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

214 A. Marneros et al.Table 9.7 Diagnostic criteria for ‘cycloid psychosis’ according to Perris and Brockington(1981)1. An acute psychotic condition, not related to the administration or abuse of any drugor to brain injury, occurring for the first time in subjects in the age range15–50 years2. The condition has a sudden onset with a rapid change from a state of health to a full-blownpsychotic condition within a few hours or at most a very few days3. At least four of the following must be present:* Confusion of some degree, mostly expressed as perplexity or puzzlement* Mood-incongruent delusions of any kind, most often with a persecutory content* Hallucinatory experiences of any kind, often related to themes of death* An overwhelming, frightening experience of anxiety, not bound to particular situationsor circumstances (pananxiety)* Deep feelings of happiness or ecstasy, most often with a religious coloring* Motility disturbances of an akinetic or hyperkinetic type which are mostly expressional* A particular concern with death* Mood swings in the background and not so pronounced to justify a diagnosis ofaffective disorder4. There is no fixed symptomatological combination: on the contrary, the symptomatologymay change frequently during the episode and shows a bipolar characteristicmore the rule than the exception. Perris did not find any convincing evidence that adifferentiation into ‘‘ideal’’ subtypes would have a practical value. This knowledgeled Perris (together with Brockington) to develop operational criteria for cycloidpsychoses, ignoring Leonhard’s differentiation of the three subgroups (Perris andBrockington, 1981,Table9.7).The Perris studies verified the abrupt or acute onset of cycloid disorder ingeneral, but also anecdotally: ‘‘One of the investigated patients, who has beenfollowed for several years and who has suffered several episodes, always becomes illin the middle of the night after having gone to bed in a state of complete health’’(Perris, 1974). Prodromal symptoms were found to be very rare, and when theyoccurred, they most often consisted of irritability and poor sleep. No seasonaldependence of onset was found. The development of psychotic symptoms was alsovery fast. They were mingled together without any discernible pattern and continuouslychanged, not only from day to day, but also in most instances from onehour to the next. The occurrence of schizophrenic first-rank symptoms(Schneider, 1959; Marneros, 1984) was very common. Further studies of Perrisin cooperation with Brockington (Brockington et al., 1982a, b) showed a very poorconcordance between cycloid and schizoaffective psychoses. Only 20 of 108