Manic-Depressive Psychosis

MANIC-DEPRESSIVE PSYCHOSIS. - Manic-depressive p., as an independent nosological entity, was born with the work of Kraepelin in 1893. Already in the preceding years (1877-93) some French psychiatrists (Palret, Baillarger, Morel) had affirmed the morbid unity of the manic and melancholic forms; subsequently Kretschmer (1921) studied its constitutional aspect, Luxemburger (1936) completed its picture from the genetic point of view, and the whole morbid entity took on a definitive aspect both for the typical forms and for the transitional ones, regarding some of which doubt still lingers as to their legitimate belonging to this disease.

Manic-depressive p. is an endogenous and hereditary psychosis, which presents as its primary symptom alterations of the affective sphere. The characteristic notes that make it a well-defined picture in its own right are principally: variability (the possibility of the appearance in the same patient of periodic and diverse psychic disturbances: manic and melancholic phases, mental confusion, stupor, delirious periods); benignity (such periods of psychic alteration, after a more or less long time, can heal, or in any case almost never lead to a demented state, unlike the other endogenous psychoses); heredity (in union with constitutionality and of notable importance both genetically and diagnostically); finally, according to Bleuler, the capacity to regulate, on the tone of the affective state, the entire ideational patrimony (hence the capacity to attune with the environment even in rather grave conditions). Considered as a constitutional and hereditary disease, manic-depressive p. appears notably different from the other endogenous or exogenous psychoses, and a unitary criterion is reaffirmed in the face of manifest clinical manifestations. However, even while admitting such genetic aspects, the nature of the biological substrate, the periodic course of the disease and the reason for the onset of such periods remain obscure.

The frequency of manic-depressive p. in individuals without family precedents is 0.4%; the probability for children with one affected parent rises to 32.2%, if both parents are ill to 38.8%; there is still no agreement on the type of heredity, that is, whether it be dominant or recessive (on this subject one should consult the works of Luxemburger). One speaks of a manic-depressive constitution (v.) of the pyknic type (present in 64% according to Kretschmer), brevilineal or megalosplanchnic (Pende), in which, beyond the particular anthropometric notes, there appears a quite clear liveliness of affective tone and lability of mood.

The psychopathological analysis of the subject shows, as fundamental symptoms: depressive or euphoric dysphoria (that is, the alteration of mood at its extreme limits), the acceleration or the retardation of ideation (one passes from the flight of ideas to absolute mutism) and the facility or the inhibition of psychic and physical activities; among the accessory or secondary symptoms we find delusional ideas in relation to the alteration of mood, visual or auditory hallucinations, psychogenic, neurasthenic and cenesthenic symptoms and, commonly, insomnia. Typical of this disease is the absence of any residual symptom in the periods of remission.

Clinically there appear, as the most important, two pictures: the manic and the depressive. The manic period is characterized by an abrupt onset, with or without premonitory signs (insomnia, restlessness), with variable severity (the mildest degree is hypomania), from which one subsequently passes to the fundamental disturbances: exaltation, excitement, agitation and hyperfunction of the psychic activities. In this period one notes a physiognomic expression (lare with mimetic lability and frequent gesticulations, a euphoric mood, with optimism and cheerfulness in the face of all situations. At times the agitation leads to furious episodes, in which the patient becomes aggressive; at the same time the psychic processes have become more rapid and the rapidity of perception, memory ("manic hypermnesia") and mental agility have increased. This rapid succession of thoughts and memories leads to an unrestrainable logorrhea ("flight of ideas"). Conduct changes and to the physical hyperactivity may be added sexual immorality. Delusional ideas, always changing, and hallucinations may be present. The manic period has a variable duration, on average about 6 months, often less in young people; at times it becomes chronic. The transition to a depressive period is frequent.

The melancholic period has a generally slow onset in which digestive disturbances, insomnia, tendencies to sadness and restlessness are complained of, then passing to the abandonment of professional and social activity. As with the manic form, there exist different degrees, the mildest of which is called hypomelancholia. The melancholic or depressive phase is characterized by a mimetic attitude of profound sadness, pensive, with crying fits; the subject complains and loses interest in everything around him; the psychic functions are depressed and thoughts are expressed slowly and with a monotonous voice, while the intellectual functions remain intact. Conduct is modified by the conviction of incapacity and uselessness, and often there is refusal of food and suicide. Hallucinations are rare, while delusional ideas are more frequent, especially those of guilt, unworthiness, ruin and hypochondriacal ones. The duration, on average, ranges from six months to a couple of years in advanced age. There exist, then, alongside these typical pictures, mixed forms: such as anxious melancholia, melancholic stupor, obsessive depression, whose names themselves indicate the fundamental psychopathological elements that constitute them.

The periods described above may present themselves only once in a lifetime, but, almost always, they repeat subsequently. In 75% one finds circular psychosis, that is, the alternation of manic periods with melancholic ones. In the remaining 25%, the psychosis has a monosymptomatic course; in these cases, the depressive forms are about 20% and the manic forms 5%.

The diagnosis is easy in full-blown cases because of the constitutional and clinical elements. In borderline cases, the course is often decisive. Admission to psychiatric wards is absolutely necessary in grave cases and often advisable in cases of medium severity, because of the possible and often unforeseen suicide attempts ("raptus melancholicus"). Therapy often gives brilliant results, especially for the depressive forms; the method of choice is electroconvulsive therapy.

Luisandro Canestrini

MORAL IMPUTABILITY

The individual affected by m.-d. p., in the course of the manic or melancholic period, is to be considered a true mentally ill person, deprived of the faculty of understanding rightly and of directing his own acts with free motivation; in relation to this his moral and juridical responsibility is abolished, always saving a possible imputability in cause. In the interval periods, the particular notes of his temperament and of his disposition with a neuropathic background and the possible persistence of psychic alterations in the affective and ideational field, can determine a greater or lesser reduction of his faculties of understanding and willing and correspondingly of his responsibility (v. PSICOPATICHE PERSONALITÀ).

Giuseppe de Ninno