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Contents lists available at ScienceDirect

European Psychiatry
journal homepage: http://www.europsy-journal.com

1
2 Review

3 Diagnostic validity of ICD-10 acute and transient psychotic disorders

4 and DSM-5 brief psychotic disorder
5 Q1 A. Castagnini a,*, P. Fusar-Poli b
6 a
School of Child Neuropsychiatry, University of Modena and Reggio Emilia, Modena, Italy
7 b
King’s College London, Institute of Psychiatry, and OASIS Service, South London and the Maudsley NHS Foundation Trust, London, UK

A R T I C L E I N F O A B S T R A C T

Article history: Background: Short-lived psychotic disorders are currently classified under ‘‘acute and transient psychotic
Received 17 March 2017 disorders’’ (ATPDs) in ICD-10, and ‘‘brief psychotic disorder’’ (BPD) in DSM-5. This study’s aim is to
Received in revised form 17 May 2017 review the literature and address the validity of ATPDs and BPD.
Accepted 22 May 2017
Method: Papers published between January 1993 and December 2016 were identified through searches
Available online xxx
in Web of Science. Reference lists in the located papers provided further sources.
Results: A total of 295 articles were found and 100 were selected for inclusion in the review. There were
Keywords:
only a few studies about the epidemiology, vulnerability factors, neurobiological correlates and
Acute transient psychosis
Brief psychotic disorder
treatment of these disorders, particularly BPD was seldom a specific topic of investigation. Existing
Classification studies suggest that short-lived psychotic disorders are rare conditions and more often affect women in
Diagnosis early to middle adulthood. They also are neither associated with premorbid dysfunctions nor
Nosology characteristic family predisposition, while there seems to be greater evidence of environmental factors
particularly in developing countries and migrant populations. Follow-up studies report a favourable
clinical and functional outcome, but case identification has proved difficult owing to high rates of
transition mainly either to schizophrenia or, to a lesser extent, affective disorders over the short- and
longer-terms.
Conclusions: Although the lack of neurobiological findings and little predictive power argue against the
validity of the above diagnostic categories, it is important that they are kept apart from longer-lasting
psychotic disorders both for clinical practice and research. Close overlap between ATPDs and BPD could
enhance the understanding of these conditions.
C 2017 Published by Elsevier Masson SAS.

8
9 1. Introduction by: acute onset within 2 weeks; polymorphic, schizophrenic or 23
predominantly delusional syndromes; and association (or not) with 24
10 Although the late 19th century Kraepelinian [1] dichotomy of stressful events (Table 1). Acute polymorphic psychotic disorder 25
11 dementia praecox, (subsequently to be renamed schizophrenia), (APPD) refers to earlier diagnostic concepts such as bouffée délirante 26
12 and manic-depressive insanity remains central to current psychi- and cycloid psychosis [5–7], featuring varied delusions, hallucina- 27
13 atric nosography, its inability to encompass all types of psychosis tions, perceptual changes, perplexity and emotional turmoil shifting 28
14 has made for great unclarity in classification of intermediate daily or even faster, and can include schizophrenic symptoms. 29
15 categories with adverse effects on psychiatric practice and Complete remission within 1 or 3 months sets the ATPD subtypes 30
16 research, particularly for short-lived psychotic disorders that do with schizophrenic symptoms apart from schizophrenia, as the ICD- 31
17 not display prominent affective features [2]. 10 diagnosis of schizophrenia requires at least 1 month’s duration, 32
18 Framed in the wake of the WHO study on acute psychoses [3], and the subtypes with polymorphic or delusional features from 33
19 the category of ‘‘acute and transient psychotic disorders’’ (ATPDs) persistent delusional disorder, which lasts longer than 3 months. 34
20 was introduced in the ICD-10 Classification of Mental and The Diagnostic and Statistical Manual of Mental Disorders (DSM) 35
21 Behavioural Disorders (ICD-10) within the group of ‘‘schizophrenia, of American Psychiatric Association has, since its fourth edition [8], 36
22 schizotypal and delusional disorders’’ [4]. ATPDs were characterized listed ‘‘brief psychotic disorder’’ (BPD). Diagnostic criteria have 37
remained unchanged in DSM-5 and involved the sudden onset of 38
florid psychotic symptoms such as delusions, hallucinations, 39
* Corresponding author. disorganised speech, and grossly disorganised or catatonic 40
E-mail address: [email protected] (A. Castagnini). behaviour lasting at least 1 day but less than 1 month [9]. It is 41

http://dx.doi.org/10.1016/j.eurpsy.2017.05.028
0924-9338/ C 2017 Published by Elsevier Masson SAS.

Please cite this article in press as: Castagnini A, Fusar-Poli P. Diagnostic validity of ICD-10 acute and transient psychotic disorders and
DSM-5 brief psychotic disorder. European Psychiatry (2017), http://dx.doi.org/10.1016/j.eurpsy.2017.05.028
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Table 1
ICD-10 F23 Acute and transient psychotic disorders (ATPDs) and DSM-5 298.9 Brief psychotic disorder (BPD).

ICD-10 ATPDs DSM-5 BPD

b
Onset Acute onset within 2 weeks Not specified
Symptoms Polymorphic, schizophrenic and Delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behaviour
predominantly delusionala
Duration Shorter than 1 or 3 months One day to less than 1 month with full return to premorbid functioning
Specify if with Acute stress within 2 weeks Marked stressor or onset within 4 weeks postpartum
Exclusion Substance-induced psychosis, Affective disorder, substance-induced psychosis, psychosis due to medical
organic disorders, manic and conditions, psychotic disorder NOS
depressive disorder
a
ATPD category comprises six subtypes: ‘acute polymorphic psychotic disorder’ (F23.0), which can include schizophrenic symptoms (F23.1); ‘acute schizophrenia-like
psychotic disorder’ (F23.2); ‘acute predominantly delusional psychotic disorder’ (F23.3); and ‘other’ and ‘unspecified’ acute and transient psychotic disorders (F23.8-9).
b
Acute onset is defined as a change from a state without psychotic features to a clearly psychotic state within 2 weeks or less. It is also possible to specify ‘‘abrupt onset
within 48 hours’’.

42 also possible to specify if BPD follows marked stressors or arises in 3.1. Antecedent validators 87
43 the postpartum period. Moreover, the criteria for ATPDs and BPD
44 exclude substance-induced psychosis, organic psychosis, manic 3.1.1. Demographic factors of ATPDs 88
45 and depressive disorder, however comparative studies revealed The annual incidence of ATPDs ranges from 3.9 in the UK to 89
46 that the two diagnostic categories overlap only in part owing to 9.6 in Denmark per 100,000 population, and the 2-year and 3-year 90
47 differences in onset, duration and symptomatology [10–15]. rates for those with unchanged diagnosis are 6.7 and 1.4, 91
48 Although it is more than 20 years since ATPDs and BPD have respectively [19–21] (Table 2). ATPDs seem to affect more 92
49 appeared in official psychiatric classifications, their distinctive frequently women or both genders almost equally [21–24], and 93
50 features remain uncertain [15,16]. The aim of this paper is to the mean age of onset is intermediate between schizophrenia and 94
51 review the literature and address the validity of ATPDs and BPD, bipolar disorder [21]. Male incidence picks early in the mid-20s, 95
52 then to discuss implications for future classification, clinical yet the highest rates for women occur ten years later and are 96
53 practice and research. greater than those for men over 40 years [21,24]. 97
There are also differences in age and sex distribution across the 98
54 2. Methods ATPD subtypes: APPD is more common in women and arises later 99
than both subtypes with acute schizophrenic features, which 100
55 We conducted a two-step literature search following the predominate in young males [25]. No gender difference was found 101
56 guidelines for systematic reviews and meta-analysis provided in acute predominantly delusional disorder, which has a later onset 102
57 by the PRISMA statement [17]. Web of Science (WOS) searches, than any ATPD subtype [21]. 103
58 including WOS collection and Medline, were made using the Reports on ATPD prevalence are also varied ranging from 5.8% 104
59 terms: acute polymorphic psychosis OR acute polymorphic to 19.0% [19,20,22,23,26], with greater rates frequently observed in 105
60 psychotic disorder OR non-affective acute remitting psychosis low and middle-income countries, where these conditions are 106
61 OR acute transient psychosis OR acute transient psychotic disorder reported to have an earlier age of onset than in high-income ones 107
62 OR ‘‘acute brief psychosis’’ OR ‘‘acute brief psychoses’’ OR ‘‘brief [27–31]. 108
63 psychotic disorder’’ OR ‘‘brief psychotic disorders’’. The search Further evidence suggests that ATPDs have an increased 109
64 included works in English, French and German, published in peer- mortality both from natural and unnatural causes [32,33]. The 110
65 reviewed journals between 1st January 1993 and 31 December mortality risk of ATPDs is nearly twice as high in males, and similar 111
66 2016. Reference lists in the located papers provided further to that for schizophrenia, while there seems to be a small but 112
67 sources. Selection of relevant papers was restricted to studies significant higher overall and natural cause mortality than bipolar 113
68 including at least 10 cases, and diagnosis made using criteria for disorder. Suicide is the major cause of premature death and 114
69 ICD-10 F23.0-9 ATPDs and DSM-IV/DSM-5 289.8 BPD. In addition, accounts for a quarter of excess mortality [33]. Two reports on 115
70 follow-up studies required a minimal duration of 12 months, and suicidal behaviour estimated rates between 36% and 55%, with the 116
71 clearly defined measures of outcome and/or diagnostic stability. highest risk during the acute phase characterised typically by 117
72 Where publications reported overlapping data the most informa- rapidly changing and variable delusions ad hallucinations, agita- 118
73 tive or recent were selected. tion and mood instability [34,35]. In addition, late-onset ATPDs 119
74 To assess the validity of ATPDs and BPD, the available evidence (over 60 years) are associated with a high risk not only of mortality 120
75 was reviewed according to Kendler [18] in 3 main classes of but also of dementia; in these cases, a differential diagnosis from 121
76 potential validators: delirium proves often difficult [36]. 122

78  antecedent validators (i.e. demographic features, family aggre- 3.1.2. Predisposing factors of ATPDs 123
79 gation, premorbid and precipitating factors); Das et al. [37] found that the risk of ATPDs was 3 times higher in 124
80  concurrent validators (biological markers, psychological tests, first-degree relatives of patients with ATPDs than in family 125
81 genetics, symptom measures); members of schizophrenic patients, while the risk of schizophrenia 126
82  prognostic validators (diagnostic stability, course, outcome and was significantly increased in the family of patients with 127
83 response to treatment). schizophrenia. A later study reported that ATPD patients with a 128
family history of mental disorder experienced fewer life events 129
before illness onset than those without family psychiatric 130
84 3. Results antecedents; in keeping with the stress-vulnerability model, 131
family predisposition would produce its effect by increasing 132
85 A total of 295 papers were identified and 100 were selected for emotional reactivity, which renders subjects less likely to cope 133
86 inclusion in the review (Fig. 1). with adverse events [38]. 134

Please cite this article in press as: Castagnini A, Fusar-Poli P. Diagnostic validity of ICD-10 acute and transient psychotic disorders and
DSM-5 brief psychotic disorder. European Psychiatry (2017), http://dx.doi.org/10.1016/j.eurpsy.2017.05.028
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Articles identified through Additional records identified

search in WOS through other sources
(n = 264) (n = 31)

Records aer duplicates removed

(n = 295)

Abstract screened Records excluded

(n = 295) (n = 127)

Full-text arcles assessed Full-text arcles excluded

for eligibility (n = 68 )
(n = 168) 32: case report/<10
cases or shorter than
12 months
16: incomplete or
overlapping data
Studies included in the
20: reviews
review
(n = 100)

Fig. 1. PRISMA flow diagram showing the number of papers identified, those selected and excluded, and the reason for exclusion.

135 Jørgensen et al. [39] found that almost two-thirds of their cases more common in migrant populations [48,49]. Lau et al. [50] 168
136 with ATPDs had an additional diagnosis of personality disorder; reported that the risk of ATPDs in Hong Kong is two times higher in 169
137 this rate dropped one year later probably because personality foreign domestic workers; homesickness and marital problems 170
138 changes resulted either from psychotic decompensation or treatment were the most frequent stressful events. These findings lend 171
139 as most patients recovered and/or discontinued medication. support to reports from European countries showing that first- and 172
140 Marneros et al. [23] observed higher psychiatric morbidity in second-generation immigrants have a greater risk of ATPDs than 173
141 family members of patients with ATPDs than in relatives of healthy native populations [51]. 174
142 controls, but no significantly raised risk of psychotic disorder. Further evidence indicates that stressful events are more often 175
143 ATPD patients were also more likely to have a better premorbid associated with ATPDs than schizophrenia, persistent delusional 176
144 social functioning and to exhibit lower neuroticism, higher disorder, schizoaffective disorder or manic disorder [23,44,52–54]. 177
145 extroversion and conscientiousness than patients with schizo- Examination of 1904–1905 Welsh religious revival revealed a 178
146 phrenia and/or schizoaffective disorder [40]. In addition, there significant increase in hospital admissions with brief polymorphic 179
147 seems to be a close relationship between speed of onset and psychotic symptoms, pointing out that these conditions are part- 180
148 duration of untreated psychosis (DUP), and short DUP would be caused by environmental factors [55]. 181
149 consistent with diagnosis of ATPDs [41].
150 Furthermore, a large scale population-based family study [42] 3.1.4. Demographic and vulnerability factors for BPD 182
151 reported no specific predisposition, as the risk of ATPDs was No epidemiological study has yet been conducted; available 183
152 increased if patients had not only first-degree relatives affected data suggest that BPD is more common in women and accounts for 184
153 with ATPDs, but also with bipolar disorder, and particularly with 2.0–7.0% of individuals with a first-episode of psychosis [56–60]. A 185
154 schizophrenia; yet the risk of schizophrenia and bipolar disorder Finnish study estimated the lifetime prevalence of BPD at 0.05% 186
155 was markedly high if patients with schizophrenia and bipolar [61]. It was also found that BPD is not associated with family 187
156 disorder have family members with the same condition. As regards history of schizophrenia, and more often is triggered by emotional 188
157 the ATPD subtypes, the risk of APPD was significantly high in and sociocultural factors than schizophrenia and/or schizophre- 189
158 patients having first-degree relatives with either ATPDs or niform disorder [62]. Furthermore, patients with BPD exhibit fewer 190
159 schizophrenia; schizophrenia in family members had the greatest schizoid and schizotypal traits, and enjoy better social and 191
160 effect on those subtypes featuring schizophrenia-like symptoms; occupational functioning than those with schizophrenia [63]. 192
161 and bipolar disorder did not increase significantly the risk for any
162 ATPD subtype. 3.2. Concurrent validators 193

163 3.1.3. Precipitating factors of ATPDs 3.2.1. Symptom measures of ATPDs 194
164 Social and cultural factors are more likely to be associated with Despite variations in symptom profile, ATPDs are more likely 195
165 ATPDs in low- and middle-income countries [27,38,43,44] than in to be characterised by acute onset of fleeting polymorphic 196
166 high-income ones, where only a relatively small number of cases features such as delusions and hallucinations, mood changes, 197
167 are triggered by life events [10,19,23,45–47]. ATPDs seem also anxiety, agitation, insomnia and fewer negative symptoms than 198

Please cite this article in press as: Castagnini A, Fusar-Poli P. Diagnostic validity of ICD-10 acute and transient psychotic disorders and
DSM-5 brief psychotic disorder. European Psychiatry (2017), http://dx.doi.org/10.1016/j.eurpsy.2017.05.028
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Table 2
Antecedent and concurrent validators for ICD-10 acute and transient psychotic disorders (ATPDs).

Study Demographic features

Singh et al. [19] 32/162 cases of FEP had ATPDs (19%); incidence 3.9/100,000. After 3 years, this rate decreased to 1.4 with a reversal of sex-rate ratio
for women
Castagnini et al. [20] ATPD incidence 9.6/100,000 in people aged over 15 years based on DPCR data; mean age significantly later in women than men
(46.2 vs. 37.8 years)
Castagnini and Foldager [21] In- and out-patients aged 15–64 years enrolled in the DPCR with ATPDs (n = 3350), SZ (n = 4576), and BD (n = 3200) in 1995–2008;
ATPD incidence 6.7/100,000, mean age intermediate between SZ and BD
Queirazza et al. [24] Consecutive admissions (n = 2923) from the Scottish Morbidity Record in 1997–2010. ATPD incidence 4.1/100,000, significantly
greater in men than women (4.6 vs. 3.6); mean age at onset higher in women than men (41.8 vs. 33.8 years)
Esan and Fawole [30] First admissions with ATPDs (n = 124) in Nigeria; overall mean age 29.5 years; no sex difference
Mehta et al. [31] Hospital admissions with ATPDs (n = 185) in India; no significant sex difference; mean age 27.0 years; most cases were married,
unemployed and/or living in rural areas
Castagnini and Bertelsen [32] 87/503 (17.3%) patients with ATPDs had died (70% aged over 65 years) over 6-years, accounting for excess morality both from
natural (SMR 2.9) and unnatural (SMR 9.2) causes
Castagnini et al. [33] In 1995–2008, ATPD mortality in 15–64 year olds (232/4157; 5.6%) from DPCR significantly raised from natural (SMR 3.9) and
unnatural causes (SMR 7.3); particularly suicide (SMR 14.7). Mortality risk of ATPDs (SMR 4.7) was twice as high in men and
similarly high to SZ
Kørner et al. [36] Late-onset ATPDs (over 60 years) associated with a high risk of mortality and dementia (RR 8.1)

Family predisposition and premorbid functioning

Marneros et al. [23] No significantly raised risk of psychotic disorder in family members of ATPD patients (n = 42) compared with healthy controls
Das et al. [37] The risk of ATPDs was 3 times higher and that of SZ lower in family members of ATPD patients (n = 40) than in the family of patients
with SZ
Das et al. [38] A third of ATPD patients (13/44) was associated with acute stress; most cases had a family history of mental disorder and
experienced fewer life events than those without family psychiatric antecedents
Jørgensen et al. [39] Nearly two-thirds of ATPD patients (n = 51) had a diagnosis of personality disorder; this rate dropped one year later probably in
consequence of symptom remission and/or discontinuing medication
Pillmann et al. [40] ATPDs patients (n = 42) did not differ from healthy controls on personality traits using the 5-NEO Factor Inventory, but have higher
neuroticism, lower extroversion and conscientiousness than those with SZ and/or schizoaffective disorder
Castagnini et al. [42] Genetic epidemiological study based on DPCR data comparing ATPDs (n = 2537), SZ (n = 10,639), and BD (n = 5292); family
psychiatric morbidity effects a smaller increase of risk for ATPDs (RR 1.6) than SZ (RR 2.8) and BD (RR 3.7)

Precipitating factors/social adversities

Krahl and Hashim [48] ATPDs more frequently diagnosed in southeast Asian migrant workers in Malaysia than in native populations
Shaltout et al. [49] ATPDs were preponderant among young foreign workers, particularly males, in hospital admissions from Qatar
Lau et al. [50] Foreign domestic workers in Hong Kong have a risk of ATPDs twice as high as local populations
Alexandre and Ribeiro [51] ATPDs more common in first- and second-generation black immigrants from African Portuguese speaking countries; most were
males and had an earlier illness onset than indigenous population
Linden et al. [55] Historical report showing significantly increased admission rates for short-lived psychotic disorders linked to 1904–1905 Welsh
religious revival

Symptom measures

Marneros et al. [23] Comparative study of ATPDs (n = 42), SZ, and schizoaffective disorder. ATPDs involved more often changing and varied delusions,
anxiety and mood instability
Pillmann et al. [40] ATPDs (n = 41) display varied and fleeting symptoms and fared significantly better delusional disorder
Esam and Fawole [52] Cross-sectional study of hospital admissions with ATPDs (n = 124) and SZ in Nigeria; anxiety and excitement more common in
ATPDs
Jäger et al. [53] Cross-sectional study of patients with SZ, ATPDs (n = 116), delusional disorder, and schizoaffective disorder. ATPDs had fewer
negative symptoms, shorter duration and better functioning than SZ
Kampman et al. [68] Little specificity of ATPD diagnosis probably due to unwillingness to diagnose SZ in the first-episode of psychosis

Neurobiological factors

Sahoo et al. [69] ATPD patients (n = 25) reported differences in auditory P300 amplitude and latency indicative of cerebral hyper-arousal compared
with cases with SZ and healthy controls
Pepplinkhuizen et al. [70] Polymorphic psychotic symptoms associated with metabolic changes in amino acid pathways.
Bach et al. [71] Higher serum levels of total bilirubin in ATPD patients (n = 31) than those with paranoid SZ and/or schizoaffective disorder
Rotting et al. [72] No significant difference in EEG recordings between ATPD patients and those with SZ and/or schizoaffective disorder
Kanazawa et al. [73] Genome-wide association study of 47 cases with atypical psychosis showing that putative genetic alterations overlapped with
those for SZ

ATPDs: acute and transient psychotic disorders; BD: bipolar disorder; DPCR: Danish Psychiatric Central Register; FEP: first-episode psychosis; RR: relative risk; SMR:
standardized mortality risk; SZ: schizophrenia.

199 schizophrenia, persistent delusional disorder and schizoaffective ATPD subtypes featuring polymorphic [23,27,64,66], schizophrenic 208
200 disorder [23,53,64,65]. Jäger et al. [53] reported that patients with [22,45,47], and predominantly delusional symptoms [19,46]. 209
201 ATPDs have shorter hospital admission and achieved more rapidly The field trials of ICD-10 showed that many ATPD subtypes 210
202 functional recovery than those diagnosed with schizophrenia, failed to achieve established standards of reliability [67]. More 211
203 delusional disorder and/or schizoaffective disorder. Attempts to to the point, little evidence supports the division of acute 212
204 differentiate schizophrenia from ATPDs on the basis of Schneider’s polymorphic psychotic disorder into subtypes ‘‘with’’ or 213
205 first-rank symptoms (FRS) failed because they occur in both ‘‘without’’ schizophrenic symptoms based on 1 or 3 months’ 214
206 conditions; only negative symptoms seem to be indicative of duration, and acute predominantly delusional disorder is a 215
207 schizophrenia [53]. There are also diversities in the frequency of diagnosis by exclusion from polymorphic psychotic disorder, 216

Please cite this article in press as: Castagnini A, Fusar-Poli P. Diagnostic validity of ICD-10 acute and transient psychotic disorders and
DSM-5 brief psychotic disorder. European Psychiatry (2017), http://dx.doi.org/10.1016/j.eurpsy.2017.05.028
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217 persistent delusional disorder and schizophrenia. In addition, predominantly delusional symptoms, which are more likely to 279
218 changes between clinical and research diagnosis of ATPDs, the herald schizophrenia and related disorders [25,27,45,47,66,87]. 280
219 latter made using standardized instruments, suggest little Further evidence suggests that ATPDs in low- and middle- 281
220 specificity [68]. income countries have low rates of recurrence and high temporal 282
stability ranging from 54% to 100% [27,43,88–90]. For example, 283
221 3.2.2. Neurobiological factors of ATPDs Sajith et al. [27] reported that nearly three quarters of their series 284
222 Apart from differences in auditory P300 event-related poten- of cases did not develop another diagnosis, and more than half 285
223 tials indicative of cerebral hyper-arousal from schizophrenia and experienced no relapse over three years. 286
224 healthy controls [69], neither structural nor functional brain
225 changes have been observed in ATPDs. Pepplinkhuizen et al. [70] 3.3.2. Diagnostic stability, course and outcome of BPD 287
226 described a series of metabolic alterations in amino acid pathways There were 10 studies on course and outcome of BPD with 288
227 by analogy with psychedelic drug induced psychosis, and Bach follow-up periods from 15 months to 10 years (Table 4). Over the 289
228 et al. [71] reported higher serum levels of bilirubin than in short-term, four studies found that about two-thirds of cases with 290
229 schizophrenia and/or schizoaffective disorder, but the clinical BPD do not develop another diagnosis and/or remitted rapidly 291
230 meaning of these findings remain unclear. In addition, Rottig et al. [57,91–93], while others reported far higher transition rates 292
231 [72] examined EEG recordings of ATPD patients, but no significant mainly to schizophrenia and related disorders [56,94,95]. The 293
232 change was found. latter findings compare favourably with longer-term follow-up 294
233 More recently, Kanazawa et al. [73] conducted a genome-wide studies showing that many cases with BPD evolved into more 295
234 association study of 47 cases with ‘‘atypical psychosis’’, a close severe and persistent affective and/or psychotic disorders 296
235 variant of ATPDs described in Japan [74], and reported that the [59,60]. In keeping with results of meta-analyses of studies of 297
236 putative genes overlap towards those for schizophrenia. first-episode psychosis, the overall stability of BPD reached only 298
45% on average within 4.5 years [78], and the risk of recurrence 299
237 3.2.3. Symptom measures and cognitive dysfunction of BPD ranged from 20% after 6 months to 53% after 3 or more years 300
238 Korver-Nieberg et al. [58] observed shorter duration, less [79]. Moreover, Pillmann et al. [96] found that patients with BDP 301
239 emotional distress, fewer negative and disorganized symptoms, experience high rate of relapse, but they have significantly better 302
240 higher quality of life and social functioning in BPD than in clinical and social outcome than schizophrenic patients. 303
241 schizophrenia, schizophreniform disorder, schizoaffective disorder
242 and/or unspecified psychosis. Moreover, Lyne et al. [75] found that 3.3.3. Response to treatment of ATPDs 304
243 negative symptoms are rare in BPD, while resulted significantly Khanna et al. [97] compared low- and high-dose haloperidol in 305
244 more frequent in schizophrenia and related disorders. 40 patients with ATPDs, but no significant difference in achieving 306
245 Although symptoms seem to be less severe in BPD than in symptomatic remission was observed over four weeks. Chaudhury 307
246 schizophrenia and/or schizophreniform disorder [62], cognitive et al. [98] reported that risperidone induced fewer extrapyramidal 308
247 impairment is common to psychotic patients [63,76]. BPD patients, symptoms and proved more effective than haloperidol in reducing 309
248 however, improved more rapidly, particularly in processing speed, both positive and negative symptoms in the early stage of 310
249 than those with schizophrenia, schizophreniform disorder and/or treatment. Agarwal and Sitholey [99] conducted a six-week trial 311
250 unspecified psychotic disorder after six months [77]. of olanzapine in 23 paediatric patients with ATPDs showing 312
symptom remission and relatively few side effects such as dry 313
251 3.3. Prognostic validators mouth, sedation, increased appetite and weight gain. 314

252 3.3.1. Diagnostic stability, course and outcome of ATPDs 3.3.4. Response to treatment of BPD 315
253 The course and outcome of ATPDs have been mapped by about Ehlis et al. [100] noted that atypical antipsychotics bring about 316
254 25 papers with follow-up periods from 1 to 20 years (Table 3). a positive effect on prefrontal brain functions in cases with BPD 317
255 Based on meta-analyses of studies of first-episode psychosis using neurophysiological techniques. 318
256 the overall stability of ATPDs was estimated at around 65% on
257 average after 4.5 years [78], and the risk of relapse ranged from 4. Discussion 319
258 30%–38% after 1–2 years to 54% after 3 or more years [79]. The
259 greatest diagnostic variability tended to occur in the 24 months To our knowledge, this is the first comprehensive review that 320
260 following the initial episode mainly either to schizophrenia and addresses the validity of ICD-10 ATPDs and DSM-5 BPD. It brings 321
261 related disorders or affective disorders [24,46]. Women are about a better understanding of these diagnostic categories and 322
262 significantly less likely than men to develop another diagnosis offers an opportunity to reconsider how they have been 323
263 [10,19,46,66,78,80,81]. Moreover, there were 30%–60% of patients differentiated from schizophrenia and related disorders, though 324
264 with ATPDs who enjoyed stable symptomatic remission and/or limited data are available about the epidemiology, vulnerability 325
265 discontinued medication [10,22,45,82]. They also had better factors, neurobiological correlates and treatment, particularly BPD 326
266 clinical and functional outcomes than patients with schizophrenia, has failed to encourage research. 327
267 schizoaffective disorders and/or persistent delusional disorder
268 over the short- and longer-terms [23,65,80]. 4.1. Antecedent validity factors 328
269 In addition to female gender, good premorbid adjustment,
270 abrupt onset, short DUP and early remission within 4 weeks are Existing studies suggest that ATPDs and BPD are rare mental 329
271 reported to predict favourable outcome and/or diagnostic stability disorders and more often affect women with onset in the early- 330
272 in ATPDs [19,27,45,54,83]; yet the risk of conversion into middle adulthood [19–21,24]. Higher rates have been reported in 331
273 schizophrenia or schizoaffective disorder seems to be associated Scandinavia, in migrant populations and in some developing 332
274 with family history of schizophrenia, male gender, age of onset countries owing to the lingering importance of reactive psychosis 333
275 below 35 years, longer hospital admission, and Schneider’s FRS typically triggered by emotional and sociocultural factors, and to 334
276 [24,45,64,66,84–86]. an unwillingness to diagnose schizophrenia in the first-episode of 335
277 Among the ATPD subtypes, APPD showed a higher diagnostic psychosis [27,28,38,48–52,68,101]. Yet, cases with schizophrenia 336
278 consistency than those featuring acute schizophrenic or show earlier age of onset and are prevalent in males [102]. 337

Please cite this article in press as: Castagnini A, Fusar-Poli P. Diagnostic validity of ICD-10 acute and transient psychotic disorders and
DSM-5 brief psychotic disorder. European Psychiatry (2017), http://dx.doi.org/10.1016/j.eurpsy.2017.05.028
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Table 3
Prognostic validators for ICD-10 acute and transient psychotic disorders (ATPDs).

Study N/F-up Length Diagnostic stability, course and outcome

Jørgensen et al. [10] 51/46 1y 52% ATPDs (1/3 recurrent course), 17% changed to SZ and/or delusional disorder, 8% affective disorders
Singh et al. [19] 32 3y FEP study: 35% ATPDs (2/3 recurrent), 35% SZ or delusional disorder, 19% affective disorders, 9% other. Female
gender and good premorbid adjustment predicted diagnostic stability. ATPD mean GAS score > 70
Jäger et al. [22] 94/73 3–7 y ATPDs: 42% single episode, 58% recurrent course, 12% persistent impairment. Negative and/or depressive
symptoms associated with unfavourable prognosis
Queirazza et al. [24] 2923 4–7 y Case-record study; 54% ATPDs; 13% SZ, 12% affective disorders. Age below 30 years, male gender and longer
admission associated with increased risk and earlier transition to SZ
Castagnini and Foldager [25] 5426 9.3 y Case register study; APPD more common in women, higher stability and lower rates of recurrence than the
remaining subtypes with schizophrenic or delusional features
Sajith et al. [27] 45 3y Prospective study of APPD; 73% same diagnosis, 22% BD, 4% unspecified psychosis; admission shorter than
1 month, and abrupt onset predicted temporal stability
Okasha et al. [43] 50 1y WHO study on acute psychoses (Egyptian cohort); 74% had ATPDs and 54% did not change diagnosis (2/3 full
remission, 14% recurrent course); 20% SZ and 26% affective disorders
Aadamsoo et al. [45] 153/107 2y Prospective study; 52 (49%) ATPDs (2/3 full remission; GAF score > 70), 50% SZ/schizoaffective disorder. APPD
more common in women, and associated with later age of onset and fewer changes to SZ
Castagnini et al. [46] 5426 7.3 y Case register study: ATPD overall stability 45%, 31% SZ and related disorder, 13% affective disorders, other 8%.
Women were less likely to develop another diagnosis
Rusaka and Rancans [47] 294/144 5.6 y Retrospective study: abrupt onset, polymorphic symptoms and anxiety associated with diagnostic stability
Castagnini et al. [54] 47 1y WHO study on acute psychoses (Aarhus cohort); 47/91 ATPDs: 28 (60%) did not change diagnosis, 28% affective
disorders, 13% SZ/schizoaffective disorder. Nearly all patients with unchanged diagnosis had full remission
Heslin et al. [60] 29 8y FEP study; ATPDs: 4 (17%) retained the same diagnosis, 7 (29%) SZ, 6 (25%) affective disorders, other 6 (25%)
Suda et al. [64] 25 9.7 y Case-note study; 15 (60%) ATPDs, 40% SZ; ATPD episodic course and longer remission than cases converting to
SZ
Salvatore et al. [66] 55 2y FEP study; ATPDs: 62% did not change diagnosis; 30% polymorphic psychotic disorders vs. 72% schizophrenia-
like disorder evolved into longer-lasting affective or psychotic disorders
Möller et al. [80] 30 15 y First admission psychosis study; ATPDs: 30% single episode, 50% remitting course and 20% chronic course.
ATPDs fared better than SZ and delusional disorder
Remberk et al. [81] 46 8y Prospective EOP study; ATPD diagnosis and female gender associated with better clinical and functional
outcome than SZ
Pillmann and Marneros [82] 42/39 7y Prospective study; 54% ATPDs (3/4 recurrent episodes), 30% affective disorders, 18% SZ and schizoaffective
disorder. ATPDs: 30% stable remission discontinued medication, GAS score > 80
Chang et al. [83] 17 5y FEP study: 35% ATPDs, 35% SZ, 12% schizoaffective disorder and 18% BD
Björkenstam et al. [84] 868 5y Swedish case register study; 41% ATPDs, 22% SZ/schizoaffective disorder, 8% BD, 29% other. The risk of
conversion into SZ or BD was twice as high for ATPD patients with family members with SZ or BD
Rusaka and Rancans [85] 102/41 2.2 y Prospective study: 20% ATPD recurrent course; thought disorder predicted transition to SZ
Poon and Leung [86] 87 20 y Case-note study of first admissions in Hong Kong; one third unchanged diagnosis; young age, family
psychiatric morbidity and high rates of recurrence associated with diagnostic changes
Abe et al. [87] 16 12 y Retrospective study; 10 (63%) ATPDs (2/3 recurrent course), 30% SZ and personality disorder
Amini et al. [88] 10 1y ATPD diagnosis remained unchanged, only one case relapsed
Thangadurai et al. [89] 87 13 mth Case-note study: 64% ATPDs, 11% recurrent course; 26% SZ, 9% affective disorders
Narayanaswamy et al. [90] 57/43 2y Retrospective study: 63% ATPDs (50% recurrent course); 21% BD, 16% SZ or unspecified psychosis

Response to treatment

Khanna et al. [97] 40 4 wk Clinical trial comparing low (5 mg) and high (20 mg) dose haloperidol; no significant difference in achieving
symptomatic remission
Chauhdury et al. [98] 30 4 wk Randomized trial comparing haloperidol and risperidone; the latter proved more effective in reducing both
positive and negative symptoms in the early phase of treatment
Agarwal and Sitholey [99] 23 6 wk Open trial of olanzapine in patients aged 6–16 years showing symptomatic improvement and relatively few
side effects

APPD: acute polymorphic psychotic disorder without schizophrenic symptoms; BD: bipolar disorder; EOP: early-onset psychosis; FEP: first-episode psychosis; GAF/S: Global
Assessment of Functioning/Scale; SZ: schizophrenia; y: year; mth: month; wk: week.

338 Similar conditions such as the ‘‘non-affective acute remitting least partly attributable to the fact that the ATPD category includes 356
339 psychoses’’ described by Susser and Wanderling [103] have an clinical subtypes, which are set apart from schizophrenia only by 357
340 uneven geographical distribution with a greater incidence in low- temporal criteria. Yet, the relationship between ATPDs and 358
341 and middle-income countries, particularly in women. These affective disorders remains uncertain [23,42,54]. 359
342 disorders have been observed in the wake of stressful events, As regard the clinical subtypes encompassed by ATPDs, APPD is 360
343 fever or systemic infections, and do not conform either to remitting more common in females and tend to occur later than the subtypes 361
344 schizophrenia or atypical affective disorders in clinical profile, with schizophrenic symptoms [25]. 362
345 course and outcome [104–109], but seldom fulfil the diagnostic
346 criteria both for ATPDs and BPD having a modal duration of 2–4 4.2. Concurrent validity 363
347 months [110,111].
348 There also is in ATPDs an increased risk of premature mortality It would appear that ATPDs and BPD have the following 364
349 both from natural and unnatural causes, similarly high to that for commonalities: acuteness of onset, variable clinical profile, fewer 365
350 schizophrenia [33,36]. negative symptoms and shorter duration for episode than 366
351 Further evidence suggests that short-lived psychotic disorders schizophrenia and related disorders [23,52,53,62,75,96,111]. 367
352 are neither associated with premorbid dysfunctions nor charac- However, no convincing evidence of neurobiological correlates – 368
353 teristic predisposition [19,23,37,39,40]. Family psychiatric mor- e.g. changes in amino acid metabolism, bilirubin serum level, 369
354 bidity has a smaller impact on ATPDs than on schizophrenia and auditory P300 event-related potentials, and putative genetic 370
355 bipolar disorder, and argues for a kinship to schizophrenia [42], at alterations overlapping with those for schizophrenia – lends 371

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Table 4
Antecedent, concurrent and predictive validators for DSM-5 Brief psychotic disorder.

Study Vulnerability factors

Ngoma et al. [62] BPD is not associated with family history of SZ and more often triggered by emotional and sociocultural factors than SZ and/or
schizophreniform disorder
Lee et al. [63] BPD exhibits fewer schizoid and schizotypal traits, and better social and occupational functioning than SZ

Symptom measures and cognitive dysfunctions

Korver-Nieberg et al. [58] Cross-sectional study showing shorter duration, less emotional distress, fewer negative and disorganized symptoms, and higher
quality of life in BPD than SZ and related disorders
Ngoma et al. [62] BPD differs from both SZ and schizophreniform disorder in terms of cognitive and social functioning, positive symptoms and
excitement
Lee et al. [63] Symptoms are less severe in BPD than SZ; no difference in attention, memory and executive function
Lyne et al. [75] Negative symptoms were significantly fewer in BPD than in SZ spectrum disorders
Ngoma et al. [76] Patients with BPD, SZ and schizophreniform disorder were more severely impaired than healthy controls, but no selective deficit
was found
Ayesa-Arriola et al. [77] BPD patients improved more rapidly than those with SZ, schizophreniform disorder and psychosis NOS after 6 months

Diagnostic stability, course and outcome

Schwartz et al. [56]a 3/11 cases (27%) first-admitted with BPD did not change diagnosis after 2 years
Salvatore et al. [57]a 22/36 cases (61%) with BPD did not develop another diagnosis after 2 years
Kingston et al. [59]a Many cases with BPD had rapid remission after the initial episode, but 80% developed longer-lasting psychotic and affective
disorders over 6 years
Heslin et al. [60]a 3/13 cases (23%) with BPD retained the same diagnosis after 8 or more years
Schimmelmann et al. [91]a 8/11 cases (73%) with BPD did not change diagnosis at 18 months follow-up
Rahm and Culberg [92]a Two-thirds of cases with BPD (n = 21) recovered; the remaining patients developed mainly SZ and/or affective psychosis over
3 years
Haahr et al. [93]a Diagnostic stability of BPD (n = 20) reduced from 75% after the first year to 60% after 2 years; most transitions were to SZ and/or
affective disorders
Rufino et al. [94]a 7/31 cases (23%) with BPD attending an emergency service did not change diagnosis after 15 months; no difference in clinical and
functional outcome from SFD and affective disorders
Subramaniam et al. [95]a 4/13 cases (31%) with BPD did not change diagnosis: short hospital stay and high premorbid functioning predicted diagnostic
stability
Pillmann et al. [96] 23 admissions with BPD had high rates of relapse but significantly better clinical and social outcomes than SZ patients over
2.5 years

Response to treatment

Ehlis et al. [100] Atypical neuroleptics seem to have a positive effect on prefrontal brain functions

BPD: brief psychotic disorder; Psychosis NOS: not otherwise specified; SZ: schizophrenia.
a
First-admission/episode psychosis study.

372 support to the concurrent validity of these disorders. It has been There may also be variations in course and outcome of ATPDs 399
373 suggested that acute psychosis in black immigrants would arise between high-income countries and low- and middle-income 400
374 from interaction between social adversities and a vitamin D ones, where these disorders are more often associated with 401
375 deficit [112]. sociocultural factors and have lower rates of relapse and diagnosis 402
changes [27,43,88–90]. This raises the question of whether 403
376 4.3. Prognostic validity environmental factors mediated by emotion-driven pathways 404
not only trigger the onset [38], but also make the outcome of acute 405
377 In absence of aetiological factors and biological markers, the psychosis more favourable; while insidious-onset psychosis would 406
378 validity of diagnostic categories hinges mainly on their predictive be associated with cognitive impairment, negative symptoms and 407
379 power, as they are expected to prove useful in making predictions poorer outcome [113,114]. 408
380 of treatment and outcome. Follow-up studies of ATPDs and BPD
381 report quite variable patterns of course and outcome, and a high 4.4. Implications for clinical practice and research 409
382 risk of recurrence with subsequent transitions either to schizo-
383 phrenia and related disorders or, to a lesser extent, affective ATPDs and BPD may cause difficulty in assessment and 410
384 disorders [10,19,24,46,56,59,60,78,79,95]. Apart from female treatment. First, it is not easy to identify cases in practice because 411
385 gender, the other factors identified as predicting favourable of the lack of distinctive clinical features and too restrictive 412
386 outcome and/or diagnostic stability in ATPDs such as good temporal criteria. Differential diagnosis includes early schizophre- 413
387 premorbid adjustment, short DUP and early remission need to nia or affective psychosis, substance-induced psychosis, psychosis 414
388 be replicated. A distinctive feature of ATPD patients who do not due to brain dysfunction or general medical conditions, and 415
389 develop longer-term illness is the lack of cognitive deterioration simulation psychosis. 416
390 and impaired functioning; they also fare better than patients with Secondly, follow-up studies report a tendency to recur and high 417
391 schizophrenia, schizoaffective disorder and/or delusional disorder, rates of transition to longer-lasting psychotic and affective 418
392 though a relatively small number enjoyed stable remission and disorders. These are probably the reasons why ATPDs and BPD 419
393 discontinued medication [10,22,45,65,82]. No predictive factor has have been often left out from epidemiological surveys of first- 420
394 yet been found for BPD, but patients seem to have a better outcome episode psychosis, and hence the number of those who experience 421
395 than those with schizophrenia [96]. acute onset, florid psychotic symptoms and early remission 422
396 Moreover, APPD has a more favourable course and higher remains uncertain. 423
397 diagnostic stability than the subtypes featuring schizophrenic or Thirdly, individuals with acute psychosis usually require 424
398 predominantly delusional features [25,27,45,66]. hospital admission owing to disorganized behaviour, impaired 425

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426 insight, aggressive and/or suicidal acts; in these cases, antipsy- neurobiological correlates, high risk of recurrence and subsequent 486
427 chotic medication is prescribed not only for acute symptomatology change to another diagnosis argue against their validity. Nonethe- 487
428 but also for prevention of recurrences [16]. In absence of any less, it is desirable that the above categories are revised and kept 488
429 evidence and guidance [15,16,115], high-dose or prolonged usage separated from longer-lasting psychotic disorders both for clinical 489
430 of antipsychotics need to be considered cautiously, as they can practice and research. 490
431 induce a number of adverse effects; atypical antipsychotics are also
432 more likely to be associated with increased risk of cardiovascular Disclosure of interest 491
433 disease, diabetes and premature mortality [116]. It will be
434 rewarding for future treatment trials to identify the most The authors declare that they have no competing interest. 492
435 appropriate therapy for patients with acute psychosis.
436 Further research is expected to address the relationship of References 493
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DSM-5 brief psychotic disorder. European Psychiatry (2017), http://dx.doi.org/10.1016/j.eurpsy.2017.05.028