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with Kleist™s view that they were bipolar disorders (while differing essentially from
manic-depressive illness).
The anxiety“happiness psychosis is characterized by continuous changing
between severe all-pervasive anxiety and ecstatic happiness. It is possible that
only one pole “ anxiety or ecstasy “ becomes manifest. Anxiety is often associated
with delusions and hallucinations. While the experience of anxiety is overwhelm-
ing, its intensity fluctuates, and patients can suddenly turn to a state of ecstatic
happiness. In the happiness“ecstasy phase, the patients experience a feeling of
revelation and of closeness to God. They feel like wanting to help others, to save
them, to make them as happy as they themselves are. A peculiarity of the affects in
this condition is their changing character during the episode. Clear-cut depressive
or clear-cut manic mood is not recognizable or long-lasting.
The excited“inhibited confusion psychosis is characterized by thought distur-
bances which become incoherent and perplexed, in the excited phase but do not
continue in the inhibited pole. Incoherence is mostly manifest in an inconsequen-
tial choice of themes or by an inconsequential use of different languages. In the
most extremely inhibited form, the patient becomes mute. A wondering perplexity
is present. Hallucinations and delusions are frequently present. Most often, a
polymorphous, rapidly changing pattern characterizes the episodes of illness.
The main characteristic of the hyperkinetic“akinetic motility psychosis is a
disturbance of motility. In the hyperkinetic type, there is an increase in reactive
and expressive movements and in pseudospontaneous movements. In contrast to
the increased activity of many patients, they do not suffer pressure of speech. The
patients remain mute in the hyperkinetic phase. In the akinetic phase, only a few
isolated movements are carried out. In extreme cases, the patient may lie com-
pletely motionless in a stupor and in cataplexia. The difference to catatonia lies in
the fact that the way in which movements are carried out is not qualitatively
disordered in motility psychoses (Leonhard, 1961).
The 1974 study by Perris comprised a clinical and family investigation of 60
patients and their first- and second-degree relatives. The author recognized at the
beginning of the study that a clear-cut distinction among the three different
subtypes of cycloid psychoses proposed by Leonhard (1957) was not always
possible. An admixture of symptomatology of all three pairs appeared to be
214 A. Marneros et al.

Table 9.7 Diagnostic criteria for ˜cycloid psychosis™ according to Perris and Brockington

1. An acute psychotic condition, not related to the administration or abuse of any drug
or to brain injury, occurring for the first time in subjects in the age range
15“50 years
2. The condition has a sudden onset with a rapid change from a state of health to a full-blown
psychotic condition within a few hours or at most a very few days
3. At least four of the following must be present:
* Confusion of some degree, mostly expressed as perplexity or puzzlement

* Mood-incongruent delusions of any kind, most often with a persecutory content

* Hallucinatory experiences of any kind, often related to themes of death

* An overwhelming, frightening experience of anxiety, not bound to particular situations

or circumstances (pananxiety)
* Deep feelings of happiness or ecstasy, most often with a religious coloring

* Motility disturbances of an akinetic or hyperkinetic type which are mostly expressional

* A particular concern with death

* Mood swings in the background and not so pronounced to justify a diagnosis of

affective disorder
4. There is no fixed symptomatological combination: on the contrary, the symptomatology
may change frequently during the episode and shows a bipolar characteristic

more the rule than the exception. Perris did not find any convincing evidence that a
differentiation into ˜˜ideal™™ subtypes would have a practical value. This knowledge
led Perris (together with Brockington) to develop operational criteria for cycloid
psychoses, ignoring Leonhard™s differentiation of the three subgroups (Perris and
Brockington, 1981, Table 9.7).
The Perris studies verified the abrupt or acute onset of cycloid disorder in
general, but also anecdotally: ˜˜One of the investigated patients, who has been
followed for several years and who has suffered several episodes, always becomes ill
in the middle of the night after having gone to bed in a state of complete health™™
(Perris, 1974). Prodromal symptoms were found to be very rare, and when they
occurred, they most often consisted of irritability and poor sleep. No seasonal
dependence of onset was found. The development of psychotic symptoms was also
very fast. They were mingled together without any discernible pattern and con-
tinuously changed, not only from day to day, but also in most instances from one
hour to the next. The occurrence of schizophrenic first-rank symptoms
(Schneider, 1959; Marneros, 1984) was very common. Further studies of Perris
in cooperation with Brockington (Brockington et al., 1982a, b) showed a very poor
concordance between cycloid and schizoaffective psychoses. Only 20 of 108
215 Acute and transient psychotic disorder

patients who met the criteria of schizoaffective psychoses (mostly schizomanics)
were diagnosed as cycloid. Patients identified as cycloid showed a significantly
better short-term and long-term outcome than did other psychotic patients.
Although the knowledge about epidemiology of cycloid psychotic disorder is
still scanty, Perris assumed that 10“15% of psychotic patients are cycloid.

´ ´
Bouffee delirante
Bouffee delirante is another important synonym given by the WHO for ATPD. It can
be regarded as the French root of ATPD and brief psychoses. The modern concept of
bouffee delirante of francophonic psychiatry is based on operational criteria, includ-
ing sudden onset, specific symptomatology, and the evolution of the disorder
(Pichot, 1986a; Pull et al., 1983). The concept of the bouffee delirante has been
influential in French psychiatry for more than a century (Appia, 1964; Pichot
1986a, b). In the 1880s, Valentin Magnan (1835“1916) described for the first time
a psychopathological condition named syndromes ´pisodiques des degenerees or bouf-
´´ ´´
´´ ´´ ´´
fee delirante des degenerees. The concept created by Magnan was completed by his
pupils Legrain and Saury (Legrain, 1886; Saury, 1886; Magnan and Legrain, 1895).
It was Henri Ey who renewed interest in the entity of bouffee delirante, which he
refined and contrasted to a more narrowly defined concept of schizophrenia (Ey,
1954). In this theoretical framework, the bouffee delirante, among other acute
psychoses, displays a level of destructuration intermediate to manic-depressive
illness and schizophrenia. Hallmarks of this intermediate level of psychopatho-
logical disturbance are oneiroid phenomena (Ey, 1954). It is this intermediate level
of disturbance that explains the benign prognosis of the bouffee delirante. The
diagnosis conforms with the desire of many French psychiatrists to put more weight
on course than on symptomatology and to separate the acute psychoses from
schizophrenia (Pull et al., 1984). Hence, the French psychiatric school, even after
the incorporation into its nosology of Kraepelinan dementia praecox and later of
´ ´
Bleulerian schizophrenia, has retained the category bouffee delirante as
an independent mental disorder (Pichot, 1982). Bouffee delirante has its place in
French psychiatry, as documented by its inclusion in the classification system of the
´ ´
Institut National de la Sante et de la Recherche Medicale (INSERM, 1969) and the
formulation of operational criteria by Pull et al. (1983, 1984, 1987) and
the continuing publication of case reports, theoretical articles, and clinical studies.
The term, however, is not always used very strictly by French psychiatrists (e.g., it has
also been applied to substance-induced delirious states: Devillieres et al., 1996).
The operational criteria that have been developed by Pull and his colleagues
(1983) are shown in Table 9.8.
The frequency of patients found with bouffee delirante was much lower when
applying the criteria used by Pull and coworkers (1983) than was the frequency of
216 A. Marneros et al.

´e ´lirante (Pull et al., 1983)
Table 9.8 Diagnostic criteria for bouffe de

1. Age of onset: approximately 20“40 years
2. Onset: acute, without any prior psychiatric history (other than identical episodes)
3. No chronicity: active phases fade away completely in several weeks or months, possibly
recurring under the same form: the patient remains devoid of all abnormalities in the
4. Characteristic symptoms (all of the following):
* Delusions and/or hallucinations of any type

* Depersonalization/derealization and/or confusion

* Depression and/or elation

* Symptoms vary from day to day even from hour to hour

5. Not due to any organic mental disorder, alcoholism, or drug abuse

patients found with the acute polymorphic psychotic disorders of the ICD-10 and
cycloid psychosis when applying the criteria used by Perris (Pillmann et al., 2003b;
Marneros and Pillmann, 2004). They can be assumed to be a part of the acute
polymorphic psychotic disorders, as defined by the WHO (Pillmann et al., 2003b;
Marneros and Pillmann, 2004).

Other predecessors
Another synonym for ATPD is that of ˜˜atypical psychoses,™™ which is mainly a
Japanese concept (Perris, 1986). The creator of the concept of atypical psychoses in
Japan was Hisatoshi Mitsuda, who presented this topic for the first time in 1941.
Atypical psychoses are characterized by an acute onset of illness, a favorable
prognosis, and a tendency toward relapse. They show strong similarities with the
concept of cycloid psychoses. In contrast to Kleist and especially to Leonhard,
Mitsuda had doubts regarding the full remission of all cases with atypical psy-
choses (Mitsuda, 1965; Kimura et al., 1984; overview in Fukuda, 1990). According
to family studies by Mitsuda and Fukuda (1974), atypical psychoses have to be
regarded as separate from both schizophrenia and depressive psychoses and from
the epileptic psychoses, although some overlaps may occur. It has been assumed
that atypical psychoses, as defined by the Japanese psychiatrists, have some
similarities to epileptic psychoses. This assumption could not be supported in
the HASBAP (Rottig, 2001; Marneros and Pillmann, 2004).
Reactive or psychogenic psychoses are also among the synonyms given by the
WHO for ATPD. So-called reactive/psychogenic psychoses have a very strong
tradition, mainly in Scandinavia (Stromgren, 1986). The basic concept was devel-
oped by August Wimmer (1916) in parallel with Karl Jaspers (1913). According to
217 Acute and transient psychotic disorder

Stromgren (1986), the reactive/psychogenic psychoses include emotional syn-
dromes (depressions, excitations), syndromes with disturbance of consciousness
(delirious states, dissociative states, twilight states, fugues), and paranoid (delu-
sional) states (sensitive delusions of reference, litigious paranoia, incarceration
psychoses, delusional psychoses in the deaf, and delusional psychoses in other
forms of sensory deprivation). The original broad concept of reactive psychoses is
still being used in Scandinavia, where up to 13“30% of all psychiatric admissions
are diagnosed with reactive psychosis (Dahl, 1986; Opjordsmoen, 2001). The
concept has been strongly advocated by Stromgren (1986, 1987). More recently,
Ungvari has pleaded for the acceptance of an independent category reactive
psychoses (Ungvari and Mullen, 2000; Ungvari et al., 2000).
Dream-like states, independent of organic conditions and not identical to
schizophrenia, have been described by Mayer-Gross (1924) in Germany.
Schizophrenia-like emotional psychoses were described by Staehelin (1931,
1946) and Labhardt (1963) in Switzerland, and emotional psychoses by Storring
¨ ¨
and by his pupil Boeters in Germany (Storring et al., 1962; Storring, 1969; Boeters,
1971). Psychiatrists in Spain, Portugal, Italy, Greece, Hungary, Bulgaria, and
Russia described states very similar to those mentioned above (overview in
Perris, 1986). They shared clinical and prognostic features with the above-
described disorders.

What are acute and transient psychotic disorders?
The creation by the WHO of the category of ATPD in the ICD-10, as well as the
creation by the American Psychiatric Association of a category of brief psychosis in
DSM-IV, reflects the efforts to gather other psychotic disorders referring in some
extent from classical schizophrenia and of course of affective disorders. Both
systems include them in the ˜˜schizophrenic spectrum.™™ But the WHO, in spite
of creating this new category, remains uncertain about its accuracy:

The nomenclature of these acute disorders is as uncertain as their nosological status [ . . . ]
Systematic clinical information that would provide definitive guidance on the classification of
acute psychotic disorders is not yet available, and the limited data and clinical tradition that
must therefore be used instead do not give rise to concepts that can be clearly defined and
separated from each other. (WHO, 1992).

This is quite true, but also a challenge for research on the topic. That became yet
another reason to design and carry out the HASBAP.
The most systematic and voluminous study on the topic “ the HASBAP “ gave
some answers to essential questions which can be found in the first book written
on the topic (Acute and Transient Psychoses by Marneros and Pillmann, 2004).
218 A. Marneros et al.

Summarizing the findings of the HASBAP, it can be said that ATPD, as defined
by the ICD-10, are disorders:
* mainly concerning females

* with possible onset in all ages of adult life, but usually between the 30th and 50th

years of life
* having an acute or even abrupt onset

* with an onset only rarely dependent on acute severe stress

* with a very short psychotic period

* with a very good response to antipsychotic drugs

* with a usually favorable outcome, in spite of the fact that they are usually

People suffering from ATPD can be described as follows: a majority of patients


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