Cycloid psychoses -- from clinical concepts to biological foundations

Mood Disorder or Psychotic Disorder? Yes: A Case Report on Cycloid Psychosis

Cycloid psychosis is a disorder defined by episodic, acute psychoses involving thought, affect, and motor disturbances with polymorphous symptomatology followed by periods of full remission. Antipsychotics, benzodiazepines, and electroconvulsive therapy have been used empirically in acute treatment. This disorder has faced nosologic challenges and is not yet identified as a diagnostic entity by the Diagnostic and Statistical Manual of Mental Disorders (DSM). Questions remain as to whether cycloid psychosis is a primary psychotic or primary affective disorder, given that its course and episodicity are like that of affective disorders, while its clinical manifestations include prominent psychotic symptoms. This report describes the case of a 38-year-old male with classic features of cycloid psychosis and highlights the unique characteristics that distinguish cycloid psychosis from other similar diagnoses.

All roads lead to the motor cortex: psychomotor mechanisms and their biochemical modulation in psychiatric disorders

Psychomotor abnormalities have been abundantly observed in psychiatric disorders like major depressive disorder (MDD), bipolar disorder (BD), and schizophrenia (SCH). Although early psychopathological descriptions highlighted the truly psychomotor nature of these abnormalities, more recent investigations conceive them rather in purely motor terms. This has led to an emphasis of dopamine-based abnormalities in subcortical-cortical circuits including substantia nigra, basal ganglia, thalamus, and motor cortex. Following recent findings in MDD, BD, and SCH, we suggest a concept of psychomotor symptoms in the literal sense of the term by highlighting three specifically psychomotor (rather than motor) mechanisms including their biochemical modulation. These include: (i) modulation of dopamine- and substantia nigra-based subcortical-cortical motor circuit by primarily non-motor subcortical raphe nucleus and serotonin via basal ganglia and thalamus (as well as by other neurotransmitters like glutamate and GABA); (ii) modulation of motor cortex and motor network by non-motor cortical networks like default-mode network and sensory networks; (iii) global activity in cortex may also shape regional distribution of neural activity in motor cortex. We demonstrate that these three psychomotor mechanisms and their underlying biochemical modulation are operative in both healthy subjects as well as in MDD, BD, and SCH subjects; the only difference consists in the fact that these mechanisms are abnormally balanced and thus manifest in extreme values in psychiatric disorders. We conclude that psychomotor mechanisms operate in a dimensional and cross-nosological way as their degrees of expression are related to levels of psychomotor activity (across different disorders) rather than to the diagnostic categories themselves. Psychomotor mechanisms and their biochemical modulation can be considered paradigmatic examples of a dimensional approach as suggested in RDoC and the recently introduced spatiotemporal psychopathology.

Psicoses Cicloides. Passado e futuro

Este artigo pretende rever a origem do conceito de Psicoses Cicloides, a sua psicopatologia e a sua evolução. Através de uma análise da literatura, os autores procuram perceber a validade nosológica deste conceito, assim como o seu enquadramento atual e a sua utilidade futura na psiquiatria.

Schizophrenia with prominent catatonic features: A selective review

A widely accepted consensus holds that a variety of motor symptoms subsumed under the term 'catatonia' have been an integral part of the symptomatology of schizophrenia since 1896, when Kraepelin proposed the concept of dementia praecox (schizophrenia). Until recently, psychiatric classifications included catatonic schizophrenia mainly through tradition, without compelling evidence of its validity as a schizophrenia subtype. This selective review briefly summarizes the history, psychopathology, demographic and epidemiological data, and treatment options for schizophrenia with prominent catatonic features. Although most catatonic signs and symptoms are easy to observe and measure, the lack of conceptual clarity of catatonia and consensus about the threshold and criteria for its diagnosis have hampered our understanding of how catatonia contributes to the pathophysiology of schizophrenic psychoses. Diverse study samples and methodologies have further hindered research on schizophrenia with prominent catatonic features. A focus on the motor aspects of broadly defined schizophrenia using modern methods of detecting and quantifying catatonic signs and symptoms coupled with sophisticated neuroimaging techniques offers a new approach to research in this long-overlooked field.

Cycloid psychoses in the psychosis spectrum: evidence for biochemical differences with schizophrenia

Cycloid psychoses (CP) differ from schizophrenia regarding symptom profile, course, and prognosis and over many decades they were thought to be a separate entity within the psychosis spectrum. As to schizophrenia, research into the pathophysiology has focused on dopamine, brain-derived neurotrophic factor, and glutamate signaling in which, concerning the latter, the N-methyl-d-aspartate receptor plays a crucial role. The present study aims to determine whether CP can biochemically be delineated from schizophrenia. Eighty patients referred for psychotic disorders were assessed with the Comprehensive Assessment of Symptoms and History, and (both at inclusion and after 6 weeks of antipsychotic treatment) with the Positive and Negative Syndrome Scale and Clinical Global Impression. From 58 completers, 33 patients were diagnosed with schizophrenia and ten with CP according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Leonhard criteria, respectively. Fifteen patients were diagnosed with other disorders within the psychosis spectrum. At both time points, blood levels of the dopamine metabolite homovanillic acid, brain-derived neurotrophic factor, and amino acids related to glutamate neurotransmission were measured and compared with a matched control sample. Patients with CP showed a significantly better response to antipsychotic treatment as compared to patients with schizophrenia. In CP, glycine levels were elevated and tryptophan levels were lowered as compared to schizophrenia. Glutamate levels were increased in both patient groups as compared to controls. These results, showing marked differences in both treatment outcome and glutamate-related variable parameters, may point at better neuroplasticity in CP, necessitating demarcation of this subgroup within the psychosis spectrum.

Recurrent Idiopathic Catatonia: Implications beyond the Diagnostic and Statistical Manual of Mental Disorders 5th Edition

We describe a case of recurrent, life-threatening, catatonic stupor, without evidence of any associated medical, toxic or mental disorder. This case provides support for the inclusion of a separate category of “unspecified catatonia” in the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) to be used to classify idiopathic cases, which appears to be consistent with Kahlbaum’s concept of catatonia as a distinct disease state. But beyond the limited, cross-sectional, syndromal approach adopted in DSM-5, this case more importantly illustrates the prognostic and therapeutic significance of the longitudinal course of illness in differentiating cases of catatonia, which is better defined in the Wernicke-Kleist-Leonhard classification system. The importance of differentiating cases of catatonia is further supported by the efficacy of antipsychotics in treatment of this case, contrary to conventional guidelines.

The process of recovery in women who experienced psychosis following childbirth

BACKGROUND

Psychosis following childbirth affects 1-2 mothers per 1000 deliveries. Onset is rapid and functioning is severely affected. Although prognosis in terms of symptom remission is generally good, long-term disability can persist. The study's aim was to develop a theoretical understanding of recovery from psychosis following childbirth.

METHODS

Semi-structured interviews were conducted with 12 women with experience of psychosis following childbirth. Interview transcripts were analysed using grounded theory methodology.

RESULTS

A theory of four superordinate themes was developed from the data, including: (i) the process of recovery; (ii) evolving an understanding; (iii) strategies for recovery; and (iv) sociocultural context. The process of recovery and women's understanding of their experience were conceptualised as parallel processes, which informed one another. Women found that a diagnosis facilitated their use of particular strategies.

CONCLUSIONS

This study highlighted a complex and ongoing process of recovery from psychosis following childbirth. Sensitivity to a woman's position in the process of recovery has the potential to facilitate professionals in assessing readiness for different interventions which will be likely to result in women feeling more understood, accepted and supported.

Schizoaffective Disorder in the DSM-5

Characterization of patients with both psychotic and mood symptoms, either concurrently or at different points during their illness, has always posed a nosological challenge and this is reflected in the poor reliability, low diagnostic stability, and questionable validity of DSM-IV Schizoaffective Disorder. The clinical reality of the frequent co-occurrence of psychosis and Mood Episodes has also resulted in over-utilization of a diagnostic category that was originally intended to only rarely be needed. In the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, an effort is made to improve reliability of this condition by providing more specific criteria and the concept of Schizoaffective Disorder shifts from an episode diagnosis in DSM-IV to a life-course of the illness in DSM-5. When psychotic symptoms occur exclusively during a Mood Episode, DSM-5 indicates that the diagnosis is the appropriate Mood Disorder with Psychotic Features, but when such a psychotic condition includes at least a two-week period of psychosis without prominent mood symptoms, the diagnosis may be either Schizoaffective Disorder or Schizophrenia. In the DSM-5, the diagnosis of Schizoaffective Disorder can be made only if full Mood Disorder episodes have been present for the majority of the total active and residual course of illness, from the onset of psychotic symptoms up until the current diagnosis. In earlier DSM versions the boundary between Schizophrenia and Schizoaffective Disorder was only qualitatively defined, leading to poor reliability. This change will provide a clearer separation between Schizophrenia with mood symptoms from Schizoaffective Disorder and will also likely reduce rates of diagnosis of Schizoaffective Disorder while increasing the stability of this diagnosis once made.

Increased motor activity in cycloid psychosis compared to schizophrenia

Although cycloid psychoses share psychopathological features with schizophrenia, their course and outcome are comparable to those seen in bipolar affective disorder. The diagnostic category is of interest because it has been demonstrated that cycloid psychoses can be diagnosed reliably and distinguished from other psychoses based on treatment response and neurophysiology. Despite this, only few studies have investigated the neurobiological differences between cycloid psychoses and schizophrenia, and although hyper- and hypoactivity have been observed in patients with cycloid psychoses, no studies have investigated motor activity in this group to date. Therefore, we aimed to quantify motor activity during the waking hours of the day as assessed by wrist actigraphy in 16 patients with cycloid psychosis and 16 patients with paranoid schizophrenia. All patients were matched for gender and age, and wrist actigraphic assessment took place during acute episodes. The level of activity and proportion of active vs. inactive periods during waking hours were significantly higher in patients with cycloid psychosis. The results of the present study are interpreted in light of a previously reported general arousal in cycloid psychoses that is expressed in motor activity. Our data support the concept of cycloid psychoses as a syndrome with distinct symptomatology and pathophysiology.

Schizophrenia: from the brain to peripheral markers. A consensus paper of the WFSBP task force on biological markers

Objective. The phenotypic complexity, together with the multifarious nature of the so-called "schizophrenic psychoses", limits our ability to form a simple and logical biologically based hypothesis for the disease group. Biological markers are defined as biochemical, physiological or anatomical traits that are specific to particular conditions. An important aim of biomarker discovery is the detection of disease correlates that can be used as diagnostic tools. Method. A selective review of the WFSBP Task Force on Biological Markers in schizophrenia is provided from the central nervous system to phenotypes, functional brain systems, chromosomal loci with potential genetic markers to the peripheral systems. Results. A number of biological measures have been proposed to be correlated with schizophrenia. At present, not a single biological trait in schizophrenia is available which achieves sufficient specificity, selectivity and is based on causal pathology and predictive validity to be recommended as diagnostic marker. Conclusions. With the emergence of new technologies and rigorous phenotypic subclassification the identification of genetic bases and assessment of dynamic disease related alterations will hopefully come to a new stage in the complex field of psychiatric research.

Psychosis genetics: modeling the relationship between schizophrenia, bipolar disorder, and mixed (or "schizoaffective") psychoses

As a result of improving technologies and greatly increased sample sizes, the last 2 years has seen unprecedented advances in identification of specific genetic risk factors for psychiatric phenotypes. Strong genetic associations have been reported at common polymorphisms within ANK3 and CACNA1C in bipolar disorder and ZNF804A in schizophrenia and a relatively specific association between common variation in GABA(A) receptor genes and cases with features of both bipolar disorder and schizophrenia. Further, the occurrence of rare copy number variants (CNVs) has been shown to be increased in schizophrenia compared with controls. These emerging data provide a powerful resource for exploring the relationship between psychiatric phenotypes and can, and should, be used to inform conceptualization, classification, and diagnosis in psychiatry. It is already clear that, in general, genetic associations are not specific to one of the traditional diagnostic categories. For example, variation at ZNF804A is associated with risk of both bipolar disorder and schizophrenia, and some rare CNVs are associated with risk of autism and epilepsy as well as schizophrenia. These data are not consistent with a simple dichotomous model of functional psychosis and indicate the urgent need for moves toward approaches that (a) better represent the range of phenotypic variation seen in the clinical population and (b) reflect the underlying biological variation that gives rise to the phenotypes. We consider the implications for models of psychosis and the importance of recognizing and studying illness that has prominent affective and psychotic features. We conclude that if psychiatry is to translate the opportunities offered by new research methodologies, we must finally abandon a 19th-century dichotomy and move to a classificatory approach that is worthy of the 21st century.

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.

Major psychoses with mixed psychotic and mood symptoms: are mixed psychoses associated with different neurobiological markers?

OBJECTIVE

Evidence related to overlapping clinical and genetic risk factors in schizophrenia and bipolar disorder (BD) have raised concerns about the validity of 'Kraepelinian dichotomy'. As controversies mainly arise in mixed psychoses that occupy the intermediate zone between schizophrenia and BD, investigating neurobiological markers of mixed psychoses may be relevant to understanding the nature of psychotic disorders.

METHOD

In this article, we review studies comparing magnetic resonance imaging, neuropsychological and electrophysiological findings in mixed psychoses with each other, as well as with more prototypical cases of schizophrenia and BD.

RESULTS

The evidence reviewed suggests that mixed psychoses may be associated with different genetic and neurobiological markers compared with prototypical forms of schizophrenia and BD.

CONCLUSION

These findings may be compatible with more sophisticated versions of dimensional and continuum models or, alternatively, they may suggest that there is an intermediate third category between prototypical schizophrenia and BD.

Psychiatric disorders related to menstrual bleeding among an ultra-orthodox population: case series and literature review

The relationship between menstrual cycle and obsessive-compulsive disorder (OCD) has been documented in the past and is related to sexual hormone changes. In the ultra-orthodox Jewish population menstrual bleeding is associated both with meticulous rituals of cleanliness and with stressful meanings related to sin, impurity and punishment. Those aspects of the menstrual cycle can be related to specific OCD symptoms among ultra-orthodox women. The current study presents three cases related to the development of obsessive-compulsive symptoms in relation to the menstrual cycle among ultra-orthodox women, and discusses the biological and social-cultural basis of the disorder.

The etiology of some menstrual disorders: a gynecological and psychiatric issue

Some menstrual disorders with distinct gynecological character such as amenorrhea or menometrorrhagia (MMR) may have psychogenic etiology. On the other hand, in menstrual psychosis (MP), a distinctly psychiatric disorder, the etiology is not necessarily psychogenic, but rather is hormonal-biological. We present 4 cases, one each of primary and secondary amenorrhea, MMR, and MP, respectively. In the first 3 cases (2 amenorrhea and 1 MMR), we found psychogenic factors: an insult to feminine development after rape (case 1) or marriage problems (cases 2 and 3). In the case of a recurrent MP, no relevant psychological etiology was found. Furthermore, some of the patient's relatives had menstrual or peripartum psychiatric disorders. Menstrual disorders' etiology can be psychogenic or hormonal. The correct etiology is the guide for the adequate therapeutic way: psychotherapy based in psychogenic disorders and neuroleptic or antiovulatory drugs in those of biological etiology.

Cycloid psychosis: an examination of the validity of the concept

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

A review of postpartum psychosis

OBJECTIVE

The objective is to provide an overview of the clinical features, prognosis, differential diagnosis, evaluation, and treatment of postpartum psychosis.

METHODS

The authors searched Medline (1966-2005), PsycInfo (1974-2005), Toxnet, and PubMed databases using the key words postpartum psychosis, depression, bipolar disorder, schizophrenia, organic psychosis, pharmacotherapy, psychotherapy, and electroconvulsive therapy. A clinical case is used to facilitate the discussion.

RESULTS

The onset of puerperal psychosis occurs in the first 1-4 weeks after childbirth. The data suggest that postpartum psychosis is an overt presentation of bipolar disorder that is timed to coincide with tremendous hormonal shifts after delivery. The patient develops frank psychosis, cognitive impairment, and grossly disorganized behavior that represent a complete change from previous functioning. These perturbations, in combination with lapsed insight into her illness and symptoms, can lead to devastating consequences in which the safety and well-being of the affected mother and her offspring are jeopardized. Therefore, careful and repeated assessment of the mothers' symptoms, safety, and functional capacity is imperative. Treatment is dictated by the underlying diagnosis, bipolar disorder, and guided by the symptom acuity, patient's response to past treatments, drug tolerability, and breastfeeding preference. The somatic therapies include antimanic agents, atypical antipsychotic medications, and ECT. Estrogen prophylaxis remains purely investigational.

CONCLUSIONS

The rapid and accurate diagnosis of postpartum psychosis is essential to expedite appropriate treatment and to allow for quick, full recovery, prevention of future episodes, and reduction of risk to the mother and her children and family.

Beneficial effect of atypical antipsychotics on prefrontal brain function in acute psychotic disorders

Disturbance of prefrontal brain functions is assumed to be responsible for prominent psychopathological symptoms in psychotic disorders. Treatment with atypical, in contrast to typical antipsychotics is considered as a possible strategy for an improvement of prefrontal brain function. In the present study, response control as a specific prefrontal brain function was assessed by means of the Nogo-anteriorization (NGA) derived from the event-related potentials elicited during a Go-NoGo task in a consecutive sample of 39 patients suffering from acute psychotic disorders (brief psychotic disorders, 298.8, n = 34 and schizoaffective disorders, 295.70, n = 5; cycloid psychoses according to the Leonhard classification). A highly significant positive correlation between the amount of antipsychotic medication in terms of chlorpromazine equivalents per day and the NGA as a measure of prefrontal response control was only found in the subgroup of patients treated exclusively or predominantly with atypical antipsychotics but not for those treated with typical antipsychotics. These results are in line with the notion that atypical antipsychotics may exert a beneficial effect on prefrontal brain function.

Evidence for unaltered brain electrical topography during prefrontal response control in cycloid psychoses

OBJECTIVE

Prefrontal structures such as the anterior cingulate cortex (ACC) play a decisive role in processes of action monitoring and response control, functions often impaired in schizophrenia. Patients with cycloid psychoses exhibit some characteristic neurophysiological features not indicative of the cerebral hypofrontality observed in schizophrenia. This study aimed at examining if cycloid psychoses-unlike schizophrenias-involve a normal brain-electrical topography during a task demanding prefrontal response control.

METHODS

Thirty-seven patients with cycloid psychoses and 37 healthy controls were investigated electrophysiologically while performing a Continuous Performance Test (CPT). Topographical analyses were conducted to individually quantify the Nogo-anteriorisation (NGA) as a neurophysiological index of prefrontal response control.

RESULTS

The patients exhibited an unaltered topography with a mean NGA not significantly different from the controls. They did, however, differ from the control group regarding their Global Field Power (GFP), with a significantly reduced GFP (p<0.001) and decreased latencies (p<0.01) during Nogo trials. On a behavioral level, patients exhibited prolonged reaction times and an increased rate of omission errors.

CONCLUSIONS

The investigated patients showed an activation of specific (presumably frontal) brain areas during Nogo trials, resulting in a frontalisation of the brain-electrical field comparable to the control group. However, the strength of this activation was apparently reduced. The patients' unaltered topographical pattern contrasts with previous findings in schizophrenic patients and supports the hypothesis that cycloid psychoses entail less severe prefrontal deficits than schizophrenias, which might be an indication of different biological backgrounds for both groups of endogenous psychoses.

Cycloid psychoses are not part of a bipolar affective spectrum: results of a controlled 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. 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.

Nonschizophrenic psychotic disorders: the case of cycloid psychoses

BACKGROUND

Cycloid psychosis is a psychiatric disorder known for about 100 years. This disorder is at present partly and simplified represented in the ICD-10.

SAMPLING AND METHODS

Over a period of 15 months, 139 consecutively acutely admitted psychotic patients were assessed, by means of different diagnostic instruments, in order to investigate the prevalence and the symptom profile of cycloid psychoses. In addition, the concordance between the diagnoses cycloid psychosis, brief psychotic disorder, and acute polymorphic psychotic disorder with or without symptoms of schizophrenia was calculated.

RESULTS

Cycloid psychoses were present in 13% of the patients. There was a significant but small overlap with the DSM brief psychotic disorder and the ICD acute polymorphic psychotic disorder.

CONCLUSIONS

This study demonstrates that cycloid psychoses can be identified with the proper diagnostic instruments in a proportion that is also found in other studies. Since this type of psychosis entails a distinct prognosis and may require a specific treatment, its identification is of clinical importance. Limitations are the nature of the psychiatric facility with an inherent bias in the selection of patients and the lack of a long-term evaluation.

Karl Kleist (1879-1960)- a pioneer of neuropsychiatry

Karl Kleist (1879-1960) was instrumental in pioneering German neuropsychiatry and neuropsychology, including the description of frontal, constructional, limb-kinetic (innervatory) and psychomotor apraxias, frontal akinesia and aspontaneity, as well as object and form blindness. Besides isolating episodic twilight states, involutional paranoia and symptomatic (especially influenza) psychoses, he was particularly involved in applying Wernicke's syndromatic and Kraepelin's prognostic and aetiological principles to classify "neurogenous" psychoses by refuting the assumption of mixed entities whenever possible. Thus, has phasophrenias denoted manic-depressive illness, unipolar affective disorders and marginal, i.e., atypical psychoses. The rather benign cycloid psychoses form the most prominent examples of the latter. Schizophrenias, on the other hand, were limited to poor long-term catamnestic outcomes. Kleist conceptualized the core group of schizophrenic illness as psychic system diseases-hence the origin of the term "systematic schizophrenias" within the Wernicke-Kleist-Leonhard School. Kleist was mainly influenced by Wernicke and his psychic reflex arc, but Ernst Mach's empiriocriticism, Theodor Meynert's cerebral connectionism, and associationism also shaped his outlook. Kleist's localization of cerebral functions by lesion analyses was indeed the best available at the time and continues to reveal insights to the interested reader. From his Frankfurt School, which may have been the last of a completely unified neuropsychiatry, came sound representatives of psychiatry, neurology and neurosurgery. His technical mastery and achievements seem indisputable, but his balancing acts during the Third Reich may today be questioned. Despite joining the National Socialist German Workers' Party (NSDAP) and the local Court of Genealogical Health (Erbgesundheitsgericht), Kleist was, however, one of the few German physicians who continued to treat Jewish patients, to employ Jewish colleagues and to voice evident criticism of the policies of "eugenics" and "euthanasia". This paper attempts to illuminate Kleist's biography and life's work in the relevant historical context.

Postpartum psychoses: prognosis, risk factors, and treatment

Puerperal psychoses do not represent a nosological entity, but rather a selection of puerperally triggered "ordinary" functional psychoses with cycloid psychoses predominating and schizophrenias occurring very rarely. The prognosis is basically favorable concerning symptom remission and social and occupational functioning. However, there is a considerable frequency of relapses and an increased suicide rate. The most important risk factors for an episode of a puerperal psychosis are being primiparous and having suffered a previous episode of a psychosis, particularly a cycloid psychosis. Controlled treatment studies up to now are absent. Case studies suggest in acute episodes the efficacy of a symptom-oriented pharmacologic treatment where ablactation is recommended. With respect to prophylactic treatment some authors propose to apply lithium in late pregnancy or immediately after delivery. Because of its possible teratogenic effects and the altogether rather sparse data, the authors however cannot recommend the use of lithium during pregnancy. Applying estradiol after delivery may be beneficial and safe, but further studies are necessary to clarify these issues.