Hausmann Armand, Dehning Julia, Heil Michel, Mauracher Laurin, Kemmler Georg, Grunze Heinz
Department Psychiatry, Psychotherapy and Psychosomatics, Medical University of Innsbruck, Innsbruck, Austria.
Psychiatrie Schwäbisch Hall & Paracelsus Medical University Nuremberg, Nuremberg, Germany.
Front Psychiatry. 2020 Nov 12;11:561746. doi: 10.3389/fpsyt.2020.561746. eCollection 2020.
Categorial systems of nosology are based on a cross-sectional enumeration of symptoms with a predefined cut-off, but hardly capture rapid fluctuations of manifestation nor longitudinal characteristics, e.g., cyclicity. Especially with disorders presenting with an admixture or frequent change of psychotic and affective symptoms, diagnostic specifity of the DSM and ICD diminishes. In those instances, alternative concepts as cycloid psychosis might display more accurately the very characteristics and course of a mental disorder and help to tailor individualized treatments. Karl Leonhard described three major subtypes of cycloid psychosis: anxiety-happiness psychosis, confusion psychosis, and motility psychosis, all showing a pleiomorphic symptom profile resembling intraphasic switching of poles. Here we present the case of a 59-year-old woman suffering from cycloid psychosis as defined by the criteria of Perris. Between 2013 and June 2019, the patient was admitted 35 times for compulsory treatment. A frequent change of diagnoses, ranging from adjustment disorder to complex PTSD, and from unipolar depression to "pseudoneurotic schizophrenia," resembles the puzzling manifestations. Most of the time the patient was labeled as schizoaffective disorder despite never displaying clear psychotic core symptoms. Despite treatment with different antipsychotics including LAI the cumulative length of hospitalization increased steadily from 74 days in 2014 to 292 days in 2017. When reviewing the case in 2017 the longitudinal pattern of her disorder and the diverse acute manifestations were finally conceptualized as a cyclic on-off of an atypical psychosis. After starting lithium to pre-existing LAI antipsychotics and valproic acid, the number of days per year spent in inpatient care sharply dropped to 136 in 2018. We propose to reconsider cycloid psychosis as a useful clinical concept whose descriptive value, validity and utility for treatment decisions should be further evaluated. Lithium alone or in addition to valproic acid may act on cyclicity as a core symptom of cycloid psychosis as well as of bipolar disorder, even in the absence of major affective symptoms.
疾病分类系统基于对具有预定义临界值的症状进行横断面列举，但几乎无法捕捉症状的快速波动或纵向特征，例如周期性。特别是对于伴有精神病性和情感症状混合或频繁变化的疾病，《精神疾病诊断与统计手册》（DSM）和《国际疾病分类》（ICD）的诊断特异性会降低。在这些情况下，诸如环性精神病等替代概念可能更准确地显示精神障碍的特征和病程，并有助于制定个性化治疗方案。卡尔·莱昂哈德描述了环性精神病的三种主要亚型：焦虑-欣快性精神病、混乱性精神病和运动性精神病，所有这些都表现出多形性症状谱，类似于两极的阶段内转换。在此，我们报告一例符合佩里斯标准定义的59岁环性精神病女性病例。2013年至2019年6月期间，该患者因强制治疗入院35次。诊断频繁变化，从适应障碍到复杂性创伤后应激障碍，从单相抑郁到“假神经症性精神分裂症”，表现令人困惑。大多数时候，尽管该患者从未表现出明确的精神病性核心症状，但仍被诊断为精神分裂情感障碍。尽管使用了包括长效注射剂在内的不同抗精神病药物进行治疗，但住院累计时长从2014年的74天稳步增加到2017年的292天。2017年复查该病例时，其疾病的纵向模式和多样的急性表现最终被概念化为非典型精神病的周期性发作与缓解。在已有的长效注射剂抗精神病药物和丙戊酸基础上加用锂盐后，2018年每年住院天数急剧降至136天。我们建议重新审视环性精神病这一有用的临床概念，其描述价值、有效性以及对治疗决策的实用性应进一步评估。单独使用锂盐或联合丙戊酸可能作用于环性精神病以及双相情感障碍的核心症状——周期性，即使不存在主要的情感症状。
