Diagnosis, prognosis, and treatment of brief psychotic episodes: a review and research agenda.

Brief psychotic episodes represent an intriguing paradox in clinical psychiatry because they elude the standard knowledge that applies to the persisting psychotic disorders such as schizophrenia. This Review describes key diagnostic considerations such as conceptual foundations, current psychiatric classification versus research-based operationalisations, epidemiology, and sociocultural variations; prognostic aspects including the risk of psychosis recurrence, types of psychotic recurrences, other clinical outcomes, prognostic factors; and therapeutic issues such as treatment guidelines and unmet need of care. The advances and challenges associated with the scientific evidence are used to set a research agenda in this area. We conclude that brief psychotic episodes can be reconceptualised within a clinical staging model to promote innovative translational research and improve our understanding and treatment of psychotic disorders.

A Biased Diffusion Approach to Sleep Dynamics Reveals Neuronal Characteristics.

We propose a biased diffusion model of accumulated subthreshold voltage fluctuations in wake-promoting neurons to account for stochasticity in sleep dynamics and to explain the occurrence of brief arousals during sleep. Utilizing this model, we derive four neurophysiological parameters related to neuronal noise level, excitability threshold, deep-sleep threshold, and sleep inertia. We provide the first analytic expressions for these parameters, and we show that there is good agreement between empirical findings from sleep recordings and our model simulation results. Our work suggests that these four parameters can be of clinical importance because we find them to be significantly altered in elderly subjects and in children with autism.

Nocturnal Dynamics of Sleep-Wake Transitions in Patients With Narcolepsy.

Introduction: We investigate how characteristics of sleep-wake dynamics in humans are modified by narcolepsy, a clinical condition that is supposed to destabilize sleep-wake regulation. Subjects with and without cataplexy are considered separately. Differences in sleep scoring habits as a possible confounder have been examined. Aims and Methods: Four groups of subjects are considered: narcolepsy patients from China with (n = 88) and without (n = 15) cataplexy, healthy controls from China (n = 110) and from Europe (n = 187, 2 nights each). After sleep-stage scoring and calculation of sleep characteristic parameters, the distributions of wake-episode durations and sleep-episode durations are determined for each group and fitted by power laws (exponent α) and by exponentials (decay time τ). Results: We find that wake duration distributions are consistent with power laws for healthy subjects (China: α = 0.88, Europe: α = 1.02). Wake durations in all groups of narcolepsy patients, however, follow the exponential law (τ = 6.2-8.1 min). All sleep duration distributions are best fitted by exponentials on long time scales (τ = 34-82 min). Conclusions: We conclude that narcolepsy mainly alters the control of wake-episode durations but not sleep-episode durations, irrespective of cataplexy. Observed distributions of shortest wake and sleep durations suggest that differences in scoring habits regarding the scoring of short-term sleep stages may notably influence the fitting parameters but do not affect the main conclusion.

Agreement of different methods for assessing sleep characteristics: a comparison of two actigraphs, wrist and hip placement, and self-report with polysomnography.

OBJECTIVE: To assess the agreement of sleep parameters measured by two actigraphs (SOMNOwatch plus, ActiGraph GT3X+) at two different placements (wrist, hip) and of self-reported sleep with polysomnography (PSG). METHODS: We estimated agreement with PSG for total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), number of awakenings after sleep onset (NASO), and sleep efficiency (SE%) for 100 participants of the general population, aged 18-75 years by judging mean differences to PSG and intervals of agreement using Bland-Altman plots. RESULTS: Mean difference to PSG for TST was 8.3 min (95% confidence intervals [CI] -7.4; 24.1) for SOMNOwatch plus (wrist), 39.8 min (95% CI 24.3; 55.3) for self-report, -79.0 min (95% CI -89.0; -68.9) for SOMNOwatch plus (hip), and -81.1 min (95% CI -91.9; -70.4) for GT3X+ (hip), respectively. The width of intervals of agreement differed with the placement of the devices. Mean differences to PSG were higher for hip-based measurements compared with wrist placement for most parameters. CONCLUSIONS: Agreement of sleep parameters assessed by actigraphy with PSG differs with the placement of the device and is limited for hip-based measurements. Agreement of self-report with PSG is comparable to that of actigraphy for some parameters.

Clinical course and personality in reactive, compared with nonreactive, delusional disorder.

OBJECTIVE: Reactive delusional disorder (DD) (with a precipitating factor) has been postulated to differ clinically from nonreactive DD and to show a better prognosis. Our study tests this hypothesis in a sample of patients with persistent DD (International Classification of Diseases, 10th Revision) or DD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) followed during a period of more than 10 years. METHOD: As part of a long-term study on DD, 19 patients with DD and a stressful life event preceding the onset of the disorder were compared with 24 DD patients without such a life event. Diagnoses, social and biographical data, life events, and outcome were assessed by a semistructured interview and validated rating scales. Personality features were assessed by the NEO Five-Factor Inventory and by the Inventory of Clinical Personality Accentuations. RESULTS: Patients with reactive DD tended to be somewhat younger but showed otherwise little differences to patients with nonreactive DD. In particular, there were no differences in the course of the disorder. However, patients with reactive DD were significantly more often in a stable relationship and showed higher values on neuroticism and more pronounced dependent and borderline personality accentuations in dimensional personality measures. CONCLUSIONS: Reactive DD was not found to have a better prognosis than nonreactive DD. However, the results suggest an increased vulnerability for interpersonal conflicts in these patients.

Acute and transient psychotic disorders versus persistent delusional disorders: a comparative longitudinal study.

AIM: The aim of this work is to investigate differences between two non-schizophrenic, non-organic psychotic disorders, namely persistent delusional disorders (PDD) and acute and transient psychotic disorders (ATPD) according to ICD-10. METHOD: In a prospective and longitudinal study, we compared all 43 inpatients with PDD who were treated at Halle-Wittenberg University Hospital during a 14-year period to a previously investigated cohort of 41 patients with ATPD in regard to demography, long-term symptomatic outcome, and social consequences. Sociobiographical data were collected using a semi-structured interview. Follow-up investigations were performed at a mean of 10-12 years after the onset of the disorder using standardized instruments. RESULTS: With the exception of the duration of the psychotic symptoms, the PDD patients were significantly different from the ATPD patients on various levels, such as sex ratio (female predominance only in ATPD), age at onset (older in PDD), the number of preceding stressful life-events in the index hospitalization (more frequent in ATPD), richness and variety of symptoms (higher in ATPD), and persistence of positive psychotic symptoms (in PDD). Patients with PDD had significantly less re-hospitalizations during the course of their illness. Long-term outcome was marked by chronicity of delusional symptoms and lower global functioning in PDD than in ATPD, while negative symptoms and loss of independence were infrequent in both conditions. CONCLUSIONS: PDD differs from ATPD not only in the duration of the psychotic symptoms, but also in a variety of significant variables. They appear to be two separate entities within a psychotic spectrum.

Delusional disorders--are they simply paranoid schizophrenia?

OBJECTIVES: This article tries to give an answer to the question of whether International Classification of Diseases (ICD-10) persistent delusional disorder (PDD) or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) delusional disorder (DD) is simply paranoid schizophrenia (PS). Because ICD-10 PDD and DSM-IV DD are identical, we use DD as a synonym. METHODS: A prospective and longitudinal study compared all inpatients with DD treated at the Halle-Wittenberg university hospital during a 14-year period with a previously investigated selected cohort of patients with PS. Sociodemographic data, symptomatology, course, and outcome parameters were examined using standardized instruments. The duration of the follow-up period in patients with DD was 10.8 years and for the PS patients 12.9 years. RESULTS: Significant differences between DD and PS were found: DD patients are, in comparison to patients with PS, significantly older at onset. Less of their first-degree relatives have mental disorders. They less frequently come from a broken home situation. First-rank symptoms, relevant negative symptoms, and primary hallucinations did not occur in patients with DD. Patients with DD were less frequently hospitalized, and the duration of their hospitalization was shorter. Their outcome is much better regarding employment, early retirement due to the disorder, and psychopharmacological medication. They more often had stable heterosexual partnerships and were autarkic. They had lower scores in the Disability Assessment Scale and in Positive and Negative Syndrome Scale. The diagnosis of DD is very stable over time. CONCLUSIONS: The findings of this study support the assumption that DDs are a separate entity and only exceptionally can be a prodrome of schizophrenia.

Gender-related features of persistent delusional disorders.

This paper presents gender-related features of Delusional Disorder. It is part of the Halle Delusional Syndromes Study (HADES-Study). All inpatients fulfilling the DSM-IV/ICD-10 criteria of Delusional Disorder/Persistent Delusional Disorder (DD) during a 14-year period were included and followed up for an average of 10.8 years. Gender distribution was almost equal, women became ill significantly later than men, and almost all women had a stable diagnosis-in contrast to men. The great majority of women, at the end of the follow-up period, had an unremitted DD. Women more frequently had low social functioning at admission, but then were more compliant and received more frequently pharmacological medication. There were no differences in the delusional topic and no differences regarding long-term disability and autarky. In spite of previous reports, the HADES-Study found no gender difference in the frequency of DD. However, men tended more frequently to change into schizophrenia and schizoaffective disorder. In these cases, the DD might have been a prodrome of schizophrenia or schizoaffective disorder, which manifests later in life. Although in both female and male DD patients, the majority remained unremitted, almost none of them lost their autarky (independent living). While women more frequently received psychopharmacological medication, their DD was usually found to be unremitted.

Complex dream-enacting behavior in sleepwalking.

OBJECTIVE: Currently, dream-enacting behaviors are viewed as occurring typically in association with a REM-sleep behavior disorder. In some cases, dream-like mentation is found also in non-REM parasomnia. METHODS: We report a case of complex and dramatic sleepwalking behavior in a 26-year-old adult male who tied his 4-month-old daughter to the clothesline in the attic of his house. RESULTS: The explanation of this seemingly senseless behavior, which was related to psychosocial stressors, was found in a detailed dream-like mentation that was reported by the patient. At the same time, an organic factor, namely, a worsening of the patient's asthma, was identified as the cause of an increased fragmentation of sleep. CONCLUSIONS: In some cases of non-REM parasomnia, detailed dream-like mentation may act as a bridge between psychosocial stressors and the specific parasomnic behavior.

Late-life somnambulism after therapy with metoprolol.

We present a case involving a 66-year-old woman with a history of childhood somnambulism who presented with a recent recurrence of sleepwalking. The diagnosis of somnambulism was confirmed polysomnographically and linked etiologically to the start of using metoprolol, a lipophilic beta-blocker, for treating her hypertension. The parasomnia disappeared completely after discontinuation of the drug. Recurrence of non-REM parasomnias, such as somnambulism, has previously been described as an adverse effect of the beta-blocker, propranolol, solely in patients with migraine. There was no history of migraine in the patient presented here. The clinical significance of the findings and possible underlying mechanisms are discussed.

Is there evidence in the EEG for increased epileptiform activity in ICD-10 acute and transient psychotic disorder?

BACKGROUND: The aim of this study was to examine whether there is electroencephalographic evidence for an increased epileptiform activity in the EEG of ICD-10 acute and transient psychotic disorders (ATPD; F23) as a hint for a closer relationship to epilepsy. METHODS: We analyzed the EEGs of 39 inpatients with ATPD, comparing them with 'positive' schizophrenic and bipolar schizoaffective controls matched for age and gender. The evaluation was performed visually and qualitatively using a rating scale of demonstrated reliability. RESULTS: We found no indication of an increased incidence of epileptiform discharges in ATPD compared with 'positive' schizophrenic and bipolar schizoaffective controls. CONCLUSION: The hypothesis of a relationship between ATPD and epilepsy could not be confirmed by EEG findings.

Longitudinal follow-up in acute and transient psychotic disorders and schizophrenia.

We prospectively studied the long-term course of individuals with acute and transient psychotic disorders and a control group with positive schizophrenia matched for age and gender. Follow-up investigations using standardised instruments were performed at three time-points covering 7 years after the index episode or 12 years after the first episode. During follow-up, those with positive schizophrenia experienced a deterioration in their general functioning whereas those with acute and transient psychotic disorders retained their high level of functioning. At the end of the observation period, 12 out of 39 (31%) of those with acute and transient psychotic disorders were functioning well without medication compared with 0 out of 38 with positive schizophrenia.

Is the psychopathology of acute and transient psychotic disorder different from schizophrenic and schizoaffective disorders?

OBJECTIVE: This study explores psychopathological aspects of acute and transient psychotic disorders (ATPD), a diagnostic category introduced with ICD-10, to elucidate its relationship with schizophrenia and schizoaffective psychoses. METHODS: We recruited all consecutive inpatients fulfilling the ICD-10 criteria of ATPD (F23) during a 5-year period as well as control groups with "positive" schizophrenia (PS) and bipolar schizoaffective disorder (BSAD) matched for gender and age at index episode. For the evaluation of psychopathological parameters during index episode a standardized symptom list was used. Prepsychotic (prodromal) symptoms were also assessed. RESULTS: During the prepsychotic period few differences between the groups were detected. The most important difference between ATPD and the other two other psychotic disorders regarding phenomenology of the full-blown episodes was a higher frequency of "rapidly changing delusional topics", "rapidly changing mood" and anxiety in ATPD. CONCLUSION: ATPD show a characteristic psychopathological picture consistent with earlier concepts such as cycloid psychoses and bouffée délirante. Nevertheless, psychopathology alone is not enough to establish ATPD as an independent nosological entity.

What is schizophrenic in acute and transient psychotic disorder?

Acute and transient psychotic disorder (ATPD) is supposed to differ from schizophrenia, but little research has been done on the subject. In a prospective longitudinal case control study we compared all inpatients with ATPD (ICD-10 F23) treated at Halle University Hospital during a 5-year period with matched controls with "positive" schizophrenia (PS) and with mentally healthy controls. Followup investigations were performed at a mean of 2.2 years after the index episode or 8.2 years after the first episode. Female preponderance in ATPD was marked (78.6%). ATPD and PS patients were similar to each other (but different from healthy controls) in the prevalence of a "broken home" situation and a family history for mental disorders. Compared with PS patients, ATPD patients showed better premorbid social adaptation, and they more often displayed rapidly changing symptoms in the index episode and a negative life event preceding the episode. Despite comparable relapse rates, at followup ATPD patients showed better social adaptation, less psychological impairment, and better global functioning than PS patients. These data support the delineation of ATPD from schizophrenia.

Personality and social interactions in patients with acute brief psychoses.

Although a particularly vulnerable personality has been postulated by some authors as a pathogenetic factor in acute and transient psychotic disorders (ATPD) as introduced with ICD-10, little empirical work has been done on the subject. We therefore evaluated personality features and social interactions in a comparative study of patients with ATPD. We recruited all consecutive inpatients fulfilling the ICD-10 criteria of ATPD (F23) during a 5-year period, as well as control groups with "positive" schizophrenia (PS) and bipolar schizoaffective disorder (BSAD) matched for gender and age at index episode. For assessment of personality features and premorbid social contacts, we administered the NEO Five-Factor Inventory and a semi-structured interview. The assessment of the "Big Five" personality dimensions (neuroticism, extraversion, openness to experience, agreeableness, conscientiousness) with the NEO-FFI did not show any significant difference between ATPD patients and healthy controls. BSAD patients differed from mentally healthy controls on 2 of 5 subscales of the NEO-FFI (neuroticism, extraversion), but were otherwise indiscernible from ATPD patients and mentally healthy controls. In contrast, PS patients showed the most pronounced differences from the mentally healthy controls on the NEO-FFI, and had significantly less premorbid social interaction than the clinical controls. Within the limits of retrospective assessment, the present findings indicate that (1) patients with ATPD do not share the premorbid social impairment characteristic of schizophrenic patients and (2) the personality of patients with ATPD does not differ substantially from the general population.

Bouffée délirante and ICD-10 acute and transient psychoses: a comparative study.

OBJECTIVE: ICD-10 acute and transient psychotic disorder (ATPD; F23) has one of its historical roots in the French concept of bouffée délirante. This study explores the empirical relationship of the two concepts. METHOD: During a 5-year period, all inpatients with ATPD were identified; the diagnosis of bouffée délirante was also determined. We systematically evaluated demographic and clinical features and carried out follow-up investigations at an average of 2.2 years after the index episode using standardized instruments. RESULTS: Forty-two (4.1%) of 1036 patients treated for psychotic disorders or major affective episode fulfilled the ICD-10 criteria of ATPD. Of these, only 28.6% also fulfilled the criteria of bouffée délirante. Patients with bouffée délirante were significantly younger than the remaining ATPD patients. Outcome parameters were generally more favourable for patients diagnosed with bouffée délirante than for ATPD patients without a concurrent diagnosis of bouffée délirante, but the difference was statistically significant only for occupational status. CONCLUSIONS: There are indications that a diagnosis of bouffée délirante carries a somewhat better prognosis than ATPD in general. However, the low frequency of operationally diagnosed bouffée délirante suggests that the criteria might be too narrow.

Suicidal behavior in acute and transient psychotic disorders.

The aim of the study was to investigate the frequency and characteristics of suicidal behavior in a cohort of patients with acute transient psychotic disorder (ATPD), diagnosed according to ICD-10 (F23). In a longitudinal study, 42 patients fulfilling the ICD-10 criteria of ATPD were investigated in comparison to matched control groups with 'positive schizophrenia' (PS) and bipolar schizoaffective disorder (BSAD). Suicidal behavior was studied in the index episode and during the long-term course, including a 5-year prospective follow-up. The prevalence of suicidal behavior during the entire course of illness in ATPD was 35.7% compared to 57.1% in BSAD and 40.5% in PS. The difference was not significant when the duration of the illness was taken into account. Suicidal behavior in ATPD was associated with the acute episode, while in PS, suicidal behavior mainly occurred during the longitudinal course. In logistic regression models, suicidal behavior was associated with a higher educational level and lower conscientiousness in the NEO Five-Factor Inventory for patients with PS, but not ATPD. Suicidal behavior in ATPD is frequent, in particular during the acute episode. It seems to be associated with the dramatic psychotic symptomatology during the acute episode.

A comparison of DSM-IV brief psychotic disorder with "positive" schizophrenia and healthy controls.

To determine the psychosocial features, course, and outcome of DSM-IV brief psychotic disorder (BPD) in a comparative study, we recruited a cohort of 26 consecutive inpatients fulfilling DSM-IV criteria of BPD as well as a control group with "positive" schizophrenia (PS) and psychiatrically healthy controls matched for age and sex. Demographic and clinical features were systematically evaluated and follow-up investigations were performed at an average of 2.1 years after the index episode or 7.8 years after onset of the disorder using standardized instruments. The index group of 26 cases represented 2.5% of 1,036 patients treated as inpatients for psychotic disorders or major affective episode during the 5-year inclusion period. Eighty-one percent of the BPD patients were female. Indicators of premorbid functioning slightly favored BPD patients. Age at first episode and episode frequency did not differentiate between BPD and PS patients. Relapse was frequent in both groups. At follow-up BPD patients had a significantly more favorable outcome than patients with PS as evidenced by employment, independent living, social role functioning, psychological impairment, and global functioning. As a group, in many respects BPD patients approached the status of psychiatrically healthy controls. DSM-IV BPD is a psychotic disorder of favorable prognosis despite frequent relapse.