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Cycloid psychoses in the psychosis spectrum: evidence for biochemical differences with schizophrenia
(2016)
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.
Background and Objectives: Cycloid psychoses are characterized by polymorphic symptomatology with intraphasic bipolarity, a remitting and recurrent course and favourable prognosis. Perris and Brocicington (P&B) described the first set of operational criteria that were partly incorporated in ICD-10. The present study investigates psychopathological profiles according to the P&B criteria and the original descriptions by Leonhard, both against the background of the criteria from the prevailing international classification systems.
Methods: Eighty patients with psychotic disorders were recruited and assessed with various psychometric instruments at baseline and after six weeks of antipsychotic treatment in order to investigate the presence of cycloid psychoses according to Leonhard (LCP) and the effect of treatment with antipsychotics. The overlap between LCP and DSM-IV Brief Psychotic Disorder (BPD), ICD Acute Polymorphic Psychotic Disorder (APP) and P&B criteria was calculated.
Results: Using P&B criteria and a symptom checklist adapted from the original descriptions by Leonhard, 14 and 12 cases of cycloid psychosis were identified respectively reflecting a prevalence of 15-18%. Small though significant concordance rates were found between LCP and both DSM-BPD and ICD-APP. Concordance between LCP and P&B criteria was also significant, but modest.
Conclusions: This study demonstrates that LCP can be identified in a substantial number of patients with psychotic disorders. Cycloid psychoses are not adequately covered in current classification systems and criteria. Since they are demonstrated to have a specific psychopathological profile, relapsing course and favourable prognosis, it is advocated to include these psychoses in daily differential diagnostic procedures.
With the introduction of new genetic techniques such as genome-wide array comparative genomic hybridization, studies on the putative genetic etiology of schizophrenia have focused on the detection of copy number variants (CNVs), ie, microdeletions and/or microduplications, that are estimated to be present in up to 3% of patients with schizophrenia. In this study, out of a sample of 100 patients with psychotic disorders, 80 were investigated by array for the presence of CNVs. The assessment of the severity of psychiatric symptoms was performed using standardized instruments and ICD-10 was applied for diagnostic classification. In three patients, a submicroscopic CNV was demonstrated, one with a loss in 1q21.1 and two with a gain in 1p13.3 and 7q11.2, respectively. The association between these or other CNVs and schizophrenia or schizophrenia-like psychoses and their clinical implications still remain equivocal. While the CNV affected genes may enhance the vulnerability for psychiatric disorders via effects on neuronal architecture, these insights have not resulted in major changes in clinical practice as yet. Therefore, genome-wide array analysis should presently be restricted to those patients in whom psychotic symptoms are paired with other signs, particularly dysmorphisms and intellectual impairment.
In a retrospective study of 80 chronic DSM 111-R schizophrenics and 80 controls, the occurrence of obstetric complications (OCs) into the development of chronic schizophrenias was investigated using Leonhard s distinction in systematic schizophrenia (no obvious familial loading) and unsystematic schizophrenia (mainly genetically determined according to Leonhard). The Lewis & Murray and Fuchs scales were used for evaluation. In both scales, unsystematic schizophrenias did not differ from controls, but those with OCs were significantly (p < 0.01) earlier hospitalized (20.5 years) than those without OCs (25.6 years). Systematic schizophrenics had an increased frequency, severity and total score of OCs compared to controls in the Fuchs scale (p < 0.0 I). Likewise, in the Lewis & Murray scale systematic schizophrenia showed an increased presence ofOCs compared to controls (p < 0.05) and to unsystematic schizophrenia (p < 0.1 ). Systematic schizophrenias were significantly allocated to matemal infectious diseases during mid-gestation. Patients with matemal infections showed moreadditional OCs than those without (p < 0.05; Lewis & Murray scale). In systematic schizophrenia, a history of OC was not associated with an early onset of the disease. In the genetic determined schizophrenias prenatal and perinatal disturbanccs Iead to an early onset of the disease, however, in systematic schizophrenias they seem to be of causal importance for the development of the disease.
In 55 chronic schizophrenics, the occurrence of infectious diseases during their mothers' pregnancies was investigated. Different psychiatrie diagnostic systems were compared. Infections were reported by the mothers of familial and sporadic DSM I1I-R schizophrenics in equal proportion. However, applying Leonhard's classification, the frequency of infections was found to be significantly increased in 'systematic' schizophrenia (mainly exogenously induced in the view of Leonhard) compared to 'unsystematic' schizophrenia (mainly genetically determined according to Leonhard's findings). Most of the infections occurred during the second trimester (nine out of 13). Thus, in the 'systematic' forms of schizophrenia (low genetic loading), maternal infections in this crucial period of neurodevelopment would appear to be important causative factors in the cytoarchitectural deviance detected in the central nervous system of schizophrenics.
Anhand von drei exemplarischen fällen wird. das Krankheitsbild der selbstquälerischen Depression, eine Form der reinen Depressionen Leonhards, dargestellt. Im Zentrum stehen die Ideen der Selbsterniedrigung und Selbstentwertung und der sich daran entwickelnde ängstlich-depressive Affekt. Charakteristisch ist auch die Angst um die nächsten Angehörigen. In ihren Selbstanklagen erwarten und fordern die Patienten für sich die schrecklichsten Strafen. Diese wenigen Leitsymptome kehren in jeder Krankheitsphase gleichförmig wieder. Andere depressive Symptome wie Denkhemmung und psychomotorische Hemmung treten dagegen völlig in den Hintergrund. Der Krankheitsverlauf ist streng monopolar. Die Dauer der Krankheitsphasen wurde von Leonhard mit durchschnittlich 5,8 Monaten angegeben. Sie betrug bei unseren Patienten durchschnittlich 4,1 Monate. Das klinische Erscheinungsbild ist durch moderne Behandlungsstrategien nicht wesentlich zu beeinflussen. Eine familiäre Belastung mit affektiven Psychosen findet sich nur sehr selten.
In 55 chronic DSM I11 -R schi zophre nics the occurrence of obstetr ic complica ti ons (OCs) was investigated us ing the famili al/sporael ic strategy and Leonhard's unsystemati c/systematic distin ction. The overa ll frequency and severity of OCs elid not differ be tween patie nts anel controls. A sub-sample of patients, whose genetic ri sk was supposed to be high in both class ification systems (d iagnos is 01' unsystematic anel fa mili al sc hizophre ni a), had s igni ficantly fewer OCs than controls on the Lewis anel Murray scale (P < 0.05). With reference to previous reports of inc reased morta lity rates in the offspring of schizop hre nics, high genetic risk and addition al perinatal stressors may in crease perin atal mortality. In contrast, pat ie nts whose genetic ri sk was sllpposed to be low in both systems (di agnos is of systematic and sporadic sc hizophrenia) showed a trend to an increased freqllency of OCs in the Fuchs scale. In the context of the recently reported highl y signi ficantly increased rate of matern al infections dllring midgestation in these pati e nts, it was supposed th at perin atal complications may be of so me ae tio logical importance in sc hizophrenics with low genetic ri sk.
In einer retrospektiven Untersuchung erinnerten 16 von 80 Müttern von chronisch Schizophrenen eine schwere Infektionserkrankung in der Schwangerschaft. Im zweiten Trimenon waren gehäuft Infektionen aufgetreten. Zehn von 80 Müttern von Kontrollpersonen erinnerten ebenfalls eine Infektion. Im Vergleich zu den Kontrollen halfen Mütter Schizophrener im 5. Schwangerschaftsmonat häufiger Infektionen als in den anderen Gestationsmonaten (p < 0,05). Bei "familiären" und "sporadischen" Schizophrenen gemäß DSM III-R kamen im Vergleich zu Kontrollen Infektionen in gleicher Häufigkeit vor. Wurden hingegen in der Diagnostik schizophrener Psychosen die Definitionen von Leonhard zugrunde gelegt, ergaben sich signifikante Unterschiede! Bei den systematischen Schizophrenen (denen nach Leonhard keine erbliche Disposition zugrunde liegt) waren Infektionen gehäuft im 2. Schwangerschaftsdrittel aufgetreten, sowohl im Vergleich zu Kontrollen (p < 0,01) als auch im Vergleich zu den unsystematischen Schizophrenen, die hauptsächlich genetisch bedingt zu sein scheinen (p < 0,001). Infektionserkrankungen im 5. Schwangerschaftsmonat waren ausschließlich bei den Müttern von systematischen Schizophrenen vorgekommen. Bei diesen Krankheitsformen scheinen Infektionen im 2. Schwangerschaftstrimenon und insbesondere im 5. Schwangerschaftsmonat wichtige ätiologische Faktoren zu sein und könnten mitursächlich sein für die beschriebenen zytoarchitektonischen Aberrationen im Zentralnervensystem von chronisch Schizophrenen.
Low P300 amplitudes and topographical asymmetries have been reponed in schizophrenic patients, but reference-independent amplitude assessment failed to replicate reduced amplitudes. P300 amplitude is conventially assessed at midline electrodes (PZ), anti asymmetric topography as reported in schizophrenics, may conj'ound this measurement. We lnvestigated the possible Interaction between P300 ropography and assessments of amplitudes. ln 41 clinically stable schizophrenics and 31 normal controls, the generalfinding ofreduced amplitudes at the P'l electrode and topographical asymmetrles in the patient group were replicated. ln both groups, a.symmetries of the P300 field (lateralized peaks) reduced the standard amplitude assessment at the midline parletal electrode, but did not Qjfoct the reference-independent, global amplitude assessment. This shows thal asymmetry per se does not imply reduced field strength. in addition, in schizophreraics. but not in controls, there was a significcmt effect oftlae direction of asymmetry on both amplltude measures, amplitudes belng lower with increasing shift ofthe P300 peak to the right side. Considering also the slightly left-lateralized peaks in the normal controls. this suggests rhat only right lateralized P300 peaks upressfunctional deficits in schizophrenics, whereas left lateralized pealcs fall wlthin the physiological variability of the P3OO field. Tht refonnce-independent amplitude assessment is proposed for unambiguous amplitude assessment in order to better define the clinical, psychological and physiopathological mtaning of the P3OO alterations in schizophrenics.
Evidence of hemispheric asymmetries in schizophrenia has been reported from different research areas. Asymmetries in evoked potential P300 topography are still controversial because of inconsistent findings. In the present study. previous results of abnormal lateralization of P300 were replicated in stabilized residual Schizophrenie patients. Auditory P300 was recorded during an odd ball task in which subjeets detected rare target stimuli. Schizophrenie patients had the P300 peak shifted to the right hemisphere and differed signifieantly from age- and sex-matched normal control subjects who had left-lateralized P300 peaks. A comparison of different methods of assessment and analysis of the topographical features of the P300 electric fields showed that the extraction of reference-independent descriptors of P300 topography is a reliable and sensitive method for statistical handling of the maps. The results suggest left hemispheric dysfunction during cognitive tasks in a subgroup of Schizophrenie patients. Inconsistencies between previous sturlies are likely to be due to heterogeneous patient groups, which may have included patients in an acute Schizophrenie episode or patients in clinical remission. lnvestigation of the clinical meaning of P300 alterations requires careful psychopathological definition of the patient groups.