What are the changes in the diagnosis of brief psychotic disorder across Diagnostic and Statistical Manual of Mental Disorders (DSM) (Diagnostic and Statistical Manual of Mental Disorders) 3, 4, 5, and 5-Text Revision (TR), and International Classification of Diseases (ICD) (International Classification of Diseases) 10 and 11?

Evolution of Brief Psychotic Disorder Diagnostic Criteria Across DSM and ICD Versions

DSM-3 to DSM-5-TR Evolution

The most significant change across DSM versions has been the progressive refinement of duration criteria and the elimination of categorical subtypes in favor of dimensional symptom assessment, with DSM-5 maintaining brief psychotic disorder as a diagnosis requiring symptom duration of at least 1 day but less than 1 month with eventual full return to premorbid functioning. 1

Key Changes in DSM Versions

• DSM-3 to DSM-IV: The diagnostic concept evolved from broader "brief reactive psychosis" to the more refined "brief psychotic disorder," with clearer delineation of the 1-month maximum duration criterion that distinguishes it from schizophreniform disorder 2

• DSM-IV to DSM-5: The major structural change involved eliminating schizophrenia subtypes and replacing them with a dimensional approach based on symptom assessments, though brief psychotic disorder itself retained its categorical structure 3, 1

• DSM-5 to DSM-5-TR: The text revision maintained the core diagnostic criteria while enhancing cultural context integration with diagnostic criteria to improve international compatibility 1

Diagnostic Stability Concerns

• Brief psychotic disorder demonstrates the lowest diagnostic stability among psychotic disorders at only 61.1% over 24 months, compared to bipolar I disorder (96.5%) and schizophrenia (75.0%) 4

• When diagnoses change from brief psychotic disorder, they most commonly evolve to schizoaffective disorder (53.6% of changes), followed by bipolar I disorder (25.9% of changes), then schizophrenia (12.5% of changes) 4

• Diagnostic instability is predicted by nonaffective psychosis presentation, auditory hallucinations, younger age, male sex, and gradual onset 4

ICD-10 to ICD-11 Evolution

ICD-11 represents a more substantial paradigm shift than DSM-5, introducing dimensional symptom specifiers across six domains rated on a 4-point scale, fundamentally changing how brief psychotic episodes are characterized and documented. 5

Major Structural Changes in ICD-11

• ICD-11 introduced dimensional symptom specifiers for the entire Schizophrenia or Other Primary Psychotic Disorders grouping, including brief psychotic episodes, assessing severity across six domains: positive symptoms, negative symptoms, depressive symptoms, manic symptoms, psychomotor symptoms, and cognitive symptoms 5, 6

• Each symptom domain is rated on a 4-point scale ranging from "not present" to "present and severe," allowing clinicians to complement categorical diagnoses with a profile of specific symptoms that conveys additional information beyond the categorical label 5

• ICD-11 added course specifiers with two components: episodicity (first episode, multiple episodes, or continuous course) and cross-sectional acuity (currently symptomatic, partial remission, or full remission) 5

ICD-10 vs ICD-11 Acute Psychotic Disorders

• ICD-10 classified acute and transient psychotic disorders (ATPD; F23) with polymorphic and schizophreniform subtypes, which showed only 61.9% concordance with DSM-IV brief psychotic disorder 2

• ICD-11 reorganized acute and transient psychotic and delusional disorders, moving toward greater harmonization with DSM-5 while maintaining some conceptual differences 3

• The ICD-10 ATPD category was broader than DSM-IV brief psychotic disorder, with 31.0% of ATPD patients meeting criteria for schizophreniform disorder instead, suggesting the DSM time criteria may be too narrow 2

Comparison of Latest Versions: DSM-5-TR vs ICD-11

Fundamental Philosophical Differences

• DSM-5-TR maintains a predominantly categorical approach for brief psychotic disorder, requiring specific symptom criteria and duration thresholds without mandatory dimensional assessment 1

• ICD-11 implements a hybrid categorical-dimensional model that requires both categorical diagnosis and encourages dimensional symptom profiling across multiple domains 5

Dimensional Assessment Advantages in ICD-11

• ICD-11's dimensional approach provides more nuanced profiles for contexts where detailed information is needed beyond overall severity to inform treatment, particularly for psychotherapy planning 5

• The stepwise diagnostic approach in ICD-11 allows rapid communication based on categorical diagnoses while providing dimensional assessments for specialized settings and research 5

• Mental health professionals rated ICD-11 as having higher clinical utility compared to ICD-10, with 82.5% to 83.9% perceiving the guidelines as quite or extremely easy to use, accurate, clear, and understandable 5

Harmonization Efforts and Remaining Differences

• Both DSM-5 and ICD-11 development processes were driven by a desire to ensure better alignment between the two systems, representing unprecedented collaboration between the American Psychiatric Association and World Health Organization 1

• Despite harmonization efforts, ICD-11 retains distinct conceptual orientations, particularly in its emphasis on dimensional assessment and global applicability across diverse healthcare settings 5, 3

• ICD-11 field studies demonstrated higher diagnostic accuracy and perceived clinical utility compared to ICD-10, though advantages were largely limited to new diagnostic categories rather than refinements of existing ones 5

Critical Clinical Implications

Diagnostic Pitfalls to Avoid

• Do not assume diagnostic certainty at initial presentation: Brief psychotic disorder has the lowest stability of all psychotic diagnoses, and patients often first present during acute psychosis before meeting duration criteria for other disorders 4, 7

• Plan for longitudinal reassessment: The diagnosis may evolve as the temporal relationship between mood and psychotic symptoms becomes clearer over time, requiring systematic life charting to document symptom sequences 7

• Recognize that complete recovery within 6 months is unusual for schizophrenia, as negative symptoms typically persist, whereas brief psychotic disorder by definition requires eventual full return to premorbid functioning 7

Evidence-Based Assessment Approach

• Use structured diagnostic interviews (SCID-5 or MINI 7.0) rather than unstructured clinical assessment to reduce diagnostic bias and improve reliability 7

• Create detailed life charts documenting the longitudinal course of symptoms, mapping onset, duration, and offset of each psychotic episode chronologically, along with periods of remission and functional status 7

• Gather collateral information from family members and other observers, as patient insight may be limited during acute psychotic episodes 7

Future Directions

• Factor-based models of psychosis, supported by consistent evidence from genetics, pathobiology, and clinical presentation studies, may represent the optimal structural choice for future diagnostic systems beyond current DSM and ICD versions 8

• Factors are inherently dimensional and multidimensional, providing the detail needed for treatment decisions while remaining concordant with personalized medicine and hierarchical diagnostic models currently being explored 8

• The stepwise diagnostic approach introduced in ICD-11 for some categories may expand to additional disorder groupings, meeting the needs of different user groups from primary care to specialized research settings 5