Psychopharmacology and the Classification of Functional Psychoses 

By Thomas A. Ban and Bertalan Pethö

Four-Dimensional Classification

Affective Psychoses

Cycloid Psychoses

Therapeutic Considerations

Because a diagnostic formulation is a prerequisite for treatment and/or for the study of the effectiveness of different treatment modalities, cycloid psychoses have no generally accepted therapy which is based on findings in properly designed and conducted clinical studies. In spite of this there is sufficient evidence that patients with cycloid psychoses show a differential response to antipsychotics, antidepressants and mood-stabilizer lithium salts. The same applies to the three different forms and the six subtypes.

A pattern frequently seen in the pharmacotherapy of cycloid psychoses is that of a patient who become depressed when treated with an antipsychotic-neuroleptic, increasingly psychotic when treated with an antidepressant, and develop a toxic confusional state when given lithium salts. The prototype of such patients was a 24-year-old woman with a hyperkinetic motility psychosis. She was brought to hospital because of alleged erotic advances to unknown men in public. During the initial period of hospitalization she displayed severe hyperkinesia with stamping of feet, squinting and grimacing. When questioned she responded with excessive movements but with short phrases followed by long pauses. The provisional diagnosis of mania was made and haloperidol was prescribed. As a result, excessive movements ceased and were replaced by severe akinesia. Because the akinesia was so severe that patient stopped responding to bodily needs, medication was discontinued. Discontinuation of haloperidol resulted in a shift back to the hyperkinetic state. Lithium was prescribed, but it had to be stopped because of the confusional state it induced even when below therapeutic blood levels. After approximately 12 weeks of unsuccessful therapeutic attempts with various neuroleptics, the patient promptly responded to electroconvulsive treatment. Remission was complete and there was no recurrence of psychosis during a three-year follow-up period.

Although there are no verified findings, there are indications that a considerable proportion of patients with cycloid psychosis are treated with ECT, lithium salts and/or different drug combinations, i.e., antidepressant-antipsychotic, anxiolytic-antidepressant, lithium-antipsychotic, and antidepressant-lithium. In the absence of recognized treatment, ECT remains the most effective and reliable method among the various treatment modalities employed.