From the second century AD it was known that mania and melancholia often were two aspects of the same illness, and from the s manic-melancholic later manic-depressive or bipolar] mixed states were described [ 23 ]. Thus, disturbed mood and energy had been viewed as a central part of functional psychoses ever since the antiquity. However, from the second half of the s the idea of unitary psychosis receded into the background.
Kahlbaum also described catatonia [ 27 ], i. Thus, at the end of the s many professionals thought that there were several different psychotic illnesses, whereas others, as Gustav Specht — , continued to think that all functional psychoses derive from an abnormal affect [ 8 ]. A turning point came in when Emil Kraepelin — presented his dichotomy.
He grouped hebephrenia, catatonia, and dementia paranoides which he himself described in dementia praecox. The Kraepelinian concept of manic-depressive illness was broad. His concept of dementia praecox was narrow due to the criterion of a course leading to psychic invalidity. Melancholic and manic syndromes were neither included nor excluded [ 6 ].
However, the self-criticism of the older Kraepelin was little noticed, whereas the dichotomy of the younger one was appealing in its simplicity. Bleuler included the possibility of melancholic, manic and catatonic syndromes in his criteria [ 6 ], and explicitly stated that the diagnosis of manic-depressive insanity should only be made after exclusion of schizophrenia [ 31 ]. The expanded schizophrenia concept of Bleuler is illustrated by a quotation from his textbook [ 32 ]:. The importance of affective symptoms was strongly downgraded. Therefore, it was important to make an early diagnosis.
All this made the concept of schizophrenia extensive and unclear — as is still the case [ 8 ]. Lake [ 8 ] believes that these patients today would have got the diagnosis of psychotic mood disorder. From this, it is obviously difficult to differentiate between schizoaffective and affective psychosis. The Norwegian psychiatrist Gabriel Langfeldt — followed in the —30s a similar patient group, which he labelled schizophreniform psychosis [ 6 ]. However, a later follow-up examination of the case records indicated that most of his patients had suffered from affective disorders [ 35 ].
The German psychiatrists Karl Kleist — and Karl Leonhard —88 described similar syndromes in the first and midst of the twentieth century. They launched the term cycloid psychosis due to the cyclic course.
From its predecessors motility and anxiety psychoses of Wernicke they delineated three overlapping forms: motility psychosis, confusion psychosis and anxiety-elation-psychosis [ 6 , 36 — 38 ]. These names point to disturbed motor activity from severe agitation to immobility, i. The Italian-Swedish psychiatrist Carlo Perris — extended the works of Kleist and Leonhard [ 6 , 40 ], and underscored the importance of response to electroconvulsive therapy and lithium.
In ICD [ 9 ] the new term acute polymorphic psychosis was chosen for syndromes as above, due to the diverse and often abrupt changing symptoms. It is assigned to chapter F2 psychotic disorders. However, it has much in common with affective psychosis, and can be considered a subgroup of bipolar disorder as well. Thus, the Swedish psychiatrist Jan-Otto Ottosson, in his textbook from to , uses cycloid syndrome as a synonym for polymorphic psychosis, and classifies it as a variant of bipolar disorder [ 47 ]. The terms paranoid psychosis and paranoid schizophrenia are often used interchangeably, the latter preferentially later in an illness course or if hallucinations are present [ 6 ].
However, one should always suspect hidden mood disorder behind persecutory and bodily delusions [ 17 , 22 ]. The extensive concept of schizophrenia was increasingly criticized, particularly in USA. This compromises both clinical treatment and research.
In , however, ICD [ 9 ], too, included affective syndromes as exclusion criteria for schizophrenia. It may develop in different directions, most often to a non-psychotic mood disorder [ 51 ]. Lauveng [ 50 ] also describes a phase compatible with hypomania prior to her psychosis, indicating a mood disorder. Pathologic depression is not common sadness, but mental pain and often also physical pain [ 22 ], with a distinct quality that cannot be fully defined [ 7 , 52 ].
However, none is fully adequate. Anhedonia is central to depression [ 7 ], as are impaired self-respect, self-esteem, self-love, and self-preservation [ 52 ]. Suicide is often the only way out of frantic hopelessness, emotional pain, ruminative flooding and near psychotic somatization [ 22 , 53 ]. In DSM-IV it was possible to add catatonia as a specifier to other diagnoses than schizophrenia, but again without codes. This is important because catatonia often requires other treatment options than schizophrenia and other psychoses [ 16 , 55 , 56 ].
Lake and Hurwitz [ 8 , 11 , 17 ], too, seems to have been listened to — the subgroups of schizophrenia have been removed in DSM Thus, there are no longer any psychotic symptoms specific of schizophrenia or other disorders. The works on diagnosing psychoses seems to have been of doubtful value. They argued for the polydiagnostic approach, however, neither this approach seems to have contributed much [ 57 ]. Kraemer et al. Accordingly, brain imaging [ 60 — 62 ] and morphological [ 63 , 64 ] studies show overlapping results for schizophrenia and bipolar disorder.
There is also a marked genetic correlation between schizophrenia, bipolar disorder and major depressive disorder [ 65 ], although there are likely also genetic loci specific to each disorder [ 66 ], and the clinical variations are innumerable. Tesli et al. Van Os and Kapur [ 70 ] suggested rating of the five dimensions psychosis positive symptoms , negative symptoms, neurocognitive alterations, mania and depression, in addition to category diagnosis.
In my opinion, motor and vegetative symptoms should be included as separate dimensions. RDoC implies relating neurobiological findings genes, molecules, cells, circuits, physiology to behaviour, self-report and treatment effects independent of predefined categories, to find new constellations or dimensions with better validity [ 64 ]. Various treatment options may be indicated across diagnostic categories. Differences in response rate between groups cannot be relied upon when treating an individual patient.
Although antipsychotics are usually first choice among drugs in psychosis, they are often insufficient [ 72 ]. Antidepressants may reduce negative symptoms [ 78 ] and suicide in schizophrenia [ 79 , 80 ], and in one study reduced transition to psychosis in high-risk subjects more than antipsychotics [ 81 ], consistent with psychotic experiences being a marker foremost of affective dysregulation [ 82 ]. In spite of limited efficacy of available treatment options, all methods must be considered as soon as possible, because psychotic or near psychotic states in general are more serious than the risks of treatment trials [ 90 , 91 ].
Diagnostic labels for psychotic disorders, especially schizophrenia and paranoid psychosis, may have been obstacles to other treatment options than antipsychotics [ 49 , 72 ]. The concept of schizophrenia may disappear and the diagnosis of psychoses characterized as a failure. However, there are signs of rebuilding. Such syndromes often represent end-stages [ 51 ], like heart failure being the end-stage of different heart diseases.
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All available treatments must be tried to stop a development towards this stage. This strengthens the importance of optimal treatment of mood disorders, which may be the most important cause of schizophrenia and other functional psychoses. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Arlington: American Psychiatric Association; Tesli M, Andreassen OA. Psychosis - one or many? Nord Psychiatrist. Bergsholm P. Forsvinner schizofreni? Psykosediagnostikkens fallitt. Tidsskr Nor Psykologforen.
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Diagnostic criteria for functional psychoses. Cambridge: Cambridge University Press; Berrios GE.
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