. 36
( 68 .)


G1. There 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 2 weeks
G2. If transient states of perplexity, misidentification, or impairment of attention and
concentration are present, they do not fulfill the criteria for organically caused clouding
of consciousness as specified for F05, criterion A
G3. The disorder does not meet the symptomatic criteria for manic episode (F30), depressive
episode (F32), or recurrent depressive disorder (F33)
G4. There 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; this must be decided by clinical judgment and
requirements of the research project in question
G5. Most commonly used exclusion clause. There must be no organic mental disorder
(F00“F09) or serious metabolic disturbances affecting the central nervous system
(this does not include childbirth). (The duration of the disorder must not exceed
3 months in subtypes F23.0, F23.3, and F23.8; it must not exceed 1 month in the
subtypes F23.1 and F23.2, which include schizophrenic symptoms)

Acute onset
The acute onset is defined as the change from a non-psychotic to a clearly
psychotic state within 2 weeks or less. The distinction between ˜˜abrupt™™ and
˜˜acute™™ onset is recommended because there is some evidence that the prognosis
of ATPD with abrupt onset (less than 48h) could be more favorable.

Typical syndromes
The typical syndromes are first, the quickly changing and variable manifestations
called ˜˜polymorphic,™™ and second, the presence or lack of typical schizophrenic

Acute stress
The association with acute stress follows the tradition of the ˜˜reactive™™ or ˜˜psycho-
genic™™ psychoses (Stromgren, 1986). Nevertheless, ATPD can be manifested with-
out an association with acute stress, which makes its presence not decisive for the
209 Acute and transient psychotic disorder

Table 9.2 Subtypes of acute and transient psychotic disorder (World Health Organization,
1992) according to ICD-10

Acute polymorphic psychotic disorder
with symptoms of schizophrenia (F23.1)
without symptoms of schizophrenia (F23.0)
Acute schizophrenia-like psychotic disorder (F23.2)
Other acute predominantly delusional psychotic disorders (F23.3)
Other acute and transient psychotic disorder (F23.8)
Unspecified acute and transient psychotic disorder (F23.9)

Table 9.3 Acute polymorphic psychotic disorder without symptoms of schizophrenia

A. 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:
* Emotional turmoil, characterized by intense feelings of happiness or ecstasy, or

overwhelming anxiety or marked irritability
* Perplexity, or misidentification of people or places

* Increased or decreased motility, to a marked degree

E. If any of the symptoms listed for schizophrenia (F20.0“F20.3), criterion 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 3 months

According to the WHO, a full remission can be achieved within 2 or 3 months, but
often even after a few weeks or a few days. Nevertheless, some patients may develop
persistent alterations. The present state of knowledge, however, does not allow for
a definition of prognostic predictors.
The HASBAP shows that the ATPDs are mostly independent from associated
acute stress. The factor ˜˜acute stress™™ does not have any defining, but also not any
prognostic, value in regard to the long-term prognosis of ATPD (Marneros and
Pillmann, 2004).
It is essential to note that the WHO defines some subgroups of ATPD, Table 9.2.
The most important group is that of the acute polymorphic psychotic disorder
(Table 9.3). The majority of patients diagnosed as having ATPD fulfill the criteria
210 A. Marneros et al.

Table 9.4 Acute polymorphic psychotic disorder with symptoms of schizophrenia

A. Criteria A, B, C, and D of acute polymorphic psychotic disorder (F23.0) must be met.
B. Some of the symptoms for schizophrenia (F20.0“F20.3) must have been present for the
majority of the time since the onset of the disorder, although the full criteria need not be
met, i.e., at least one of the symptoms in criteria G1(1)a to G1(2)c
C. The symptoms of schizophrenia in criterion B above do not persist for more than
1 month

Table 9.5 Diagnostic criteria for brief psychotic disorder according to Diagnostic and
Statistical Manual of Mental Disorders, 4th edn (DSM-IV: American Psychiatric
Association, 1994)

A. Presence of one (or more) of the following symptoms:
* Delusions

* Hallucinations

* Disorganized speech (e.g., frequent derailment or incoherence)

* Grossly disorganized or catatonic behavior

Note: Do not include a symptom if it is a culturally sanctioned response pattern
B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with
eventual full return to premorbid level of functioning
C. The disturbance is not better accounted for by a mood disorder with psychotic features,
schizoaffective disorder, or schizophrenia, and is not due to the direct physiological effects
of a substance (e.g., a drug of abuse, a medication) or a general medical condition
Specify if:
With marked stressor(s) (brief reactive psychosis): if symptoms occur shortly after and
apparently in response to events that, singly or together, would be markedly stressful to
almost anyone in similar circumstances in the person™s culture
Without marked stressor(s): if psychotic symptoms do not occur shortly after, or are not
apparently in response to events that, singly or together, would be markedly stressful to
almost anyone in similar circumstances in the person™s culture
With postpartum onset: if onset is within 4 weeks postpartum

of this subgroup. Our studies have shown that the polymorphic symptomatology
is also of essential diagnostic and prognostic validity (Marneros and Pillmann,
ICD-10 differentiates acute polymorphic psychotic disorders with symptoms of
schizophrenia from acute polymorphic psychotic disorders without such symp-
toms (Table 9.4).
211 Acute and transient psychotic disorder

However, the distinction of the acute polymorphic psychotic disorders in a
group ˜˜with symptoms™™ and another one ˜˜without symptoms of schizophrenia™™ is
absolutely useless. No defining or prognostic validity has been found (Marneros
and Pillmann, 2004).
Another crucial point is that subgroups of acute polymorphic psychotic dis-
order have the strongest relationship to the most essential predecessors of the
concept of ATPDs namely the cycloid psychoses and bouffee delirante (Pillmann
et al., 2001; Pillmann and Marneros, 2003; Marneros and Pillmann, 2004).
The Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV:
American Psychiatic Association, 1994) has a similar category to ICD-10, the
˜˜brief psychotic disorder™™ (298.8) (Table 9.5).
By definition, patients fulfilling the DSM-IV BP criteria also fulfill the ICD-10
criteria for ATPD, but not those of other ICD-10 psychotic groups. In other
words, all DSM-IV brief psychosis patients are also ICD-10 ATPD, but the
converse is not true. ˜˜Brief psychosis™™ of DSM-IV does not differ from other
ATPDs as defined by ICD-10 in all essential parameters. There is no necessity to
consider them as a separate diagnosis (Pillmann et al., 2002a, b; Marneros and
Pillmann, 2004).

The predecessors of the acute and transient psychotic disorders
When looking at the synonyms given by the WHO for ATPDs (Table 9.6), we
cannot help but recognize their predecessors. However, the most essential pre-
decessors are cycloid psychosis and bouffee delirante, which show relevant similar-
ities to the subgroup of ATPD ˜˜acute polymorphic psychotic disorders.™™

Table 9.6 Synonyms for acute and transient
psychotic disorder

Acute (undifferentiated) schizophrenia

Bouffee delirante

Cycloid psychosis


Paranoid reaction

Psychogenic (paranoid) psychosis

Reactive psychosis

Schizophrenic reaction

Schizophreniform attack or psychosis

Remitting schizophrenia

Good-prognosis schizophrenia
212 A. Marneros et al.

Cycloid psychoses
The most closely related concept to that of acute psychotic disorders of the ICD-10,
as well as that of brief psychotic disorders of the DSM-IV, is the concept of cycloid
psychoses. It was created and developed by the so-called ˜˜three Karls™™: Karl
Wernicke, Karl Kleist, and Karl Leonhard. It was originated by Karl Wernicke
and further developed by the work of his pupil, Karl Kleist (who also provided the
name ˜˜cycloid™™). It was then completed by the work of Kleist™s pupil, Karl
Leonhard (see also Perris, 1986; Marneros, 1999; Sigmund and Mundt, 1999;
Marneros and Angst, 2000; Beckmann and Franzek, 2001; Marneros and
Pillmann, 2004). The concept of the ˜˜three Karls™™ focused mainly on clinical and
later also on genetic findings (Neele, 1949; von Trostorff, 1968).
The theoretical roots of the concept can be easily traced back to the work of
Augustin Morel (1857) and to his concept of degeneration. Perris (1986) pointed
out that it was very likely Valentin Magnan who, for the first time, linked an acute
polymorphic psychotic disorder to a state of degeneration. In the 1880s, Magnan,
inspired by Morel, described in some detail a psychopathological condition
characterized by sudden onset, polymorphous symptomatology, and a recurrent
course in successive generations of ˜˜degenerate™™ families (syndromes ´pisodiques
´´ ´´ ´´ ´´ ´´
des degeneres, bouffee delirante des degeneres). The concept of ˜˜degeneration
psychosis™™ (no longer linked to the hypothesis of ˜˜degeneration™™) won acceptance
in Germany and laid the foundation for the concept of ˜˜cycloid psychoses.™™
Many important German authors of the first quarter of the twentieth century
(e.g., Bonhoeffer, 1907; Schroder, 1918, 1920, 1922, 1926; Birnbaum, 1923;
Binswanger, 1928) published important work on ˜˜degenerative psychoses™™
(Perris, 1986). Paul Schroder, who stressed the polymorphism of the picture of
˜˜degenerative psychoses™™ (1920), was aware of the criticism about the concept of
degeneration and wrote: ˜˜albeit one should be more concerned with the essence of a
problem rather than with its name, a bad name has a detrimental effect on
the problem.™™ He changed the term ˜˜degenerative psychoses™™ to ˜˜metabolic
psychoses™™ (from the Greek verb metaballein, which translates to ˜˜prone to
change™™) to stress the polymorphism and the variability of such psychotic
disorders. But the term ˜˜metabolic psychoses™™ has never been established
(Pillmann et al., 2001; Pillmann and Marneros, 2003; Marneros and Pillmann,
2004). The concept of cycloid disorder was mainly focused on clinical and prog-
nostic aspects, but later also on genetic findings (Neele, 1949; von Trostorff, 1968;
Franzek and Beckmann, 1998).
Karl Kleist, the most influential pupil and coworker of Wernicke at the
University of Halle-Wittenberg and later Professor of Psychiatry in Rostock and
Frankfurt, defined cycloid psychoses as bipolar disorders, but not identical to
213 Acute and transient psychotic disorder

Kraepelin˜s ˜˜manic-depressive insanity.™™ Kleist™s conclusions were based on clini-
cal, prognostic, and family findings (Kleist, 1924, 1925, 1926, 1928, 1953).
Leonhard (1957) allocated the cycloid psychoses into three pairs:
(1) the anxiety“happiness psychosis
(2) the excited“inhibited confusion psychosis
(3) the hyperkinetic“akinetic motility psychosis
The three pairs of cycloid psychoses conceived by Leonhard were in accordance


. 36
( 68 .)