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with ATPD have an average education, occupational status, and level of function-
ing, with no significant difference from the mentally healthy population. They
have an average level of social interaction and activities, as well as the same frequency
of stable heterosexual partnerships as mentally healthy people do. But, because of the
recurrence of their illness, it is possible in some socioeconomic systems, especially in
times of high unemployment, to be excluded from the labor market. Nevertheless,
even in such situations, they do not usually lose their autarky.
There are some significant differences between acute and transient psychotic dis-
orders and schizophrenia. Summarizing the findings of the HASBAP, it can be noted
that there are significant differences between ATPD and schizophrenia regarding:
* gender distribution

* age at onset

* premorbid level of functioning and social interactions

* onset, development, duration, and phenomenology, as well as structure of

symptomatology
* level of postepisodic functioning and outcome in general

But it seems that a subgroup of ATPD “ the ˜˜acute schizophrenia-like psychoses™™ “
has a closer relationship to schizophrenia and schizoaffective disorders.
According to the findings of the HASBAP, the question of the nosological
independence of the ATPD in general, but especially of their core group “ the
brief polymorphic psychoses “ must be rejected. This is not only due to the many
and relevant overlaps in all the domains investigated with the other two psychotic
groups, and, considering the knowledge available, with the major affective disorders,
but mainly because of their syndromatic instability. Even if the group of schizo-
phrenia-like psychoses is excluded, and, if only the more homogeneous group of
acute polymorphic psychoses is considered, then it is still clear that 60% of patients
with more than one episode have other kinds of episode (especially affective and
schizoaffective) than ATPD episodes during the course. The changeability of type of
219 Acute and transient psychotic disorder


episodes during the course, namely the manifestation of episodes belonging to other
major disorders, is one of the most important arguments “ although not the only
one “ against the assumption that ATPD, or its subgroup acute polymorphic
psychoses, is a separate nosological entity.
The same findings (i.e., family, premorbid, course, outcome data and, espe-
cially, kind of episode) support the assumption that the brief polymorphic psy-
choses are also related to the affective spectrum.


Methods of the HASBAP
In order to determine the relationship between ATPDs especially with regard to the
relationship between the core groups of the acute polymorphic psychotic disorders
and the bipolar affective and schizoaffective disorders, we combined them and
compared the findings of the HABILOS, described in chapter 1, with the previously
mentioned HASBAP. The HABILOS has been described elsewhere in this book,
therefore, we only give a short description of the HASBAP in this chapter:
The HASBAP combines three methodological approaches:
(1) a prospective approach, studying a consecutively recruited inpatient sample
with a diagnosis of ATPD or brief psychotic disorder
(2) a case-control design in which every patient of the original index cohort was
matched for age and gender with two clinical groups and a non-clinical
control group
(3) a longitudinal approach for all three clinical groups
The sample investigated in the HASBAP comprised all inpatients with ATPD
treated as inpatients at the Department of Psychiatry and Psychotherapy of
Martin“Luther University Halle-Wittenberg from 1993 to 1997. The hospital is
situated in the city of Halle, Germany, and takes patients from the city, as well as
from the surrounding communities, which comprise both rural and industrial
areas. It can be said that Halle University Hospital serves a large municipal and
suburban area with a non-selective admission policy. Moreover, ATPD are acute
and usually dramatic psychotic states that “ considering the German health care
system “ nearly always lead to inpatient treatment. The HASBAP sample can be
regarded as representative of a clinical inpatient population with ATPD. With
some restrictions, the findings of this study might also be regarded “ because of the
above-mentioned reasons “ as a reasonable approximation of ATPD in general,
and not only for inpatients.
The number of patients fulfilling the criteria of ATPD during this period amounted
to 42 patients. For the present analysis, three patients were excluded because they had
shown affective or schizoaffective mixed states during earlier episodes, leaving a group
size of 39 patients. The control groups comprised gender- and age-matched:
220 A. Marneros et al.



Table 9.9 Instruments used for assessment and evaluation in the Halle Study on Brief and
Acute Psychotic Disorder

Sociobiographical interview (SBI)
ICD-10 and DSM-IV checklists
Schedules for Clinical Assessment in Neuropsychiatry (SCAN)
World Health Organization Psychological Impairments Rating Schedule (WHO/PIRS)
World Health Organization Disability Assessment Schedule (WHO/DAS)
Global Assessment Scale (GAS)
Positive and Negative Syndrome Scale (PANSS)
Neuroversion, Extroversion, Openness Five-Factor Inventory (NEO-FFI)

ICD-10, Tenth Revision of the International Classification of Diseases; DSM-IV, Diagnostic and
Statistical Manual of Mental Disorders, 4th edn.

(1) patients with an acute episode of ˜˜positive™™ schizophrenia
(2) patients with an acute episode of bipolar schizoaffective disorders
(3) surgical patients without any mental disorder
The basic instruments applied in the various stages of the HASBAP are shown in
Table 9.9.
The statistical comparisons between ATPD and the bipolar group included a
number of combinations:
1. ATPD versus bipolar affective mixed states versus bipolar schizoaffective mixed
states
2. polymorphic subgroup of ATPD versus bipolar affective mixed states versus
bipolar schizoaffective mixed states
3. ATPD versus all mixed states (affective plus schizoaffective)
4. polymorphic subgroup of ATPD versus all mixed states (affective and
schizoaffective)
5. ATPD versus the groups of bipolar affective mixed states, bipolar schizoaffec-
tive mixed states, non-mixed bipolar affective disorders, and non-mixed bipolar
schizoaffective disorders



Results

ATPD versus bipolar affective mixed states versus bipolar schizoaffective mixed states
We first intended to ascertain what differences, if any, exist between ATPD and the
bipolar mixed states of bipolar affective disorders, as well as the mixed states of
bipolar schizoaffective psychoses “ mixed states, respectively. Therefore, these
groups were compared on the basis of a large number of variables, including age
221 Acute and transient psychotic disorder


at onset, gender, birth complications, developmental abnormalities, ˜˜broken-
home™™ situation in the family of origin, educational level, long-term heterosexual
partnership, occupational status, personality, symptomatology at follow-up, gen-
eral level of functioning, and social disability. For these and all following compar-
isons, the group of ATPD patients only comprised patients who never during the
course of their illness had an episode that fulfilled the criteria of a mixed affective
or schizoaffective episode. Table 9.10 shows the variables with significant differ-
ences between the groups.
The main findings shown in Table 9.10 can be summarized as follows:
* Women predominate in ATPD and, to a lesser extent, in bipolar affective mixed

states, while there is a slight preponderance of males in bipolar schizoaffective
mixed states. The differences between ATPD and bipolar schizoaffective mixed
states are statistically significant.
* ATPD and bipolar affective mixed states have a higher age at onset than bipolar

schizoaffective mixed states. The differences are significant at trend level.
* ATPD patients were significantly more often of asthenic/low self-confident

personality type than affective or schizoaffective mixed states. ATPD were also
significantly less often obsessoid or sthenic/self-confident than bipolar schizo-
affective mixed states.
* At follow-up, ATPD patients less often received disability pension than bipolar

affective mixed states and bipolar schizoaffective mixed states. The difference
from the schizoaffective mixed states was significant.
* In the NEO-FFI, ATPD patients showed higher scores on conscientiousness and

agreeableness than bipolar schizoaffective mixed states.



Polymorphic subgroup of ATPD versus bipolar affective mixed versus bipolar
schizoaffective mixed states
Since the results of the HASBAP indicate that the polymorphic subgroup of ATPD
(F23.0 and F23.1) are the most homogeneous group of ATPD as regards their core
form (Marneros and Pillmann, 2004), the above comparisons were repeated with
only the polymorphic subgroup of ATPD. Table 9.11 shows the results.
As shown in Table 9.11, the gender ratio remained essentially the same as in the
voluminous group of ATPD. The age at onset was slightly lower for acute poly-
morphic psychosis than for ATPD in general, and no longer differed significantly
from schizoaffective mixed states. The proportion of asthenic/low self-confident
personalities in ATPD-polymorphic subtype remained high, as did the high rating
of conscientiousness, but not of agreeableness, in ATPD. One new association
occurred: there was a significantly lower number of suicide attempts in acute
polymorphic psychoses than in schizoaffective mixed states.
Table 9.10 Significant differences between acute and transient psychotic disorder (ATPD), affective mixed states, and schizoaffective mixed states

Bipolar
Bipolar affective schizoaffective
ATPD mixed states mixed states
(n ¼ 39) (BAD-MIX: n ¼ 16) (BSAP-MIX: n ¼ 32)
n (%) n (%) n (%) Statistical analysis a

Gender
Female 30 (76.9) 11 (68.8) 15 (46.9) ATPD > BSAP-MIXÃÃ
Male 9 (23.1) 5 (31.3) 17 (53.1)
Age at onset ATPD > BSAP-MIX
35.4 Æ 11.4 37.0 Æ 11.3 29.3 Æ 10.5
BAD-MIX > BSAP-MIX b
Disability pension at follow-up c 4 (10.3) 5 (35.7) 17 (65.4) ATPD < BAD-MIXÃÃÃ
ATPD < BSAP-MIXÃÃÃ
Premorbid personality c n ¼ 35 n ¼ 11 n ¼ 23
Obsessoid 8 (22.9) 5 (45.5) 11 (47.8) ATPD < BSAP-MIXÃ
Sthenic/highly self-confident 5 (14.3) 5 (45.5) 7 (30.4) ATPD < BSAP-MIXÃ
Asthenic/low self-confident 19 (54.3) 0 4 (17.4) ATPD > BSAP-MIXÃÃ
ATPD > BAD-MIXÃÃ
Table 9.10 (cont.)

Bipolar
Bipolar affective schizoaffective
ATPD mixed states mixed states
(n ¼ 39) (BAD-MIX: n ¼ 16) (BSAP-MIX: n ¼ 32)
n (%) n (%) n (%) Statistical analysis a

Nervous-tense 3 (8.6) 1 (9.1) 1 (4.3) NS
Dimensional personality scores (NEO-FFI) c n ¼ 32 n ¼ 15 n ¼ 27
Neuroticism NS
1.89 Æ 0.58 2.22 Æ 0.65 2.01 Æ 0.68
Extroversion NS
2.06 Æ 0.52 1.98 Æ 0.50 1.87 Æ 0.51
Openness for experiences NS
2.17 Æ 0.38 2.08 Æ 0.44 2.33 Æ 0.48
Agreeableness ATPD > BAD-MIXÃ d
2.73 Æ 0.43 2.39 Æ 0.41 2.53 Æ 0.42
Conscientiousness ATPD > BAD-MIXÃ e
2.76 Æ 0.44 2.31 Æ 0.71 2.43 Æ 0.50

a
Only pairwise comparisons with significant differences (2-test or Fisher™s exact test, two-tailed) are shown.
b
´
Differences overall significant in ANOVA (P ¼ 0.027); pairwise comparisons given are significant on trend level (P < 0.1) in Scheffe test.
c
Reduced n, because some patients could not be followed up or information was insufficient to rate this item.
d
´
Differences overall significant in ANOVA (P ¼ 0.027); pairwise comparisons given are significant (P < 0.05) in Scheffe test.
e
´
Differences overall significant in ANOVA (P ¼ 0.010); pairwise comparisons given are significant (P < 0.05) in Scheffe test.
Ã
P < 0.05; ÃÃ P < 0.01; ÃÃÃ P < 0.001; NS, no significance.
NEO“FFI, NEO Five-Factor Inventory; ANOVA, analysis of variance.
Table 9.11 Comparison of the polymorphic subtype of acute and transient psychotic disorder (ATPD) with affective and schizoaffective mixed states

Bipolar affective
mixed states Statistical
Bipolar schizoaffective
analysis a
ATPD(n ¼ 25) (BAD-MIX: n ¼ 16) mixed states
n (%) n (%) n (%)
(BSAP-MIX: n ¼ 32)
Gender
Female 20 (80.0) 11 (68.8) 15 (46.9) ATPD > BSAP-MIXÃ
Male 5 (20.0) 5 (31.3) 17 (53.1)
Age at onset BAD-MIX > BSAP-MIX b
34.5 Æ 8.0 37.0 Æ 11.3 29.3 Æ 10.5
Disability pension at follow-up c 2 (8.0) 5 (35.7) 17 (65.4) ATPD < BSAP-MIXÃÃÃ
Number of suicide attempts ATPD < BSAP-MIX d
0.40 Æ 0.65 0.87 Æ 0.92 1.41 Æ 2.08
Premorbid personality c n ¼ 35 n ¼ 11 n ¼ 23
Obsessoid 5 (22.7) 5 (45.5) 11 (47.8) ATPD < BSAP-MIXÃ
Sthenic/highly self-confident 5 (22.7) 5 (45.5) 7 (30.4) ATPD < BSAP-MIXÃ
Asthenic/low self-confident 10 (45.5) 0 4 (17.4) ATPD > BSAP-MIXÃÃ
ATPD > BAD-MIXÃÃ
Table 9.11 (cont.)

Bipolar affective
mixed states Statistical
Bipolar schizoaffective
analysis a
ATPD(n ¼ 25) (BAD-MIX: n ¼ 16) mixed states
n (%) n (%) n (%)
(BSAP-MIX: n ¼ 32)
Nervous-tense 2 (9.1) 1 (9.1) 1 (4.3) NS
Dimensional personality
scores (NEO-FFI) c n ¼ 19 n ¼ 15 n ¼ 27
Neuroticism NS
1.88 Æ 0.50 2.22 Æ 0.65 2.01 Æ 0.68
Extroversion NS
2.12 Æ 0.62 1.98 Æ 0.50 1.87 Æ 0.51
Openness to experiences NS
2.14 Æ 0.41 2.08 Æ 0.44 2.33 Æ 0.48
Agreeableness NS

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