psicosis cicloides

- Psisosis marginales de Kleist. K. Kleist

(Introducción del prof. Demetrío Barcia). http://www.psiquiatria.com/psiquiatria/vol1num2/artic_8.htm

- Perris, C.: A study of cycloid Psychoses. Acta psychiat. scand. Suppl. 253. 1974.

- Devender Singh Yadav. Cycloid Psychosis: Perris Criteria Revisited. Indian J Psychol Med. 2010 Jan-Jun; 32(1): 54–58.

Peralta V¹, Cuesta MJ. Cycloid psychosis: a clinical and nosological study. Psychol Med. 2003 Apr;33(3):443-53.

Modestin J¹, Bachmann KM.Is the diagnosis of hysterical psychosis justified?: Clinical study of hysterical psychosis, reactive/psychogenic psychosis, and schizophrenia. Compr Psychiatry. 1992 Jan-Feb;33(1):17-24.

- Demetrio Barcia, y sus estudios sobre las Psicosis Cicloides.

- Victor Peralta¹ , Manuel J. Cuesta and Maria Zandio

Cycloid psychosis: An examination of the validity of the concept. Current Psychiatry Reports. Volume 9, Number 3 / junio de 2007

Karl Kleist (1879-1960), el principal discípulo de Wernicke, introdujo en la nosología las "psicosis cicloides" (1924), como trastornos "bipolares", pero diferenciados de las Psicosis maniaco-depresivas de Kraepelin. Su mejor alumna Edda Neele (1949), estudió las "psicosis fásicas" (unipolares o bipolares), y siguió con el estudio de las psicosis cicloides.

Karl Leonhard (1904-1988) completó el concepto de Psicois cicloides, y creó la clasificación de las "psicosis endógenas", contraponiendo su propia nosología a la de Kraepelin.

Breve reseña histórica de Karl Leonhard.

Nacido en Edelsfeld, Bavaria, de padre clérigo protestante, se educó en Erlangen, Berlin y Munich, y cómo médico a partir de 1936 en Frankfurt, donde fue alumno de Karl Kleist. Durante el Tercer Reich, rechazó diagnosticar de Esquizofrenia para evitar las consecuencias eugenésicas del Programa de Eutanasia T-4. Posterior director de psiquiatría del la Univ. de Humboldt (en Berlín Este), en 1960 se le impidió emigrar a Alemania del Oeste, a cambio, se le propició soporte científico para sus trabajos de investigación sobre psicosis. Gran clínico, entrevistó y trató a más de 2000 pacientes psicóticos, al final con la colaboración del Dr. Sieglinde von Trostorff. Murió en el Berlin del Este. Su obra apenas se tradujo al inglés, salvo el reconocimiento de Frank Fish en su obra "Schizophrenia" ( 1962 ) y "Clinical Psychopathology" (1967).

Leonhard es conocido por su clasificación de las "psicosis endógenas", incluyendo la psicopatología de las "psicosis cicloides" de K. KLeist y su discípula Edda Neele.

Sirva este texto de homenaje a este gran psicopatólogo, y a toda la escuela de C. Wernicke, K. Kleist y K. Leonhard.

Bibliografía indispensable de Psicosis clicloides:

- D. Barcia Salorio. Psicosis cicloides. Psicosis marginales y bouffees delirantes. Ed. Triacastela. 1998.

- D. Barcia Salorio. Tratado de psiquiatría. Psicosis cicloides. Cap. 16. Aran Ediciones 2000.

- Claudia Derito, G. Martínez Rodríguez y A. Monchablon. Las Psicosis Cicloides: Psicosis Bipolares no Maníaco-depresivas ALCMEON 47 Año XV - Vol.12 Nro. 3-2005 pag. 271 a 299

- R. Fernández Carcía-Andrade. Tesis doctoral de Univ. Madrid. Dpto de Medicina: "Psicosis cicloides. Validez clínica y ubicación nosológica". Madrid. 2014.

- Klaus Jürgen Neumärker ^[2] y Andreas Joachim Bartsch. Karl Kleist (1879-1960) – un pionero de la neuropsiquiatría.^[1] ALCMEON 48 Año XV - Vol.12 Nro. 4- noviembre de 2005 pag. 333 a 370

- Neumärker KJ¹, Bartsch AJ Karl Kleist (1879-1960)- a pioneer of neuropsychiatry. Hist Psychiatry. 2003 Dec;14(56 Pt 4):411-58

- Daniel R. Martínez. La escuela de Wernicke-Kleist-Leonhard. Una revisión. Rev. Asoc. Esp. Neuropsiq., vol. XVI, n.º 58,1996, pp. 235-248.

- Andreas Joachim Bartsch "Karl Kleist, 1879–1960." American Journal of Psychiatry, 157(5), p. 703

- Karl Leonhard. Classification of Endogenous Psychoses and their Differentiated Etiology, 2nd edition New York/Wien: Springer-Verlag 1999

PSICOSIS CICLOIDES de K. Leonhard.

A) Psicosis de angustia-felicidad:

Un psicosis aguda, endógena, ¿psicogénica?, cuya clínica princeps es la expresión de una afectación emocional (de angustia, emoción intensa, incluso felicidad) psicótica.

- La angustia, inquietud psicomotriz, labilidad emocional, gran vivencia de ansiedad incontrolable, asociado a vivencias de felicidad y éxtasis, domina el cuadro agudo.

- Breve, recortado, de buen pronóstico (aunque recidivante) y sin escisión ni alteración de la identidad posterior,...(si la Restitutio ad integrum es total)

- En La psicosis cicloide de angustia-felicidad (Leonhard) la crisis psicótica aguda, se expresa con gran excitación angustiosa, de ansiedad, de éxtasis, con expresión en ocasiones de felicidad, exuberancia afectiva, con intensa labilidad emocional siempre.

Este estado de angustia-felicidad, va acompañado de:

- síntomas psicóticos paranoides: suspicacia, desconfianza, autorreferencias, sin delirios estructurados.

- de afectación de la corporalidad: extrañeza, cenestesias, cenestopatías, con ideas de transformación del cuerpo e hipocondríacas frecuentes

- afectación de la autoestima, del yo: con ideas de inferioridad, de autoponición, que se pueden acompañar de ideas de exaltación, de alegría: Se combinan las ideas de depreciación e hipertrofia yoica: distimia extásica e ideas de felicidad, con ideas de autopinición, y gran labilidad afectiva,...

- No son infrecuentemente también por alucinaciones (verbales, visuales, y de la corporalidad) y vivencias de influencia, deliro de control, que afectan a la corporalidad y la identidad de forma transitoria.

- Un yo psicótico poseído -de forma transitoria- por una ansiedad-felicidad inexplicable..

- Las ideas de felicidad se generan en un afecto expansivo, altruista (Kleist ), con un aumento de los sentimientos comunitarios, solidaridad, prodigalidad, fusión empática con el otro,... que puede predominar en un plano religioso, erótico o político-social.

(En la manía bipolar, la euforia es egocéntrica, "egoísta", con hipertrofia yoica y proactiva, sobreimplicada con el entorno...)

En las formas leves de psicosis coloides de angustia-felicidad : la alegría se expresa en la expresión sintónica, alegre de felicidad, con vivencia de elevada autoestima, sin existir disforia, ni delirios de grandeza: No obstante, la exploración del contenido ideico e identidad nos asombra: Cree que está destinado para una misión superior, para auxiliar a los demás, para ayudar contra las enfermedades, y que se casará con una persona influyente, y actuará a través de sus hijos, etcétera.

(ver siempre la posibilidad de evolución hacia formas de delirios pasionales (escuela de H. Ey), tipo erotomanía..)

En la forma moderada: Sobre la experiencia endógena de ansiedad-felicidad, se agregan las ideas de inspiración divina, los pacientes sienten una fuerza sobrenatural para llevar a cabo la idea de salvar a las personas, y al mundo. Estas ideas y esta fuerza son vividas como inspiradas por Dios, por los Santos, por el Espíritu, etcétera. Han sido objeto de una revelación. Aparecen ideas de vocación, de prosperidad, de redención. Les han encomendado una misión loable, de paz y amor...

¿génesis primaria del afecto o predomino de lo ideico?.

Los sentimientos anímicos están incrementados en los dos polos. Pueden ir desde un aumento de la actividad dirigida, de la iniciativa con mayor confianza en sí mismos, de mayor valoración, y pasar rápidamente a la irritabilidad con angustia, acompañada de ideas de perjuicio.

Este sentimiento puede asociarse con hipertimia, hiperactividad y fuga de ideas. (con tendencia pues al polo maníaco de la Psicosis Maniaco depresiva)

En las formas Severas: a las ideas de inspiración se agrega un estado de ánimo eufórico, con vivencias alucinatorias que pueden ser en ópticas , acústicas, o en ambos sentidos. Hay percepciones delirantes, vivencias de un encuentro con Dios o con algo sagrado, superior. En estos casos puede parecerse a una euforia exaltada mística.

A veces se observan rasgos hipercinéticos , estereotipias motoras, signos de bendecir, etcétera. Se pueden mezclar con angustia e ideas de referencia extáticas. (ya descrito)

Para Leonhard: “Las ideas de angustia y las ideas de felicidad suelen relacionarse tan íntimamente que suelen fusionarse en una única idea”... El paciente dice: “Yo quiero sacrificarme por toda la humanidad, así todo vuelve a estar bien”. “En estas ideas se representa el pensamiento cristiano de la liberación a través del sacrificio”...

La angustia y el éxtasis pueden aparecer al mismo tiempo y se expresarían, por ejemplo, en: “Morir como una forma de sacrificio por los otros”.

En las formas más graves: a la felicidad extática se añaden ya grados de perplejidad, afecto francamente extático, incoherencia en el curso del pensamiento. Se pueden agregar síntomas hipercinéticos o acinéticos. Pueden adoptar posturas rígidas con gestos de patetismo, y también llegar al estupor (paciente rígido con facies sonriente).

Pueden presentar euforia con perplejidad, o bien imitar otras formas de euforias puras, como la euforia exaltada, la improductiva o la confabulatoria. De allí pueden pasar a angustias extremas con perplejidad.

- En ocasiones, los síntomas básicos no han de estar siempre necesariamente en primer plano, también pueden aparecer cuadros que muestren rasgos más o menos claros de la enfermedad maníaco depresiva (por el predominio afectivo), de la psicosis confusional (por la alteración conductual y desorganización) o de la psicosis de la motilidad (por la quietud, mutismo versus crisis excitatorias).

- Un síntoma principal de la psicosis de angustia-felicidad es el polimorfismo, que puede recordar a las "Boufée delirnates" de Henri Ey.

Las forma clínica de Psicosis cicloide de angustia, es más frecuente que la presentación completa de Psicosis de felicidad / éxtasis.

* Nótese la similitud entre la "melancolía agitada" (De Kraepelin) y estas formas de psicosis agudas, polimorfas, en forma de psicosis de angustia.

(la fenomenología de la melancolía no deja dudas por su clínica de psicosis afectiva endógena: ver:

* Nótese la similitud clínica con la fase de manía agitada, con felicidad y éxtasis hipertímico. (ver "Psicosis endógenas, afectivas: tipos de fase de manía)

Duración de la enfermedad: tipos

- autolimitada, breve, tipo "Episodio psicótico agudo, Psicosis esquizofreniforme, psicosis reactiva breve, "Boufée",..con alternancia del humor angustioso y extático.

- forma evolutiva más similar a la psicosis maniaco-depresiva.

- formas evolutivas más prolongadas, que indican evolución a proceso esquizofrénico..

- Rasgos previos, de carácter, y personalidad de base: es decir una tendencia hacia una fuerte excitabilidad afectiva, vulnerabilidad afectiva, impresionabilidad emocional, en ocasiones pitiatismo, y labilidad franca. (no siempre, y en cualquier caso de buen pronóstico). Neuroticismo de base?

- Los llamados " temperamentos exaltados" de K. Leonhard.

b) Psicosis confusional excitada - inhibida:

La génesis psicótica recae en la afectación del pensamiento (excitado-inhibido) y en su expresión verbal y conductual. La característica princeps será la "confusión" , la desorganización ideico-conductual, que se manifiesta en gran incoherencia confusional y onírica.

De la verborrea al mutismo.

- el pensamiento taquipsíquico, descarrilado, con severo déficit asociativo, incoherencia ideo-verbal, asonancias, bloqueos, estereotipias verbales, repeticiones y fuga ideica, logorrea, hasta la total confusión ideica - verbal.

En las formas Graves de psicosis confusional excitada: con mayor excitación puede imitar a la manía confusa. Como ya mencionamos, la diferencia fundamental es que la manía sigue siendo reactiva a los estímulos del entorno, en tanto que el confusional-excitado pierde el interés razonable por el medio.

Si hay angustia puede imitar una depresión agitada con ideas hipocondríacas y de inferioridad.

Pueden mezclarse síntomas de la serie motora (acinesia o hipercinesia), al presentar por ejemplo, excitación con logorrea incoherente, acompañado de rigidez en la actitud y en la mímica.

Similitudes y diferencias con la manía: ver: Hipertimias y Estados de exaltación mental: La Manía.

En la psicosis confusional excitada parecería que la atención estuviera dirigida hacia el propio individuo, hacia su pasado, y prestara poca atención a los estímulos que vienen del entorno. El discurso es acelerado pero por lo general se refiere a su acontecer biográfico, a temas que tienen que ver con su pasado, con sus propios intereses y deseos. De hecho, a veces quedan “adheridos” a algún acontecimiento de su vida, en el que actualizan la carga emocional con la que se vivió en su momento y que según la gravedad del trastorno del pensamiento refieren en forma más o menos confusa.

Sin interés, ni implicación con el entorno - a diferencia de la manía endógena- el resto de las esferas instintivas -afectivas tampoco estarán tan afectadas.

Clínica de la llamada: psicosis confusional inhibida.

- El pensamiento pude aparecer bloqueado, inhibido,..hasta el mutismo: con bloqueo total de la expresión motora verbal. Se añaden signos de perplejidad ideica, extrañeza, escisión..que puede llegar a gran latencia de respuesta verbal o motora, incluso hasta el mutismo total, como máxima expresión de la expresión del lenguaje, que pierde su cualidad comunicacional.

En las formas moderadas: se añade la perplejidad; el pensamiento más enlentecido ya no puede integrar los estímulos exteriores. Presentan incapacidad de expresar "qué sucede", o de describir el entorno, o sus pensamientos.

Este bloqueo expresión verbal y comunicacional se traduce en la mímica por una mirada inquisitiva, interrogante, a la que se agrega una expresión angustiosa, temor y perplejidad.

En las formas Severas de esta psicosis de la expresión verbal "confusional inhibida": se profundiza la confusión y la inhibición, aparecen ideas de significado, psicóticas, a la perplejidad se agrega gran angustia. Las ideas de significado se convierten en ideas de referencia, de perjuicio, amenazantes.

La situación externa es vivenciada como extraña y amenazante (porque no se la comprende). Los enfermos dicen: “La gente entra y sale...”, “Los autos van demasiado rápido...”, "no entiendo qué pasa",...(forma perpleja)

Con frecuencia se agregan alucinaciones acústicas, ópticas y somatopsíquicas. El paciente, en este estado de inhibición del pensamiento, puede sentir que ha sido “vaciado de sus pensamientos” por una influencia externa (delirios de control)

En las formas graves: cuando la inhibición es elevada se produce mutismo. Al estupor perplejo se le pueden agregar síntomas acinéticos. Es probable que la acinesia induzca al diagnóstico de catatonia aguda.

Formas míxtas: Puede coexistir inhibición del pensamiento con acinesia y rasgos de la psicosis de felicidad con humor extático. El paciente aparece inmóvil con una expresión alegre en el rostro. En el estupor perplejo es posible que haya síntomas de la serie hipercinética, y en consecuencia se observa estupor perplejo acompañado de movimientos sin sentido, estereotipias, o crisis excitatorias confusionales.

Störring (1969) dice que los pacientes con estupor perplejo se diferencian de los catatónicos, en que no están tan tensos, ambivalentes ni negativistas. El estupor es blando y se dejan entrever las emociones. Si se los estimula reaccionan con cambios abruptos del humor y muy expresivos.

Gustav Wilhelm Störring (1860-1946) ( The 100th anniversary of Gustav Wilhelm Störring's )

Alteración del contenido ideico, propio de una psicosis:

En los contenidos anormales, aparecen en la excitación principalmente errores de reconocimiento de personas, de hiper o hipoidentificación, y con frecuencia también ideas de referencia, de alusión, que llegan hasta el deliro transitorio / agudo de perjuicio, saltígrado, variable, caprichoso, sin cristalizar ni estructurar. Las alucinaciones acompañan al cuadro clínico, sobre todo de carácter acústico, verbal, sin descartar las visuales, cenestésicas, o de la corporalidad.

En la fase inhibida, en caso de perplejidad, aparecen frecuentemente ideas de referencia y de significación. Con intenso temor, miedo a sufrir daño, o convicciones delirantes de muerte inminente, o de disolución, despersonalización del yo.

A menudo el cuadro de estado de la enfermedad no es puro y debido al carácter polimorfo de la psicosis aparecen rasgos que en general son propios de la psicosis de la motilidad, de la psicosis de angustia-felicidad o de la enfermedad maníaco-depresiva.

El curso es cambiante, fluctuante, predominando en ocasiones la logorrea incoercible, con periodos de mutismo y perplejidad.

Entre la personalidad previa: Se sospecha de un carácter prepsicótico, con afectación de la expresión verbal y emocional, con una mayor amplitud del pensamiento, un pensamiento divagante o por el contrario una introversión de base, pensamiento lento, con tendencia al bloqueo improductivo.

c). Psicosis de la motilidad hipercinético acinética:

La génesis psicótica recae en la psicomotricidad, entre los polos acinético (inhibición, mutismo, estupor) y el polo hipercinético (excitación motora, agitación, furor caótico, desorganizado y pseudo confusional) .

Psicosis de la motilidad hipercinética:

La clínica predominante será la hipercinesia agitada, una excitación psicomotriz que se manifiesta en su forma leve: deambulación sin sentido, acatisia, gesticulización, etc. Así el paciente hace gestos de alegría, pena, enojo, erotismo, patean el suelo mostrando impaciencia, saludan, amenazan con un brazo, etcétera.

Estado hipercinético: movimientos en cortocircuito, así por ejemplo, manosean su cabello, frotan sus manos, su cuerpo, y se sobre implican con el exterior: desarman las camas, cambian objetos de lugar, se suben a las sillas o las mesas, golpean las puertas, etcétera.

En las formas leves de la psicosis de la motilidad hipercinética: los movimientos expresivos y reactivos están incrementados, pero conservan toda su naturalidad: gesticulan en exceso, por ejemplo, a modo de saludo, amenaza, atracción o rechazo, manosean su cuerpo, coquetean, tiran objetos, los desarman, sujetan a otras personas, etcétera.

La angustia o la felicidad son estados de ánimo que acompañan con frecuencia el incremento de los movimientos, puede haber hipercinesia con humor elevado o con ideas de referencia angustiosa, pero lo más frecuente es que junto a la hipercinesia re registren rápidas oscilaciones del estado de ánimo entre los dos polos.

En la forma Moderada de esta llamada psicosis de la motilidad: los movimientos expresivos y reactivos pierden su naturalidad, son exagerados, pero aún no están claramente desorganizados. Es evidente en el lenguaje porque emiten frases cortas, sin coherencia, en cortocircuito, quizás también como exteriorización de la hipercinesia, obedeciendo al desorden de la esfera motora.

La hipercinesia moderada más un afecto alegre puede parecer una manía, pero hay que tener en cuenta que la hipercinesia es un estado más primitivo de agitación en su manifestación.

En las formas severas: los movimientos se distorsionan. Los movimientos expresivos se transforman en muecas y los reactivos en una inquietud desordenada. El habla como impulso psicomotor puede darse como gritos inarticulados: una inquietud agitada se apodera del paciente. Un deambular sin sentido, una "acatisia" imparable, que el agita sin finalidad aparente.

En las formas más graves: la hipercinesia se asocia a confusión del pensamiento, conducta desorganizada, que en la forma excitada se manifiesta con logorrea incoherente. Es posible que aparezcan también falsos reconocimientos de personas, ideas de referencia y alucinaciones. Pueden tener humor elevado con ideas de felicidad o bien angustia paranoide.

- Con mayor excitación puede alcanzar la forma de la catatonía letal de Stauder, o la "hipercinesia amenazante" de Edda Neele.

- Es habitual la emisión de sonidos inarticulados, o que se trate de una "hipercinesia muda" de Wernicke.

- En los casos graves, se acompaña de un síndrome neurovegetativo, y evolución catatónica.

Nota histórica sobre catatonia:

1- Edda Neele y la “Escuela de Neuropsiquiatría de Frankfurt”.

Edda Neele (1910 -2005), compañera de K. Leonhard, colaboradora de Karl Kleist, contribuyó a definir el concepto de "unipolar" (‘einpolig’) y "bipolar" (‘zweipolig’), en forma de "unipolar depresión", "trastorno bipolar". Con su tesis sobre "cyclical psychoses" fue admitida en Frankfurt University Neuropsychiatric Clinic, entre 1938-1942. La primera mujer que obtuvo la "habilitación" de psiquiatría en Alemania. Opositora al nazismo, muy influida por el teólogo protestante Karl Barth. Posterior práctica privada en Frankfurt hasta su retiro en 1986, a los 76 años.

2- Stauder (1934), publica su famoso trabajo: "Die Tödliche Katatonie", con tres pacientes que padecieron de forma aguda una catatonía, con catalepsia, hipercinesia hipertérmica, de evolución fatal

3-. J. Delay y P. Deniker, en 1952, inician tratamiento neuroléptico con Largactil ® , y en 1956, se publica : "fatal hyperpyrexia following chlorpromazine therapy"; una Catatonía aguda hipertérmica pero acinética, no hipercinética como era la de Stauder. En 1961 se publican ya primeros casos: "le sindrome malin des neuroleptiques" o "des catatonies a evolution mortelle". Ver: Catatonía neuroléptica maligna y su tratamiento por el Dr. Alberto Monchablon.

Para describir la psicosis de la motilidad hipercinética, Leonhard, (1995) nos presenta un caso clínico:

Psicosis cicloide de la motilidad hipercinética (Leonhard, 1995)

Klara A., nacida en 1916, ya en 1942 y 1948 padeció fases psicóticas juntamente con excitación confusa. En 1955 volvió a enfermar y fue internada en nuestra clínica neurológica. Su excitación es descripta de la siguiente manera en la historia clínica: “Está sentada en la silla, balancea las piernas, pega un salto, se levanta la camisa y baila el vals por la habitación, extiende los brazos, de vez en cuando toca la llave de luz, continúa con sus movimientos de baile, cruza los brazos sobre el pecho, junta las manos como para rezar, se para erguida como un soldado, extiende las manos hacia adelante, agarra las cosas que están sobre la mesa, saluda militarmente, mira coquetamente hacia todas partes y expresa incoherencias verbales”.

La excitación variaba de intensidad pero mantenía el carácter descrito. El afecto oscilaba mucho, a menudo había excitación. No se presentaron otros síntomas esenciales. La enferma se tranquilizó en un plazo de tres meses y fue dada de alta en diciembre de 1955. Dos años más tarde le hice el control y la encontré completamente sana. Se mostró accesible, amable, de humor bueno y estable.

Psicosis de la motilidad acinética (Leonhard, 1995)

La forma psicomotora de la inhibición es la acinesia. Están afectados los movimientos voluntarios e involuntarios, y llega a extremos tales como la anulación de los movimientos reactivos y la rigidez de la motilidad expresiva.

Lo esencial de este cuadro es la pobreza motora, bradicinesia, con tendencia al bloqueo motor y mutismo.

En las psicosis cicloides las formas acinéticas e hipercinéticas son puras; la aparición de movimientos paracinéticos (acinesia e hipercinesia que se dan en forma simultánea, como en la catatonía paracinética) no serían típicos de estas psicosis cicloides.

En las forma leves: Hay disminución de los movimientos expresivos y reactivos, hipocinesia (pobreza motora) y bradicinesia . Faltan las acciones y el habla por propia iniciativa. Aun cuando el trastorno es psicomotor, se pueden asociar perplejidad e ideas de referencia y también una excitación del pensamiento. Se pueden agregar fluctuaciones afectivas entre la angustia y con menos frecuencia la felicidad.

En la forma moderada: Se caracteriza por una disminución importante de los movimientos expresivos y reactivos, la permanencia en una postura, "posturismo", en ocasiones oposicionismo, rigidez muscular o bien laxitud muscular generalizada (catalepsia).

Responde a órdenes simples, y siguen ejecutando algunas conductas básicas de autocuidados, como vestirse o ir al baño.

En la forma severa de psicosis de la motilidad acinética: Si la acinesia es incompleta, todavía pueden ejecutar movimientos voluntarios. Hay rigidez de la postura y de la mímica y retardo en los movimientos reactivos. Aún responden a requerimientos sencillos, como extender un miembro, dar la mano, dirigir la mirada. Se pueden injertar rasgos confusionales excitados que resultan en posturas rígidas con logorrea incoherente. En la forma Grave, hay rigidez de la motricidad expresiva y anulación de los movimientos reactivos. No responden a los requerimientos más sencillos, no se levantan, no se visten, no buscan el baño, no reaccionan al dolor.

La postura es rígida, les falta la expresión del tronco, de la cabeza y de los brazos. El rostro está rígido, así hasta la catatonia.

Caso clínico de Leonhard : Helga F., nacida en 1940, enfermó por primera vez en 1954, a los 14 años. Primero estuvo excitada por un período corto, hablaba confusamente y luego permaneció sentada en un rincón de la habitación sin hablar una sola palabra durante cuatro semanas. Luego sanó nuevamente. Un año más tarde se volvió a presentar el mismo estado de escasez de movimiento, el cual esta vez duró 14 días. Nuevamente medio año después, es decir, en diciembre de 1955, se encontró en un estado de inmovilidad durante seis días. En enero de 1956 éste volvió y duró 14 días. Por último la niña enfermó nuevamente en marzo de 1956 y vino a nuestra clínica. Estaba completamente acinética y tenía gesto y postura rígida. No prestaba atención cuando uno le hablaba y movía los ojos lentamente y en forma no definida. Cumplía las órdenes en forma extraordinariamente lenta bajo la persistente rigidez postural. Si bien mostraba movimientos acompañantes de los brazos al caminar, éstos parecían de madera. No respondía a las preguntas. No se alimentaba por sí misma; se le debía dar la comida con cuchara. También mojaba la cama cuando no era llevada a tiempo al sanitario. Esta vez el estado duró aproximadamente tres semanas, y luego terminó a los pocos días.

Helga era ahora una niña de 16 años psíquica y completamente normal, abierta, amable y natural. En 1957 la cité para un control. El resultado fue el siguiente: la Nochebuena de 1956, es decir 3/4 año después de su salida, fue nuevamente acinética, no iba más al sanitario, y solamente ingería los alimentos cuando le eran dados directamente. Luego de cinco días todo había pasado. Ocho días antes de las Pascuas, este estado volvió a presentarse y esta vez duró 10 días. Después, según manifestó la madre, la niña parecía “recién nacida”, “totalmente fuera de las casillas”, más vivaz que en otros tiempos. Este leve estado de excitación también pasó rápidamente y Helga fue otra vez como antes. Cuando me vino a ver para su control, aparentaba estar completamente sana, vivaz, amable y accesible. Quizás demostraba un leve rasgo hipomaníaco que ya se había observado al salir de la clínica

PSICOSIS CICLOIDES: Validez clínica y ubicación nosológica después de la finalización de las fases acinéticas: La niña recordaba todos los detalles de su estado, podía referir exactamente lo que había vivido, y estaba evidentemente orientada en todas las fases de su enfermedad en cuanto al tiempo y lugar y acerca del ámbito que la rodeaba. Según contaba, algunas veces tenía ideas depresivas y/o angustiantes. Creía que le querían hacer algo, quizás llevarla a la cárcel. En octubre de 1971 el resultado catamnésico era: H. estaba sana, activa como peluquera y felizmente casada. En el transcurso de los años padeció algunas "fases" más en su casa en las cuales no hablaba ni comía.

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Hasta aquí la vindicación clínica de las Psicosis cicloide de la escuela de . Wernicke, K. Kleist y K. Leonhard. Sirva de homenaje a estos excepcionales clínicos, psicopatólogos, y a todos los pacientes que colaboraron en la descripción y relato de sus clínica.

¡¡ esto no lo encontrarás en el DSM- 5 ¡¡

Texto adaptado por Dr.J.L. Día.

El lector podrá disfrutar de los casos clínicos de los pacientes con "psicosis cicloides", y del texto original de K. Leonhard.

Karl Leonhard.

Classification of Endogenous Psychoses and their Differentiated Etiology.

The Cycloid Psychoses.

Psychotic syndromes of cycloid psychoses have been described by both WER­NICKE (1900) and KLEIST (1928). My concept of these disorders is somewhat different. For WERNICKE anxiety-happiness psychosis appears in two separate forms: anxiety psychosis on the one hand, and "expansive autopsychosis with autochthonous ideas" on the other. WERNICKE developed the concept of "motility psychosis", but he did not separate periodic catatonia from it. Later KLEIST and FUNFGELD (1936) described the differential diagnosis from schiz­ophrenic disorders. Wernicke denoted the two poles of the disorder as "cyclic motility psychosis". Confusion psychosis appeared to him as either "periodic maniacal auto psychosis" or "agitated confusion", inhibited confu­sion psychosis as "intrapsychic akinesia". In the latter KLEIST spoke of "con­fused stupor". The concept "confusion" comes from MEYNERT. KLEIST included anxiety psychosis and happiness psychosis which he considered as "inspiration psychosis" in his "paranoid marginal psychoses", while he grouped motility psychosis and confusion psychosis with "cycloid marginal psychoses" .

The cycloid psychoses, of which three are to be distinguished, are charac­terized by complete recovery from each phase. If this does not hold the diag­nosis is usually wrong. A chronic course corresponding to chronic mania is very rare. It may be observed that patients with cycloid psychoses rarely lose some of their vigor after repeated phases and hospitalizations. This also hap­pens in manic-depressive illness, and can be seen as a reaction to this disorder. Recovery from cycloid psychoses was confirmed by thorough follow-up examinations carried out by Frau VON TROSTORFF and myself (LEONHARD and VON TROSTORFF 1964). I emphasize the follow-ups because the cases reported below were all observed until the end of each phase; some of them could be followed over a long period of time. PERRIS (1974) has paid much attention to the cycloid psychoses in recent times and has confirmed their separate status.

Nevertheless, in spite of remissions occurring in cycloid psychoses it must be emphasized that there is a certain relationship between them and some forms of schizophrenia - the unsystematic schizophrenias. Parallel to the three cycloid psychoses the three unsystematic schizophrenias manifest cer­tain symptomatic similarities. Perhaps here and there the disease process involves similar brain functions, but the genetic differences clearly call for separate categorization. This I will consider in detail. The cycloid psychoses are not at all similar to other forms of schizophrenia; in systematic and com­bined systematic schizophrenia the clinical picture is completely different.

Anxiety-Happiness Psychosis.

Happiness psychoses are considerably rarer than anxiety psychoses. This parallels manic-depressive illness in which depressive phases are more com­mon than mania. However with closer observation it seems that if actual ecstatic phases are absent anxiety may be interrupted by a state of happiness lasting for a short time, perhaps an hour or even less, during which ideas of being summoned or of salvation are expressed. These transitory states are very useful in confirming the bipolarity of the psychosis. However they are not necessary for the diagnosis; anxiety-happiness psychosis can be recog­nized from the picture of the anxiety phase alone. Fears such as being tortured or killed, of losing relatives are characteris­tic. They are rarely present in pure form, but rather appear in association with paranoid symptoms. The anxiety is characterized by distrust and ideas of reference. It develops not only from within, but patients also see it con­stantly reconfirmed by events in their environment. For example they believe that the police is following them, that a man standing before them is threatening them, that their houses are surrounded, that patients in the hospital are avoiding them, or that employees are talking about their pend­ing arrest. Accompanying these ideas of reference, less precise reinterpreta­tions occasionally appear in which events in the environment seem to be threatening without definite foundation. If this latter form of idea construc­tion with accompanying perplexity begins to predominate, then the differ­ential diagnosis leans toward confusion psychosis, where we will again meet ideas of significance. However despite the perplexed traits, the basic mood of anxiety psychosis remains primarily anxious. There are transitions from ideas of reference to illusionary and hallucinatory experiences. If patients claim, for example, that they deduced from the gestures of people in con­versation that these people were discussing the patients' imminent execu­tion, then we are dealing with ideas of reference; if they claim to have under­stood what had been said, then it is a case of illusions; if they claim to have heard discussions of their execution though no words were spoken at all, then we must assume the presence of hallucinations. All these phenomena occur in anxiety psychosis and are often difficult to sort out. Sometimes patients refer to olfactory experiences where it is difficult to differentiate whether odors are being misinterpreted or if they are being hallucinated. Similarly patients may complain that the food is poisoned. The absence of precise symptoms, the fluctuation between ideas of reference and hallucina­tions is characteristic for anxiety psychosis.

Hypochondriacal experiences are often found: itching, feeling of heat, something like shaking of the body, and the like. Sometimes patients claim that they are being bodily influenced. However they seldom confirm that these phenomena affecting them have external origin; rather they describe sensations similar to those in hypochondriacal depression. If patients speak more definitely of being influenced from outside, that they are perhaps hyp­notized, a possible diagnosis is affective paraphrenia, as we will see later.

However, simple misperceptions are hardly less frequent in anxiety psychosis than ideas of reference. They may even dominate the picture. It is the nature of polymorphism in bipolar psychoses that first one symptom will predomi­nate and then another. Furthermore, varied degrees of inferiority, self-accu­sation and occasionally alienation phenomena may appear.

Paranoid symptoms are considered to be prognostically unfavorable by many psychiatrists; such may even be considered to be characteristic of early schizophrenia. However the more pronounced the underlying anxiety is the less justified is this negative prognosis, as we will see more clearly in relation to affective paraphrenia. The lively, often extraordinarily severe anxiety dif­ferentiates the condition from suspicious depression, as mentioned before

The direct expression of anxiety varies considerably. Patients may wail, moan, scream, or plead in a high degree of excitement and repel every attempt to approach them; this may far exceed the excitement of agitated depression. They may however be rigid and motionless, revealing their anxiety only in their facial expression. The rigidity may suddenly turn into excite­ment. To what extent these are psychologically different reactions to anxiety on one hand, or psychomotor symptoms on the other, is not always deter­minable. Certainly both exist.

Just as we found some symptoms of manic-depressive illness overlapping other polymorphic psychoses, in anxiety-happiness psychosis we find the same phenomenon. Psychomotor symptoms overlap those of motility psy­chosis. In anxiety psychosis akinesia may appear as a rule for only a short period of time, even though a high degree of anxiety does not psychologi­cally explain such rigidity. Perplexed forms of stupor are also found, border­ing on the symptomatology of confusion psychosis. Symptoms which resem­ble the excited pole of motility psychosis or confusion psychosis may appear in anxiety psychosis. Situations then arise comparable to the mixed states of manic-depressive illness. At times it is hard to determine readily which form of polymorphic psychosis is present. However with the lessening of these phenomena the accompanying symptoms generally recede as well, and the anxiety psychosis with its characteristic picture becomes clear. Milder forms of the disease may resemble melancholia, if depression accompanies anxiety. Ideas of inferiority and sinfulness may be present. The polymorphism of anxiety-happiness psychosis may also resemble that of manic-depressive illness. Of the pure forms, agitated depression is the most likely to be imitated, as discussed in relation to that disorder. Only rarely do paranoid symptoms recede enough for agitated depression to be confirmed. When less anxiety is present and ideas of reference predominate, suspicious depression may be simulated.

Happiness psychosis, the other pole, may resemble exalted euphoria. As in the latter similar ideas appear with the feeling of happiness of an ecstatic character. Patients feel elevated, often immeasurably, even to a divine level; they do not want merely to feel overjoyed by themselves, they also want to make others happy. They may express ideas of being called, of great fortune, or of salvation. The calling to a higher duty often comes from God, and the idea itself is perceived as having been inspired by God. If the affective waves are less strong, patients may assume the role of helpers, without reference to a higher duty - helpers against diseases for example. In a broad sense, all such ideas may be summarized as ideas of happiness, meaning both the patient's own happiness as well as that of others. Sometimes women do not act like this themselves, but want to be effective through their child, like Mary through Jesus, or through a man, usually a prominent one, whose mar­riage proposal they await with the feeling of happiness, marked by erotic undertones. Even un religious persons may express religious ideas. On the other hand patients commonly feel called upon to undertake social or polit­ical tasks, wanting to bring justice or eternal peace. The picture of happiness psychosis, like that of exalted euphoria, is complemented by pseudohallucinatory experiences, particularly those that include meetings with God or a saint. During these appearances, which are visual, auditory, or both, patients receive their alleged mission. Often they reinterpret actual observations, so that ecstatic ideas of reference develop, replacing their anxious experiences. Thus a harmless remark may be perceived as a calling.

At the height of the disorder, as may also occur in the anxiety phase, slight or more definite incoherence of the thought process may appear, resem­bling symptoms of excited confusion psychosis. Hyperkinetic traits as seen in motility psychosis may also appear. Furthermore rigidity of postures is not infrequently found in happiness psychosis. Should this seem to look like a lofty gesture, for example, that of blessing, this can be understood psycho­logically as a consequence of the ecstatic affect. It may also happen that the patients remain nearly motionless for long periods, not saying a word, behaviour that does not seem to make any sense. It could then be suspected that, aside from the ecstatic affect still recognizable in the facial expression, a stu­porous state has developed as an independent syndrome comparable to either akinetic motility psychosis or inhibited confusion psychosis. Perplexity with elevated mood could point toward one of the euphorias, while rigid pos­ture may indicate a form of akinesia. In milder form this cycloid psychosis may imitate manic-depressive illness. Both as post-phasic fluctuations and as interim phases lasting somewhat longer, pictures resembling mania or hypomania may be found, characterized by elevated mood, overactivity, and flight of ideas. If specific emotional levels are affected certain forms of pure euphoria other than the exalted form may be imitated, such as unproductive euphoria or confabulatory euphoria.

The affect of anxiety-happiness psychosis has another peculiar character­istic besides its tendency to become excessive. It may mount suddenly and then abate just as quickly. Both anxiety and ecstasy have this fluctuating char­acter. One hour the patients may run through the room with the greatest anxiety, while in the next they may calmly reply to questions and perhaps try to prove their calmness with a smile. Again, in a state of highest ecstasy they may assume a lofty posture, preaching to other patients, then suddenly becoming calm and able to participate in the activities on the ward. In exalted euphoria and self-tortured depression we saw, affect rise when the patients' ideas were discussed with them. The same phenomenon is found to a lesser degree in anxiety-happiness psychosis. Mood fluctuations are precip­itated less through the patient's ideas than other stimuli. Unusual occur­rences on the ward, such as taking a blood sample or giving an injection, may cause anxiety attacks; the visit of a clergyman, or another patient's com­plaining, may produce waves of ecstatic emotions. Basically however, the affect of anxiety-happiness psychosis is labile from within.

Not infrequently this leads to the peculiar phenomenon in which the most severe ideas of anxiety are expressed without inner excitement; the same applies to ecstatic ideas. When the patients smile while expressing their ideas of anxiety, they are generally trying to hide their anxiety; but even when that is known, the contrast of the smile to the content of the ideas is so striking that smiling ought to be impossible. In contrast to this patients may express ecstatic ideas with a mildly displeased face. Here too the unhappy expression probably has the purpose of disguising how important the ideas really are for the patient. But this tendency to disguise shows that the affect is no longer associated with the ideas. The explanation for the remarkable phenomenon is that the patients arrive at both their ecstatic and their anx­ious ideas while in the extremes of their affect, and, after the usually rapid abatement of the affect, do not correct the ideas but only become rather unsure. Pronounced ecstasy lasts considerably less long than anxiety, so that the contrast with the ideas is more common. A similar fluctuation of the affect is not found in the pure forms. Lability of mood is a common feature of manic-depressive disease, but not to such an extent as in anxiety-happi­ness psychosis.

The mood fluctuation does not only have to occur between one pole and the center; it can occur between the two poles, even between the greatest extremes of anxiety and ecstasy. Patients who have just expressed the most severe fears may very rapidly assume ecstatic postures, declare that it is all behind them and that now they and the rest of humanity are going to be saved. This type of affect change has an influence on the idea construction in a particular manner. As we have just seen, convictions that arise during a pathological affect disappear only slowly after the affect itself has disap­peared. On the other hand since anxiety ideas cannot conform to an ecstatic affect nor ecstatic ideas to an anxious affect, there may be a transition from one to the other during which the ideas are double-faced. For example, the patients believe they are approaching a great destiny, full of severe suffering but leading to a great reward. Depending on the mood at that moment, one or the other aspect moves into the foreground. For this type of ideation, reli­gion with its doctrines of punishment and salvation offers a very suitable con­tent. Anxious and ecstatic symptoms are particularly apparent when patients believe that they must die a "sacrificial death" for others. Religious col­oration is also often found in anxiety psychoses when there is no recogniz­able affective swing toward the ecstatic pole. Presumably the affective swing is hinted at and produces the religious content of these ideas. Neither in manic-depressive illness nor in other pure forms of depression do ideas of anxiety and inferiority take on the character of sin and divine punishment as often as in anxiety psychosis.

Despite the polymorphism of the psychosis it should be emphasized that in general the clinical picture is dominated either by anxiety with paranoid and hypochondriacal features or by feelings and ideas of happiness.

Case 39: Helene Hem, born in 1884, first became ill in 1931 at the beginning of her menopause. She became depressed, developed feelings of anxiety, and complained of inner unrest and obsessive brooding. After six weeks of treatment at Spa K, she improved and was discharged. Nine months later she had to be readmitted. This time she com­plained of lack of will-power, feelings of anxiety, inner unrest, and prickling in the eyes. Her facial expression was rigid. Two months later she was discharged and remained well except for depressive periods that developed every fall and lasted until spring. In 1940 she became ill again, following influenza; this time she was excited and had to be admitted to the Frankfurt Hospital. Here she declared that she was not sick: "I am happier than the happiest human being." She claimed that Mrs. K, who had been following her and had made her nervous had been taken to hell by the devil. The elevation of her mood took on a markedly ceremonious form. She spoke only in monotones, as if she was praying a litany, and sang religious songs with eyes closed. When asked if she was blessed she nod­ded beatifically. Among other things she claimed: "The most holy one is coming soon. The mother of God has appeared to me. She wore a garment of heavenly blue, stood in heaven and waved to me"; "The day of the last judgement will be tomorrow. You will be astonished at what will happen. Stars will fall from heaven. The moon will no longer shine. The sun will be darkened and the dead will arise. I am happier than ever." She urged the other patients to kneel and await the most holy one. The ecstasy remained at this pitch for seven days and then gradually receded. However a ceremonious elevated mood remained longer. Finally this mood too disappeared. The patient became rational, corrected her ideas and explained that she could not have acted otherwise. She had seen the mother of God and had received the knowledge that she must save mankind. Eight weeks after admission she seemed a bit depressed but was discharged. At home the depression gradually increased; six months later she had to be readmitted after having expressed suicidal ideas. She was very anxious and suspicious, believing that people were talking about her and wanted to do something to her. She also complained of pains in the chest, prickling in the head, as if fire were inside, and prickling throughout the whole body. She cried and moaned a lot, then stood around with no energy. After five weeks she improved somewhat, and was discharged. At home she was well on the whole, although at times somewhat depressed. In 1944 she again became ill, was anxious and believed that people were following her. As she wanted to take her life she was readmitted to hospital. She complained that she could no longer work and that her thoughts were not right. Her whole body felt like fire or prickling needles; she claimed that anxiety was torturing her, but she did not know why. At times she complained vividly, at other times she was almost motionless. After four weeks she was transferred to Institution "\IV. Here at first she was anxious, complaining and hypochondriacal, then she rapidly improved. After three months she was considered to have recovered completely. She had complete insight. At her own request she remained in the institution as a nursing assistant. In March 1946 she was temporarily depressed after she had influenza, but then remained quite normal and she was discharged. Her sister became ill in 1925, three months post-partum. She was anx­iously excited, could no longer work, complained of inner unrest, and wanted to kill her­self and her child. After this condition had lasted three months, she was admitted to Insti­tution M., where she seemed more affectively labile than depressed. She complained that she had changed internally, felt an antipathy toward her child, and felt as if something were wobbling inside her head. Her deep depression seemed to have disappeared. Her mood normalized quickly and discharge followed.

The happiness psychosis of this patient is very impressive. The ecstatic affect is easily recognized from the ceremonious posture and exalted religious ideas. At the height of the illness visual hallucinations appeared in which the patient saw the Mother of God. Likewise her anxiety psychosis, with ideas of reference and hypochondriacal symptoms, is typical, with its contrast to the happiness phase. Another patient's condition was characterized by rapidly alternating affect. She begged not to be shot dead, but right away said that she was not afraid to die, and even wanted to sacrifice herself in order to rid the world of hatred. Another female patient called herself a sinner, but at the same time offered herself to die as a sacrifice for the sake of redeeming the .world and bringing peace to all mankind. A male patient expressed the belief that he would be guilty of the downfall of the world, at the same time hearing a divine voice assigning important tasks to him.

If the ecstatic pole is missing, investigation of the family nevertheless may confirm its genetic presence. In the following case the illness of her brother shows that the patient who had only anxiety phases was in fact afflicted with anxiety-happiness psychosis.

Case 40: Katharine Klin, born in 1905, first became ill in 1936. She no longer wanted to work, believed that people were watching her and were thinking that she had had an abortion. She believed that she had a bad influence on others, declaring that she should be shot. She was admitted to the Frankfurt Hospital because of her inn-easing anxious excitement. She cried copiously that she wanted to die, the doctor was recording every­thing incorrectly, the other patients were laughing about her, people thought she was a criminal, and that she was going to be electrified. Alternating with excitement she at times showed stuporous behaviour. After four months she calmed down and was dis­charged. In 1942 she again became ill, expressing suicidal thoughts, and was readmitted to the hospital. This time she was despairing, explaining that she was a great sinner; for a long time she would not answer questions, but stared into space. Then she would run around in anxious agitation. After three weeks she was transferred to Institution G., where her condition alternated between excitement and calmness continued. Yet she always remained anxious, making suicide gestures while she was either in an excited or an outwardly inhibited phase. During a remission she explained that everything had seemed changed and that she had thought that everything referred to herself. At that time from her facial expression it could be deduced that she had a wrong impression of the envi­ronment. After nine months she improved, her mood normalized, and she was dis­charged. Her brother became ill in 1934 after appendectomy and was admitted to the Frankfurt Hospital. He explained that the world had changed and was standing still. Simultaneously he had an elevated mood and he misjudged his environment. He thought a fellow patient was Hitler. Soon his mood became more anxious; he declared that the chimneys had stopped smoking and that it was probably his fault. Then an ecstatic phase followed during which he claimed that rays came from his hands, he had divine power, and he would establish a new religion. Periodically he developed incoherent pressure of speech. He sang, whistled, and made gymnastic movements. He spoke of angelic figures and of a spiritual face that he had seen. Although he appeared outwardly euphoric and laughed, he repeatedly spoke of a sin that he had committed. After eight weeks he calmed down and was discharged. However he returned to hospital after a week, explaining that people had greeted him peculiarly, that a bridge had appeared golden and seemed to belong to a different part of the world. He also claimed that a log on which he sat seemed to be pulsating from below, he felt as if he was swaying. His condition varied between high and low; occasionally he was afraid of being thrown into a pit. After three weeks he again appeared normal and was discharged. Two months later he was admitted to Institution G. in a state of ecstasy; the world appeared to him to be full of miracles. Four months later he was improved and was discharged. At home he remained well for several years until 1940 when he relapsed again. He became very active sexually with his wife, and was overly excited. He said his neck was burning. He was readmitted to Institution G., explaining that there had been terrible noises everywhere, the ticking of the clocks and the crum­pling of the pillow had been so peculiar, and there had been a sweetish taste in his mouth. He believed that the Copernican system was no longer correct. He felt rays in his body emanating from surrounding objects. In talking like this he was still anxious, but soon became euphoric and somewhat pathetic. He then stated that he wanted to remain a Ger­man. After three months he was improved and explained that he had had curious notions and had heard voices; that it had been a relapse of his earlier mental disease. He was dis­charged in an equable mood with very good insight.

In the cases presented there were no symptoms which might have led to any other diagnosis than anxiety-happiness psychosis. But overlap with the other two cycloid psychoses occurs quite frequently. I could have presented cases where it could not be determined which of the cycloid psychoses was to be diagnosed. One such an example is two sisters, one of whom had anxiety­happiness psychosis, whereas the other had confusional psychosis. It was not possible to determine which of the two conditions was genetically present in reality. This circumstance should not lead to the conclusion that genetically there was no difference. Furthermore it should not make it easier to just diagnose a cycloid psychosis. In every case the effort should be made to make a more accurate diagnosis. For if in spite of such overlaps the characteristic symptoms can be ascertained the certainty of the correct diagnosis is estab­lished. Under no circumstances should the diagnosis of a cycloid psychosis be made if the clinical picture is not clear, rather it should always contain the typical symptoms. Even more so, it should not be permitted to diagnose a cycloid psychosis merely because the illness has a benign course. The course merely confirms the previous diagnosis. Apart from overlaps within cycloid psychoses some others should be taken into consideration. Overlap with manic-depressive illness has already been discussed in detail. Differential diagnosis from affective paraphrenia will be dealt with later.

Summary

One pole of anxiety-happiness psychosis is characterized by anxiety, accompanied by distrust, ideas of reference, hypochondriacal ideas, ideas of inferiority, and not infrequently sensory illusions as well as occa­sionally feelings of being influenced. The other pole is characterized by ecstatic mood and feelings of happiness, at times accompanied by ideas of reference and sensory illusions. The basic symptoms need not always be in the foreground. There may be pictures with more or less clear traits of manic-depressive illness, confusion psychosis, or motility psychosis. This is an expression of the polymorphism of anxiety-happiness psy­chosis. The anxious phases are much more common than the ecstatic, so that cases of only anxiety psychosis are frequent, while those of only hap­piness psychosis are rare. The duration of the various conditions is simi­lar to that of manic-depressive illness, whereas a sudden change between anxious and ecstatic mood occurs often in the same phase. Prepsychotic traits are often found, hinting at a more severe disorder later, that is, a tendency towards becoming greatly excited, the so-called exuberant temperament (LEONHARD 1970b).

Excited-Inhibited Confusion Psychosis

The basic disorder of confusion psychosis lies in the thought process, which becomes incoherent during excitement and does not progress during inhi­bition. The incoherence here is different from that in confused mania; it can no longer be regarded as an abundance of flight of ideas. Flight of ideas do occur, but are not more frequent at lower levels of the disorder; on the con­trary, they are rarer. Confused patients with lesser degrees of excitement characteristically keep on speaking of things not relevant to the theme, for instance, of experiences at home or in the hospital not at all related to the immediate topic. The listener does not understand why the patients have chosen a certain topic, but often there is no lack of logic. Thus the doctor coming to see the patient expects the patient to talk about his health, about events in the ward or about a visit he has received; instead the patient talks about experiences he had years ago somewhere else. Why this happens is unclear and cannot be determined by questions. Every question brings on a new story, the connection to the momentary situation remaining open. I call this type of thought disorder incoherence of thematic choice. Here confu­sion psychosis does not imply distractibility by momentary events in the envi­ronment.

If the thinking disorder is less marked - mild cases occur frequently - the theme is not entirely abandoned, rather through partial comprehension of its content it determines the theme that follows. For example, if the patient is asked for the difference between a tree and a bush, instead of a logical answer the patient may talk about the berrybushes in the garden at home. If the patient is asked for the difference between to give a present and to bor­row something, the patient may talk about presents given on the occasion of celebrations. My term for this is digressive choice of theme. The distinction from digressive flight of ideas is that each thought is held on to for a while, whereas true flight of ideas continually produces new notions.

Excited thinking leads directly to verbal excitement; thus incoherent pressure of speech is an essential symptom of excited confusion psychosis. On the other hand, when with higher degrees of inhibition thought stands still, verbalizations also stop so that mutism arises. It simultaneously hides thought inhibition which cannot be immediately determined in a mute per­son. It can be deduced however from the fact that the patients are only stuporous in the sense that complicated movements requiring thought, are absent. Automatic movements and simple movements in response to com­mands are preserved. When requested the patients will dress and undress themselves. They feed themselves and go to the bathroom on their own. All movements are somewhat slowed down, most likely because the drive behind the thought is impaired. There is impoverishment of facial and other expres­sive movements to the extent expected from the emptiness of thought, but there is no rigidity. All this helps in the differentiation of the stupor from aki­nesia, which will be discussed under motility psychosis.

Due to inadequacy of their thoughts patients in the inhibited phase are unable to judge correctly events in their surroundings, thus becoming per­plexed. The few verbal expressions they offer generally indicate that they do not know what is going on or what it all means. The perplexity can often be recognized from the searching, questioning anxious facial expression Both excitement and inhibition of thought lead to abnormal ideas. In excitement patients easily display misidentification of persons which how­ever is generally transitory and often playful. This is not the same as the pecu­liar declarations of some schizophrenics that people in their surroundings are acquaintances. Transitory ideas of reference and auditory hallucinations are also common. On the other hand, during stupor at first nothing can be discovered about pathological ideation, although the patients may later report their experiences from hindsight. In milder forms when patients are not completely mute but only taciturn, pathological ideation may be observed. The patients no longer understand the connections in the events around them, everything appears peculiar. They look for the significance of the events which they no longer understand. This perplexed questioning for meaning characterizes ideas of significance. Incomprehensible events often arouse a fear that something is being planned against them. Thus ideas of significance may turn into ideas of reference. This is particularly true when anxiety as an independent symptom accompanies perplexity. In this case ideas of reference appear even with only mild inhibition. Misdiagnosis of schizophrenia should not be made. Ideas of reference and of significance are part of the schizophrenic symptomatology only if more severe inhibition or anxiety is absent. Patients with excited-inhibited confusion psychosis may claim that something is being planned but is hidden from them, everything is disguised, that it is all only a rehearsal, magic is being practiced, the food tasted strange, so many people were coming and going, the cars were going so fast, etc. Hallucinations often occur, primarily auditory, but visual and somatopsychic forms may also appear.

Here too some unusual pictures are found due to the polymorphism of the psychosis. If the intensity of the disorder is low, manic-depressive illness may be imitated; the patient may appear to be quite manic. If there is con­fused mania it may not be possible to decide whether the phase belongs to manic-depressive disease or to confusion psychosis. If the patients remain approachable, respond to everything, and observe their surroundings despite the confusion, then mania is likely, since confused patients often lose the capacity of taking in their surroundings sensibly. Elevated affect is also evidence of mania. Misidentification of people nearly always points to con­fusion psychosis. Similarly it may be impossible to differentiate inhibited confusion from stuporous depression seen in cases of manic-depressive ill­ness. While depression may point to one and perplexity to the other, the emotional state is often hard to judge in the presence of stupor; severely depressive coloration is not rare in confusion psychosis.

Commonly the affect is more anxious than just depressed, in this way overlap of confusion psychosis with anxiety psychosis occurs. The formation of ideas in confusion psychosis takes on an anxious coloration here. Ideas of reference and of significance take on a threatening character. Significant events in the surroundings appear to the patients to be preparations for his arrest or mistreatment. Other symptoms, similar to those in anxiety psy­chosis, such as ideas of inferiority or hypochondriacal ideas may develop. If the anxiety is not combined with inhibited but with excited confusion psy­chosis, a type of mixed condition occurs. These anxious confusion psychoses are very common, much more common than confused anxiety psychoses, i. e. cases which are essentially anxiety psychoses but which display traits of confusion psychosis. However the anxiety is generally only transitory and is readily relieved by elevated as well as indifferent mood.

Occasionally a mild ecstatic mood develops in inhibited confusion psy­chosis, recognizable from some remarks made and the joyous facial expres­sion of the patient. In excited confusion psychoses, ecstatic emotional upheavals are much more common. Since conversely patients with happi­ness psychoses, as we have seen, may become incoherent differential diag­nosis at that time may be impossible. In happiness psychoses incoherence is generally only of short duration, and in confusion psychoses ecstasy is less pronounced, thus observation of the course of the condition generally results in a clear picture.

Even so, differential diagnosis is complicated by rapid affective fluctua­tion (which we found in anxiety-happiness psychosis) commonly occurring in confusion psychoses. It is however less a change between anxiety and ecstasy and more a simple labiality of the mood between tearfulness and joy­fulness. In this form change of affect is particularly significant for confusion psychosis.

Frequently symptoms of confusion psychosis overlap with those of motil­ity psychosis. Akinetic symptoms may accompany stupor and hyperkinetic symptoms may accompany incoherence. Traits of motility psychosis may in fact temporarily dominate the picture. Patients may at first present the char­acteristic picture of excited confusion psychosis, and shortly thereafter the picture of hyperkinetic motility psychosis. Differential diagnosis is then impossible and may even remain in doubt when the whole phase is observed. Occasionally a mixture of opposite poles occurs. In incoherent excitement with pressure of speech, rigidity of posture and facial expression may reveal an accompanying akinesia; in perplexed stupor without change of the per­plexity or lack of initiative, purposeless movements may signal the presence of hyperkinesias. Their considerable uniformity reveals the underlying thought inhibition.

The frequent overlap of the symptomatic pictures of confusion psychosis and motility psychosis might arouse the suspicion that they might be two forms of the same disorder. Nevertheless marked differences arise from the statistics. Observation of the relatives shows that disorders within the family are generally of the same type and that there is no indiscriminate fluctuation between the picture of confusion psychosis and that of motility psychosis. In our investigation of twins, as we shall see later, there was a strikingly opposite trend between these two psychoses. - The following are descriptions of two cases of confusion psychosis with other cases in the family.

Case 41: Margarete Hil, born in 1913, became ill in 1941. She was excited, spoke a lot, broke a window pane, and was admitted to the Frankfurt Hospital. Here she was cheerful, loquacious, and displayed flight of ideas. She misidentified people around her and con­fabulated that she had met the doctor three years earlier in a wine bar. Then her mood became more irritable, alternating between cheerfulness, irritability, and tearfulness. Her thought process became quite incoherent; for example, she said: "1 will also pull your feet - yes, a fallen woman - 1 love freedom - yesterday Kurt stood before the door, he had his heart in the right place - no, we don't need to die ... " She gave the doctor a false name and claimed he had had an affair with her previously. She claimed that other people had several names and that a certain nurse was her biological sister. Frequently she scolded in a confused manner. After four months, the excitement receded and she was discharged. She calmed down at home and remained well.

A sister who is also a subject, Katharina Mark, born in 1909, became ill in 1949, wan­dering aimlessly through the city and bothering passersby with her confused speech; she was admitted to the Frankfurt Hospital, where she resisted everything, struck out around herself, and claimed her husband was standing in the garden; her mood changed con­tinuously between irritability and friendliness. She did not reply to questions appropri­ately, but showed confused pressure of speech: "Deutschland, Deutschland über alles ­the Kaiser has a guilty conscience - where is my husband, where is the Kaiser, where is the pastor - who has already seen the good Lord - blessed are they who do not see but yet believe - 1 want a ring even if it is only made of tin - then I'll take my clothes and go - give me water to wash my hands ... " She moaned and cried but soon thereafter her mood became elevated, partially amused and partially ecstatic. On one occasion she declared "1 am Hitler", and saluted rigidly. She rapidly improved under shock treatment with cardia­zol, and was discharged six weeks after admission.

The two sisters had the typical picture of excited confusion psychosis. One of them appeared to have gone through a brief ecstatic phase, in that she claimed to be Hitler; otherwise there were only mild disturbances of mood, compatible with the picture of confusion psychosis. Another patient consid­ered herself to be Hitler's daughter; her ecstatic phase was of short duration as part of her inhibited confusion psychosis. A description of her case follows.

Case 42: Helene Heus, born in 1914, became ill in 1940, showing extreme anxiety, hear­ing herself being spoken about and cursed. She was admitted to. the Frankfurt Hospital where she was stuporous. She rarely answered questions, in a manner revealing a per­plexed anxious mood.. She remained in this stuporous state, and instead af answering laoked around quite perplexed. Under cardiazol shack treatment she gradually improved. Four months after admission she had recovered and could be discharged. At home she returned to. her occupation. After ten months she relapsed and was readmitted to. the Frankfurt Hospital. She was again stuporous, spoke rarely, and displayed a per­plexed facial expression without anxiety. Rather, she seemed euphoric, her few remarks hinted at a jovial mood.. She described herself as Hitler's daughter and explained that this would be made known throughout all Germany. Under cardiazol shock treatment the symptoms receded. At first she was still shy and embarrassed, but later she felt well and her behavior was unremarkable. She was discharged barely three months after admisión.

In the first phase of the patient's disorder, apart from inhibition there was anxiety, in the second phase ecstasy. As most of the time she was mute it was not possible to ascertain her pathological ideas. After her recovery no report of her mental state was available. - The following patient illustrates a bipolar course.

Case 43: Elisabetll Schrib, born in 1989, first became ill in 1932, and was admitted to. tile Frankfurt Hospital. She was excited, developed pressure of speech, and recited in an affected tone af voice. The mood varied, erotic tendencies appeared, and a hyperkinetic restlessness developed with capering and gesticulating as well as a uniform beating motion and repetition of individual words. She then became nearly mute, appeared anx­ious, and complained about masks that she saw everywhere; even the nurses were only masks. Excitement fallowed, this time mostly verbal, with flight of ideas and incoherence. After five months she calmed dawn and could be discharged. In 1939 she became ill again, going into an "attack of frenzy", necessitating readmission to the Frankfurt Hospital.

She cried, screamed, jumped out of bed looking frightened, and developed incoher­ent pressure of speech. She then became inhibited and perplexed, declaring she wanted to have nothing to do with electrical things. She continued to alternate between incoher­ent-excited and perplexed-inhibited states. After ten weeks she calmed dawn. She was only slightly labile in her mood at that paint and could be discharged. However she returned six days later, very much inhibited, stating that everything at home had been so. strange, so empty. The advertisements on the street had seemed so funny. Her husband had been different, the lenses in his glasses had turned around all of a sudden. "Haw strange, when touched him, he was so. empty - the people walk so strangely; every now and then there are mix-ups.". To her it was a complete mystery how it all had happened. She also. had the feeling that she herself and other persons were being manipulated. After four months this perplexed-inhibited state disappeared; she was friendly and open, dis­played no. abnormality, and was discharged. A brother became ill in 1929. He was afraid of being poisoned, and was admitted to the Frankfurt Hospital. Here he was depressed, moaned that he had made mistakes, that his brain had failed, and that he had suddenly seen spirits before his eyes. His friend was persecuting him and his sisters were not healthy as could be seen by the color of their faces. He said people thought he was a homosexual and they described him as a Jew. Food smelled strange, he was distrustful, holding himself back. Then suddenly he recovered with insight into his condition and ten weeks after admission he was discharged against advice. At home he improved further and was well for many years. In 1939 he again became ill and committed suicide before he could be brought back for observation.

This female patient first showed hyperkinetic symptoms; later there were no symptoms incompatible with excited-inhibited confusion psychosis. The last phase is very well described making it possible to recognize the presence of inhibited confusion psychosis with impressive ideas of significance. The patient spoke with partial insight at the time when inhibition was minimal. Her declaration that at times she felt guided fits in with the syndrome of per­plexed significance. - Her brother showed confusion with inhibition and anxiety.

In the chapter on anxiety-happiness psychosis I mentioned two sisters of whom one had that disorder, while the other had confusional psychosis. In the following case, too, differential diagnosis would have been impossible if both sisters had not had lengthy religious affiliations. One was a nun, the other was a member of a religious congregation. The religious attitude which they brought with them as they became psychotic partially explained their ecstatic religious ideas to the extent that the symptoms of confusion received a greater weight as an expression of their disorder.

Case 44: Matilde Wig, teacher and nun, was born in 1901. She first became ill in 1936, was excited, claimed to be graced by God, and declared that the Holy Father had given her a mission. She stated that she was clairvoyant, could prophesy, had received the stigmata and her body was changed; since she had angina the marrow was flowing out of her bones. She was admitted to Institution R., where she was very cheerful and excited, spoke without interruption with flight of ideas in a confused manner. At times she shouted, danced, and believed that she had received the wounds of Christ. After six weeks her con­dition improved rapidly, she became calm, friendly and composed, and was discharged. She returned to teaching, but after three months she relapsed. She again spoke of divine grace, made mysterious allusions, always seemed to be hearing something, and signifi­cantly placed her finger on her mouth. She then became very excited, and had to be read­mitted seven months after her discharge. At first anxious she was afraid both of the other patients and of dying. She resisted everything, was very excited, screamed confusedly for hours at a time, admitted hearing voices, and spoke of queer bodily sensations. Gradually she became calm, but remained anxious and seemed somewhat confused. She was dis­charged six months after admission, but at home soon became excited again and had to be readmitted. She spoke of divine signs, heard the voice of the prioress, explaining that it all came from the lower part of her abdomen. Pressure of speech, flight of ideas, inco­herence and confused excitement lasted for six months with fluctuations, then the patient calmed down. She remained well for three years. In 1941 she again became ill, was excited, spoke a lot, displayed elevated mood, and was brought to the Frankfurt Hospital. There she ran aimlessly through the ward, did not respond to any questions, and spoke in total confusion. Her mood was generally cheerful, intermittently also anxious. On one occasion in a state of perplexed excitement she screamed "I am full of lice and bugs." Her condition fluctuated for three months, after which she settled down and could be dis­charged.

Her sister Aloisia Wig, born in 1911, is also a subject. She became ill in 1941; she prayed in church with conspicuous pathos, explained that she had offered herself to God as atonement and would die. She was admitted to the Frankfurt Hospital where she was greatly excited from the beginning, got out of bed, hit the nurses, was distracted by all impressions from her surroundings and developed a senseless pressure of speech which included many religious notions; for example: she was in the middle of the cathedral, she must sacrifice herself for the world; she was waiting for him who would come and to whom she would become engaged to be married. Her mood was consistently elevated. Under cardiazol shock treatment the excitement lessened. Pressure of speech continued but gradually became less incoherent and more digressive. She then became mildly inhib­ited, somewhat perplexed, producing a connection between the name of her doctor and the name of her religious congregation. Finally, three months after admission the psy­chosis remitted, and she was discharged.

Religious coloration of the clinical picture may of course be the product of anxiety-happiness psychosis, but if the religious attitude already dominated the healthy personality it cannot seriously be regarded as a symptom of the illness. Thus both sisters were given the same diagnosis of confusion psy­chosis.

In the history of one of the two sisters and in that of some other patients mention is made of flight of ideas. Partially these may overlap with a manic state, but more frequently incoherence of the thought process overshadows flight of ideas.

Summary

Confusion psychosis is accompanied in the excited phase by incoher­ence, and in the inhibited phase by inhibition of the thought process. At lower degrees of excitement only "incoherence of thematic choice" appears. Excitement of thought is connected with pressure of speech, and thought inhibition with verbal impoverishment, even mutism. In the excited phase symptoms include misidentification of persons and often ideas of reference and hallucinations, particularly auditory. In the inhibited phase, perplexexity may be accompanied by ideas of signifi­cance and of reference, less often by hallucinations. Frequently the pic­ture is not pure; traits belonging to motility psychosis, anxiety-happiness psychosis, and manic-depressive illness may be present. The course varies: sometimes only one pole of the disorder is observed, sometimes the poles follow one another. Not infrequently there is rapid alternation between the two poles. Frau VON TROSTORFF (1966) found a frequent prepsychotic characteristic in the form of digressive or, on the contrary, retarded thinking within the range of the temperament. We did not undertake more intensive investigations into any other prepsychotic characteristics. In terms of physique the pyknic form seems to predomi­nate.

Hyperkinetic-Akinetic Motility Psychosis

The hyperkinesia of motility psychosis represents a psychomotor form of excitement and does not depend on disorder of thought or feeling, as do the excitements of confusion and anxiety-happiness psychosis. Therefore the movement disorders seen in this psychosis do not depend on higher mental activity, but are more or less reflexive, i. e. movements of expression and reaction. The former appear in connection with certain mental states, and the latter because of their pathological exaggeration, called short-circuit movements by KLEIST, are immediate reactions to sensory impressions. At times the former predominate, at other times the latter, at still other times both occur equally. Correspondingly the patients gesticulate, i. e. make wink­ing, threatening, beckoning, resisting, forbidding, or encouraging move­ments, etc. Some of their head and shoulder movements express other men­tal contents. They may stomp their feet as if they were quite impatient. Their facial expressions reflect joy, sorrow, eroticism, anger, worry, disappointment and much more. With their reactive movements they show hyperkinesia by grabbing their bodies, their hair, or their clothes, shaking their beds, ripping out mattrasses, climbing on chair or tables, rattling the doors, banging on the walls, clutching other patients, and so on. Expressive and reactive move­ments combine in various gymnastic and dancing displays.

If hyperkinesia is moderate, movements of expression and reaction remain quite natural. With increasing excitement, the movements lose some of their naturalness, and become exaggerated though not greatly distorted. Only in severe hyperkinesia does "grimacing" and a similar disorganized restlessness of the rest of the body occur. Under such circumstances the prognosis in terms of life is often unfavorable since the picture may become one of "fatal catatonia" (STAUDER) or "dangerous hyperkinesia" (NEELE); however the prognosis in general remains favorable. Disorganized expres­sive and reactive movements point toward a worse prognosis when they appear with only moderate restlessness. This will be discussed under peri­odic catatonia.

Speech is little affected in pure hyperkinesia. Verbal expressions require preparatory thought and are not increased by the psychomotor excitement. On the other hand un articulated screaming, often of an expressive nature (for example, howling as an expression of anger) is common. Speech may even be inhibited by movements of expression and reaction, so that the patients appear dumb. WERNICKE described this as "silent hyperkinesia". On the other hand occasionally in motility psychosis short disconnected sen­tences may be emitted. These may be verbal expressions arising during hyperkinesia without preparatory thought as unarticulated sounds. In such cases overlap with confusion psychosis does not have to be considered.

The opposite pole of hyperkinesia, i. e. akinesia, represents a pure psycho­motor form of inhibition, recognizable in both cases by the fact that invol­untary movements are affected. In perplexed stupor only those activities cease which require preparatory thought; reactive movements are main­tained, and expressive movements are only slightly diminished, because impoverishment of thought occurs. In contrast, in akinesia reactive move­ments disappear and expressive movements become rigid. The patients do not respond to the simplest demands which ordinarily are followed automat­ically. They no longer get up, no longer get dressed, and stop going to the toi­let. They do not ward off stimulation of the skin unless it is strong and deep reflexes come into play. Posture is stiff, the torso, the head and the arms are expressionless and the face is rigid. In incomplete akinesia voluntary move­ments are still carried out, but akinesia is recognizable from the stiffness of the posture and facial expression and in the slowed reaction time. Thus even in mild cases the differential diagnosis from stupor of confusion psychosis may generally be made easily. Activities based on the patient's own initiative, which disappear in stupor, are also active in akinesia, since impulses perhaps still arising centrally may no longer lead to realization due to the psychomo­tor disturbance. Occasionally in akinesia persistent postures and holding against objects are present, on the other hand, a general muscular flexibility may be found. Probably this depends on the rest of the condition, particu­larly the affective element, whether reflexive movements occur or not.

The characteristic picture of hyperkinetic-akinetic motility psychosis is often complicated by traits of other polymorphic psychoses. Confusion symptoms are particularly common. Hyperkinesia may be combined with incoherent pressure of speech if the kind of excitement seen in confusion psychosis is present. Misidentification of persons, ideas of reference and hal­lucinations occur as well. On the other hand akinesia may be associated with perplexity, and as later questioning may reveal, perplexed idea construction. In "mixed" cases thought inhibition may lead to hyperkinesia; as with confu­sion psychosis movements become more uniform. Akinesia may be com­bined with excitement of thinking which occasionally breaks through if the akinesia is of moderate degree - incoherent pressure of speech then appears with stiff posture and rigid facial expression.

Not infrequently symptoms of anxiety-happiness psychosis accompany motility psychosis. Hyperkinesia may be accompanied by elevated mood and feelings of happiness or by anxiety and anxious ideas of reference. Anxiety and less frequently ecstasy may accompany akinesia. Both are hard to recog­nize from the rigid facial expression, so sometimes only later questioning provides hints about the affective fluctuations.

Finally there are also pictures reminiscent of mania and melancholia. If cheerful affect accompanies moderate hyperkinesia, differential diagnosis with mania may be difficult. Such conditions develop particularly in the early stages or recession of motility psychoses. In general however the distinction between manic compulsive overactivity and the considerably more primitive hyperkinesia remains clear. On the other hand akinesia may display transi­tion to stuporous depression. - Differential diagnosis from periodic catato­nia will be considered in more detail later.

Several cases will now be described; first a patient with hyperkinesia, then a patient who in the course of decades had more phases of akinesia than hyperkinesia.

Case 45: Maria Streub, born in 1914, became ill in 1938. She was in an elevated mood, sang a lot, and showed pressure of speech easily losing the thread. She was admitted to the Frankfurt Hospital where she displayed severe hyperkinesia. She sang, danced, threw herself on the floor, made pleading and other pathetic gestures; she hit out around her, stamped her feet, made faces, blinked with her eyes, hit the doctor on the head and then threw herself into his arms. With vivid movemenl~ she exhibited herself at first as exces­sively cheerful, then impertinent and erotic, and finally angl-Y. With cardiazol shock treat­ment she improved rapidly; after a short relapse following termination of treatment she became calm and remained calm for the next three months. She maintained a lively, cheery temperament which she had had prior to her illness.

Case 46: Kiithe Dint, born in 1897, first became ill in 1916. At times she spoke a lot and at other times not at all. She was admitted to Institution M. displaying flight of ideas, haugh­tiness and impertinence. She was diagnosed as a psychopath, and was discharged after two months. At home her condition continued to vary. In 1919 she was readmitted to Institution M. where she was again lively and talkative, intermittently mildly in a bad mood. In 1920 a similar condition necessitated her return to the institution. In 1923 she became more severely ill. At home she was related to have been excited, in Institution M. she was at first severely inhibited. She lay rigidly in bed, kept he eyes shut, resisted passive movements, was incontinent of urine, and had to be tube-fed. After a few days she sud­denly became excited, jumped around, climbed up on the window, and spoke no sensible word, but screamed in great distress. Then a state of rigidity with catalepsy followed. This alternating behavior took place several times. Five months after admission she was con­sidered improved and she was discharged. At home she continued to fluctuate in a mild form. In 1925 she was readmitted to Institution M. and once again was rigid, motionless, and did not speak. After a few weeks she became excited, ran about naked, and washed herself for hours at a time. Then she calmed down, explaining that she had misrecog­nized her surroundings and that during her inhibition she had experienced many terri­ble as well as beautiful things; on one occasion she had sworn five oaths, on another had heard voices of angels. Three months after admission she recovered and was discharged. At home she remained unremarkable for a year, but in 1926 she was admitted again. At times she was mute and akinetic, at others more normal. She again recounted her expe­riences during the akinesia; on one occasion she had had the feeling that she was the uni­verse and wanted to turn off the air in order to become a human being again. After six months of fluctuations between inhibition, excitement and reasonable behaviour she was discharged, having made a rapid recovery. She was normal for a year, industrious and helpful. In 1927 she was again excited; she wanted to jump out ofa window to put an end to her life of sin, and had to be returned to Institution M. At times she was stuporous, at other times cheerful. For most of 1928 she was in a "catatonic stupor", although inter­mittently friendly and open. In 1929 she went through a long period of akinesia, after which she slowly recovered. In 1930 she was "mentally well and cheerful". Mild depressive phases occurred, but she was discharged in good condition. She worked well at home and had many interests. After six months she again became depressed and complained of bodily sensations. In the Institution she was akinetic, hid under her blanket, and was mute. She clenched her teeth and kept her eyes closed. She then became excited, began hitting out around herself, and jumped about. Three months after readmission she had improved again and was quite unremarkable. She explained that during this last phase she had thought that the world was coming to an end. She was readmitted during the same year, 1931, lying down stiff, motionless, and had to be tube-fed. This condition lasted a few weeks, then mild fluctuations began. In 1932 she was discharged. At home she at first behaved normally, but was returned to the Institution after a few weeks because she had stopped speaking. Soon after she was talking again and explained that she had thought she was in a different world, either a darker one or a lighter one. She then alter­nated between mild states of inhibition and excitement. In 1933 she was discharged. She remained well for several years; she seemed normal except for periods of moodiness. In 1936 she again spent two months in the Institution in a "catatonic stupor". She then remained well at home for eight months. In 1937 she returned to the Institution with stu­por, rigid posture, and fixed facial expression. The akinesia lasted for several months, again necessitating tube-feeding. The patient then became alert and active and was dis­charged. She was readmitted in 1939, excited and running around; she then became stu­porous. In 1940 she alternated between being stuporous and being overactive, lively, and approachable. Although she still talked a lot in 1941, she was discharged. Five months later she was admitted to the Frankfurt Hospital where she was mute, but strongly resisted having her blood tested. She then became deeply akinetic, lay rigidly, kept her head lifted off the bed, and had to be tube-fed which she permitted without resisting. After a few weeks the akinesia began to recede, but soon returned. Three months after admission she became well. She was vivacious, talkative, had a lively facial expression, joked and wrote natural, emotional warm letters to her family. No personality change could be found.

This patient is of particular interest because in the course of more than two decades she had many periods of severe akinesia which were understandably interpreted as catatonic; but 25 years after her first psychosis she displayed no defect at all. On the contrary, after the disappearance of the akinesia she experienced in the Frankfurt Hospital in 1941 she was remarkably lively, sym­pathetic, and in good contact, i. e. of light hypomanic temperament.

I will now present a patient with overlapping symptoms of motility with confusion psychosis.

Case 47: Paula Tom, born in 1921, first became ill in 1938 and was admitted to the Frank­furt Hospital. She displayed pressure of speech, flight of ideas, and incoherence. Her mood was cheerful, but easily shifted to tearfulness. Although her motor system was active there was no real hyperkinesia. After ten weeks she improved and was discharged. In 1941 she again became ill and was readmitted to the Frankfurt Hospital. This time there was severe hyperkinesia, she hit out, turned her bed over, gesticulated, grimaced, rolled about, and spoke only disconnected single words and sentences. Under shock treatment she became quieter and similar to her condition at her first admission. She developed pressure of speech, flight of ideas, incoherence, and was cheerful in alternation with tear­fulness. A relapse of hyperkinesia occurred, but lasted only a few days. Finally she calmed down and was discharged six months after admission. A sister was in the Frankfurt Hos­pital in 1927 at the age of 17. She displayed hyperkinesia with screaming, kicking and rolling about, and many gestures and facial expressions. After a few days she became qui­eter and was taken home by her family. At home she remained well.

In this case the picture in the first phase resembled that of confusion psy­chosis. In the second phase the pure picture of hyperkinetic motility psy­chosis became evident. The hyperkinesia was severe. Even more severe was the sister's condition. It is not uncommon for it to last only a few days. Motil­ity psychoses are often of short duration, but may recur frequently. WERNICKE described a form of motility psychosis recurring at menstruation.

Two cases follow showing overlap with anxiety-happiness psychosis. In the first case there was anxiety with mistrust, in the second the illness began with an ecstatic phase.

Case 48: Elisabeth Dor, born in 1908, became ill in 1942. She was anxious, believing some­body wanted to poison her, and she was admitted to the Frankfurt Hospital. There she was perplexed, looked about anxiously, and asked, "What am I accused of?" She distrusted her husband believing that he had incited other people against her, that he had been unfaithful, and that he wanted to get rid of her. She became increasingly restless, whined, jumped out of bed, ran around, wrung her hands, gesticulated continuously, held on to other patient~, and climbed up on the window sill. After this excited condition had lasted three months suddenly she became akinetic. She was quite motionless, kept her eyes closed, had to be fed during which she barely opened her mouth; when she was brought to a sit­ting position she let her head fall forward. The phase continued four weeks, then excite­ment returned, which however stayed within moderate limits and gradually abated. She was well six months after admission, happy, lively, industrious, and could be discharged.

Case 49: Maria Trös, born in 1923, became ill in 1941. She had an elevated mood, seemed ecstatic, claiming that she had heard the voice of the Mother of God. She wanted to die for Germany. She was admitted to the Frankfurt Hospital where she laughed and cried, continued to express ideas of happiness, but from the start was predominately hyperki­netic. She whistled, sang, did gymnastics, threw her feet in the air, gesticulated with her hands, hit out around her, and made many mimic movements. This condition disap­peared after three weeks, leaving her calm, cool and collected, and she was discharged five weeks after admission. A sister had a "similar disease" during adolescence. For a while she had been "crazy", confused and excited. She recovered without having to be hospitalized.

In case 48, apart from the accompanying affective symptoms, the course of the disorder is especially impressive in that severe hyperkinesia suddenly turned into extreme akinesia.

In all cycloid psychoses, if the disorder becomes very severe, clouding of consciousness may occur. In the following patient there is a hint of this in that visual hallucinations appear during an acute phase of akinetic motility psychosis. Similar to this are the dreamlike symptoms described in detail in case 46.

Case 50: Friedrich Hoff, born in 1901, became ill in 1940. He was quiet, hardly spoke, did not react to questions, wanted to cry but could not; he was admitted to the Frankfurt Hos­pital. There he moved very slowly, did not speak, and became gradually more severely inhibited until he was completely rigid, resistant, with an expressionless face. The akine­sia lasted for four weeks, then receded rapidly. He explained then that during this period of time he had always had anxiety and had been afraid that something had happened to his family. He had also seen many pictures. On one occasion a whole trial took place in which he was condemned for the reason that he was no longer of any use to the world. He then came back to normal in mood and psychomotor function, and was discharged.

The akinesia in this patient was of very brief duration. Apparently both hyperkinesia and akinesia if severe tend to have a short course. Furthermore patients with "malignant hyperkinesia" recover rapidly if death from exhaus­tion is prevented.

Summary

The excited pole of motility psychosis is characterized by restlessness composed mainly of expressive and reactive movements. Likewise in the inhibited pole, reactive and expressive movements are affected; volun­tary movements only in so far as they contain the psychomotor elements. In milder cases the disorder is recognized in the rigid posture and facial expression despite the continued presence of voluntary movements. In this way mild cases of akinesia can be differentiated from the stupor of confusion psychosis. Incoherent pressure of speech often accompanies hyperkinesia. Incoherence of the kind where disconnected words are blurted out with interruptions is, in fact, typical of motility psychosis. However the presence of pressure of speech points to an element of con­fusion psychosis.

A circular fluctuation of the psychosis between the two poles is quite common; akinesia is rarer than hyperkinesia. On the other hand the duration of akinesia is often longer and may last for months whereas hyperkinesia lasts less long, usually only a few weeks. In terms of physique, without more precise investigations it can only be said that the leptosomic element is considerably more prevalent here than in confu­sion psychosis.

Prepsychotic signs frequently manifest a "temperament of motility" with abundance of expressive movements and at times a dance­like nature (VON TROSTORFF, 1966).

Hasta aquí, querido lector, el texto adaptado de Psicosis atípicas, de K. Leonhard.

¡¡ esto no lo encontrarás en el DSM - 5 ¡¡

Agradecemos al Dr K. Leonhard y a sus pacientes, la descripción clínica detallada de las así llamadas "psicosis atípicas".

Dr Día Sahún. Chusé

jldiasahun@gmail.com

Hospital Univ. Miguel Servet.

Psiquiatra. Prof asociado Univ. Zaragoza.

Tutor formación MIR psiquiatría.