Differential diagnosis and therapy of cycloid psychoses: A case report

Kraepelin already challenged his dichotomy of psychoses, because in clinical practice too many cases were not in line with his pattern. Different terms for these disorders were coined. Leonhard separated cycloid psychoses from other forms of endogenous psychoses. The idealized subtypes (anxiety-beatific, hyperkinetic-akinetic-motility and confusional exited-inhibited) are characterized by a bipolar course with complete recovery. Operationalised criteria were developed by Perris. We report on a 60 year old woman diagnosed as schizophrenic in 1984/1985 and 2006. In August 2015 she was admitted with stupor and mutism and therefore was treated with fluphenazine and lorazepame. Six days later the clinical picture changed, she became confused and very agitated. After change of treatment to benperidole her clinical condition improved within 12 days. After 3 further days she became confused, agitated and euphoric again. The symptoms persisted in spite of a change of treatment to haloperidole. After diagnostic revision therapy was augmented with lithiumcarbonate. Six days later the psychotic symptoms began to improve and were completely remitted after 10 further days. The case report points out that a differential-diagnostic revision of an apparently therapy-resistant schizophrenia should not only be carried out according to ICD 10 criteria but a cycloid psychosis should be taken into account, too. Perris-criteria are contrasted with ICD 10-criteria for schizophrenia and mania with psychotic symptoms. Symptomatology and clinical course in our patient fulfilled exactly the Perris-criteria. We recommend an augmentation trial with lithium in acute phases of cycloid psychoses by all means before ECT.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Cycloid psychosis: From Kleist until our days

IntroductionAfter Emil Kraepelin's division of psychoses into a group of dementia praecox and manic-depressive insanity, the classification of psychoses with atypical symptoms, which could not be assigned in this dichotomy created a debate, that lasts until our days. These “atypical psychoses” had been described under many terms and concepts in different countries.In 1926, Kleist coined the term “cycloid psychosis” to describe cases which did not meet the typical presentation shown in Kraepelian's dichotomy. Three decades later, Karl Leonhard established the concept of cycloid psychosis as a nosologically independent group of endogenous psychosis.Objectives/AimsMake an historical review of the concept of cycloid psychosis. Discuss the clinical features and debate the classification of this clinical entity.MethodsA bibliographical review is made of the cycloid psychosis, based on the data published in Pubmed.ResultsAccording to Leonhard, cycloid psychosis generally present with bipolar, polymorphous clinical symptomatology, and run a phasic course with complete remissions after each episode. Furthermore, Leonhard delineated three subtypes: anxiety-happiness psychosis, confusion psychosis and motility psychosis presenting with different symptoms. In 1981, Perris and Brockington formulated the first set of operational criteria for cycloid psychoses. In recent years, new data about this entity have been acknowledged due to information displayed by different clinical studies and imaging techniques.ConclusionThe phenomenology and classification of cycloid psychosis still needs more evidence for a greater use in clinical practice. However, this clinical entity can solve the void for the diagnosis of many of the so-called “atypical psychoses”.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Cocaine Use and Liability to Psychotic Symptoms

In a pilot study with 55 inpatients, primarily admitted for cocaine addiction, the following hypotheses were found: Patients with cocaine addiction and comorbide core schizophrenia (according to Kreapelin, n=17) respond completely different on cocaine use than all other groups of patients including a schizophrenia spectrum group (without core schizophrenia according to Kraepelin). When using cocaine the schizophrenic patients do not experience new psychotic symptoms and existing symptoms do not get worse. Most of them are less bothered of negative symptoms and some of them are, even more, less bothered of positive symptoms. In all other patients with various comorbidity (n=28) and without comorbide psychiatric disorders (n=10) positive psychotic symptoms occur dependent on the dosage of cocaine. In some of them the positive symptoms are also triggered by stress alone. The symptoms occurred in a dosage dependent hierarchical structure: mistrust - delusions of reference with fear - delusions of persecution and illusions with anxiety or panic - threatening voices and noises - disorganized and catatonic behavior.The psychopathology induced by cocaine prooved to be similar to one of the core symptoms of cycloid psychoses.The hypothesis is raised that there is an individual genetically and/or environmentally caused liability to the developing of positive psychotic symptoms under various stress factors including drugs. These reactive psychoses have to be distinguished from schizophrenia. Their relationship to the spectrum of cycloid psychoses is discussed.