.Similar to acute and transient psychotic disorders, brief psychotic disorder is more common among women than men. Also similar to acute and transient psychotic disorders, age of onset of brief psychotic disorder in industrialized settings appears to be higher than in developing countries.EtiologyLittle is known about the etiology of acute and transient psychotic disorders and even less is known about brief psychotic disorder. The available evidence for acute and transient psychotic disorders points to both biological and sociocultural factors as possible causes. In one study from India, for example, a history of antecedent fever was reported in 47 percent of individuals with an acute and transient psychotic disorder. In all patients, the fever had resolved before the onset of psychotic symptoms, making it unlikely that the psychosis was the direct effect of an acute infection. Similar reports from other developing country settings and classic European psychiatric literature also note high rates of febrile illness prior to the development of acute and transient psychotic disorders, which may in part explain the higher incidence of these disorders in developing country settings where infectious diseases are common.

Information on the biochemical, physiological, and anatomical correlates of these disorders is limited, and the available data do not reveal any distinctive abnormalities that would suggest a specific etiology. Researchers from Japan have noted hypothalamic–pituitary axis abnormalities in subsets of female patients with recurrent atypical psychoses who are more likely to experience episodes at the time of menstruation and parturition; however, the relevance of these findings to other patients with acute and transient psychotic disorders is unclear. Most available data on biological correlates of these conditions are based on work involving patients with cycloid psychosis, which overlaps with ICD-10 acute transient psychotic disorders and DSM-IV-TR brief psychotic disorder. Auditory evoked potential studies in patients with cycloid psychosis recorded P300 peaks over the left hemisphere, similar to normal controls, but cycloid psychosis patients had a higher P300 amplitude than normal controls, suggesting a higher level of arousal. This finding is consistent with a regional cerebral blood flow study of cycloid psychosis that recorded increased hemispheric blood flow during the psychotic episode that was directly related to symptom severity and that returned to a normal level after remission. However, results of computed tomography (CT) scan studies and electrophysiological studies of patients with cycloid psychosis show little or no differences from findings in normal control groups.No genetic studies and few family studies of ICD-10 acute and transient psychotic disorders or brief psychotic disorders have been conducted. A study from India reported a higher risk of acute transient psychotic disorders and a lower risk of schizophrenia and mood disorders in the first-degree relatives of probands compared with schizophrenia probands. Similar results were obtained in family studies of cycloid psychosis and reactive psychosis in other settings.The high incidence rate of acute and transient psychotic disorders in developing country settings has also led to speculations about the role of sociocultural factors in the etiology of these syndromes. It has been suggested that rapid cultural change and modernization P.1610

in the developing countries expose individuals to loss of status and stress arising from role confusion, making individuals vulnerable to psychotic reactions.Acute stress (within about 2 weeks of onset of psychosis) has been noted by ICD-10 as a feature of illness in some individuals with acute and transient psychotic disorders. However, the actual proportion of patients who experience acute stress in this time frame varies considerably across studies, ranging from 10 to 69 percent. Assessment of acute stress is also complicated by lack of a clear definition of such stress in ICD-10 and the possible impact of recall bias. Furthermore, the stressors likely vary according to social and cultural context. Thus, for example, among women in developing countries, departure from or return to their parental village was a major stressor in one study, whereas among men in these settings, job-related problems were the main stressor.Similarly, the specifiers “with” or “without marked stressor(s)” are noted in the DSM-IV-TR criteria of brief psychotic disorder. However, there are few reliable data on the proportion of cases that are preceded by such stressors.Clinical lore suggests an association between pre-existing personality disorders and both acute and transient psychotic disorders and brief psychotic disorder. However, reliable assessment of premorbid personality disorders in patients with psychotic conditions is often difficult and may be affected by recall bias or residual psychotic symptoms. This point was highlighted in a Danish study of acute and transient psychotic disorders in which the majority of patients were diagnosed with a pre-existing personality disorder shortly after recovery from psychosis, whereas a year

later only a minority received such a diagnosis. Similarly, a study from Germany did not find significant differences with regard to premorbid adjustment or the “big five” personality dimensions (neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness) between patients who had recovered from an acute transient psychotic episode and normal controls.A psychodynamic formulation of brief reactive psychosis links this condition to deficient ego strength. According to this formulation, psychosis occurs in response to an intense emotionally stressful event that, in the absence of support in the environment, overwhelms the individual's ego defense mechanisms.Diagnosis and Clinical FeaturesAcute and Transient Psychotic DisordersRecognition of acute and transient psychotic disorders early in their course is difficult. In the first few weeks of the illness, there are no specific indicators that would distinguish acute and transient psychotic disorders from other nonaffective psychotic disorders with acute onset. Furthermore, even in retrospect, it is often difficult to assess the duration of a psychotic episode or distinguish spontaneous remission from remission due to antipsychotic medication treatment. Therefore, a definitive diagnosis of acute and transient psychotic disorder is often only possible retrospectively and when extensive information on the patient's past history is available.The ICD-10 provides a sequence of three “key features” to be used for diagnosing acute and transient psychotic disorders. In order of priority, these features are: (a) an acute onset (within 2 weeks); (b) presence of typical syndromes, which are the basis for the subcategorization into specific disorders; and (c) the presence of associated acute stress (within about 2 weeks of onset). 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. 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, as described above, and abrupt onset (i.e., onset within 48 hours), noting that the latter may be associated with even better outcome.With regard to the presence of a typical syndrome, ICD-10 describes two such 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. The provided case study of Mrs. C. from the ICD-10 Casebook illustrates these features:Mrs. C. is a 25-year-old Frenchwoman who was brought by ambulance to a hospital emergency department in the city where she lived. Her husband reported that she had been perfectly normal until the previous evening, when she had come home from work complaining that “strange things were going on” at her office. She had noticed that her colleagues were talking about her, that they had been quite different all of a sudden, and that they had started behaving as if they were acting a part. Mrs. C. was convinced that she had been put under surveillance and that someone was listening in on her telephone conversations. All day she had been feeling as if she

was in a dream. When she looked in the mirror, she had seemed unreal to herself. She had become increasingly anxious, incoherent, and agitated during the course of the day and had not been able to sleep at all during the night. She had spent most of the night looking out of the window. Several times she pointed at the crows in a nearby tree and told her husband, “The birds are coming.” In the morning, Mr. C. found his wife on her knees as if she were praying. She knocked her head repeatedly against the floor and talked in a rambling way, declaring that she had been entrusted with a special mission, that her boss was a criminal, there were spies everywhere, and something terrible would happen soon. All of a sudden she calmed down, smiled at her husband, and told him that she had decided to convert from Catholicism to Islam. At that stage she became quite elated, started laughing and shouting, and declared that she and her husband could pray to the same god from then on. Shortly afterward she was terrified again and accused her husband of trying to poison her.Mrs. C. was brought up in a town in the west of France, where her parents owned a small restaurant. She did well in school, went on to college, and trained as an interpreter. During her training she met her future husband, who had come to France from Algeria to train as an interpreter himself. Because both she and her husband were agnostics, the fact that they came from different religious backgrounds had never been a problem. She took a job with an administration related to the European Communities, and her husband found a position with an international interpreting company. The couple was doing well, they had bought a nice house on the outskirts of Mrs. C.'s home town, and were planning to have a child in the near future.Mrs. C.'s parents were in good health. She had a brother and two sisters. At age 18, her younger sister had had a nervous breakdown and in the ensuing years had been hospitalized repeatedly in a psychiatric hospital with a diagnosis of schizophrenia.Both Mrs. C. and her husband refrained from drinking alcohol and were strongly opposed to any kind of drugs, including prescription medicines.Mr. C. described his wife as an outgoing, sociable, and perfectly normal woman. However, he was quite worried about what was happening, all the more since she appeared to have symptoms resembling those he had observed in his sister-in-law.On admission Mrs. C. was frightened and bewildered but was oriented in time, place, and person. She was restless and constantly changed position, standing and sitting, moving about the room, shouting and screaming, weeping and laughing. She talked in a rambling way, shifting from one subject to another without any transition. Something criminal was going on at her office, she said, and she had discovered a secret plot. There were microphones hidden everywhere, she added, and “the birds are coming.” She wondered whether the physician was a real physician or a spy in disguise. She went on to speak about “my mission,” declared that Jesus had been a False prophet, that Muhammad was the real prophet, and that she would convince the world of what was right and wrong. She then began to explain that the truth was to be found in numbers. The digit “3” signifies good, she said, and the digit “8” represents evil. Suddenly she started to weep, explaining that her parents had died and that she wished to join them in heaven.During the first days of hospitalization, Mrs. C. continued presenting a rapidly changing symptomatology. Her mood frequently shifted from sadness to elation, and the content of her delusions changed from persecution to mysticism. On several occasions she came out of her room and complained that she had heard people speaking about her, even when there was no one in the vicinity. When asked to describe what she was hearing, she spoke of voices coming from the corridor. She firmly denied that the voices might emanate from within her own body.

The physical examination did not reveal any abnormality. Results of blood tests, including thyroid function, were within normal limits, as were all other special investigations such as an electroencephalogram and brain scan.Mrs. C. was treated with 30 mg of haloperidol [Haldol] during the first week, and with half this dose for the following week. After 2 weeks all of her symptoms had disappeared, and she was discharged on medication. She was seen once a week in the outpatient department for another month, during which the medication was progressively reduced and then stopped completely. Two months after the onset of the delusional episode, the patient continued to be free of symptoms.Discussion of Mrs. C.'s symptoms began abruptly (i.e., over less than 48 hours) and included unsystematized polymorphous delusions, auditory hallucinations, rapidly fluctuating changes in mood, depersonalization, and derealization. She had no clouding of consciousness, suggesting that her symptoms did not result from delirium. Her symptoms had resolved within 2 weeks of illness onset and did not recur over a several month period despite tapering of her antipsychotic, suggesting that her symptoms were not the result of schizophreniform disorder or schizophrenia. Consequently, since she had no symptoms of schizophrenia and no precipitating stressor, Mrs. C.'s diagnosis would be best described as acute polymorphic psychotic disorder, without symptoms of schizophrenia, and without associated acute stress.P.1611

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,” as the provided case study of Mr. T. from the ICD-10 Casebook illustrates:Mr. T. is a 25-year-old Moroccan. He is unemployed, having given up his studies in mechanical engineering. Mr. T.'s mother had just gotten into bed one evening when she smelled smoke coming from her son's room. She rushed in and found Mr. T. fanning the flames of a smoldering heap of clothes. She attempted to stop him, but he violently pushed her away, so she ran outside for help. Several neighbors came to her aid and overpowered Mr. T., who tried to stop them from entering the house. The neighbors managed to put out the blaze, but not before it had destroyed Mr. T.'s room and much of his mother's. Mr. T. was admitted to the psychiatric clinic after this incident. Prior to setting fire to the house, he had become increasingly violent toward his family. The current episode of difficulties started 10 days previously, when he had begun smoking hashish and seemed to lose interest in his studies. He started neglecting his appearance and became excessively preoccupied with religious duties and mystical topics. He became particularly aggressive toward his mother and began accusing her of having behaved sinfully in the past.Mr. T. came from a family of average socioeconomic status. He started school at the age of 6. He was well adjusted, and his school grades were very good. He was able to obtain a grant to continue in higher education and began to study mechanical engineering. His parents separated when he was 3 years old. At the time of Mr. T.'s admission to the clinic, his father was 62 years old but had had no contact with his son. His mother was 48 years old and had remarried 10 years before. Mr. T. was brought up by an uncle and attended boarding schools. His mother was in regular contact with him and even did some household chores for the uncle because he was not married. Mr. T. was well adjusted socially. He was outgoing and had many friends, both male

and female. He first smoked hashish during adolescence and was reported to smoke it occasionally. He was cheerful but temperamental. He was interested in sports and traveling abroad and was said to have good religious and moral standards. Although Mr. T. had had no serious physical illnesses, when he was 22 years old he had been in a traffic accident and was treated for a cut on his scalp. No fracture was noted. He had attended the university hospital's psychiatric outpatient department that same year, complaining of problems of adjustment after starting his university studies. He stopped attending the outpatient department while still being evaluated and was never given a diagnosis.Physical examination of Mr. T. showed no abnormalities. Complete blood count, liver functions, erythrocyte sedimentation rate, and blood urea nitrogen were normal, as was brain mapping. On admission the patient was overtly irritable, agitated, disheveled, and unshaven. There was no manneristic behavior, nor were there stereotypies or other catatonic behavioral features. He complained of nervous tension only. During conversation he stopped abruptly and said he was unable to remember what he was going to say.Three days after the incident, when he was asked about his attempt to burn down the house, Mr. T. said he was carrying out “holy justice” because his mother was a sinful woman. He explained that if he had succeeded in burning the house down, ‘those who have to be punished’ would have gone to hell, and their past would have been reduced to ashes. He had not been successful, he said, because a neighbor had secretly reported him to the police.Asked whether he ever heard voices, he said he sometimes heard the orders of evil spirits. However, these voices had not affected his behavior, he said, because they were not directed toward him. Rather, the reason he was able to hear the spirits was simply because he was carrying out a special holy mission. There was no evidence of cognitive impairment or of pyromania.Mr. T. first showed signs of mental distress when he was age 22. However, there is no information as to whether a disorder began developing at that time and continued insidiously. Therefore, the current illness must be regarded as a solitary episode that began 10 days before his admission to the clinic. Mr. T. has overt signs and symptoms of a thought processing disorder (blocking), delusions (e.g., carrying out holy justice), and clear hallucinatory experiences. He had a clear-cut psychotic state that fulfills the criteria for ICD-10 schizophrenia, except that the time criterion (i.e., symptoms lasting at least 1 month) is not fulfilled. The diagnosis was therefore acute schizophrenia-like psychotic disorder. According to the description of this category in ICD-10, if the schizophrenia symptoms last more than 1 month, the diagnosis should be changed to paranoid schizophrenia.It should be noted that there is concurrent hashish smoking, and the possibility of a psychotic disorder induced by psychoactive substance use is present. The information about Mr. T.'s physical state revealed neither signs of intoxication (i.e., reddening of the conjunctiva or increased heart rate) nor any abnormality in the liver tests. Nevertheless, a provision for schizophrenia-like psychotic disorder due to use of cannabinoids should be made. This diagnosis can be made only when the patient remits, with no residual symptoms of the psychotic state.P.1612

The ICD-10 section on acute and transient psychotic disorders 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 acute and transient psychotic disorder requires ruling out typical manic or depressive episodes, alcohol or drug intoxication, delirium, dementia, and mental disorders due to medical etiologies.DSM-IV-TR Brief Psychotic DisorderThe diagnosis of brief psychotic disorder is based on the presence of one or more psychotic symptoms, including delusions, hallucinations, disorganized speech, and disorganized or catatonic behavior. Although sudden onset is discussed as an essential feature of brief psychotic disorder in the text of DSM-IV-TR, it is not included in the diagnostic criteria. Similar to the ICD-10 diagnostic criteria for acute and transient psychotic disorders, DSM-IV-TR criteria for brief psychotic disorder allow for specifiers indicating presence or absence of marked stressor(s). These are defined as events that would be “markedly stressful to almost anyone in similar circumstances in the person's culture.” The manual does not specify stressors that would qualify as marked stressors, but examples reported in the literature include serious surgery or medical illness, immigration, war and other mass violence, torture, and even intensive training programs such as military training. The provided case study of the Norwegian lumberjack from the DSM-IV-TR Casebook presents an example of a young man who experienced an episode of brief psychotic disorder during military training:A Norwegian lumberman was admitted to the psychiatric ward of a hospital shortly after starting his required military duty at the age of 20. During the first week after his arrival at the military base, he thought the other recruits looked at him in a strange way. He watched the people around him in order to see whether they were out “to get” him. He heard voices calling his name several times. He became increasingly suspicious and after another week had to be admitted to the Psychiatric Department at the University of Oslo. There he was guarded, scowling, skeptical, and depressed. He gave the impression of being very shy and inhibited. His psychotic symptoms disappeared rapidly when he was treated with an antipsychotic drug. However, he had difficulties in adjusting to hospital life. Transfer to a long-term mental hospital was considered; but after 3 months, a decision was made to discharge him to his home in the forest. He was subsequently judged unfit to return to military services and was struck from the military lists.The patient, the eldest of five siblings, was the son of a farm laborer in one of the valleys of Norway. His father was an intemperate drinker who became angry and brutal when drunk. The family was very poor, and there were constant quarrels between the parents. As a child, the patient was inhibited and fearful and often ran into the woods when troubled. He had academic difficulties and barely passed elementary school.When the patient became older, he preferred to spend most of his time in the woods, where he worked as a lumberman from the age of 15. He had his own horse, lived in a log cabin, and disliked being with people. He sometimes took part in the youth dances in the village. Although never a heavy drinker, he often got into fights in the village when he had a drink or two. At the age of 16, he began to keep company with a girl 1 year his junior who sometimes kept house for him in the woods. They eventually became engaged.The Norwegian psychiatrist who provided this case made the Scandinavian diagnosis of reactive psychosis, paranoid type. The patient displays the typical features of the disorder: Reaction to extreme stress that exacerbates underlying psychological conflicts, in which the prognosis for full recovery is very good. In order to label a psychosis reactive, the psychic trauma must be considered of such significance that the psychosis would not have appeared in its absence. There must be a temporal connection between the trauma and the onset of the psychosis, and the content of the psychotic symptoms must reflect the traumatic experience. In this case, for an

extremely shy and isolated man, military service was a much more serious stressor than for an ordinary person of the same age.According to DSM-IV-TR, the differential diagnosis would be between delusional disorder and brief psychotic disorder. The nonbizarre delusion that he was being persecuted suggests delusional disorder, persecutory type; but delusional disorder requires a duration of at least 1 month, and this patient apparently recovered from his psychotic symptoms within a few weeks. Therefore, the diagnosis would be brief psychotic disorder, since this diagnosis applies to psychotic illnesses of at least 1 day but no more than 1 month, with eventual full return to premorbid functioning as in this case. The importance of the stressor could be indicated on Axis IV.Although the lumberman has had a tendency toward social isolation and difficulties with peers as an adolescent, there is insufficient information to justify a personality disorder diagnosis. Therefore, we shall simply note the presence of schizoid personality traits on Axis II.The patient was reinterviewed by hospital personnel at 4 years, 7 years, and 23 years after his admission. He has had no recurrences of any psychotic symptoms and has been fully employed since 6 months after he left the hospital. He married the young woman to whom he was engaged, and at the last follow-up, he had two grown children.After leaving the hospital, the patient worked for 2 years in a factory, and then as lumberman. For the past 20 years, he has managed a small business, which he has run well. He has been happy at work and in his family life. He has made an effort to overcome his tendency toward isolation and has several friends. Among other duties, he has been chairman of a sheep-rearing association in the country. He is well liked in the village.The patient believes that his natural tendency is to be socially isolated and that his disorder was connected with the fact that in the military situation, he was forced to deal with other people.Although in the case of the lumberman, the temporal order of stressor and psychotic episode was clear, it is not always easy to determine whether a specific stressor was a precipitant or consequence of the illness. Other sources of information, such as information from spouse or friends about the level of functioning before the onset of episode, as well as history of response to similar stressors in the past, may be helpful in determining the order of events. The DSM-IV-TR criteria for brief psychotic disorder also allow for a “with postpartum onset” specifier for episodes starting within 4 weeks of giving birth.Although “emotional turmoil” and “confusion” are not among the diagnostic criteria for brief psychotic disorder, they are noted as typical experiences in the text of DSM-IV-TR. The text also notes rapid shifts from one intense affect to another in some individuals. A study of brief reactive psychosis from Swaziland, South Africa, also notes that the clinical presentation in that setting is characterized more by volatile affect and behavior, altered states of consciousness, and dissociative experiences than by clear-cut psychotic symptoms.DSM-IV-TR diagnosis of brief psychotic disorder requires ruling out typical mood disorders, schizoaffective disorder, schizophrenia, P.1613

substance-induced disorder, and disorders that are due a general medical condition.Differential DiagnosisA definitive diagnosis of acute and transient psychotic disorders or brief psychotic disorder 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. Therefore, during the first few days or weeks of an episode, the diagnosis is usually provisional.Many aspects of the differential diagnosis of acute and transient psychotic disorders relate to symptom duration. A provisional ICD-10 diagnosis of acute polymorphic psychotic disorder without symptoms of schizophrenia would be changed to a diagnosis of ICD-10 persistent delusional disorder or other nonorganic psychotic disorder if the illness lasts more than 3 months. Similarly, a diagnosis of acute polymorphic psychotic disorder with symptoms of schizophrenia would be changed to ICD-10 schizophrenia if the episode lasts more than 1 month (note that the minimum duration criterion for schizophrenia in ICD-10 is different from DSM-IV-TR).Similar considerations apply to DSM-IV-TR brief psychotic disorder, in which the duration of an episode is defined as less than 1 month. If the duration of illness (from prodrome through recovery) exceeds 1 month, the diagnosis would need to be changed to schizophreniform disorder, schizophrenia, delusional disorder, or psychotic disorder NOS, depending on other symptoms and the duration of the illness. Remission of psychotic symptoms within 1 month as a result of successful treatment also makes it difficult to distinguish brief psychotic disorder 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 brief psychotic disorder. In many cases, however, only the long-term course of illness can resolve diagnostic uncertainties.Perhaps the most critical differential diagnostic issue for both acute and transient psychotic disorders and brief psychotic disorder is to rule out delirium, dementia, psychotic disorder due to medical illness, and drug or alcohol intoxication or withdrawal. Careful physical and laboratory examination is often indicated. Toxicological screens and imaging studies may also be necessary. A positive drug or alcohol screen does not necessarily rule out a diagnosis of acute and transient psychotic disorder or brief psychotic disorder. Some patients with acute and transient psychotic disorder or brief psychotic disorder may use substances in an attempt to ameliorate their symptoms. The temporal relationship between onset of psychosis and the pattern of substance abuse may be helpful in differentiating a substance-induced psychotic episode from a nonsubstance-induced one. Symptoms that persist for many days after all traces of the substance are eliminated from blood and urine would support a diagnosis of acute and transient psychotic disorder or brief psychotic disorder.Both acute and transient psychotic disorder and brief psychotic disorder may be associated with confusion and perplexity, making it difficult to distinguish these disorders from delirium or medical causes of psychosis. Diurnal variation of consciousness, which is a characteristic of delirium, may also be confused with variable “polymorphic” psychotic symptoms seen in the acute and transient psychotic disorders. However, compared with delirium, changes in consciousness in acute and transient psychotic disorders are generally less severe and less persistent. Furthermore, a medical cause of delirium can often be identified through history, physical examination, laboratory tests, or imaging studies.Acute psychotic episodes have been reported in a number of medical conditions 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 brief psychotic disorder and of acute and transient psychotic disorders, variability of symptoms, and the presence of mood symptoms sometimes make it difficult to

differentiate these diagnoses from mood disorders. Presence of a full mood syndrome that meets the criteria for a manic or a depressive episode excludes diagnosis of brief psychotic disorder in DSM-IV-TR and excludes diagnosis of acute and transient psychotic disorders in ICD-10.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 brief psychotic disorder may be warranted.Finally, a number 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. The issue of the nosological relationship of these conditions and acute and transient psychotic disorders or brief psychotic disorder remains unresolved.Course and PrognosisAcute and transient psychotic disorders have a favorable early course by definition: Full remission within 1 to 3 months is a diagnostic criterion in ICD-10. Although there are few first-admission studies that allow for reliable assessment of course and outcome, the available evidence indicates that most of the recovered patients remain well in ensuing years, and even among those who experience further episodes, these episodes are transient and the outcome is generally favorable. Recurrence rates of 39 to 47 percent have been reported in first-admission samples followed for 3 to 4 years, but full recovery is common. Only about 6 to 18 percent 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. A 12-year follow-up study from India also reported favorable long-term outcome. The long-term course and outcome of acute and transient psychotic disorders in industrialized settings have not been studied.A number of studies from various countries have assessed the diagnostic stability of the ICD-10 acute and transient psychotic disorders. In studies from India and Denmark, 27 to 48 percent of patients had a different diagnosis 1 to 3 years after their index episodes. Some studies have found that diagnostic stability was associated with the patients' clinical features. Thus, a study from Germany found differences between the acute schizophrenia-like psychotic disorder subtype, of whom only 30 percent maintained their original diagnosis at follow-up, and other subtypes of acute and transient psychotic disorders, of whom 67 percent maintained their original diagnosis. Similarly, in a retrospective long-term study from Japan, 63 percent of patients with acute polymorphic psychotic disorder without symptoms of schizophrenia maintained their original diagnosis for an average follow-up period of 20 years. The diagnostic stability of an acute and transient psychotic disorder may also vary depending on the patient's gender. In a British study, the diagnoses of acute and transient psychotic disorders remained unchanged in 73 percent of women, but P.1614

only 14 percent of men at the 3-year follow-up. Most changes were into the schizophrenia or mood disorder categories.Brief psychotic disorder also has a benign early course by definition: Full remission within 1 month is a DSM-IV-TR criterion for this diagnosis. Some individuals, however, experience relapses. In a study of consecutive psychotic admissions in Germany, 83 percent of the patients initially diagnosed with brief psychotic disorder maintained this diagnosis when re-evaluated 2

years later, and 70 percent experienced relapses during the 2-year follow-up. Because changes in diagnosis are more likely to occur in the early course of psychotic conditions and the German study used cross-sectional diagnosis at the time of follow-up, these rates of diagnostic change and of relapse would likely be higher than in a first-admission or first-episode sample. Nevertheless, the social functioning of these individuals was much better than individuals with schizophrenia; over 90 percent were living independently and over half were employed.Several other studies have also examined the stability of the brief psychotic disorder diagnosis. In a prospective epidemiologic study of a first-admission cohort from Suffolk County, New York, only 27 percent of those receiving a consensus research diagnosis of brief psychotic disorder at 6-month follow-up maintained this diagnosis when re-evaluated at the 24-month follow-up, with 9 percent rediagnosed with schizophreniform disorder and 18 percent with psychotic disorder NOS. The remainder were rediagnosed with mood disorders (27 percent), schizophrenia (9 percent), or other conditions (9 percent). A Brazilian study of first-episode patients admitted to an emergency psychiatric unit also found that only about 23 percent of patients with a clinical discharge diagnosis of brief psychotic disorder maintained this diagnosis 1 year later. These findings suggest that the overall prognosis for brief psychotic disorder is likely to vary with diagnostic stability in an individual patient.