Diagnostic stability over 2 years in patients

with acute and transient psychotic disorders

KAIRE AADAMSOO, ERIKA SALUVEER, HARRI KÜÜNARPUU,
VEIKO VASAR, EDUARD MARON

Aadamsoo K, Saluveer E, Küünarpuu H, Vasar V, Maron E. Diagnostic stability over 2 years in

patients with acute and transient psychotic disorders. Nord J Psychiatry 2011;65:381–388.
Nord J Psychiatry Downloaded from informahealthcare.com by Deakin University on 10/06/13

Objective: The nosological entity of acute and transient psychotic disorders (ATPD) as an
independent diagnostic category has become a subject of controversial opinions. The present
study aimed to follow-up the diagnostic stability of index episode of ATPD and to examine the
influence of clinical and socio-demographic factors on the ATPD prognosis. Method: A sample
of 153 (60.1% females; mean age 27.8 ⫾ 8.2) first-admitted patients with ATPD was followed
over 2 years. The clinical manifestations, global functioning and quality of life were regularly
evaluated during follow-up period. Results: At the end of follow-up, the overall stability rate of
ATPD, excluding the cases not readmitted until last assessment, reached 34%. The diagnostic
transition was observed in 35.9% of the patients, mostly to schizophrenia and schizoaffective
disorders. There was a significant deterioration in several clinical and social indicators among
the patients who developed schizophrenia, compared with those with stable ATPD, whereas no
reliable predictors were found for diagnostic transition to schizophrenia, except younger age,
For personal use only.

unmarried status and period of the first hospitalization. Conclusion: A sizeable proportion of
the patients with initial diagnosis of ATPD is likely to represent early manifestations of
schizophrenia-related disorders. In agreement with some previous observations, our study
indicates a lack of strong rationale for separating ATPD from other psychotic disorders within
the ICD-10 F2 category.
∑ acute and transient psychotic disorders; schizophrenia; follow-up; first-episode psychosis

Kaire Aadamsoo, M.D., Head of Psychiatry Clinic, North Estonia Medical Centre Foundation,
J. Sütiste tee 19, Tallinn 13419, Estonia, E-mail address: kaire.aadamsoo@regionaalhaigla.ee;
Accepted 21 February 2011.

A cute and transient psychotic disorders (ATPD) are

characterized by the acute onset psychotic spectrum
symptoms associated with psychological distress (ICD-10).
The ATPD comprise 8–9% of all psychotic disorders (1),
whereas incidence rate may vary across different cohorts
from 3.9 to 9.6 per 100,000 population, with slightly
higher prevalence among females (2, 3). Although ATPD
are postulated to have more favourable outcomes than
schizophrenia, increased rates of relapse and poor stabil-
ity were demonstrated: 30–60% of patients with ATPD
converted to either affective disorders or schizophrenia in
the short or long term (3–5). To date, only few readmis-
sion and prospective studies have evaluated the diagnos-
tic stability of ATPD among first-admitted patients with
psychosis (2). Overall, these studies reported low relapse
rates and relatively high diagnostic stability of ATPD in
developing countries (6–8), whereas the findings were
more variable for industrialized countries. Particularly,
the stability rate of ATPD was 52% in a Danish study
showing diagnostic change in half of 46 patients after
1-year follow-up: 15% converted to schizophrenia, 28%
to affective disorders and 33% relapsed (4). In the study
of Singh et al. (5), the diagnosis of ATPD was more sta-
ble among females than in males of British descent (73%
vs. 14%, respectively) after a 3-year follow-up, whereas
schizophrenia or delusional disorder were the most com-
mon new diagnoses in both genders. Another longitudinal
study with an average observation time of 10 years dem-
onstrated that 54% of German descent psychotic patients
had monomorphous course of ATPD and only 8% deve-
loped schizophrenia during follow-up (9). Recently,
Castagnini et al. (3) conducted a 6-year analysis of read-
mission patterns of 503 patients with ATPD drawn from
the Danish cohort of psychiatric register comprehensive
of inpatient and outpatient admissions. At the last admis-
sion, the diagnosis of ATPD remained unchanged in 39%
of the cases, including those never readmitted after the
first episode; however, half of the changed diagnoses

© 2011 Informa Healthcare DOI: 10.3109/08039488.2011.565800

 K. AADAMSOO ET AL.
were shifted to another psychotic category and 11% to
affective disorders.
Taken together, the diagnostic stability of ATPD contin-
ues to be a challenging topic in the research on psychotic
disorders. Most of the published follow-up studies on
ATPD were conducted in small samples, suggesting that
their data should be considered with caution. The under-
standing of diagnostic stability of ATPD over time has
implications for long-term prognosis and appropriate man-
agement of these patients. In the present study, we evalu-
ated the stability of first-admission diagnosis of ATPD
over 2 years follow-up in one of the largest sample of
ATPD drawn from an Estonian population. We also exam-
ined the role of psychopathological and socio-demographic
factors in the diagnostic shift and accessed social adjust-
Nord J Psychiatry Downloaded from informahealthcare.com by Deakin University on 10/06/13
ment of the patients during observation period.
Methods
The study sample consisted of 153 patients who met the
diagnostic criteria for ATPD on admission to the Psychia-
try Clinic of North Estonia Medical Centre Foundation
(Tallinn, Estonia) in 2002–2007 because of their index
episode. The catchment area of this clinic is approximately
625,000 inhabitants and approximately 300 new patients
For personal use only.
with first-episode psychosis, about 8% of them comprising
the ATPD, admitted to hospital each year. The diagnoses of
ATPD were reviewed and formulated by two experienced
research psychiatrists on the basis of a checklist incorpo-
rating ICD-10 research criteria. The both psychiatrists
previously acted as responsible investigators in several
clinical trials in psychotic patients and had regularly per-
formed rater-trainings to establish a high inter-rater reli-
ability. Kappa values for the diagnostic reliability achieved
0.90. The same psychiatrists also determined the reasons
for changes in the diagnosis during the follow-up period.
Only subjects for whom a diagnostic consensus was reached
and who gave informal consent were included in the
study. The subjects who had significant substance-related
disorders, mental retardation, or organic mental disorders
during the index hospitalization and the follow-up period
were excluded. Complementary to the psychiatric exami-
nation and interviews, the Brief Psychiatric Rating Scale
(BPRS) was used to evaluate the manifestation and
severity of psychotic symptoms. The patients were re-
interviewed 6, 12 and 24 months after the enrolment, and
assessed in the interim if needed. Several socio-demographic
and background characteristics, including age, gender,
years of education, marital and occupational status, and
risk, were evaluated for associations with the diagnostic
status at first admission and during observation period.
Additionally, the level of functioning and quality of
life were assessed in all patients during first admission
and during follow-up using the Global Assessment of
Functioning (GAF) and WHO Quality of Life (QOL)
382
scale. The number and duration of further hospitalizations
were recorded for those patients who were re-admitted
during the study. After the first admission, 150 (98%)
patients received antipsychotic medication, mostly atypi-
cal antipsychotics (Table 1) that was individually man-
aged over the study follow-up period.
Data analysis
The data were analysed using the software package Sta-
tistica 8 (StatSoft Inc., Tulsa, OK, USA). The compari-
sons of socio-demographic and clinical data between
groups were done by the chi-square (χ2) test and one-way
analyses of variance (ANOVA) as appropriate. Data are
presented as the means ⫾ standard deviations. Multiple
logistic regressions were done to analyse the relative
contribution of predictive characteristics. Only the char-
acteristics showing a significant relationship with diag-
nostic changes in univariate analyses were entered into
multivariate models. For all statistical analyses, a P-value
⬍0.05 was considered statistically significant.
Results
Characteristics of patients at index admission
Table 2 shows the clinical and socio-demographic charac-
teristics of the patients with ATPD as evaluated at their
first hospitalization. The most frequent subcategory of
ATPD was acute schizophrenia-like psychotic disorder
(F23.2) followed by acute polymorphic psychotic disorder
with symptoms of schizophrenia (F23.1) and polymorphic
disorder without symptoms of schizophrenia (F23.0). Sixty
per cent of followed-up patients were females, whereas a
significantly higher proportion of female patients was
among F23.0 subgroup (χ2 ⫽ 20.5, df ⫽ 5, P ⫽ 0.001
when all subgroups were compared and χ2 ⫽ 17.9, df ⫽ 2,
P ⫽ 0.0001, when only F23.0, F23.1 and F23.2 sub-
groups were compared). Furthermore, the F23.0 subgroup
was characterized by higher mean age (F(2,13) ⫽ 3.93,
P ⫽ 0.02) and slightly higher educational level (F(2,13) ⫽
2.42, P ⫽ 0.09) compared with F23.1 and F23.2 subgroups.
Table 1. The frequency of prescribed antipsychotic medications
in acute and transient psychotic disorders (ATPD) patients at the
first admission.
Type Number
FGA 2 (1%)
Clozapine 2 (1%)
Amisulpride 15 (10%)
Olanzapine 66 (43%)
Risperidone 41 (27%)
Sertindole 5 (3%)
Quetiapine 13 (9%)
Other (e.g. sulpiride) 6 (4%)
None 3 (2%)
FGA, first-generation antipsychotics.
NORD J PSYCHIATRY·VOL 65·NO 6·2011
 DIAGNOSTIC STABILITY IN PATIENTS WITH PSYCHOTIC DISORDERS

Table 2. Socio-demographic and clinical characteristics of patients with acute and transient psychotic disorders (ATPD) at the first
admission.

Education Single Employed/ Hazardous

Code Number Females Age (years) Married living studying behaviour BPRS score GAF score QOL score

F23.0 38 (25%) 34 (89%) 30.8 ⫾ 10.3 13.7 ⫾ 2.2 15 (40%) 6 (16%) 23 (61%) 6 (16%) 39.7 ⫾ 23.4 41.1 ⫾ 26.8 45.0 ⫾ 15.0
F23.1 44 (29%) 20 (45%) 25.9 ⫾ 6.4 12.7 ⫾ 2.9 17 (39%) 6 (14%) 28 (64%) 15 (34%) 37.8 ⫾ 12.7 32.2 ⫾ 11.3 48.4 ⫾ 9.8
F23.2 54 (35%) 31 (57%) 27.1 ⫾ 7.7 12.5 ⫾ 3.1 12 (22%) 7 (13%) 37 (69%) 8 (15%) 39.1 ⫾ 15.9 35.7 ⫾ 19.0 46.6 ⫾ 13.2
F23.3 4 (3%) 2 (50%) 28.8 ⫾ 7.2 12.3 ⫾ 3.6 1 (25%) 1 (25%) 2 (50%) 0 (0%) 21.5 ⫾ 2.4 45.5 ⫾ 8.4 33.5 ⫾ 23.0
F23.8 10 (6%) 4 (40%) 26.9 ⫾ 8.4 13.7 ⫾ 1.8 4 (40%) 2 (20%) 4 (40%) 2 (20%) 35.9 ⫾ 11.3 35.7 ⫾ 13.0 45.5 ⫾ 7.8
F23.9 3 (2%) 1 (33%) 31.0 ⫾ 4.4 14.3 ⫾ 2.9 2 (67%) 0 (0%) 1 (33%) 1 (33%) 41.3 ⫾ 17.2 31.3 ⫾ 15.0 52.3 ⫾ 3.5

F23.0, acute polymorphic psychotic disorder without symptoms of schizophrenia; F23.1, acute polymorphic psychotic disorder with symptoms of
schizophrenia; F23.2, acute schizophrenia-like psychotic disorder; F23.3, other acute predominantly delusional psychotic disorders; F23.8, other acute
and transient psychotic disorders; F23.9, acute and transient psychotic disorder, unspecified.
BPRS, Brief Psychiatric Rating Scale; GAF, Global Assessment of Functioning; QOL, WHO Quality of Life scale.
Note: see statistics in Method section.
Nord J Psychiatry Downloaded from informahealthcare.com by Deakin University on 10/06/13

These differences disappeared when all diagnostic sub-
groups were compared (P ⫽ 0.13 and P ⫽ 0.25, respec-
tively). The subgroups did not significantly differ from
each other in respect to the number of married subjects
(P ⫽ 0.30), living alone (P ⫽ 0.94) or being employed
or studying (P ⫽ 0.49). The higher number of patients
having hazardous behaviour was observed in F23.1 sub-
group compared with F23.0 and F23.2 subgroups (χ2 ⫽ 6.3,
For personal use only.
patients, whereas in nine (5.9%) patients the initial ATPD
diagnosis was changed to another ATPD diagnostic sub-
type. The overall stability rate of ATPD, excluding those
not readmitted until last assessment, reached 34%. The
diagnosis was changed to another category in 55 (35.9%)
patients, mostly to schizophrenia (63.6%) or schizoaffec-
tive disorders (32.7%). The diagnostic shift to schizophre-
nia was predominantly observed in the patients with initial

df ⫽ 2, P ⫽ 0.04); however, this difference did not reach
statistical significance when all subgroups were compared
(P ⫽ 0.17). Neither BPRS nor GAF or QOL scores sig-
nificantly differed between the diagnostic subgroups at
the first admission (P ⫽ 0.47, P ⫽ 0.34 and P ⫽ 0.28,
respectively, when all subgroups were compared; P ⫽ 0.88,
P ⫽ 0.12 and P ⫽ 0.49, respectively, when F23.0, F23.1
and F23.2 subgroups were compared).
The diagnostic stability over follow-up
From the 153 patients, 46 (30.1%) dropped out from
follow-up, whereas 107 (69.9%) had attended all face-to-
face interviews and re-assessments over 2 years. The lower
rate of drop-outs was in F23.2 subgroup (Table 3). Taken
together, after the 2-year follow-up period the initial
diagnosis of ATPD remained unchanged in 43 (28.1%)
F23.1 or F23.2 diagnosis. In order to explore, whether
ATPD group without schizophrenia symptoms was differ-
ing from those with schizophrenia symptoms in terms of
diagnostic stability, we compared the main follow-up out-
comes between the F23.0 group and the combined F23.1
and F23.2 group. A significantly higher percentage of drop-
outs was noted in the F23.0 group compared with the
F23.1 ⫹ F23.2 group (36.8% vs. 25.9%; χ2 ⫽ 7.6, P ⫽
0.006). However, the rate of diagnostic stability was simi-
lar between the two groups (31.6% vs. 35.3%; χ2 ⫽ 0.1,
P ⫽ 0.73). The percentage of transition to schizophrenia
was significantly higher for the F23.1 ⫹ F23.2 group
compared with the F23.0 group (29.0% vs. 10.5%; χ2 ⫽
5.4, P ⫽ 0.02), whereas no significant difference was
observed in respect to the diagnostic change to schizoaf-
fective category (9.9% vs. 21.1%; χ2 ⫽ 2.8, P ⫽ 0.09).

Table 3. Acute and transient psychotic disorders (ATPD) diagnostic stability over 2 years.

Code Initial Drop-out Same F23 Other F23 F20 F22 F25

F23.0 38 14 (36.8%) 11 (29.0%) 1 (2.6%) 4 (10.5%) 0 (0%) 8 (21.1%)

F23.1 44 13 (29.6%) 14 (31.8%) 4 (9.1%) 10 (22.7%) 0 (0%) 3 (6.8%)
F23.2 54 12 (22.2%) 15 (27.8%) 1 (1.9%) 19 (35.2%) 0 (0%) 7 (12.9%)
F23.3 4 2 (50.0%) 1 (25.0%) 0 (0%) 0 (0%) 1 (25.0%) 0 (0%)
F23.8 10 3 (30.0%) 2 (20.0%) 2 (20.0%) 2 (20.0%) 1 (10.0%) 0 (0%)
F23.9 3 2 (66.7%) 0 (0%) 1 (33.3%) 0 (0%) 0 (0%) 0 (0%)

F23, acute and transient psychotic disorder; F20, schizophrenia; F22, persistent delusional disorders; F25, schizoaffective disorders; F23.0, acute
polymorphic psychotic disorder without symptoms of schizophrenia; F23.1, acute polymorphic psychotic disorder with symptoms of schizophrenia;
F23.2, acute schizophrenia-like psychotic disorder; F23.3, other acute predominantly delusional psychotic disorders; F23.8, other acute and transient
psychotic disorders; F23.9, acute and transient psychotic disorder, unspecified.
Note: see statistics in Method section.

NORD J PSYCHIATRY·VOL 65·NO 6·2011 383

 K. AADAMSOO ET AL.
The prediction of diagnostic transition
Several background characteristics were compared between
the patients who remained diagnosed with ATPD during
follow-up and those who changed to schizophrenia, in order
to identify the factors that may predict diagnostic transition
(Table 4). These two groups did not significantly differ by
gender, years of education, living situation, occupational
status or risk. However, at the baseline, the patients who
developed schizophrenia were significantly younger and
were less likely to be married. There were no significant
differences in the mean scores of BPRS, GAF or QOL
scales between the two diagnostic groups. Although QOL
scores at the baseline assessment were somewhat lower in
the patents who developed schizophrenia than in those who
remained diagnosed with ATPD, this difference did not
Nord J Psychiatry Downloaded from informahealthcare.com by Deakin University on 10/06/13
reach statistical significance (Table 4). The first hospitaliza-
tion was significantly longer in the patients whose diagno-
sis was later changed to schizophrenia compared with the
patients with stable ATPD (Table 4). A logistic regression
analysis was performed to determine whether the examined
factors were significant predictors of change to the diagno-
sis of schizophrenia. This analysis revealed that the transi-
tion to the diagnosis of schizophrenia was associated with
younger age (β ⫽ ⫺0.22, P ⫽ 0.037) and unmarried status
(β ⫽ ⫺0.33, P ⫽ 0.002) at first admission as well as
For personal use only.
with a longer period of the first hospitalization (β ⫽ 0.32,
P ⫽ 0.003). There was no significant difference in the distri-
bution of medications between the two groups (χ2 ⫽ 4.0,
P ⫽ 0.86), although in both groups the most prescribed
antipsychotic was olanzapine (Fig. 1).
Comparison of diagnostic groups at follow-up
assessments
The data on the last assessment showed that several socio-
demographic and clinical characteristics significantly
distinguished the patients who remained diagnosed with
Table 4. Comparison of characteristics between stable acute and transient psychotic disorders (ATPD) and schizophrenia at index
admission.
Characteristics F23 (n ⫽ 52)
Gender (M/F) 18/34
Age 29.0 ⫾ 8.7
Education (years) 13.3 ⫾ 2.4
Married 22 (42.3%)
Single living 9 (17.3%)
Employed or studying 38 (73.1%)
Hazardousness 9 (17.3%)
BPRS score 37.1 ⫾ 13.8
GAF score 35.3 ⫾ 15.9
QOL score 46.5 ⫾ 10.2
First hospitalization (days) 29.6 ⫾ 13.2
F23, acute and transient psychotic disorder; F20, schizophrenia; BPRS, Brief Psychiatric Rating Scale; GAF, Global Assessment of Functioning; QOL,
WHO Quality of Life scale.
384
ATPD from those with the diagnosis changed to schizo-
phrenia during follow-up period (Table 5). After 2 years
of follow-up, there was still significantly lower proportion
of married persons among the schizophrenia patients
compared with the stable ATPD subgroup; however, simi-
lar proportions of single living status were observed in
both diagnostic categories. The patients with schizophre-
nia were significantly less likely to be employed or study-
ing, and had lower GAF and QOL scores, than those
with ATPD at the end of follow-up. The schizophrenia
subgroup was also characterized by higher BPRS score,
higher proportions of subjects with persistent psychotic
symptoms and those requiring antipsychotic maintenance
and re-hospitalized during follow-up compared with those
remaining in the ATPD category (Table 5). There was a
significant disproportion in medications use between the
two groups (χ2 ⫽ 36.2, P ⫽ 0.00002), whereas 40% of
the patients with stable ATPD stopped taking antipsy-
chotic medication prior to the last assessment (Fig. 1).
Remission rates
The remission criteria were defined as the absence of psy-
chotic symptoms (delusions, hallucinations, formal thought
disorder or catatonia) for at least 1 month with the total
score on the BPRS lower than 10 and the GAF score higher
than 70 at the last interview. According to this definition,
35 patients with ATPD and only four patients with schizo-
phrenia met the criteria of remission (Table 5).
Discussion
Diagnostic stability of ATPD
The nosological entity of ATPD group has been under
scrutiny because of the opposing views on its validity as
an independent diagnostic category among psychotic dis-
orders. The present study provides more insight into the
F20 (n ⫽ 35) Statistics
18/17 χ2 ⫽ 2.4, P ⫽ 0.12
25.3 ⫾ 6.2 F ⫽ 4.48, P ⫽ 0.037
13.2 ⫾ 3.5 F ⫽ 0.00, P ⫽ 0.95
4 (11.4%) χ2 ⫽ 9.5, P ⫽ 0.002
5 (14.3%) χ2 ⫽ 0.1, P ⫽ 0.71
22 (62.9%) χ2 ⫽ 1.0, P ⫽ 0.31
8 (22.9%) χ2 ⫽ 0.4, P ⫽ 0.52
37.7 ⫾ 11.8 F ⫽ 0.04, P ⫽ 0.84
30.1 ⫾ 10.0 F ⫽ 3.03, P ⫽ 0.09
49.1 ⫾ 11.7 F ⫽ 1.26, P ⫽ 0.27
39.4 ⫾ 16.1 F ⫽ 9.73, P ⫽ 0.003
NORD J PSYCHIATRY·VOL 65·NO 6·2011
 DIAGNOSTIC STABILITY IN PATIENTS WITH PSYCHOTIC DISORDERS

Other
(a) Other Clozapine
Sertindole 4%
FGA
6% 6%
Sertindole 2% 2%
Risperidone
2% Amisulpride
4%
12%

None
40%
Risperidone Quetiapine
27% 19%

Olanzapine
37% FGA
Olanzapine
Quetiapine 15% 2%
Amisulpride
Nord J Psychiatry Downloaded from informahealthcare.com by Deakin University on 10/06/13

12%
10%

(b) Other
6% Amisulpride Other Clozapine
Sertindole 11% 9% 14%
6%
Sertindole
11%
For personal use only.

Risperidone
31% Risperidone
Olanzapine 17%
40% Olanzapine
38%

Quetiapine
Quetiapine 11%
6%

Fig. 1. Distribution of prescribed antipsychotics. (A) Distribution of prescribed antipsychotics after index admission (left) and 2 years
of follow-up (right) in patients with stable acute and transient psychotic disorders (ATPD) diagnosis. (B) Distribution of prescribed
antipsychotics after index admission (left) and 2 years of follow-up (right) in patients with schizophrenia diagnosis.

diagnostic stability of first-admission diagnosis of ATPD
and complements the evidence from previous follow-up
observations. Our results showed that 34% of the patients
with established ATPD at their first admission retained
this diagnosis over 2 years of follow-up. However, we
demonstrated that the diagnostic stability of ATPD is not
representing a homogeneous clinical entity since different
F23 subtypes markedly varied in respect to their course
and outcome. Despite similar diagnostic stability rates for
ATPD groups with and without schizophrenia symptoms,
significantly more patients dropped out from follow-up
among those initially diagnosed with F23.0 compared
with the patients with F23.1 or F23.2 diagnoses. It is
tempting to speculate that the higher rate of drop-outs in
ATPD patients without schizophrenia symptoms reflects
their higher recovery rate and is an indirect proof of more
favourable prognosis for F23.0. Nevertheless, F23.0 did
not seem to have a higher level of stability, as neither
diagnostic stability nor favourable outcome was associated
with any particular F23 subcategory in some of the previ-
ous studies (3, 5, 10). Therefore, we held more conserva-
tive stability rate of ATPD by excluding those patients not
readmitted until last assessment, but we recognize that diag-
nostically stable patients may represent, in fact, a higher
proportion in our sample if drop-outs would be included
in calculation as was done in study of Castagnini et al. (3).
On the other hand, the transition to schizophrenia, but not
to schizoaffective disorders, was significantly more often
observed among the patients with F23.1 or F23.2 sub-
types, which seemed not surprising considering the provi-
sional criteria of ICD-10 to change ATPD diagnosis in
cases when schizophrenic symptoms persist for longer than

NORD J PSYCHIATRY·VOL 65·NO 6·2011 385

 K. AADAMSOO ET AL.
Table 5. Comparison of characteristics between stable acute and transient psychotic disorders (ATPD) and schizophrenia subgroups after
2 years of follow-up.
Characteristics F23 (n ⫽ 52)
Married 22 (42.3%)
Single living 7 (13.5%)
Employed or studying 43 (82.7%)
Presence of symptoms 3 (5.8%)
Re-hospitalizations
Patients 5 (9.6%)
Re-admissions 0.2 ⫾ 0.6
Total days 2.9 ⫾ 9.4
Treatment maintenance 31 (59.6%)
BPRS score 8.3 ⫾ 14.4
GAF score 78.6 ⫾ 10.1
QOL score 61.2 ⫾ 10.4
Remission rates 35 (67.3%)
Nord J Psychiatry Downloaded from informahealthcare.com by Deakin University on 10/06/13
F23, acute and transient psychotic disorder; F20, schizophrenia; BPRS, Brief Psychiatric Rating Scale; GAF, Global Assessment of Functioning; QOL,
WHO Quality of Life scale.
1 month. However, the ATPD groups with and without
schizophrenia symptoms did not significantly differ from
each other in the severity of psychotic manifestations,
general functioning or quality of life at the time of index
admission. This suggests that several clinical and psycho-
social factors probably lack predictive effect on the ATPD
For personal use only.
outcomes, as it will be discussed below. Nevertheless,
F23.0 group was characterized by an over-representation
of females and older mean age compared with F23.1 and
F23.2 groups, which is in agreement with the recent
report that ATPD subtype with schizophrenic features
was preponderant in males with an earlier age of onset,
indicating its close kinship with schizophrenia (2).
Predictors of transition to schizophrenia
Although several socio-demographic and clinical factors
were evaluated in respect to their possible association
with diagnostic transition, only few predicted a change
from ATPD to schizophrenia. In particular, the patients
who developed schizophrenia were significantly younger
and less frequently married at the time of index admission
compared with the patients with stable ATPD diagnosis.
Notably, there was still a similar proportion of patients
living alone in these two groups, suggesting that diffi-
culty to make or keep intimate relationships rather than just
isolation is a possible factor predicting diagnostic shift to
schizophrenia. This statement is also supported by Suda
et al. (11), who reported that the ATPD patients who
developed schizophrenia had significantly poorer premor-
bid heterosexual relations. It should also be noted that
significantly younger age of the patients later diagnosed
with schizophrenia may explain their less frequent married
status; however, it is widely recognized that schizophrenia
has an earlier onset, indicating that the young age and
poor intimate relationship are two independent factors
associated with a higher risk of developing schizophrenia.
386
F20 (n ⫽ 35) Statistics
4 (11.4%) χ2 ⫽ 9.5, P ⫽ 0.002
4 (11.4%) χ2 ⫽ 0.08, P ⫽ 0.78
15 (42.9%) χ2 ⫽ 14.9, P ⫽ 0.0001
16 (45.7%) χ2 ⫽ 19.6, P ⫽ 0.0000
28 (80.0%) χ2 ⫽ 44.0, P ⫽ 0.00000
2.3 ⫾ 2.0 F ⫽ 52.1, P ⫽ 0.00000
61.2 ⫾ 64.5 F ⫽ 41.5, P ⫽ 0.00000
35 (100%) χ2 ⫽ 18.6, P ⫽ 0.0000
17.5 ⫾ 11.1 F ⫽ 10.4, P ⫽ 0.002
57.9 ⫾ 11.9 F ⫽ 76.2, P ⫽ 0.00000
53.3 ⫾ 8.3 F ⫽ 14.2, P ⫽ 0.0003
4 (11.4%) χ2 ⫽ 26.4, P ⫽ 0.00000
Interestingly, we found that neither clinical manifestation
nor functional presentation were associated with diagnostic
transition, because both groups, stable ATPD and those
who developed schizophrenia, were similar at the index
admission in terms of hazardous behaviour, psychotic
symptom severity, occupational activity and quality of
life. This evidence is in line with the challenges that
clinicians commonly face in respect to the prognosis of
the patients with psychotic disorders in everyday practice.
Nevertheless, we found that a lower level of general
functioning may indicate a non-favourable prognosis in
patients with a first psychotic episode. Particularly, the
patients with ATPD who were later diagnosed with schizo-
phrenia scored somewhat lower on the GAF scale than
the patients with stable ATPD, thus demonstrating certain
impairments in their general functioning prior to the first
admission. Interestingly, recent studies have shown strong
correlations between a lower global social functioning
and reduced P300 event-related potentials in subjects at
ultra-high risk of developing psychosis (12) as well as
between P300 asymmetry and worse global functioning
evaluated by GAF in the patients with the first episode of
schizophrenia spectrum psychosis (13). Supposedly, P300
abnormalities are associated with changes in information
processing and are one of the most reliable biological
markers of schizophrenia (12). Previously, a better pre-
morbid social adaptation was also reported for patients
with ATPD compared with those with schizophrenia (9).
Thus, deterioration in global social functioning, which is
presumably related to information processing deficits,
could be considered a reliable marker predicting further
development of schizophrenia in subjects having high risk
and particularly in those with first-episode psychosis.
Finally, we observed that the patients whose diagnosis later
changed to schizophrenia had longer period of the first
hospitalization than patients demonstrating stable ATPD
NORD J PSYCHIATRY·VOL 65·NO 6·2011

features. Thus, more time may be needed to stabilize the
patients later diagnosed with schizophrenia compared with
stable ATPD group. Importantly, there was no significant
difference in the types of initially prescribed antipsychotic
medications for the patients who developed schizophrenia
and those remained with ATPD, thus excluding the impact
of treatment choice on diagnostic transition.
Distinguishing between ATPD and schizophrenia
Our follow-up study revealed dramatic divergences in
clinical course and social adjustment between the patients
with stable ATPD and those who changed to schizophre-
nia. The latter group was characterized by significant and
gradual deterioration practically in all clinical and social
aspects during the 2 years after their index ATPD epi-
Nord J Psychiatry Downloaded from informahealthcare.com by Deakin University on 10/06/13
sode. This is in line with an assumption that unstable
ATPD is not compatible with the concept of a “transient”
psychotic disturbance, but rather is an early manifestation
of chronic schizophrenic disorder (4). Indeed, in contrast
to the stable ATPD group, the ATPD patients with tran-
sition to schizophrenia showed not only lack or insuffi-
cient improvement in their mental state, but also evidence
of withdrawal from social life being repeatedly re-hospi-
talized during the follow-up period. As a consequence of
clinical deterioration and repeated prolonged re-hospital-
For personal use only.
izations, the patients with schizophrenia were markedly
more often unemployed and not in school when com-
pared with their status at index admission. Moreover,
both global functioning and quality of life were notice-
ably improved in stable ATPD group during follow-up
period, but little improvement in these areas was seen in
the patients with transition to schizophrenia. Similarly,
Pillmann & Marneros (1) reported significantly worse
global functioning in those with schizophrenia compared
with stable ATPD group at the end of their longitudinal
follow-up. Additionally, they demonstrated that 31% of
those with ATPD, but none of those with positive schizo-
phrenia, could be regarded as being in stable remission
without medication after follow-up period. In our sample,
the remission rate was 67% for group of stable ATPD
and only 11% for patients with schizophrenia, as deter-
mined at the end of the 2-year follow-up. These findings
are in accordance with previous studies demonstrating a
favourable outcome for the majority of patients with
ATPD (4, 9, 10). Notably, all our patients with the diag-
nosis of schizophrenia and 60% of those with ATPD
were maintained on antipsychotic medications over the
follow-up period. Interestingly, 14% of the patients who
developed schizophrenia were switched to clozapine dur-
ing follow-up and none of those initially prescribed
amisulpride was taking this antipsychotic at a later time,
mostly because of its insufficient efficacy. Clozapine is a
medication of choice in cases of treatment resistance or
predominant negative symptomatology (14), which were
also the reasons for switching to clozapine in our study.
NORD J PSYCHIATRY·VOL 65·NO 6·2011
DIAGNOSTIC STABILITY IN PATIENTS WITH PSYCHOTIC DISORDERS
Methodological considerations and limitations
The strength of our study includes careful clinical and
social assessments within multiple points of follow-up in
ethnically homogenous cohort sample. Several limitations
of this study should be taken into account. Similarly to
other studies, there was a substantial proportion of patients
who dropped out during the follow-up period, which may
lead to an underestimation of the actual rate of diagnostic
stability of ATPD. It should be also noted that the fre-
quencies of F23 subcategories significantly differed across
samples in the available follow-up studies. For example,
F23.1 and F23.2 diagnoses were markedly less present in
the sample of Castagnini et al. (3) compared with ours;
however, the frequencies of ATPD subtypes in our study
were similar to those found in other samples (9, 10). The
demonstrated dissimilarities in frequencies of ATPD
subgroups in different follow-up studies could perhaps be
explained by the relatively low reliability of this diagnostic
category. Furthermore, there were certain methodological
differences between the studies in terms of clinical assess-
ment, sampling or interviewing methods (see for review
Castagnini & Berrios (2)). All these might bias the results
reported in different follow-up studies, particularly in terms
of stability and outcomes of ATPD subtypes. Although
the sample size in our study was one of the largest among
the recent follow-up studies, it was probably underpow-
ered to detect certain predictors of diagnostic transition
in the patients with initial ATPD diagnosis. The follow-up
period in the present study was shorter than in some other
studies, but was reasonably long to observe the course of
disorder after the first episode of ATPD. Additionally,
almost all patients in our study were treated with atypical
antipsychotics according to the accepted treatment guide-
lines for psychotic disorders. As the study was not designed
to compare the efficacy of different types of antipsychotics,
the possible between-medication differences in the impact
on the ATPD prognosis were not addressed. Finally, the
diagnostic assessments during the follow-up period were
done independently by two experienced psychiatrists in
accordance to the ICD-10 research criteria, but were not
blind to the index diagnoses.
Conclusion
Similarly to other follow-up studies, particularly those
conducted in industrialized countries, our findings demon-
strate that ATPD has a modest diagnostic stability. The
current study provides evidence that a significant propor-
tion of the patients diagnosed with ATPD at their index
episode of psychosis represent an early manifestation of
schizophrenia or schizoaffective disorders. Despite the fact
that one third of ATPD patients showed stable longitudinal
course, only few reliable demographic, social or clinical
predictors for favourable outcomes were detected. Thus,
our results are in agreement with previous notions of a
387
 K. AADAMSOO ET AL.
vague status of the nosological independence of ATPD,
indicating less reason to separate ATPD from other
psychotic disorders within the F2 category.
Acknowledgements—We acknowledge support from the Estonian Ministry
of Science and Education grant SF0180125s08. We thank Dr Jakov Shlik
for a helpful review of the draft manuscript and our colleagues Katrin Eino,
Kai Konsap and Marge Vonk for their valuable assistance.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content
and writing of the paper.
References
Nord J Psychiatry Downloaded from informahealthcare.com by Deakin University on 10/06/13
1. Pillmann F, Marneros A. Longitudinal follow-up in acute and
transient psychotic disorders and schizophrenia. Br J Psychiatry
2005;187:286–7.
2. Castagnini A, Berrios GE. Acute and transient psychotic disorders
(ICD-10 F23): A review from a European perspective. Eur Arch
Psychiatry Clin Neurosci 2009;259:433–43.
3. Castagnini A, Bertelsen A, Berrios GE. Incidence and diagnostic
stability of ICD-10 acute and transient psychotic disorders.
Compr Psychiatry 2008;49:255–61.
4. Jørgensen P, Bennedsen B, Christensen J, Hyllested A. Acute
and transient psychotic disorder: A 1-year follow-up study. Acta
Psychiatr Scand 1997;96:150–4.
For personal use only.
5. 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.
6. Amini H, Alaghband-rad J, Omid A, Sharifi V, Davari-Ashtiani R,
Momeni F, et al. Diagnostic stability in patients with first-episode
psychosis. Australas Psychiatry 2005;13:388–92.
7. Okasha A, el Dawla AS, Khalil AH, Saad A. Presentation of acute
psychosis in an Egyptian sample: A transcultural comparison.
Compr Psychiatry 1993;34:4–9.
388
8. Sajith SG, Chandrasekaran R, Sadanandan Unni KE, Sahai A.
Acute polymorphic psychotic disorder: Diagnostic stability over
3 years. Acta Psychiatr Scand 2002;105:104–9.
9. Marneros A, Pillmann F, Haring A, Balzuweit S, Blöink R.
Features of acute and transient psychotic disorders. Eur Arch
Psychiatry Clin Neurosci 2003;253:167–74.
10. Jäger MDM, Hintermayr M, Bottlender R, Strauss A, Möller HJ.
Course and outcome of first-admitted patients with acute and
transient psychotic disorders (ICD-10: F23). Focus on relapses and
social adjustment. Eur Arch Psychiatry Clin Neurosci
2003;253:209–15.
11. Suda K, Hayashi N, Hiraga M. Predicting features of later
development of schizophrenia among patients with acute and
transient psychotic disorder. Psychiatry Clin Neurosci 2005;59:146–50.
12. Tricht MJ, Nieman DH, Koelman JH, van der Meer JN, Bour LJ, de
Haan L, et al. Reduced parietal P300 amplitude is associated with
an increased risk for a first psychotic episode. Biol Psychiatry
2010;68:642–8.
13. Renoult L, Prévost M, Brodeur M, Lionnet C, Joober R, Malla A,
et al. P300 asymmetry and positive symptom severity: A study in
the early stage of a first episode of psychosis. Schizophr Res
2007;93:366–73.
14. Falkai P, Wobrock T, Lieberman J, Glenthoj B, Gattaz WF, Möller HJ,
et al. World Federation of Societies of Biological Psychiatry
(WFSBP) guidelines for biological treatment of schizophrenia, Part 1:
Acute treatment of schizophrenia. World J Biol Psychiatry
2005;6:132–91.
Kaire Aadamsoo, North Estonia Medical Centre Foundation, Psychiatry
Clinic, Tallinn, Estonia.
Erika Saluveer, North Estonia Medical Centre Foundation, Psychiatry
Clinic, Tallinn, Estonia.
Harri Küünarpuu, North Estonia Medical Centre Foundation, Psychiatry
Clinic, Tallinn, Estonia.
Veiko Vasar, Department of Psychiatry, University of Tartu, Tartu, Estonia.
Eduard Maron, Department of Neuropsychopharmacology and Molecular
Imaging, Imperial College London, London, UK. North Estonia Medical
Centre Foundation, Psychiatry Clinic, Tallinn, Estonia; Department of
Psychiatry, University of Tartu, Tartu, Estonia.
NORD J PSYCHIATRY·VOL 65·NO 6·2011