Leonhard and the classification of psychomotor psychoses in childhood and adolescence

The classification 'psychomotor psychoses' goes back to Wernicke, Kleist and Leonhard. The incidence of psychomotor deficiencies is a typical trait. The motility psychoses (a form of the cycloid psychosis), the periodical catatonia (a form of unsystematic schizophrenias) and the catatonic forms of systematic schizophrenias belong to the group of 'psychomotor psychoses'. To some extent they correspond with the 'catatonic type' according to DSM-III (295.2). The number of children and adolescents with psychomotor psychoses, who were examined by Leonhard and Neum?rker have shown beside different clinical-psychopathological features a significant difference as regards the age-related manifestation of each psychomotor psychosis.     

The genetic heterogeneity of "schizophrenia".

The main reason for the inconsistent findings in schizophrenia research is the lack of diagnostic conformity. This has not changed markedly following the introduction of modern operational diagnostic systems. Taking schizophrenia as a disease entity or assuming schizophrenia spectrum psychoses to represent a continuum of diseases without any clear dividing lines, the results of family and twin studies point to a multifactorial etiology based on a polygenic mode of transmission. Further, then it has to be assumed a familial continuum from schizophrenia to affective psychosis and other spectrum disorders. However, in family and twin studies based on Leonhard's classification, there is clearcut evidence that schizophrenic spectrum psychoses have to be divided into clinical and etiological subgroups with a completely different genetic background. For example, systematic catatonia is, for the most part, a sporadic disease, whereas periodic catatonia aggregates in families in a manner consistent with a major gene effect. Further, the results indicate that schizophrenic spectrum psychoses consist of three main valid categories: cycloid psychoses, unsystematic schizophrenias and systematic schizophrenias. In the case of cycloid psychosis and systematic schizophrenias, genetic loading seem to be very low, while "environmental" factors, for example, birth complications, may play an important etiological role. Unsystematic schizophrenias, however, are predominantly inherited and "environmental" factors are not very prominent.     

The Genetic Heterogeneity of “Schizophrenia”

Summary: The main reason for the inconsistent findings in schizophrenia research is the lack of diagnostic conformity. This has not changed markedly following the introduction of modern operational diagnostic systems. Taking schizophrenia as a disease entity or assuming schizophrenic spectrum psychoses to represent a continuum of diseases without any clear dividing lines, the results of family and twin studies point to a multifactorial etiology based on a polygenic mode of transmission. Further, then it has to be assumed a familial continuum from schizophrenia to affective psychosis and other spectrum disorders. However, in family and twin studies based on Leonhard's classification, there is clearcut evidence that schizophrenic spectrum psychoses have to be divided into clinical and etiological subgroups with a completely different genetic background. for example, systematic catatonia is, for the most part, a sporadic disease, whereas periodic catatonia aggregates in families in a manner consistent with a major gene effect. Further, the results indicate that schizophrenic spectrum psychoses consist of three main valid categories: cycloid psychoses, unsystematic schizophrenias and systematic schizophrenias. In the case of cycloid psychosis and systematic schizophrenias, genetic loading seem to be very low, while “environmental” factors, for example, birth complications, may play an important etiological role. Unsystematic schizophrenias, however, are predominantly inherited and “environmental” factors are not very prominent.     

The importance of Karl Leonhard's classification of endogenous psychoses

In this paper the author highlights the importance that the classificatory work carried out by Leonhard has had for recent international developments in the classification of mental disorders. In particular, the diagnostic relevance of a distinction between bipolar and unipolar affective disorders and the separation of the cycloid psychotic disorders from other major psychoses is underscored.     

The influence of Karl Kleist on the nosology of Karl Leonhard

Leonhard was largely influenced, during his years at the Frankfurt Mental Hospital, by the Wernicke follower Karl Kleist (1879-1960). Kleist was a representative of brain pathology. His psychopathological concepts, which he developed using the evaluation of brain injuries, look very modern. He tried to attribute different symptoms to definite functional centers and regulatory loops. His theory of the 'autonomous psychic syndromes', his categories of psychomotor activity, his concepts of cycloid psychoses and schizophrenic subgroups are described. The author emphasizes that the differentiation between unipolar and bipolar affective psychoses is based on the team work of Kleist, Edda Neele and Leonhard. Because of Kleist's great contribution to the classification of psychoses, it would be more correct to use the term 'Kleist-Leonhard classification system'.     

Genetic markers for schizophrenic subgroups

By the study of hereditary serum protein markers in psychotic patients and normal controls, a surplus of Gc 1-1 (p less than 0.01) and transferrin B variants (p less than 0.0027) has been established in schizophrenias. Affective psychoses are characterized by an excess of the haptoglobin (Hp) serum type 2-2 (p less than 0.001). These general statements have to be modified in regard to the clinical and psychopathological subdivision beyond the traditional classification into two major groups of endogenous mental disease. Using Leonhard's criteria, the prevalence of Gc 1-1 is restricted to the systematic schizophrenias reaching its highest value in hebephrenias, which are followed by paraphrenic and catatonic forms in this trait. In contrast to this, periodical catatonia and affective paraphrenia, classified as subgroups of the unsystematic schizophrenias, have Gc 1-1 frequencies like healthy controls. On the other hand, the Hp 2-2 value is not increased in the systematic schizophrenias, but it displays a relative overplus in the unsystematic forms. Concerning the Hp 2-2 and Gc 1-1 frequencies a certain similarity can be observed between affective paraphrenia and the paranoid psychoses with late onset, it they are characterized by a cyclic axis syndrome as described by the Vienna school. The cycloid psychoses are marked by an extreme surplus of Hp 2-2 (p less than 0.001) and an overweight of Gc 1-1 (p less than 0.05). Probably the Gc and Hp alleles play a role as risk factors or accidental effectors in the multifactorial genetic systems responsible for the biological background of psychoses. For both serum systems a selective interaction is discussed considering the vitamin D transport by the Gc proteins with the relation to neuronal consolidation and the possible influence of Hp 2-2 on transport and receptor functions.     

Cycloid psychoses revisited: case reports, literature review, and commentary

Emil Kraepelin proposed to separate psychiatric disorders with psychotic features into two major categories, dementia praecox (later schizophrenia) and manic-depressive insanity (later bipolar disorder and major depression). Over the past century, there have been many efforts to categorize conditions that do not fit readily in either group. These conditions include many cases of acute psychotic illnesses of limited duration, with recovery between recurrences. For some of these conditions, Karl Kleist proposed the term cycloid psychosis: acute features were psychotic, as in schizophrenia, but the course was episodic, as in manic-depression. His concept was later elaborated by Karl Leonhard and Carlo Perris, and validated by modern studies. Leonhard described three overlapping cycloid subtypes (anxiety-beatific, excited-inhibited confusional, and hyperkinetic-akinetic motility dysfunction forms); Perris proposed a more unitary syndrome with operational diagnostic criteria; and recent investigators have considered relatively affective versus thought-disordered subtypes. The cycloid concept is not explicitly included in standard international diagnostic schemes, but both DSM-IV and ICD-10 have broad categories for acute, recurrent psychotic disorders, whose validity remains insecure. We present two cases of probable cycloid psychosis, review the history of the concept, and propose that it be reconsidered as a clinically useful category whose validity and utility for prognosis and treatment can be further tested.     

Cycloid psychoses as atypical psychoses: 'concordance' and 'discordance'

The term 'atypical psychosis' coined by Mitsuda in 1942 describes a group of psychosis that show similarities to schizophrenia as well as manic-depressive diseases. It is controversial whether it refers to a uniform group of diseases exposing typical characteristics. According to Leonhard a typical uniform group of cycloid psychoses can be contrasted with a group of atypical schizophrenias. The position of the so-called atypical psychoses in the sense of a nosological position within the classification systems of different psychiatric schools will be analyzed and discussed.     

A contribution to the validity of Leonhard's classification of endogenous psychoses

The author made a clinical-genetical study of the schizophrenias and cycloid (schizoaffective) psychoses following the Leonhardian classification, using the traditional pedigree analysis and multiple threshold method. According to the latter method--on the basis of phenotypical correlations--the systematic schizophrenias could be clearly distinguished from the cycloid psychoses, while the non-systematic category presumably occupies a genetical position between the two former categories.     

The predictive validity of the Leonhardean classification of endogenous psychoses

To our knowledge, no previous long-term studies of the Leonhardean classification in the whole spectrum of endogenous psychoses have been conducted. This prospective study (n = 276; female patients n = 222; normal control persons n = 54) started in 1967-1976. The same population was followed-up by participation of a "blinded control" psychiatrist in 1997-2002 [patients available at follow-up = 125 (56.3%); available controls = 38 (70.4%)]. Patients for this investigation were selected by two independent diagnosticians from eight nosological groups based on full diagnostic agreement. Diagnostic agreement at follow-up (weighted-kappa) was 0.87. Predictive validity of the diagnostic categories was measured empirically and using a stochastic (Markovian) model, thus combining validity and reliability. Hebephrenias, group of normal persons and of schizophrenias proved to be valid categories, with diagnostic stabilities of 0.94, 0.91, and 0.93, for the three groups, respectively. In addition, bipolar manic-depressive psychoses and cycloid psychoses were also valid (diagnostic stability of 0.77 and 0.76, respectively). Unipolar depression was valid (diagnostic stability = 0.84) only by forming a "nosological family" based on diagnostic stability and on current status and clinical presentation during the period preceding the follow-up with regard to other mood-congruent disorders and outcome-diagnosis "normal control". Validity of systematic paraphrenias (diagnostic stability = 0.69) was in the moderate range. Division of schizophrenias in "systematic versus non-systematic" nosological categories was inconclusive; the categories of affect-laden paraphrenia, periodic catatonia and systematic catatonias could not be confirmed reliably in this study.     

The effect of the menstruation cycle on manifestations of pychiatric diseases

In the present study we investigated whether a correlation exists between menstrual cycle phase on the day of an acute psychiatric admission and diagnostic entities. Therefore we assessed the menstrual cycle phase in 155 women at the time of acute admission for any non-organic psychiatric disorder. A specific diagnosis according to ICD-10-criteria and to Leonhard's nosology was established without knowledge of the menstrual cycle phase. Independent of diagnosis and classification, the majority of patients (57%) was admitted during the pre-menstrual/menstrual period. Comparing the frequencies of admission before (increasing blood-estrogen-level) and after ovulation (decreasing blood-estrogen-level) we found using ICD-10 criteria there were no significant differences between affective psychoses (F3), acute polymorphous psychotic disorder (F23), schizophrenia/schizoaffective psychoses (F20 and F25) and patients suffering from neuroses or personality disorders (F4-F6). Applying Leonhard's criteria we found no significant differences between endogeneous psychoses and personality disorders and no significant differences between cycloid psychoses and affective psychoses or affective psychoses and schizophrenias as well. However, patients with cycloid psychoses were significantly more frequently admitted to hospital during the luteal-/menstrual phase than patients with schizophrenia (chi 2-Test, p = 0.02). These findings do not confirm a specificity of a pre-menstrual exacerbation of psychotic symptoms for schizophrenia. Rather we found cycloid psychoses to be significantly more frequently associated with premenstrual exacerbation of symptoms.     

Long-term prognosis and course of schizo-affective, schizophreniform, and cycloid psychoses

From the Bonn study including 502 patients followed up an average 22.4 years after onset of schizophrenic disease diagnosed according to the criteria of K. Schneider, we selected 113 cases of schizo-affective, schizophreniform, and cycloid psychoses in accordance to the definitions given by Kasanin, Retterst?l, Angst, and Leonhard. These psychoses have a better prognosis than the whole sample: characteristic residues are seen more rarely, complete remissions and noncharacteristic residues more frequently. This group of psychoses differs from the whole sample in the hereditary taint, too: the morbidity risk with affective psychoses and with schizophrenic psychoses in first- and second-degree relatives is higher than in the total sample of the Bonn study. In spite of the better prognosis and other differences described in the paper, we believe that these results do not justify the classification of schizo-affective and related disorders as an independent disease group. Between these different subtypes of schizophrenia only a differential typology and not a differential diagnostic is possible.     

What can genetics contribute to reduce the problems of schizo-affective psychoses?

The biological base of psychoses is controlled by multifactorial genotype compounds using sometimes the same gene locus or DNA information section for diverse diseases, but always in different and repeatable combinations. These compounds can be formed by special regulatory or junction genes. With the help of inherited serum markers of the haptoglobin and the Gc system including quantitative studies of the ceruloplasmin and transferrin serum level, the combinations of diverse biological factors have been presented especially for cycloid psychoses, unsystematic schizophrenias, and paranoid psychoses with late onset and a cyclic axis syndrome. Considering the specifications of genetic control and clinical course no indefinite mixtures in the sense of schizo-affective psychoses should be discussed furthermore.     

Absence of a subgroup of chronic schizophrenia in monozygotic twins. Consequences for considerations on the pathogenesis of schizophrenic psychoses

In the region of Lower Franconia, Germany, all twins born after 1930 and hospitalized for a schizophrenia spectrum psychosis were ascertained in a systematic twin study comprising 22 monozygotic (MZ) and 25 dizygotic (DZ) pairs. One aim of the study was to compare concordance rates between MZ and DZ pairs with regard to various diagnostic classifications. Two experienced psychiatrists independently classified the probands according to DSM-III-R, ICD-10, and Leonhard’s classification. Schizophrenic psychoses were found among MZ and DZ pairs in equal proportions according to DSM-III-R and ICD-10 criteria. In contrast, when Leonhard’s classification was applied it became apparent that systematic schizophrenias, which represent the core group of schizophrenias in Leonhard’s nosology, were completely lacking among the 34 ill MZ twins. Among the 30 ill DZ twins, 6 suffered from a systematic schizophrenia (p < 0.01). Unsystematic schizophrenias and cycloid psychoses occurred among MZ twins at a frequency of 58.8% and 41.2%, respectively. In the course of his own twin-investigations, Leonhard also observed an absence of systematic schizophrenias in MZ twins, although his twins were not systematically ascertained. This striking finding requires an explanation regarding its significance for the etiology of chronic schizophrenic psychoses. In view of the absence of other conclusive theories, one speculative explanatory model is that specific psychosocial factors, i.e., a lack of communication during childhood, may result in distinct biological damage to functional brain systems and, thus, may play a role in the pathogenesis of these psychoses. Received: 25 May 1998 / Accepted: 1 December 1998     

Cycloid psychoses as atypical manic-depressive disorders. Results of a family study

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. PATIENTS AND METHODS: In a controlled family study, we recruited 46 patients with cycloid psychosis (CP), 33 with manic-depressive illness (MDI), and 27 controls. Three hundred fifty-six of 389 living first-degree relatives were personally examined by experienced psychiatrists blinded to the diagnosis of the index proband. RESULTS: The relatives of CP patients showed significantly lower morbidity risk of functional psychoses than relatives of patients with MDI in Kaplan-Meier life table calculation. The morbidity risk for functional psychoses in relatives of patients with CP did not differ significantly from that in relatives of controls. CONCLUSION: These results suggest that CP are etiologically different from bipolar affective psychoses and cannot be integrated into the spectrum of bipolar affective disorders. The findings provide further evidence for a nosological independence of CP.     

Clinical aspects of puerperal psychoses. Review with 3 case examples

Psychic disturbances in the post-partum period are divided into the postpartum blues, postpartum depression, and postpartum psychoses. The latter are severe endogenous psychoses which mostly fulfill the diagnostic criteria for cycloid psychoses according to Leonhard. Based on three case reports, characteristic symptoms, the phasic clinical course with remissions, and distinct etiological, therapeutic, and forensic aspects of cycloid psychoses in the post-partum period are discussed. The high relapse rate of approximately 50% in patients at risk requires intensive psychiatric care in the peripartal period. In particular, the possibility of a prophylactic treatment of patients at risk with lithium immediately after delivery is emphasized. However, this sophisticated therapeutic strategy requires close cooperation between gynecologists and psychiatrists.     

Cycloid psychosis and affective disorder: borderland cases.

A subsample of untreated cycloid psychoses satisfying the requirements for major affective disorder according to DSM-III was compared with a subsample of cycloid psychoses getting other DSM-III diagnoses. The concept of cycloid psychosis applied thus was wider than permitted by the criteria stipulated by Perris and Brockington with respect to the prominence of the mood component. Since it could be demonstrated that no decisive differences prevailed with respect to frequencies of single features tested, a modified discriminant analytic procedure was applied. In this analysis, 76% of cases were correctly assigned. On average affective cases were more similar to the score profile derived from the nonaffective group than nonaffective cases were to the same profile, i.e. to themselves. Symptomatologically the affective cases had their main point in a distinctive confusion syndrome.     

Schedule for operationalized diagnosis according to the Leonhard classification of endogenous psychoses

Psychiatric diagnoses in endogenous psychoses are still largely based on clinical psychopathology. Despite intensive efforts including progress to more reliability in classification, no definite and causally relevant biological abnormalities have been identified so far. This failure might be due to the present standard classification systems like DSM or ICD being too crude to allow the distinction of homogeneous nosological entities. The classification developed by K. Leonhard offers a more subtle alternative. In order to facilitate the handling of this system and in the interest of reliability, an algorithm for computer-assisted diagnostic decision making based on similarities to Leonhard's ideal types is presented.