CHAPTER XITHE MANIC-DEPRESSIVE PSYCHOSES
The manic-depressive psychoses as first described by Kraepelin are of comparatively recent origin. The history of the clinical entities included in this new grouping, however, may be easily traced back to the earliest days of psychiatry. Although these terms were not used perhaps as they came to be later, mania and melancholia were, as has already been shown, known in the Hippocratic era, over four hundred years before the time of Christ. They were referred to again in the works of Aretaeus in the first century A. D. and were recognized by Celsus, Caelius Aurelianus and Galen. Daniel Sennert[267]of Wittenberg (1572-1637) defined melancholia as a "delirium or deprival of imagination and reason, without fever, with fear and sadness, arising from dark and melancholy animal spirits, and occasioning corresponding phantoms." Mania he described as a "delirium or deprival of imagination and reason without fear, but, on the contrary, with audacity, temerity, anger, and ferocity, without fever, arising from a fervent and fiery disposition."
Sydenham[268]recommended bleeding, followed by purgation, as the treatment indicated for mania:—"Thus the humours, which in mania would invade the citadel of the brain, are gradually drawn off towards the lower parts, a fresh bias being given to them."
Thomas Willis[269]made some very significant referencesto the relation existing between mania and melancholia, in the seventeenth century:—"After melancholia we have to treat of mania, which has so many relations to the former, that the two disorders often follow each other, the former changing into the latter, and inversely. The melancholic diathesis, indeed, carried to its highest degree, causes frenzy, and frenzy subsiding changes frequently into melancholia (atrabiliar diathesis). These two disorders, like fire and smoke, often mask and replace each other, and if we may say that in melancholia the brain and the animal spirit are obscured by smoke and black darkness, mania may be compared to a great fire destined to disperse and to illuminate it." Morgagni,[270]"the father of pathology," also saw a close relation between these two conditions as is shown by the following quotation from his "De Sedibus et Causis Morborum;" etc., in 1761. "Melancholia," he says, "is so nearly allied to mania, that the diseases frequently alternate, and pass into one another; so that you frequently see physicians in doubt whether they should call a patient a melancholiac or a maniac, taciturnity and fear alternating with audacity in the same patient; on which account, when I have asked under what kind of delirium the insane persons have laboured whose heads I was about to dissect, I have had the more patience in receiving answers which were frequently ambiguous and sometimes antagonistic to each other, yet, which were, perhaps, true in the long course of the insanity." Flemming[271]in 1844 described a "dysthymia atra" (melancholia), a "dysthymia candida" (cheerful dysthymia) or "melancholia hilaris" characterized by elation with playfulness and a "tendency to see everything in the most pleasant and cheerful light" as well as a "dysthymia mutabilis,"an alternating variety involving both of the above forms. He also spoke of a "dysthymia sparsa" (apathica) or "melancholia attonita," and a "vesania maniaca" or mania which he divided into the acute, delirious, alcoholic, affective, and puerperal types, together with an "occult amentia" embracing all of these forms. Griesinger[272]in 1845 called attention to the fact that "the transition of melancholia into mania, and the alternation of these two forms, are very common." In 1851 Falret, senior, first described circular insanity in his lectures at the Salpêtrière, quoted by Tuke[273]as follows:—"We have also to mention another case of intermittence observed between the periods of remission and excitement in the forme circulaire des maladies mentales." "It is a special form which we call 'circular' and which consists, not as has been frequently said, in a change of mania into melancholia separated by a more or less prolonged lucid interval, but in the change from maniacal excitement—simple overactivity of all the faculties—into mental torpor."
In 1854 at the Academy of Medicine in Paris Falret presented his "Mémoire sur la folie circulaire, forme de maladie mentale caractérisée par la reproduction successive et régulière de l'état maniaque, de l'état mélancolique, et d'un intervalle lucide plus ou moins prolongé." In the same year Baillarger described his "Folie à double forme," summarized by him in a Bulletin of the Academy of Medicine asfollows:—
"(1) Besides monomania, melancholia, and mania, there exists a special form of insanity characterized by two regular periods, one of depression, the other of excitement.
(2) This form of insanity: (1) presents itself in isolated attacks; (2) reproduces itself in intermissions; (3) the attacks may follow each other without interruption.
(3) The duration of the attacks varies from two days to one year.
(4) When the attacks are short, the transition from the first to the second period takes place suddenly, and generally during sleep. It takes place slowly and gradually when the attacks are prolonged.
(5) In the latter case, the patients seem to enter into a state of convalescence at the end of the first period, but this return to health is incomplete; after a fortnight, a month, six weeks or more, the second period breaks out."
This was described as "Folie à double phase" by Bellod, "Folie à formes alternés" by Delaye, "Délire à formes alternés" by Legrand du Saulle, "Die cyclische Psychose" by Ludwig Kirn and "Das circuläre Irresein" by Krafft-Ebing.
At a meeting of the American Association in 1886 the classification of the British Medico-Psychological Association was adopted with the omission of moral insanity and the addition of toxic insanity. This included the following types of mania:—Recent, chronic, recurrent, à potu, puerperal and senile, and classified melancholia as recent, chronic, recurrent, puerperal and senile. In his "Clinical Lectures on Mental Disease" Clouston in 1898 described eight varieties of melancholia and six of mania, not including alternating forms. Kahlbaum in 1882, reverting apparently to the phraseology of Flemming, spoke of dysthymia, hyperthymia and mixed or circular forms—cyclothymia. Many of the conditions afterwards classified under dementia praecox he described as "vesania typica."
It will be observed that, based somewhat on the conceptions of Griesinger, states of mental excitement were generally characterized as mania and all depressions as melancholia. As has been shown, the view that there was some definite relation between these two conditions had been gaining ground for many years and culminated in the "circular insanity" concept. In the meanwhile over fifty varieties of mania and thirty forms of melancholia were described by various authors. Aside from an emotional exaltation and increased psychomotor activity, few definite characteristics were insisted upon in a consideration of mania. There was almost invariably a disturbance of sleep but always with a sense of well-being and no feeling of exhaustion. The milder type of the disease was often referred to as "hypomania." In the more severe forms varying grades of violence developed. There was at times a clouding of the sensorium, a temporary appearance of hallucinations of sight and hearing, delusions of a persecutory or grandiose nature and incoherence of speech. Impulsive acts occasionally were noted during the height of the excitement. These attacks were frequently preceded by brief periods of depression. Many cases made rather early recoveries—others, however, were spoken of as having reached a chronic stage. Many terminated in dementia. These very often showed stereotypies, verbigeration, impulsive excitements, mannerisms and other symptoms now held to be characteristic of dementia praecox. Melancholia was looked upon as including all emotional depressions with hallucinations and delusions as the prominent symptoms. The mental state was essentially one of sadness but with fear, agitation and anxiety appearing at times. There was, however, no attempt at any differentiation between psychomotor retardation with genuine depression and apathetic states or actual mental dulness. Mutism and resistiveness were common. A refusal of foodwas rather to be expected. Stuporous states with muscular rigidity frequently occurred. Various physical changes were described. Cyanosis of the extremities was emphasized, with loss of weight and a lowered temperature. Many of the cases were untidy in their habits. Brief initial attacks of excitement were mentioned as usually ushering in the disease. These depressions recovered, became chronic, lasting for years, or terminated in a partial or complete dementia. These were in substance the views of practically all of the earlier writers on insanity.
Sankey[274]in 1884 included in his idiopathic psychoses due to pathological conditions, general paresis and "ordinary insanity." "This is the disease which in its course presents such varying phenomena, and has thus given occasion for multiplying the names." Prominent in this group were the various forms of mania and melancholia and it undoubtedly included dementia praecox. "Like other diseases it may be artificially divided into separate stages, and this is useful for facilitating description, but such artificial divisions must not be looked upon as different species of disease." ... "Thus, a case in the primary attack commences by symptoms of melancholy; these may, when successfully treated, pass off, and the patient recover, or the melancholic stage may be aggravated, and the patient die in this stage;—the disease may exhibit symptoms of violence and become acutely maniacal. There is no ground on this account to say, that the patient has a new disease, any more than the appearance of an eruption in an eruptive disease would be the inauguration of a different kind of malady." Although obviously he had no idea as to the fundamental differences between manic-depressive insanity and dementia praecox, he unquestionably was one of the first to emphasize the fact that mania andmelancholia were often definite stages of one disease process.
In 1896 Kraepelin described melancholia as essentially an involutional condition. Under the heading of periodic constitutional disorders he included mania, circular and depressive forms, the mania, melancholia, and circular insanity of other writers. Schüle[275]in 1886 described circular, periodical and alternating psychoses. In 1894 Ziehen[276]included in his classification under the heading of combined psychoses a "melancholisch-maniakalisches" form in addition to mania and melancholia, which he spoke of as affective psychoses.
It was not until 1899 that these conditions were clearly differentiated by Kraepelin[277]and the purely emotional and recoverable forms separated clinically from the deteriorative processes which he has associated with dementia praecox. The former he described as manic-depressive psychoses, which included mania, melancholia and a majority of the circular and alternating types previously described. This delimitation had a prognostic as well as an important symptomatic significance. The emotional excitements were characterized by an increased psychomotor activity, with a flight of ideas and distractibility, usually associated with a clear sensorium. Graver forms were, however, recognized, with a clouding of consciousness, and disorientation, occasionally terminating in stupor. Hallucinations and delusions when present were not prominent symptoms. The depressions were characterized by an emotional disturbance in the form of sadness with difficulty in thinking, associated with marked retardation in speech and a motor inhibition. More advanced stages showed clouding, disorientation, stuporous phases and hallucinations. He also recognized alternating or circular as well as mixed types. The prognosticimportance of this clinical grouping was the tendency towards a complete recovery from the individual attack, with, however, an extreme probability later of a recurrence, the subsequent attacks assuming either form of the disease. As a rule Kraepelin found that the unfavorable types formerly included in the manias and melancholiac, together with the hebephrenia and katatonia of his fifth edition, presented the definite characteristics of the disease which he described as dementia praecox. His views have been modified from time to time. For instance, he at one time excluded the involutional and anxiety psychoses from his manic-depressive group. Later these were included. In his last edition he has described depressed and agitated forms of dementia praecox, which would strongly suggest that his lines of demarcation were not so clear as he believed them to be in 1899. Of the manic-depressive psychoses he says, "Manic depressive insanity as described in this chapter includes on the one hand the entire domain of the so-called periodic and circular insanities, on the other, simple mania, the larger part of the disease process described as melancholia and also a not inconsiderable number of cases of Amentia. Finally we include certain mild morbid emotional states, some periodical, some continuous, which heretofore have been looked upon either as introductory to more severe disturbances or as belonging, without being sharply circumscribed, to the domain of individual makeup. As years go by I have become more and more convinced that these all represent manifestations of one disease process." The following classification of manic-depressive psychoses was shown in Kraepelin's last edition(1913):—
Manic types:
Hypomania, Acute mania, Delusional and Delirious forms.
Depressive types:
Melancholia simplex, Melancholia gravis, Stupor, Paranoid, Phantastic and Delirious forms.
Mixed types:
Depressive mania.Excited depressions.Mania with poverty of thought.Manic stupor.Depression with flight of ideas.Retarded mania.
The mixed and atypical forms are of special importance, as they occupy the middle ground between the classical types of manic-depressive insanity and dementia praecox. It is here that difficulties arise and errors in diagnosis are made. They have never received sufficient attention until recently. In practice many of these have undoubtedly been classed with the dementia praecox group. The first of these as described by Kraepelin is depressive or anxious mania—characterized by a depressive mood with anxiety and excitement and, at the same time, a flight of ideas. The patients are distractible, observant of everything in their surroundings, and complain that thoughts obtrude themselves upon them. Some have a mania for scribbling. Often there are delusions of persecution, sin, and hypochondriacal ideas. The mood is one of anxiety or despair. Impulsive acts are occasionally observed. They are inclined to weep, wring their hands, pull out their hair and throw themselves on the ground.
Instead of a flight of ideas there may be poverty of thought and retardation with excitement—an "excited depression." The patients may be very wordy and monotonous in expression but are entirely clear as to their surroundings. The mood is anxious and tearful, often with delusions. There is a considerable excitement, butnot of such a stormy character as in the depressive or anxious mania.
Mania with poverty of thought, an "unproductive" form, shows a more cheerful mood but without a flight of ideas. This form Kraepelin speaks of as a common one. Speech is monotonous and expressionless. The patients present almost an appearance of feeblemindedness, although exceedingly variable and changeable. The mood is cheerful and sometimes irritable. The excitement is shown by jumping around, making faces, etc., but without any occupational activity. This alternates with periods of quiet when but little is said. They show no desire to occupy themselves in anything useful. Sudden outbursts of violence often occur.
Stuporous, almost cataleptic forms with occasional delusions of a hypochondriacal type, fairly well oriented and with a clear sensorium, are spoken of as "manic stupor." This is interrupted by excitement and violence, with laughter, witty remarks and even eroticism. They often have a clear memory of all occurrences. This stuporous type may appear suddenly in an ordinary manic attack, or take place between excitements and depressions.
In the course of an ordinary depression a flight of ideas may also replace the usual retardation—"depression with flight of ideas." The delusions are interspersed with cheerful thoughts and the patients show certain activities and an interest in their surroundings, although still depressed and hopeless. When they begin to talk they complain of an inability to control their thoughts. There is an inhibition of speech but not of thought. They may be quite prolific in writing, and may show a characteristic flight of ideas. This condition often merges into genuine excitement.
Kraepelin also speaks of an inhibited or "retarded mania," showing a cheerful mood with flight of ideasand psychomotor retardation. These eases are excited, distractible, inclined to witticisms with "klang associations," but lie quietly in bed. He believes that there is an inner tension manifesting itself at times in acts of violence. Kraepelin also speaks of various other mixtures of depression, anxiety and excitement. Specht has described an "irascible mania" (Zorntobsucht) and Stransky a bashful mania (verschämte Manie). Dreyfus has described a partial inhibition or retardation (partiellen Hemmung). Hecker is responsible for a "grumbling" or faultfinding variety of mania (nörgelnden Formen der Manie). In any event, Kraepelin's conceptions constitute a distinct advance and have materially clarified a much involved confusion of entities which seem to warrant complete differentiation. His views have, of course, not been universally accepted. The English school of psychiatrists has been slow in expressing its approval of his theories. No textbook of late years has appeared, however, in this country that has failed to recognize the manic-depressive psychoses practically as Kraepelin originally described them.
The psychological mechanisms of manic-depressive insanity have been studied exhaustively by Karl Abraham and other psychoanalysts. He looks upon retardation as a symbol of death and interprets it as a defensive reaction, the patient taking refuge in a retarded state to avoid contact with the outer world. The ideas of poverty associated with depressions he considered as symbolic of an inability to love and occurring in individuals who have not obtained sexual gratification in a normal way. When repression is no longer possible mania ensues and the patient enters upon a new existence, all instinctive inhibition being lost. The flight of ideas he looks upon as a reestablishment of infantilism. He suggests these views, however, as tentative. The delusions of the manic-depressive psychoses have been interpretedas an expression of repressed complexes. White[278]would explain these mechanisms as follows:—"Manic-depressive psychosis is the type of extroversion reaction. That is, the patients instead of turning within themselves (introversion) try to escape their difficulties (conflict) by a 'flight into reality.' This flight into reality is the manic phase of the psychosis with its flight of ideas, distractibility and increased psychomotor activity during which the patient seems to be at the mercy almost of his environment having his attention diverted by every passing stimulus. The great activity can be understood as a defense mechanism. The patient appears, by his constant activity to be covering every possible avenue of approach which might by any possibility touch his sore point (complex) and so he rushes wildly from this possible source of danger to that meanwhile keeping up a stream of diverting activities. He is at once running away from his conflict—into reality—and trying to adequately defend every possible approach.... This method I have described as a 'flight into reality' which is the characteristic of the manic phase, while the failure to deal adequately with the difficulty is manifested by the depression of the depressive phase. In the depression the defenses have broken down and the patient is overwhelmed by a sense of his moral turpitude (self-accusatory delusions). This sense of being sinful is the conscious appreciation of tendencies which should have been left behind to become a part of the historical past (the unconscious) in the course of the development of the psyche but which still demand expression.... The benign character of the manic-depressive group of psychoses is explained because of their extroverted mechanism. Reality is the normal direction for the libido and because the direction is normal they more readily result in recovery."
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-depressivepsychoses:—
"This group comprises the essentially benign affective psychoses, mental disorders which fundamentally are marked by emotional oscillations and a tendency to recurrence. Various psychotic trends, delusions, illusions and hallucinations, clouded states, stupor, etc., may be added. To be distinguished are:
"Themanicreaction with its feeling of well-being (or irascibility), flight of ideas and over-activity.
"Thedepressivereaction with its feeling of mental and physical insufficiency, a despondent, sad or hopeless mood and in severe depressions, retardation and inhibition; in some cases the mood is one of uneasiness and anxiety, accompanied by restlessness.
"Themixedreaction, a combination of manic and depressive symptoms.
"Thestuporreaction with its marked reduction in activity, depression, ideas of death, and often dream-like hallucinations; sometimes mutism, drooling and muscular symptoms suggestive of the catatonic manifestations of dementia praecox, from which, however, these manic-depressive stupors are to be differentiated.
"An attack is calledcircularwhen, as is often the case, one phase is followed immediately by another phase, e.g., a manic reaction passes over into a depressive reaction or vice versa.
"Cases formerly classed as allied to manic-depressive should be placed here rather than in the undiagnosed group.
"In the statistical reports the following should be specified:—(a) Manic type; (b) Depressive type; (c)Stuporous type; (d) Mixed type; (e) Circular type; (f) Other types."
Diefendorf[279]states that manic-depressive insanity comprises from twelve to twenty per cent of the admissions to hospitals for mental diseases. He reports defective heredity as being shown in from seventy to eighty per cent of the cases. He also found about seventy-five per cent of the patients suffering from this disease to be of the female sex. Buckley[280]states that sixty per cent of the cases give positive histories of "familial neuropathy and psychopathy." Paton[281]is of the opinion that heredity is a factor in from eighty to ninety per cent of all cases. Hoch has called attention to the constitutional makeup of individuals subject to manic-depressive attacks and suggests that they are usually of a moody, morose type, unduly optimistic or temperamentally unstable. Kraepelin[282]found suicidal tendencies in 14.7 per cent of the female patients, and in 20.4 per cent of the men. Nine per cent of his cases showed a manic makeup; 12.1 per cent, a depressive temperament; 12.4 per cent were irascible or nervous; and from three to four per cent exhibited cyclothymic tendencies. Of the cases admitted to his clinic 48.9 per cent were depressive forms; 16.6 per cent, manic; and 34.5 per cent represented both types in various combinations. Melancholia simplex and gravis constituted 23.5 per cent of the simple forms, 13.5 per cent showed phantastic delusions and 6.1 per cent anxieties. Hypomanias made up four per cent, and acute mania, 9.8 per cent of the cases. Confused and stuporous states constituted 8.2 per cent and compulsions, one per cent. Lighter forms constituted ten per cent, and more severe types, nine per cent of the admissions. Stupors and clouding were found in 4.9per cent and delusional states in 4.9 per cent of the total. He quotes Walker as reporting, in a study of 674 cases, that excitements contributed eleven per cent; depressions, 55.7 per cent; and circular forms 33.3 per cent of the male cases; and excitements, 6.2 per cent; depressions, 70.2 per cent; and circular types, 23.6 per cent of the female admissions. In from sixty to seventy per cent of Kraepelin's cases the first attack was a depression. In two-thirds of them, after the first mild attack there was a remission. In one-third of the cases, the depression terminated in an excitement followed by recovery. When the disease begins with a manic attack, two-thirds of the cases are followed by a remission. He reports excitements with a duration of ten years and depressions of fourteen years standing. In a study of 703 remissions he found ninety-six lasting from ten to nineteen years; thirty-four, from twenty to twenty-nine years; eight, from thirty to thirty-nine years; and one of forty-four years. He is of the opinion that the length of remission bears no relation to the duration of the attack. Of the depressions, 167 had a remission of six years; forty-six of 2.8 years; and twenty-seven of two years or more. Of the manic forms, fifty-three had remissions of 3.3 years; twenty-four of 4.5 years; and twenty of two years or more. Manic-depressive psychoses constitute from ten to fifteen per cent of the admissions at Kraepelin's clinic. He found hereditary taint in eighty per cent of his Heidelberg cases and quotes Walker as reporting 73.4 per cent; Saiz 84.7 per cent; Weygandt, ninety per cent; and Albrecht, 80.6 per cent. A history of alcoholism was found in twenty-five per cent and syphilis in eight per cent of the male patients.
Rehm made an interesting study of the offspring of manic-depressives. Of forty-four children in nineteen families, fifty-two per cent showed evidences of psychic degenerations, twenty-nine per cent of which consistedin an abnormal emotional makeup usually of the depressive types. In 157 cases from fifty-nine families, Bergamasco found that 109 showed manic-depressive psychoses. Kraepelin noted that the highest percentage of the first attacks occurred between the ages of fifteen and twenty. Reiss made a very significant analysis of the various forms of the disease manifested by individuals possessing definite predisposition. Thus, of the cases with a depressive makeup 64.2 per cent had depressive attacks, 8.3 per cent, manic, and 27.5 per cent, combined forms. Of those with manic temperaments, 35.6 per cent had depressive attacks, 23.3 per cent, manic, and 41.1 per cent, combined forms. Of the irritable individuals, 45.5 per cent had depressive attacks, 24.4 per cent, manic, and 30.1 per cent, combined forms. Of the cyclothymic persons, 35.3 per cent had depressions, 11.7 per cent, excitements, and fifty-three per cent, combined forms.
An analysis of the number of cases of manic-depressive insanity admitted to American institutions is exceedingly interesting in view of the opinions expressed by Kraepelin. From 1912 to 1919 there were 49,640 first admissions to the thirteen New York state hospitals. Of these, 7,499, or 15.1 per cent, were diagnosed as having manic-depressive psychoses or allied conditions. During the years 1918 and 1919, when the Association's classification was officially used throughout, the percentage of manic-depressive psychoses was 14.57. In the fourteen state hospitals of Massachusetts in 1919 there were 3,011 first admissions. Two hundred and eighty-three, or 9.39 per cent, of these were manic-depressive psychoses. In twenty-one state hospitals in fourteen other states, practically all in 1917, 1918 and 1919, there were 18,336 first admissions. Of these 3,409, or 18.59 per cent, were cases of manic-depressive insanity. Thus, of the 70,987 first admissions reported from forty-eight hospitals in sixteen different states there were 11,191 casesof manic-depressive insanity, a percentage of 15.76. This may probably be looked upon as fairly representative of the incidence of manic-depressive psychoses in American institutions.
When it comes to an analysis of the various forms of manic-depressive psychoses reported, the indications are not so clear. In New York during 1918 and 1919 there were 1,980 cases distributed asfollows:—
During the eight-year period referred to above in the New York hospitals there were 6,091 cases of manic-depressive and allied conditions, classified asfollows:—
The fourteen Massachusetts hospitals reported 672 cases in 1917 and 1918, classified asfollows:—
In the twenty-one hospitals in fourteen other states there were 3,409 cases of manic-depressive psychoses asfollows:—
The total from all of these institutions, of 12,152 cases, was classified asfollows:—
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 stuporous forms constitute the smallest percentage reported in all hospitals, except in 1918 and 1919 in New York. We would be warranted, apparently, in the conclusion that in this country manic forms are the more common, the depressive being second in frequency, followed by the circular and stuporous types in the order mentioned.
The statement is, I think, also warranted that there is a considerable difference of opinion as to the classification of the different forms of manic-depressive insanity and that diagnostic procedure is far from being standardized. Many of these discrepancies are doubtless due to difficulties in differentiating between certain cases of manic-depressive psychoses and dementia praecox. The hospitals reporting lower percentages of the former usually show a much higher rate of the latter. Certainly there is room for an honest difference of opinion in many instances. It must be admitted, moreover, that our fundamental conceptions of these two great groups do not permit of a hard and fast line of demarcation between them in all cases.