Abstract
The association between the season and the occurrence of acute transient psychotic disorder (ATPD) has been sparsely studied. We would like to report five patients who presented with acute psychotic symptoms during the summer and discuss other risk factors that could be associated with this seasonal predilection.
Keywords: ATPD, psychosis, summer
INTRODUCTION
Acute transient psychotic disorder (ATPD) is a clinical entity in the tenth edition of the International Classification of Diseases (ICD-10).[1] It has an acute onset presenting with atypical symptom clusters with one of the four distinct symptom clusters that include acute polymorphic psychotic disorder without symptoms of schizophrenia, acute polymorphic psychotic disorder with symptoms of schizophrenia, acute schizophrenia-like psychotic disorder, other acute predominantly delusional psychotic disorder, and other acute and transient psychotic disorders, and some cases can be associated with stress; however, symptoms usually resolve within 2 to 3 months.[1] Similar presentations have been described by several other names, such as reactive psychosis, cycloid psychosis, schizophreniform psychosis, and hysterical psychosis.[1] It is diagnosed as a brief psychotic disorder in the Diagnostic Statistical Manual, fifth edition (DSM-5), characterized by sudden onset of psychotic symptoms and remission within a month.[2] In the eleventh edition of ICD (ICD-11), it is categorized as acute polymorphic psychotic disorder, and other types are subclassified as schizophrenia and other primary psychotic disorder.[3]
The influence of seasonality on several mental disorders has been studied often. Evidence states that mood disorders such as depression, mania, and seasonal affective disorders are related to seasonality.[4] In psychosis and schizophrenia, a relation to seasonality has been less commonly described. As per the evidence we have so far, during the summer season, the occurrence and admission rates of psychotic disorders were common.[4] The evidence is sparse regarding the association between seasonality and ATPD.
Here, we describe five clinical cases of ATPD, who were presented to the Dept. of Psychiatry within a 20-day span at our tertiary care hospital. This series of cases of ATPD diagnosed as per ICD-10 was admitted for inpatient treatment from March 20, 2022, to April 10, 2022, at our hospital. None of the patients had medical or psychiatric comorbidity. Written informed consent was obtained from all the patients. The confidentiality of patients has been strictly maintained. Table 1 describes the details of each case.
Table 1.
Details of the patient profile
| Age | Gender | Diagnosis | Treatment | BPRS score | Temperature |
|---|---|---|---|---|---|
| 22 years | Female | ATPD with symptoms of schizophrenia | Olanzapine 10 mg | Initial—36 Later—5 |
>96 F |
| 34 years | Female | ATPD without symptoms of schizophrenia | Risperidone 6 mg | Initial—40 Later—4 |
96 F |
| 23 years | Male | ATPD schizophrenia-like psychotic disorder | Risperidone 6 mg | Initial—36 Later—5 |
96 F |
| 30 years | Female | ATPD with symptoms of schizophrenia | Olanzapine 15 mg | Initial—40 Laster—4 |
97 F |
| 23 years | Female | ATPD schizophrenia-like psychotic disorder | Olanzapine 15 mg | Initial—38 Later—6 |
96 F |
CASE SERIES
Case 1
A twenty-two-year-old single woman belonging to middle socioeconomic status, with premorbid anxious traits and a family history of psychosis in first-degree relative who was maintaining well on 15 mg of olanzapine, presented with 1-week history of fearfulness, insomnia, irritability, third-person auditory hallucinations, and delusion of persecution. The patient was admitted, and a diagnosis of ATPD with symptoms of schizophrenia was made. The score on the Brief Psychiatric Rating Scale (BPRS) was 36. The patient was started on oral olanzapine 10 mg. After improvement in objective and subjective clinical characteristics (BPRS score of 25), the patient was discharged. On follow-up a month later, there was complete remission of symptoms, substantiated by a BPRS score of 5.
Case 2
A 34-year-old married woman, with well-adjusted premorbid personality with no significant family history, history of ATPD 4 years ago that lasted for a month, and responded well to risperidone 6 mg, currently presented with 4-day history of wandering behavior, irritability, insomnia, and aggressive episodes, delusion of persecution, poor self-care, and self-talk. She was diagnosed with ATPD without symptoms of schizophrenia. The score on the BPRS scale was 40. She was started on oral risperidone 2 mg and gradually increased to 6 mg. After the improvement in objective and subjective clinical characteristics (BPRS score of 29), the patient was discharged. On follow-up of 20 days later, there was complete remission of symptoms, substantiated by a BPRS score of 4.
Case 3
A 23-year-old single man from middle socioeconomic status, with no significant family and history and well-adjusted premorbid personality, presented with disorganized behavior, reduced self-care, irrelevant talk, wandering behavior, insomnia, and third-person auditory hallucinations for 3 days following interpersonal conflicts in the workplace. He was diagnosed with ATPD schizophrenia-like psychotic disorder, and his initial score of BPRS was 36; he was started on oral risperidone, increased up to 6 mg. On follow-up after a month, he was significantly improved, with a BPRS score reduced to 5, and he maintained well.
Case 4
A 30-year-old married woman from middle socioeconomic status, with no significant family and history and with well-adjusted premorbid personality, presented with disorganized behavior, self-talk, self-smiling, insomnia, delusions of persecutions and reference, and reduced self-care of 5 days following the loss of job. She was diagnosed with ATPD with symptoms of schizophrenia. The BPRS score during the initial presentation was 40, and she was started on oral olanzapine 10 mg and increased to 15 mg, following which her symptoms subsided. On follow-up after 20 days, the BPRS score was 4, and she was maintaining well.
Case 5
A 23-year-old single woman from middle socioeconomic status, with premorbid anxious traits, no significant family, and history, presented with suspiciousness, delusion of persecution and reference, third-person auditory hallucinations, irritability, reduced appetite, and insomnia for the past 7 days following interpersonal conflicts at home. She was diagnosed to have an ATPD schizophrenia-like illness. The score on BPRS is 38. She responded well to 15 mg of olanzapine. On follow-up after 30 days, her BPRS score had reduced to 6 and there was complete remission of symptoms.
RESULTS
All patients belonged to the age range of 20–30 years. Of five patients, four patients were female. Three patients had an episode following a stressful situation, one patient had a family history of psychiatric illness, and other patients had a history of ATPD. All patients were staying in a location of 96 F. Insomnia was seen in all patients, along with psychotic symptoms and poor self-care. Table 1 presents the details of the patients.
DISCUSSION
From January 2022 to December 2022, we evaluated a total of nine ATPD cases in our treating unit and five of them were seen during a 20-day period, that is, from March 20 till April 10. The weather forecast for those 20 days revealed a temperature >96 F[5] in our location. Sociodemographic attributes and psychosocial stress can increase the likelihood of having psychotic symptoms.[4] Although environmental factors may not directly cause psychotic symptoms, they can exacerbate the severity of psychotic symptoms.[4] Climate can have an impact on the etiological pathway for the occurrence of acute psychotic disorders.[4] Extreme temperature and excessive exposure to sunlight can cause serotonin and dopamine dysfunction and shift in the circadian rhythm, which can aggravate a psychotic episode.[4]
In our case series, not all patients had a family or history of psychotic episodes or stress. However, the one factor common to all the cases was the season of occurrence of the symptoms. The increase in temperature may have been an additional factor for the development of acute episodes. Evidence suggests that first-episode psychosis is predominately seen in summer seasons as compared to winter season, which is in line with our findings as well.[6] Another comparative study from India for patients with non-affective nonorganic remitting psychosis and patients with schizophrenia also showed a summer peak in patients with acute psychosis compared with patients with schizophrenia.[7] The previous literature has also suggested that women tend to have psychotic breakdowns more often during summer, a finding that is also reflected in our case series.[8] There are also inconclusive reports in the literature that it is younger adults who have summer psychotic breakdown.[8,9] The possible reasons for psychotic symptoms in summer may be associated with the physical effects of heat, neuroendocrine changes due to temperature, and activation of certain viruses at this temperature.[9] Other reasons that can increase hospitalization are frustration due to an increase in temperature, irregular circadian rhythm, and concordant discordant light exposure that may be responsible for abnormal melatonin synthesis.[4] Few studies have demonstrated that high night temperatures can cause sleep disturbance in terms of reduced slow wave, rapid eye movement sleep, frequent sleep interruptions, and increased body movements. Sleep disturbance has been associated with difficulty with focused attention and increased emotional reactivity.[10] Studies looking at these associations are scarce, despite there being a fairly high prevalence of acute and transient disorder of around 3.6 to 9 per 100.000 population.[11] It may be worthwhile noting the possible effects of the climate and related factors such as humidity and sunlight exposure in patients who present with acute psychosis. The condition has a fair prognosis, and knowing some of these additional predispositions may aid in preventing relapses in these patients.
Declaration of patient consent
The authors declare that they have obtained consent from patients. Patients have given their consent for their images and other clinical information to be reported in the journal. Patients understand that their names will not be published and due efforts will be made to conceal their identity but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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