Abstract
Psychosis that does not fit into schizophrenia or affective disorder categories is designated as atypical, schizophreniform, schizoaffective or acute and transient psychotic disorder (ATPD). There is no discrete category of ‘confusional psychosis’ in DSM-IV and ICD-10. This case report highlights the diagnostic dilemma of a case of ‘recurrent confusional psychosis’.
Mr V. a 32-year-old married man, presented with 4 weeks history of looking confused, repetitive utterances of abusive words, an urge to pick up rubbish, occasionally hearing voices, jumping, sleep disturbance and urinary incontinence. Onset had been abrupt without clear precipitating factors.
His past history revealed nine such episodes in the previous 7 years. During the first 2 years, the episodes occurred in April and November, but subsequent episodes occurred only in November or December. During these episodes, the patient would utter abusive words without provocation, and have transient command hallucination telling him to jump. He would look confused and was not able to attend to conversation. His speech was monotonous and difficult to understand. He was slow in performing routine activities such as eating and bathing. While walking, he would suddenly make a posture as if he was picking up material from the ground.
In the current episode only, whilst fully awake, he had urinary incontinence on four occasions and fecal incontinence once. On a number of occasions, he made attempts to drink water out of the latrine. Mental status examinations revealed stereotyped movements of fingers and disorganized speech with echolalia and perseveration. His affect was perplexed. He was orientated to time, place and person. Concentration was impaired, but memory (short-term and long-term) was preserved. Organic work-up was negative. He improved over a number of months on no specific treatment.
Our patient exhibited core features of perplexity, compulsive behaviour and incoherent speech in the absence of emotional symptoms. He fulfils the diagnostic criteria of cycloid psychosis as defined by Perris [1]. Several studies have confirmed that the long-term prognosis of cycloid psychosis is favourable [2, 3]. Some authors [4, 5] have reported that it is possible to differentiate cycloid psychosis from schizoaffective psychosis and core schizophrenia, as well as its prognostic validity. We suggest that: (i) there should be a separate subcategory of acute confusional psychosis under ATPD; and (ii) ATPD should be further subdivided according to seasonal and recurrent pattern.