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Cycloid psychosis

Article in International Review of Psychiatry · March 2005


DOI: 10.1080/00207390500064684 · Source: PubMed

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International Review of Psychiatry, February 2005; 17(1): 53–62

Cycloid psychosis

VICTOR PERALTA, & MANUEL J. CUESTA

Psychiatric Unit, Virgen del Camino Hospital, Pamplona, Spain

Summary
This article reviews the concept, nosological status, diagnostic features, associated clinical characteristics, and the
etiopathological variables involved in cycloid psychosis. The concept of cycloid psychosis is based on sound
psychopathological and course underpinnings, and despite the inclusion of some cycloid features in the current diagnostic
systems such as ICD-10 and DSM-IV, these systems do not capture well the diagnostic construct of this disorder. Cycloid
psychosis is a valid clinical constructs that can be easily differentiated from the boundary disorders on clinical grounds. It
seems to be heterogeneous from the etiopathological point of view, in that a variety of factors seems to be involved to a
different degree in most of the patients. Future studies should examine putative subtypes of the disorder in relation to
etiological, pathophysiological and clinical variables.

Brief historical introduction to the concept phases of anxiety and elation, which are respectively
related to paranoid and grandiose delusions, and set
The cycloid psychosis concept has a long tradition in
the modern conceptualization of cycloid psychosis
the European psychiatry (Leonhard, 1957; Fish,
(Leonhard, 1957; 1961). More recently, Perris
1964; Perris, 1988), and its current conceptualiza-
tion stems from the Wernicke-Kleist-Leonhard (1974; 1988) produced a number of classical
school of psychiatry that considered the disorder as papers on the disorder and introduced the first
a third psychosis in opposition to the Kraepelin’s operational criteria for diagnosing the disorder
influential ‘two-entity’ principle of endogenous (Perris & Brockington, 1981). According to Perris
psychoses (Leonhard, 1957; 1961). On the basis of (1988), cycloid psychosis ‘is an acute, most often
fine psychopathological descriptions and course self-limiting, and as a rule functional psychotic
of the disorders, Leonhard delineated five types of condition . . .the clinical picture is almost consistently
endogenous psychoses: unipolar phasic psychoses, characterized by the presence of some degree of
manic-depressive disease, cycloid psychoses, unsys- confusion or distressed perplexity, and, most of all
tematic schizophrenias and systematic schizophre- by a polymorphous and shifting symptomatology’.
nias. This author considered the cycloid psychoses as There is a broad agreement among authors that the
a group of acute recoverable psychoses that are main defining features of this disorder are acute
neither manic-depressive nor schizophrenic. The onset, remitting course, benign outcome in the long
term ‘Zycloiden Psychosen’ was first used by Kleist in run, and symptom polymorphism; however, these
1926 to group together disorders described so far, four characteristics are shared by alternative, some of
and also many other conditions that he had them national-based concepts, namely schizoaffec-
previously classified under the headings ‘delusional tive psychosis (Kasanin, 1933), schizophreniform
affective psychoses’ and ‘affective psychoses’ (Perris, states (Langfeldt, 1939), reactive psychosis
1995). Kleist described two variants of the disorder, (McCabe, 1975), bouffée délirante (Pichot, 1982),
confusional insanity characterized by contrasting atypical psychosis (Mitsuda, 1965) or puerperal
phases of confused excitement and stupor, and psychosis (McNeil, 1986). Each of these different
motility psychosis characterized by contrasting conceptualizations of (probably) the same disorder,
phases of hyperkinesis and hipo- or akinesis. reflect the degree to which different features are
Leonhard introduced a third variant, the anxiety- regarded as essential. The cycloid psychosis concept
elation psychosis, characterized by contrasting seems to have prevailed over the rest on the basis of

Correspondence: Victor Peralta, Psychiatric Unit, Virgen del Camino Hospital, Irunlarrea 4, 31008 Pamplona, Spain. Tel: þ
34 8484 2 2488. Fax: þ 34 8484 2 9924. E-mail: victor.peralta.martin@cfnavarra.es
ISSN 0954–0261 print/ISSN 1369–1627 online ß 2005 Institute of Psychiatry
DOI: 10.1080/00207390500064684
54 V. Peralta & M. J. Cuesta

both its integrative character and the well-developed According to Leonhard, cycloid psychoses need to
nosological system from which it is rooted. be diagnosed on the basis of the presence of at least
The cycloid psychosis construct appears to have one of six basic bipolar axial syndromes, namely
historical, face and clinical validity. However, the anxiety-happiness, excitation-confusion, inhibition-
nosological status of cycloid psychosis within the confusion, and hypermotility-hypomotility, which
broad field of psychotic disorders, particularly mood respectively conform the sub-forms of anxiety-
disorders and schizophrenia continues to be a matter happiness psychosis, confusion psychosis, and
of debate. Studies addressing this question have motility psychosis (Table II). Anxiety-happiness
supported the view of cycloid psychosis either as an psychosis shows extreme alterations of the affective
independent nosological entity (Leonhard, 1961; state, with paranoid anxiety on the one hand and
Perris, 1974; Maj 1988; 1990), as an atypical variant ecstatic states with feelings of elation accompanied
of affective psychosis (Cutting, 1990), as an atypical by ideas of a calling or salvation, on the other.
form of schizophrenia (Vaillant, 1964), as a hetero- Confusion psychosis presents an excitation or
geneous condition (Fish, 1964; Mojtabai, 2000; inhibition of thought processes with incoherence of
Peralta & Cuesta, 2003a). Finally, other studies thematic choice in the excited states and perplexity in
have reached inconclusive results (Cutting, Clare & the inhibited states. Motility psychosis is character-
Mann, 1978; Brockington, Perris, Kendell, Hillier & ized by a hyperkinesis or hypokinesis of psychomotor
Wainwright, 1982a). phenomena affecting predominantly expressive and
The cycloid psychosis concept has received reactive motions independent of disturbances of
much attention in the international literature emotion or thought. Each sub-form of the cycloid
during the past half century, although a glance at psychoses presents intrasyndromal bipolarity (for
the number of publications in the last 15 years shows example, hypomotility and hypermotility features),
an important decrease of studies on this topic. This and sometimes symptoms from other axial
may, at least in part, be due to both its uncertain syndromes are also present, all of which confer a
nosological status, and to the (probably misleading) typical polymorphous character to the whole clinical
idea that the concept has become assimilated by picture. Leonhard described these sub-forms as
the current formal diagnostic systems under the prototypal variants of a single disorder. In practice,
different variants of non-affective remitting psychotic however, pure forms corresponding to each subtype
disorders. seldom occur, and most frequently, various cycloid
syndromes may appear during the same episode and/
or combine and merge together. This author
Diagnosis of cycloid psychosis
reported some differences in subtypes of cycloid
According to Leonhard (1961), cycloid psychoses psychosis regarding heritability (which is more
(plural) are a group of acute and remitting psychotic pronounced in the motility sub-form), gender
disorders that can be reliably diagnosed on the basis distribution, age at onset, and number and length
of a cross-sectional assessment of the characteristic of episodes, however, the validity of subtyping
clinical picture. Leonhard states that ‘when the cycloid psychosis remains to be demonstrated.
diagnosis of cycloid psychosis is made, then it Recently Jabs et al. (2003) and Sigmund & Mundt
necessarily follows that a complete remission will (1999) have respectively developed diagnostic cri-
occur and even if the illness recurs no defect will be teria and diagnostic guidelines for diagnosing cycloid
left behind’ (Leonhard, 1961). The main reason for psychosis and its subtypes, which are very close to
recognising the cycloid psychosis concept is that the Leonhard conception. However, the reliability
patients presenting with cycloid symptoms may be and validity of these criteria and guidelines remains
erroneously diagnosed of schizophrenia, which may to be studied.
convey dramatic therapeutic and prognostic implica- The Leonhard approach to the diagnosis of cycloid
tions. While Leonhard made a fine and thorough disorder represents a ‘down-top’ approach (basic
description of the clinical picture of cycloid psychosis axial syndromes, subtypes, disorder), whereas the
and its sub-forms, he never developed operational Perris and Brockington criteria represent a ‘symptom
diagnostic criteria. This task was undertaken by collection’ approach without specific syndrome
Perris and Brockington (1981) who set the first patterns, and therefore, subtypes of the disorder.
operational criteria for diagnosing the disorder, Unfortunately, the two concepts have not been
which are intended to capture the core features empirically compared yet, and the extent to which
of the Leonhard’s concept. These criteria were they represent the same conceptualization of the
developed on the basis of the comprehensive study disorder differs, remains unknown.
by Perris (1974), and they have become the An important feature of the Perris and
standard ones for diagnosing cycloid psychosis (see Brockington criteria is that good outcome, a typical
Table I). feature of cycloid psychoses, is not included in the
Cycloid psychosis 55

Table I. Diagnostic criteria for cycloid psychosis.

Perris & Brockington (1981) criteria.


1. Acute (functional) psychotic condition occurring for the first time in the range 15–50 years
2. Sudden onset with a rapid change from a state of health to a full-blown psychotic condition within a few hours or at most very few days
3. At least four of the following must be present:
a. Confusion
b. Mood-incongruent delusions
c. Hallucinatory experiences of any kind
d. Pan-anxiety
e. Deep feelings of happiness or ecstasy
f. Motility disturbances (akinetic or hyperkinetic)
g. A particular concern with death
h. Mood swings in the background and not so pronounced to justify a diagnosis of affective disorder
4. There is no fixed symptomatological combination; on the contrary, the symptomatology may change frequently during the episode and
shows a bipolar characteristic

Leonhard criteria as operationalized by Bräuning (1995).

1. At least one of the following basic cycloid syndromes that are characterized by specific symptoms
a. Anxiety cycloid syndrome
b. Happiness cycloid syndrome
c. Agitation-confusion cycloid syndrome
d. Inhibition-confusion cycloid syndrome
e. Hyperkinesis cycloid syndrome
f. Hypokinesis cycloid syndrome
g. Atypical cycloid syndrome
2. Emotional turmoil
3. Bipolarity
4. Switching
5. Syndromic instability
6. Symptom polymorphism
7. Syndrome disharmony
For diagnosing cycloid psychosis 1 through 7 are necessary.

Table II. The Leonhard sub-classification of cycloid psychoses.

Anxiety–happiness psychosis Confusion psychosis Motility psychosis


Ecstasy Excitation Hyperkinesia
Ecstatic mood with ideas of calling, happi- Incoherence of thought with compulsive Increase in expressive and reactive motions,
ness, reflecting an altruistic component of speech or incoherence of thematic choice severe distractibility by environmental
the ecstasy or digressive theme choice conditions with continued senseless motor
activity
Anxiety Inhibition Hypokinesia/Akinesia
Severe anxiety with distrust and ideas of Inhibition of thought, perplexedness ideas of Disappearing of reactive motions, stiffness
reference, ideas of threat or persecution, meaning, ideas of reference, acoustic, visual of expressive motions, reduction or
anxiously coloured somatic sensations or somatopsychic hallucinations standstill of voluntary movements
General symptoms
Affect generated illusory or hallucinatory Fleeting misrecognitions of persons, ideas of Incoherent speech, unarticulated sounds of
phenomena reference, fleeting hallucinations expressive character, or mutism
Facultative symptoms
Rapid change of anxiety and ecstatic mood Lability of affect with rapid changes between Mood alterations from anxious to ecstatic
joy and tearfulness hallucinations

From Jabs, Pfuhlmann, Bartsch, Cetkovich-Bakmas & Stober (2003).

definition (as is the case in the modern diagnostic an exclusion criterion, elsewhere (Perris, 1988)
systems) and therefore a tautological definition of the clearly stated that there is never a fully developed
disorder is avoided. A major issue concerning these manic or depressive syndrome. This is an important
criteria refers as to whether the presence of a full question that influences the results of any nosological
affective syndrome should be considered as an or validation study, since many authors have
exclusion criterion for diagnosing the disorder or considered the presence of a major mood syndrome
not, since whereas these authors do not explicitly as incompatible with a cycloid psychosis diagnosis.
include the presence of a full affective syndrome as We believe that the co-existence of a full affective
56 V. Peralta & M. J. Cuesta

syndrome should not be considered an exclusion with psychotic features, or psychotic disorder not
criterion for diagnosing cycloid psychosis because: otherwise specified.
(a) this specific criterion was not included in the Two studies that have specifically examined the
original criteria; (b) a major assumption underlying concordance between the ICD-10 acute/transient
the concept of cycloid psychosis is that it is a specific psychoses and cycloid psychosis have found that
pattern of symptoms which may be defined irrespec- between 30–45% of patients with an ICD-10
tive of other psychopathological features; and (c) this diagnosis of acute/transient psychosis met the criteria
procedure allows one to examine the predictive for cycloid psychosis (Pillmann, Haring, Balzuweit,
validity of the concept in relation to other clinical Blöink & Marneros, 2001; Peralta & Cuesta, 2003b).
syndromes on a pure descriptive basis without a Accordingly, identity of the two disorders cannot be
priori assumptions about the association (or the lack taken for granted, and the attempts to include
of it) among psychopathological syndromes (Peralta aspects of the cycloid psychosis concept in the
& Cuesta, 2003b). consensus classifications under the diagnoses of
reactive psychosis (DSM-III-R), brief psychotic
disorder (DSM-IV) or acute and transient psychotic
Cycloid psychosis in the formal diagnostic systems disorder (ICD-10) seem to have been unsuccessful.
Perhaps the major reason for the observed poor
The successive editions of the formal diagnostic
concordance of cycloid psychosis with DSM-IV brief
systems have not incorporated the cycloid psychosis
psychotic disorder and ICD acute/transient psycho-
diagnosis, and the degree to which these diagnostic
tic disorder is the duration criteria, 1–3 months
systems have included cycloid features, other than
depending of the specific disorder, since the duration
the remitting course, varies highly among classifica-
of a cycloid episode may exceed several months
tions. The third edition of the Diagnostic and
(Leonhard, 1957; Kirov, 1995; Peralta & Cuesta,
Statistical Manual (DSM-III) did not include spe-
2003a). In line with this it has been described that
cific cycloid features, whereas the DSM-III-R the modal duration of the acute remitting psychoses
included emotional turmoil and perplexity or is 2–4 months (Mojtabai, Varma & Susser, 2000).
confusion as defining features for the brief reactive Both, the relative long duration of some cycloid
psychosis. In the DSM-IV these symptoms are episodes and the ability of the cycloid concept to
considered to be ‘associated’ but not defining predict a good outcome, this irrespective of its
features for the brief psychotic disorder. length, clearly suggest that cycloid psychosis does
In contrast to DSM classifications, the ICD-10 not equal with brief duration. Accordingly, if formal
includes many cycloid features under the diagnosis diagnostic systems have to incorporate the cycloid
of acute and transient psychotic disorders and more psychosis concept adequately, the duration criterion
specifically under the subgroups of acute poly- should be relaxed (in this respect some authors
morphic psychotic disorder without and with symp- propose to extend the duration criterion to six
toms of schizophrenia (F23.0 and F23.1, months [Mojtabai, Susser & Bromet, 2003]) or not
respectively). These features include: acute onset, included at all. A further reason for the lack of
shifting symptomatology, emotional turmoil, per- concordance between the two diagnoses is that for
plexity, and changes in the psychomotor activity. diagnosing acute/transient psychoses the exclusion of
This has led to some authors to erroneously equate a mood syndrome is required; by which mood-
the concept of cycloid psychosis with the acute and related cycloid syndromes do not meet the criteria
transient psychotic disorders from the ICD-10 for that diagnosis.
(Susser, Varma, Malhotra, Conover & Amador,
1995; Das, Malhotra & Basu, 1999).
Despite the inclusion of some cycloid features in Discriminant validity of the cycloid psychosis
the formal diagnostic systems, they capture the diagnosis
cycloid psychosis construct only partially. Studies Applying a discriminant analysis to Perris and
examining the nosological status of cycloid psychosis Brockington’s criteria for cycloid psychosis in a
in the modern classifications have consistently shown mixed sample of psychotics, Peralta and Cuesta
that cycloid psychosis does not correspond closely to (2003a) showed that the discriminant model cor-
any DSM-III, DSM-III-R, DSM-IV or ICD-10 rectly classified 94.7% of the patients, and that
category (Maj, 1988; Brockington & Roper, 1990; among the cycloid symptoms confusion and mood
Beckmann, Fritze & Lanczik, 1990; McGorry et al., swings had the highest discriminant power. A
1992; Peralta & Cuesta, 2003b). In fact, most cases number of studies have empirically verified that
of cycloid psychosis are diagnosed by these systems cycloid psychosis can be reliably differentiated from
as either brief psychotic disorder, schizophreniform other psychotic disorders using numeric taxonomy
disorder, schizoaffective disorder, mood disorder techniques (Meda, Martinez & Morgante, 1997),
Cycloid psychosis 57

cluster analysis (Jönsson, Jonsson, Nyman & Nyman, schizophrenia. During a cycloid episode the majority
1991; Angst, 1993), latent class analysis (Peralta & of the patients present an incomplete affective
Cuesta, 2003b), and factor analysis supplemented by syndrome and almost half of the patients a complete
canonical variate analysis (Brockington et al., 1991). affective syndrome, and over the illness course these
The studies by Angst (1993) and Peralta and Cuesta figures are even greater (Peralta & Cuesta, 2003a).
(2003b) analyzed both index episode and lifetime
ratings of psychopathology, and interestingly, the
Course and outcome
cycloid psychosis class emerged only in the analysis
of index episode ratings. Brockington et al. (1991) The average age of onset of the disorder is towards
also used lifetime ratings of psychopathology, and the second decade of the life. The natural course of
they reported that bipolar and cycloid groups were the disorder shows a typical recurrent pattern, and
difficult to differentiate. These data converge to on average, patients untreated prophylactically tend
indicate that many patients diagnosed as cycloid at to recur every four years without any particular
the index episode are mainly diagnosed as atypical seasonal distribution of the episodes (Perris, 1974).
schizophrenics or schizobipolars in the long run The duration of most psychotic episodes ranges
(Peralta & Cuesta, 2003b), which suggests that the between several weeks and several months, and
cycloid psychosis concept may be less consistent in although an episode duration of several days and of
the long term. one year or more have been reported, these are
exceptions rather than the rule. In order to avoid an
erroneous diagnosis of schizophrenia, particularly
Clinical characteristics during a first episode of the illness, it is important to
Demographic features acknowledge that the cycloid episode may last several
months.
Cycloid patients represent 10–15% of all admissions It has been assumed that the diagnosis of cycloid
for a functional psychotic disorder. The only epi- psychosis is stable over time (Leonhard, 1957; Perris,
demiological study (Lindvall, Axelsson & Öhman, 1974), and that there are little shifts between the
1993) showed that the one-year incidence rate for sub-forms, however, no sound studies addressing
first-admission patients with cycloid psychosis was this topic have been conducted to date. Leonhard’s
0.043 per 100,000 inhabitants, which represented own catamnesic studies shown that about 12% of
almost one quarter of all functional psychoses in the cycloid patients changed the diagnosis, most of them
age group up to 50 years. A slight female predomi- to schizophrenia (Trostorff & Leonhard, 1990).
nance has been consistently reported. Leonhard and Perris have repeatedly maintained
that cycloid patients do fully recover from each
Premorbid background psychotic episode without any deterioration. How-
ever, residual defect symptoms have been observed
Most studies examining the premorbid characteris- in 7–17% of the patients, with higher rates of deficit
tics of cycloid patients did not find salient features, states corresponding with greater length of the follow-
and patients typically present a premorbid adjust- up (Hatotani & Nomura, 1983; Ambruster, Gross &
ment similar to affective disorders and much more Huber, 1983; Beckmann, Fritze & Lanczik, 1990).
better adjustment than schizophrenics (Perris, 1974; Furthermore, in a four-year follow-up study of non-
Pillmann, Blöink, Balzuweit, Haring & Marneros, affective acute remitting psychosis, a diagnosis close
2003). One study reported that in a mixed sample of to cycloid psychosis, Mojtabai et al. (2003) showed
psychotic patients the presence of a histrionic that 8% of the patients were not fully recovered.
personality increased by a factor of 10, and alter-
natively the presence of a schizoid personality
decreased by a factor of two, the likelihood of a Treatment
diagnosis of cycloid psychotic disorder (Peralta & Unfortunately, no controlled studies of cycloid
Cuesta, 2005). psychoses treatment have been conducted to date,
this being mainly due to the fact that the disorder
remains largely unrecognized in the formal diagnostic
Associated psychopathology
systems. Accordingly, data on treatment continue to
Along the defining symptoms of the disorder, rely on clinical experience, uncontrolled studies, and
virtually all the acute symptoms of the psychoses anecdotal case reports. Electroconvulsive therapy
can be found in cycloid patients. In this way, cycloid (ECT) has been the treatment of choice for many
patients display rates of Schneider’s first-rank symp- years, and it is likely to produce a dramatic improve-
toms and global levels of psychotic and disorganiza- ment after only a few sessions, particularly for
tion symptoms comparable to those reported in those disorders with prominent motor features
58 V. Peralta & M. J. Cuesta

(Little & Ungvary, 2000). According to clinical lore, shown a substantial homotypical intrafamiliar pattern
neuroleptics seem to be effective in aborting the of transmission of about 40% (Leonhard, 1957;
episode, but their potential to reduce relapse rates Mitsuda, 1965; Perris, 1974; Ungvari, 1985), how-
remains unclear. A number of uncontrolled studies ever, these studies are subject to a number of
have shown that lithium is particularly effective in methodological limitations. A systematic twin study
reducing morbidity in the long run (Perris, 1978; showed a low heritability index (0.21) for cycloid
Maj, 1984). In the case of cycloid psychoses psychosis, together with a similar concordance rate
associated with oestrogen withdrawal states, there for monozygotic (39%) and dizygotic (31%) pairs
are surprisingly few studies about the possible (Franzek & Beckmann, 1998), which suggests a
therapeutic effect of an estradiol substitution, remarkable role for non-genetic factors. Studies
although some reports support that such a hormonal examining the morbidity risk for schizophrenia and
therapy may be effective (Ahokas, Aito & Rimon, mood disorders in the relatives of cycloid probands
2000; Stein, Blumenshon & Witztum, 2003). Last have been rather consistent, since they have uni-
but not least, it should always be kept in mind that a formly found a higher risk for mood disorder than for
cycloid episode may remit spontaneously, particu- schizophrenia (Mitsuda, 1965; Maj, 1990; Cutting,
larly when precipitating factors can be recognized and 1990; Franzek & Beckmann, 1998; Peralta & Cuesta,
suppressed. In such an instance and when the 2003a).
symptoms are not severely disruptive, a conservative
approach to the treatment (such as with benzodiace- Obstetric complications (OC)
pines) may be desirable.
The reported prevalence of obstetric complications
(OC) in cycloid psychoses ranges between 20%
Etiological and neurobiological factors (Maj, 1990) and 60% (Stöber, Kocher, Franzek &
Psychosocial factors Beckmann, 1997). This broad range of prevalence
probably reflects differences in the method for the
Several studies have examined negative early child- assessment of OC, which makes the studies hardly
hood experiences such as parental loss, separation comparable and the results difficult to interpret.
from either parent, or family dysfunction in cycloids For example, Maj (1990) reported more OC in
relative to other psychiatric disorders such as cycloids than in affective and schizoaffective patients,
schizophrenia and affective disorders (Perris, 1978; and Stöber et al. (1997) reported a lack of difference
Peralta & Cuesta, 2003a). No sharp inter-group in the prevalence of OC among cycloids, affective
differences were found suggesting that early family patients and controls. Despite these incongruities, a
dysfunction does not play a specific role in the few data support a role for OC in the etiology of
further development of a cycloid disorder. cycloid psychosis. In the twin study by Franzek &
Given that cycloid disorder is sometimes regarded Beckmann (1998) it was found that the rate and
as closely related to the reactive psychoses, much severity of obstetric complications for the twins with
attention has been paid to investigate to what extent cycloid psychosis were significantly higher than for
the cycloid episodes are precipitated by stressful live their partners. In line with this, the same research
events. The reported rate of psychosocial precipitat- group has reported a birth excess in the first half of
ing factors ranges between 30 and 65% (Cutting the spring for probands with cycloid psychosis
et al., 1978; Perris, 1974; Peralta & Cuesta, together with viral infections in the mother during
2003a), and cycloid patients show more and more the gestation, all of which would support the
severe psychosocial stressors compared with schizo- hypothesis of an exogenically-induced disturbance
phrenia and mood disorders (Peralta & Cuesta, of brain maduration during the gestation (Franzek &
2003a). Interestingly, precipitating factors (either Beckmann, 1992).
psychosocial or biological) are found especially
at the earlier episodes, later on the disorder
seems to take an ‘autonomous’ course that is Hormonal factors
relatively independent of precipitating factors The puerperium, a state of dramatic changes in
(Perris, 1988). hormone levels including a decrease in the estradiol
level, is considered to be a risk factor for the
development of puerperal psychosis, a clinical con-
Heritability
dition that highly resembles cycloid psychosis. In
Studies addressing the heritability of the disorder are fact, Pfuhlmann, Stöber, Franzek & Beckmann
not fully concordant. Family studies examining the (1998) showed that over half the patients (54%)
diagnosis of cycloid psychosis in relatives of pro- with a severe postpartum psychiatric disorder could
bands with the same diagnosis have consistently be diagnosed as having cycloid psychosis.
Cycloid psychosis 59

Furthermore, the premenstruum (that is, the late disorder that may indicate an enhanced level of
luteal phase; Severino & Yonkers, 1993), and other arousal (Strik, Fallgatter, Stoeber, Franzek &
oestrogen withdrawal states such as cessation of Beckmann, 1996). Epileptic-like EEG abnormalities
exogenous administration of oestrogen, administra- have been reported in some patients with ‘atypical
tion of an antagonist of the oestrogen receptors, and psychosis’, a diagnosis that largely corresponds to
blockade of the endogenous secretion of oestrogen cycloid psychosis (Mitsuda, 1965).
(Mahé & Dumaine, 2001) have been associated with
cycloid-like psychoses. Deuchar and Brockington
Other factors
(1998) have proposed a unitary etiological hypothesis
for puerperal and menstrual psychoses, which can be A series of studies have addressed the occurrence of
extended to all oestrogen withdrawal states, on the possible associations between cycloid psychosis and
basis of a precipitous reduction in the brain oestro- well-known genetic markers such as blood groups,
gen environment in predisposed individuals. The red-cell enzymes and HLA antigens. No clear
pathophysiological mechanisms underlying the asso- differences emerged with respect to schizophrenia,
ciation between oestrogen withdrawal and cycloid affective disorders and normal controls, excepting for
disorder are not clear, although it is well-known that an excess of RH- in cycloids as compared with all
oestrogen has a wide array of effects on several other groups (Perris, 1988).
neurotransmitter systems such as an increases in the
sensitivity of dopamine receptors (Wieck et al.,
Hypotheses about the nature of cycloid psychosis
1991). Furthermore, variation at the serotonine
transporter gene (Coyle, Jones, Robertson, Lendon The intriguing character of cycloid psychosis, a
& Craddock, 2000) and raised cortisol post- disorder comparable to schizophrenia in terms of
dexametasone (Paykel, Martin Del Campo, White psychotic symptoms and to mood disorders in terms
& Horton, 1991) have been involved in puerperal of course and outcome, together with the broad
psychosis, findings that are also shared by affective array of illness-related etiological and pathophysiolo-
disorders. gical factors raises the question about its very true
nature. Fish (1964) comprehensively reviewed the
hypothetical origins of the disorder, and according to
Neuroimaging
this author, cycloid psychosis may be understood as:
A few neuroimaging studies have been conducted to (1) a schizoaffective disorder due to the inheritance of
date, and they have reached inconclusive findings. a predisposition to schizophrenia and affective dis-
Franzek et al. (1996) found more ventricular orders; (2) there is an unitary psychosis and the
abnormalities in cycloid patients than in patients cycloid psychosis is the transitional group; (3) a mild
with other psychiatric disorders, including schizo- form of schizophrenia; (4) a form of manic-depressive
phrenia. Falkai et al. (1995) reported that cycloid illness; (5) an entirely independent disorder; (6) a
psychosis differed from controls by significantly psychogenic reaction; and (7) an heterogeneous group
higher ventricular-brain ratios, larger area of the of disorders. We will discuss briefly each of these
third ventricle, and wider frontal cerebrospinal fluid hypotheses taking into account the available data.
spaces. However, Becker, Stöber, Lanczik, Hofmann The consideration of cycloid psychosis as part of
& Franzek (1995) and Höffler, Bräuning, Krüger & the schizophrenia spectrum has been made on the
Ludvik (1997) did not find clear structural brain basis of theoretical or psychopathological grounds
differences between cycloid patients and normal such as the high prevalence of ‘schizophrenic’
controls. The only published study to date using symptoms, namely, the so-called first-rank symp-
functional neuroimaging showed a positive correla- toms (Vaillant, 1964), and beside this we are not
tion between level of cortical blood flow and level of aware of any empirical study linking the disorder to
symptoms and that flow normalized again after schizophrenia. The ‘schizoaffective’ hypothesis is
clinical remission (Warkentin et al., 1992). supported by the frequent co-existence of cycloid
However, preliminary findings from an ongoing features with affective symptoms and syndromes
SPECT study did not yield any evidence for both during the acute episode and in the long run,
enhanced brain perfusion (Bartsch et al., 2001). however, schizoaffective and cycloid disorders show
meaningful differences in cross-sectional psycho-
pathology, course and outcome (Leonhard, 1983),
Neurophysiology
all of which is in line with low concordance that has
A single study has shown that some cycloid patients been consistently reported between the two diag-
have normal P300 topographies and latencies, but noses. The ‘affective’ hypothesis is supported by the
significantly higher amplitudes than controls, a high co-occurrence of mood symptoms and syn-
finding not described in any other psychiatric dromes, the increased morbidity risk of mood
60 V. Peralta & M. J. Cuesta

disorders, and the remitting course. The strong remitting psychotic disorders) on phenomenological
reactive component would support the ‘psychogenic’ grounds. Despite the high internal consistency of the
hypothesis, but only in a subgroup of patients, since concept, we are probably confronted with a disorder
only a minority of cycloid patients have substantial that is heterogeneous from the etiological point of
stressors. The ‘independent entity’ hypothesis is view, in that psychosocial stressors, homotypical
mainly based in both the characteristic clinical heredity, affective liability, and hormonal factors
picture and the relatively high homotypical familial seem to be involved to a different degree in most of
loading of the disorder. Support for the ‘unitary the patients with the disorder. Regarding the
psychosis’ hypothesis comes from the fact that neurobiological basis of cycloid psychosis, the exist-
cycloid psychosis is often difficult to differentiate ing data are still fragmentary or inconclusive and
from the boundary disorders such as schizoaffective most of them await replication. Accordingly, at our
disorder, affective disorder with psychotic symptoms, current level of knowledge, we cannot articulate a
and other non-affective remitting psychotic disor- neurobiological hypothesis for the disorder.
ders, and in many ways cycloid psychosis can be Despite their distinctive psychopathological char-
conceptualized as a third psychosis between schizo- acteristics, a large proportion of cycloid patients
phrenia and manic-depressive illness, which in more cannot be meaningfully classified by using the
or less extension shares a number of features with ICD-10 and DSM-IV systems. Although the intro-
these two disorders. In fact, it has been shown that duction of the category of acute and transient
most of the patients diagnosed with Kahlbaum’s psychotic disorders in the ICD-10 was an advance
catatonia, one of the main paradigms of the unitary toward incorporating cycloid psychosis in modern
psychosis theory, can be diagnosed with cycloid diagnostic systems, many cases of cycloid psychosis
psychosis (Peralta, Cuesta, Serrano & Mata, 1997). do not fit these criteria, mostly because of the
Lastly, and given the lack of a single integrative restrictive duration criterion. Irrespective of the
hypothesis explaining most of the features of cycloid nosological status, putative etiology, and neuro-
psychosis, some authors have proposed that the biological basis of cycloid psychosis, the heuristic
disorder actually represents a heterogeneous and practical value of the concept cannot be ignored.
condition. In line with this, Fish (1964) described In fact, there are a number of reasons for considering
four putative subtypes, namely, psychogenic reac- cycloid psychosis as a separate diagnosis, at least at a
tions, atypical affective disorders, epileptoid psycho- descriptive level that does not necessarily imply a
sis (thus is cycloid psychosis associated with EEG nosological entity hypothesis in the sense of specific
abnormalities), and true cycloid psychosis. More causes and mechanisms. These are: (a) the internal
recently, Mojtabai (2000), using latent class analysis, consistency of the diagnosis; (b) its discriminant
could differentiate affective and non-affective sub- value regarding the boundary diagnoses; (c) its
groups of cycloid psychosis, and Peralta and Cuesta predictive value of a relatively benign course; and
(2003a) provided some support for such a distinction (d) taking into account the presence of a cycloid
in that, compared with the affective group, the non- syndrome within an otherwise typical schizophrenic
affective group had a predominance of females, clinical picture may avoid a misdiagnosis of schizo-
better premorbid adjustment, less previous hospita- phrenia and therefore treatment mistakes. All these
lizations, better treatment response, and more severe features reflect well the clinical and research rele-
psychosocial stressors. vance of a concept that deserves to be included, on
As can be seen from the above discussion, the lack its own, in future formal diagnostic criteria of
of a single nosological hypothesis underlying the psychotic disorders, at least as a provisional or
cycloid psychosis diagnosis reflects well the perplex- alternative diagnosis, in order to promote a more
ing and complex nature of the disorder. Not- complete examination of its clinical and biological
withstanding, the degree to which that diagnosis fits underpinnings. Future studies should pay particular
the alternative hypotheses varies highly. In this way, attention to the examination of putative subtypes
the ‘independent’, ‘affective’ or ‘heterogeneity’ hypo- (that is, the classical anxiety-elation, motility and
theses are much more plausible that the ‘schizo- confusion forms, and the affective-non-affective
phrenia’, ‘schizoaffective’ or ‘psychogenic’ hypotheses. distinction) in relation to clinical, etiological and
pathophysiological variables.
Conclusions and future directions
Cycloid psychosis represent a valid clinical construct
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