MANIC-DEPRESSIVE PSYCHOSIS. — Manic-depressive psychosis, as an independent nosological entity, originated with Kraepelin’s work in 1893. Already in the preceding years (1877–93), some French psychiatrists (Palret, Baillarger, Morel) had asserted the morbid unity of manic and melancholic forms; subsequently, Kretschmer (1921) studied its constitutional aspect, Luxemburger (1936) completed its picture from the genetic point of view, and the entire morbid entity assumed its definitive form, both in its typical forms and in its transitional forms, some of which are still the subject of doubt as to their legitimate inclusion within this disease.
Manic-depressive psychosis is an endogenous and hereditary psychosis whose primary symptom is alteration of the affective sphere. The characteristic features that make it a clearly defined entity in its own right are chiefly: variability (the possibility that periodic and different psychic disturbances may appear in the same individual: manic and melancholic phases, mental confusion, stupor, and delirious periods); benignity (such periods of psychic alteration may, after a more or less lengthy time, resolve, or in any event almost never lead to a demential state, unlike other endogenous psychoses); heredity (in conjunction with constitutionality, and of considerable importance both genetically and diagnostically); and finally, according to Bleuler, the capacity to regulate the entire ideational patrimony according to the tone of the affective state (thus the capacity to attune oneself to the environment even under fairly serious conditions). When manic-depressive psychosis is considered a constitutional and hereditary disease, its considerable difference from other endogenous or exogenous psychoses becomes apparent, and a unitary criterion is reaffirmed in the face of diverse clinical manifestations. Nevertheless, even while admitting these genetic aspects, the nature of the biological substrate, the periodic course of the disease, and the reason for the onset of these periods remain obscure.
The frequency of manic-depressive psychosis in individuals without a family history is 0.4%; the probability for children with one affected parent rises to 32.2%, and, when both parents are ill, to 38.8%; there is still no agreement concerning the type of heredity, that is, whether it is dominant or recessive (on this subject, consult Luxemburger’s works). There constitution (v.) of the pyknic type (present in 64% according to Kretschmer), or of the brevilinear or megalosplanchnic type (Pende), in which, in addition to particular anthropometric features, a distinctly lively affective tone and lability of mood appear.
The psychopathological analysis of the subject reveals the following fundamental symptoms: depressive or euphoric dysphoria (that is, alteration of mood at its extreme limits), acceleration or retardation of ideation (ranging from the flight of ideas to absolute mutism), and the facilitation or inhibition of psychic and physical activities; among the accessory or secondary symptoms we find delusions related to the alteration of mood, visual or auditory hallucinations, psychogenic, neurasthenic, and coenesthetic symptoms, and, commonly, insomnia. The absence of any residual symptom during periods of remission is typical of this disease.
Clinically, two pictures appear as the most important: the manic and the depressive. The manic period is characterized by a sudden onset, with or without prodromal signs (insomnia, restlessness), and by variable severity (the mildest degree is hypomania), followed by the fundamental disturbances: exaltation, excitement, agitation, and hyperfunctioning of psychic activities. During this period there are a lively facial expression with labile mimicry and frequent gesticulation, and a euphoric mood, with optimism and cheerfulness in the face of every situation. 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 perceptual speed, memory (“manic hypermnesia”), and mental agility have increased. This rapid succession of thoughts and memories leads to irrepressible logorrhea (“flight of ideas”). Conduct changes, and sexual immorality may be added to physical hyperactivity. Delusions, always shifting, and hallucinations may be present. The manic period varies in duration, averaging approximately six months, often less in young people; at times it becomes chronic. Transition to a depressive period is frequent.
The melancholic period generally begins slowly, with digestive disturbances, insomnia, tendencies toward sadness, and restlessness, followed thereafter by abandonment of professional and social activity. As in the manic form, there are different degrees, the mildest of which is called hypomelancholia. The melancholic or depressive phase is characterized by an expression of profound sadness, a pensive attitude, and bouts of weeping; the subject complains and loses interest in everything around him; psychic functions are depressed, and thoughts are expressed slowly and in a monotonous voice, while intellectual functions remain intact. Conduct is altered by the conviction of incapacity and uselessness, and there is often refusal of food and suicide. Hallucinations are rare, whereas delusions are more frequent, especially those of guilt, unworthiness, ruin, and hypochondria. Its duration averages from six months to a couple of years in advanced age. Alongside these typical pictures there are also mixed forms: anxious melancholia, melancholic stupor, and obsessional depression, whose names in themselves indicate the fundamental psychopathological elements composing them.
The periods described above may occur only once in a lifetime, but almost always they recur subsequently. In 75% of cases one finds circular psychosis, that is, the alternation of manic and melancholic periods. In the remaining 25%, the psychosis follows a monosymptomatic course; in these cases, depressive forms account for approximately 20% and manic forms for 5%.
Diagnosis is easy in fully developed cases because of the constitutional and clinical elements. In borderline cases, the course is often decisive. Admission to psychiatric wards is absolutely necessary in severe cases and often advisable in cases of moderate severity, because of the possible and frequently unforeseen attempts at suicide (“melancholic raptus”). Therapy often produces brilliant results, especially in depressive forms; the treatment of choice is electroshock therapy.