CYCLOID PSYCHOSIS: C XC ; Tf*

PHENOMENOLOGY, COURSE AND (

-A NATURALISTIC STUDY '%
■A

UNDER THE GUIDANCE OF

!^f. JV. eS^axtna
PROFESSOR OF PSYCHIATRY

CENTRAL INSTITUTE OF PSYCHIATRY

RANCHI

By
®r. Sunil Verma

THESIS
SUBMITTED IN PARTIAL FULFILMENT OF THE

M. D. DEGREE

In

PSYCHOLOGICAL MEDICINE

RANCHI UNIVERSITY,
RANCHI (INDIA)

1991
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 DECLARATION
\,

1 hereby delare that the prement study entitled

"Cycloid Pmychomim : Phenomenology* Courme and Outcome -

A Naturalietic Studyn ham been carried out by me at the

Central Inmtitute of Pmychiatry» Ranchi.

1 almo declare that no part of thim study ham

been previoumly publ imhed or mutmi t ted for any degree or

diploma of any Unixtermity.

DR. SUNIL VERNA

Ranchi

imt Nay lOOi.

 ffiETTFICATE

CENTRAL 1MST8TTCE OF PSTCtflATRT

RAMCIHB . i ■

Dr. Sunil V*raa is a siudani of Gentral Institute

of Psychiatry, Ranchi, under training for N.D. degree in

Psychological Medicine course of Ranchi University for

the academic years 1000-01.

This is to certify that the study of "Cycloid Psychosis :

Phenomenology, Course and Outcome - A Naturalistic Study", which

has been submitted by the candidate as a thesis in partial

fulfilments of the requirements for M. D. degree in Psychological

Medicine of Ranchi University has been dorm under my personal

supervision. It has not formed the basis for award of any degree

or diploma to the candidate. This is a record of candidates

personal effort.

Dr. L.N. Sharae

Professor of Psychiatry

Ranchi

Date :
 ACKNOWLEDGEMENTS

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lAay Aaua gluon.

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having &tamL 4y m« - aluiwyo.

 CONTENTS

INTRODUCTION................................. 1

REVIEW OF LITERATURE............. ft

AIMS AND OBJECTIVES .................. 47

SUBJECTS AND METHODS ........................ 48

RESULTS ...................................... ftft

DISCUSSION....... 78

CONCLUSIONS......... 80

BIBLIOGRAPHY................................. OS

APPENDICES ................................... 101

INTRODUCTION
V7W

Kraepelin founded modern psychiatry when he divided the

functional psychosis into two main groups on the basis of
difference in outcome. Since then research on the nosology of
fuctional psychosis has mainly concerned schizophrenia and
affective disorders espcially on the methods of refining the
boundries between the two.
Among many psychiatrists the sharp division of the non-
organic psychosis into schizophrenia and manic depressive disease
*

has been carried to the eytremes in the mistaken belief that that
any non-organic psychosis mujst belong to one group or the other.
On one hand there are thosb psychiatrists who tacitly believe
that schizophrenia always ends in a defect state and diagnose all
recoverable psychosis as affective disorders despite the presence
of gross schizophrenic symptoms. On the other hand there are
those, who because they have a very wide concept of
schizophrenia, call any psychosis in which there are unusual
symptoms as schizophrenic. The situation has not improved with
the introduction of schizoaffective disorders which some
psychiatrists regard it with horror while others use it as a
"each way" bet (Fish, 1«64).
Psychiatrists unhappy with the limitations of this approach have
drawn attention to conditions which differ from the two major
psychosis or contain sufficient elements to make the distinction
easy. Thus terms like Boufee del itrantes (Magnan - 18°3),
Reactive psychosis (Jaspers - IP13), Homosexual panic (Kempf -

tpr'i'W
 1?2<M, Metabolic psychosis (Schroder - l?2b) and Cycloid
psychosis have been used for these conditions.
Although the concept of "cycloid psychosis" (or cycloid
psychotic disorder) has a very long history and is currently
applied in several Europeon countries# it is still poorly
understood. It has been inconsistently used in the Anglo-saxon
psychiatric literature where the related concepts
"schizoaffective", "atypical", "mixed", or "schizophreniform"
psychosis have been given more popularity, and are mistakenly
used interchangeably.
Until <^uite recently the term "cycloid psychosis" has not
been included in any of the successive revisions of the World
health organisation's (WHO) Internationa^ Classification of
Diseases (ICD 5 through ICD ?), nor has it appeared in any of the
classification manuals of American Psychiatric Association (DSM).
wr-iir’ However it is now comprised under the heading "Acute or
transient psychotic disorders" (F23) in the lGth revision of the
ICD, that is now undergoing field trials, and it will probably be
taken into account in DSM-IV, now in preparation (Perris, 1?88).
The most acceptable definition of cycloid psychosis is the
one given by Perris and Brockington (1P81). According to this
condition the term refers to: "An acute, most often self
remitting, and as a rule recurrent psychotic condition not
«

related to the admnistration or abuse of any drug, or brain

injury. The clinical picture is almost consistently characterised
by the presence of some dergree of perplexity, and, most of all
by a polymorphous and shifting symptomatology (that is , all

•y
 sorts of symptoms are jumbled together suggesting the

simultaneous presence of several different psychotic disorders).

There is never a fully developed manic, depressive, or paranoid

syndrome. Schneiderian first rank symptoms do frequently occur

and also any other type of delusional and hallucinatory

experiences. Non-precipitated, overwhelming anxiety is the most

prominent affect. When elation ioccurs, it is mostly in the form

of ecstatic happiness. Precipitating events may be detected in a

r«Mfr *

minority of cases".

Though it is obviously difficult to make any definitive

statement, patients presenting with the above mentioned clinical

picture, would be classified according to the OSH IIIR (American

Psychiatric Association, 1P8?) asschizophreniform disorder

(2P5.40), brief reactive psychosis (238.80) or atypical psychosis

(238.30), that is mainly under one of the residual categories. An

inclusion Under any of the diagnosis of affective disorder would

not be justified because of the absence of a dominating, enduring

mood change of a manic or depressive type, whereas a diagnosis of

a schizophrenic disorder would not only be excluded because of

t

the clause of duration, but also because of the shifting

sympt omat o1ogy.

Our present day understanding of Cycloid Psychosis is mainly

the result of the tremendous amount of work done by Leonhard,

Perris, Brockington and Maj, who have sought to establish

cycloid psychosis as an independent entity. The data reported by

them in literature supports the clinical construct of of cycloid

psychotic disorder which is consistent, easy to identify and

3
 clearly distinct from other clinical constructs for which
diagnostic criteria have been made available. In particular the
assumption that cycloid, psychosis is synonymous with
schizoaffective disorder does not get any support at all. The
independent status of cycloid psychosis is supported not only by
its distinct clinical picture but also from its better short and
long term outcome as compared to other pyehotic conditions. This
makes it all the more important to correctly identify patients
with this disorder so as to adopt better management strategies.
In India, Acute Psychotic conditions which have defied
traditional approaches to classification have been long
recognised. The studies which have been done on these acute
psychotic conditions have used vaguely defined criteria as a
result of which the subjects studied by them have comprised of a
heterogenous group. Though most researchers have admitted that
the conditions identified by them are akin to cycloid psychosis,
the matter has not been systematically assessed. This was the
impetus for the present study which sought to clarify whether the
entity of Cycloid Psychosis as currently defined does exist in

our setting and if so how does its phenomenology, course and

^.outcome differ from the traditional psychotic disorders, namely
Schizophrenia and Affective Disorders.

4
REVIEW OF LITERATURE
 mm & km&iuBE
Kraepelin's principle of the two disease entity in 18<?fe of

dementia praecox and manic depressive insanity has recieved world

wide acceptance and continues to provide the conceptual framework

.^w.fcr psychiatric nosology in the °0's. This traditional dichotomic

division of endogenous psychosis still dominates the psychiatric

classification, but is definitely not considered to be all

inclusive. This is not due to Kraepelin's own work but the

result of the way in which his successors have used his concept.

Kraepelin himself was not satisfied with the rough division of

endogenous psychosis into the two forms. He never ceased trying

to isolate more disease enities and therefore though he defined

two major groups of endogenous psychosis, this did not mean that

he limited the number of diagnostic categories. Kraepelin's

successors however, behaved «|uite differently. They merely

fastened onto the division of endogenous psychosis into two

groups and made this diagnostic system a rigid one. As result of

this we have seen alternately the widening and narrowing down of

the concepts of schizophrenia and affective disorders, with cases

not ideally fitting into these categories being forced into them

depending on ones own conceptualisation of these conditions.

Bleuler's introduction of a new name, schizophrenia, was in

part responsible for the broadening of the concept. While

Kraepelin's name for the disorder stressed the importance of

course and outcome, Bleuler's term stressed the importance of

characteristic symptoms of the disorder. This produced a gradual

*

shift in the perspective and conceptalisation, with patients

5
being diagnosed as schizophrenia if the fundamental symptoms, the
i
four A's ( which were poorly defined ), were present even in the
presence of a full blown affective episode.
The fact that there were cases which were not typically
schizophrenic or manic depressive was recognised right from the
time Kraepelin presented his views at the historic Heidelberg
conferance, and a series of psychosis which were "atypical" were
described at the begining of the century, most of them from
Germany, where great emphasis was given to the fine details of
clinical observation ( Table 1 ). Though most of these atypical
psychotic conditions had their roots in the descriptions given in
the mid nineteenth century, it must be remembered that the term
atypical did not have any meaning before Kraepelin as there was
no consensus among the psychiatrists as to what should be
considered as typical.
The American and the E'uropeon approaches to the condition
described as being atypical has differed considerably. The
Americans with their faith firmly rooted in the Kraeplenian
dichotomy between dementia praecox and manic depressive insanity
continued to treat these atypical cases in an "either / or"
manner. The work of the Europeon researchers has been just the
opposite : that is, to attempt a better characterisation of mixed
psychotic syndromes by treating them at least provisionally as
distinct entities and building diagnostic criteria on the basis
of clinical evidence, rather than attempting an artful balance
between schizophrenia and affective disorders (Maj, 1984).
Therefore in qrder to understand the present day
 TABLE 1

Some of the eponyms proposed to label quite similar psychotic

syndromes (Perris, 1974).

Degenerationpsychosen Morel, Magnan

Bell's mania Bell
Expansive Autopsychose durch
autochtone Ideen Wernicke
Moti1it at psychosen Wernicke
Homosexual panic Kempf
Mischenpsychosen Gaupp
Metabolic Psychose Schroeder
Benign stupor Hoch
Randpsychosen, Degeneration­
psychosen, Phasophrenics Kleist
Schizoaffective psychosis Kasenin
(Atypische psychosen)
(Randpsychosen)
lykloiden psychosen Leonhard
Schizophreniform psychosis Langfeldt
Acute exhaustive psychosis Adiand
Oneirophrenia Meduna, Meyer-Gross
Legierungspsychosen Kretschmer, Hoffman,Arnold
Schizomanie Claude
Boufees delirantes Magnan, Ey
Emotionpsychosen, Oneiroiden
Emotionpsychosen I Labhard.Storring, Boaters .
Atpical Psychosis Mitsuda, Asano,Kaij
Pauleikhoff
Pyschogenic Psychosis Faergeman, Stromgren
Benign Schizophreniform psychosis Weiner l Stromgren
Atypische phasenhafte
fami 1ienpsychosen Elsasser
Periodische (rekurrent)
schizophrenia Shneshnewsky

conceptualisation of Cycloid Psychosis it is also neccessary to

understand the development of some related overlapping concepts

which are in current use, namely Schizoaffective psychosis.

Schizophreniform psychosis. Reactive psychosis and Boufee

deli rante, and are unfortunately often used synonymously.

7
EVOLUTION OF THE CONCEPT OF CYCLOID PSYCH0813:

The roots of the condition which we now call cycloid

psychosis can be traced back to the work of Morel. Psychosis in

which the symptoms are schizophrenic and the course of the

illness is manic-depressive were called "degeneration psychosis"

(the name did not have any pejorative connotation then) by the

older Continental psychiatrists (Fish, 1964). This designation

originated following the work of Morel, who believed that some

mental illnesses were a result of a degenerative process within a

given family. The mental illness became more severe with each

successive generation until the family died out. Thus the grand­

parents may be neurotic, the parents psychotic, and the

granchildren mentally retarded. Later Magnan described mental

illnesses of the same kind occuring in successive generations of

degenerate families. He used the word degenerate in much the same

way as Schneider used the word "psychopath" (Schneider, 1958).

Magnans description of the psychotic episodes was as follows:

"The hereditary degenerates and becomes insane in a

characteristic way and their insanity has certain typical
features. The main is the sudden appearance of psychosis; in
a few hours or few days or at the most in a few weeks, one
sees the development of a very severe mental illness which
can assume any form (maniacal, mystical erotic, grandiose,
etc.). The mental illness develops rapidly. It may be
simple, that it consists of only one form, but frequently
one sees several forms succeeding one another, so that a
patient who was grandiose yesterday is persecuted today and
within a few days will become hypochondriacal. This is the
chrachteristic way in which the hereditary degenerate become
insane" (Fish, 1964),

Magnan realised that these illnesses were phasic and

 I

separated them from those disorders which we call today affective

m-*r '"-fMI *
or
•
schizophrenic.
*
His concept of these illnesses occuring as
psychotic episodes in abnormal personalities has a lot in common
with the present day Scandanavian concepts of "reactive” and
"psychogenic" psychosis. Magnan described for the first time in
some detail the psychopathoiogical condition, boufee delirantee
de les degenerees characterised by a sudden onset, a polymorphous
psychotic, symptomatology and a recurrent course in successive
generations of degenerate families.
Magnan's description of boufees delirente appealed to
Wernicke and his pupils, who were not prepared to accept the very
comprehensive definition of manic depressive insanity. Wernicke,
unlike Kraepelin, described several endogenous states along with
boufees delirante, although he did not succeed in having them
generally recognised, and Kleist, who was his pupil for a short
while prior to his death continued along the same lines. Wernicke
has been credited with introducing the term "motility psychosis",
including a hyperkinetic, an akinetic and a cyclic form, which he
said was frequently associated with menstruation and childbirth.
i
This syndrome was originally regarded as !a "Symptomkomplex" which
occured during the course of different diseases, but Kleist later
maintained its nosological autonomy.

At a time when the psychiatric world was completely taken up

with Kraepelin's classification, Kleist was following an
independent p»ath in psychiatry. Many psychiatrists will be
disconcerted with the fact that both Wernicke and Kleist sought
in cerebral pathology an explanation for the symptoms they

9 r
 encountered in the endogenous psychosis. Kleist compared these
syndromes with organic disturbances, finding many similarities
and believing them to be of organic aetiology, with cruder but
essentially related symptoms. He therefore looked for similar
localisations in the brain. But if we think only of this emphasis
of cerebral pathalogy as an explanation for mental illness, then
we see Kleist and Wernicke, both outstanding clinical observers,
in false light. Kleist*s main concern was always with his
i
clinical findings, and it was this concern which made him unable
to accept the view that the endogenous psychosis could be fully
understood by dividing them into schizophrenia and manic
depressive insanity, for he found many atypical forms. He took
1
Kraepelins formulations as an overall framework, but within
schizophrenia he described many subdivisions, which he and his
"fair' • pupils sought to uphold by means of comprehensive catamnestic
investigations. Kleist found atypical illnesses not only within
Kraepelin's categories but even outside them.

The term "Zykloide Psyshose" first appeared in a paper by

Kleist (Kleist, 1928). In this contribution, a classification of
“Oegenerationpsychosen" was provided, in which these conditions
were divided into typicaland atypical forms, the former
including manic-depressive insanity, paranoia and epilepsy, and
the latter cycloid, paranoid and epileptoid psychosis. Within the
cycloid psychosis the sub groups of confusion psychosis
(Verwirrtheitspsychose), motility psychosis (Motllitatspsychose),
and ego psychosis (Ichpsychose), the last one inclusive of
!

"Expansive Konfabulose" and "Hypochondria", were classified.

10
These concepts were further developed by Funfgeld (Maj, 1984) who
asserted the independence of these syndromes from dementia
praecox and manic depressive psychosis.
Finally, confusion and motility psychosis together with
•anxiety elation" psychosis (resulting from the from the fusion
of Kleist's "akute Eingebungspsychose" - acute revelation
psychosis - and “akute pereskutorische Halluzinose" - acute
persecutory hallucinosis, previously included in the group of
"paranoid psychosis"), became the three subgroups of Leonhard's
cycloid psychosis (Leonhard, 19fel).

LEONHARD'S CLASSIFICATION OF CYCLOID PSYCHOSIS:

Most of our present day concepts of Cycloid Psychosis are a

result of the work done by Leonhard. Leonhard who had earlier
used the term "atypical endogenous" to denominate the same type
of clinical condition shifted later to using the term Cycloid
Psychosis (Leonhard ,1980). Leonhard regards cycloid psychosis as
"endogenous psychosis which are neither schizophrenic nor manic
depressive". He maintains that contrary to manic depressive
illness, in which there is disturbance of all three spheres of
psychic activity (thinking, affectivity, and psychomotor
activity), in these conditions only one sphere is severey
affected - thinking in confusion psychosis, affectivity in
elation anxiety psychosis and psychomotor activity in motility
psychosis. Cycloid psychosis is believed to be bipolar
illnesses, with the opposite types of symptoms occuring either in
different episodes or in the same episode.! The three different

11
sub-types of cycloid psychosis which 'were described by Leonhard

are:

<A> Motility Psychosis

<B> Confusion Psychosis

<C> Anxiety-Elation Psychosis

Though Leonhard had earlier on maintained that there is a

rather clear cut distinction between the three subtypes, studies

done later often showed that it was not always feasible to

ditinguish between the three subtypes, a point which was later

accepted by Leonhard himself (Perris, 1988), The descriptions of

T
the various subtypes of cycloid psychosis has been well

discussed by Leonhard (1961 6 1980), Fish ( 1964), Maj ( 1984) and

Perris (1988).

MOTILITY PSYCHOSIS:

This illness has a hyperkinetic and a akinetic pole. Whereas

manic depressive illness affects thinking, affectivity, and

psychomotor activity in the same way, motility psychosis is a

pure psychomotor illness. Hyperkinesia or akinesia occurs

depending upon the direction of the change in psychomotor

activity but in either case the change is essentially

quantitative, i.e., there is an excess or deficiency of activity,

the way in which the movements are carried out is not

qualitatively disordered. The increase or decrease of motor

activity concerns reactive and expressive movements, that is

those which are based in psychomotor activity itself and which do

not need concious consideration or intention. Accordingly when

these patients are hyperkinetic, they relate to all events in the

12
envoirment. They look at everything, listen to everything and

handle everything. They also produce a large number of expressive

movement, facial expressions and guestures and even utter

expressive words spontaneously. Both forms of movements cease in

akinesia and even the neccessary reactions to external events and

bodily needs may be absent. Facial expressions and guestures

become stiff and in complete akinesia the patient is almost

motionless. However the unnatural postures which are found in

catatonia never occur.

CONFUSION PSYCHOSIS:
In confusion psychosis the disorder affects thinking, and

in typical cases psychomotor activity and affectivity are not

affected. Thinking is accelerated in the excited pole, as a

result of which incoherence may occur. The patients talk about

matters which have nothing to do with the task at hand. They

treat their theme in an orderly way, but the next arguement that

they take up has no connection with the previous one, or the

question they have been asked. The alteration is therefore,

different from that of a manic patients, who always take up the

question which has been asked of them though there may be a

flight later on. Pressure of speech is not a ditinguishing point

as it may be found in both, mania and confusion psychosis

Misidentification of persons is also very often seen in confusion

psychosis

In the inhibited pole a sub-stuporose behaviour can be

observed. Inhibition of thought leads to poverty or even complete

absence of speech. Mutism is in fact the characteristic picture

13
of inhibited confusion psychosis. However simple movements which

require no previous thought are preserved, i.e., reactive

movements in response to envoirmental stimuli or from bodily

functions. Facial expression usually shows perplexity. If the

patient is able to speak he describes the perplexity by saying

that he does not know what is going around him and everything

seems queer. Sometimes the perplexity gives rise to ideas of self

reference. According to Leonhard the ideas of self refernce in

association with a general stuporose pattern of behaviour are in

no way indicative of schizophrenia but on the contrary they are

chracteristic of of the rcoverable confusion psychosis. They even

make the differentiation of this illness from stupor in manic

depressive illness and motility psychosis more certain.

ANXIETY-ELATION PSYCHOSIS:

In the anxiety elation psychosis the affectivity is mainly

involved. This affective change is not a change in the sense of

cheerfulnes or sadness as in a manic depressive illness, but it

takes the form of affects which disturb the patient profoundly.

One pole is anxiety and the other pole is ecstacy.

In the anxious pole, anxiety is usually associated with

ideas of being watched or threatened, auditory threatening

hallucinations and unpleasant bodily sensations. Anxiety may

express itself in differnt ways: there may be severe excitement,

with complaints and cries for help, or the patient may be

completely immobilised by inner tension. This differs from

depressive psychosis because the affect in the anxiety phase is

one of fear and from "harried" (agitated ) depression by the

presence of morbid fears of beinf followed or threatened
(Brookington, 1982).

In the elated pole, the clinical picture is dominated by the

ecstatic mood. The pathological affect gives rise to ideas which
the patient cannot explain and which are therefore, often
attributed to "brain waves" or inspirations. As a rule these
ideas are not concerned with personal happiness, but with
happiness of others. They may lecture about their ideas in a
solemn way, or announce the day of judgement, the prod aimat ion
of world peace and so on. Visions in which God or saints appear
are common and the voice of Higher beings may also be heard in
these ecstatic states. Usually the affect does not continue so
intensely for more than a brief period of time. When these
patients are not seen in these extreme states of ecstacy but are
later asked about them they will at first talk about them without
any severe emotional disturbances, but the longer the patient
talks about his tremendous experiences the more he becomes
emotionally moved by them. The condition is different from a
manic patient who is irritable, labile and distressed,
hyperactive and distractable whereas the cycloid is calm and has
a sense of i11imunation.

DIAGNOSTIC CRITERIA

None of the older German authors ever presented any formal

set of diagnostic criteria. Such an approach would have seemed
unthinkable to extremely skilled clinicians who spent a greater

15
part of their life in direct contact with their patients. Thus
the initial studies on cycloid psychosis were done on the basis
of the extensive clinical descriptions provided by Leonhard.
Though Leonhard had earlier maintained that there is a
distinction between the three sub-types, studies done later
showed that it was not always feasible to distinguish between the
three subtypes, a point which was later conceded by Leonhard
himself (Perris, 1988). Accordingly Perris in his landmark study
on cycloid psychosis used the following criteria (Perris, 1974):

a> Symptomatology: Syndromes characterised by affective symptoms

(mood swings) and two or more of the following: confusion with
agitation or retardation ; paranoia like symptoms (delusions of
reference, or influence, or persecution) and/or hallucinations
not syntonic with the level of the mood: motility disturbances:
states of ecstacy; pan anxiety.
b> Severity: Psychotic or occasionally psychotic, with levels
changing during the course of the illness.
c> Course: Single episode or recurrent episodes with periods of
remission in between. Not sensitive to changes in the enviorment
(e.g. hospitalisation).
However since the St. Louis group (Feighner et. al., 1972)
proposed the operationalisation of clinical diagnosis by means of
defined criteria, their use has generally been acknowledged as a
major advance in increasing diagnostic consistency and
facilitating communication. The preliminary set of diagnostic
criteria which was used by Perris in 1974 was not considered to
be satisfactory by him as its formulations could easily be

16
misunderstood. Accordingly a new set of criteria was proposed by
Perris and Brockington (Perris If Brockington, 1781). and it
closely corresponds to the criteria that will be given in ICD-10
(World Health Organisation, 1989). The operationalised criteria
for cycloid psychosis is as follows:
1) An acute psychotic condition, not related to administration or
abuse of any drug or to brain injury, which occurs for the first
time in the age range of 15-50 years.
2) The condition has a sudden onset with a rapid change from a
state of health to a fullblown psychotic condition within a few
hours to at the most a few days.
3) At least four of the following must be present:
<A> Confusion of some degree, mostly expressed as perplexity
or puzzlement.
<B> Mood-incongruent delusions of any kind : most often with a
persecutory content.
<C> Hallucinatory experiences of any kind, often related to
themes of death.
<D> An overwhelming, frightening experience of anxiety, not
bound to particular situation or circumstances
(pananxiety).
<E> Deep feelings of happiness or ecstacy, most often with a
religious colouring.
<F> Motility disturbances of a akinetic or hyperkinetic type
which are mostly expressional.
<G> A particular concern with death.
<H> Mood swings in the background, and not so pronounced to
justify a diagnosis of affective disorder.

17
4. There is no fixed symptomatological combination ; on the

contrary, the symptomatology may change frequently during the

episode and shows 4 bipolar chracteristic.

The definition of Cycloid Psychosis in its present

formulation appears very clearly defined, but it is neccessary to

understand the development of some related concepts to show that

there is no overlap between them and Cycloid Psychosis.

EVOLUTION OF CONDITIONS RELATED TO CYCLOID PSYCHOSIS

SCHIZOAFFECTIVE PSYCHOSIS:
Y

The question of the nosological status of schizoaffective

disorders remains one of the most controversial issues in

clinical psychiatry. The history of the evolution of

schizoaffective psychosis represents the vicissitudes of the

concept in U.S.A., the country where the concept was born and

reached its largest diffusion. The evolution of the concept can

be described in three phases (Maj, 1985).

The first phase which can be called pre-Bleulerian, is that

preceding the publicaton of his textbook in U.S.A. in 1923. In

this period the mixed psychotic syndromes occuring in literature

such as Kirby's "remitting catatonic syndrome" and Hoch's "benign

stupor” were unanimously regarded as subtypes of manic depressive

illness. It is easy to realise that such a interpretation was

influenced by Kraepelin's very comprehensive definition of manic

depressive insanity and a much narrower delineation of dementia

praecox.

18
 The second phase which can be cal Id as Bleulerian started
Y

with the publication of Bleuler's textbook and extended for the

next forty years. It was during this period that Kasanin

1 introduced the term Acute Schizoaffective Psychosis when he

described nine young adults who had become "acutely psychotic
with emotinal turmoil. had a blending of affective and
schozophrenic symptoms, distortion of the outside world and the
presence of false sensory impressions". Patients with this type
of psychosis recovered fully within a few weeks or months though
there was a marked tendency to reccur (Kasanin. 1933).
Thus under Bleulerian influence these cases were subsumed
under the broad heading of schizophrenia, a stand which was
summed by Valliant (19b3),"there seems no justification of
separating remitting schizophrenics from the broader
classification of the group of schizophrenias” and "there is
little doubt that every schizophrenic who recovers will also be
diagnosed as schizoaffective". This stance was formalised in DSM-
I and OSM II.
The third phase of the evolution started between the late
'60s and early '70s. In those years several factors, including
the increasing evidence of over diagnosis of schizophrenia in the
U.S.A. as compared to U.K. (Cooper et. al., 1972) and the
demonstration of the efficacy of lithium in manic depressive
illness which stressed the necessity of careful differentiation
of patients suffering from affective disorders, concurred to
support the further revision of the boundary between
schizophrenia and major affective disorders. Thus during the

19
1970*s there was a narrowing of the concept of schizophrenia and
broadening of the concept of affective disorders. Consistent with
this change has been the shifting of schizoaffective disorders
from the schizophrenic domain to the affective domain. With
operationalised criteria coming into use,there were a host of
criteria for schizoaffective disorders, ranging from very broad
based ones like Kendall's (1983) to much narrower ones like
Weiner's (1974) and Spitzer's (1972), all of them having a poor
concurrent concordance (Brockington, 1979).The change was
formalised in the DSM-III (American Psybhiatric Association,
1980) also, but it encouraged the use of this category in
relatively rare circumstances when the differentiation between
mood disorders and.schizophrenia and schizophreniform disorders
was not possible. It gave no criteria for the category. The DSM-
IIIR (American Psychiatric Association, 1987) is in a way an
improvement on the DSM-III as it specifies the criteria needed to
make a diagnosis and so schizoaffective no longer remains a
diagnosis of exclusion. The DSM-IIIR criteria which are simillar
to the RDC criteria require a concurrent occurence of an
affective syndrome with schizophrenic symptoms and a period of
two weeks when there have been delusions and hallucinations in
the absence of affective symptoms. Thus the DSM-IIIR and RDC
definitions lean more towards mood disorders (Procci, 1989). The
ICD-9 (World Health Organisation, 1978) classification lists
schizoaffective as a subtype of schizophrenia, giving vey vague
guidelines in the glossary. In the ICD-10, 1987 (WHO, 1987)draft,
schizoaffective disorders were listed under mood disorders as a
seperate category taking into account the view that had recieved

20
tho most empirical support (Sprock, 1988). However ICD-10, 1988

(WHO, 1988) draft has relocated them into the section of

Schizophrenia (F2), thus reflecting their still controversial

status (Zaudig et. al.. 1990).

Thus there might have been an overlap between Acute

Schizoaffective Psychosis as defined by Kasanin and Cycloid

Psychosis, but the present day concept of "concurrent

schizoaffective disorder" just focuses on the simultaneous

occurence of clear cut manic or depressive symptoms together with
typical schizophrenic symptoms. As most of the criteria for

schizoaffective disorders require the presence of a full blown

affective syndrome there is liitle difficulty in distinguishing

them from cycloid psychosis according to Perris and Brockingtons

criteria in which mood swings should not be prominent enough to

justify a diagnosis of affective disorder. This poor concordance

between schizoaffectives and cycloids was well shown in a study

in which only 20 patients of the 108 patients who met the study

criteria for schizoaffective psychosis, met the criteria for

cycloid psychosis (Brockington et.al., 1982).

SCHIZOPHRENIFORM PSYCHOSIS*.

The term was introduced by 6. Langfeldt in 1939 as an effort

to essentially separate patients whof were diagnosed as

schizophrenia but had a good response to somatic therapy. The

features which were considered by Langfeldt to be correlated with

good prognosis were - an emotionally and intellectually well

developed premorbid personality, a precipitating factor, an acute

onset, a symptomatology characterised by a mixed picture.

21
especially admixtures of manic depressive traits# clouding of

conciousness or symptoms of organic (perhaps toxic) origin and

lacking the typical blunting of affect.

However the contemprory usage of the term is completely

different and has particularly aquired a different meaning in the

DSM. The DSM-III redefined the term schizophreniform disorder as

a disorder identical with schizophrenia except for the duration

of symptoms. Langfeldt himself pointed out the discrepancy and

indicated that the DSM-III does not accurately reflect his

original concept of schizophreniform disorder. The DSM-IIIR

specifications for the condition remain exactly the same except

that a specification has to be made if good prognostic features

are present. The DSM-IIIR criteria are given in Table 2# and it

can be seen that though the criteria used by Lanfeldt was in a

way simillar to the critreria given for cycloid psychosis# it

would be difficult to diagnose patients of cycloid psychosis with

typical features of anxiety# esctacy# and motility disturbances

as Schizophreniform Disorder.

Table 2

Diagnostic Criteria for Schizophreniform Disorder

A. Meets criteria A and C of scizophrenia.

B. An episode of disturbance (including prodromal# active and
residual phases) lasts less than S months.
C. Does not meet the criteria for brief reactive psychosis and it
cannot be established that an organic factor initiated or
maintained the disturbance.
Specify good prognostic features, at least two of the following:
1. Onset within 4 weeks
2. Confusion, disorientation, perplexity at the height of the
psychotic episode.
3. Good premorbid social and occupational functioning.
4. Absence of blunted or flat affect.

22
BOUFEE DELIRANTE:

Independently from the German "cycloid concept”, French

psychiatrists developed a taxonomy, also not influenced by

Kraepelin's dichotomy. The origin of boufee delirante also lies

in Magnan's concept of "degeneration” Thus boufee delirante is

characterised by Magnan as a psychotic condition occuring on the

basis of a hereditary predisposition, which shows a sudden onset,

a polymorphic symptomatology, a brief duration and a recurrent

course (Maj, 1984).

The concept of boufee delirante has been afterwards

developed by Ey and his group (Pichot, 1984). According to this

author, the most significant features of this condition can be

summarised as follows :

1. It occurs in young people

2. It is more frequent in women than in men.

3. A hereditary and personality predisposition may play a part.

4. Psychic and somatic precipitating factors can sometimes be

detected

5. The onset is acute.

6. The symptomatological picture always includes delusions and

hallucinations, is polymorphic and rapidly changing.

7. A disturbance of conciousness can be observed.

8. Mood is altered, and rapidly shifts from depressed to excited

pole

9. Resolution of the episode is complete, but the condition tends

to recur.

The diagnostic concept of boufee delirante has taked a firm

23
root in French psychiatry. According to Pull et. al. (1983), most

French clinicians recognise its existence independent of

schizophrenia and manic depressive psychosis. Pull has also

developed an operationalised criteria for boufee delirante,

differentiating the classical boufee delirante as described by

Magnan, and a reactive variant, where psychosocial precipitants

are considered to be of aetiological significance. The

operationalised criteria for boufee delirante has been given in

Table 3. It can be seen that the concepts of boufee delirante and

cycloid psychosis refer to the same psychosis, but Perris's

definition appears more comprehensive. According to ICD-9,

cycloid psychosis is synonymous with schizoaffective psychosis

and boufee delirante as acute paranoid reaction, which fails to

convey the concepts of either of these two conditions (Zaudig,

1990).

TABLE 3

Diagnostic criteria for "boufee delirante"

A. Age of onset: 20 - 40 years

B. Onset acute, without any prior psychioatric history (other
than identical episodes.
C. No chronicity : active phase fades away in several weeks or
months. The patient is devoid of all abnormality in the interval.
D. Characteristic symptoms, all of the following:
1. Delusions and/or hallucinations of any type.
2. Deprsonalisation / deralisation and/or confusion.
3. Deprssion and/or elation
4. Symptoms vary from day to day, even hour to hour.
E. Not due to organic mental disorder, alcoholism, or drug abuse.

24
 REACTIVE PSYCHOSIS
The concept of reactive psychosis has had a peculiar fate At

the begining of the century, under the influence of Jaspers

(Jaspers, 1913), the psychogenic psychosis came into common use

in Europeon psychiatry. In the Scandinavian countries this trend

was greatly influenced by August Wimmers monograph in 1916

(Stromgren, 1989), who defined this condition as "by psychogenic

psychosis we designate the various, clinically independent

psychosis the main feature of which is that they usually on a

(designate) predisposed foundation - are caused my mental agents

(mental traumata), and in a such a way, that these agents

determine the point in time of the start of the psychosis, the

fluctuations of the disease and very often its ceassation,

Likewise the form and content of the psychosis are more or less

directly and completely determined by the precipitating factors.

To this criteria can, finally, be added the predominant tendency

of these disorders to reccur, and more specifically never end in

detori at ion".

During the 1930*s the German speaking psychiatrists

gradually ceased using the term under the influence of Schneider,

who made a change in the conceptual scheme, using the word

^ psychosis for conditions which could be supposed to have an

organic basis. Thus, to him, the word "psychogenic psychosis",

was a contradicto in adjecto. The other reason for the gradual

decline in the use of the term was the realisation that though

psychogenic factors could act as specific causal agents, they

could also be predisposing factors, precipitating factors, ar.d

25
pathoplastic factors. The concept of reactive or psychogenic

psychosis has until recently never found a place in Anglo-Saxon

psychiatry. This has been mainly been under the influence of

Aubrew Lewis, who failed to find any distinction between

reactive and endogenous psychosis and suggested that the term

psychogenicc be given a decent burial (Lewis, 1972). In U.S.A.,

there was no use of the concept of psychogenic psychosis during

the long period when allpsychosis were regarded as psychogenic

and most of them labelled “schizophrenic reaction".

However recently there has been a ressurgence of intrest in

reactive psychosis influenced to great extent by McCabe's study

(McCabe, 1975), which showed that these conditions have no

relationship to schizophrenia, but a possible relationship to

manic depressive illness. As far as the present status of the

condition is concerned, in the ICD-9 (WHO, 1977), reactive

psychosis is disguised under the term "other non-organic

psychosis", and does not have an adequate definition. The DSM-

IIIR categorisation of Brief Reactive Psychosis comes closest to

the Scandanavian concept of Reactive Psychosis, (though the

presence of a mood syndrome is an exclusion criteria in the DSM-

IIIR). Also there is an upper limit of duration of symptoms and

conditions lasting longer than that will probably be have to

reclassified as Schizophreniform disorder.

The diagnostic criteria given for Brief Reactive psychosis

are similar to that of Cycloid Psychosis except that the

presence of an "understandable" stressful event is not a criteria

neccessary for diagnosing Cycloid Psychosis. In this respect the

ICD-10 is an improvement, because in the category of Acute and

26
Transient Psychotic Disorder (F23), the presence or absence of

associated stress has to be specified. Cycloid Psychosis is given

as an inclusion term in this category, and the dignostic

guidelines for F23.0 - Acute Polymorphic Psychotic Disorder

(without symptoms of schizophrenia) (Table 4), is based on the

operationalised criteria given for Cycloid Psychosis given by

Perris and Brockington.

TABLE 4

F23.0 Acute polymorphic Psychotic Disorder (without symptoms of

schizophrenia) : diagnostic criteria for researoh (ICD-10. Draft
1989)

A. The general criteria for acute and psychotic disorders (F23)

must be met.

B. The symptomatology is rapidly changing in type and intensity

from day to day or within the same day.

C. The presence of any type of either hallucinations or delusions,

for at least several hours, at any time since the onset of the
disorder.

D. Symptoms from it least 2 of the following categories at the

same time:
1. Emotional turmoil, characterised by intense feelings of
happiness or ecstacy, or overhelming anxiety or marked
irr itabi1ity.
2. Perplexity, or misidentification of people or places.
3. Increased or decreased motility, to marked degree

E. None of the synptoms should be present with sufficient con­

sistency to fulfil the criteria for schizophrenia (F20).
F. The total duration of the disorder does not exceed 3 months.

Thus it can be seen that though the original descriptions of

Acute Schizoaffective Psychosis by Kasanin and Schizophreniform

Psychosis by Lanfeldt did overlap with the descriptions of

2?
Cycloid Psychosis but their present day concepts are markedly

different. The concept of rudimentary cycloid psychosis has

survived in the DSM-IIIR as Schizophreniform disorders but

without typical features like anxiety and elation (Zaudig, 1990).

The French concept of boufee delirantee describes a condition

which is closely allied to cycloid psychosis, but the description

of this condition in the ICD-9 has very little to do with the

French concept. The Scandanavian concept of Psychogenic Psychosis

has found a place in the ICD-10 (Draft) as Acute and Transient

Psychotic Disorders and Cycloid Psychosis is an inclusion term

under this category. The sub-category Acute Polymorphic Psychotic

Disorders (without symptoms of schizophrenia) best describes the

condition defined by Perris and Brockington.

general £*AB££IE81§I1£§ QE £X£LQ1Q E3X£tiQS18

EPIDEMIOLOGY:

There are no exhaustive epidemiological sudies on cycloid

psychosis, and most of the studies deal with the proportion of

patients of cycloid psychosis in different series. Brockington

et.al. (1981) reported that about 105c of all psychotic patients

admitted to different hospitals in U.K. fulfilled the criteria

for cycloid psychosis. Cutting et. al. (1978), in their series of

2500 patients using an earlier definition of cycloid psychosis

given by Perris (1974), found that 35c of all admissions and 85c of

admissions for functional psychotic admissions in the

Professorial Unit of Maudsley Hospital in London met the criteria

for cycloid psychosis. Zaudig and Vogl ( 1983) found 155c cycloids

28
in aseries of 128 patients admitted to Max Planck Institute in

Munich.

In a re-evaluation of the prospective longitudnal study of

incidence and risk in the 1947 cohort of the Lundby study

(Linvall et. al.,1986), 3 female cases were diagnosed as cycloid

psychosis according to the diagnostic criteria of Perris and

Brockington. No male cases were seen, giving an an incidence rate

(per 100 observation years) as 0.016* for women. The cummulative

probability risk upto the age of 60 years) was found to be 0.7*.

The incidence and risk for women for seen to be half of the

coresponding values for schizophrenias.

Apparently the prelimnary results reported above are

consistent. They suggest that psychosis acounts for a substantil

proportion of psychotic disorders especially in women (20* in the

epidemiological sudy by Linvall et.al.) who have been

consistently been found to be over-represented in all sudies

(Perris, 1988).

SEX RATIO?

Most studies have reported a higher female to male ratio.

Perris's study in Umea (Sweden) had 60 patients, 44 of whom were

females and 16 males (Perris, 1974). Cutting et al (1978) found

90* of their cycloids to be females as compared to 53* in mania,

55* in depression, 51* in schizophrenia and 47* in

schizoaffectives. The difference remained at statistically

significant levels even when peurpereal patients were excluded.

Brockington's study sample had 17 female cases out of 30 and in

29
the study conducted by Mao (1988), 13 0f the 20 patients were

females. The higher prevalence of female patients was found by

Perris in the relatives also, of the patients diagnosed as

cycloids, and the difference disappeared only if relatives who

had comitted suicide and therefore could not be assesed were

excluded.

MARITAL STATUS J

Patients with cycloid psychosis are more likely to be

married when compared to schizophrenics and their figures are

comparable to to patients with affective disorders. In the Umea

study by Perris the number of unmarried cycloids was found to be

higher than those with Bipolar disorder but the differences did

not reach the level of statistical significance. Cutting (1978)

found that 38* of the schizophrenics were "ever" married, and

this was significantly lower than £>3* of the cycloids who were

married. There was no difference in the marital status of the

cycloids when compared manics, depressives and schizoaffectives.

Maj (1988) also did not fnd any differences when comparing

cycloids with depressives, manics, schizodepressives and

schizomanics.

GENETIC FACTORS :

There are a lot of studies concerning hereditary factors in

patients suffering from mixed psychotic states, but the variety

of concepts employed in these studies do not make them

comparable. Slater (1938) as quoted by Perris (1974) found that

genetic loading was higher in patients sufering from manic

depressive psychosis as compared to those with an admixture of

30
schizophrenic and affective symptoms, but the differences were

not statistically significant. Asano <1960) found no cases of

schizophrenia or atypical psychosis in relatives of probands

diagnosed as MOP, whereas atypical probands showed an increased

prevalence of atypical MDP and atypical schizophrenia. Simillar

results have been reported by Mitsuda <1967). In a study by

Leonhard and von Trostorff (von Trostorff, 1968) the percentual

morbidity risk, MR* <i.e. the percentage of probands whose

relatives are having a mental illness) in probands diagnosed as

cycloid psychosis was 4.6* in parents and and 4.7* in sibs for

endogenous psychosis (without any specifications regarding the

type of psychosis). These figures are lower than those reported

elsewhere.

Shneshnewski (1972) studied recurrent schizophrenias, which

according to Perris by and large corresponds to the category of

cyloid psychosis, and found that the MR* risk was 18* for

parents, 19.3* for sibs, and 26.3* for children with a marked
phenotypical polymorphism and an absence of schizophrenia with a

malignant course. The results of a much better planned study by

Perris showed that the MR* for among first and second degree
relatives was much higher for a homotypical illness. He found the

homotypical MR* to be 11.4* for parents,7.4* for siblings as

compared to a MR* of 1.4* for schizophrenia and 0.68* for bipolar

disorders. The MR* for grandparents and uncles and aunts was

found to be 2.7* and 8.1* respectively.

The only reported twin studies have been by Leonhard (1986).

According to him the concordance rates of cycloid psychosis

31
differ in the different sub-types. Of the 6 pairs with anxiety

elation psychosis only one was concordant but 9 of the 11 pairs

with motility psychosis were concordant and this difference was

attributed by him to early developmental patterns.

As to the kind of transmission. Mitsuda has hypothesised a

dominant inheritance (Perris,1988). An analysis of the 1974

series according to a computation model proposed by Slater,

showed statistically significant results favouring a hypothesis

of a dominant inheritance as compared to a polygenic type of

transmission. The possible association of well known genetic

markers (blood groups, red-cell enzymes, HLA antigens) have been

studied (Beckman et.al.,1980) but the results are prelimr.ary. The

significant findings have been an excess of Rh -ive and an

association with Gc 2-1 group.

v

BIOCHEMISTRY *.

Very little systematic work has been done on the biochemical

derangements in cycloid psychosis. Platelet MAO activity has been

reported to be inconsistent in schizophrenics. The activity is

generally low in chronic schizophrenics and normal to low in

acute cases. According to Perris those with a low platelet MAO

activity are cycloid psychotics who are misdiagnosed as

schizophrenics. In afew cycloid psychotics Perris found an

increased RBC lithium to serum lithium ratio when compared to

bipolar affective disorder, but these findings have not been

replicated.

In an intresting study, Bruinvels et.al. (1988), postulated

that cycloid psychotics suffered from an abnormality in one

32
 carbon metabolism resulting in the formation of beta carbolines,

which were held responsible for evoking the psychotic symptoms.

'""'" Since serine is the principal donor for one-carbon units, serine

was administered to nonsymptomatic patients. Two to three hours

after the administration the patients became psychotic again.

Analysis of blood samples from these patients showed a decreaed

fasting plasma concentration of serine and an increased

concentration of taurine. In addition a decreased formation of

serine from glycine was found. According to the authors these

findings are in agreement with the postulated derangement of one-

carbon metabolism in cycloid psychosis.

CLINICAL PROFILE J

Premorbid Characteristics: A dysfuctional developmental

envoirment has been reported by Leonhard <198b), but according to

Perris it is unlikely that it represents anything more than a

contributing factor to the development of cycloid psychosis and

no dysfunctional premorbid personality characteristics have been

evident in patients who became cycloid psychotics.

In the Umea study significantly higher proportions of

patients were found to have lost either parent before the age of

15 years as compared to bipolars or healthy controls. In a later

study by Perris (1978), family constellation and childhood

experiences were studied ina larger series. On the whole, few

inter-group differences were found, suggesting that negative

childhood experiences are common to all psychiatric patients and

were not specific to any of the disorders which had been taken

into account.

33
 Taking into account that cycloid psychotic disorders are

sometimes regarded as being closely related to Reactive

psychosis, the exent to which the cycloid psychotic disorders are

precipitaed by stressful events has been investigated by Perris.

Using a broader criteria for defining a strssful life event than

is required by the OSM for Brief Reactive Psychosis, only 30* of

the patients reported such an occurence prior to the first

episode. Stressful life events were much less evident during the

subsequent episodes (Perris, 1988). A condition emphasised by

Perris as being likBly to precipitate an episode of cycloid

psychosis is childbirth. According to him most instances of post­

partum psychosis are nothing but cycloid psychosis.

Onset of symptoms : The acuteness of the onset of cycloid

psychotic disorder has been stressed by a number of

investigators. One of Perris's patients who has been followed for

several years always becomes ill in the middle of the night after

having gone to bed in a perfect state of health. The most common

mode of onset is acute with a full blown pictue emerging over a

period of hours to at the most few days. In Perris's study of

the 209 episodes in 60 patients, 182 were acute.

Because of its sudden debut the seasonal distribution of

these episodes have been studied. They have been found to be

evenly distributed without any peaks of other psychotic

conditions (Perris, 1988).

Symptom Profile : The general symptomatological profile of the

patients has been discussed while describing Leonhard's sub­

classification. The distinctive characteristic of cycloid

34
psychosis is that all the psychopathoiogical symptoms occur at

the same time. They are intermingled without any discernable

pattern and continuously change not only from day to day but from

hour to hour. Therefore sub-classifying patients on the basis of

polarities as suggested by Leonhard is most often not possible.

According to Perris when Leonhard spoke of a "Bipolar" course of

the cycloid psychosis* he not only refered to successive

occurence of episodes of different clinical polarity but but also

a shift of polarity within one and same episode.

Most of the studies on the symptom profile of cycloid

psychotics have revealed a symptom profile which has been a

reflection of the diagnostic criteria used. This point becomes

even more evident when we take into account the fact that many of
I
them had a retrospective design. Thus in the study by Cutting et.

al (1978) 100% of the cycloids showed delusions/hallucinations

and mood swings. 88% showed perplexity. 48% motility disturbances

and 41% pananxiety. Thier findings on the conventional aspects of

the mental status showed that none of the patient had depression

or elation alone, thought disorder was present in 70% of the

patients and first rank symptoms in 53% of the patients. In the

Umea study, confusion, anxiety and delusions were present in more

than 50% of the patients.

Brockington et. al (1982) studied the clinical features of

the cycloids by comparing the PSE symptoms with other psychotic

patients. 24 of the 140 items showed significant differences at

the 1% level or better. Eight of them were manic symptoms, six

were in the area of delusions and hallucinations or passivity

35
phenomenon, and the remainder in the area of affect and
behaviour, While some of the symptoms were directly related to
symptoms comsidered characteristic of cycloid psychosis, others
which were less likely to be related werO thought insertion,
auditory hallucinations and manic symptoms of loss of reserve and
flight of ideas.
In another study by Maj (1988), 20 patients with cycloid
psychotic disorder were asessed on CPRS along with 25
schizodepressives and 25 schizomanics. A rating of 2 or more on
items of inner tension, delusional mood, visual hallucinations,
perplexity and agitation was significantly more frequent in
cycloids than in both schizodepressives and schizomanics whereas
item sadness was rated more frequently in schizodepressives than
in cycloids and the items elation and ideas of grandeur were
rated more frequently in schizomanics than in cycloids.
Schneiderian first rank symptoms are reported to be very
common in cycloid psychosis. In the British series (Brockington
et.al., 1982) 41% had complained of thought insertion and 42% had
felt controlled by alien forces. In MaJ's series 20% of the
patients each had delusions of control, disrupted thoughts, and
commenting voices.
The most important clinical charateristic of the patients
with cycloid psychosis is the marked variability in their
clinical picture, and it is this characteristic which makes them
very difficult to classify. In Haj's series, 60% of the patients
recieved a diagnosis of Acute Schizophrenic Episode (295.4) on
the ICD-9,while the rest of them were distributed among Paranoid
Schizophrenia (295.3), Schizophrenia - Schizoaffective (295.7),

36
 Schizophrenic Psychosis - Other (295.8)*and Acute Paranoid

Reaction (298.3). On the DSM-III 75X of the patients recieved a

diagnosis of Schizophreniform disorder (295.40). The poor

concordance of cycloid psychosis which is apparent here has been

studies systematically by Brockington (1982) and Zaudig and Vogl

(1983) paricularly with reference to schizoaffective disorders.

COURSE AND OUTCOME :

The most important characteristic of the concept cycloid

psychotic disorder is its prognostic validity. In this respect

the opininion of all the authors who have been concerned with

this concept concept seems to converge.

From the case vignettes described by Leonhard in his text­

book (Leonhard* 1980)* it clearly emerges that cycloid psychosis

hve a good short and long term prognosis* and no defect state as

seen in patients with a narrow definition of schizophrenia is

seen in cycloid psychosis. The studies on prognosis have been

done both in relation to a single episode ai^d long term outcome

All patients in the 1974 series of Perris made a complete

recovery at the index episode. In the British series 90* of the

'"■' patients were judged to have recovered from the index episode.

The duration of the episode has not been systematically

studied. According to Leonhard the mean duration of the anxiety-

elation psychosis is 3.9 months and 3.1 months and 2.8 months for

confusion and motility psychosis respectively. However at times

the akinetic phase of motility psychosis can last for several

months. In general the duration of an episode of cycloid

psychosis is shorter than that of bipolar affective disorder.

37
Perris has reported that 10k of the patients may have a
spontaneous remission, but the Umea study had no such patients,

as any patient who improved due to a change in envoirment was

excluded from the study. This criteria was probably added to

exclude cases with reactive psychosis.

Recurence: There is a general agreement that these conditions

have a strong tendency to recur. However no definite results are

available which can answer the question : How great is the risk

of experiencing successive episodes after having suffered the

first one ? There are reports in Leonhards book of patients

having suffered only one episode though the duration of follow up

is not mentioned very clearly.

Leonhards studies showed the mean number of episodes over a

15 year observation period was 3.2 for confusion psychosis, 3.6

for motility psychosis and 2.4 for anxiety elation psychosis.

Male patients had a higher tendency to relapse than female

patients. Probands with a homotypical hereditary loading have

more frequent episodes when compared to those with a

heterotypical loading or those without any family history.

Angst has calculated the length of intervals between

successive episodes to be 42.1 months with a pronounced tendency

to become shorter after many episodes. Perris has reported

average cycle length to be 2 years with the duration between the

first and the second episodes being twice as long.

Outcome: The good outcome of a single episode or recurrent

episodes with periods of complete remission in between without

defects was incorporated into the definition of cycloid psvchos-Is

38
in Perris's study. The long term outcome has been studied by
various authors across different variables.
Cutting et.al. (1978), compared 73 cycloids with an equal
number of manic, depressives, schizophrenics and 49
schizoaffectives. Follow up of at least one year was obtained in
98% of the patients and the mean follow up period ranged from 6.5
years for the affective subgroup to 10 years in the cycloid
group. Their findings show that cycloids had the best outcome of
any group and significantly better than schizophrenia. The
subsequent course of the patients was shown in two ways - first
the proportion of patients who remained wll through out is
contrasted with those who had subsequent admissions or required
psychiatric attention. By this estimate the cycloids had the
worst prognosis : they were least likely to remain well and most
likely to require admission. Another way of presenting the
information was in the form of annual rates per patient of new
I
admissions episodes and the time spent in the hospital. Cycloid
patients were admitted four times as often as depressives, twice
as often as manics, but the time spent in hospital was shorter
thanschizophrenics or schizoaffectives and approximately the same
as affective disorders.
In the study by Brockington (1982) the outcome of 30
cycloids was compared with 203 patients in the Nertherne series
and schizoaffective series. Cycloids were seen to have a better
prognosis as 90% of the cycloids as compared to 67% of the whole
series made complete recovery from the episode of florid
illness.The benign course of cycloids was even more obvious when
it is compared with that of schizophrenia and this was done by

39
using several definitions of schi2ophrenia. For example of the

128 CATEGO schizophrenics, there were 24 cycloids, and 92% made

complete recovery as compared to 59% schizophrenics. Their mean

outcome score was,1.28 as compared to 1.84 for of schizophrenics.

The statistical analysis was carried out with & other definitions

of schizophrenia and they all showed large and statistically

significant differences in the mean outcome except for RDC

schizophrenics.

Cutting analysed the differential effect on prognosis

attributable to each of the elements in the cycloid definition.

This was done by analysing the admission rates and length of stay

in hospital of cycloid patients and those among the comparison

group who exhibited perplexity, pananxiety or motility

disturbances, the presence of one of the four elements did not

predict the outcome as in the cycloid group suggesting that

either a combination of one or more of these elements or one of

these in combination with mood swings was neccessary to determine

the characteristic cycloid outcome.

Fujii et al (1983) have thoroughly investigated the clinical

course and outcome in 102 patients suffering from peiodic

psychosis who had been followed for a mean period of 21 years.

The authors maintain that their concept of periodic psychosis

corresponds to that of cycloid psychosis as defined here.The

Japenese authors found that their patients suffered from 6.6

psychotic episodes on an average but 76% of the patients required

less than 3 months of hospitalisation. 60% of the patients had

full social adaptation and residual states characterised by

40
flattening of affect, residual productive symptoms, breakthruogh
dysfunctional premorbid characterises were found in only 15* of
the patients.

TREATMENT :
There are no specific treatment approaches to the management
of cycloid psychosis. So far no controlled of the treatment of
cycloid patients have been reported. This partly due to the fact
that cycloid patients have not been recognised as such, and
partly to the fact that their numbers have been too small at any
single centre for allowing the possibility of a controlled blind
trial. Electroconvulsive therapy has been found to consistently
to produce dramatic results after a few applications. However a
relapse in symptomatology has been reported frequently if the
treatment was not continued for 6-8 applications Perris, 1988).
The increased use of ECTs in these conditidns can be considered
to be more a reflection of the polymorphous nature of these
conditions which necissitated a prompt control of symptoms rather
than any specificity of ECTs. The approaches to the treatment
have been the use of neuroleptics or neuroleptics in combination
with tricyclic antidepressants, particularly in the anxiety
phase. Tricyclics alone have been rarely used.
Lithium has been used as a prophylactic agent in cycloid
psychosis. In a mirror image study involving 30 patients with
cycloid psychosis (Perris, 1978) who were put on prophylactic
lithium (0.6-0.8 mEq/L) there was a significant reduction in
morbidity as acertained by the number of episodes and time spent
in hospital.The teatment stategy advocated by Perris in cases of

41
cycloid psychosis is rapid neuroleptisation with with haloperidol

(initially 20-40 mgm injected intramuscularly) combined with

1ithium.

ms mm ttssKcms i
There have been no Indian studies on Cycloid Psychosis as

yet. However observers in India repeatedly observed the

considerable variation between the psychiatric phenomenon

observed here as compared to those traditionally classified in

western cultures. Interstingly there has been a close simillarity

between reports from other third world coMntries and India and

these have been summarised by Wig (1985) as following :

1. Gross psychiatric symptoms particularly psychotic reactions

tend to be acute and short lived.

2. The psychiatric symptoms tend to be dramatic and

exaggerated.

3. The psychological expression of symptoms is often global,

mixed or amorphous as result of which differentiation

between various categories is difficult.

4. Somatic complaints are frequently present along with the

clinical psychological syndromes.

5. Primitive reaction of fear and panic are quite common.

The fact that traditional class!ficatory systems were

considered to be inadequate in India prompted Wig and Singh to

put fortha classificatory system for use in India (Wig et.al..

1967). They introduced a category of Acute Psychosis of Uncertain

Aetiology as one of the main innovations of their classificatory

42
system. This category was for patients who presented with florid

psychotic symptoms of sudden onset with some clouding of

conciousness, specially in the early stages. The subsequent

picture was described as being varied with marked emotional

disturbances, manic or depressive with primary delusions and

paranoid and hallucinatory experiences. The clinical course in

most of these cases was described as being episodic with complete

recovery and no personality change. Though the authors did not

propose any operationalised criteria, they stated that the

condition they sought to isolate would overlap with conditions

which had been labelled as Orienophrenia (Meduna),

Schizophreniform Pychosis (Langfeldt), Cycloid Psychosis

(Leonhard),Schizoaffective Psychosis (Kasanin) etc. They felt

that cases so identified on clinical grounds, would be a

heterogenous group, some of which on.foolow up might turn out to

be typical schizophrenics or manic depressives, some with organic

toxic psychosis, but even after excluding such cases,there would

still be a large number of cases which would be a genetically

distinct group. The conditions so described were clearly

distinguished from Hysterical Psychosis which was described as a

condition occuring in patients with hysterical personality or

hysterical neurosis and in the presence of a precipitating

factor.

Thus, though the need for a category of a third psychosis

was felt and the guidelines laid down, the number of studies done

in India have few and infrequent. Wig and Narang (1969) described

cases of short lived psychosis with marked;hysterical features,

following a life event corresponding to the category of

43
Hysterical Psychosis. Simillar cases were also described by
Kurvilla and Sitalaxmi (1982). Kapur and Pandurangi compared
patients of Acute Psychosis with and without a precipitating
factor and followed them for a period of seven months. Though the
criteria used by them were not well defined, there would be many
cases in the group ao acute psychosis without precipitating
factor which would correspond to cycloid psychosis. They were
able to demonstrate differences between these two groups on the
basis of premorbid personality, family history, phonomenological
characteristics, course and outcome. G. Singh and Sachdeva (1980)
/

in a clinical stusy and follow up af atypical psychosis,

described a sub-group of patients, which according to them
corresponded to Leonhards definition of Cycloid Psychosis, as an
independent entity. These patients were differentiated from
patients with Schizoaffective Psychosis on the basis of family
history, phenomenology and course of illness.
A major multicentered study was conducted by the Indian
Council of Medical Research (1985), with more than three hundred
cases between the ages 15-60 years and with an acute onset (less
than two weeks) of psychosis. The most striking feature of the
study was that more than 75* of the patients had fully recovered
with no relapse of psychotic illness by the time of one yaer
follow up. In a similar study sponsored by WHO and conducted in
New Delhi with cases of acute first episode psyehpsis. Wig and
Parhee (1984) repoted that nearly 70* of the patients had
completely recovered at the end of one year. The ICD-9 diagnosis
'at the time of initial assessment did not differentiate cases

44
with a good recovery from those with a poor outcome in either the

ICMR or the WHO-sponsored studies. Another striking feature of

these studies was the difficulty in classifying acute psychotic

cases into either schizophrenia or manic depressive psychosis,

the traditional categories of psychotic disorders. Only 49* of

the sample in the WHO-sponsored study and 60SC in the ICMR study

were given a diagnosis of schizophrenia or manic depressive

psychosis at the initial assessment. From the description of the

operationalised criteria used in

purely the
descriptive
T
diagnostic classification of acute psychosis many of the cases

would fulfil the diagnostic criteria for cycloid ps,chosis,

though such an excercise was not carried out by the researchers.

It was observed that more than 50* of the cases belonged to the

two descriptive categories of predominantly excited and paranoid

types, with the next two common categories being withdrawn and

depressed (25*).

Summarising. Wig (1988) has stated that cases of acute and

transient psychosis are regularly and fequently seen in the

psychatric services in India. By and large these cases have a

good outcome with more than two third of the cases recovering by

the end of the year without any relapse. The present knowledge

suggests that acute tansient psychosis is not a unitary concept

but a mixture of heterogenous disorders. There is no uniform

picture and the symptomatology seems to rapidly change over time.

The most common presentation in India is diorganised social

behaviour. with generalised excitement and persecutory

delusions.Major psychological and phsiological stress is seen in

only half the cases and accordig to the strict criteria many of

45
these cases do no fit well with either ICD-9 or DSM-III

classifications and have to be labelled as "Atypical Psychosis"

or "Psychosis Not Otherwise Specified".

The criteria used for studying patients in the studies

quoted above, suggests that many of these cases would overlap

with the concept of Cycloid Psychosis as defined by Perris and

Brokington as also with the category of Acute and Transient

Psychotic disorders in the ICD-10 (Draft). The fact that there

have been no systematic studies on cycloid psychosis in India

prompted the present study in which the phenomenology, course and

outcome of Cycloid Psychosis was systematically assesed.

4b
AIMS AND OBJECTIVES
 AIMS m QBJ££I1Y£§

The aims and objectives of the present study were:

(1) To study the hospital admission rates pf Cycloid Psychosis

(2) To study the phenomenology of Cycloid Psychosis

(3) To study the short term course and outcome of Cycloid

Psychosis prospectively.

(4) To compare and contrast the phenomenology, course and outcome

of Cycloid Psychosis with Mania and Schizophrenia.

47
SUBJECTS AND METHODS
THE EVALUATION SETTING

The present study was conducted at the Central Institute of

Psychiatry (C.I.P.), Ranchi. This is a 642 bedded teaching
psychiatric hospital with approximately 2000 admissions per year
and ouer 12,000 outpatient visits per year, and has a wide
catchment area. The hospital admits patients directly as well as
those referred to it from the neighbouring hospitals, through its
out patient department which is a 24 hours-a-day, and 7 days-a-
week walk-in clinic and the main entry point for outpatient and
inpatient care at C.I.P.

THE STUDY POPULATION

The study had a prospective design and was carried out in

three samples of hospitalised patients, who were admitted in
C.I.P. between 15th February and 28th May 1990, after obtaining
an informed consent to participate in the sjtudy.

1> 25 consecutive patients meeting the criteria of Perris

and Brockington (1981), for Cycloid Psychosis (Appendix I).
2> 25 consecutive patients meeting the DSM IIIR criteria for
a Manic Episode (American Psychiatric Association, 1987), who
were matched for age and sex to the patients in the cycloid
group, and were admitted to C.I.P. around the same period
(Appendix II).

48
 3> 25 consecutive patients meeting the DSM IIIR criteria for
Schizophrenia (American Psychiatric Association, 198?), who were
matched for age and sex to the patients in the cycloid group, and
were admitted to C.I.P. around the same period (Appendix III).

INITIAL ASSESSMENTS

All patients included in the study underwent the following

assessments:

1. Sasic Data Sheet in which information was collected regarding

demographic and socio-ecnomic variables. In this details were
collected regarding the patients age, sex, marital status,
address, religion, type of family, education and income.

2. Schedule for Affective Disorders and Schizophrenia (SADS)

(Endicott St Spitzer, 1978) was administered to all patients. SADS
is a semi-structured interview designed for use by interviewers
with clinical experience. The SADS was designed to evaluate
symptoms of disorders as defined by the Research Diagnostic
Criteria (RDC) (Spitzer et al., 1978), but because of its
comprehensive nature can generate diagnosis on the DSM IIIR also.
The full SADS interview is intended for use with psychiatric
patients, or with subjects currently experiencing some
psychopathology. It consists of two main sections which cover a
number of areas to be clinically explored with subjects in order
to determine the most valid ratings. The first section contains
multi-point items (mostly six point items) for rating the
severity of patients' current conditons. Generally speaking, a

49
score of three or more on the scale for a symptom is regarded as

clinically significant. Each symptom and the criteria for rating

it are defined in the SADS interview schedule, and the severity

levels are defined with “anchor points" and are not left to

unspecified clinical judgement. Symptom severity is assessed for

both, the worst period during the present episode, and the level

of severity during the week prior to admission. The second part

of SADS covers subjects' lifetime history. The items are

clustered according into diagnostic specific sections, and are

largely rated as dichotomous (present or absent).When used

together, the first and second parts of SADS provide information

for makinf both current and lifetime psychiatric diagnosis.

In the present study the first half of SADS was completed

shortly after admission. The second half of SADS which concerned

lifetime diagnosis was often delayed until the symptoms had

somewhat subsided and the patient became a better informant. The

information which was available from the accompanying ralatives

was also incorporated.

3. All patients were rated on the Comprehensive

Psychopathoiogical Rating Scale (CPRS) (Asberg et. al., 1978) at

the time of admission, then at weekly intervals for the first

four weeks, and after that at two weekly intervals till the

patient was discharged. The scale consists of 65 items covering a

wide range of reported (1-40) and observed (41-65)

psychopathology, as well as "global rating of illness" (66), and

"assumed reliability of rating" (67) items. Each item is

50
 described in simple non-technical terms. For each variable, the

scale steps from 0 to 3 have been operationally defined, and the

use of half steps is recomended. The following general rules have

been used in their construction: 0 = absent; 1 = pathological,

although it may be a normal variation; 2 = clearly pathological;

and 3 = extreme degree of psychopathology. The dimensions used

for defining and arranging the individual items are intensity,

frequency, and duration of symptoms. The scale is recomended for

use by trained mental health workers . An iterview technique that

is as close to clinical psychiatric interview is recomended,

although it is also possible to use the scale as a questionnaire.

Generally, correlations for inter-rater reliability for reported

psychopathology have been higher than those recorded for observed

psychopathology (Jacobsson et al., 1978; Kasa and Hitomi, 1985).

4. All patients were assessed on the Global Assessment Scale

(GAS) (Endicott et al., 197b), at the time of admission, as apart

of SADS and at the time of discharge. GAS evaluates the overall

functioning of a subject on a continuum from psychological

sicknes to health (scoring 1 - 100, respectively). The scale is

.divided into 10 intervals, each a ten point scale of global

severity. Each level of severity is operationally defined. The

two highest intervals ( 81 - 100 ) are used for individuals

without any psychopathology who also exhibit traits of a positive

mental health (e.g. superior functioning, wide range of intrests,

..^social effectiveness warmth or integrity). The next interval, 71-

80, is for individuals where psychopathology is minimal or

absent. The majority of patients in treatment are rated between

51
1-70. In making a rating, one selects the lowest interval that

describes the patients overall functioning. The final rating

within the scale interview ( e.g. 21-30) is done on the basis of

the proximity of the overall psychopathology to the higher rating

(31-40) or the lower one. The time period assessed is generally

one week prior to admission. According to Endicott et al ( 197b)

the inter class correlation of inter-rater reliability varies

from 0.69 to 0.91, and there was a 95* confidence for ratings to

be within 10 to 11 ponts of each other.

TREATMENT

As one of the aims of the present study was to find out the

"naturalistic" course of the illness, i.e. to study its course in

routine clinical practice, treatment which all the patients

recieved was not controlled. All decisions regarding treatment

were left to the treating psychiatrists. The treatment philosophy

of all the units is simi liar and can be described as being

eclectic with slightly heavier emphasis on somatic forms of

therapy. Details of all the treatment recieved by the patients

was recorded,

FOLLOW-UP ASSESSMENT t

Follow-up assessments for all patients was planned at one

month, three months and six months following discharge. The

folow-up rates at the end of one month following discharge was

92* for the patients in the cyloid and manic sub-groups while it

52
was 805c for the schizophrenic sub-group. All patients who did not

turn up for their follow-up assessments were sent letters

requesting them to come for a check-up. At the end of six months

follow-up assessments could, be done on 845c of the cycloids, 805c

of the manics and 725c of the schizophrenics. The global

assessment scale ratings of the patients at the time of discharge

of the patients who did not come for follow-up was not

significantly different from the other patients in the same group

who came for follow-up.

At the follow-up assessment information was taken regarding

the occurence of any new episodes or exacerbation of symptoms and

the patients were rated on CPRS and GAS. In addition the patients

were rated on Schedule for Assessment of Psychiatric Disability

(SAPD), (Indian Council of Medical Research, 1988) to rate their

social and occupational funtioning. The schedule (Appendix IV) is

a modification of the Disability Assessment Schedule (Jablensky

r
et.al., 1980), has been adapted to suit Indian population. It was

developed as a part of Multicentered Collaborative Study of

Factors Associated with Course and Outcome of Schizophrenia. It

consists of four parts which assess the patients overall

behaviour, social functioning, occupational functioning and

overall disability. The first three sections are rated on a 6

point rating scale (0-5), wth arating of 9 being given if rating

is not possible- The scale is easy to administer an its

reliability in Indian setting well established (ICMR, 1988).

53
STATISTICAL ANALYSIS :

Statistical analysis was done using t - test for comparisons

involving continuous variables and Chi squared tests (X2) for

those involving categorical variables, while Analysis of Variance

(ANOVA) was done when the comparisons involved more than two

groups. Cluster analysis ws done on patients CPRS ratings using

the method described by Cohen (1988). All statistical analysis,

including cluster analysis were done on IBM-compatible PC using

programmes given by Cohen (1988).

54
RESULTS
AGE ft SEX!

The sample consisted of 25 patients in each diagnostic

category, namely Cycloid Psychosis, Manic Disorder, and

Schi2ophrenic Disorder. The 25 cycloids who were taken into the

study constituted 4.3% of the patients admitted during the

period. There were 17 males and 8 females in each sub-group who

were matched for age and sex. The mean age of the sample was

31.28 years (S.D. 7.47), with ages of the patients ranging from

20 years to 45 years. The mean age of the female patients was 34

years (S.D. 9.07), which was higher than that of the male

patients, mean 30 years (S.D. 6.5), and this difference was

statistically significant (t = 2.95, 23 df, p < 0.01).

The female patients constituted 32% of the study sample.

Though this percentage of female patients in the study group was

more than the percentage of the female patients admitted in the

hospital during the same period, which was 25.83%, the difference

was not statistically significant ( X2 = 0.204, 1 df, N.S. ).

SOCIO-DEMOGRAPHIC VARIABLES : (Table - A)

MARITAL STATUS: There were 20 subjects in the cycloid sub-group

who were married while the number of the subjects in the manic

and schizophrenic subgroup was 20 and 18 respectively. The inter

goup differences between the married and the unmarried subjects

was not significant (X2 = 1.59, 2 df, N.S. ).

55
 TABLE - A

SOCOO - IDOIOdRAlPtHQC VAROABLES

CYCLOID MANIC SCHIZ.

Married CO 20 C 8090 20 C809D 18 C72X3

Hindus C2J> 18 C72X3 21 C84SO 18 C72X3

Rural C3J> 15 C60SO 14 C56X3 15 C60X3

Nuclear Family C43 18.C72X3 18 C72» 11 C 4490

Education C5J> 5.SB Cl.563 5.52 Cl.733 5.52 Cl.663

Incow C6J>

< Rs. 900 7 C28JO 7 C2890 O C36SO

Rs. 000-1400 10 C 40)0 7 C28X3 6 C24SO

> Rs. 1400 8 C32X3 11 C44X3 10 C 40X3

1. = 1.50, 2df, NS

2. *2 » 1.30, 2df, NS

3. *2 » 0.10, 2df, NS

4. *2 « 5.50, 2df, p < 0.01

5. F ratio * 0.18, 2,72 df, NS

6. £2 * 1.20, 4 df, NS
RELIGION*. In the cycloid subgroup 18 of the 25 subjects were

hindus, there were 5 muslims and 2 Christians. In the manic

subgroup there were 21 hindus and 4 muslims while in the

schizophrenic there 18 hindus, 4 muslims, 2 Christians, and 1

sikh. The inter group differences between the hindus and the non-

hindus was not significant (X2 = 1.3, 2 df,N.S.>.

RESIDENCE: The number of patients from the rural areas in the

cycloid sub-group was 15 while the other 10 were from urban

areas. The number of patients from rural areas in the manic and

schizophrenic sub-group was 14 and 15 respectively and there were

no inter group differences (X2 = 0.1, 2df, N.S. ).

TYPE OF FAMILY: There were 18 patients in the cycloid and manic

sub group who were from nuclear families, while the other 7 came

from non-nuclear families (extended nuclear or joint families).

The number of subjects in the schizophrenic group who were from

non-nuclear families was 14 and the the inter group differences

were statistically significant (X2 = 5.59, 2df, p < 0.01).

EDUCATION: There were 5 subjects in the cycloid group who had no

formal education, while their number in the manic and

schizophrenic groups was 5 and 7 respectively. The number of

subjects who had been to school but did not finish high school in

the cycloid subgroup was lb and that in the manic and the

schizophrenic subgroup was 13 and 12, while those who had some

college education in the cycloid, manic and schizophrenic groups

57
 was 4, 7 and 6. The mean scores of the patients on the education

sub-scale (on SADS) for the cycloids was 5.5b (S.D. 1.56), manics

5.52 (S.O. 1.73) and schizophrenics 5.52 (S.D. 1.66). The inter

group differences in the level of education were not significant

(F* 0. 18, 2,72 df, NS).

INCOME: The number of patients in the cycloid group whose income

was less than Rs.900 per month was 7 while those in the manic and

schizophrenic groups with simillar incomes was 7 and 9

respectively. Those with an income in the range of Rs.900-1400 in

the three groups were 10, 7 and 6 while those with an income of

more than Rs.1400 were 8, 11 and 10 in the three sub-groups of

cycloids, manics and schizophrenics. These differences in the

three groups were not statistically significant (X2 = 1.96, 4df,

NS).

CLINICAL VARIABLES :

ONSET: The onset of symptoms was seen to be acute in patients

with cycloid psychosis. The mean time period over which the

symptoms evolved in the cycloid psychotic group was 4.32 days

(S.D. 6.04) which was significantly less than than the time

period over which the symptoms evolved in the manic group, mean

10.44 (S.D. 9.9) , t =2.63, 48df, p < 0.05.

DURATION OF SYMPTOMS: The duration of symptoms prior to

hospitalisation was 16.44 days (S.D. 13|.93) in the case of

58
■■lire-
 TABLE - B

CLNCAL VARIABLES OF THE PATENTS

CYCLOID MANIC SCHIZ.

GAS CON ADM. 1* 18. 62C ±6. 81 25. 64C ±5. 51 26. 60C ±5. 7i

SYMPTOM REMISSION*
16. 44C ±0. 03 20. 08C ±12.13 30. IOC ±12. 81

HOSPITAL STAY** 33. 68C ±16. 49 37. 56C ±10. Q1 46. 24C ±10. 31

NEUROLEP.DOSE"
473.3C +301.13 886. OC ±477. 55 583.1C±336. 01

GAS CON DISCH.I 61.36C ±3. 83 57. Q2C ±4.31 55. 88C ±4. 61

* F * 12.8, 2,72 df, p < O.Ol

Cycloid vs Manic t - 4.02, 48df, p < 0.001.
Cycloid vs Schiz t > 4.48, 48df, p < 0.001.
* F ■ 0.14 2,72 df, p < 0.01

Cycloid vs Schiz. i > 4.20, 48df p < 0.001

** F ■ 2.08, 2,72 df NS

F ■ 0.13, 2,72 df, p < 0.01.

59
 cycloid psychosis while that in the manic sub-group was 50.2

(S.D. 53.14). The duration of symptoms prior to hospitalisation

was significantly less in in the cycloid psychotics (t = 3.05,

48df, p < 0.05). The duration of symptoms and the time period

over which the symptoms was not assessed in the schizophrenics as

most of them had a long duration of illness.

GAS ON ADMISSION: The mean Global Assessment scale ratings of the

patients in the cycloid psychotic group was 18.6 (S.D. 6.83) as

compared to 25.64 (S.D. 5.5) and 26.6 (S.D., 5.7) in the manic and

the schizophrenic sub-group. Thus the cycloids were found to

significantly more disturbed than the manic or the schizophrenic

■•yrwimr patients (F = 12.87, 2,72 df, p < 0.01). Specifically comparing

the cycloids to the manics, the difference in the mean GAS scores

was significant at the 0.001 level (t = 4.02, 48 df).

SYMPTOM REMISSION: All patients were rated at weekly intervals

for a period of one month and following this once in two weeks

till they were discharged, and the time taken for each patient to

achieve a symptomatic remission was calculated. Symptom remission

was defined as the time taken to achieve a score of 1.5 or below

on the Global scale of the CPRS. The global assesssment ratings

were made on the basis of the patients symptom profile, his

biological functioning and his social functioning in the ward

melieu. The mean time taken for the cycloid patients to achieve a

symptomatic remission was 16.44 days (S.D. 9.7) while the time

taken by the manics was 20.08 days (S.D. 12.1) and in the

schizophrenic sub-group it was 30.1 days (S.D. 12.8). The inter

60
group differences were significant with cycloids taking much less
time to achieve a symptomatic remission (F = 9.14, 2,72 df,
P<0.01.). The difference in time taken by the cycloids and manics

was not statistically significant (t = 1.1b, 48df, NS), while the

difference in the time taken by cycloids and schizophrenics to
achieve a symptomatic remission was significantly different (t =
4.2, 48df, p < 0.001). Comparing the duration of episode, that is
from the time when the first symptoms appeared to the time when
the patient achieved a symptomatic remission for the cycloids and
the manics the mean episode duration was 33.12 days (S.D. 18.4)
for the cycloids which was significantly less when compared to
the manics mean duration of the episode of 76.12 days (S.D.
59.03), (t s 3.48, 48df, p<0.001).

HOSPITAL STAY: The total hospital stay for the patients in the
three sub-groups ws also calculated, which was the number of days
from the time of admission till the date of discharge. The mean
number of days spent in the hospital was 33.68 days (S.D. 16.44)
for the patients in the cycloid group while the mean hospital
stay for the manics was 37.56 days (S.D. 19.9) and for the
r
schizophrenics it was 46.24 days (S.O. 19.3). Though the cycloids
had the least stay in the hospital the diferences across the
three groups were not statistically significant (F = 2.98, 2,72
df, NS).

TREATMENT: All patients in the manic and the schizophrenic

subgroups were treated with neuroleptics. In cycloid sub-group
one patient was treated tricyclic antidepressants and

Electroconvulsive therapy (ECT) and one patient had a

spontanoeous remission of symptoms while under observation

awaiting diagnostic clarification. The mean daily dose of

neuroleptics (converted into chlorpromazine equivalents) was

437.3 mgms. (S.D. 301.2) for the patients in the cycloid sub-

group. The mean daily dose for the manic and schizophrenic groups

was 886.9 mgms. (S.D. 477.5) and 583.1 mgms. (S.D. 336.9)

respectively. The cycloid sub group required the least amount of

neuroleptcs and the inter group differeces were statistically

significant (F% = 9.13, 2,72 df, NS), with the difference between

the cycloids and the manics being significant at 0.001 level (t =

3.98, 46 df).

In addition to neuroleptics 56% of the patients in the manic

sub group were in addition given lithium while only 8% of the

patients recieved lithium and another 8% receved carbamzepine in

the cycloid sub-group, one of the schizophrenic patients receved

lithium.

5 patients in the cycloid sub-group receved tricyclic

antidepressants in combination with neuroleptics / ECTs while

only one patent in the schizophrenic sub-group recieved

antidepressants. None of the patents in the manic subgroup were

given antidepressants.

ECT as a mode of treatment was used in 4 patients in the

manic subgroup (the mean number of applications was 5.25) as

compared to 3 aptients in the cycloid sub-group (the mean number

62
of appliations was 5)

GAS ON DISCHARGE : The patients in the cycloid sub group not only

improved fater but were rated to be better as compared to manics

and schizophrenics at the time of discharge. The mean GAS of the

cycloids at the time of discharge was 61.36 (S.D. 3.81) as

compard to GAS score of 57.92 (S.D. 4.25) for the manic sub-group

and 55.88 (S.D. 4.56) for the schizophrenic subgroup.These

intergroup differences were statistically significant, F'4 -

11.34, 2,72 df, p < 0.01.

PHNOMENOLOGY

The phenomoenology of the patients with cycloid psychosis

0

was assessed in two ways based on the patients ratings on CPRS.

In the first method the differences in the patients ratings

|
on CPRS in patients with cycloid psychosis were found out. This

was donecomparing the number of patients who had a score of 2 or

more on the items of the CPRS with those in the manic and the

schizophrenic subgroup. The results are shown in Table C.

This analysis shows that patients with cycloid psychosis

show an increased frequency Inner tension, Reduced appetite.

Reduced sleep. Subjective feeling of anxiety,Auditory and Visual

hallucinations. Inappropriate affect. Objective autonomic

disturbances. Perplexity, Incoherence, Agitation and Mannerisms

and posturing when compared to with mania. The manics were

differentiated from the cycloids on the increased frequency

Elation, Increased libido. Grandiosity, Objectively rated elated

63
 TABLE - C

PERCENTAGE OF PATIENTS SCORING 2 OR ABOVE ON THE CPRS

CYCLO0 MANC SCHIZ.

Sadness 12 O 16
Elation 20 96444 16
Inner Tension 52 4444 20
Hostile Feelings 28 32 20
Inability to feel 12 0 6
Pessimistic thoughts 16 0 12
Suicidal thoughts 8 0 8
Hypochondriasis 20 4 12
Worrying 20 4 12
Compulsive thoughts 8 0 8
Phobias 4 0 8
Rituals 0 6 4
Indecision 12 8 16
Lassitude 12 4 16
Fatigue 8 0 12
Low concentration 2 0 16
Reduced Memory 16 0 16
Reduced appetite 52 1644 48
Reduced sleep 84 12444 4844
Inceased sleep 0 0 8
Reduced sexual intrest 8 0 12
Increased sexual inrest 0 4044 4
Anxiety 64 Aeae 2044
Aches and pains 20 8 12
Muscular tension 4 0 8
Conversion 4 O 8

64
 TABLE - C CContd.l

PERCENTAGE OF PATIENTS SCORING 2 OR ABOVE ON THE CPRS

CYCLOD MAMC SCHZ

D»r»alisation 16 0 20
Depresonalisailon 16 0 24
Feeling controllad 12 4 484
Disruptad thoughts 8 4 4444
Parsacution 68 86 88
Grandaur 40 02*** 24
Dalusional mood 12 0 0
Ecstatic 16 12 0
Norbid jaalosy 16 4 32
Othar dalusions 44 32 44
Voicas commenting 4 4 3244
Auditory hallucinations 84 «U444 86
Visual hallucinations 48 12*4 32
Othar hallucinations 12 12 16
Sadnass 24 0 16
Elation 28 02444 4
Hostility 72 82 40
Labila 82 32 24
Inappropriate affact 40 044 86
Autonomic disturbances 44 84 124
Reduced sleep 76 80 64
Distratibility 28 684 12
Withdrawl 16 0 12
Parpaxity 82 0444 044=
Blank spalls 4 0 0
Disoriantation 28 12 8
Pressure of speech 4 60444 0
Reduced speech 12 0 8
Speech defect 4 0 0

65
 TABLE - C CContd. >

PERCENTAGE OF PATIENTS SCORING 2 OR ABOVE ON THE CPRS

CYCLOD MANC SCHE

Flight of ideas 12 68444 0

Incoherence 56 10
Perseveration 4 O 4
Overactive 40 64 84
Reduced movements 16 0 4
Agitation 72 324 644
Involuntary movements 0 0 4
Muscle tension 12 0 0
Mannerisms and posturing 32 044 44
Hallucinatory behaviour 20 4 604

with Yates correction

4 p < O.S

44 p < 0.01

444 p < 0.001

66
mood, Distractibility, Pressure of speech and Flight of ideas.

When compared to the schizophrenics, the cycloids had

increased sleep difficulties, anxiety, objectively rated
autonomic disturbances. Perplexity, Voices commenting.
Overactivity and Agitation, while the schizophrenics had more
disrupted thoughts, delusions of control and hallucinatory
behaviour.

In an attempt to see if the patients with cycloid psychosis

can be grouped on the basis of their clinical profile, the
patients ratings on the CPRS were subject to cluster analysis. In
the method used for doing the cluster analysis (Cohen, 1988),
distance matrices were made on the basis of the correlation
coefficients of each variable against the other, which was then
subtracted from one to get rid of the negative sign. Dendograms
were then made from the distance matrix to yeild the clusters. To
reduce the size of the matrix only ratings of the observed
section of the CPRS was taken togeter with items relating to the
psychotic phenomenon which were relevent to the three diagnostic
sub-categories being sudied were taken. A total of 38 variables
was thus obtained and these were subjected to cluster analysis.
The 38 variables which were taken were : Delusions of control
(XI); Disrupted thoughts, including thought block, thought
withdrawl and thougt brodcast (X2); Delusions of Persecution
(X3); Delusions of grandeur (X4): Delusional mood (XS); Esctatic
expereinces (X6); Morbid jealosy (X7); Other delusions <X8);
Commenting voices (X9); Other auditory hallucination (X10);

67
Visual hallucinations (Xll); Other hallucinations (X12); Apparent

sadness (X13); observed elation (X14); Hostility (X15); Labile

emotional responses (Xlb); Lack of appropriate emotion (X17);

Autonomic disturbances (X18); Sleep (X19); Distractabi1ity (X20);

Withdrawl (X21); Perplexity (X22); Blank spells (X23);

Disorientation (X24); Pressure of Speech (X25); Reduced speech

(X2b); Speech defects (X27); Flight of ideas (X28); Incoherent

speech (X29); Perseveration (X30); Overactivity (X31): Slowness

of Movements (X32); Agitation (X33); Involuntary movements

(X34);Muscular tension (X35); Mannerisms and Posturing (X36);

Hallucinatory behaviour (X37); Global rating of illness (X38);

The distance matrix for cycloid psychosis is given Appendix V.

The cluster analysis revealed the following clusters of

symptoms :

(I) Incoherence, Perseveration, Hostility, Overactivity,

Inappropriate affect and Lability.

(II) Pressure of speech. Flight of ideas. Distractibi1ity and

Delusions of control.

(III) Auditory and Visual hallucinations. Delusions of

persecution.

(IV) Grandiosity and esctacy.

(V) Agitation and reduced sleep.

(VI) Reduced speech, blank spells, and withdrawl.

6B
(VII) Reduced movements. Mannerisms and Posturing,

(VIII) Perplexity, Autonomic symptoms and Disrupted thoughts.

These were the first eight clusters to emerge and the rest

of the symptoms did not form any clusters. The severity of the

illness was not related to any particular cluster. From the

clustering it is evident symptoms in clusters VI and VII

correspond to the inhibition of phase of confusion psychosis and

the akinetic pole of motility psychosis respectively. Clusters

III, IV and VIII are best related to Anxiety elation psychosis.

Clusters I and II which have the largest number of symptoms are

polymorphous in the sense that have intermingled symptoms of the

excited phase of Confusion psychosis and the Hyperkinetic pole of

Motility psychosis while cluster V does not seem to be typical of

any one subtype.

Similar cluster analysis was carried out in the other two

groups also using the same 38 variables. In case of patients with

a manic disorder, the clusters which emerged were:

(I) Severity of illness, Distractibility, Pressure of speech,

Flight of ideas and Grandiosity.

(II) Lability of affect, Visual hallucinations and Other

delusions.

(III) Delusions of prosecution. Hostility abd Auditory

hallucinations.

Patients with symptoms in the first cluster would correspond

to atypical elated grandiose manic while those in the other two

69
clusters would correspond to a Manic disorder with with psychotic

features.

Clustering techniques applied to the schizophrenic patients

revealed the following clusters :

(I) Severity of illness. Hostility and Agitation.

(II) Voices commenting. Visual hallucinations, Other

hallucinations. Pressure of speech.

(III) Incoherence and Other delusions.

(IV) Delusions of control Persecution and Auditory

hallucinations.

(V) Delusions of Persecution, grandiosity and elation.

(VI) Reduced movements, Ulithdrawl and Reduced speech.

The symptoms in the last cluster correspond to Residual

Schizophrenia, while the other clusters would be related to

Paranoid, Disorganised and Undifferentiated schizophrenia

depending upon the content of psychopathology.

The variability of the clinical picture of cycloid psychosis

was also reflected in the final diagnosis which the patients

recieved at the chart meeting on I CD-9 following their discharge.

Whereas all patients in the schizophrenic sub-group had a

diagnosis of schizophrenia (ICD-9, 295) and 24 of the 25 patients

in the manic subgroup had a diagnosis of MDP-M (296.0 or 296.2)

of the 25 cycloids, 5 patients recieved a diagnosis of

Schizophrenia ( 2 Acute Schizophrenic Episode, 1

70
Schizoaffective St 2 - Schizophrenia NOS). 9 Patients had a
diagnosis of Manic-Depressive Psychosis (6 - MDP-M, 1 - MDP-D, 2
- MDP Current condition not specified) and 11 patients had a
diagnosis of Other Nonorganic Psychosis (2 - Excitative Type & 9
- Psychosis Not otherwise specified).

£QUB§£ m QUIQQ8& i
The course and outcome of the patients in the three
categories was assessed using the ratings from SADS, GAS. and
SAPD (Table - D).

AGE OF ONSET i

The mean age of onset of the patients in the cycloid group

was 29.52 years (S.D. 7.27). while the mean age of onset for the
manic and the schizophrenic subgroup was 27.24 years (S.02) and
24.7b years (S.D. b.65) respectively.These inter-group
differences were significant at the 15f level (F = 3.18, 2,72 df).
The cycloids had a later age of onset as compared to the manic
subgroup but the difference in the age of onset did not approach
statistical significance (t = 1.22, 48 df, NS). In the the
cycloid group the mean age of onset of the illness in the females
was 32.5 years (S.D. 8.02) was later than the age of onset in the
males 28.11 years (b.&8) but the diference was not significant
statistically (t = 1.44, 23df, NS)

71
 TABLE - D

PRE - HOSPITALISATION VARIABLES

CYCLOID MANIC soaz

AGE OF ONSET 20. S2 m 27.24 24.76 F - 3.184
C7.273 t C6.023 C6.653

ADOLESCENT. 2.02 3.12 4.44 F * 18.34

FRIENDSHIP CO. 765 CO. 783 CO. 773

EPISQDE&/YR. 0.73 0.63 NS

CO. 783 CO. 183

TINE IN HOSP. 52.32 107.2 88.36 NS

CDAYS3 C32.O03 018. 353 C88.323

WORK LAST 1.38 2.40 4.80 F - 50.784

S YRS. CO. 643 Cl.083 Cl.773

4 F ratio, 2,72 df, p < O.Ol.

72
PBE-MOBBID CHARACTERISTICS i

There were no differences in the occurence of maladaptive

personality traits in the patients in the three groups as

assessed by SADS, but if we take adolescent friendship patterns

as a measure of premorbid adjustment then significant differences

emerged. The mean score on the adolescent friendship (on SADS)

for the cycloid subgroup was 2.92 (S.D. 0.7b) while the scores

for the manic and schizophrenic subgroup was 3.12 (S.D. 0.78) and

4.44 (S.D. 0.77) respectively. These inter group differences were

significant at the 1 v. level (F = 18.3, 2,72 df).However the

differences in the manic and the cycloid groups was not

statistically significant (t s 0.92, 48 df), revealing that the

schizophrenics were more likely to be maladjusted premorbidly

than the other two groups.

COURSE OF ILLNESS *.

The course of illness was continuous for all patients in the

schizophrenic group while it was episodic for patients in the

cycloid and the manic groups. There were lb patients in the manic

subgroup who had had more than one episode of illness as compared

to 11 patients in the cycloid group. The mean frequency of

episodes per year for patients in the manic group was 0.63 (S.D.

0.18) as compared to the frequency in the cycloid sub-group of

0.73 (S.D. 0.49). This increased frequency in the cycloid sub-

group was not statistically significant (t = 0.63, 25df, NS)

The patients scores on the work output in the last 5 years

(on SADS) was compared to give an idea of level of functioning

prior to admission for the index episode. The mean score for the

73
cycloids was 1.36 (S.O. 0.64) as compared to the manics (S.O.

1.08) and the schizophrenics who had a score of 4.8 (S.D. 1.77).

The inter group differences were significant at the IX level (F =

50.78, 2,72 df). The functioning of the cycloids was better than

the manics (t = 4.14, 48 df, p < 0.001), while that of the manics

was better than the schizophrenics (t s 5.88, 48 df, p < 0.001).

The mean time spent by the patients in hospital during their

entire course of illness, in the cycloid group was 52.32 days

(S.O. 32.09) while it was 107 days (S.D. 118.8) and it was 84.36

days (S.D. 88.32) for the schizophrenic sub-group. Though the

mean time spent in the hospital was much less in the cycloid sub­

group, the differences were not statistically significant in view

of the high variances involved ( F = 2.98, 2,72 df, NS ).

OUTCOME OF ILLNESS :

The outcome of the illness was assessed using GAS and SARD

at one and six months following discharge (Table - E and F). Of

the 25 patients in the cycloid sub-group, 3 patients were

readmitted with fresh episodes of illneiss. All the three patients

were males, and two of these patients had episodes exactly

simillar to the previous ones and in one patient the episode

fulfilled the criteria for a manic disorder. In the manic sub­

group 2 of the patients were readmitted and in one of the

patients the episode fulfilled the criteria for a schizomanic

disorder,

74
 TABLE - E

RESULTS OF FOLLOW - UP AT ONE MONTH

CYCLOID MANIC schiz

GAS 66.32 61.70# 65.60## F ■ 80. 12*

C 3. 03) C3.16) C3.47)

OVERALL BEH. 0.61 0.61 0.81# F ■ 6.18 *

CO. 30) CO. 52) CO. 53)

SOCIAL ROLE 0.41 0.42 0.76 MM F ■ 8.48 *

CO. 30) CO. 31) CO. 33)

OCCUP. ROLE 0.43 0.80 • 1.43 F * 15.2 *

CO. 20) CO. SB) CO. 63)
•

OVERALL DIS. 0. 60 1.30 ~ 1.85~~ F - 20.13*

CO. 63) CO. 68) CO. 60)

F ratio, 2,63 df, p < O.Ol

# Cycl. vs Manic t a 4.0, 44df , P < 0.001
## Cyci. vs Schiz t a 6.1, 41 df, P < 0.001
# Cycl. vs Schiz t a 2.1, 41 df, P < 0.08
## Cycl. vs Schiz i a 3. 6, 41 df, P * 0.001
• Cycl. vs Manic t a 3.6, 44df , P < 0.001
Cycl. vs Manic t a 3.8, 44df , P < 0.001
Manic vs Schiz t ■ 4.4, 41 df, P < 0.001

75
 TABLE - F

RESULTS OF FOLLOW - UP AT SIX MONTHS

CYCLOID MANIC soaz

GAS 60.2 66.6 90*6 4 F m 25.0 *

C3.0Q3 C4.033 C3.793
OVERALL BEH. 0.39 0.47 0.76 44 F - 5.93 *
CO. 330 CO. 413 CO. 373

SOCIAL ROLE 0.32 0.20 0. 63 # F ■ 7.7 *

CO. 275 CO. 213 CO. 373

OCCUP. ROLE 0.54 0.86 ~ 1.33 MM F * 20.4 *

CO. 303 CO. 903 CO. 993

OVERALL DIS. 0.54 1.05 1.93 ~~ F.- 10.82

CO. 503 CO. 673 CO. 713
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76
ONE MONTH FOLLOW-UP

At one month follow-up the cycloids were significantly

better than the schizophrenics on all measures of outcome,

namely, GAS, Overall behaviour. Social role. Occupational role

and Overall disability (Table - E). When compared to the manics,

the cyloids were better on measures of GAS, Occupational role,

and overall disability, but there were no significant differences

on their score on overall behaviour and social role,

SIX MONTH FOLLOW-UP :

At the end of six months the differences between the

cycloids and manics had further narrowed down and except for the

difference in occupational role there was no sighificant

difference as measured by GAS, Overall behaviour. Social role and

Overall disability (Table - F) The inter group differences which

persisted at a significant level was due to the poorer outcome of

schizophrenics on all the measures.

77
DISCUSSION
 The present study identified patients with Cycloid Psychosis
and their phenomenology, course and outcome was studied and
compared with age and sex matched patients of Schizophrenia and
Mania. The randomness of the matching procedure was ensured by
taking the consecutive patients who were suitable into the study,
and this makes the study very highly comparable even though the
sample size was not very large.
The 25 patients of cycloid psychosis who were taken into the
study constituted 4.3% of all psychotic patients who were
admitted during the same period. This hospital admission rate of
Cycloid Psychosis appears to be lower than the proportions which
have been reported by Brockington (1981b) of 10% and of Cutting
(1978) of 8% of all psychotic admissions. This could be because
both the studies mentioned had retrospective study design which
enabled them to diagnose cases after all the information
regarding the phenomenology of the case during the admission and
the course of the illness were available to them, whereas in the
present study paients were taken ino the study only if they
fulfilled the study criteria of Cycloid Psychosis at the time of
admission. Thus patients presenting with an acute disorganised
behaviour who were not diagnosable at the time of admission, but
later on suggested a diagnosis of cycloid psychosis missed being
included into the present study. It is of course possible that
the hospital admissions of cycloid psychosis are lower here than
that seen in the west, but we are more inclined to accept the

78
former explanation.
There was also a difference in the proportion of the female
patients which constituted the present sample as compared to
other studies. Most of the different studies have commented on
the over representation of female patients in studies on cycloid
psychosis. In the present study female patients comprised of 32%
of the sample, and though it is less than the propotion which
has been found by Perris - 73% (1974), Cutting - 90% (1978) and
Maj - 65% (1988), our study proportion of female patients was
higher than the hospital proportion of female patients who were
admitted during the same period, which was 25.83%. The less
proportion of female patients is probably due to a multitude of
social factors operating in our country whifeh make it less likely
for the guardians to bring female patients for hospitalisation,
and this less number of female patients is not something which is
specific for cycloid psychosis. Another reason for the less
proportion of female patients could also lie in the emphasis
which both Perris (1988) and Cutting (1978) have placed on post­
partum psychotic disorders presenting as cycloid psychosis. In
our study sample there were no cases which presented with onset
of symptoms in the post-parturn period.
There were no significant differences across the various
socio-demographic variables of marital status, religion, income,
education or residence which could explain the difference in the
results obtained by the study.. It is intresting to note that 66%
of the schizophrenics were from joint or extended nuclear
families as compared to 38% in the other two groups, highlighting
the role of social factors which are believed to contribute to

79
the better prognosis of schizophrenia in the developing nations
(International Pilot Study of Schizophrenic, WHO, 1973).
The acute onset of symptoms in patients with cycloid
psychosis was very much obvious in this study, with the mean
period of time over which the symptoms evolving being 4.32 days
and this was significantly less than the manics, who have also
been described to have an acute onset of illness. Of the 25
cycloids, 15 (60%) of the patients had their symptoms evolving in
less than 48 hours while by 96 hours 84% of the patients had a
full blown psychotic condition. There were only four patients who
had non-specific prodromal symptoms lasting one to two weeks. The
present study figures of the evolution of symptoms are comparable
to those in Perris’ study, in which 86% of the patients had an
acute onset of illness.
The evolution of a full blown psychotic episode over a short
period of time was reflected in more than one way in the present
I
study. The mean duration of symptoms prior to hospitalisation in
these cases was significantly less when compared to manics
suggesting that patients with cycloid psychosis are consdired to
be more seriously disturbed, and hence are brought earlier to the
hospital. The significantly higher level of behavioural
disturbance was also reflected in their mean GAS ratings at the
time of admission. The cycloids were consistently rated as more
disturbed as compared to the manics or the schizophrenics.
All the cycloid patients in the present study achieved a
symtomatic remission as did the manic and the schizophrenic
patients, according to the criteria employed for measuring

80
 symptomatic remission, however the post hospitalisation
functioning of the schizophrenics was poorer than the the other
two groups. As a consequence of having lesser duration of
symptoms prior to hospitalisation and achieving a quicker
remission of symptoms, the mean episode of length of the
cycloids, which was 33.12 days was significantly less as compared
to the manics. It must be emphasised that duration of the episode
was defined as the time from the onset of the first signs of the
illness to the time taken to achieve a score of 1.5 on the global
rating item of the CPRS. This episode length of 33.12 days was
much less than what has been reported fey Leonhard, who stated
that the length of the epiosode of anxiety elation psychosis is
simillar to that of affective disorders, shorter for those
with confusion psychosis and longer for those with motility
psychosis. Perris (1974) has commented upon the unsatisfactory
!
method of assessing episode;durat ion in Leonhard's study. The
episode length which was assessed by Leonhard was dependent upon
nri** the case notes, the hospital policy on discharges, and the
initial diagnosis and treatment being given to the patient (e.g.
a diagnosis of schizophrenia would mean prolonged insulin coma
therapy). The retrospective nature of most of the studies
prevented the author from assessing this question properly. The
results of the present study suggest that the previous reports
may have overestimated the duration of the episode, though these
findings must be regaded as prelimnary keeping in mind the small
sample size.
The lesser duration of the episode in case of patients with
cycloid psychosis or the more time taken by the schizophrenics to

81
 I

achieve a symptomatic remission was not reflected in the mean

duration of the hospital stay. Though the cycloids spent lesser

time in the hospital as compared to the other two groups* these

differences were not statistically significant. This is just a

reflection of the hospital policy which encourages discharges

only when the guardians come to take their patients* as a result

of which the discharge of the patients is often delayed.

One of the most interesting findings of the present study

was with reference to the treatment which was recieved by the

patients. The mean daily neuroleptic dose given to cycloid

psychotics (converted nito CPZ equivalents) was 437.3 mgms. which

was significantly less than the daily dose given to the manics.

The excellent response shown by the patients while on lower doses

of neiirleptics is paticularly important when we consider the fact

that Perris has suggested a treatment strategy for cycloid

psychotics* which is used by him consisting of rapid

neuroleptisation with haloperidol* in doses of 20-40 mgm./day in

combination with lithium. The usefulness of rapid

neuroleptisation in Psychiatric disorders has not yet been

established (Salano et.al.* 1789)* and the findings of the

present study brings about the need for more definitive

treatment stategies for cycloid psychosis. In this connection it

is intresting to note that in the study by Kapur and Pandurangi

(1979) the mean daily requirement of chiorpromazine in patients

of Acute psychosis without a precipitating factor (which would

ovelap with the concept of cycloid psychosis) was 377 mgm./day

which nearer to our findings. The different neuroleptic

82
requirement in the cycloid group cannot be attributed to

concurrent use of lithium or ECTs as fewer patients in the

cycloid group were given ECTs or put on lithium, nor can it be

attributede to severity of illness as patients in the cycloid

group were more severly disturbed. ECT did not appear to be the

prefered mode of treatment for cycloid psychotics as only three

patients were given ECTs, of whom two had shown previous response

to treatment with ECTs. The mean number os applications which

were needed were S which is simillar to what Perris (1988) has

suggested that these patients require 6-8 applications.

The phenomenology of the patients with cycloid psychosis was

assessed in two ways. The percentage of patients who rated two or

above on items of CPRS was compared with t|*e other two groups.

The results obtaine this way were in part a reflection of the

diagnostic criteria used diagnose these patients. Thus patients

with cycloid psychosis were more likely to have inner tension,

complaints of reduced sleep and apetite, anxiety, auditory and

visual hallucinations, inappropriate affect, incoherence,

agitation, mannerisms and posturing as compared to manics, while

the manics as expected had greater prevalence of elated affect,

increased libido, grandiosity, pressure of speech, and flight of

ideas. Simillarly the schizophrenics had lesser complaints about

about apetite, lesser anxiety, perlexity, overacivity and

agitation and more delusions of control, disrupted

thoughts,voices commenting and hallucinatory behaviour. Of the

First Rank Sumptoms (FRS), as assessed by SADS and CPRS, 72% of

the schizophrenics had FRS as compared to 12% in the manic

subgroup and 20% in the cycloid psychotics. This figure of 20% is

83
in the cycloids is less when compared to the 41* in the British

series who had FRS (Perris, 1988) who had thought insertion and

42* had thought alienation (though the total percentage of

patients having FRS is not Known). Simillarly Cutting (1978) had

reported 53* of his cycloids as having FRS. in the same study the

percentage of manics with FRS was 8* and schizophrenics was 60*.

The results of the present study are in closer to Maj's findings

(1988) who foud 20* of his patients as having alienation

experiences, disrupted thoughts and voices commenting each

(though once again the total percentage of patients having FRS is

not known). The higher percentage of FRS in schizophrenics can be

understood when we take into account the fact that the DSM-IIIR

criteria which were used are heavily weighted towars FRS. We feel

that great caution must be excercised in commenting upon FRS in

cycloid psychotics. Fish (1985) has spoken of some anxious and

bewildered patients who cannot think clearly, and may therefore

feel "as if" they are being controlled by foreign inluences. As

they have difficulty in thinking and putting their thoughts into

words, if they are asked about these experiences these patients

are likely to take up the suggestion and agree with it as it

explains their difficulties in thinking and acting.

The results of the cluster analysis confirm the findings of

Perris (1974) which had suggested that most of the time it is not

possible to classify patients int sub-types as originally

described by Leonhard. Though the symptom clusters suggesting

anxiety elation psychosis, inhibited confusion psychosis and the

akinetic phase of motility psychosis did qmerge, the largest of

84
the clusters suggested that the syptomatology of cyloids is

polymorphous. This was reflected in the final ward diagnosis of

these patients which was distributed across Schizophrenia. Manic-

Depressive Psychosis and Other Nonorganic Psychosis as has been

repported earlier by Cutting (1978) and Maj (1988). The episodic

nature of the illness was the most frequent rationale in

diagnosing these patients as Affective Disorders, while their

categorisation into Psychosis NOS (298.9) reflects the diagnostic

uncertainty which the clinicians faced and they therefore put

them in a residual category. 88‘4 of the patients recieved a

differential diagnosis which was from another diagnostic

category. A differential diagnosis of Complex Partial Seizures

with psychosis was considered in 3 patients of cycloid psychosis,

mainly because of the sudden appearance of the symptoms with

perplexity and clouding of sensorium.

The findigs of the present study confirm that the patients

of cycloid psychosis have a course and out come which is

different from other psychotic conditions. In the present study

sample the cycloids had a mean age of 31.28 years which is

simillar to the mean ages of the study sample of Brockington

(1982b) which was 32 years and that of Cutting (1978) which was

31.5 years but lower than the mean ages of the samples studied

by Perris (1974) of 38.9 years and by Maj (1988) of 35 years.

However what is more important that the present study confirmed

that the mean age of onset of illness of patients with cycloid

psychosis is later than that of Manics and the age of onset is

later in femalBS as compared to amles. Our findigns of the mean

age of onset of illness for males as being 28.11 years and for

85
females being 32.5 years are simillar to the findings of Perris
(1974) who had reported the mean age of onset to be 26.2 years
for males and 32.2 years for females. The schizophrenics were
significantly more maladjusted pre-morbidly as compared to
cycloids though the difference between the cycloids and manics
was not significantly different. Both schizophrenics and manics
had apoore work output as compared to the cycloids in the 5 years
preceding the index admission, but this was probably because of
their earlier age of onset.
Both Perris (1988) and Cutting (1978) had reported that
cyloids had an tendency to have more frequent episodes as
compared to the patients with affective disorders. Our findings
on patients who had had more than one episode (including the
index episode) showed that the frequency of episodes per year for
the cycloids was 0.73 and that for the manics was 0.63. Our
figures for the episode frequency are simillar to those quoted by
Perris (1988) about the studies done by Angst and Hatoni.
However though the episode frequency of the cycloids as compared
to the manics was more, these differences were not statistically
significant. In the prospective follow-up of these patients, 3
patients of cycloid psychosis had a fresh episode as compared to
2 episodes in the manic but these figures are too small for any
meaningful statistical analysis. Perris has also reported that
I
males has reported that males have greater chance of a relapse as
compared to females. In our series all the patients with cycloid
psychosis who relapsed were males.
The cycloids were best differentiated from the other two
 groups when their short term course and outcome is compared. The
patients with cyclod psychosis were rated to be better at the
time of discharge as compared to both manics and schizophrenics.
At one month post discharge the cycloids had shown better
adjustment and were rated to be better than patients with
schizophrenia on all measures. As compared to patients with manic
I
disorder, cycloids were better when assessed on GAS. Assessments
on SAPO revealed significant differences in overall disability

-frw-f**' and occupational functioning but were simillar to the cycloids as

far as their overall behavior and social functionig was
concerned.
These differences between the cycloids and the manics
further reduced when assessment was done after 6 months. There
was no significant difference between the cycloids and manics
when comparisons were made of their scores on GAS and all the
items of SAPO except their scores on occupational functionig.
which showed that manics had a poorer outcome as for as
occupational functioning is concerned when compared to cycloids.
The schizophrenics had a poorer outcome consistently on all
measures of outcome when compared to the cycloids or manics.
These findings lead credence to the most important characteristic
of the concept of cycloid psychosis, that is its undoubted
prognostic validity. Though the duration of the prospective
followup in this study has been short our findings support the
contention that cycloid psychotics have a significantly better
short term outcome as compared to patients with mania or
schizophrenia though in case of patients with mania the
differences tend to ease out with longer follow -up period.

87
CONCLUSIONS
 The present study has shown that using the criteria for
Cycloid Psychosis a significant proportion of patients being
admitted in our hospital can be diagnosed as Cycloid Psychosis,

These patients have a distinct clinical profile which is

well differentiated from both schizophrenia and mania. However
because of their polymorphous symptomatology they most often get
slotted into Affective Disorders because of their episodic course
or into the Schizophrenic Disorders on the basis of some aspect
of their clinical profile or in the residual category of
Psychosis Not Otherwise Specified.
Patients with Cycloid Psychosis can be differentiated from
Schizophrenia and Affective Disorders on the basis of their
course and outcome. They have a later age of onset as compared to
these two disorders, a shorter duration of episode and better
inter-episodic functioning when compared to patients with
Affective Disorders. Though the duration of follow-up was short
patients with cycloid psychosis have shown a tendency to have
I
more frequent relapses than patients with Affective Disorder.

On outcome measures patients with Cycloid Psychosis did

significantly better than schizophrenics, but when compared to
manics at the end of six months except for the area of
occupational functioning where the outcome of manics was poorer
there were no significant differences.

89
 Acute psychosis have for long been recognised as common mode

presentation for psychotic disturbances in India. They have also

been recoghised to comprise of a very heterogenous group, though

distinct from schizophrenia and affective disorders. Their

overlap with other "atypical" psychotic conditions have also been

long recognised. The present study has shown that a substantial

proportion of these cases are cases of Cycloid Psychosis which

masquerade under a variety of diagnostic labels. These patients

sq identified have a clinical profile, course and outcome which

is simillar to that which has been described in other parts of

the world. The present study has sought to establish the

nosological validity of this condition on the basis of its

clinical profile and course and outcome. However more studies

will be needed to establish the validity of this disorder on

other parameters which not been touched in the present work,

namely family studies, biological corelates including genetic

factors, psycho-social factors which may be implicated in this

condition and the issue of treatment. There is preliminary

evidence to suggest that Cycloid Psychosis can be differentiated

on all these facotrs, but furter studies would be needed.

The problem with research on Cycloid Psychosis for long has

been the lack of an accepted diagnostic criteria. Its inclusion

in the 10th revision of the International Classification of

Diseases is a big step forward. It is also auspicious that a

similar addition will occur in the DSM-IV. Its recognition in

these two major classificatory systems will pave way for research

with much larger series of patients and from different regions

90
than has till now been reported. It is only after this that the
position of Cycloid Psychosis in psychiatric nosology can be
firmly established.

91
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100 !
APPENDICES
 APPENDIX - 1

DIAGNOSTIC CRITERIA FOR CYCLOID PSYCHOSIS

1) An acuta psychotic condition, not ralatad to

administration or abusa of any drug or brain injury, which
occurs for tha first tima in tha aga ranga of 18-00 yaars.

2} Tha condition has a suddan onsat with a rapid changa

from a stata of haalth to full blown pschotic condition within a

faw hours to at tha most faw days. r

33 Atlaast four of tha following must ba prasant :

<A> Confusion of soma dagraa mostly axprassad as
parplaxity or puzzlamant.
<B> Mood incongruant dalusions of any kind, most
of tan with a parsacutory contant.
CO Hallucinatory axpariancas of any kind, of tan
ralatad to thamas of daath.
<D> An ovarhalming, f r i ghtani ng axparianea of
anxiaty, not bound to particular situation or
cicumstancas Cpananxiaty3.
<E> Daap faalngs of happinass or acstacy, most oftan
with a raligious colouring.
<F> Motility disturbancas of tha akinatic or
hyparkinatic typa which ara mostly axprassional.
<G> A particular concarn with daath.
<H> Mood swaings in tha background, not so
pronouncad to justify a diagnosis of affactiva
disordar.
43 Thara is no fixad symptomatological combination : on tha
contrary, tha symptomatology may changa fraquantly during an
apisoda and shows a bipolar charactaristic.
 APPENDIX -II

SUMMARISED DSM-IIIR CRITERIA FOR MANIC EPISODE

A> A distinct period of abnormally and per si s tent 1 y

elevated* expansive or irritable mood.
ID Three of the following C/our if the mood is only
irritable^
1. Grandiosity
2. Decreased need for sleep.
3. More talkative.
4. Flight of ideas or racy thoughts.
5. Distractability.
6. Increased goal directed activity.
7. Excessive involvement in pleasurable activities.
O Impairment in social or occupational functionig or
hospi tal i sati on.
D) No delusions or hallucinations for as long as two weeks
in the absence of mood symptoms.
E> Not superimposed on schizophrenia, schizophreniform
disorder. Delusional disorder or Psychotic disorder NOS.
F) Not due to organic factors.

102
 APPENDIX -HI

SUMMARISED DSM-IIIR CRITERIA FOR SCHIZOPHRENIA

A) Presence in the active phase of either CiD, C2D or

C33.for atleast on* week.
C13. Any two
a) Dol-usions
63 Prominent hallucinations..
c3 /ncoherence or marked formal thought disorder.
cD Catatonic behaviour.
e> Flat or grossly inappropriate affect.
C23 Bizzare delusions.
C33 Non-affactive hallucinations.

B3 Impair merit in personal, social and occupational

functioning.

O Schizoaffective and mood disorders have been ruled out.

D> Continuous illness for 6 months including prodromal and

residual symptoms.

E3 Organ!city has been ruled out.

Y.

■m-*- •**•«*" •

103
 APPENDIX -IV

SCHEDULE FOR ASSESSMENT OF PSYCHIATRIC DISABILITY FOR

OUT - PATIENTS CSAPD3

0 1 2 3 4 5 0

part - I OVERALL BEHAVIOUR

t.i Self Care
1.2 Spare tin** Activity
1.3 Speed of Pot formane e
1.4 Intrest and Information
1.5 Emergency Situations

PART - II SOCIAL ROLE

2.1 Housshold Activities.
2.2 Communication
2.3 Social Contact Friction
2.4 Marital - Affsctixus
2.5 Marital Sexual
2.6 Parental Role

part - hi OCCUPATIOAL ROLE

3.1 Performance
3.2 No. of utorhing days
3.3 Occupational intrests.

part - iv OVERALL DtSABUTY c o, l 2 3, 3

104
 APPENDIX - V

BISI&aCE B5IBI* EQ8 CiCLQIQ eSXCliQSIS

XI X2 X3 X4 XS X6 X7 X8

XI 0
X2 1.091 0
X3 0.771 1.068 0
X4 1. 137 0.812 0.753 0
X5 0.782 1.086 0.842 1. 138 0
X6 1. 186 0.824 0.768 0.368 1. 121 0
X7 1.108 1. 124 0.716 1.082 1. 166 1.230 0
X8 0.747 0.757 0.816 0.933 0.932 1.005 1.064 0
X9 1.060 1.070 0.842 1.220 0.363 1. 128 1.075 1. 168
X10 0.791 0.830 0.343 0.649 1.012 0.721 0.844 0.990
Xll 0.677 0.706 0.672 0.699 0.982 0.678 1.009 0.795
X12 0.702 1.147 0.644 0.948 0.887 0.931 0.870 0.823
X13 1. 176 0.962 1.247 1.503 1.016 1.375 0.934 1. 169
X14 1.210 1.127 1. 126 0.453 1. 177 0.606 0.989 1.246
X15 0.877 1. 120 0.812 0.542 1.830 0.852 0.848 1.026
X16 1.318 1.290 1.643 0.897 1. 100 0.788 0.825 0.982
X17 0.854 0.902 0.676 0.877 0.795 1.005 0.557 0.932
X18 1.254 0.527 0.828 0.834 1.086 0.726 0.838 0.905
X19 0.702 1.008 0.280 0.576 0.944 0.712 0.896 0.883
X20 0.489 1.156 1.047 1. 125 0.999 0.873 0.857 0.895
X21 1. 170 0.859 1.396 1.370 0.965 1.285 1.062 1.082
X22 0.930 0.573 0.780 0.729 0.801 0.871 0.819 0.559
X23 1.098 0.603 1.394 1. 173 1. 150 1.209 0.896 1.007
X24 1.069 0.874 1.382 0.990 1.053 1.003 1.350 1.253
X25 1.137 1.064 1.388 0.750 1.079 0.562 l. 170 1.272
X26 1.123 0.769 1.370 1. 124 0.796 1.264 1. 153 0.956
X27 1.060 1.069 0.842 1.220 0.363 1.129 1.074 1. 168
X28 1.080 1.091 0.999 0.882 1. 121 0.488 1.098 1.222
X29 0.941 1.201 0.918 0.690 1.153 0.864 0.776 1.056
X30 1.060 1.069 0.842 1.220 0.363 1. 129 1.074 1. 168
X31 1.260 0.967 0.952 0.689 1.093 0.744 0.870 1.265
X32 1. 143 0.860 1.352 1. 149 0.898 1.305 1.043 0.878
X33 0.930 0.970 0.597 0.682 0.957 0.541 0.913 1. 112
X34 1.060 1.069 0.842 1.220 0.363 1.129 1.074 1. 168
X35 1. 134 0.727 1.239 1. 119 1. 145 1.087 1.166 0.992
X36 1.172 0.915 1.224 1. 139 0.966 1.368 0.798 1.060
X37 0.769 0.762 0.917 1. 123 0.878 1.278 1.088 1.038
X38 0.880 0.977 0. 170 1.227 0.913 1.426 0.851 1.282

105
 DISTANCE MATRIX FOR CYCLOID PSYCHOSIS (Contd. )

X9 X10 Xll X12 X13 X14 X15 X16

X9 0
X10 0.809 0
Xll 0.870 0.375 0
X12 0.646 0.713 0.618 '0
X13 1.121 1.392 1.396 1.258 0
X14 1. 146 0.986 0.879 1.074 1.251 0
X15 1.033 0.767 0.833 1.003 1.341 0.880 0
X16 0.871 0.975 0.905 1.022 1.322 0.634 0.700 0
XI? 0.899 0.875 0.879 0.928 1.021 1. 186 0.528 0.940
X18 0.850 0.601 0.508 0.821 1.309 1.303 1.158 0.796
X19 0.794 0.360 0. 577 0.767 1.416 0.947 0.509 0.972
X20 1. 156 0.878 0.711 1.068 1.280 1.063 0.704 0.742
X21 1.118 1. 156 1.357 1.077 0.267 1.351 1.426 1.494
X22 0.900 0.690 0.509 0.727 1.296 1.067 1.134 0.908
X23 1.068 1. 103 0.898 0.883 0.749 1.237 1.418 1.228
X24 0.900 1.063 0.918 1. 122 1.076 0.884 0.98? 1.051
X25 1.095 1. 173 0.986 1.202 1.277 0.541 0.896 0.590
X26 1.085 1.346 1.094 1. 181 0.618 1.119 1.576 1. 159
X27 0.000 0.909 0.870 0.646 1. 121 1. 145 1.033 0.871
X28 1.055 0.924 0.828 1.116 1. 160 1.035 0.822 0.665
X29 1.008 0.935 0.723 1.017 1.489 0.823 0.246 0.575
X30 0.000 0.810 0.870 0.646 1.121 1. 146 1.033 0.871
X31 0.804 0.892 0.832 1.096 1.276 0.676 0.403 0.509
X32 1.099 1.340 1.084 1.054 0.716 1T. 127 1.421 1. 108
X33 0.763 0.533 0.834 0.817 1.32? 1.054 0.473 0.994
X34 0.000 0.810 0.870 0.646 1. 121 1. 146 1.033 0.871
X35 1.092 1.343 1.124 1. 196 0.734 1.273 0.608 1. 122
X36 1. 119 1.115 0.870 0.964 0.780 1. Ill 1.210 1.087
X37 0.640 0.490 0.597 0.858 1. 158 1. 160 0.952 1. 161
-yrv*"*- ■ X38 0.917 1.215 1.260 1.294 0.931 1.208 0.840 1.224

106
 DISTANCE MATRIX OF CYCLOID PSYCHOSIS (Contd. )

X17 X18 X19 X20 X21 X22 X23 X24

X17 0
X18 0.810 0
X19 0.460 0.794 0
X20 0.682 1.049 0.817 0
X21 1.084 1. 116 1.536 1.358 0
X22 0.727 0.380 0.688 1.025 1. 114 0
X23 1. 197 0.709 1.386 1. 170 0.428 0.683 0
X24 1.233 1.049 1.087 0.940 0.889 1.020 0.705 0
X25 0.888 0.906 1.040 0.621 1.268 1.214 1. 154 1.044
X26 1. 120 0.868 1.455 1.229 0.421 0.692 0.443 0.730
X27 0.898 0.850 0.794 1. 156 1. 116 0.899 1.068 0.899
X28 0.707 0.803 0.796 0.560 1. 155 1.104 1.089 1. 146
X29 0.578 0.911 0.547 0.657 1.439 0.873 1.285 0.925
X30 0.899 0.850 0.794 1. 156 1. 118 0.899 1.068 0.899
X31 0.524 0.845 0.570 0.818 1.458 0.897 1.415 0.767
X32 1.094 0.859 1.418 1.223 0.449 0.706 0.389 0.760
X33 0.571 1.029 0.380 0.701 1.410 1.023 1.364 1.011
X34 0.899 0.850 0.794 1. 156 1. 118 0.899 1.068 0.899
X35 0.817 1. 150 1.122 1.094 0.736 1.216 1.074 0.776
X36 1.014 0.904 1.408 1. 150 0.591 0.858 0.466 0.712
X37 1.008 0.762 0.810 1.016 1. 142 0.893 0.844 0.789
X38 0.628 1.299 0.906 0.837 0.927 1. 159 0.865 0.787

107
 DISTANCE MATRIX OF CYCLOID PSYCHOSIS (Contd.)

X25 X26 X27 X28 X29 X30 X31 X32

X25 0
X26 1. 194 0
X27 1.095 1.085 0
X28 0.337 1.113 1.054 0
X29 0.806 1.405 1.008 0.753 0
X30 1. 100 1.085 0.000 1.055 1.088 0
X31 0.701 1.329 0.804 0.742 0.373 0.804 0
X32 1.226 0.076 1. 100 1. 131 1.250 1.099 1.370 0
X33 0.848 1.669 0.763 0.688 0.657 0.763 0.531 1.677
X34 1.095 1.085 0.000 1.055 1.008 0.000 0.804 1.099
X35 1. 155 1. 106 1.092 1. 122 0.657 1.092 0.695 1.084
X36 1.272 0.308 1. 119 1. 157 1.126 1.119 1. 178 0.250
X37 1.244 0.909 0.640 1. 166 0.961 0.640 1.130 0.857
X38 0.946 0.829 0.917 0.890 0.751 0.917 0.849 0.802

X33 X34 X35 X36 X37 X38

X33 0
X34 0.763 0
X35 0.868 1.093 0
X36 .1.474 1. 119 0.971 0
X37 0.971 0.640 0.990 0.747 0
X38 0.872 0.917 0.815 0.762 0.760 0

108