East Asian Arch Psychiatry 2014;24:75-80


Onset of Acute and Transient Psychotic Disorder in India: a Study of Socio-demographics and Factors Affecting Its Outcomes

印 度 急 性 短 暂 性 精 神 病 : 社 会 人 口 统 计 学 和 影 响 治 疗 结 果 的 因素

S Mehta, A Tyagi, MK Swami, S Gupta, M Kumar, R Tripathi

Dr Shubham Mehta, MD, Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan, India.
Dr Alok Tyagi, MD, Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan, India.
Dr Mukesh K Swami, MD, Department of Psychiatry, BPS Government Medical College for Women, Sonepat, Haryana, India.
Dr Suresh Gupta, MD, Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan, India.
Dr Mahesh Kumar, MD, Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan, India.
Dr Richa Tripathi, MD, Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan, India.

Address for correspondence: Dr Shubham Mehta, Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan, India.
Tel: (91) 9467550100; Email: drshubhammehta@gmail.com

Submitted: 10 July 2013; Accepted: 5 December 2013

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Objective: Acute and transient psychotic disorder has been accepted as a distinct diagnostic entity in the ICD-10. However, there are few studies delineating its demographics and factors affecting its outcome. This study aimed to examine the socio-demographic profile of patients with acute and transient psychotic disorder and the variables associated with the onset of illness and their effect on illness outcome in an Indian setting.

Methods: This was a retrospective study in which case notes of patients admitted from 1 January to 31 December 2012 and diagnosed with acute and transient psychotic disorder (according to the ICD-10 diagnostic criteria) were analysed. Socio-demographic variables and variables associated with the onset of illness were noted. Duration of hospital stay was used as a proxy measure for clinical outcome. Results: A total of 185 patient records were analysed. Overall, 49% of the patients were males and 51% were females. Most of the cases (60%) were aged between 20 and 39 years. The majority was married, unemployed, educated up to middle school, living in a nuclear family, and had a rural background. Age (p = 0.05) and marital status (p = 0.03) significantly affected the outcome. Overall, 46% of the patients had stress as a precipitating factor, 27% reported substance use, and 23% had a family history of psychiatric illness prior to the onset of their illness. The onset of illness was from May to October in 54% of the patients, with the duration of untreated illness ranging from 7 to 15 days in 38% of the patients. The clinical outcome was significantly affected by duration of untreated illness (p = 0.05).

Conclusions: Acute and transient psychotic disorders show slight female preponderance and occur in early adulthood. There is no precipitating stress in most cases and shorter duration of untreated illness predicts favourable clinical outcome.

Key words: India; International classification of diseases; Stress, psychological; Treatment outcome


目的:虽然急性短暂性精神病已被接受为国际疾病分类第十版(ICD-10)的独立诊断实体,但 有关其人口统计学和影响其治疗结果的研究仍寥寥可数。本研究旨在检视在印度某医院的急性 短暂性精神病患者其人口统计学背景,以及与发病相关因素和其对治疗效果的影响。 方法:这项回顾性研究纳入从2012年1月1日至12月31日期间,经ICD-10确诊急性短暂性精神 病的患者并分析其病历记录,以及记下社会人口学因素和与发病相关因素。研究并以住院时间 作为临床结果的替代测量指标。 结果:共分析185名患者的病历。总体来说,49%患者为男性,51%为女性。大部份(60%) 患者的年龄介乎20至39岁。多数已婚、失业、有中学程度教育、生活在核心家庭以及居於农 村。年龄(p = 0.05)和婚姻状况(p = 0.03)显著影响治疗结果。总体来说,46%患病的诱发 因子来自压力,27%患者承认有服用药物,而23%患者在发病前有精神病家族史。此外,54% 患者於五月至十月期间发病,而38%患者未治期介乎7至15天。未治期对临床结果有显著影 响。 结论:急性短暂性精神病的女性患者比例稍高且多於成年早期发病。大部份病例没有出现诱发 性压力;未治期较短对临床结果有显著正面影响。



Before the advent of the ICD-10,1 acute psychosis as a group did not exist separately and was classified under the broad category of schizophrenia. In India, Wig and Singh2 made the first observation regarding the existence of acute psychosis as a separate nosological entity. Their work pointed towards an acute-onset psychosis having florid symptomatology and good prognosis and also highlighted that the equivalent nosological entities in ICD were acute psychosis of uncertain origin and hysterical psychosis. Another study from India3 considered the existence of 2 types of acute psychosis, namely, acute psychosis with and without stress. Singh and Sachdeva4 suggested that “acute schizophrenia episode” was different from schizophrenia and manic depressive psychosis (MDP) and stressed that it should not be included under schizophrenia. One study5 described reactive psychosis which had manifested psychopathology, personality traits, life events, and family history. The landmark Indian Council of Medical Research (ICMR) acute psychosis study6 found that 35% of cases were categorised as schizophrenia, 25% as MDP, and 40% as non-organic psychosis as per ICD-9. Moreover, 52% of the cases of acute psychosis could not be classified into any of the diagnostic categories.6

Acute and transient psychotic disorder (ATPD) as a descriptive entity was recognised for the first time in 1992 when ICD-10 included it under psychotic disorder (F23) as a three-digit code.1 Acute and transient psychotic disorder has certain key features, such as acute onset (within 2 weeks) and rapidly changing, variable polymorphic picture, which are accepted as defining criteria; stress may or may not be present with the condition. Recovery is complete within 2 to 3 months in most cases.1

Epidemiological data on the incidence of acute psychosis suggest that acute and transient psychosis is 10 times more common in developing countries than in developed countries.7 Despite the long period since ATPD received a distinct nosological status, its status as a separate diagnostic entity has been questioned time and time again because of its diagnostic instability due to overlap of symptoms with schizophrenia and affective psychosis in many cases. Relatively few studies from India have examined the diagnostic validators of ATPD and conclusive data are lacking. In view of the need to define this category more precisely, the current study aimed to delineate socio-demographics (an antecedent diagnostic validator as per schema of Robin and Guze8) and clinical variables associated with the onset of ATPD, and how these affect the outcome (a predictive diagnostic validator) of the same.


A retrospective study was conducted in the Department of Psychiatry, SMS Medical College and Hospital, Jaipur, India. Case notes of all inpatients diagnosed with ATPD (according to the ICD-10 diagnostic criteria) from 1 January 2012 to 31 December 2012 were analysed. A total of 191 such subjects were identified. Of these, patients who were discharged against medical advice (n = 2) or absconded (n = 4) were excluded as clinical improvement could not be established in these patients. The socio-demographic data of the patients were collected on a self-designed performa. Information regarding presence of a stressor prior to the onset of illness, family history of any psychiatric illness, history of substance abuse, duration of untreated illness (DUI), month of onset of psychosis, and duration of hospital stay was recorded. Stressors were categorised into biological (i.e. causing hormonal and biochemical changes) and psychosocial (i.e. changes in social environment).

For the purpose of analysis, duration of hospital stay was used as a proxy for clinical outcome and treatment response. The response was arbitrarily divided into 2 groups: early response (duration of stay < 7 days) and late response (duration of stay ≥ 7 days). The 2 groups, thus formed, were compared with respect to all variables.

Descriptive statistics were used to express data with frequencies and percentages. The Chi-square test and Fisher’s exact test were used, where appropriate, to examine the association between variables. All analyses were performed with the help of SPSS Windows version 17.0.


A total of 185 subjects were diagnosed with ATPD during the study period. Table 1 shows the socio-demographic features of the study subjects. Overall, 91 (49%) patients were males and 94 (51%) were females. Most of the patients (60%) were aged between 20 and 39 years, and 68% were married. The majority (74%) was unemployed; 24% of the patients were illiterate and most patients were educated up to middle school. The bulk of our study population came from rural areas (88%). Almost half of the patients (52%) were living in a nuclear family, 43% lived in a joint family and only 4% lived in a nuclear extended family. Among the socio-demographic variables, only age (p = 0.05) and marital status (p = 0.02) significantly affected our study outcome (Table 2).

1402 V24N2 p75 Table1

As shown in Table 3, 46% of the patients had a precipitating factor for their illness. Types of stressors could be grouped into biological (including fever and child birth) and psychosocial (including quarrel within family or friends, financial loss, loss of loved ones, job loss, and marriage). Fever was found to be a major individual precipitating factor in most of the cases reporting the presence of a stressor (33%). Only 27% of the patients were using any sort of substance prior to illness, and 23% had a family history of psychiatric illness. Overall, 38% of the patients had DUI ranging from 7 to 15 days, and this was the only factor with significant influence on our study outcome (Table 4). The month of onset of ATPD in the study sample is shown in the Figure. In most cases (54%), the onset was from May to October, i.e. peak summer months when the temperature ranges from 30°C and 45°C in India.


The present study highlights the demographics of ATPD patients along with the variables associated with the onset of illness and their effect on its outcome.

Demographics and Outcome

The mean age of onset of ATPD in our sample was 27 years. The most common age-group (20-39 years) of our patients was more or less similar to that observed in other studies.6,9,10 The mean age of onset was older in females (29 years) then males (27 years). Castagnini et al11 also reported older age of ATPD onset in females than males, though the mean age of onset was higher than that in our patients. Of note, the mean age of ATPD onset seems to be later than onset do vary.10,11

In our study, patients younger than 20 years were slow responders and had relatively increased duration of hospital stay. Patients with onset of illness at or after the age of 20 years showed early response to treatment and, thus, had a favourable clinical outcome. This implies that, even though early adulthood is the most vulnerable period, the onset of ATPD in this age can predict an early treatment response. Furthermore, younger patients (< 20 years) might represent a subgroup of patients that is likely to develop major psychiatric illness in the long term.

In our study, more females than males were affected by ATPD (male-to-female ratio, 0.95:1). Similar to our ratio of non-affective acute remitting psychosis of 0.96 in developing countries. The female preponderance of ATPD has also been shown in several previous studies.6,11-13 The more common occurrence of ATPD in females distinguishes it from schizophrenia which has slightly higher incidence in young males.14,15

More than half of our patients (68%) were married and 52% belonged to nuclear families. Marital status of the patients significantly affected the outcome of their illness, though the type of family did not. It may be argued that married patients had an early treatment response, as indicated by their shorter duration of hospital stay because of the important support from their spouses. The majority of patients was unemployed, and this group, predominantly, included housewives and students who were educated up to middle school. Occurrence of ATPD was more common in people from rural areas, similar to that reported in many Indian studies.7,16-18 Locality did not influence the outcome, probably because the number of urban patients was very small for correct inference.

Variables Associated with Onset and Outcome

More than half of our cases (54%) did not experience stress prior to onset of illness as opposed to the studies by Malhotra19 and ICMR6 which reported stress in almost 60% and 70% of the cases, respectively. However, studies in European countries reported ‘acute stress’ only in small number of cases.12,14,20

1402 V24N2 p75 Table2

Fever was the most common event among those who experienced some precipitating stress just prior to onset of illness. Previous studies16,21,22 have reported a significant association of fever with onset of acute psychosis in developing countries. This was attributed to the hormonal and biochemical changes in the brain due to fever, resulting in psychosis.

Of the 85 patients reporting a stressor prior to onset of illness, 56 (66%) were females. Malhotra et al16 also found that stressful events were more commonly reported among female than male patients with non-affective acute psychosis.

We also studied the presence or absence of a family history of any psychiatric disorder in first-degree relatives of our cases as it determines the constitutional vulnerability of an individual for the disorder. Only one-fourth of our study population had a family history of psychiatric illness. This is in sharp contrast to findings of a previous Indian study5 which reported a family history of psychiatric illness in a high proportion of patients of reactive acute psychosis. In another study,23 the proportion of first-degree relatives with any mental disorder was higher in a group of ATPD patients compared with healthy controls.

Overall, 63% (27 of 43 cases) of patients with a family history of psychiatric disorders among first-degree relatives also had a stressor prior to onset of illness, thus, pointing towards the cumulative role of stress and constitutional vulnerability in causation of illness. Substance use was found in 50 (27%) cases. Nicotine was the most commonly used substance; 2 cases were using alcohol and 4 were using cannabis.

The majority of patients had DUI of 7 to 15 days. Those patients with DUI of < 7 days showed favourable outcome than those with longer DUI. According to Sajith et al,9 abrupt or acute onset of psychotic episode was a predictor of favourable outcome in their study.

1402 V24N2 p75 Table3

We found that the onset of ATPD was in summer in 54% of our cases, similar to the findings by Malhotra et al16 who reported that onset of acute psychotic states tends to peak in summer months. However, it remains to be determined whether this association is attributable to the physical effects of the heat, neuroendocrine changes due to temperature, endogenous circadian rhythms or activation of some viruses at this temperature range predisposing to fever and subsequent acute psychosis. Since there are not much data on the month of onset of acute psychotic states, this finding remains inconclusive.

To the best of our knowledge, the sample size of our study is the largest among all the studies on ATPD in developing countries. This provides strength to the findings of our study though it was retrospective.

The major limitation of our study was that we assessed the outcome by a proxy measure and not by any standardised instruments. Although the information about patients was obtained from the most reliable informant (family member in most cases), the reliability of information could not be controlled due to the retrospective study design. Also, our study findings could not be generalised as the sample was drawn from a single centre.

Acute and transient psychotic disorders occur in both males and females, with slight preponderance in females. It is more common in early adulthood, and in the married, unemployed, and  rural  people. Age  of  onset  and  marital status had significant effect on the outcome. In most cases, the onset of illness was not associated with a prior precipitating stress, substance use, and a history of psychiatric disorder in first-degree relatives. Further research in this area is warranted


The authors declared no conflict of interest in this study.

1402 V24N2 p75 Table4

1402 V24N2 p75 Figure1


  1. The ICD-10 classification of mental and behavioral disorders. Geneva: World Health Organization; 1992.
  2. Wig NN, Singh G. A proposed classification of psychiatric disorders for use in India. Indian J Psychiatry 1967;9:158-71.
  3. Kapur RL, Pandurangi AK. A comparative study of reactive psychosis and acute psychosis without precipitating stress. Br J Psychiatry 1979;135:544-50.
  4. Singh G, Sachdeva JS. Acute schizophrenic episodes: Are they schizophrenic? Indian J Psychiatry 1981;23:200-5.
  5. Chavan BS, Kulhara P. A clinical study of reactive psychosis. Acta Psychiatr Scand 1988;78:712-5.
  6. Indian Council of Medical Research. Final report of phenomenology and natural history of acute psychosis. New Delhi: ICMR; 1985.
  7. Susser E, Wanderling J. Epidemiology of non-affective acute remitting psychosis: sex and socio-cultural setting. Arch Gen Psychiatry 1994;51:294-301.
  8. Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry 1970;126:107- 11.
  9. Sajith GS, Chandrasekaran R, Sadanandan Unni KE, Sahai A. Acute polymorphic psychotic disorder: diagnostic stability over 3 years. Acta Psychiatr Scand 2002;105:104-9.
  10. Pillmann F, Marneros A. Longitudinal follow-up in acute and transient psychotic disorders and schizophrenia. Br J Psychiatry 2005;187:286- 7.
  11. 1 Castagnini A, Bertelsen A, Berrios GE. Incidence and diagnostic stability of ICD-10 acute and transient psychotic disorders. Compr Psychiatry 2008;49:255-61.
  12. Das SK, Malhotra S, Basu D. Family study of acute and transient psychotic disorders: comparison with schizophrenia. Soc Psychiatr Psych Epidemiol 1999;34:328-32.
  13. 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.
  14. Tandon R, Keshavan MS, Nasrallah HA. Schizophrenia, “just the facts” what we know in 2008. Epidemiology and etiology. Schizophr Res 2008;102:1-18.
  15. McGrath J, Saha S, Welham J, El Saadi O, MacCauley C, Chant D. A systematic review of the incidence of schizophrenia: the distribution of rates and the influence of sex, urbanicity, migrant status and methodology. BMC Med 2004;28:2-13.
  16. Malhotra S, Varma VK, Misra AK, Das S, Wig NN, Santosh PJ. Onset of acute psychotic states in India: a study of sociodemographic, seasonal and biological factors. Acta Psychiatr Scand 1998;97:125-31.
  17. Susser E, Varma VK, Malhotra S, Conover S, Amador XF. Delineation of acute and transient psychotic disorders in a developing country setting. Br J Psychiatry 1995;167:216-9.
  18. Varma VK, Malhotra S, Yoo ES, Jiloha RC, Finnerty MT, Susser E. Course and outcome of acute non-organic psychotic states in India. Psychiatr Q 1996;67:195-207.
  19. Malhotra S. Acute and transient psychosis: a paradigmatic approach. Indian J Psychiatry 2007;49:233-43.
  20. 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.
  21. Collins PY, Wig NN, Day R, Varma VK, Malhotra S, Misra AK, et al. Psychosocial and biological aspects of acute brief psychoses in three developing country sites. Psychiatr Q 1996;67:177-93.
  22. Collins PY, Varma VK, Wig NN, Mojtabai R, Day R, Susser E. Fever and acute brief psychosis in urban and rural settings in north India. Br J Psychiatry 1999;174:520-4.
  23. 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.
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