Manic-depressive disorder

“ What we have to say is therefore published not so much to convince as to stimulate further work. The problem is wider than that of the mere etiology of the stupors we are considering. Their relationship to manic-depressive insanity is so intimate that we must tentatively consider this affectless reaction as belonging to that larger group. A discussion of the basic pathology of manic-depressive insanity is outside the sphere of this book. ”

“ The total from all of these institutions, of 12,152 cases, was classified as follows:—
It will be noted that manic cases are more common than the depressive in New York, the number of the former being fifteen per cent greater than the latter. In Massachusetts the number of depressive forms is twenty-two per cent higher than the manic. In the other states the depressive types are less than five per cent higher than the manic. In all institutions the mixed forms are more common than the circular or stuporous. ”

“ The associated symptoms are no less dissimilar. The difficulty in thinking which troubles the depressed patient is slight in proportion to his emotional gloom, and he feels himself to be much more incompetent intellectually than examination proves him to be. On the other hand, in the stupor reac [125] tion we find that the thinking disorder runs hand in hand with the apathy and that the intellectual capacity of the patient is really markedly interfered with, as can be shown by more or less objective tests. ”

“ The reader will note that this view is opposed to that of Kraepelin, who has written largely on so-called "mixed conditions" in manic-depressive insanity. We believe that careful clinical studies confirm our opinion and that his classification is based on less thorough observation and analysis. This subject will be discussed at greater length in a forthcoming book on "The Psychology of Morbid and Normal Emotions," by Dr. MacCurdy. ”

“ Reality is the normal direction for the libido and because the direction is normal they more readily result in recovery." [421]
The American Psychiatric Association, in its manual designed for the assistance of hospitals for mental diseases in the compilation of statistical data, makes the following suggestions as to the delimitation of the manic-depressive psychoses:—
"This group comprises the essentially benign affective psychoses, mental disorders which fundamentally are marked by emotional oscillations and a tendency to recurrence. ”

“ Psychiatrists are more or less aware of there being typical ideational contents in the different manic-depressive psychoses. For instance, every one is familiar with ideas of wickedness and inadequacy in depression, ideas of violence in anxiety, or expansive and erotic fancies in manic states. Quite similarly we have seen that death is a dominant topic in a stupor. Now in addition to these typical ideas we often hear expressed what we might term non-specific delusions, ideas that seem to have nothing to do with a peculiar type of reaction which the patient presents. ”

“ First, depression is a highly emotional state in which the sadness of the patient is as evident from his facial and vocal expression as from what he says, while these stupor reactions are by observation and confession states of indifference. Secondly, there is no such disturbance of the intellectual processes in depression as is here chronicled. Let the retardation once be overcome so that the will is exercised and [49] no real defect is demonstrable. ”

“ It is fundamental because it seems as if the symptoms built around apathy constitute the stupor reaction. The emotional poverty is evidenced by a lack of feeling, loss of energy and an absence of the normal urge of living. This is quite different from the emotional blocking of the retarded depression, for in the latter the patient shows either by speech or facial expression a definite suffering. The tendency to reduction of affect produces two effects on such emotions as internal ideas or environmental events may stimulate. Exhibitions of emotion are either reduced or dissociated. ”

“ The occurrence of other mood reactions than apathy in the same patient is also characteristic. Manic states (usually hypomanic) frequently occur during the phase of recovery from the stupor. This is an unusual, although not unknown, phenomenon in recovery from severe retarded depressions. The circular cases who swing from depression to elation usually show the milder types of depressive reaction which would never be confused with stupor. ”

“ Our psychological hypothesis would be incomplete and probably unsound if it could not offer as valid explanations for the atypical features in our stupor reactions as for the typical. The unusual features which one meets in the benign stupors are ideas or mood reactions occurring apparently as interruptions to the settled quietude or in more protracted mild mood reactions, such as vague distress, depression or incomplete manic symptoms, which have been described in the chapter on affect. The interruptions are easily explained by the theory of regression. ”

“ When epileptics do become insane the insanity is generally one of the forms of mania. Either the patient suffers from sudden furious attacks of excitement in which consciousness is entirely abolished, or the mania is of the type of the elevated stage of folie circulaire (manic-depressive insanity) and alternates with periods of deep depression. In the elevated period the patient shows exaggerated self-esteem, with passionate outbursts of anger, and periods of religious emotionalism. While in the stage of depression the patient is often actively suicidal. ”

“ The affective setting of these different formulations is important. A delusion of literal death occurs with complete apathy. The wish to die is apt to appear without the usual accompaniment of sadness or distress but still with considerable energy when impulsive suicidal attempts are made. A prospect of death, particularly when there is anticipation of being killed, is apt in manic-depressive insanity to occur in a setting of anxiety. ”

“ In other words, our reason for the enlargement of the stupor group to include all apathetic reactions (except those of dementia præcox) is the belief that this dulling of the emotional response is as specific a type of emotional change as is anxiety, depression or elation. Perhaps it would be more accurate to say that this clinical group is founded on the symptom complex which is built around apathy. There is never any resemblance between apathy and the mood of elation or anxiety. [124] A discrimination from depression is the only differentiation worth discussion. ”

“ Without sufficient means he throws up his job and tries to get the new work he longs to do. Sometimes he fails to get it, and then he becomes an unemployed problem.
This type of uncontrolled energy reaches its height in the manical or manic phase of the disease already described as manic depressive insanity. The "manic personality," which need not become insane, is characterized by high energy, vivacious emotions, rapid flow of thought and irrelevant associations. ”

“ The patients become excited, treat the visitors rudely, perhaps even assault them, and all their symptoms are aggravated. But the stupor needs excitement, and an habitual emotional interest is more apt to arouse him than an artificial one. In another point the situation differs. As a rule manic-depressive patients have delusional ideas or attitudes in connection with their nearest of kin, so that contact with these stirs up the trouble. The stupor regression going beneath the level of such attachments leaves family relationships relatively undisturbed. ”

“ He concludes, however, that a form of depression, earlier described as melancholia, is still to be separated from the manic-depressive psychoses although not entirely clear as to its significance or exact delimitation. [287]
These are the most severe and rapidly fatal forms of anxious excitements, as a rule developing suddenly and included now in his presenile group. "These cases are anxious, restless, sleepless, self-accusatory and show delusions of persecution." The delusional ideas are depressive, extravagant and hypochondriacal. "They have offended everybody; are eternally damned ”

“ This looks like a combination of two psychotic tendencies, the stupor reduction process which inhibits emotional response and the tendency to develop abnormal affects which characterize other manic-depressive psychoses. There is no general psychological law which makes this view unlikely. One cannot be anxious and happy at the same instant, although one can alternate in his feelings; but one can fail to react adequately to a given stimulus when inhibited by general indifference. ”

“ Depression of the manic-depressive variety, therefore, may either precede or follow upon an attack of maniacal excitement, or it may be the chief and only obvious symptom of the disease and may recur again and again. The disease attacks men and women with equal frequency, and as a rule manifests itself either late in adolescence or during the decline of life. Hereditary predisposition has been proved to exist in over 50% of cases, beyond which no definite predisposing cause is at present known. ”

“ The most important difference between stupor and depression lies in the affect. Although inactive and sometimes appearing dull the depressive individual is not apathetic but is suffering acutely. He feels himself wicked, paralyzed by hopelessness, and finds proof of his damnation in the apparent change of the world to his eyes and in the slowness of his mind. ”

“ Somatic delusions of a hypochondriacal nature occur. Insomnia is usually marked. The tendency of the disease is towards deterioration. Retardation and psychomotor inactivity are not to be expected. Melancholia is to be differentiated from manic-depressive insanity by the prominence of anxiety and apprehension, the absence of any retardation or psychomotor inhibition, the unusual frequency of self-accusation with ideas of sinfulness, the clearness of the sensorium, the comparatively unfavorable prognosis and the great frequency of suicidal impulses. ”

“ Régis has thought that the delusional generosity and liberality of the paretic, and his willingness to lend his wealth and talents to social progress, is helpful for diagnosis when contrasted with the more personal egoism of the victim of manic-depressive psychosis. The self-satisfaction of the manic-depressive patient often does not reach a delusional stage, but remains a mere feeling of pathological well-being or euphoria. The maniacal patient may compare himself with some great man but he does not identify himself with him. ”

“ Similarly one ordinarily observes fear in the patient who has delusions of drowning or burial. In the stupor cases, however, this painful affect seems to be reduced to a mere dazed bewilderment or feeble exhibitions of a desire for safety, such as the slow swimming movements of a patient who thought she was under the water. When these ideas of danger become allied to everyday interests—husband or child imperiled, etc.—a weak affect in the form of depression is apt to occur.
Physical symptoms are more common than in any other benign psychosis. ”

“ On the other hand, deep stupors very frequently are terminated by manic reactions, and if not by such means, recovery seems to occur merely in virtue of a gradual attenuation of the stupor symptoms. Rarely do we see a change to depression or anxiety heralding improvement. This tendency of the stupor reaction to remain pure or change to hypomania is a peculiarity which seems to put stupor in a class by itself among the manic-depressive reactions, as all the other mood reactions frequently change from one to the other. ”

“ The first point that should be made is that there is a difference between marked depression and the mood of stupor. In the former we get a retardation with a feeling of blocking, rather than of an absence of energy. The expression of the patient is one of dejection, not of vacancy, which bespeaks a mood of sadness, even when the patient is so retarded as to be mute and therefore incapable of describing his emotions. ”

“ For instance, in the states where one would expect anxiety during the onset of stupor or in its interruptions, manifestation of this anxiety is often reduced to an expression of dazed bewilderment. In the anxiety states associated with stupor one does not meet with the restlessness and expressions of fear which would be ex [127] pected. Quite similarly, when a manic tendency is present, it occurs either in little bursts of isolated symptoms of elation (such as smiling or episodic pranks) , or some of the evidences of elation which we would expect are missing. ”

“ Stupor represents, psychologically speaking, the simplest and completest regression. Adaptation to the actual environment being abandoned, attention reverts to earlier interests, giving symptoms of other manic-depressive reactions in the onset or interruptions, and finally dwindles to complete indifference. The disappearance of affective impulse leads to objective apathy and inactivity, while the intellectual functions fail for lack of emotional power to keep them going. The complicated mental machine lies idle for lack of steam or electricity. ”

“ This lack of contact with the environment leads also to inactivity. If one's attention and interest is turned inwards, there can be no evidence of mental energy exhibited until the patient is roused to contact with the people or things about him. It is noteworthy that in these cases emotional expression emerged when the patients were stimulated to some productiveness in speech.
These conditions really constitute a different psychosis in the manic-depressive group, essentially they are perplexity states such as have recently been described by Hoch and Kirby. ”