Journal of Affective Disorders 83 (2004) 11 – 19 www.elsevier.

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Research report

Cycloid psychoses are not part of a bipolar affective spectrum Results of a controlled family study
B. Pfuhlmann *, B. Jabs, G. Althaus, A. Schmidtke, A. Bartsch, G. Sto ¨ ber, H. Beckmann, E. Franzek
Department of Psychiatry and Psychotherapy, University of Wuerzburg, Fuechsleinstrasse 15, D-97080 Wuerzburg, Germany Received 5 January 2004; received in revised form 17 March 2004; accepted 19 March 2004

Abstract Background: Whereas a growing body of evidence suggests that cycloid psychoses have to be separated from schizophrenic psychoses, their relations to bipolar affective disorder are less clear. To further clarify this issue a controlled family study was undertaken. Methods: All living and traceable adult first-degree relatives of 45 cycloid psychotic, 32 manic-depressive and 27 control probands were personally examined by an experienced psychiatrist blind to the diagnosis of the index proband. Data about not traceable relatives were collected by the ‘‘Family-History’’-Method. A catamnestic diagnosis was established for each of the 431 relatives blind to family data. Age-corrected morbidity risks were calculated using the life-table method. Results: Relatives of cycloid psychotic patients showed a significantly lower morbidity risk for endogenous psychoses in general and manic-depressive illness compared to relatives of patients with manic-depressive illness. The familial morbidity risk for cycloid psychoses was low and did not differ significantly in both proband groups. Relatives of cycloid psychotic patients however did not differ significantly from relatives of controls regarding familial morbidity. Limitations: Our time-consuming methodical procedure implicated a relatively small number of participants due to restricted personnel resources. The restriction to hospitalised probands could possibly cause a limited representativity of the study sample. Conclusions: Our results suggest that cycloid psychoses are aetiologically different from manic-depressive illness and could not be integrated into a spectrum of bipolar affective disorders. The findings provide further evidence for a nosological independence of cycloid psychoses. D 2004 Elsevier B.V. All rights reserved.
Keywords: Cycloid psychoses; Manic-depressive illness; Family study; Nosology

1. Introduction One of the central problems of psychiatric genetics is the diagnostic differentiation of clinically homogeneous syndromes on the phenotypical level (Leboyer
* Corresponding author. Tel.: +49-931-201-77130; fax: +49931-201-77120. E-mail address: bruno.pfuhlmann@mail.uni-wuerzburg.de (B. Pfuhlmann). 0165-0327/$ - see front matter D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2004.03.005

et al., 1998; Hyman, 1999). Whereas up to now reliability was considered to be the main weak point of psychiatric diagnostics, there is now increasing evidence that the validity of diagnoses is much more questionable (Ungvari, 1983; Tsuang et al., 1992; Kringlen, 1993; Maj, 1998; Hyman, 1999; Klosterko ¨ tter, 1999; Hojaij, 2000). In view of these problems the use of Leonhard’s classification of endogenous psychoses (Leonhard, 1999) could be advantageous, since it allows a differentiated diagnostic assignment

Leonhard. The essential criteria are the presence of mixed states or partial states. Recent findings suggest that cycloid psychoses as described by Leonhard (1999) may represent a distinct clinical entity (Beckmann and Franzek. Subjects and methods 2. Maj. Motility psychosis displays a hyperkinesia or akinesia affecting predominantly expressive and reactive motions independent of disturbances of emotion or thought. 2002). Maj. 1990. Franzek et al.. 1999. and also to examine the nosological distinctiveness of cycloid psychoses contrasted with manic-depressive illness.. A number of biological findings could underline the diagnostical validity of the cycloid psychoses and their unrelatedness to schizophrenias (Beckmann et al.. / Journal of Affective Disorders 83 (2004) 11–19 of manifold clinical pictures. Jo ¨ nsson. Confusion psychosis is characterised by an excitation or inhibition of thought with incoherence of thematic choice in the excited states and perplexity in the inhibited states. By contrast monopolar affective psychoses according to Leonhard are characterized by stable uniform syndromes recurring in every episode in the same form. Beckmann et al. 1990. This classification is based on sophisticated clinical descriptions and hierarchical symptom patterns occurring during the longterm course of psychiatric diseases. 1982. Ungvari. on the other. Until now no family study applying current methodological standards had considered cycloid psychoses in Leonhard’s original sense as a distinct diagnostic category. 2000). Cycloid psychoses are subdivided into the subforms anxiety– happiness psychosis. The clinical validity of the diagnosis of a cycloid psychosis could be demonstrated by several independent authors (Perris. Thus cycloid psychoses according to Leonhard have an equivalence neither within ICD-10 nor within DSM-IV.. Brockington et al.. 1994) to ‘‘brief psychotic disorder‘‘. Pfuhlmann et al. Cycloid psychoses are bipolar phasic psychoses with complete remission after each episode and absence of residual symptoms. particularly as cycloid psychoses are viewed by several authors as atypical variants of bipolar affective psychoses (Jamison. ‘‘disorganized speech’’ and ‘‘disorganized or catatonic behavior’’. 1985. The age-restriction was imposed . Cutting. Therefore their delimitation towards bipolar affective psychoses is now becoming the focus of interest. 1974. Leonhard’s conception of manic-depressive illness also displays some important differences compared to usual conceptions of bipolar affective psychoses (Leonhard. The aim of the present study was to obtain systematically data on the familial morbidity of cycloid psychoses. 1996. 1996. 1990.. 1997). ‘‘schizophreniform’’ symptoms are frequently present during the acute episodes. Franzek and Beckmann. 1991) cycloid psychoses are mostly assigned to ‘‘acute transient psychotic disorders‘‘ and within DSM-IV (American Psychiatric Association. 1998. 1968. 2003). 1992. Recruitment and diagnostics of index probands and relatives All in-patients between 18 and 50 years of age who were admitted to the Clinic for Psychiatry and Psychotherapy of the University of Wuerzburg between 1997 and 1999 and were diagnosed as having a cycloid psychosis or manic-depressive illness were asked to participate. and the lability of the affect. Applied methodology and diagnostic criteria were however rather different in these studies. According to Leonhard it is possible to diagnose ostensibly depressive states as episodes of a manic-depressive illness if characteristic clinical features are present. Strik et al.. It can be applied with high reliability by experienced and thoroughly trained psychiatrists (Franzek and Beckmann. Within the ICD-10 (World Health Organization. 2001. On the other hand. 1997). 1990. 1982. Anxiety – happiness psychosis shows extreme affective alterations with paranoid anxiety on the one hand and ecstatic states with feelings of elation accompanied by ideas of calling or salvation. Franzek and Beckmann. 1999). Peralta and Cuesta. Pfuhlmann et al. These diagnoses are based to a large extent on rather arbitrary criteria of an acute onset and a rapid remission whereas the symptomatology is described only superficially with ‘‘delusions’’. Mojtabai. 1990. 1999). In this they resemble manic-depressive illness. ‘‘hallucinations’’.. confusion psychosis and motility psychosis. Jabs et al. 2. 1992.12 B. Sto ¨ ber et al. In previous investigations of familial morbidity in cycloid psychoses morbidity risks between 4% and 11% were reported for psychoses in first-degree relatives (Perris. 1974.1.

To be included. A case record was made for every relative. After complete description of the study to all subjects written informed consent was obtained. At least one first-degree relative had to be available for an examination. 45 of which suffered from a cycloid psychosis and 32 from a manic-depressive illness. Patients without cooperative relatives did not differ from those with cooperative relatives with respect to age. a proband had to have at least one first degree relative available for a psychiatric examination. The exploration concerned a detailed recording of the sociobiography. With the aid of the resident’s registration office controls from the general population were recruited. eventual psychiatric history and present psychopathological state of the subject whereby the investigator had no knowledge whether the person was a relative of a patient or a control. In the case of overcrowding of the clinic.2%) of the 383 living relatives could be examined personally. Secondly another experienced psychiatrist who had insight into the case record and into all available objective documents. The 104 index probands had 508 first-degree relatives. 433 of whom were 18 years of age or older. in 16 a confusion psychosis and in 10 a motility psychosis. In total 77 patients could be included. Altogether 27 control persons could be included. Controls were also psychiatrically examined. 1999) which define exactly all symptoms required for a distinct diagnosis. made a diagnosis of his own. The principle of confidentiality was strictly adhered to throughout the study. In both cases. Leonhard repeatedly stressed that the illness of a given patient belongs to the group of cycloid psychoses only insofar as it can be assigned to one of the subtypes. Therefore. due to similar differential diagnostic considerations. In 19 of the cycloid psychotic probands an anxiety-happiness-psychosis was diagnosed. In 19 cases the diagnosis could not be confirmed. in another 18 none of the relatives was available for a personal examination. Catamnestic diagnoses of relatives were elaborated by two investigators independently of each other. the assembly of diagnostical criteria for a single category of ‘‘cycloid psychosis’’ as proposed by Perris and Brockington (1981) may be a potentially hazardous over-simplification. 1960). Information about relatives who could not be examined was obtained by the ‘‘FamilyHistory‘‘-method. The supply area of the clinic covers mainly the urban area and the district of Wuerzburg. At the time of inclusion in the study 48 (11. patients from this supply area are at times also admitted to a neighbouring state hospital. In one cycloid psychotic proband and in one control person we could not obtain sufficient information about the fathers. Pfuhlmann et al. All cooperative first-degree relatives living up to 300 km around Wuerzburg were examined in a detailed psychiatric exploration by an experienced psychiatrist in order to maximize the validity of the obtained information. The ascertained cohen’s kappa coefficient was 0. gender. In two cases the diagnoses of both raters were discordant. Relatives who had not been examined personally were rated as ill only if objective documents about their illness were available. A total of 353 (92. The interrater-reliability was tested in a group of 30 randomly selected ill relatives by calculating a Cohen’s Kappa-value (Cohen. it still seems advantageous to use Leonhard’s original descriptions of the subforms of cycloid psychoses as a diagnostic guideline. For these reasons. congruous consensus diagnoses could be elaborated. Probands with a simultaneous diagnosis of an addiction or an oligophrenia were excluded. / Journal of Affective Disorders 83 (2004) 11–19 13 in order to allow personal examination of as many parents as possible. age at onset of the illness and number of episodes of illness. The age of onset in ill relatives was defined by the date of the first in or out-patient treatment. Approval was obtained from the ethics committee of the University of Wuerzburg.878. Firstly the investigator who had performed the examination established a diagnosis on the basis of his findings. Existing objective documents about a psychiatric disorder were consulted whenever possible.B. During the study period 114 patients had agreed to participate. . These were drawn from a list with a random selection of residents between 18 and 50 years of age. All diagnoses were established adhering strictly to Leonhard’s original criteria (Leonhard.1%) of the remaining 431 relatives were deceased. In every proband the diagnosis was secured in the course of a detailed examination by an experienced psychiatrist without any knowledge of family data.

Statistical analysis At first global differences were ascertained which in the case of significance were followed by a posteriori pairwise comparisons between the groups including an adjustment of the level of significance according to the method of Bonferroni.2.8%. Pfuhlmann et al. H-ANOVAs for global tests and Mann –Whitney – U-tests for a posteriori comparisons were conducted.05). Twenty of thirty-two MDI probands (62. By contrast CP probands did not differ significantly from controls with respect to the frequency of a positive family history. 11 of 45 CP probands (24. Psychoses in relatives 3. BIP: bipolar affective disorder. was used.8 MDI 32 9/23 38.5 172 157 48.4 4.0 – – 106 93 50. 3.001).8%) displayed a positive family history. The diagnostic classification of the index probands according to DSM-IV is shown in Table 2. 3. Chi2-tests were applied for nominal data.799.001). Cycloid psychotic (CP) probands here are disseminated over a broad spectrum of heterogeneous diagnostic categories. df = 1.4%) and 4 of 27 controls (14. UD: unipolar depression. and illness-parameters no significant differences were found. / Journal of Affective Disorders 83 (2004) 11–19 Table 2 Distribution of Leonhard-Index diagnoses within DSM-IV Leonhard-Diagnosis DSM-IV-Diagnosis SZ SA BPD BIP UD NS Cycloid psychosis (n = 45) Anxiety – happiness psychosis Confusion psychosis Motility psychosis Manic depressive illness (n = 32) 3 3 – – – 12 6 5 1 1 20 5 10 5 2 9 5 – 4 27 – – – – 2 1 – 1 – – 2. 1958).3.0 84 49. p < 0. we compared the percentage of probands with a positive history of endogenous psychoses in firstdegree relatives. likewise the difference between MDI and controls (v2 = 13. The significance of the differences between the morbidity risks in the respective groups was estimated by the log-rank-test. One sister of a CP proband could not be diagnosed unequivocally though there was no doubt that she had suffered from a phasic psychosis.0 3.1. In the case of parametric data ANOVAs were used for global testing and t-tests for a posteriori comparisons. Results 3.4 Controls 27 15/12 37. Among the 153 relatives of the MDI . SA: schizoaffective disorder.5 146 48. NS: non organic psychosis not otherwise specified. p < 0. Age corrected morbidity risks Twelve of the one hundred seventy-two relatives of the CP probands had suffered from an endogenous psychosis corresponding to an age-corrected morbidity risk of 10. SZ: schizophrenia.9 Table 3 displays the raw prevalences of the main nosological groups of endogenous psychoses according to Leonhard among first-degree relatives.3 27.2 123 47. For all statistical calculations the program SPSS 10. Demographical data and illness parameters of the study participants Main demographical data and illness parameters of index probands as well as age and number of investigated relatives are shown in Table 1. df = 1.1 153 133 47. Among the manic-depressive (MDI) probands were significantly less male individuals than in the other groups ( p < 0. version 0.1 28. The tests were two-tailed if not otherwise stated. If the data were non-parametric. In a first step.2.14 B. The difference between MDI and CP probands was highly significant (v2 = 11. BPD: brief psychotic disorder. Regarding all other demographical data Table 1 Main demographical data and illness parameters Proband group CP N probands M/f Mean age (years) Mean age at illness onset (years) Mean number of illness episodes N relatives z 18 years of age N living relatives Mean age of living relatives (years) N personally examined relatives Mean age of personally examined relatives (years) 45 24/21 35.5%). Age-corrected morbidity risks were estimated by life-table analyses according to Kaplan – Meier (Kaplan and Meier.261.

If only personally examined relatives were evaluated the morbidity risk for an endogenous psychosis in relatives of CP probands was 7.001). Pfuhlmann et al. Neither in the families of MDI probands nor in the families of CP probands did we find a substantial genetic dispo- Fig. —— – manic-depressive illness (153 relatives). The latter risk was again significantly higher than the respective risk of 7. The great majority of the ill relatives of MDI probands had homonymous psychoses. further evaluations were always carried out considering all relatives.8%) – Total 153 1 (0.50. CP probands however did not differ significantly from controls. p < 0.cycloid psychosis (172 relatives). A posteriori comparisons revealed that the risk of getting an endogenous psychosis was significantly lower in relatives of CP probands than in relatives of MDI probands (v2 = 22.6%) 1 (1. The risk of getting a MDI was significantly lower in relatives of CP probands compared to relatives of MDI probands.. In the control group there occurred four cases of an endogenous psychosis among 106 relatives.6%) Raw prevalences without age correction. Fig. 1.48. . CP probands once again did not differ significantly from controls.0001).2%) (1.2%) – – – Total 106 3 (2. controls also had a significantly lower familial morbidity risk for endogenous psychoses than MDI probands ( v2 = 23.6%) 5 (2.6%) (1.75.5% and therewith significantly lower than the corresponding risk in relatives of MDI probands which amounted to 28. Since the results for personally examined relatives did not display essential differences from the findings for all relatives.9%) – 1 (0. The corresponding Kaplan-Meier graphs are in Fig.4%) – – 1 (0.5% ( v2 = 18.6%) 34 2 1 2 (22.0001). df = 1. p < 0.59.6%) 1 (0. Morbidity risk of endogenous psychoses in relatives.. p < 0. p < 0.7%) 2 (1. p < 0. The global logrank-test showed that these differences were highly significant (v2 = 39.8%) 1 (0. / Journal of Affective Disorders 83 (2004) 11–19 Table 3 Raw prevalencesa of endogenous psychoses in relatives Index-probands Cycloid Psychosis Personally examined N relatives Diagnosis of relative Unipolar affective psychosis Manic-depressive illness Cycloid psychosis Systematic schizophrenia Diagnosis unclear a 15 Manic-depressive illness Total 172 Personally examined 123 1 (0.31. — — — — controls (106 relatives).2%. 1. CP probands and controls however did not differ significantly regarding the familial morbidity risk of MDI. 3).3%) (0.4%) 2 (1.9%) – – – 146 – 5 (3.0001). relatives of CP probands did not differ significantly from relatives of MDI probands (Fig. df = 1. probands 40 individuals with an endogenous psychosis were observed resulting in a morbidity risk of 35.9%) 5 (2.7%.. df = 2. These differences each were also significant after Bonferroni correction..0001). df = 1.B..3%) Controls Personally examined 84 3 (3. With respect to the risk of suffering a cycloid psychosis. df = 1. As expected. The morbidity risk came out at 5. Among the relatives of controls cycloid psychoses were not observed.8%) 23 (18. . 2 shows the morbidity risk of manic depressive illness in relatives.6% in relatives of controls (v2 = 12.

The only case of a relative with a schizophrenic psychosis was a case of a systematic schizophrenia in a brother of a MDI proband. 32 probands with manic-depressive illness and 27 controls with altogether 431 adult first-degree relatives. 1993. — – manicdepressive illness (153 relatives). This is without doubt a limitation of the study which we endeavoured to compensate by our extensive methodology of examination.. Therefore the number of participants in our study is relatively small. 4. The restriction to hospitalised probands could possibly cause a limited representativity of the study sample. Morbidity risk of cycloid psychoses in relatives.cycloid psychosis (172 relatives). number of illness episodes and proportion of personally examined relatives. Maier et al. whereas for instance in larvated depressions a gap between illness onset and obtaining treatment is more probable. Pfuhlmann et al. — – manic-depressive illness (153 relatives). Morbidity risk of manic-depressive illness in relatives. 3. an examination of relatives by trained lay interviewers using structured interviews would not have been appropriate. In our opinion. Concerning age at onset... Discussion The present investigation aimed to examine the familial morbidity and the nosological position of cycloid psychoses. sition for schizophrenic psychoses. both proband groups did not differ significantly. — — — — controls (106 relatives). Included were 45 probands with cycloid psychoses.. In each comparison. but would concern both proband groups in the same manner.. . / Journal of Affective Disorders 83 (2004) 11–19 Fig. no other method is comparable to such an approach with regard to the validity of the obtained information. . For the determination of the age at onset we chose the date of the first consultation of a physician due to the psychiatric symptoms as a conservative measurement. the morbidity risk of any endogenous psychosis as well as the risk of a manic- Fig.. 1991) for the recruitment of index probands. age at onset and obtaining treatment should usually nearly coincide.. 2. Our procedure however involved some difficulties with the recruitment and examination of a sufficient number of cooperative participants since our personnel resources were restricted and relatives sometimes shrank back from an examination by a psychiatrist. In cycloid psychoses and also in manias which both have mostly an acute beginning. In the face of our endeavour to realize a phenotype diagnosis of the greatest possible validity. 1993). . The diagnostic classification of both index cases and available relatives was established based on a detailed exploration in free form by an experienced psychiatrist.16 B.......cycloid psychosis (172 relatives). On the other hand the proportion of personally examined relatives was with 92% of all living adult first-degree relatives in our sample rather high in comparison to other studies with greater patient samples (Kendler et al. We applied the ‘‘sample-of-convenience‘‘-method (Ritsner et al.

According to the findings of most of these studies. in relatives of MDI probands manic-depressive illnesses predominated by far. By contrast. Moreover he did not further specify the diagnoses among relatives. the criteria of Perris and Brockington nevertheless are closely related to Leonhard’s original descriptions allowing for a principal comparability of the patient samples. 1974. since Leonhard did not accomplish a systematic investigation of all family members. This might be due to his non-blind examination of family members which may have influenced some differential-diagnostic decisions. Concerning the morbidity risk of cycloid psychoses. 1993). Our family data therefore point out that manic-depressive illness diagnosed along the lines of Leonhard represents a clinically and genetically homogenous entity. Whereas Perris (1974) and Maj (1990) applied the diagnostic criteria of Perris and Brockington (1981). Schizophrenic psychoses did not play an appreciable role in any group of relatives. relatives of CP probands did not differ significantly from relatives of MDI probands. Such findings ostensibly seem to argue for a nosological overlap of unipolar and bipolar affective psychoses. This of course must affect data regarding familial loading in that actually bipolar relatives are often misclassified as suffering from unipolar illnesses (Blacker and Tsuang. Due to the varying frequency and duration of Schneiderian first rank symptoms and bipolar mood changes respectively there were considerable differences regarding the classification according to DSM-IV even between the three subtypes of cycloid psychoses. 1990. 1999. 1990. 1993. and depressive episodes occur more frequently than manic episodes (Clayton. In relatives of CP probands affective psychoses occurred beside cycloid psychoses. in contrast to our findings Perris reported a largely homotypical heritability. Unipolar depressive psychoses according to Leonhard occurred very rarely. According to DSM-IV criteria. bipolar disorders do not occur with increased frequency in the families of unipolar depressives (Maier et al. 1995).. However. In both proband groups cycloid psychoses were rarely observed among relatives whereas they were completely absent in relatives of controls. Albeit adhering strictly to Leonhard’s original descriptions maximizes the validity of the diagnosis of a cycloid psychosis.. / Journal of Affective Disorders 83 (2004) 11–19 17 depressive illness was in relatives of CP probands significantly lower than in relatives of MDI probands. 1999). Precisely this is of outstanding significance in Leonhard’s classification. Ungvari.. Leonhard’s slightly lower figures regarding the familial frequency of endogenous psychoses (around 5%) presumably result from the differences in the methodological standards. This is understandable due to our procedure of a personal examination of relatives by an experienced psychiatrist which minimizes the risk of overlooking secondary cases. 1999). These problems underline the importance of a detection of even subtle signs of the opposite pole already in the cross-sectional clinical picture of an affective disorder. unipolar depression is even much more frequent in relatives than bipolar disorder. However. 1985. patients with cycloid psychoses had to be classified within a broad spectrum of various diagnostic categories suggesting that these psychoses do not have an equivalent in this classification. the results of Perris (1974) are very similar to ours. Pfuhlmann et al. We found in manic-depressive illness higher familial morbidity rates than Leonhard himself and also higher rates than most other studies (Goodwin and Jamison. but only by means of the course. The markedly increased familial loading with homotypical secondary cases suggests that genetic influences play an important role in the aetiology of this disorder. 1993).B. Franzek and Beckmann. Contrary to our results the majority of family studies of bipolar affective psychoses however report an increased morbidity rate for unipolar depression in relatives of bipolar probands. Maj.. 2001). Concerning the magnitude of the general familial morbidity with psychoses. the other authors used Leonhard’s original criteria for cycloid psychoses. Our findings on familial morbidity risks in cycloid psychoses are highly compatible with findings of previous investigators despite some methodological differences (Perris. Winokur et al. Between CP probands and controls there was no significant difference in the familial morbidity risk of an endogenous psychosis. Other authors like Franzek and Beckmann . suggesting a unipolar/bipolar distinction. Winokur et al. an overrepresentation of unipolar depression is to be supposed if usual diagnostic criteria are applied (Ghaemi et al. Since according to usual diagnostic criteria bipolar disorders can not be identified cross-sectionally. Leonhard.

vol. Psychopathology 23. Specific Psychiatric Disorders: Part 1. 1998) which described a low heritability in cycloid psychoses. Lauter. Diagnostic and Statistical Manual of Mental Disorders. Twin and family findings thus consistently point out that predominantly non-genetic factors seem to be important in the aetiology of cycloid psychoses.2% for affective disorders and 4. suggesting that in cycloid psychoses disturbances of cerebral development and cerebral ripening arise in consequence of prenatally operating exogenous biological noxes (Franzek et al. Franzek. Lauter. Other biological findings confirm this assumption. D.A. Genet. Perris.8% for ‘‘mixed psychosis‘‘ in relatives. A prospective follow-up study.. Cutting. This is consistent with findings of a twin study (Franzek and Beckmann. five CP probands had a relative with a manic depressive illness.T.. Tsuang. 3. 1960. Schizophrenic. Kendell.E. Since the morbidity risk for manic depressive illness in relatives of CP probands did not differ significantly from the risk for manic depressive illness in control families. Springer.J. Meas. Blacker. H.18 B.. J. Henn. These figures largely correspond with our results. Washington. Sartorius. H. a replication of our findings by independent research groups using Leonhard’s diagnostic system is necessary. A coefficient of agreement of nominal scales.. N. Springer. In: Helmchen.. 1982.. one would have to expect the higher familial loading in cycloid psychoses due to their more serious symptomatology. V. H. H. E. Sto ¨ ber et al. H... Berlin.. 2001. Affective and Related Disorders. 1990. Maj (1990).P. Clinical picture and course of bipolar affective disorder. 1990. Two of these probands suffered from an anxiety-happiness psychosis. Reliability and validity of the Leonhard classification tested in a five year follow-up study of 50 chronic schizophrenics. reported morbidity risks of 4. Henn. To further substantiate these results. our results suggest that neither a simple dichotomization of the functional psychoses nor their summarization to a uniform continuum of psychotic disorders adequately reflects reality. C. / Journal of Affective Disorders 83 (2004) 11–19 (1999) and Maj (1990) also described the occurrence of affective psychoses in relatives of CP patients. Acknowledgements This study was supported within the ‘‘expanded promotion of research‘‘ program of the Free State of Bavaria (‘‘Erweiterte Forschungsfo ¨rderung des Freistaates Bayern’’). The assumption of a continuous spectrum of bipolar disorders including cycloid psychoses as well as manic-depressive illness would hardly be associable with our results. Psychopathology 23. Unipolar relatives in bipolar pedigrees: are they bipolar? Psychiatr. In our sample. 4th ed. 97 – 105.. Beckmann. If one simply supposed a genetic continuum of bipolar psychoses from slighter to more serious forms. M. Wainwright.. Sartorius. Relationship between cycloid psychosis and typical affective psychosis. 5 – 16. Cohen. Contemporary Psychiatry. Pfuhlmann et al. pp.. N. But the results of our study showed the contrary: in cycloid psychoses genetic susceptibility does not play an important role in aetiology. The course and outcome of cycloid psychosis Psychol. 1997).. In conclusion.F.. Specific Psychiatric Disorders: Part 1. 387 – 398. Our family data provide additional evidence that cycloid psychoses may form a nosologically independent group of psychoses. (Eds. Educ. Therefore our findings together with the results of the above mentioned studies confirm the distinctiveness of cycloid psychoses as against schizophrenias and furthermore suggest the distinctiveness of cycloid psychoses as against manic-depressive illness. References American Psychiatric Association..C. Fritze. 1996. 1993. 209 – 216.. M. In cycloid psychotic twins concordance rates were nearly equal in monozygotic and dizygotic pairs. pp. Affective and Related Disorders. In: Helmchen. R.. H. Franzek. whereas schizophrenic psychoses were not found. 20. F. 212 – 219.E. S. Brockington. E. Lanczik. 3.). 37 – 46. 12. 1992. Hillier. 3. DC. Cycloid psychoses and their differentiation from schizophrenic and affective psychoses.. whose study most closely matches the present investigation under methodical aspects. Haynal. J... . I..). F. 205 – 211. 2001. Contemporary Psychiatry. Beckmann. the cases of a manic depressive illness among CP relatives rather seem to reflect the considerable frequency of manic depressive illness in the population than a genuine genetic relation between cycloid psychoses and manic depressive illness. Prognostic validity of the cycloid psychoses. vol. Psychol. H. J. A. F. American Psychiatric Press. P. Med. Schizophrenic. (Eds.. Beckmann. 1994.E. Berlin.. In: Ferrero.. Clayton.. two from a motility psychosis and one from a confusion psychosis..

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