Acute and transient psychotic disorders in a rapidly developing country, State of Qatar

Summary. Background. Little is known about acute and transient psychotic disorders, which is a diagnostic group, introduced with International Classification of Disease, 10th revision. It is an interesting area of research receiving a lot of attention. Objective. The aim of the study was to find the incidence of acute and transient psychotic disorders in the population and determine its sociodemographic features in the State of Qatar. Design. This is a retrospective descriptive study. Methods. psychotic psychotic disorders psychotic disorders (F23.2). There was no statistically significant difference in the frequency of acute and transient psychotic disorders between males and females, Qatari and non-Qatari Arabs, and single and married. Conclusion. The study found markedly lower incidence rate of acute and transient psychotic disorders in females than males. The highest frequency was found in the early adulthood (16–29 years). No cases were found in children aged less than 15 years. It is important to find ways to promote healthier lifestyles in this population in order to prevent the onset of psychotic disorders.


Introduction
Patients with psychotic disorders are found to have abnormalities in information processing. These abnormalities can be studied in similar ways in different species. In everyday language, a person is said to be psychotic when the things he/she does or the things he/she believes cannot be grasped by others and cannot be put into a context meaningful to others. Acute and transient psychotic disorders (ATPDs) by definition are a heterogeneous group of disorders, characterized by the acute onset of psychotic symptoms such as delusions, hallucinations, perceptual disturbances and by the severe disruption of ordinary behavior (1). They comprise 8-9% of all psychotic disorders and arguably have a benign long-term course (2).
These psychotic symptoms with acute onset, dramatic and polymorphous symptomatology, followed by rapid resolution, have been given many names in the past, such as cyclo-psychosis, bouffée délirante, psychogenic psychosis, and good-prognosis schizophrenia. Most ATPDs have their onset in the late adolescence or young adulthood and are uncommon in early adolescence, but if it occurs, it may progress to an enduring and disabling disorder with major health and social implications (3). It is noted that if the first episode of a psychotic disorder lasts for a month or longer, this will often predict the development of schizophrenia.
The aim of this study was to find the incidence of ATPDs in the population and determine its sociodemographic features in the State of Qatar, since no study on the incidence of ATPDs in Qatar has been conducted yet. There has also been very limited age-specific research on psychotic disorders, because as mentioned above, brief psychotic episodes with an acute onset may be an early manifestation of a severe mental disorder such as schizophrenia; therefore, it is vital to identify patients with ATPDs and find their characteristics as early as possible.

Background information about the State of Qatar
The estimated population of the State of Qatar for the year 2003 was 724 125. Approximately 30% of the population were nationals and the rest were expatriates, mostly from the Middle East, South Asia, and Southeast Asia. The discovery of oil and natural gas in the middle of the last century has allowed Qatar to witness a rapid development in many aspects of life during the last two decades. In the State of Qatar, the Psychiatry Department of the Hamad Medical Corporation is the only provider of secondary and tertiary psychiatric healthcare. This 56-bedded unit provides a high-quality and standard multidisciplinary comprehensive services to the psychiatric patients for the assessment and treatment of psychiatric disorder. It is also the most ideal site for population-based studies in this specialty.

Design and subjects
The 10th revision of International Classification of Diseases (ICD-10) gives this disorder the operational definition under the name of ATPD (F23) (4). Acute onset, transient psychotic disorders, with a good outcome is recognized in both the ICD-10 and the DSM-IV as distinct from schizophrenia and affective psychoses (5). During the period extending from August 1996 until January 2004, a total of 174 patients were treated in the Department of Psychiatry. The study recruited all consecutive inpatients and outpatients fulfilling the ICD-10's criteria for ATPDs. This is a retrospective study conducted during the period from August 1, 1996, to January 1, 2004, where 174 patients were diagnosed as having ATPDs. The study focused on a group of formally classified patients experiencing psychotic disorders. Any patient who had been diagnosed with any of the psychotic disorder at any time during the study period was enrolled in this study. Discharge diagnosis was in accordance with nomenclature of WHO ICD-10.
The database of the Department of Psychiatry was used in this study. The Section of Medical Records in the Department of Psychiatry classified all the psychiatry cases based on ICD-10. The research assistants collected retrospectively the data of all the patients who were admitted or visited the outpatient clinics of the Department of Psychiatry during the study period. The patients were evaluated for: 1.Main complaint and duration of the complaint. 2.Associated symptoms. 3.Length of inpatient stay. 4.Family history of similar illness. 5.Outcome of the treatment.
All recorded diagnoses of psychotic disorders and sociodemographic features were collected for each patient from the database or clinical records. Table 1 shows sociodemographic features of the studied subjects with ATPDs. Of the total 174 patients studied, 120 (69%) were males and 54 were females (31%). There were no cases found in children younger than 15 years of age. The highest frequency was found in early adulthood among 16-29-year-old persons (43.7%) followed by the 30-40 years old age group (32.2%). More than half (58%) of the subjects were married. In terms of nationality, most of them were expatriates (66.7%) followed by Qatari (18.4%), and the rest were non-Qatari Arabs (14.9%). More than half (63.8%) of the studied subjects were employed.
Among the 174 ATPD patients, acute schizophrenia-like psychotic disorders (ASLPDs) were most common (35.6%), followed by acute polymorphic psychotic disorders (APPDs) without symptoms of schizophrenia (23%) and acute polymorphic psychotic disorders with symptoms of schizophrenia (20.7%) ( Table 2). There was no statistically significant difference in the incidence of ATPDs among men and women, Qatari and non-Qatari, and single and married. Table 3 shows that 43% of patients visited the clinic only once, and more than 15% came to the clinic more than 10 times. More than half (60%) of the ATPD patients received outpatient clinic services, with only 14.9% being admitted for the treatment.

Discussion
The sociodemographic representation of the studied group of patients with ATPDs (according to the age) has showed that these disorders begin to develop in the early adulthood (in the 16-to 29-year age group). Unfortunately, unlike the younger age group whom seem resistant to ATPDs, affection of this group usually hits them hard and presents with an ASLPD in more than 56% of the patients. With age, as persons grow old, their chance of developing the disorder de- Something worth noting is that females and Arabs (Qatari and non-Qatari) were less susceptible to developing these disorders; the percentages of males and expatriates with ATPDs were 69% and 66.7%, respectively. The incidence of ATPDs was higher among employed persons (both skilled (32%) and unskilled workers (31%)) and married people (58%) than among unemployed or single people.
ATPDs hold a small but noticeable proportion of the total psychiatric patient count, since 1.4% of all our psychiatric patients complain of ATPDs. It was noticed that this figure somehow holds an international standard as studies done in Denmark (6) reported that ATPDs is an infrequent condition, with onset in early adult life. In Germany, ATPDs account for 8.5% of all inpatient nonorganic psychotic disorders (7).
And to continue the international trend, Al Ain District General Hospital reported a male to female ratio of 1.5:1 (8), whereas Kingdom of Saudi Arabia reports a ratio of 1.4:1 (9). In England, a slightly higher ratio of 1.87:1 was reported (10), and the ratio of 2.2:1 was found in our study. So not do the ATPDs compromise the same proportion of psychiatric patients they also say males are more affected and by almost the same ratio.
One very important point that is worth mentioning is the relation between ATPDs and nationality; our studies showed that nationality might play a big role in determining who develops ATPDs. In reality, this number is biased, because of what happens here. When expatriates come to live in Qatar, some of them are hit by a psychic trauma because of leaving home and moving to a new place with a different lifestyle, or leaving his loved ones behind, or not liking the atmosphere and so on. These psychosocial stresses may precipitate the attack of ATPD. When this occurs, the patient either decides to leave the country or his sponsor refuses to sponsor him. Therefore, he leaves the country. This explains the large number of expatriates who complain of ATPDs.
This phenomenon can help to explain the clinic trends where we will notice that more than 83% of the patients came to the clinics less that 10 times, almost half of which only came once. More than half (60%) of the patients only came to the outpatient clinics and were not admitted as inpatients.
Therefore, it would not be correct to consider ATPD as a simple problem that could be treated on an outpatient basis, with very few visits, and that only a few need to be admitted, but it only implies that after diagnosis of the case, most of the patients would not continue to seek medical assistance, which leads to the progression of the disorder and the arising of complications.
An aggressive form of ATPDs called acute schizophrenia-like psychotic disorder affects 1% of the worldwide population. Approximately, 2.6 million Americans (11) are affected by ASLPD. This is clear in our study that the most common diagnosis made was ASLPD (35.6%), and it was found mostly in the age group of 16-29 years.
Very few epidemiological studies of first-episode ATPDs are conducted in the Middle East region. Hence, it is difficult to compare the findings of our study with other reports.

Conclusions
Acute and transient psychotic disorders are a relatively new class of disorders, which develops in early adulthood, more frequently in males, and it can progress to even more catastrophic disorders if not diagnosed and treated promptly and properly. There is also an inadequacy of statistics in this field, and it would be helpful if other centers would perform their own studies and help in shedding light in this relatively unknown part of psychiatry. Taher Shaltout, Abdulbari Bener, Majid Al Abdullah, et al.