Eur. J. Psychiat. Vol. 26, N.° 4, (266-278) 2012 Keywords: Cycloid psychosis; Classification; Sym p - to matology; Leonhard; DSM-IV; ICD-10. Cycloid psychoses: Leonhard’s descriptions revisited Noortje W.A. van de Kerkhof* Frank M.M.A. van der Heijden* Marc K.F. Schneider* Bruno Pfuhlmann** Gerald Stöber** Jos I.M. Egger*,***,**** Willem M.A. Verhoeven*,***** * Vincent van Gogh Institute for Psychiatry, Centre of Excellence for Neuropsychiatry, Venray ** University of Würzburg, Department of Psychiatry, Psychosomatics and Psychotherapy, Würzburg *** Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen **** Behavioural Science Institute, Radboud University Nijmegen ***** Erasmus University Medical Centre, Department of Psychiatry, Rotterdam GERMANY THE NETHERLANDS ABSTRACT – Background and Objectives: Cycloid psychoses are characterized by poly- morphic symptomatology with intraphasic bipolarity, a remitting and recurrent course and favourable prognosis. Perris and Brockington (P&B) described the first set of operational criteria that were partly incorporated in ICD-10. The present study investigates psy- chopathological profiles according to the P&B criteria and the original descriptions by Leonhard, both against the background of the criteria from the prevailing international classification systems. Methods: Eighty patients with psychotic disorders were recruited and assessed with various psychometric instruments at baseline and after six weeks of antipsychotic treat- ment in order to investigate the presence of cycloid psychoses according to Leonhard (LCP) and the effect of treatment with antipsychotics. The overlap between LCP and DSM-IV Brief Psychotic Disorder (BPD), ICD Acute Polymorphic Psychotic Disorder (APP) and P&B criteria was calculated. CYCLOID PSYCHOSES ACCORDING TO LEONHARD 267 Results: Using P&B criteria and a symptom checklist adapted from the original de- scriptions by Leonhard, 14 and 12 cases of cycloid psychosis were identified respectively reflecting a prevalence of 15-18%. Small though significant concordance rates were found between LCP and both DSM-BPD and ICD-APP. Concordance between LCP and P&B criteria was also significant, but modest. Conclusions: This study demonstrates that LCP can be identified in a substantial num- ber of patients with psychotic disorders. Cycloid psychoses are not adequately covered in current classification systems and criteria. Since they are demonstrated to have a specific psychopathological profile, relapsing course and favourable prognosis, it is advocated to include these psychoses in daily differential diagnostic procedures. Received: 13 March 2012 Revised: 11 June 2012 Accepted: 16 July 2012 Introduction rater reliability (Cohen’s kappa: 0.82-0.89) of Leonhard’s classification system13. As an independent group, the term “cy- As to prognosis, cycloid psychoses show a cloid psychoses” was first coined by Kleist in remitting and recurrent course with a favou - 14-16 19261. Psychoses with atypical symptoms had rable outcome . The only study on the been described from the turn of the nineteenth pharmacological treatment of cycloid psy- choses has demonstrated beneficial effects of century and were termed e.g., “bouffées déli- 17 rantes des dégenerées”2, “Degenerationspsy- lithium . More recently, some evidence has been obtained that, in the acute phase, atypi- chose”3, acute schizoaffective psychosis4, cal antipsychotics may be useful18. “degeneratiepsychose”5 and atypical psy- chosis6. About two decades ago, the psy- Although in 1952 the first edition of the chopathological concepts about this type of DSM comprised a psychotic disorder with psychoses were reviewed in detail by Tappe7. atypical symptoms resembling some features of the cycloid psychosis (termed schizo- In general, cycloid psychoses present with phrenic reaction, acute undifferentiated type), a (sub)acute onset and a polymorphic and later versions did not cover this diagnostic shifting symptomatology comprising symp- category. In fact, Kraepelin’s dichotomy in- toms from both the schizophrenic and affec- creasingly dominated the categorical struc- tive spectrum. Depending on the subtype, ture in the consecutive editions of the DSM most typical symptoms are rapid mood so that in DSM-IV19, only Brief Psychotic swings, severe anxiety and/or ecstasy, con- Disorder (BPD) and Schizophreniform Dis- fusional states and psychomotor distur- order with specifier “With Good Prognostic bances8-11. In the fifties, based on the de- Features” partially cover the cycloid concept. tailed longitudinal analysis of symptom This development and the increase of the profiles, Leonhard delineated three subtypes: clinical diagnosis of schizoaffective disor- anxiety-happiness psychosis, confusion psy- ders resulted in a gradual loss of scientific chosis and motility psychosis12. Later, and clinical interest for the cycloid psy- Pfuhlmann and coworkers found high inter- choses. Recently, in their scholarly review, 268 NOORTJE W.A. VAN DE KERKHOF ET AL. Jäger and coworkers stipulated the problem- Methods atic reliability and validity of schizoaffective disorder and hinted at a fundamental recon- Patient recruitment sideration of the current diagnostic concepts of psychosis20. Similar suggestions were All patients were recruited at the Vincent made by the research group of García-An- van Gogh Institute for Psychiatry, a large drade21. Therefore, the cycloid psychosis psychiatric teaching hospital in the southern postulate needs to be revisited, particularly part of The Netherlands with a catchment given its relevance for clinical practice. area of ~510.000 inhabitants. The recruit- ment period comprised 2.5 years (March The first set of operational criteria for cy- 2008-September 2010). cloid psychoses was formulated by Perris and Brockington22 and subsequently incor- Included were adult patients of both sexes porated in the “Diagnostic Criteria for Func- (age range: 18-65 yrs) admitted for psychot- tional Psychoses” of the World Psychiatric ic symptomatology that warranted treatment Association23. Starting with the ICD-1024, with psychotropics. Patients were included the category acute polymorphic psychotic before the start or in the first week of treat- disorder without/with symptoms of schizo- ment with psychotropics. In all cases, psy- phrenia (APP) is included that was derived chopharmacological treatment was per- from the Perris and Brockington (P&B) cri- formed according to the hospital standards by teria. This category comprises, apart from the responsible ward psychiatrist. Excluded cycloid psychosis, also the psychotic disorder were patients with proven genetic syndromes bouffée délirante, used in France as a separate or intellectual disability. For this reason, a diagnostic category. genetic work-up was performed by a regis- Clinical studies in patients with Leonhard’s tered clinical geneticist. Also excluded were cycloid psychoses (LCP), using brain imag- patients with relevant somatic or neurologic ing25 and event related potentials26,27, have diseases and females with postpartum psy- demonstrated that, in addition to variability in chopathology. All patients gave written in- symptomatology, course, and prognosis, this formed consent following the Dutch medical class of psychoses is etiologically distinct ethical guidelines (CCMO registration num- from schizophrenia and bipolar affective dis- ber NL20469.097.07). orders28,29. In rare cases of cycloid psychosis, During the study period, a total of 194 pa- disturbances in amino acid metabolism were tients were admitted for evaluation and treat- observed30,31. Hereditary factors have been ment of psychotic symptoms of whom 100 demonstrated to play a minor role32,33, where- were judged to be eligible for inclusion. as environmental factors like maternal first- Twenty patients refused to participate yield- trimester gestational infection and obstetri- ing a study group of 80 patients of whom 63 cal complications, seem to be of etiological were available for follow-up assessment after 34,35 importance . Cycloid psychoses predom- at least 6 weeks (i.e., 63% of the initial se- 36,37 inate in postpartum psychotic disorders . lected group). The present study aims at delineating cy- cloid psychoses according to Leonhard’s original descriptions and analyzes the diag- nostic overlap with P&B as well as with ICD- 10 and DSM-IV criteria. CYCLOID PSYCHOSES ACCORDING TO LEONHARD 269 Diagnostic procedures and concordance between the different categori- scoring instruments cal diagnostic groups. Significance was test- ed against p < 0.05. Baseline diagnostic instruments comprised Comprehensive Assessment of Symptoms and History (CASH)38, Positive and Negative Syndrome Scale (PANSS)39, and Clinical Results Global Impression scales for Severity and Improvement (CGI-S/CGI-I)40. The CASH Total patient sample and was specifically developed for research in symptomatic reduction the schizophrenia and affective spectrum con- after 6 weeks ditions and is not uniquely connected to a classification system. PANSS and CGI were The total group comprised 53 males and re-assessed at week 6. These assessments 27 females (mean age ± SD: 35 ± 11.5). were performed by a well trained PhD-resi- Mean age at first episode and mean duration dent in psychiatry (NvdK). of psychotic disease were 27.4 ± 10.7 and 7.6 Subsequently, classification was perfor - ± 7.9 years respectively. According to DSM- med according to DSM-IV19 and ICD-1024 IV, 48 patients met the criteria for Schizo-