Bipolar Disorders: Mixed States, Rapid-Cycling, and Atypical Forms

213 Acute and transient psychotic disorderKraepelin‘s ‘‘manic-depressive insanity.’’ Kleist’s conclusions were based on clinical,prognostic, and family findings (Kleist, 1924, 1925, 1926, 1928, 1953).Leonhard (1957) allocated the cycloid psychoses into three pairs:(1) the anxiety–happiness psychosis(2) the excited–inhibited confusion psychosis(3) the hyperkinetic–akinetic motility psychosisThe three pairs of cycloid psychoses conceived by Leonhard were in accordancewith Kleist’s view that they were bipolar disorders (while differing essentially frommanic-depressive illness).The anxiety–happiness psychosis is characterized by continuous changingbetween severe all-pervasive anxiety and ecstatic happiness. It is possible thatonly one pole – anxiety or ecstasy – becomes manifest. Anxiety is often associatedwith delusions and hallucinations. While the experience of anxiety is overwhelming,its intensity fluctuates, and patients can suddenly turn to a state of ecstatichappiness. In the happiness–ecstasy phase, the patients experience a feeling ofrevelation and of closeness to God. They feel like wanting to help others, to savethem, to make them as happy as they themselves are. A peculiarity of the affects inthis condition is their changing character during the episode. Clear-cut depressiveor clear-cut manic mood is not recognizable or long-lasting.The excited–inhibited confusion psychosis is characterized by thought disturbanceswhich become incoherent and perplexed, in the excited phase but do notcontinue in the inhibited pole. Incoherence is mostly manifest in an inconsequentialchoice of themes or by an inconsequential use of different languages. In themost extremely inhibited form, the patient becomes mute. A wondering perplexityis present. Hallucinations and delusions are frequently present. Most often, apolymorphous, rapidly changing pattern characterizes the episodes of illness.The main characteristic of the hyperkinetic–akinetic motility psychosis is adisturbance of motility. In the hyperkinetic type, there is an increase in reactiveand expressive movements and in pseudospontaneous movements. In contrast tothe increased activity of many patients, they do not suffer pressure of speech. Thepatients remain mute in the hyperkinetic phase. In the akinetic phase, only a fewisolated movements are carried out. In extreme cases, the patient may lie completelymotionless in a stupor and in cataplexia. The difference to catatonia lies inthe fact that the way in which movements are carried out is not qualitativelydisordered in motility psychoses (Leonhard, 1961).The 1974 study by Perris comprised a clinical and family investigation of 60patients and their first- and second-degree relatives. The author recognized at thebeginning of the study that a clear-cut distinction among the three differentsubtypes of cycloid psychoses proposed by Leonhard (1957) was not alwayspossible. An admixture of symptomatology of all three pairs appeared to be