Cycloid Psychosis: An Examination of the Validity of the Concept

Victor Peralta, MD, PhD, Manuel J. Cuesta, MD, PhD, and Maria Zandio, MD

Corresponding author Victor Peralta, MD, PhD Psychiatric Unit, Virgen del Camino Hospital, Irunlarrea 4, 31008 Pamplona, Spain. E-mail: victor.peralta.martin@cfnavarra.es Current Psychiatry Reports 2007, 9:184–192 Current Medicine Group LLC ISSN 1523-3812 Copyright © 2007 by Current Medicine Group LLC

Historical Perspective
The cycloid psychosis concept has a long tradition in European psychiatry, and its theoretical roots can be traced back to the work of Augustin Morel and to its concept of degeneration that was subsequently elaborated by Magnan. It was Magnan in the 1880s who first published a thorough description of a psychopathological disorder characterized by a sudden onset, polymorphous psychotic symptomatology, and recurrent course (bouffés délirantes de les dégenerées). The notion of “degeneration psychoses” won acceptance in Germany, although it is no longer linked to the degeneration hypothesis, and laid the foundation for the concept of “cycloid psychoses.” The current conceptualization on the disorder stems from the Wernicke-Kleist-Leonhard school of psychiatry that was not prepared to accept Kraepelin’s very comprehensive definition of manic depressive illness and considered cycloid psychosis as a third psychosis in opposition to Kraepelin’s influential “two-entity” principle of endogenous psychoses [1,2]. The term “zycloiden psychosen” was first used by Kleist in 1926 to group together disorders that had been described up to that point and also many other conditions that he had previously classified under the headings “delusional affective psychoses” and “affective psychoses.” Kleist described two variants of the disorder, confusional insanity (characterized by contrasting phases of confused excitement and stupor) and motility psychosis (characterized by contrasting phases of hyperkinesis and hypo- or akinesis). Leonhard introduced a third variant, the anxiety-elation psychosis (characterized by contrasting phases of anxiety and elation that are related to paranoid and grandiose delusions, respectively), and set the modern conceptualization of the disorder [1,2]. The cycloid psychoses were considered by this author as a group of acute, recoverable psychoses that are neither manic depressive nor schizophrenic. More recently, Perris [3,4] produced a number of classical papers on the disorder and introduced the first operational criteria [5]. There is a broad agreement among authors that the main defining features of this disorder are acute onset, remitting course, benign outcome in the long run, and symptom polymorphism. These traits are also shared by alternative concepts, some of them national-based,

The diagnosis of cycloid psychosis has a long tradition in European psychiatry. However, it has been poorly assimilated within the DSM IV and ICD-10 diagnostic systems. Leonhard set the basis for the current conceptualization of the disorder, and Perris and Brockington developed the first operational diagnostic criteria. However, the two conceptualizations of the disorder are not the same and differ across a number of meaningful variables. Cycloid psychosis is a useful concept in that it possesses both clinical and predictive validity. Despite the high prevalence of mood symptoms and syndromes, cycloid psychosis does not equal schizoaffective disorder. Although a substantial body of evidence suggests that cycloid psychosis differs meaningfully from typical schizophrenia, it is less clear whether it differs from major mood disorders or represents an independent nosological entity. The existence of putative subtypes is also likely, and the differentiation between affective and nonaffective subtypes has received some support.

Introduction
This commentary is designed to review and summarize the literature on cycloid psychosis in order to show both the clinical validity and utility of this diagnosis and how it can illuminate the complex relationships between the prototypical psychotic disorders such as schizophrenia and affective psychoses. An attempt is made to examine available evidence on the validity of the diagnosis of cycloid psychosis, its relationship to the diagnoses of schizoaffective and brief or transient psychotic disorders, and its status regarding alternative nosological hypotheses.

Circles represent (from innermost to outermost) the following: bouffee delirante. Sigmund and Mundt [12] and Jabs et al. Cycloid psychosis has received much attention in the international literature during the past half-century. “When the diagnosis of cycloid psychosis is made. schizophreniform states [7]. subtypes of the disorder. Perris [4] clearly stated that in cycloid psychosis. he never developed operational diagnostic criteria. Although Leonhard [2] made a fine and thorough description of the clinical picture of cycloid psychosis and its subforms. and disregarded the classification in subtypes. ICD-10 acute and transient psychotic disorders. In the words of that author. is not included in the definition (as is the case in the modern diagnostic systems). This task was first undertaken by Perris and Brockington [5]. cycloid psychoses (plural) are a group of acute and remitting psychotic disorders that can be reliably diagnosed on the basis of a cross-sectional assessment of the characteristic clinical picture.2]. An important feature of the Perris and Brockington [5] criteria is that good outcome. [13] have developed guidelines for diagnosing the disorder and its subtypes that are very close to Leonhard’s concept. The Leonhard approach to the diagnosis of cycloid psychoses represents a “down–top” approach (from symptoms across basic axial syndromes and subtypes to the disorder). there is never a fully developed manic or depressive syndrome. cycloid psychosis. Psychotic mood disorder Schizophreniform disorder Schizophrenia Major mood disorders Reactive psychoses Psychogenic triggering factors such as acute schizoaffective psychosis [6]. Diagnostic Issues According to Leonhard [1. 1). Leonhard criteria. . therefore. This seems to be due to the uncertain nosological status of that diagnosis and the misleading idea that the concept has become assimilated by the current formal diagnostic systems under the different variants of nonaffective. This is an important question that influences the results of any nosological or validation study. remitting psychotic disorders. atypical psychosis [10]. and cycloid psychoses. 2) cycloid psychosis is mainly defined by a specific pattern of symptoms irrespective of other psychopathological features. In contrast to Leonhard’s classification in subtypes. DSM IV brief psychotic disorder. or puerperal psychosis [11]. Perris and Brockington criteria. The cycloid psychosis concept seems to have prevailed over the rest on the basis of both its integrative character and the well-developed nosological system in which it is rooted. These criteria were developed on the basis of the comprehensive study by Perris [3]. Subsequently. However. a typical feature of cycloid psychoses. and they have become standard for diagnosing the disorder. who set the first operational criteria for diagnosing the disorder. Perris argued that an admixture of symptomatology was the rule rather than the exception. and 3) it allows us to examine the predictive validity of the concept in relation to other clinical syndromes on a purely descriptive basis without a priori assumptions about associations (or lack of them) among psychopathological syndromes [14]. therefore. 185 Biological triggering factors Puerperal psychoses Figure 1. which led many other authors to consider the presence of a major mood syndrome as incompatible with a diagnosis of cycloid psychosis. because 1) this specific criterion was not included in the original criteria. the reliability and validity of these criteria remain to be examined. reactive psychosis [8]. We believe that the coexistence of a full affective syndrome should not be considered an exclusion criterion for diagnosing cycloid psychosis. bouffée délirante [9]. whereas the Perris and Brockington criteria represent a “symptom collection” approach without specific syndrome patterns and. More recently. Alternative concepts of cycloid psychosis and related disorders. although there has been a steady decline in the research interest about the topic in the last 2 decades. then it necessarily follows that a complete remission will occur and even if the illness recurs no defect will be left behind” [1]. which are intended to capture the core features of Leonhard’s concept.Cycloid Psychosis: An Examination of the Validity of the Concept Peralta et al. Each of these different conceptualizations of (probably) the same disorder reflects the degree to which different features are regarded as essential (Fig. a tautological definition of the disorder is avoided.

these symptoms are considered as “associated” but not defining features of the BPD. hypomotility and hypermotility features) and symptoms from other axial syndromes. better premorbid adjustment. cycloid psychoses need to be diagnosed on the basis of the presence of at least one of six basic bipolar axial syndromes. Fish [16] described four putative subtypes (psychogenic reactions. Leonhard described these subforms as prototypal variants of a single disorder. better response to treatment. various cycloid syndromes may appear during the same episode and/or combine and merge together. lower recurrence rate. schizophreniform disorder. DSM IV. the two sets of criteria seem to represent somewhat different conceptualizations of the disorder in that they showed modest concordance ( = 0. and fewer mood symptoms. whereas the diagnosis of brief psychotic disorder (BPD) was overrepresented. the ICD-10 includes many cycloid features under the diagnosis of acute and transient psychotic disorders (ATPDs) and more specifically under the subgroups of acute polymorphic psychotic disorder without and with symptoms of schizophrenia (F23. number of episodes (higher recurrence in motility psychosis). Cycloid Psychosis Within the DSM IV and ICD-10 Diagnostic Systems The successive editions of the formal diagnostic systems have not incorporated criteria for diagnosing cycloid psychosis. schizoaffective disorder. DSM III-R. According to the DSM IV classification. The third edition of the Diagnostic and Statistical Manual (DSM III) did not include specific cycloid features. However. The sample examined was made up of 660 psychotic inpatients. age at onset (later in anxiety-happiness psychosis). More recently. using latent class analysis of symptoms and familial liability. . their validity remains uncertain.43) and differed across a number of meaningful clinical variables. and true cycloid psychosis). mood disorder with psychotic features. and hypermotility-hypomotility. cycloid psychosis is associated with electroencephalogram abnormalities]. These groups were compared across a number of variables (Table 1). could differentiate between affective and nonaffective subgroups. In the DSM IV. Despite the consideration of some cycloid features in the formal diagnostic systems. 2) fulfilling the two sets of criteria. shifting symptomatology. the diagnoses of schizophrenia and major mood disorder were underrepresented. epileptoid psychosis [thus. No further attempts to validate this subtyping procedure have been done. Studies examining the concordance between the ATPDs and cycloid psychosis have found that only 30% to 54% of patients with an ICD-10 diagnosis of ATPD met the criteria for cycloid psychosis [14. Accordingly. the Leonhard criteria capture a group of patients with higher age at onset.19]. Mojtabai [17]. perplexity. In fact. pure forms corresponding to each subtype seldom occur. other than the remitting course. better treatment response. Here we present data from our group examining the differential characteristics between the two concepts [15]. namely anxiety-happiness. The 137 patients fulfilling either of the criteria were classified as 1) fulfilling the Leonhard but not the Perris and Brockington criteria. varies highly among classifications. thus. whereas the revised edition (DSM III-R) included emotional turmoil and perplexity or confusion as defining features for the brief reactive psychosis. or 3) fulfilling the Perris and Brockington but not the Leonhard criteria. the subtypes did not show a distinctive familial pattern. In contrast to DSM classifications. and more severe psychosocial stressors. confusional. These features are acute onset. the Leonhard and the Perris and Brockington concepts have not been empirically compared previously.25••]. Summarizing these results.186 Nonschizophrenic Psychotic Disorders Unfortunately.1.2]. all of which confer a typical polymorphous character to the whole clinical picture. excitation-inhibition-confusion. This has led some authors to erroneously equate the concept of cycloid psychosis with the ATPD from the ICD-10 [18. and changes in the psychomotor activity. or psychotic disorder not otherwise specified.0 and F23. and most frequently. Compared with the Perris and Brockington criteria. and the attempts to include aspects of cycloid psychosis in the consensus classifications under Subtypes of Cycloid Psychosis According to Leonhard [1. 137 of whom met either Leonhard (n = 120) or Perris and Brockington criteria (n = 69) for cycloid psychosis. Each subform may present intrasyndromal bipolarity (ie.24. in practice. which respectively conform the classical subtypes of anxiety-happiness. and the degree to which these diagnostic systems have included cycloid features. However. the nonaffective group had a predominance of females. or ICD-10 category [14. Peralta and Cuesta [14] provided some support for such a distinction in that compared with the affective group. and motility psychoses. in the Leonhard cycloids.20–23]. identity of the two disorders cannot be taken for granted. less acute onset. Studies examining the nosological status of cycloid psychosis in the modern classifications have consistently shown that cycloid psychosis does not correspond closely to any DSM III. Leonhard reported some differences in subtypes of cycloid psychoses regarding gender distribution (female preponderance in motility and confusional psychoses). atypical affective disorders. respectively). and episode length (higher duration in anxiety-happiness psychosis). and the extent to which they represent the same conceptualization of the disorder remains largely unknown. most cases of cycloid psychosis are diagnosed by these systems as BPD. they capture the cycloid psychosis construct only partially. emotional turmoil.

2) 17 (24.58) 31 (60.63 3.5) 56 (81.12 (0.69) 74.01 (1.07 (0.02) 3.8) 11 (64.37) 2.21 (1.38) 0. B > A Comparison among groups CP according to Leonhard but CP according to both CP according to PB but not Leonhard For chi-squared not PB criteria (Group A.001 0 0.508 0.32 21 (41.14 (2.53 (1.2) 3.2 (12.8) 3.39 0.23) 1.34) 2.11 –0. n = 51) criteria (Group C.23 (2.32) 1. n = 69) criteria (Group B.29 (2.4 (20.66) 2.12) Index episode syndromes 3.14 0. C > A A>C A > B.51 0. df—degree of freedom.33) 14 (27.0) 30.74) 30.2) 1.22 3.12 (0.889 0.35 (1.7 4. y Acute onset (< 1 week).2) 10 (58.23 (2.90 (1.24 (2.096 0. n (%) Familial liability to Schizophrenia Major mood disorders Premorbid factors Early familial dysfunction Premorbid adjustment Clinical variables Age at onset. PB—Perris and Brockington.92 (1.6) 19 (27.39 (0.55) 2.3 (9. CP—cycloid psychosis.20 (1.86 (2.06) 2.2 (15.75 14.30 (1.79 (1. Differences between Leonhard and PB diagnostic criteria of CP* P 0.02 (0.7) 39 (56.011 0. Peralta et al.53) 1.48 0.70 (2.722 0.7) 51 (100) 17 (100) 26. n = 17) (df = 2) 35.54) 0.Table 1.34 0.08 (0. n (%) Psychosocial stressors Treatment response (index episode) 2. 187 . n (%) Comorbid drug abuse.35) 1.60 (2.598 C>A C>A B>A Reality distortion Disorganization Negative Depressive Mania Cycloid Psychosis: An Examination of the Validity of the Concept Catatonia *All values are mean (SD) unless otherwise specified.05 (1.06 (1.26 (0.199 0.5) 3.7) 0.36) 1.2 (9.32 0.508 0.76) 1.41 (1.0 (3.74 0.16) 0.82) 4.66) 3.5) –0.57) 2.53) 1.44) 22.0 (19.33 1. y Male gender.033 0.64) 0.99 Demographics Age.8 (8.62 (2.027 0.723 0.22 32.01 0.79) 4.68 4. n (%) Lifetime mood syndrome.36) –0.15 (0.77 (1.20) 1.65) 0.3) 4.18 (1.5) 7 (41.01 B.01) 1.62) 1.55) 0.51 0.98 (2.19 4.1 19.802 0.47) 1. C C.09 (0.9 (15.10) 76.4) 77.

df—degree of freedom.7) 4 (7.8) 1.95 13 (25.499 3 (5. n (%) Schizophrenia Schizophreniform disorder Schizoaffective disorder Major mood disorders Brief psychotic disorder Atypical psychotic disorder Nonschizophrenic Psychotic Disorders *All values are mean (SD) unless otherwise specified.56 15 (29.9) 5 (29. B C.8) 0 (0) 1.044 0. A A < C.7) 1 (1.26 0 8 (15. B > A 0. .188 Table 1.004 0.4) 1 (5.38 8 (15.7) 3 (17.4) 21. n = 69) criteria (Group B. n = 17) (df = 2) 0 (0) 24 (34.458 A. CP—cycloid psychosis.5) 6 (35.25 0. Differences between Leonhard and PB diagnostic criteria of CP* (Continued) P Comparison among groups C > B. PB—Perris and Brockington.8) 6 (8.7) 2 (11.45 0 DSM IV diagnoses.3) 20.6) 6.9) 10.4) 6 (8.4) 32 (46. n = 51) criteria (Group C. B > C CP according to Leonhard but CP according to both CP according to PB but not Leonhard For chi-squared not PB criteria (Group A.

The duration of a cycloid episode is on average 3 months and in a minority of patients may exceed several months [2]. or 5) an intermediate form between schizophrenia and mood disorders (schizoaffective disorder).31]. etiological. More specifically.35]. psychopathological. a disorder comparable to schizophrenia in terms of psychotic symptoms and to mood disorders in terms of course and outcome.23].20. namely the relatively low heritability regarding schizophrenia and mood disorders and homotypia. rapid and brief changes between affective states and mood swings not fulfilling intensity and duration criteria for a major mood syndrome are not . 2) a form of affective illness. and course features of cycloid psychosis. On the other hand. However. It is evident from inspecting Table 2 both that there are no compelling data supporting a particular hypothesis and that the most validated hypotheses are the “independent” and “mood disorder” ones. it could be reasoned that a condition with such a high prevalence of mood symptoms would be closely related to the current concept of schizoaffective disorder. its nosological status within the broad field of psychotic disorders. As a result. this irrespective of its length. the schizoaffective diagnosis as currently defined represents a rare condition within psychotic disorders with poor reliability and validity [30•]. and as a heterogeneous condition [14. 3) a heterogeneous condition. as an atypical form of schizophrenia [33].Cycloid Psychosis: An Examination of the Validity of the Concept Peralta et al.17]. as most but not all [36•] studies resulted in a familial liability pattern that is closer to mood disorders than to schizophrenia. there exists a notorious phenomenological similarity between the anxiety-happiness psychosis and manic depressive illness. Reasons for the poor concordance between BPD and ATPD on the one side and cycloid psychosis on the other are that formal diagnostic systems require the exclusion of major mood syndromes and a duration no longer than 1 to 3 months. Studies addressing this question have supported the view of cycloid psychosis as an independent nosological entity [1.16. the key question regarding the validity of the cycloid psychosis diagnosis is whether it defines a syndrome that can be meaningfully differentiated from schizophrenia on the one hand and atypical affective illness on the other. continues to be a matter of debate.3. five nosological hypotheses can be articulated that can be usefully evaluated from the existing data. Additional evidence is genetic. is 2 to 4 months [26]. Both the relatively long duration of some cycloid episodes and the ability of this diagnosis to predict a good outcome. we have comprehensively reviewed the existing data on sociodemographic.21. Evidence for the mood disorder hypothesis comes from the high prevalence of mood symptoms and syndromes and the recurring-remitting pattern. and particularly in relation to mood disorders and schizophrenia. These hypotheses consider cycloid psychosis to be the following: 1) a form of schizophrenia.20. In fact. clearly suggest that cycloid psychosis does not equal with brief duration. considered. although few of his patients would have met modern criteria for schizoaffective disorder. From a nosological perspective. Interestingly. the duration criterion should be either relaxed (some authors [27] propose to extend the duration criterion to 6 months) or not included at all [28•]. clinical. other studies have yielded inconclusive results [34. when the duration criterion is relaxed. 189 the diagnoses of BPD or ATPD may be considered as unsuccessful. Here. This represents a very restrictive view of affectivity in that in other affective domains such as anxious and ecstatic mood. The central feature of schizoaffective disorder as defined in DSM IV and ICD-10 is the coexistence of schizophrenic symptoms and a major mood syndrome. if formal diagnostic systems have to incorporate the cycloid psychosis concept adequately. Given that more than two thirds of cycloid patients may present with lifetime mood symptoms or syndromes [14]. and neither is the complex and varied temporal relationship between the schizophrenic and affective domains. 4) a distinct nosological entity. as an atypical variant of affective psychosis [32]. it has been reported that the modal duration of the acute remitting psychoses. Elsewhere [28•]. taking into account the degree of the evidence supporting each hypothesis (Table 2). we put them in relation to the five nosological hypotheses mentioned previously. Given that each hypothesis has received some support from the existing The Relationship Between Cycloid and Schizoaffective Psychoses Kleist [29] already noted that approximately one half of the patients with motility psychosis may present with a full affective syndrome within or between episodes and considered that the disorder would correspond to the circular cases of the manic depressive illness. all the studies examining the relationship between schizoaffective and cycloid disorders revealed a poor concordance between the two diagnoses [14. Accordingly. the term “schizoaffective psychosis” was coined by Kasanin [6] in 1933 to describe a clinical picture very similar to that of cycloid psychosis in which affective symptoms were present. together with the broad array of illness-related etiological and pathophysiologic factors [30•] raises the question about its very true nature. Finally. In line with this. the DSM IV and ICD-10 diagnoses of brief or transient psychotic disorders should be dismissed as proxy diagnoses for cycloid psychosis because of their conceptual bias and limited validity. Accordingly. The Nosological Status of Cycloid Psychosis The intriguing character of cycloid psychosis. The main support for the independent hypothesis comes from the distinctive symptom pattern. Familial data also support this hypothesis. depending on the specific disorder.

thus. largely because some degree of chronicity is in-built. But a much broader definition embracing all nonaffective psychotic disorders is more useful for defining a syndrome with high heritability (etiological validity). The cycloid psychosis construct appears to have historical.38•] between the prototypical disorders of schizophrenia and major mood disorders. although it must be acknowledged that in many respects. face. DSM IV schizophrenia is particularly useful for predicting outcome (clinical validity). cycloid psychosis is closer to the affective pole than to the schizophrenic one. alternatively. all the hypotheses are compatible with the consideration of cycloid psychosis on a psychotic continuum [37. That means that clinical and etiologi- cal validity may not converge. XX—some and consistent evidence. data. clinical. Clinical Validity A key issue in the validating process of any psychiatric disorder is to acknowledge that different validators (ie. that a specific syndrome may be related to a set of validators but not to others [39]. Characteristics of cycloid psychosis as supporting 5 alternative nosological hypotheses Nosological hypotheses Form of SZ Demographics Age at onset Male/female ratio Genetic factors Familial risk of MD and SZ Homotypia Heritability (relatively low) Premorbid features Premorbid functioning (good) Personality (histrionic) Triggers Hormonal Psychosocial Symptoms First-rank symptoms Symptom polymorphism Mood symptoms/syndromes Type of treatment Mood stabilizers Antipsychotics Benzodiazepines Electroconvulsive therapy Course Diagnostic stability Recurrence Outcome (good) X NE NE NE XX XX NE NE NE XX NE XX NE NE NE NE XX NE NE XX NE NE XX NE NE NE X NE NE X XX XX XX NE X NE XX NE X XX NE NE XX NE XXX NE XX X XX NE NE XX XX XX XX XX XX X X NE NE XX NE NE X X X NE NE NE NE NE XX X X NE X XX XX NE NE NE NE NE XX X X X XX X X X Form of MD Heterogeneous disorder Independent disorder Schizoaffective (third psychosis) disorder MD—mood disorder. These considerations may help to explain the fact that the validity of cycloid psychosis may vary as a function of the validators considered and that no single nosological hypothesis has received compelling support. and empirical validity in that it can be easily differentiated from neighboring syndromes on psychopathological and outcome grounds. SZ—schizophrenia. In fact. NE—no evidence. outcome) may define different populations of patients or. For example. the cycloid psychosis diagnosis appears to have clinical .190 Nonschizophrenic Psychotic Disorders Table 2. genetic. none of them should be fully disregarded. X—some but insufficient evidence. XXX—compelling evidence.

191 validity and utility [1. The disorder does not fit with the current conceptualization of schizoaffective disorder. available data support the consideration of cycloid psychosis either as an atypical form of mood disorders or as an independent entity. as the few existing studies have yielded contradictory findings [28•]. Leonhard K: Cycloid psychoses-endogenous psychoses which are neither schizophrenic nor manic-depressive. and benign psychotic disorders whose symptomatology is neither typically schizophrenic nor typically affective. 259:1–133. prognostic. 7. 3. Kasanin J: The acute schizo-affective psychoses. many questions remain about its validity. in future formal diagnostic criteria of psychotic disorders. the stability of the diagnosis should be addressed using a first-episode.14. . Acta Psychiatr Scand Suppl 1974. Treatment of cycloid psychosis with antipsychotics. Acknowledgments None of the authors has a possible conflict of interest. but no single randomized trial comparing efficacy among interventions or against placebo has been published to date. but rather polymorphic. these diagnoses should be dismissed as proxy concepts of cycloid psychosis because of both conceptual bias and limited validity. However. Munksgaard. recurrent. given that the Perris and Brockington criteria for cycloid psychosis do not fit completely with the original Leonhard conceptualization. 13:97–126. prospective approach to the diagnosis. in order to promote a more complete examination of its clinical and biological underpinnings. at least as a provisional or alternative diagnosis [40]. etiological. Brockington IF: Cycloid psychoses and their relation to major psychosis. Struwe G. 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