Les psychoses brèves

Abstract

In current classifications one may apply the concept of brief psychosis to clinical pictures dominated by the presence of psychotic symptoms but whose characteristics, mainly their duration, allow, at least in the short term, to rule out diagnoses of more typical psychoses. In DSM-IV these pictures are referred to, as brief “psychotic disorder” and “schizophreniform disorder” whereas they are subsumed under the category of “acute and transient psychotic disorder” in the ICD-10. The history of brief psychoses, which can be traced back to the concept of Bouffée Délirante of French authors is marked by the multiplicity of names these entities received depending on the perspective they were addressed from. For instance, one can mention in Germany the works of Jaspers on “reactive psychoses”, those of Mayer Gross on the “oneroïd states” as well as the “atypical psychoses” and “cycloïd psychoses” of Kleist, whereas the concepts of “schizoaffective psychosis” and “psychogenic psychoses” were influential in the Scandinavian countries. Current entities differ according to the duration of psychotic symptoms and/or the color of the clinical picture. If DSM-IV classification is mainly based on duration criteria, ICD-10 takes more into account the qualitative aspect of clinical symptomatology, especially the presence or absence of the polymorphous and fluctuating syndrome characteristic of the French “Bouffée délirante”. In this respect, empirical criteria have been proposed in France to separate the “Bouffée délirante” from other psychotic disorders. It is still difficult to assess the long term prognosis of brief psychoses due to a lot of methodological shortcomings, i.e. variability in diagnostic criteria used, number of patients included in follow-up studies, presence or absence of a comparative group, differences in treatments received, lack of compliance monitoring, duration of follow-up. However, quick onset of symptoms (<4 weeks), confusion during the episode, good premorbid functioning and lack of blunted or flat affect seem to be good pronostic factors. Etiology of brief psychoses is a complex matter, involving endogenous, psychogenic as well as social and cultural factors. The first two factors can be better understood within the framework of vulnerability models. Biological diathesis, personality factors (of both temperamental and character origin), involving vulnerability as well as resilience, are deemed to be intertwined with stress in the outbreak of psychotic episodes. The question as to whether the vulnerabilities involved in brief psychoses are or not the same as those predisposing to affective and schizophrenic disorders is still unanswered: brief psychotic disorder, schizophreniform disorder and “Bouffée délirante” may differ in this respect. The role of social and cultural factors is evidenced by the increase in prevalence observed in the context of immigration and acculturation processes. According to Guiness this prevalence may be explained by a phenomenon of “cultural transition” which on the one hand requires new adaptation strategies, especially as regards the way people have to express their mental suffering, and on the other hand increases sources of stress. A modern approach to the treatment of brief psychoses may rely upon pharmacotherapy as well as psycho- and sociotherapy. Antipsychotics, particularly those of second generation, are still the cornerstone of biological treatment. However in some cases, taking into account individual and family history as well as the characteristics of clinical picture, one can preferentially use mood stabilizers or antidepressants. A few cases may require psychotherapy as first line treatment, suggesting a close relationship to dissociative disorder.