MANIC-DEPRESSIVE PSYCHOSES

The term affectivity means the basal tones of the feeling life and the manic-depressive psychoses are called affective psychoses because the patient's ideas, actions, and feeling tones are in harmonious agreement. Classically, the disorder is characterized by alternating periods of mania and depression, but some patients exhibit only one phase, which may be either depression or elation. An occasional patient may have only 1 or 2 attacks during his lifetime, but periodic recurrences are the rule.

Etiology and incidence

If the disease is initiated by a manic episode, it most frequently occurs between the ages of 15 and 25; if by a depressive episode, between 25 and 35. Its incidence is greatest among the higher social and professional group, and twice as great in women as in men. An estimated one-third of siblings of patients with the disorder become affected; thus, presumably heredity plays a role. However, factors of environment may be of primary importance, as a child can incorporate his parents' traits through emulation and identification. The psychosis usually occurs in individuals with a "cyclothymic" temperament, which may be described under 3 subdivisions. The hypomanic is outgoing, vivacious, optimistic, and easily swayed by new impressons. His superficial judgment often leads to failures; for these he has ready excuses. Some hypomanics are hypercritical, domineering, and argumentative. The syntonic is the "normal" cyclothyme. He is genial, sociable, uncomplicated, and a practical realist. He radiates a certain warmth and ease. The melancholic often is quiet, kindly, solemn; but may be gloomy, submissive, and self-depreciatory; his hesitation and indecision betray his feelings of insecurity. He often is preoccupied with his work.

Symptoms and Signs

The manic phase.-Excitement is the cardinal symptom. It may be mild (hypomania), acute, or delirious. There is a quickening of the individual's entire tempo, which is reflected in an apparent wealth of mental associations (verbosity), tireless overactivity, and feelings of elation. The patient may be mischievous, playful, and have fleeting delusions of grandeur. Irritability and anger may punctuate his elation when his requests are denied. If "impure" effects are present-as seen in a manic with a paranoidlike reaction-he may be haughty, arrogant, and demanding, and become abusive toward those who momentarily. annoy him. Close observation reveals that his apparent wealth of ideas actually represents a limited range of associational products, and his wordiness is a flight from, rather than a product of, thinking. He is preoccupied with the phonetics instead of the meanings of words. Everything around him distracts his attention. Since he is not concerned with its ideational content, his talk assumes a character not unlike that of free associations, and thus often affords clues to his unconscious motivation.

The manic's increased psychomotor reactions range from simple oveactivity to sustained and frenzied busyness. He may tear his clothing, decorate himself bizarrely, disarrange his room, smear the wall with feces-all without malice. He sings, shouts to any passer-by, makes obscene sexual proposals, is too excited to eat, sleep, or pay attention to any physical illness, mild or serious. Particularly when his excitement is not extreme he may not appear fatigued, yet in other instances these patients rapidly exhaust themselves. Actual hallucinations are rare, but illusions that simulate hallucinations are not uncommon. While these patients usually retain correct orientation, their poorly sustained attention may disturb this. A short mild depression often precedes a manic episode.

The depressive phase.—In a considerable number of patients the episodes are confined to depressions, and often these patients' prepsychotic personality has been of the melancholic type. Manic-depressive depressions may be mild, acute, or stuporous. Many mild manic-depressive depressions are not recognized as such. They usually take the form of inertia and staleness or of hypochondriasis. In either case, the patient will be downhearted, and a patient with hypochondriacal complaints will consider these the cause rather than the result of his depression. These mildly depressed patients may be fearful, quiet, indecisive and have feelings of inadequacy. If "impure" affects exist, they may be irritable, sensitive, and morose, or peevish, stubborn, and faultfinding instead of sad. The more severe depressions often begin thus, but profound affective distress rapidly supervenes. This is reflected in a stooped posture and an immobile, or perplexed and troubled, facial expression. The patient sleeps poorly, wakes early, perhaps becomes con

stipated, and his sexual desires decrease. Because of psychomotor retardation, all physical activity becomes a great exertion. Subjectively, the patient may feel that his usual environment is strange or that a disaster is impending from which he cannot escape, and his outlook becomes hopeless. If the feelings of distress are projected, his ideas become delusional. A complaining, or a suspicious persecutory, paranoid trend may exist; or his thought life may be concerned with hypochondrical ideas, self-accusations, ideas of guilt, remorse, and self-depreciation. His intense fear may create clouding of consciousness; however, unless a patient's attention is thus impaired by affective distress, orientation is not disturbed. Illusory misinterpretations are common, but hallucinations are infrequent. The psychomotor retardation, alone, or augmented by some belief the patient holds-for instance, that he is unworthy of food-may make spoonor tube-feeding necessary. Suicidal attempts or self-mutilations are not un

common.

Stupor is the most intense form of these depressions: the patient makes no response to external stimuli, his sensorium is clouded, he is mute, and his face is masklike or wears a fixed expression of anxiety; spontaneous motor activity is slight or absent. A short hypomanic period often terminates the depressive episode. Diagnosis

The psychosis must be differentiated from schizophrenia, paresis, so-called acute paranoia, and such psychoneurotic states as compulsion neuroses, neurasthenia, and hypochondriasis (q. v.). Paresis may be differentiated by history, neurologic signs, and laboratory tests. Acute paranoia is a misnomer for a hypomania in which exuberance is replaced by anger, resentment, irritability, irascibility, and perhaps delusions and litigious tendencies. Because of the obsessive ideas which a depressed patient may express, a compulsion neurosis sometimes is simulated; the differentiation is made by determining whether the obsession or the depression came first. The patient's solicitude about his health is continuous and prolonged in neurasthenia. In hypochondriasis, mild symptoms usually will have existed for a considerable time, and the attack does not come on abruptly as in the depressive state.

Prognosis

The prognosis for individual episodes is good and there is no residual "scarring" of the personality. However, the disease may assume a certain chronicity in which the intervals between episodes are brief or nonexistent. The duration of manic-depressive episodes cannot be predicted with certainty, but on the average, manic attacks last six months and depressive attacks nine months. If a first episode is a depression, it may be the last; if it is manic, others are apt to follow. The probability of future attacks varies inversely-to a degree at least with the age when the disease first appears; if before 20, the prognosis is poor. Recurring episodes may occupy a large portion of some patients' lives; normal periods tend to become shorter as age advances. Chronic mania is uncommon before the age of forty, and the melancholia is more apt to become chronic. Repeated attacks usually leave the mind unchanged in basic functionings, but occasionally a patient may show some impairment of initiative and judgment.

Treatment

Only an occasional patient with manic-depressive psychosis can be cared for at home, and then a psychiatric consultant must be available and psychiatric nurses kept on 24-hour duty. It often is difficult to persuade the family to commit the patient to a hospital, as they do not realize to what extent the defective judgment of these patients constitutes a risk to themselves and others. When relatives are told that electroshock therapy may be indicated, and if so, that it may put an end to the episode, they may more readily agree to the patient's commitment.

The manic phase.-Manic patients want to be constantly occupied and outlets for their energy must be supplied, but not to the point of producing exhaustion. Arguments and contradictions should be avoided and the patient allowed to do as he wishes within safe limits. The patient's distractibility sometimes makes spoon-feeding or tube-feeding necessary (see Melancholia). A high caloric diet is imperative. The treatment of choice for excitement and insomnia is the use of prolonged neutral baths in tubs especially designed for the purpose ("continuous" tubs). These baths may be given for several hours daily, or continuously up to several weeks. Hypnotics are used as little as possible and

repeated only when absolutely necessary. The most suitable are paraldehyde, chloral hydrate, and the barbituric acid derivatives. Chloral hydrate (R 4), 2 to 2.6 Gm. (gr. xxx to x1), alone or combined with barbital ( 1), 0.3 to 1 Gm. (gr. v to xv), may be used. Paraldehyde (R 5) is given in doses of 4 to 12 cc. If the patient is in good physical condition, and constant nursing attention, which is absolutely essential, is available, partial narcosis, prolonged for a period of days, occasionally will terminate a manic episode. Sodium Amytal (R6) is the drug usually employed for this purpose, and the treatment is begun by giving 0.2 Gm. (gr. iii) by mouth, or rectally, every 3 or 4 hours. The doses are gradually increased during the first 3 or 4 days, until the patient is kept asleep or deeply somnolent for 15 to 20 hours daily. He is kept continuously on his side to prevent aspiration of mouth contents or strangulation, and turned at regular intervals. At least two periods of wakefulness are allowed each day for feeding and nursing care. The physician sees the patient during each of these periods. Pulse, blood pressure, and temperature are periodically determined; cyanosis is watched for, and the narcosis immediately terminated if any untoward signs or symptoms develop. If its course is uneventful, the narcosis sometimes is continued for 10 days, after which the dose of Sodium Amytal is gradually decreased over a period of 3 or 4 days. The effectiveness of this therapy is thought to depend on a partial dissolution of psychotic resistance to psychotherapeutic leverage. The psychotherapy used at this stage is entirely supportive. The constancy of the nurse's attentions and regularity of the physician's visits have supportive value. No interpretive psychotherapy is attempted at this time. After the patient has recovered from the episode, psychotherapy by an expert may decrease the probability of recurrence, but this is at best uncertain.

The depressive phase.-General care is the same as for involutional melancholia (q. v.). Electroshock convulsions, 8 to 10, will terminate many of these depressions, but since this is a recurrent disease and because of the amnesic features associated with the therapy, experienced judgment is required to decide to what extent and with which patients it is to be used.

In managing mildly depressed patients, an organized program which fills the day is desirable. None of the activities should be strenuous or exhausting. Repetitive, and what the patient may consider as mildly degrading occupations such as sorting and counting the various types in a keg of mixed nails, or weeding a lawn-may arouse resentment against the environment, and thus deflect the patient's aggression away from himself. Also, the patient may respond better to an attitude of cool kindness than to a warmly sympathetic approach. As the depression recedes, the danger of suicide increases, since there is less psychomotor retardation and the patient has more energy to carry it out. This fact (which relatives find difficult to understand) calls for doubled precautions during convalescence. Indecision is characteristic of all depressions, and is a cardinal symptom in some of the milder cases; therefore, the patient should not be required to make decisions until he has fully recovered, and in many cases should not resume his usual business occupation for weeks or months thereafter. At least in the psychotic depressions, the use of stimulative drugs such as amphetamine is of questionable value and in some instances may be harmful.

INVOLUTIONAL PSYCHOSES

Whether involutional psychoses are related to manic-depressive psychoses is debatable, but for practical purposes considering them as separate entities is justifiable. They generally occur after the age of 40: in women most often in the late 40's, and in men in the late 50's. At these ages, the woman's child-bearing potential, the symbolized source and end of energy and womanliness, is failing; and the man's physical and mental vigor, and hence the symbolized ability to coerce fate, is waning. In this psychosis, the patient's anxiety is tremendous and is accompanied by agitation, hypochondriacal and nihilistic ideas, delusions, and hallucinations. The psychodynamics probably are similar to those outlined under the manic-depressive depressions (q. v.), but with an involutional psychosis fearsome delusions are more frequent, and lacking are the manic-depressive's psychomotor retardation and history of earlier attacks of mania or depression. Etiology

The patient often will have exhibited such premorbid traits as intolerance, stubbornness, penuriousness, oversensitivity; a tendency to self-punishment as manifested by avoidance of pleasure, a rigid moral code for himself and others, and overconscientiousness. Worrying, fretfulness, apprehension, and compulsive

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meticulousness may have further reflected his insecurity. psychosis occurs a sense of frustration is perhaps usual. to have passed when earlier errors can be repaired and when unfulfilled ambitions can be achieved. Hence, old conflicts often become stronger and threaten the ego with their accompanying anxiety. This ceaseless anxiety may bring the patient to a preoccupation with thoughts of death. In some, but not all instances, the psychosis is precipitated by loss of position, the death of an individual upon whom the person was dependent, or breaking up of the home.

Symptoms and Signs

Insidious changes in attitude and behavior may precede the manifest psychosis by weeks or months. Spells of weeping, disinclination for effort, pessimism, peevishness, irritability, and insomnia are common prodromal symptoms. This drastic variation from his accustomed effects is recognized by the patient, and he perhaps states that he is beginning to lose his mind. When the manifest psychosis begins, depression, anxiety, and agitation are seen, and delusions of sin, unworthiness, and impending death occupy his mind. Guilt feelings may cause the patient retroactively to interpret some earlier indiscretion as an "unpardonable sin." He perhaps insists that he is to be butchered, or that he is damned and God cannot forgive him. He states that he deserves his fate, yet begs for reassurance, only to refute any that may be offered as illogical and ridiculous. He may rationalize that his inner distress results from organic changes and disease; that his brain has dried up, that his intestines are rotting away, or that he has no stomach. Hallucinations are common; God may talk to him, or a deceased parent reprove him. Although the patient's consciousness probably will be clear, the subjective absorption of attention may cause him to appear confused, perplexed, and bewildered. His fear of death, projected in symbolic forms and delusions, possibly accounts for the insomnia. (Characteristically, depressed patients wake up early in the morning.) Food may be refused because the patient believes it is poisoned, or because of nihilistic ideas about the absence of his stomach, or because he thinks himself unworthy. In no other psychosis is suicide so frequently attempted. This may represent an attempt to destroy rejected portions of the personality, and thus put an end to gnawing conflicts and troublesome desires. The patient loses weight, becomes dehydrated, and picks at his skin; his respirations are shallow, and his extremities cold and cyanotic. In some cases the psychosis has a distinct paranoid coloring, and these patients often will have shown prepsychotic traits somewhat like those observed in the paranoid psychoses (q. v.).

Diagnosis

In manic-depressive depressions, hallucinations are less common, and the apprehension, fear, and ideas of impending destruction are less marked. Also stereotypies (unvarying repetition) of behavior or speech, or other schizophreniclike symptoms less seldom occur. The latter are more in keeping with involutional melancholia. Patients with arteriosclerotic psychosis who are depressed seldom exhibit the profound, sustained fear seen in the involutional psychotic, and slight loss of memory is usual rather than preoccupation. In the psychoneuroses hallucinations are rare and there are no true delusions. Any fear these patients may have is paroxysmal, although they may exhibit sustained anxiety. In contrast to the psychoneurotic, a patient with melancholia strives more against his sensed danger, and as well may display gross misinterpretations of reality relationships.

Prognosis

With the advent of convulsion therapy, recoveries have been enormously increased; 80 to 90% of these patients are benefited by electroshock convulsions. Previously about 40% recovered, but frequently only after an illness of 2 or 3 years. The prognosis for the paranoid type is less favorable. With the latter, insulin may be indicated if electroshock fails to cure (see Schizophrenia). Treatment

The danger of suicide is too great to permit these patients to be cared for outside a mental hospital. A high caloric diet is essential, and refusal to eat for longer than 24 hours is an indication for tube feedings (see DIETS). Aspiration pneumonia should be guarded against through careful technique. Paraldehyde (R 5) in amounts up to 8 to 16 cc. (3i to iv) is particularly useful for the insomnia. In aged infirm patients, sedatives must be used with extreme caution. Because these patients are so fearful, all changes in routine should be carefully explained beforehand.

Electroshock therapy: Absolute contraindications to the use of electroshock therapy are few; they include extreme hypertension, severe arteriosclerosis, cardiac decompensation, coronary disease, intracranial disease, pregnancy, and skeletal deformities. Deaths attributable directly to shock therapy are rare. The occurrence of fractures can be reduced to a negligible point by proper technic. Electroshock treatments should be administered only by a physician well trained in the procedure.

Curare is a helpful adjunct. By reducing muscular spasm, it minimizes skeletal trauma during the convulsions. (The drug is contraindicated in patients with myasthenia gravis, since they are unduly sensitive to it.) A preparation suitable for I. V. injection must be used (R 15). The customary dose of standardized curare is 3 mg./17.7 Kg. (40 pounds) body wt., but 4 of this amount is safer, particularly for the first administration. Oxygen and an intracheal airway must be at hand as the larynx may become paralyzed from overcurarization. Over curarization is treated with neostigmine (R 16), 1 cc. subcut. of a 1:2,000 solution. If it is necessary to repeat the latter, then atropine (R 17), 0.4 mg. (gr. 1/150) also is given to lessen any undesirable side effects of the neostigmine. Curare should be allowed sufficient time to take full effect, usually several minutes, before the convulsion is induced.

Shock treatments are given with the patient lying on a firm, smooth, resilient surface, such as a litter with a firm pad. No metal should touch the patient; hairpins, jewelry, and false teeth are removed. After the patient is lying in correct position upon the litter, he is asked to sit up. An ordinary pillow then is placed lengthwise across the litter and against the patient's buttocks; when the patient again lies down, the necessary hyperextension of the spine is effected. Six assistants are needed. Two stand on opposite sides and apply pressure on the patient's shoulders, each with his other hand grasping the wrist of the patient's arm nearest him. The patient's arms then are flexed and held firmly but not immovably against his chest during the convulsion. Another assistant applies downward pressure on the pelvis. Two others hold the patient's legs, with one hand above, and the other below, the knee. The sixth attends to the mouth gag. This may be an applicator thickly padded at one end with gauze, which is placed between the patient's molars on one side; or a firm gauzecovered roll of cellulose may be placed in such position that, the canines bite on it as the mouth closes during the convulsion. The mouth opens widely when the convulsion begins, and during this phase the sixth assistant applies upward pressure on the jaw to prevent its dislocation and keeps the gag in position to prevent biting of the tongue or lips when the jaws close.

The

Before the electrodes are applied, the patient's temple areas are washed with warm soapy water, and an electrolytic-conducting jelly is rubbed on. amount of current and length of application necessary to produce a convulsion vary representative figures are 70 to 150 volts; 300 to 1,200 m.a. ; 0.1 to 0.5 second. More than 1 application may be required, but not more than 3 or 4 should be attempted on any one day. The patient is allowed a few deep breaths between each. Ordinarily, the operator will increase the current, or time, or both with each subsequent passage of current until the convulsive threshold is reached. Once this is determined, the same settings on the machine usually will be used initially on the next treatment day. Convulsions begin with a tonic stage affecting the extensor muscles, and end-the longer phase of the two-with clonic contractures of the flexors. A convulsion may last for 1% minutes. When it ends, the patient is kept on his back until he has taken at least one deep respiration. Then he is turned on his side and a pillow is so arranged under his head that free drainage of mucus from his mouth and throat is assured. Massaging and pinching the abdominal muscles may aid in initiating respirations and, if necessary, artificial respiration can be given. An experienced person must stay with the patient until full consciousness returns. Immediately after convulsions, patients may be so overexcited as to require restraints.

Patients develop varying degrees of amnesia if a sufficient number of convulsions are given. This usually is at first an inability to recall familiar names, and it may progress until after recovery the patient may remember few of his psychotic ideas. Severe and lasting impairment of memory may be produced if more than 20 convulsions are administered in a consecutive series. With fewer than 15, usually only a transitory amnesia results. Customarily, electroshock treatments are given 1, 2, or 3 times a week. Each patient's schedule should be individualized, taking into account his physical condition and particular needs.