Classificatory systems which are presently in vogue describe a psychotic person as having ‘hallucinations, delusions and a limited number of several abnormalities of behavior such as gross excitement and overactivity, marked psychomotor retardation, and catatonic behavior’ (ICD-10, 1992). Clinical practice, however, bears testimony to the fact that there exist a large number of patients who do not report/exhibit the above characteristics, and yet are diagnosed to be ‘psychotic’ and improve with antipsychotic medications. A typical presentation of such a patient who does not overtly manifest classical psychotic features, but is still clinically considered as psychotic could be as follows:

The patient presents with a subacute/insidious onset of illness of more than 6 months duration and behavioral abnormalities like:

1. being withdrawn and not interacting with people socially as earlier.
2. not taking adequate care of his/her usual daily activities and personal hygiene.
3. occasionally noticed to be muttering/smiling/gesturing to oneself without any evident reason. This symptom is almost always denied or met with a vacant expression when the patient is confronted and asked to explain the behavior. History of any hallucinations or other perceptual abnormalities is not elicitable.
4. mild and non-pervasive, non-persistent irritability on trivial provocation, often associated with spurts of abusiveness and assaultive behavior.
5. other symptoms of behavioral disorganization like aimless wandering, tearing off one’s clothes, and hoarding garbage.
6. sleep is disturbed in the sense that he/she sits awake in bed for long periods but does not disturb others.

On examination,

• The patient appears poorly kempt and dull. Rapport is often poor, eye to eye contact is usually avoided, and psychomotor activity is generally reduced (without any clear-cut catatonic features)
• There is usually decreased spontaneity of talk, with variably prolonged reaction times. Often, the patient gives monosyllabic responses and exhibits poverty of speech.
• It may be difficult to comment on the stream, form and possession of thought because of poor productivity of speech. Definitive delusions are not elicitable, but the patient may often acquiesce to pointed questions regarding persecutory / referential ideas without elaborating on them.
• The affect is flat or blunted, with reduced reactivity and occasional breakthrough of irritable affect on being persistently questioned.
• Definitive hallucinations and other perceptual abnormalities are not elicitable, though the patient may acquiesce to hearing voices on direct questioning without elaborating on them.
• Attention can generally be aroused initially, but is difficult to sustain. It is difficult to do a detailed cognitive assessment, but orientation and memory appear to be grossly intact.
• The patient attributes the hospital consultation and/or admission to some innocuous and inconsistent bodily complaints with denial of any psychiatric problems.

Patients with the above symptom constellation may at best be classified as suffering from ‘unspecified non-organic psychosis’ according to (International Classification of Diseases, tenth edition) ICD-10, which is virtually a "ragbag" diagnosis. They constitute a significant proportion of psychiatric out patient clinic attenders, and yet, we know precious little about the epidemiology, course, outcome and appropriate management of the syndrome. We suggest the term ‘Behavioral Psychosis’ (pending resolution of its nosological status) for the above constellation of signs and symptoms because ‘psychosis’ is being inferred from the patient’s ‘behavior’ alone and not from the perceptual or cognitive experiences. We hope that this would encourage further research in to the course, outcome and management of this syndrome. This is all the more important because presently, these patients are being managed only on an empirical basis. This syndrome cannot be classified into any specific diagnostic category like schizophrenia, affective disorders, delusional disorder or schizotypal disorder according to ICD-10. It comes close to the ICD-10 description of simple schizophrenia, but differs from the latter by not being "uncommon" and by the presence of some "soft psychotic" features (suggestive of disturbances in reality testing) as described above.

A considerable number of patients present with this ‘syndrome’ of ‘behavioral psychosis’ to mental hospitals in South India. It is not clear as to whether a similar syndrome occurs in other parts of the world. Therefore there is a need for research on the existence and validity of this syndrome so as to provide insights into the course and outcome of the syndrome and an appropriate plan of management.

International Classification of Diseases (ICD)- 10^th edition. World health Organization; 1992: Geneva.

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