Augusto Castagnini

Incidence and diagnostic stability of ICD-10 acute and transient psychotic disorders

OBJECTIVE The 10th Revision of the International Classification of Diseases (ICD-10) introduced a new diagnostic category, F23 acute and transient psychotic disorders (ATPD) to embrace clinical concepts such as the French bouffée délirante, Kleist and Leonhards cycloid psychoses, and the Scandinavian reactive and schizophreniform psychoses. The relative rarity of these disorders and insufficient follow-up studies with adequate numbers of patients makes ATPD classification as uncertain as their validity. The aim of this study was to evaluate incidence and validity of ATPD in terms of diagnostic stability. METHOD A 6-year analysis of readmission patterns of all subjects listed in the Danish psychiatric central register as having been first-ever admitted to hospital or treated in outpatient services with a diagnosis of ATPD from January 1 to December 31, 1996, was conducted. RESULTS The incidence of ATPD was 9.6 per 100 000 population, with a higher rate of females than males (9.8 vs 9.4). Incidence rates by age group were higher for males than for females, with a marked reversal of this pattern above 50 years. This contrasted with incidence of schizophrenia that was almost twice as high in males as in females, particularly in the 20-29 year age group. Of 416 cases with a first-admission diagnosis of ATPD, an increasing number tended to change on subsequent admissions, nearly half to another F2 category schizophrenia and related disorders. The overall stability rate reached only 39%. CONCLUSIONS Although demographic differences from schizophrenia are topics that deserve further research, poor diagnostic stability argues against attempts to separate ATPD from borderland disorders.

Long-term stability of acute and transient psychotic disorders.

Objective: To examine the temporal stability of the category ‘acute and transient psychotic disorders’ (ATPDs), ICD-10 Classification of Mental and Behavioural Disorders, including subtypes characterised by polymorphic, schizophrenic and predominantly delusional features. Method: We checked the readmission patterns of all patients aged 15–64 years (n = 5426), whether admitted to hospital or treated as outpatients, who were enrolled for the first time in the Danish Psychiatric Register with a diagnosis of ATPDs between 1995 and 2008. Results: An increasing number of cases with ATPDs changed diagnosis in subsequent admissions after 1, 2 and 5 years, mainly either to schizophrenia and related disorders or affective disorders. In their last admission, on average after 7.3 years, there were 2429 patients listed with ATPDs, accounting for an overall stability of 44.8%. Females were less likely than males to develop another diagnosis. Among the ATPD subtypes, polymorphic psychotic disorder without schizophrenic symptoms had a higher stability than those featuring schizophrenic or predominantly delusional features. Conclusions: The low diagnostic stability of ATPDs reflects the lack of clearly defining features and argues against their validity as a distinct category.

Wimmer’s concept of psychogenic psychosis revisited

In the early twentieth century the Danish psychiatrist August Wimmer (1872—1937) developed the concept of psychogenic psychosis (PP) as a category of mental disorders separate from schizophrenia and manic depression. It subsumed a variety of clinical conditions with affective, confusional and paranoid features typically triggered by a psychical trauma. Wimmer’s work has established itself as one of the classic texts in Scandinavian psychiatry but, for linguistic reasons, long remained almost unknown in other European countries. Translated into English in 2003, it is now available for historical and psychopathological analyses. This paper describes the original meaning of PP and sets it in context, then discusses the implications arising from the usage of the diagnostic categories introduced to replace PP in modern international classifications.

The Relationship of Reactive Psychosis and ICD-10 Acute and Transient Psychotic Disorders: Evidence from a Case Register-Based Comparison

Background: ICD-10 introduced a new diagnostic category, F23 ‘acute and transient psychotic disorders’ (ATPD), to embrace clinical concepts such as bouffée délirante, cycloid psychosis, psychogenic (reactive) psychosis and schizophreniform psychosis. The purpose of this study was to examine the relationship between the concept of reactive psychosis (RP), equivalent to the ICD-8 298 category of ‘other psychoses’, and ATPD. Sampling and Method: Since January 1, 1994, ICD-10 has replaced ICD-8 as official classification in Denmark. Patients given an ICD-8 298 diagnosis on their last admission in 1992–1993 were identified from the Danish Psychiatric Central Register, and the ICD-8 diagnoses assigned were compared with their ICD-10 diagnoses when readmitted in 1994–1995. Results: Diagnosis of RP was recorded in 19.2% of patients with functional psychoses in 1992–1993, whereas ATPD overall prevalence accounted for 8.7% of those with non-organic psychotic and affective disorders in 1994–1995. Thirty-eight per cent of patients with an ICD-8 298 diagnosis were readmitted during the years 1994–1995. Schizophrenia and related disorders (F2) and affective disorders (F3) accounted for three quarters of ICD-10 diagnoses. The most frequently used ATPD subcategories were F23.3 ‘other acute delusional psychotic disorders’, F23.0 ‘acute polymorphic psychotic disorder without symptoms of schizophrenia’ and F23.9 ‘acute and transient psychotic disorder unspecified’. A significant majority were female and associated acute stress was recorded only in 5.3% of cases. Conclusions: ICD-8 298 register diagnosis of RP showed little empirical continuity to ATPD and conformed more to F23.3 acute delusional disorder among ATPD subtypes.

Short-term course and outcome of acute and transient psychotic disorders: Differences from other types of psychosis with acute onset.

Background: The category of ‘acute and transient psychotic disorders’ (ATPDs) appeared in the ICD-10 Classification of Mental and Behavioural Disorders (ICD-10), but its distinctive features remain uncertain. Aim: To examine the course and outcome of ATPDs, pointing out differences from other types of psychosis. Methods: A one-year follow-up investigation of patients enrolled at the former World Health Organization (WHO) Centre for Research and Training in Mental Health in Aarhus (Denmark) for the WHO collaborative study on acute psychoses. Results: Of 91 patients aged 15–60 years presenting with acute psychosis, 47 (51.6%) were diagnosed with ATPD, and it occurred more commonly in females; yet, the other acute psychoses featured mainly mood disorders and affected equally both genders. After 1 year, the ATPD diagnosis did not change in 28 cases (59.6%); the remaining developed either affective psychoses (27.7%), or schizophrenia and schizoaffective disorder (12.8%). Nearly, all patients with unchanged diagnosis of ATPD enjoyed full recovery, while those with other types of acute psychosis had significantly higher rates of recurrence or incomplete remission. Duration of illness within 4 weeks and stressful events in the 3 months before symptom onset predicted 1-year favourable clinical outcome for acute psychoses. Conclusion: Although ATPDs fared better over the short-term than other acute psychoses, their diagnostic stability is relatively low.

The Relationship of Acute Transient Psychoses and Schizophrenia

This chapter deals with the historical, clinical and nosographic aspects of the acute transient psychoses and discusses the implications arising from the introduction in current classifications of diagnostic categories such as ICD-10 “Acute and transient psychotic disorder” (ATPD) and DSM-IV-TR “Brief psychotic disorder”. The first part focuses on earlier concepts of European psychiatry such as bouffee delirante, cycloid psychosis and the reactive and schizophreniform psychoses, and examines the process whereby they were incorporated into ATPD. The second part reports empirical data on ATPD pointing out differences from schizophrenia in terms of epidemiology, clinical features, course and outcome.

Incidencia y estabilidad diagnóstica de los trastornos psicóticos agudos y transitorios CIE-10

Objetivo La decima revision de la Clasificacion Internacional de Enfermedades (CIE-10) introdujo una nueva categoria diagnostica –F23: trastornos psicoticos agudos y transitorios (TPAT)– para abarcar conceptos clinicos, como el termino frances bouffe delirante , las psicosis cicloides descritas por Kleist y Leonhard y las psicosis reactivas y esquizofreniformes descritas por autores de los paises escandinavos. La relativa infrecuencia de estos procesos y el numero insuficiente de estudios de seguimiento con un numero adecuado de pacientes hacen que la clasificacion de los TPAT sea tan incierta como su validez. El objetivo del presente estudio es evaluar la incidencia y la validez de esta entidad respecto de la estabilidad diagnostica. Metodo Desde el 1 de enero al 31 de diciembre de 1996, se efectuo un analisis de 6 anos de los patrones de reingreso de todos los individuos citados en el registro central psiquiatrico danes como haber sido ingresados por primera vez en el hospital o tratados en los servicios ambulatorios con un diagnostico de TPAT. Resultados La incidencia de TPAT fue de 9,6/100.000 habitantes, con una tasa de mujeres mayor que la de varones (9,8 frente a 9,4). Las tasas de incidencia por grupo de edad fueron mayores entre los varones que entre las mujeres, con una inversion destacada de este patron en los mayores de 50 anos. Esto contrasto con la incidencia de esquizofrenia, que fue casi el doble en varones que en mujeres, en particular en el grupo de 20-29 anos de edad. De los 416 casos con un diagnostico del primer ingreso de TPAT, en un numero cada vez mayor se observo una tendencia a un cambio en los ingresos posteriores, y casi la mitad se clasificaron en otra categoria F2 de esquizofrenia y trastornos relacionados. La tasa de estabilidad general solo alcanzo el 39%. Conclusiones Aunque las diferencias demograficas de la esquizofrenia merecen estudios adicionales, la falta de estabilidad diagnostica va en contra de las tentativas de separar el TPAT de los trastornos limite.