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Incidence and diagnostic stability of ICD-10 acute and transient psychotic disorders
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Comprehensive Psychiatry 49 (2008) 255 – 261 www.elsevier.com/locate/comppsych
Incidence and diagnostic stability of ICD-10 acute and transient psychotic disorders Augusto Castagnini a,⁎, Aksel Bertelsen b , German E. Berrios a b
a Department of Psychiatry, University of Cambridge, Cambridge, UK Centre for Basic Psychiatric Research, Aarhus Psychiatric University Hospital, Risskov, DK
Abstract 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 Leonhard's 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. © 2008 Elsevier Inc. All rights reserved.
1. Introduction Although central to the current classification of psychotic disorders, the traditional distinction between schizophrenia and manic depression [1] remains problematic and has encouraged the creation of additional categories to deal with conditions that differ in some respects from the 2 major psychoses. The ICD-10 classification of mental and behavioral disorders [2] introduced, within the group F2 schizophrenia and related disorders, the category F23 acute and transient psychotic disorders (ATPD) to embrace clinical concepts such as the French bouffée délirante [3], Kleist [4] and Leonhard's [5] cycloid psychoses, and the Scandinavian reactive and schizophreniform psychoses [6-8]. Acute and
⁎ Corresponding author. Darwin College, Cambridge CB3 9EU, UK. E-mail address: [email protected] (A. Castagnini). 0010-440X/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2007.10.004
transient psychotic disorders are characterized by (a) acute onset (within 2 weeks); (b) presence of typical syndromes such as polymorphic, schizophrenia-like, or predominantly delusional; and (c) being associated or not with acute psychological stress. Complete recovery is expected by 1 or 3 months according to symptom duration stipulated to exclude, respectively, diagnosis of schizophrenia (F20) and persistent delusional disorder (F22). Yet although “emotional turmoil” and affective symptoms may be prominent, ATPD do not satisfy criteria for either manic (F30) or depressive (F32) episodes. Likewise, the Diagnostic and Statistical Manual of Mental Disorders has listed since its fourth edition [9] a similar, but not identical category, brief psychotic disorder (298.8), which “may follow or not marked stressors” or may have its onset in the postpartum period. The available evidence suggests that ATPD are not frequent [10]. With onset between early and middle adulthood, ATPD are reported as prevalent in females
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[11-13]. Although outcome is more favorable than in schizophrenia, follow-up studies have found high rates of relapse and poor stability since 30% to 60% of patients with ATPD converted either to schizophrenia or affective disorders on the short and long terms [10-15]. Furthermore, there is little concordance between ATPD and the clinical concepts to which they are likely to refer such as bouffée délirante [16], the cycloid psychoses [17-19], the Scandinavian reactive psychoses [20], and the acute remitting psychoses as frequently described in developing countries [21]. Such findings call into question the validity of diagnostic criteria and usefulness of ATPD classification into various subcategories. The methodology developed to test the validity of psychiatric categories suggests that temporal stability be a standard criterion and a measure of their predictive value [22,23]. The assumption behind this approach is that the more stable the diagnosis, the more likely it is to reflecting a common neuropathologic substrate, which enables one to make treatment decisions and to predict the course and outcome of illness. Diagnostic stability also has potential implications for service planning and resource allocation [24]. The purpose of this study was to determine incidence and validity of ATPD in terms of diagnostic stability in a cohort of patients representative of the Danish population. 2. Method Since 1994, ICD-10 has replaced ICD-8 as official classification in Denmark. A 6-year analysis of readmission patterns of all subjects listed in the Danish psychiatric central register (DPCR) as having been first-ever admitted to hospital or treated in outpatient services with a main diagnosis of F23 ATPD from January 1 to December 31, 1996, was conducted. Diagnostic stability was taken to be akin to the proportion of cases with a first-admission diagnosis of ATPD in 1996 that did not develop another psychiatric diagnosis up to the end of 2001. The overall stability rate of ATPD also included those patients who were neither readmitted to hospital nor treated in community-based services after the first episode. According to ICD-10, precedence is given to the most relevant diagnosis (main diagnosis) than others (additional diagnoses); organic (brain) disorders (F0) and schizophrenia and related disorders (F2) take the precedence than
categories lower down in the diagnostic hierarchy (ie, F3, F4, etc). Age and sex-standardized incidence rates were calculated using the Danish population in 1996 and expressed as the number of new cases per 100 000 population. The electronic database of the DPCR is comprehensive of all psychiatric admissions in Denmark, Faeroe Islands, and Greenland and covers about 5.1 million inhabitants. It has stored clinical information on inpatients since 1969 and on outpatient services since 1995. The DPCR provides data for collection of national statistics, mental health planning, and for epidemiological research. Register reports include information taken from case-notes and diagnosis made according to ICD revisions [25]. The reliability of diagnostic assessment is enhanced by uniformity of training in psychiatry throughout the country, comprising supervisions and courses that provide tuition in the Present State Examination for use in conjunction with ICD-10. Six subcategories are listed under heading of ATPD: polymorphic disorder without and with symptoms of schizophrenia (F23.0, F23.1), schizophrenia-like psychotic disorder (F23.2), predominantly delusional disorder (F23.3), other, and unspecified acute and transient psychotic disorder (F23.8, F23.9). A fifth digit may be used to indicate whether each disorder is associated or not with acute stress (F23.x1, F23.x0). Eighty-seven subjects (17.3%) of the initial cohort had died during the study period and were withdrawn from further analyses here undertaken. Because data available for register-based research do not include information that may lead to identification of the subjects being studied, approval from the ethical committee for the DPCR is not required. Data analysis was performed using the Statistical Package for Social Sciences (SPSS; SPSS Inc, Chicago, Ill). 3. Results There were 21 389 subjects coded as having been firstever admitted or treated as outpatient in 1996. Diagnosis of ATPD was found in 503 cases, accounting for 2.3% of all patients and 9.8% of those with nonorganic psychotic and affective disorders (F2 + F3 categories; 34.4% of F2 group). The incidence of ATPD was 9.6 per 100 000 population, with a slightly higher rate of females than males (9.8 vs 9.4 per 100 000). Incidence rates by age group were higher for
Table 1 Incidence of F23 ATPD in 1996 Age groups
Male Female Total
Rates per 100 000 population (numbers in brackets) b19
20-29
30-39
40-49
50-59
N60
All ages
3.5 (22) 3.1 (19) 3.3 (41)
18.7 (74) 14.5 (55) 16.6 (129)
15.6 (63) 14.3 (55) 15.0 (118)
10.3 (40) 8.7 (33) 9.5 (73)
3.7 (12) 9.0 (29) 6.3 (41)
7.2 (32) 11.7 (69) 9.4 (101)
9.4 (243) 9.8 (260) 9.6 (503)
A. Castagnini et al. / Comprehensive Psychiatry 49 (2008) 255–261 Table 2 Patients first-ever admitted with F23 ATPD in 1996 by sex and diagnostic subcategories F23 ATPD
Male
Female
Total (%)
Mean age (SD)
F23.0 F23.1 F23.2 F23.3 F23.8 F23.9 Total
49 19 23 75 10 67 243
52 16 15 81 20 76 260
101 (21.1) 35 (7.0) 38 (7.6) 156 (31.0) 30 (6.0) 143 (28.4) 503 (100.1)
42.3 (18.8) 31.8 (13.9) ⁎ 27.9 (10.6) ⁎⁎ 46.9 (20.8) 35.2 (14.0) 45.4 (22.0) 42.2 (20.2)
⁎ P = .001. ⁎⁎ P b .001.
males than for females, with a marked reversal of this pattern over 50 years (Table 1). The mean age was significantly higher in females than in males (46.2 years vs 37.8 years; P b .001). The most frequent subcategories were predominantly delusional disorder (F23.3), acute and transient psychotic disorder unspecified (F23.9), and polymorphic disorder without symptoms of schizophrenia (F23.0) (Table 2). Most patients with polymorphic and schizophrenic features (F23.1) and schizophrenia-like psychotic disorder (F23.2) were males. Their mean age was significantly lower than the overall mean age of ATPD (respectively, 31.8 years vs 42.2 years, P = .001; 27.8 years vs 42.2 years, P b .001). Eighty-seven subjects had died within the study period. Of the remaining 416 with ATPD, 70 (16.8%) were not readmitted to hospital after their first episode, whereas 346 (83.2%) had been admitted on at least one further occasion by the end of 2001. Admission patterns showed that an increasing number of patients changed diagnosis on subsequent admissions, mainly either to F2 schizophrenia and related disorders or F3 affective disorders (Table 3). In their last admission, the diagnosis of ATPD did not change in 92 cases. The overall stability rate, including those never readmitted after the initial episode, reached only 38.9%. Principal diagnostic changes were F2 schizophrenia and related disorders 29.3%, F3 affective disorders 11.0%, F4 neurotic, stress-related and somatoform disorders 4.8%, F6
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personality disorders 4.8%, F0 organic disorders 3.1%, and F1 psychoactive substance use disorders 3.1% (Table 4). Among F2 categories, F20 schizophrenia and F22 persistent delusional disorder were the most common. Bipolar disorders (F31), depressive episode (F32), and recurrent depressive disorder (F33) accounted for the majority of diagnostic shifts to F3 group (Fig. 1). Polymorphic disorder without symptoms of schizophrenia (F23.0) and predominantly delusional disorder (F23.3) were the most stable subcategories. Only a small number of those with polymorphic and schizophrenic symptoms (F23.1) and schizophrenia-like psychotic disorder (F23.2) were not readmitted. They also were more likely to develop another diagnosis of F2 group (Table 4). The residual categories other (F23.8) and unspecified (F23.9) acute psychotic disorders included almost one third of patients remained with the diagnosis of ATPD. 4. Discussion To our knowledge, this study is the first to evaluate incidence and stability of ATPD in a representative cohort drawn from a psychiatric register comprehensive of inpatient and outpatient admissions that covers an entire country. There were 503 cases listed in the DPCR with a firstadmission diagnosis of ATPD in 1996, accounting for 2.3% of all patients and 9.8% of those with nonorganic psychotic and affective disorders. The incidence of ATPD was 9.6 per 100 000 population with a higher rate of females than males. More than 80% were readmitted on at least one further occasion during the study period. In their last admission, 60% changed diagnosis, half were shifted to another F2 category and 11% to affective disorders. Ninety-two cases retained the diagnosis of ATPD with a stability rate of 38.9%, including those never readmitted after the first episode. Perhaps because of diagnostic habits revolving around the concept of reactive psychosis, commonly used in Denmark as a first-admission diagnosis until adoption of ICD-10 classification in 1994, then subsumed in heading of ATPD as subcategory “with associated acute stress,” incidence rates of ATPD so far reported could overestimate the true incidence.
Table 3 Changes in diagnosis on subsequent admissions in patients with F23 ATPD ICD-10 categories
F23 ATPD F0 organic disorders F1 psychoactive substance use disorders F2 schizophrenia and related disorders F3 affective disorders F4 neurotic and stress-related disorders F6 personality and behavior disorders Other Total
Admission patterns (%) 1st
2nd
3rd
4th
5th
10th
15th
416 (100) -
217 (62.7) 9 (2.6) 14 (4.0) 53 (15.3) 22 (6.3) 13 (3.7) 8 (2.3) 10 (2.9) 346 (83.2)
112 (41.5) 9 (3.3) 9 (3.3) 71 (26.3) 38 (14.1) 12 (4.4) 8 (3.0) 11 (4.1) 270 (78.0)
67 (30.7) 11 (5.1) 7 (3.2) 67 (30.7) 34 (15.6) 17 (7.8) 8 (3.7) 7 (3.2) 218 (80.1)
47 (28.0) 8 (4.8) 6 (3.5) 67 (39.9) 23 (13.7) 7 (4.2) 2 (1.2) 8 (4.8) 168 (62.2)
2 (3.1) 2 (3.1) 4 (6.2) 40 (62.5) 9 (14.1) 3 (4.7) 2 (3.1) 2 (3.1) 64 (38.1)
1 (4.0) 1 (4.0) 1 (4.0) 18 (72.0) 2 (8.0) 1 (4.0) 1 (4.0) 25 (39.1)
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Table 4 Distribution of ICD-10 categories in patients with F23 ATPD in their last admission ICD-10 categories
F0 organic disorders F1 psychoactive substance use disorders F2 schizophrenia and related disorders F3 affective disorders F4 neurotic and stress-related disorders F6 personality and behavior disorders Other F23 ATPD Not readmitted Total
F23 ATPD (%) F23.0
F23.1
F23.2
4 (4.6) 4 (4.6) 22 (25.6) 9 (10.5) 4 (4.6) 3 (3.5) 4 (4.6) 19 (22.1) 17 (19.8) 86
-
-
1 (3.1) 14 (43.7) 2 (6.2) 2 (6.2) 2 (6.2) 1 (3.1) 4 (12.5) 6 (18.7) 32
3 16 2 1 1 1 6 6 36
The mean age was significantly higher in females than in males, and patients with ATPD were older than those with schizophrenia, which is known to be prevalent in young males [26]. Incidence rates for schizophrenia in 1996 were almost twice as high in males as in females (9.2 vs 4.7 per 100 000 population), with a marked increase of this pattern particularly in the 20-29 year age group (26.8 vs 8.1 per 100 000 population). There are no data with which to make meaningful comparisons. Singh et al [10] estimated an incidence rate of 3.9 per 100 000 population in Nottingham, with a malefemale ratio of 1.87. The unusual male preponderance was adduced to the fact that they were more likely to have a false positive diagnosis of ATPD because only a few cases maintained the initial diagnosis after 3 years. Analysis of admission patterns here undertaken makes it possible to delineate at least 3 subgroups: (1) cases with only 1 psychotic decompensation followed by stable remission (monoepisodic ATPD); (2) cases with 2 or more psychotic episodes (recurrent ATPD); (3) a larger number of cases that heralded onset of longer lasting psychotic or affective disorders. There is also evidence that the greatest variability occurred in the first readmissions after the initial episode because nearly 60% of patients
(8.3) (44.4) (5.5) (2.7) (2.7) (2.7) (16.6) (16.6)
F23.3 3 (2.4) 2 (1.6) 33 (26.2) 16 (12.7) 9 (7.1) 5 (4.0) 7 (5.5) 33 (26.2) 18 (14.3) 126
F23.8 5 (20.0) 6 (24.0) 1 (4.0) 1 (4.0) 3 (12.0) 7 (28.0) 2 (8.0) 25
F23.9 6 (5.4) 3 (2.7) 32 (28.8) 11 (9.9) 3 (2.7) 8 (7.2) 4 (3.6) 23 (20.7) 21 (18.9) 111
F23.x 13 (3.1) 13 (3.1) 122 (29.3) 46 (11.0) 20 (4.8) 20 (4.8) 20 (4.8) 92 (22.1) 70 (16.8) 416
developed another psychiatric diagnosis by the time of their third admission. Follow-up studies suggest that stability of ATPD varies between developing and more developed countries. Sajith et al [27] found a relatively high stability and low rates of relapse over 3 years. This study included a selected cohort of Indian patients with a first-admission diagnosis of polymorphic psychotic disorder without schizophrenic symptoms (F23.0). Another follow-up reported that more than 60% of patients with ATPD did not change diagnosis and only 10% tended to recur after 1 year [28]. Likewise, the acute remitting psychoses have high stability particularly in developing countries, where these disorders show favorable outcome [29,30] but seldom fulfill criteria for ATPD [21]. Most research so far conducted derived from cohorts of patients recruited by cross-cultural studies coordinated by the World Health Organization in the '80s, which were consistent with clinical observations that patients with schizophrenia in developing countries have a better prognosis than those in Europe and North America and included acute onset psychoses that have a greater incidence [31]. In industrialized countries, longitudinal studies have found low to moderate stability rates for ATPD, ranging
Fig. 1. Relative frequency of principal diagnostic changes in patients with F23 ATPD in their last admission: F20 schizophrenia, F22 delusional disorder, F31 bipolar disorder, F32 depressive episode, F33 recurrent depressive disorder, F43 stress reaction and adjustment disorders, F60 personality disorder.
A. Castagnini et al. / Comprehensive Psychiatry 49 (2008) 255–261
from 37% [32] to just more than 50% [10]. Higher rates were reported by Marneros et al [12], Suda et al [13], and Abe et al [33] on extended follow-ups. Apart from the study of Amin et al [32], patients were collected from consecutive admissions (ie, prevalence samples) rather than at their first contact or first admissions to treatment facilities (ie, incidence samples), so variance in diagnostic stability could reflect at least partly differences in sampling methods. Other issues may be ascribed to differences in design for the retrospective nature of some studies, length of follow-ups, distribution of ATPD subtypes, and the small size of samples. In this study, the overall stability was closer to that reported by Amin et al [32] than either of the studies mentioned above. This supports the view that stability of ATPD is not only worse in industrialized countries but also relatively lower in first-admission studies than in consecutive-admission studies, in which patients with a recurrent form of ATPD are probably overrepresented. Acute psychotic and transient disorders is an unstable diagnostic category because of fleeting polymorphic symptoms and short duration assumed to rule out both schizophrenia and delusional disorder [34,35]. It has also been suggested that stability of ATPD might be improved excluding affective features, that is, emotional turmoil [36]. More to the point, patients affected with ATPD are more likely to have an episodic course with longer remission between episodes than those who later develop schizophrenia [13]. Abrupt or acute onset, short duration (b1 month), female sex, and good premorbid functioning predicted diagnostic stability and favorable outcome [10,13,27]. They also are susceptible to life events according to the stress-vulnerability model [37], and an increased reactivity to daily stress may be involved in the pathogenesis of florid psychotic disorders with good prognosis [38]. However, no independent variable recorded in the DPCR such as age on first admission, sex, acute stress, and duration of initial episode was found to be associated with ATPD. In particular, acute stress is an additional coding for the ICD-10 diagnosis of ATPD, so probably underestimated on register reports in that there were only 39 cases (7.7%) with acute stress. Distribution of ATPD included 30% of patients with predominantly delusional disorder (F23.3), whereas the polymorphic psychotic subtypes (F23.0 and F23.1), which are usually reported to be the most frequent subcategories [11,12,27,37], accounted for relatively lower figures. Predominantly delusional disorder has assumed increasing importance because the Scandinavian concept of reactive psychosis has not only become narrower, as result of changes required to accommodate it into the paradigm of ATPD, but also conformed more to delusional disorder among ATPD subcategories [20]. Yet high proportions of the residual classes other (F23.8) and unspecified (F23.9) acute psychotic disorders suggest that the core ATPD-defined polymorphic and schizophrenic disorders may be difficult to apply in the clinical setting.
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Another finding consistent with first-episode psychosis follow-ups [10] is that almost a third of cases with a register diagnosis of ATPD converted to schizophrenia and persistent delusional disorder, whereas only a relatively little proportion to F3 affective disorders. Subgroups combining polymorphic and schizophrenic symptoms (F23.1) and schizophrenia-like psychotic disorder (F23.2) showed a reverse sex distribution, these being preponderant in males, and tended to change more frequently to another category of F2 group schizophrenia and related disorders. Despite the relatively small number of cases, significant differences between the mean age of F23.1 and F23.2 and the overall mean age of ATPD emerged, indicating a closer kinship to schizophrenia. These subcategories have replaced the ICD-9 category acute schizophrenic episode (295.4); their duration is less than 1 month because the ICD-10 diagnosis of schizophrenia should be made when symptoms last longer. Otherwise, follow-up studies that included most polymorphic psychotic disorders, derived from Kleist and Leonhard's cycloid psychoses and the French concept of bouffée délirante, were more likely to report subsequent changes to affective disorders [11,12,27]. Lastly, acute polymorphic psychotic disorder (F23.0) does not have a significantly higher level of stability. This supports the view that neither diagnostic stability nor favorable outcome are associated with any particular subcategory [10,14].
5. Methodological issues Although differences in sampling method and study design make difficult meaningful comparisons with earlier studies, this work compared more favorably with firstepisode psychosis follow-ups [10,32]. Focusing on firstadmission diagnosis is important to exclude cases with a variable duration of illness, which are likely to affect course and stability of ATPD. Register data have been recommended for research purposes on the long-term course of mental disorders as they link information over time and are based on catchment areas that include entire populations [39]. Another methodological advantage pertains the possibility of ensuring that sample includes not only the most common subcategories but also be representative of the entire group of ATPD. However, first-admission rates of ATPD could overestimate the true incidence because Scandinavian views on reactive psychoses, now being subsumed in heading of ATPD, may have affected illness recognition. A further limitation is concerned with reliance on register diagnosis of ATPD, which was not validated. Acute and transient psychotic disorders are known to have a relatively low-diagnostic reliability. Apart from schizophrenia-like
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psychotic disorder, ATPD subcategories failed to achieve established standards of reliability [34]. They depend on whether polymorphic, schizophrenic, or predominant delusional features remit by 1 or 3 months according to symptom duration defined to rule out schizophrenia and persistent delusional disorder. It seems also unlikely that socioeconomical factors may have biased the results in that psychiatric treatment is free of charge and private facilities do not exist in Denmark. 6. Conclusions As might be expected from the fact that ATPD subsume a number of clinical conditions originally described as separate illnesses, this study provides evidence that they form a composite category with uncertain diagnostic stability and argues against the attempt to effect a premature separation from other disorders of F2 group. Nonetheless, acute onset, early remission, shifting polymorphic symptoms, age, and sex differences from schizophrenia are topics that deserve further investigation. Acknowledgment Thanks are due to Mrs G Perto, the programmer of the DPCR, for assistance with the register data analysis. References [1] Kraepelin E. Psychiatrie. 5 Aufl. Leipzig: Barth; 1896. [2] World Health Organization. The ICD-10 classification of mental and behavioural disorders. Diagnostic criteria for research. Geneva: WHO; 1993. [3] Magnan V. Leçon cliniques sur les maladies mentales. Paris: Bataille; 1893. [4] Kleist K. Über zykloide, paranoide und epileptoide psychosen und über die frage der degeneration psychosen. Schweiz Archiv Neurol Psychiatr 1928;23:3-37 (translated by H Marshall. Cycloid, paranoid and epileptoid psychoses and the problem of the degenerative psychoses). In: Hirsh SR, Shepherd M (eds). Themes and variations in European Psychiatry. Bristol: Wright, 1974:297-331. [5] Leonhard K. Aufteilung der endogenen psychosen. Jena: Akademie Verlag; 1957 [translated by R. Berman: The classification of endogenous psychoses. New York: John Wiley & Sons, 1979]. [6] Wimmer A. Psykogene sindssygdomsformer. St Hans Hospital Jubilæums-skcriftet 1816-1916. København: Gad; 1916. p. 85-216. [Edited and translated by J Schioldann. Psychogenic psychoses. Burnside: Adelaide Academic Press, 2003]. [7] Strömgren E. Psychogenic psychoses. In: Hirsch SR, Shepherd M, editors. Themes and variations in European Psychiatry. Bristol: Wright; 1974. p. 102-25. [8] Langfeldt G. The schizophreniform states. Copenhagen: Munksgaard; 1939. [9] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV). Washington (DC): American Psychiatric Press; 1994. [10] Singh SP, Burns T, Amin S, Jones PB, Harrison G. Acute and transient psychotic disorders: precursors, epidemiology, course and outcome. Br J Psychiatry 2004;185:452-9.
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Comprehensive Psychiatry 49 (2008) 255 – 261 www.elsevier.com/locate/comppsych
Incidence and diagnostic stability of ICD-10 acute and transient psychotic disorders Augusto Castagnini a,⁎, Aksel Bertelsen b , German E. Berrios a b
a Department of Psychiatry, University of Cambridge, Cambridge, UK Centre for Basic Psychiatric Research, Aarhus Psychiatric University Hospital, Risskov, DK
Abstract 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 Leonhard's 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. © 2008 Elsevier Inc. All rights reserved.
1. Introduction Although central to the current classification of psychotic disorders, the traditional distinction between schizophrenia and manic depression [1] remains problematic and has encouraged the creation of additional categories to deal with conditions that differ in some respects from the 2 major psychoses. The ICD-10 classification of mental and behavioral disorders [2] introduced, within the group F2 schizophrenia and related disorders, the category F23 acute and transient psychotic disorders (ATPD) to embrace clinical concepts such as the French bouffée délirante [3], Kleist [4] and Leonhard's [5] cycloid psychoses, and the Scandinavian reactive and schizophreniform psychoses [6-8]. Acute and
⁎ Corresponding author. Darwin College, Cambridge CB3 9EU, UK. E-mail address: [email protected] (A. Castagnini). 0010-440X/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2007.10.004
transient psychotic disorders are characterized by (a) acute onset (within 2 weeks); (b) presence of typical syndromes such as polymorphic, schizophrenia-like, or predominantly delusional; and (c) being associated or not with acute psychological stress. Complete recovery is expected by 1 or 3 months according to symptom duration stipulated to exclude, respectively, diagnosis of schizophrenia (F20) and persistent delusional disorder (F22). Yet although “emotional turmoil” and affective symptoms may be prominent, ATPD do not satisfy criteria for either manic (F30) or depressive (F32) episodes. Likewise, the Diagnostic and Statistical Manual of Mental Disorders has listed since its fourth edition [9] a similar, but not identical category, brief psychotic disorder (298.8), which “may follow or not marked stressors” or may have its onset in the postpartum period. The available evidence suggests that ATPD are not frequent [10]. With onset between early and middle adulthood, ATPD are reported as prevalent in females
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[11-13]. Although outcome is more favorable than in schizophrenia, follow-up studies have found high rates of relapse and poor stability since 30% to 60% of patients with ATPD converted either to schizophrenia or affective disorders on the short and long terms [10-15]. Furthermore, there is little concordance between ATPD and the clinical concepts to which they are likely to refer such as bouffée délirante [16], the cycloid psychoses [17-19], the Scandinavian reactive psychoses [20], and the acute remitting psychoses as frequently described in developing countries [21]. Such findings call into question the validity of diagnostic criteria and usefulness of ATPD classification into various subcategories. The methodology developed to test the validity of psychiatric categories suggests that temporal stability be a standard criterion and a measure of their predictive value [22,23]. The assumption behind this approach is that the more stable the diagnosis, the more likely it is to reflecting a common neuropathologic substrate, which enables one to make treatment decisions and to predict the course and outcome of illness. Diagnostic stability also has potential implications for service planning and resource allocation [24]. The purpose of this study was to determine incidence and validity of ATPD in terms of diagnostic stability in a cohort of patients representative of the Danish population. 2. Method Since 1994, ICD-10 has replaced ICD-8 as official classification in Denmark. A 6-year analysis of readmission patterns of all subjects listed in the Danish psychiatric central register (DPCR) as having been first-ever admitted to hospital or treated in outpatient services with a main diagnosis of F23 ATPD from January 1 to December 31, 1996, was conducted. Diagnostic stability was taken to be akin to the proportion of cases with a first-admission diagnosis of ATPD in 1996 that did not develop another psychiatric diagnosis up to the end of 2001. The overall stability rate of ATPD also included those patients who were neither readmitted to hospital nor treated in community-based services after the first episode. According to ICD-10, precedence is given to the most relevant diagnosis (main diagnosis) than others (additional diagnoses); organic (brain) disorders (F0) and schizophrenia and related disorders (F2) take the precedence than
categories lower down in the diagnostic hierarchy (ie, F3, F4, etc). Age and sex-standardized incidence rates were calculated using the Danish population in 1996 and expressed as the number of new cases per 100 000 population. The electronic database of the DPCR is comprehensive of all psychiatric admissions in Denmark, Faeroe Islands, and Greenland and covers about 5.1 million inhabitants. It has stored clinical information on inpatients since 1969 and on outpatient services since 1995. The DPCR provides data for collection of national statistics, mental health planning, and for epidemiological research. Register reports include information taken from case-notes and diagnosis made according to ICD revisions [25]. The reliability of diagnostic assessment is enhanced by uniformity of training in psychiatry throughout the country, comprising supervisions and courses that provide tuition in the Present State Examination for use in conjunction with ICD-10. Six subcategories are listed under heading of ATPD: polymorphic disorder without and with symptoms of schizophrenia (F23.0, F23.1), schizophrenia-like psychotic disorder (F23.2), predominantly delusional disorder (F23.3), other, and unspecified acute and transient psychotic disorder (F23.8, F23.9). A fifth digit may be used to indicate whether each disorder is associated or not with acute stress (F23.x1, F23.x0). Eighty-seven subjects (17.3%) of the initial cohort had died during the study period and were withdrawn from further analyses here undertaken. Because data available for register-based research do not include information that may lead to identification of the subjects being studied, approval from the ethical committee for the DPCR is not required. Data analysis was performed using the Statistical Package for Social Sciences (SPSS; SPSS Inc, Chicago, Ill). 3. Results There were 21 389 subjects coded as having been firstever admitted or treated as outpatient in 1996. Diagnosis of ATPD was found in 503 cases, accounting for 2.3% of all patients and 9.8% of those with nonorganic psychotic and affective disorders (F2 + F3 categories; 34.4% of F2 group). The incidence of ATPD was 9.6 per 100 000 population, with a slightly higher rate of females than males (9.8 vs 9.4 per 100 000). Incidence rates by age group were higher for
Table 1 Incidence of F23 ATPD in 1996 Age groups
Male Female Total
Rates per 100 000 population (numbers in brackets) b19
20-29
30-39
40-49
50-59
N60
All ages
3.5 (22) 3.1 (19) 3.3 (41)
18.7 (74) 14.5 (55) 16.6 (129)
15.6 (63) 14.3 (55) 15.0 (118)
10.3 (40) 8.7 (33) 9.5 (73)
3.7 (12) 9.0 (29) 6.3 (41)
7.2 (32) 11.7 (69) 9.4 (101)
9.4 (243) 9.8 (260) 9.6 (503)
A. Castagnini et al. / Comprehensive Psychiatry 49 (2008) 255–261 Table 2 Patients first-ever admitted with F23 ATPD in 1996 by sex and diagnostic subcategories F23 ATPD
Male
Female
Total (%)
Mean age (SD)
F23.0 F23.1 F23.2 F23.3 F23.8 F23.9 Total
49 19 23 75 10 67 243
52 16 15 81 20 76 260
101 (21.1) 35 (7.0) 38 (7.6) 156 (31.0) 30 (6.0) 143 (28.4) 503 (100.1)
42.3 (18.8) 31.8 (13.9) ⁎ 27.9 (10.6) ⁎⁎ 46.9 (20.8) 35.2 (14.0) 45.4 (22.0) 42.2 (20.2)
⁎ P = .001. ⁎⁎ P b .001.
males than for females, with a marked reversal of this pattern over 50 years (Table 1). The mean age was significantly higher in females than in males (46.2 years vs 37.8 years; P b .001). The most frequent subcategories were predominantly delusional disorder (F23.3), acute and transient psychotic disorder unspecified (F23.9), and polymorphic disorder without symptoms of schizophrenia (F23.0) (Table 2). Most patients with polymorphic and schizophrenic features (F23.1) and schizophrenia-like psychotic disorder (F23.2) were males. Their mean age was significantly lower than the overall mean age of ATPD (respectively, 31.8 years vs 42.2 years, P = .001; 27.8 years vs 42.2 years, P b .001). Eighty-seven subjects had died within the study period. Of the remaining 416 with ATPD, 70 (16.8%) were not readmitted to hospital after their first episode, whereas 346 (83.2%) had been admitted on at least one further occasion by the end of 2001. Admission patterns showed that an increasing number of patients changed diagnosis on subsequent admissions, mainly either to F2 schizophrenia and related disorders or F3 affective disorders (Table 3). In their last admission, the diagnosis of ATPD did not change in 92 cases. The overall stability rate, including those never readmitted after the initial episode, reached only 38.9%. Principal diagnostic changes were F2 schizophrenia and related disorders 29.3%, F3 affective disorders 11.0%, F4 neurotic, stress-related and somatoform disorders 4.8%, F6
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personality disorders 4.8%, F0 organic disorders 3.1%, and F1 psychoactive substance use disorders 3.1% (Table 4). Among F2 categories, F20 schizophrenia and F22 persistent delusional disorder were the most common. Bipolar disorders (F31), depressive episode (F32), and recurrent depressive disorder (F33) accounted for the majority of diagnostic shifts to F3 group (Fig. 1). Polymorphic disorder without symptoms of schizophrenia (F23.0) and predominantly delusional disorder (F23.3) were the most stable subcategories. Only a small number of those with polymorphic and schizophrenic symptoms (F23.1) and schizophrenia-like psychotic disorder (F23.2) were not readmitted. They also were more likely to develop another diagnosis of F2 group (Table 4). The residual categories other (F23.8) and unspecified (F23.9) acute psychotic disorders included almost one third of patients remained with the diagnosis of ATPD. 4. Discussion To our knowledge, this study is the first to evaluate incidence and stability of ATPD in a representative cohort drawn from a psychiatric register comprehensive of inpatient and outpatient admissions that covers an entire country. There were 503 cases listed in the DPCR with a firstadmission diagnosis of ATPD in 1996, accounting for 2.3% of all patients and 9.8% of those with nonorganic psychotic and affective disorders. The incidence of ATPD was 9.6 per 100 000 population with a higher rate of females than males. More than 80% were readmitted on at least one further occasion during the study period. In their last admission, 60% changed diagnosis, half were shifted to another F2 category and 11% to affective disorders. Ninety-two cases retained the diagnosis of ATPD with a stability rate of 38.9%, including those never readmitted after the first episode. Perhaps because of diagnostic habits revolving around the concept of reactive psychosis, commonly used in Denmark as a first-admission diagnosis until adoption of ICD-10 classification in 1994, then subsumed in heading of ATPD as subcategory “with associated acute stress,” incidence rates of ATPD so far reported could overestimate the true incidence.
Table 3 Changes in diagnosis on subsequent admissions in patients with F23 ATPD ICD-10 categories
F23 ATPD F0 organic disorders F1 psychoactive substance use disorders F2 schizophrenia and related disorders F3 affective disorders F4 neurotic and stress-related disorders F6 personality and behavior disorders Other Total
Admission patterns (%) 1st
2nd
3rd
4th
5th
10th
15th
416 (100) -
217 (62.7) 9 (2.6) 14 (4.0) 53 (15.3) 22 (6.3) 13 (3.7) 8 (2.3) 10 (2.9) 346 (83.2)
112 (41.5) 9 (3.3) 9 (3.3) 71 (26.3) 38 (14.1) 12 (4.4) 8 (3.0) 11 (4.1) 270 (78.0)
67 (30.7) 11 (5.1) 7 (3.2) 67 (30.7) 34 (15.6) 17 (7.8) 8 (3.7) 7 (3.2) 218 (80.1)
47 (28.0) 8 (4.8) 6 (3.5) 67 (39.9) 23 (13.7) 7 (4.2) 2 (1.2) 8 (4.8) 168 (62.2)
2 (3.1) 2 (3.1) 4 (6.2) 40 (62.5) 9 (14.1) 3 (4.7) 2 (3.1) 2 (3.1) 64 (38.1)
1 (4.0) 1 (4.0) 1 (4.0) 18 (72.0) 2 (8.0) 1 (4.0) 1 (4.0) 25 (39.1)
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Table 4 Distribution of ICD-10 categories in patients with F23 ATPD in their last admission ICD-10 categories
F0 organic disorders F1 psychoactive substance use disorders F2 schizophrenia and related disorders F3 affective disorders F4 neurotic and stress-related disorders F6 personality and behavior disorders Other F23 ATPD Not readmitted Total
F23 ATPD (%) F23.0
F23.1
F23.2
4 (4.6) 4 (4.6) 22 (25.6) 9 (10.5) 4 (4.6) 3 (3.5) 4 (4.6) 19 (22.1) 17 (19.8) 86
-
-
1 (3.1) 14 (43.7) 2 (6.2) 2 (6.2) 2 (6.2) 1 (3.1) 4 (12.5) 6 (18.7) 32
3 16 2 1 1 1 6 6 36
The mean age was significantly higher in females than in males, and patients with ATPD were older than those with schizophrenia, which is known to be prevalent in young males [26]. Incidence rates for schizophrenia in 1996 were almost twice as high in males as in females (9.2 vs 4.7 per 100 000 population), with a marked increase of this pattern particularly in the 20-29 year age group (26.8 vs 8.1 per 100 000 population). There are no data with which to make meaningful comparisons. Singh et al [10] estimated an incidence rate of 3.9 per 100 000 population in Nottingham, with a malefemale ratio of 1.87. The unusual male preponderance was adduced to the fact that they were more likely to have a false positive diagnosis of ATPD because only a few cases maintained the initial diagnosis after 3 years. Analysis of admission patterns here undertaken makes it possible to delineate at least 3 subgroups: (1) cases with only 1 psychotic decompensation followed by stable remission (monoepisodic ATPD); (2) cases with 2 or more psychotic episodes (recurrent ATPD); (3) a larger number of cases that heralded onset of longer lasting psychotic or affective disorders. There is also evidence that the greatest variability occurred in the first readmissions after the initial episode because nearly 60% of patients
(8.3) (44.4) (5.5) (2.7) (2.7) (2.7) (16.6) (16.6)
F23.3 3 (2.4) 2 (1.6) 33 (26.2) 16 (12.7) 9 (7.1) 5 (4.0) 7 (5.5) 33 (26.2) 18 (14.3) 126
F23.8 5 (20.0) 6 (24.0) 1 (4.0) 1 (4.0) 3 (12.0) 7 (28.0) 2 (8.0) 25
F23.9 6 (5.4) 3 (2.7) 32 (28.8) 11 (9.9) 3 (2.7) 8 (7.2) 4 (3.6) 23 (20.7) 21 (18.9) 111
F23.x 13 (3.1) 13 (3.1) 122 (29.3) 46 (11.0) 20 (4.8) 20 (4.8) 20 (4.8) 92 (22.1) 70 (16.8) 416
developed another psychiatric diagnosis by the time of their third admission. Follow-up studies suggest that stability of ATPD varies between developing and more developed countries. Sajith et al [27] found a relatively high stability and low rates of relapse over 3 years. This study included a selected cohort of Indian patients with a first-admission diagnosis of polymorphic psychotic disorder without schizophrenic symptoms (F23.0). Another follow-up reported that more than 60% of patients with ATPD did not change diagnosis and only 10% tended to recur after 1 year [28]. Likewise, the acute remitting psychoses have high stability particularly in developing countries, where these disorders show favorable outcome [29,30] but seldom fulfill criteria for ATPD [21]. Most research so far conducted derived from cohorts of patients recruited by cross-cultural studies coordinated by the World Health Organization in the '80s, which were consistent with clinical observations that patients with schizophrenia in developing countries have a better prognosis than those in Europe and North America and included acute onset psychoses that have a greater incidence [31]. In industrialized countries, longitudinal studies have found low to moderate stability rates for ATPD, ranging
Fig. 1. Relative frequency of principal diagnostic changes in patients with F23 ATPD in their last admission: F20 schizophrenia, F22 delusional disorder, F31 bipolar disorder, F32 depressive episode, F33 recurrent depressive disorder, F43 stress reaction and adjustment disorders, F60 personality disorder.
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from 37% [32] to just more than 50% [10]. Higher rates were reported by Marneros et al [12], Suda et al [13], and Abe et al [33] on extended follow-ups. Apart from the study of Amin et al [32], patients were collected from consecutive admissions (ie, prevalence samples) rather than at their first contact or first admissions to treatment facilities (ie, incidence samples), so variance in diagnostic stability could reflect at least partly differences in sampling methods. Other issues may be ascribed to differences in design for the retrospective nature of some studies, length of follow-ups, distribution of ATPD subtypes, and the small size of samples. In this study, the overall stability was closer to that reported by Amin et al [32] than either of the studies mentioned above. This supports the view that stability of ATPD is not only worse in industrialized countries but also relatively lower in first-admission studies than in consecutive-admission studies, in which patients with a recurrent form of ATPD are probably overrepresented. Acute psychotic and transient disorders is an unstable diagnostic category because of fleeting polymorphic symptoms and short duration assumed to rule out both schizophrenia and delusional disorder [34,35]. It has also been suggested that stability of ATPD might be improved excluding affective features, that is, emotional turmoil [36]. More to the point, patients affected with ATPD are more likely to have an episodic course with longer remission between episodes than those who later develop schizophrenia [13]. Abrupt or acute onset, short duration (b1 month), female sex, and good premorbid functioning predicted diagnostic stability and favorable outcome [10,13,27]. They also are susceptible to life events according to the stress-vulnerability model [37], and an increased reactivity to daily stress may be involved in the pathogenesis of florid psychotic disorders with good prognosis [38]. However, no independent variable recorded in the DPCR such as age on first admission, sex, acute stress, and duration of initial episode was found to be associated with ATPD. In particular, acute stress is an additional coding for the ICD-10 diagnosis of ATPD, so probably underestimated on register reports in that there were only 39 cases (7.7%) with acute stress. Distribution of ATPD included 30% of patients with predominantly delusional disorder (F23.3), whereas the polymorphic psychotic subtypes (F23.0 and F23.1), which are usually reported to be the most frequent subcategories [11,12,27,37], accounted for relatively lower figures. Predominantly delusional disorder has assumed increasing importance because the Scandinavian concept of reactive psychosis has not only become narrower, as result of changes required to accommodate it into the paradigm of ATPD, but also conformed more to delusional disorder among ATPD subcategories [20]. Yet high proportions of the residual classes other (F23.8) and unspecified (F23.9) acute psychotic disorders suggest that the core ATPD-defined polymorphic and schizophrenic disorders may be difficult to apply in the clinical setting.
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Another finding consistent with first-episode psychosis follow-ups [10] is that almost a third of cases with a register diagnosis of ATPD converted to schizophrenia and persistent delusional disorder, whereas only a relatively little proportion to F3 affective disorders. Subgroups combining polymorphic and schizophrenic symptoms (F23.1) and schizophrenia-like psychotic disorder (F23.2) showed a reverse sex distribution, these being preponderant in males, and tended to change more frequently to another category of F2 group schizophrenia and related disorders. Despite the relatively small number of cases, significant differences between the mean age of F23.1 and F23.2 and the overall mean age of ATPD emerged, indicating a closer kinship to schizophrenia. These subcategories have replaced the ICD-9 category acute schizophrenic episode (295.4); their duration is less than 1 month because the ICD-10 diagnosis of schizophrenia should be made when symptoms last longer. Otherwise, follow-up studies that included most polymorphic psychotic disorders, derived from Kleist and Leonhard's cycloid psychoses and the French concept of bouffée délirante, were more likely to report subsequent changes to affective disorders [11,12,27]. Lastly, acute polymorphic psychotic disorder (F23.0) does not have a significantly higher level of stability. This supports the view that neither diagnostic stability nor favorable outcome are associated with any particular subcategory [10,14].
5. Methodological issues Although differences in sampling method and study design make difficult meaningful comparisons with earlier studies, this work compared more favorably with firstepisode psychosis follow-ups [10,32]. Focusing on firstadmission diagnosis is important to exclude cases with a variable duration of illness, which are likely to affect course and stability of ATPD. Register data have been recommended for research purposes on the long-term course of mental disorders as they link information over time and are based on catchment areas that include entire populations [39]. Another methodological advantage pertains the possibility of ensuring that sample includes not only the most common subcategories but also be representative of the entire group of ATPD. However, first-admission rates of ATPD could overestimate the true incidence because Scandinavian views on reactive psychoses, now being subsumed in heading of ATPD, may have affected illness recognition. A further limitation is concerned with reliance on register diagnosis of ATPD, which was not validated. Acute and transient psychotic disorders are known to have a relatively low-diagnostic reliability. Apart from schizophrenia-like
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psychotic disorder, ATPD subcategories failed to achieve established standards of reliability [34]. They depend on whether polymorphic, schizophrenic, or predominant delusional features remit by 1 or 3 months according to symptom duration defined to rule out schizophrenia and persistent delusional disorder. It seems also unlikely that socioeconomical factors may have biased the results in that psychiatric treatment is free of charge and private facilities do not exist in Denmark. 6. Conclusions As might be expected from the fact that ATPD subsume a number of clinical conditions originally described as separate illnesses, this study provides evidence that they form a composite category with uncertain diagnostic stability and argues against the attempt to effect a premature separation from other disorders of F2 group. Nonetheless, acute onset, early remission, shifting polymorphic symptoms, age, and sex differences from schizophrenia are topics that deserve further investigation. Acknowledgment Thanks are due to Mrs G Perto, the programmer of the DPCR, for assistance with the register data analysis. References [1] Kraepelin E. Psychiatrie. 5 Aufl. Leipzig: Barth; 1896. [2] World Health Organization. The ICD-10 classification of mental and behavioural disorders. Diagnostic criteria for research. Geneva: WHO; 1993. [3] Magnan V. Leçon cliniques sur les maladies mentales. Paris: Bataille; 1893. [4] Kleist K. Über zykloide, paranoide und epileptoide psychosen und über die frage der degeneration psychosen. Schweiz Archiv Neurol Psychiatr 1928;23:3-37 (translated by H Marshall. Cycloid, paranoid and epileptoid psychoses and the problem of the degenerative psychoses). In: Hirsh SR, Shepherd M (eds). Themes and variations in European Psychiatry. Bristol: Wright, 1974:297-331. [5] Leonhard K. Aufteilung der endogenen psychosen. Jena: Akademie Verlag; 1957 [translated by R. Berman: The classification of endogenous psychoses. New York: John Wiley & Sons, 1979]. [6] Wimmer A. Psykogene sindssygdomsformer. St Hans Hospital Jubilæums-skcriftet 1816-1916. København: Gad; 1916. p. 85-216. [Edited and translated by J Schioldann. Psychogenic psychoses. Burnside: Adelaide Academic Press, 2003]. [7] Strömgren E. Psychogenic psychoses. In: Hirsch SR, Shepherd M, editors. Themes and variations in European Psychiatry. Bristol: Wright; 1974. p. 102-25. [8] Langfeldt G. The schizophreniform states. Copenhagen: Munksgaard; 1939. [9] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV). Washington (DC): American Psychiatric Press; 1994. [10] Singh SP, Burns T, Amin S, Jones PB, Harrison G. Acute and transient psychotic disorders: precursors, epidemiology, course and outcome. Br J Psychiatry 2004;185:452-9.
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