F23.0

F23.0 is a diagnosis within the ICD-10 framework describing acute polymorphic psychotic disorder without symptoms of schizophrenia. This disorder is characterized by the rapid onset of psychotic symptoms such as hallucinations, delusions, or severe emotional disturbances.

The term “polymorphic” indicates that the symptoms are variable and dynamic, often changing rapidly over time. Unlike schizophrenia, these symptoms do not persist for more than three months and there are no clear signs of sustained thought disorder or negative symptoms (e.g., apathy, social withdrawal).

Key features

1. Acute Onset: Symptoms appear suddenly, often within two weeks or less.
2. Polymorphic Symptoms: The presentation includes a mix of psychotic features (hallucinations, delusions) and mood disturbances (anxiety, euphoria, or depression).
3. Short Duration: Symptoms typically last from a few days to a few months but resolve entirely within three months.
4. No Schizophrenic Symptoms: Symptoms typical of schizophrenia (e.g., persistent hallucinations, disorganized speech, or catatonic behavior) are absent.
5. Good Prognosis: Most patients recover fully with appropriate treatment, and the disorder does not tend to progress to schizophrenia.

Symptoms

Psychotic symptoms

1. Hallucinations:

• May include auditory, visual, or tactile hallucinations, but they are typically transient and not pervasive.
• Hallucinations are less structured and elaborate compared to schizophrenia.

2. Delusions:

• Commonly paranoid or grandiose in nature.
• Delusions are not systematized and may shift in focus or intensity.

3. Mood and emotions:

Intense and rapidly shifting mood states:

• Anxiety, irritability, or agitation.
• Periods of euphoria or dysphoria.
• Emotional responses often seem disproportionate to the situation.
• Emotional instability that contributes to an erratic presentation.

4. Cognitive symptoms

• Confusion or disorientation, especially at the peak of symptoms.
• Difficulty concentrating or maintaining a coherent train of thought.
• Episodes of dissociation or depersonalization.

5. Behavioral symptoms

• Sudden changes in behavior (e.g., hyperactivity, withdrawal, or erratic actions).
• Impulsive actions driven by hallucinations or delusions.
• Rapid fluctuations in energy levels.

Diagnostic criteria

The ICD-10 outlines specific criteria for diagnosing F23.0:

1. Sudden onset: Symptoms must develop quickly, usually within two weeks.

2. Psychotic features:

• Presence of hallucinations or delusions.
• Symptoms do not meet the criteria for schizophrenia (e.g., no persistent bizarre delusions or thought disorganization).

3. Polymorphic symptoms:

• Symptoms are variable and do not settle into a single psychotic pattern.
• There is significant emotional and behavioral instability.

4. Duration:

• Symptoms persist for less than three months.
• Full remission occurs, typically without long-term deficits.

5. Exclusion of schizophrenia and mood disorders:

No persistent schizophrenic symptoms (negative symptoms or prolonged thought disorder).

Not better explained by bipolar disorder or major depressive episode with psychosis.

Differential diagnosis

It is necessary to differentiate F23.0 from other psychiatric disorders with overlapping symptoms:

1. Schizophrenia (F20)

• Schizophrenia requires symptoms to persist for at least six months.
• Negative symptoms (e.g., flat affect, anhedonia) are common in schizophrenia but not in F23.0.
• Schizophrenia involves structured delusions and hallucinations.

2. Bipolar disorder with psychotic features (F31.2)

• Bipolar disorder shows mood episodes (manic or depressive) that are the primary features.
• Psychotic symptoms occur exclusively during mood episodes in bipolar disorder.

3. Substance-induced psychotic disorder (F1x.5)

• Symptoms are directly linked to substance use or withdrawal.
• Psychotic symptoms resolve after the substance is cleared.

4. Delirium (F05)

• Delirium involves cognitive impairment, disorientation, and fluctuating consciousness.
• Often caused by medical conditions or substance intoxication/withdrawal.

5. Acute stress reaction (F43.0)

• Symptoms occur as a direct response to a severe stressor.
• Typically resolves within a few days.

Diagnostic process

1. Clinical history and assessment:

• Document the rapid onset of symptoms and assess their variability.
• Evaluate emotional and behavioral stability.

2. Psychiatric evaluation:

Identify the presence of psychotic symptoms without sustained schizophrenic patterns.

3. Exclude other conditions:

Perform physical examinations and lab tests (e.g., toxicology screen) to rule out substance-induced or medical causes.

4. Functional impact:

Assess the patient’s ability to function during and after the episode.

Treatment

Pharmacotherapy

• Antipsychotics (e.g., Risperidone, Olanzapine) for severe psychotic symptoms.
• Benzodiazepines for acute agitation or anxiety.

Psychotherapy

• Supportive therapy to manage emotional instability.
• Cognitive-behavioral therapy (CBT) to address residual stress or anxiety.

Hospitalization

• Required if there is a risk of harm to self or others.
• F23.0 typically has a favorable prognosis, with complete recovery expected within a few weeks to months.
• Recurrence is possible, but the disorder rarely progresses to chronic psychosis or schizophrenia.

Sources:

1. World Health Organization. (2019) International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10): F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia. Geneva: WHO.
2. American Psychiatric Association. (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5). Arlington, VA: American Psychiatric Publishing.
3. Perälä, J., Suvisaari, J., Saarni, S.I., et al. (2007) Lifetime prevalence of psychotic and bipolar I disorders in a general population. Archives of General Psychiatry, 64(1), pp. 19–28.
4. Shorter, E. (2015) The history of acute and transient psychoses. Dialogues in Clinical Neuroscience, 17(1), pp. 43–50.
5. Marneros, A. & Pillmann, F. (2004) Acute and transient psychoses. Cambridge: Cambridge University Press.
6. Pillmann, F., Haring, A., Balzuweit, S., Bloink, R., & Marneros, A. (2002) The concordance of ICD-10 acute and transient psychotic disorders and DSM-IV brief psychotic disorder. Psychological Medicine, 32(3), pp. 525–533.
7. National Health Service (NHS). (2024) Psychosis: Overview, symptoms, and treatment. Available at: https://www.nhs.uk/mental-health/conditions/psychosis/overview/ .
8. StatPearls. (2024) Acute and transient psychotic disorders. Available at: https://www.ncbi.nlm.nih.gov/books/NBK546684/ .
9. Mayo Clinic. (2024) Brief psychotic disorder: Symptoms and causes. Available at: https://www.mayoclinic.org/diseases-conditions/brief-psychotic-disorder/symptoms-causes/syc-20353349 .
10. Cambridge University Hospitals NHS Foundation Trust. (2023) Acute psychosis. Available at: https://www.cuh.nhs.uk/patient-information/acute-psychosis/ .