Parakinesia: A Delphi consensus report

Abnormal movements are intrinsic to some forms of endogenous psychoses. Spontaneous dyskinesias are observed in drug-naïve first-episode patients and at-risk subjects. However, recent descriptions of spontaneous dyskinesias may actually represent the rediscovery of a more complex phenomenon, 'parakinesia' which was described and documented in extensive cinematographic recordings and long-term observations by German and French neuropsychiatrists decades before the introduction of antipsychotics. With the emergence of drug induced movement disorders, the description of parakinesia has been refined to emphasize the features enabling differential diagnosis with tardive dyskinesia. Unfortunately, parakinesia was largely neglected by mainstream psychiatry to the point of being almost absent from the English-language literature. With the renewed interest in motor phenomena intrinsic to SSD, it was timely not only to raise awareness of parakinesia, but also to propose a scientifically usable definition for this phenomenon. Therefore, we conducted a Delphi consensus exercise with clinicians familiar with the concept of parakinesia. The original concept was separated into hyperkinetic parakinesia (HPk) as dyskinetic-like expressive movements and parakinetic psychomotricity (PPM), i.e., patient's departing from the patient's normal motion style. HPk prevails on the upper part of the face and body, resembling expressive and reactive gestures that not only occur inappropriately but also appear distorted. Abnormal movements vary in intensity depending on the level of psychomotor arousal and are thus abated by antipsychotics. HPk frequently co-occurs with PPM, in which gestures and mimics lose their naturalness and become awkward, disharmonious, stiff, mannered, and bizarre. Patients are never spontaneously aware of HPk or PPM, and the movements are never experienced as self-dystonic or self-alien. HPk and PPM are highly specific to endogenous psychoses, in which they are acquired and progressive, giving them prognostic value. Their differential diagnoses and correspondences with current international concepts are discussed.

Wernicke-Kleist-Leonhard phenotypes of endogenous psychoses: a review of their validity

While the ICD-DSM paradigm has been a major advance in clinical psychiatry, its usefulness for biological psychiatry is debated. By defining consensus-based disorders rather than empirically driven phenotypes, consensus classifications were not an implementation of the biomedical paradigm. In the field of endogenous psychoses, the Wernicke-Kleist-Leonhard (WKL) pathway has optimized the descriptions of 35 major phenotypes using common medical heuristics on lifelong diachronic observations. Regarding their construct validity, WKL phenotypes have good reliability and predictive and face validity. WKL phenotypes come with remarkable evidence for differential validity on age of onset, familiality, pregnancy complications, precipitating factors, and treatment response. Most impressive is the replicated separation of high- and low-familiality phenotypes. Created in the purest tradition of the biomedical paradigm, the WKL phenotypes deserve to be contrasted as credible alternatives with other approaches currently under discussion.
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Facial affect decoding in schizophrenic disorders: a study using event-related potentials

Deficits in emotional processing are evident in schizophrenia, but the underlying processes are still under debate. In this study we tried to replicate findings of diminished prefrontal electroencephalographic response during facial affect recognition in healthy controls and subsequently in schizophrenic patients. As a first step, we analysed the event-related potentials (ERPs) of 36 healthy subjects during emotional expression decoding compared with neutral face viewing. Subsequently, the ERPs of 22 patients with schizophrenia were compared with the ERPs of 22 healthy subjects matched for age and sex. The hypothesised increase in the negative component at 200 ms over frontal brain regions during facial affect decoding was not found in this study. Instead we found increased positive amplitudes at 300 ms over parietal brain areas for the active affect-decoding task compared with the passive neutral face-viewing task. Interestingly, schizophrenic patients had higher amplitudes in the neutral condition than did healthy controls. This effect was more pronounced in the paranoid subgroup of patients.

[Kleptomania: clinical and legal aspects]

Kleptomania is characterized by repetitive and irresistible impulses to steal objects, with growing excitement before, and relief after the incidents. The thefts are not planned, carried out without confidants and regarded as illegal by the offenders who often feel guilty for it. The objects are stolen not for monetary gain or personal use, but are mostly discarded, given away or hoarded. Though there is a debate going on for more than 100 years, the nosological position of kleptomania remains unclear. On the one hand the clinical picture is observed as an isolated disorder in otherwise healthy persons, on the other hand it may also occur as an accompanying symptom of various other psychiatric disorders, e. g. impulse control disorders, acute psychoses, affective, or organic psychic disorders. The present article gives an overview of the most important aetiopathogenetic viewpoints about kleptomania and discusses their nosological, therapeutical and legal implications.

Cycloid psychoses -- from clinical concepts to biological foundations

The modern concept of cycloid psychoses is primarily based upon the clinical delineation of their phenotypes according to Leonhard. By settling the dilemma of Kraepelinean "atypical psychoses", their description may be considered one of the major achievements of clinical psychiatry in the last century. In particular, this had been facilitated by the work of Wernicke and Kleist. Albeit not yet generally recognized, cycloid psychoses have already stimulated great efforts of research yielding remarkable results. In this article, we elucidate the concept of cycloid psychoses and present recent findings pertaining to their putative biological foundations. Finally, future perspectives for the field of biological psychiatry are proposed fostering the heuristics of Leonhard's nosology.

Differences in substantia nigra echogenicity of nosological subtypes within the schizophrenic spectrum. A preliminary transcranial ultrasound study

OBJECTIVE

Schizophrenic patients treated with neuroleptic drugs often develop neuroleptic-induced parkinsonism (NIP). Here, transcranial sonography (TCS) was used to test for differences in the susceptibility to NIP related to the echogenicity of the substantia nigra (SN) in different schizophrenic subforms.

METHODS

79 patients with schizophrenic spectrum psychoses treated by neuroleptic drugs and diagnosed according to ICD-10 and Leonhard's nosology were examined independently by TCS and, clinically, for NIP.

RESULTS

Patients with larger echogenic SN had more severe NIP (p < 0.05). Diagnostic categories according to ICD-10 did not differ significantly in SN echogenicity (p > 0.2), whereas Leonhard's did (p < 0.05).

CONCLUSIONS

These findings suggest altered SN echogenicity in subtypes of the schizophrenic spectrum. The putative role of the nigrostriatal system in the etiology of schizophrenic subtypes is discussed.

[Hypochondriacal euphoria as a special form of monopolar affective psychosis]

BACKGROUND

In contemporary concepts of affective psychoses the existence of monopolar manias is widely questioned. Nevertheless, cases of manias with monomorphous symptomatology are reported repeatedly from all over the world. Based upon subtle observation of signs and course over many years, Karl Leonhard developed a concept of affective psychoses that permits a distinction of monopolar from bipolar forms, e.g. monopolar manias and euphoric euphorias.

METHODS

As an example for the pure forms of euphorias we present two cases of hypochondriacal euphoria.

CONCLUSION

We discuss some of the literature relevant to the issue and propose the application of a differentiated psychopathological analysis for the discrimination of monopolar from bipolar manias.