This article throws light upon the three subtypes of manic depressive psychoses. The subtypes are: 1. Manic Type 2. Depressive Type 3. Circular Type.
1. Manic Type:
A manic patient is terribly optimistic, high in spirits and full of life. There is general excitement and the individual is full of activity and thus excessively mobile.
The general symptoms of the manic stages are predominant emotional mood, feeling of high optimism, and speeding up of thought process, excessive psychomotor activity. He lacks the capacity to concentrate, judgment is impaired and delusions of grandeur are commonly found.
The symptoms of the manic stage can be classified under the following heads:
(a) Excessive Psychomotor Activity:
Patients suffering from mania will like to do some kind of activity for say 20 hours in a day. They cannot sleep, nor can they relax. Any thought that occurs in their mind is immediately transformed to work. They cannot stick to a particular work or job.
They usually hastily change from one thought or task to another without completing the first one. Suppose for instance, he is working out Math or doing carpentry; immediately the idea of reading a book or playing a musical instrument may come to his mind. Thus, they start different types of work, but complete nothing. There is in fact, dramatic increase in gesturing, gimmicking and general movement.
When admitted for hospitalization, sometimes they attempt to kiss the doctor, nurse or sing or dance here and there and make lots of noises. Sometimes they even try to stop the doctor or the nurse. Though they spend a lot of energy by this they are never seen fatigued.
(b) Flight of Ideas:
Being over flooded with various types of ideas and thoughts the patient becomes inattentive and there is rapid shift of attention. As the train of ideas and thoughts come simultaneously they lack concentration power. Because of the distortion of thought process incomplete sentences are uttered and words are repeated.
(c) Emotional Reactions:
The manic patients are extremely jolly, happy go lucky, active and joyful. They feel as if they are in bed of roses; in the peak of their name and fame. They do not hesitate to be vulgarly dressed, use obscene words. They are often aggressive.
If they are slightly teased, insulted or not allowed to fulfil their wish, they become very obstinate, aggressive and violent. Often they argue and assert. But in-spite of their and qualities people can like them because of their jolly nature.
Irritability, lack of insight, suspicion, delusions and hallucinations are present to some extent though delusions are short lived. Perception is erroneous and careless. Due to poor attention and distraction, memory difficulties are found. Due to excessive excitement all the time, the patient loses his appetite.
Their faulty judgment arises out of exaggerated optimism and excessive self- confidence. Though such patients realize that they are hyper active and quite excited all the time, they do not agree with the fact that they are psychotic and abnormal. They on the contrary, take it for granted that the doctor and the nurse are abnormal and not they. They consider their hospitalization as unnecessary and useless.
Manic reactions may be divided into 3 types:
1. Hypo Mania,
2. Acute Mania,
3. Delirious Mania.
These three types of reactions have the common symptoms discussed above. However, they only vary in the degree of excitement.
In fact, there is no clear-cut difference between these stages:
a. Hypo Mania:
It is the mildest variety and the least severe type characterised by mild form of manic reaction where the person does not seem to be out of control, but appears to be in a jolly mood. Cohen (1975) reports an elevated mood, a pressured speech pattern in which words come out faster than the person can say them and an increased motor activity. However, the talk is never coherent.
Elation and flight of ideas are found only in a moderate degree and are not greatly developed. The patient feels extremely happy, has strong confidence in himself. He feels that he can do everything better than any-body else. However, he realizes his position in the society, and does not behave in a way that would clash himself with his fellow members in the society.
He shows egoism and monopolizes in discussion, gives dogmatic views, shifts from one topic to another all of a sudden and shows flight of ideas when reasoned with. He is intolerant of criticism, becomes sarcastic and rude. He may over indulge in sex and drink. He is sometimes arrogant and complains against officers, quarrels with them. The most striking symptom of a hypomanic is restlessness. He is extremely mobile.
However, there is no clouding of consciousness. His idea of time, place and person is correct and there is no evidence of delusion and hallucination. His talk is coherent and his memory is intact.
According to Cohen (1975) “he talks easily, winningly, humorously and he talks and talks and talks. He is warm, then friendly and then uninvited intimate and un-welcomely personal……………… He is constantly on the go and never seems to tire.
Only as one stays with him, does one become aware of his distractibility, of impatience and intolerance, when his wish is not. immediately gratified, of impulsive and ill considered actions of un-seemingly self indulgence and of blind disregard of patent difficulties.”
b. Acute Mania:
In this stage, without any previous hypomanic stage, all of a sudden acute excitement takes place. The elation, flight of ideas and over activity are more pronounced and intense in the acute mania stage in comparison to the hypomania stage. There is also some clouding of consciousness with disorientation and great impulsiveness.
Thus Duke and Nowicki (1979) have rightly viewed, “In acute mania, the characteristics of hypomania are present but to a greater degree. The mood disturbance is usually very apparent to others. The acute maniac may pun wisely, tease, make blasphemous comments, sing insane songs and move about widely “.
“The persons with acute mania does not seem to care about the rights of others and may read violently to those who interfere. Frequently ideas pour forth in a torrent, with hallucinations and delusions being freely communicated”.
The acute mania has a sense of superiority and he orders everybody. Though he is quite gay and merry, periods of irritability and anger are frequent. The patient becomes over aggressive at times. There is tremendous flight of ideas which may subsequently lead to incoherence. Hallucinations though may be present occasionally, are transitory in nature. Disturbance in sleep may be one of the important symptoms.
The acute mania is very restless and mobile and cannot sit at a particular place for a while. His mood is usually elated. He may be singing, dancing and giving humorous speeches. Misidentification is well evident.
Language is full of slangs and talk is incoherent. The acute maniac is not normally clearly oriented of time and environment. Attention is distracted. He pays attention to whatever he sees and comments upon it. Insight and judgment are also impaired to some extent.
c. Delirious Mania:
Delirious mania was first described by Luther Bell (1949) and so is known as Bell’s mania. It is the extreme stage. It may either occur after one has passed through hypomania or acute mania or it may occur independent of these two stages. In addition to the presence of most of the manic symptoms in an extreme degree, some additional symptoms are found in these stages.
They are, total loss of contact with reality, rampant auditory and visual hallucination and delusions. The patient has also frequent difficulty in controlling bladder and bowel functions. They are totally unconcerned about their surroundings and it is quite difficult to deal with such patients. They are over energetic and over talkative. They are careless about their personal habits and use obscene language very often.
In the delirious stage, the patient is so excited, that he can only be restrained by a powerful hypnotic state. They are extremely suspicious and never cooperate with treatment. The most strange fact is that, they never realize that they are ill and on the contrary blame the doctor for treating them.
2. Depressive Type:
Depression is the antithesis of mania. While the manic stage is characterised by elation, the depressive stage is in the opposite end of the feeling continuum. Patients with depressive mood show loss of energy and interest, guilt feeling, difficulty in concentration and loss of appetite. Thoughts of death and suicide travel their mind very often as they consider their life to be meaningless and useless.
Kraepelin also described a type of depression that begun after menopause in women and during late adulthood in men which is known as “Involution Melancholia”. Unipolar depression is found approximately 20 per cent in women and 10 per cent in men.
The lifetime expectancy of developing bipolar disorder is about 1 per cent in both men and women. Usually 20 to 25 per cent of the patients having major depression receive treatment.
It has been observed that unipolar depression prevalence is greater in women compared to men because of, several factors. Trauma of childbirth and related factors, helplessness due to social conditions, hormonal efforts, greater stress due to disadvantaged socio cultural conditions, attitude of society towards women in general and oppression by the society are some of the major reasons of such unipolar depression in men.
The fact that women cannot express their frustrations, emotions and hostility overtly like men lead to greater suppression and repression and consequently more depression. The disease onsets in 50 per cent of the patients between the age of 20—50 years. Though race does not appear to have any specific effect on unipolar disorder, marital status has.
Unipolar depression by and large is seen more in divorced or repeated persons and persons not having any close relationship. There seems to be no close relationship between social class and unipolar depression.
The patient is silent and Morse and only thinks of death. He has guilty feelings about his past deeds and is usually unsuccessful in achieving a goal. Often suicidal thoughts appear in his mind and it is the most important symptom. The type of mental disorder most likely to be associated with suicide is depression of the anxious agitated type characterized by hypo condriacal bodily delusions and the futility of existence.
The psychotic depression is also characterised by obsession, delusions of persecution and auditory hallucination of self accusing guilt. Extremely depressed moods, mental and physical slowness are other common symptoms.
According to Duke, in some other cases, uneasiness; apprehension and agitation may be found. Symptoms of depression can be rated according to various clinical scales such as that prepared by Zung (1965).
According to the degree of severity the depressive stage can also be classified into 3 types:
1. Simple depression,
2. Acute depression,
3. Depressive stupor.
Difficulty in thinking, depression and psychomotor retardation are the common symptoms in these categories. Besides, delusions, hallucinations, persecutory characteristics and irritability etc. may be added. The depression however is not accompanied by anxiety.
The chief symptoms of the depressive stage can be described in the following manner:
There is absence of initiative, energy and eagerness to do anything. The patient lacks will power and strength. So the patient remains in bed for a longer period. The deterioration is so aggravated that he requires somebody to help him to get up.
The person becomes a complete misfit and is unable to go anywhere or do anything. He withdraws himself completely from the outside world and likes to pass his time quietly, alone. He speaks very less and gives his answer to any question in a word or two.
The depressive patient often complains of paralysis of thought and inability to concentrate. Memory is lost, thought process is dis-organised. Originality and self expression is destroyed.
(b) Emotional reactions:
So far as the emotional reaction of the depressive patient is concerned he is always found to be gloomy and miserable. They assume life to be so hopeful and miserable, that sometimes they decide to get rid of this so called nasty world by committing suicide and some of them actually attempt it. They are always gloomy. So joy and humour have no meaning to them.
Sleeplessness is usually found in a depressive patient. The patient complains about bad digestion, ill health etc.
Depressive patients realize that they are mentally sick and often voluntarily seek treatment.
(e) Degree of depression:
It ranges from mild cases to stupor conditions. The patient sometimes is so much depressed that he feels that his madness cannot be cured.
a. Simple Depression:
It is mildest form of psychotic depression. Its most important characteristic is general loss of interest for mental and physical activity. The level of activity and functions of a simple depressive patient slows down to the extent of finding difficulty in doing simplest works like eating.
Social interaction and conversation is at the minimum level. For instance, he answers in monosyllables like Yes, No, Good, Right etc. This he speaks in a low voice.
However, in a simple depressive the thinking process is more or less logical and coherent and hallucination and delusions are rare. There is no real clouding of consciousness or actual disorientation. But it is different from normal depression in that the normal people experiencing depression return to the normal emotional state only after a few days and they are quite aware of the cause of their depression.
Normal depression may not relapse again. But simple depression is not connected with any real incident and its origin the victim cannot explain. Moreover, it increases in intensity gradually.
The psychomotor activity of the simple type is retarded. He is very passive, lazy and looses interest in the entire environment. He has to be assisted in his daily work, dress and food. Nevertheless, he is conscious of the environment and there is no clouding of consciousness. There is no deterioration in memory or intellect either.
The patient complains of headache which is ill defined and ill localized. He suffers from constipation, lack of appetite, fatigue, lack of concentration and enthusiasm. Sleep is frequently, but not always disturbed.
The depressive patient suffers from poverty of ideas to such an extent that at times he complains that he has no brain and his mind has stopped functioning. Feelings of unworthiness, failure and guilt dominate his thought process.
The patient accumulates energy during the depressive period and cannot release the pent up emotion. His aggression turns inward. His thought process is slowed down and he blames himself for his misdeeds and sins and thinks of committing suicide.
An Indian widower who was feeling extremely guilty for his unmarried daughter became pregnant, visited a psychiatrist for treatment of his depressiveness. He felt guilty for his daughter’s condition and deeply believed that it is God’s way of punishing him for his sins. Though the girl herself did not feel ashamed and went in for an abortion, her father cursed himself for his bad ‘Karma’.
b. Acute Depression:
It is more severe than simple depression. Physical, motor and mental retardations are acute, compared to simple depression. There is sharp decrease in psychomotor activity. Interpersonal relationship deteriorates as the patient avoids this. The feelings of loneliness, guilt’s and gloom are highly aggravated. He finds no solution to his problems. Thoughts of suicide are very frequent. He feels very restless and sleep is disturbed.
The acute depressive patient in other words, develops an attitude of great misery and dejection. He accuses himself of committing the most unforgivable sin and of bringing misfortune on others. Hypochondriacally ideas are frequently expressed. Occasionally hallucinations, illusions and delusions are present.
Bleuler has stated that the depressive delusions of such patients usually concern themselves with conscience. He draws a difference between the depressive delusions and hypochondriac delusions in viewing that in depressive delusion the patient worries about the future while in hypochondriacally delusion, he worries about the present.
An old widow tried a number of times to jump from the terrace of her building, but she could not gather courage to do so. A few times she was prevented by others while she was attempting suicide. In-spite of shock treatment her depression used to reoccur. One day however, she gathered sufficient courage and ended up her life by taking poison.
c. Depressive Stupor:
It is a state of intense psychic inhibition during which regression may occur to an infantile if not primitive level. Complete inactivity and unresponsive to people or environment are the most significant characteristics of a depressive stupor which differentiates him from simple and acute depressive type.
In majority of cases considerable dulling of consciousness occurs. He is more often than not bed ridden and totally indifferent about the happenings around him. He goes to the stuporous stage, refuses to eat and speak. He is extremely uncooperative. By and large, negativism is the most significant characteristic of this stage.
The patient requires great attention in every respect. Even he is unconcerned about his bowel and bladder functions. He has to be tube fed and have his eliminative processes taken care of confusion regarding time, place and person colours his behaviour and-hallucinations and delusions are vivid, specially about fantasies, death, rebirth and sin.
At times, abstract thinking is present. The idea of death is believed by some to be most universal in stupor reactions.
The depressive stupor thus needs hospitalization for intravenous feeding, care and catheterization. The patient requires great attention and care in every respect. A middle aged patient was admitted to hospital for severe depression.
After receiving ECT he recovered to some extent. One day he asked the doctor to call his sister. As the doctor did not have her address, he said that she would come during the visiting hours. However, when the doctor reached the ground floor of the hospital building, he heard that the patient had just jumped from the bathroom window.
3. Circular Type:
The circular or mixed type is also known as the alternative type where elation and depression occur alternatively. It is also called bipolar type of manic depressive psychoses. In this type, the manic and depressive types are combined into a single category. About 15 to 25 per cent of the manic depressive reactions actually indicate an alteration between manic and depressive symptoms.
According to Coleman (1981) although many believe that these mood swings of manic depressive state are common, in-fact, about one out of 5 manic depressive people suffers from this circular variety. An unusual case of a manic-depressive patient has been quoted by Jenner ( 1967), whose manic phase lasted for 24 hours and was then followed by a depressed stage which also continued for 24 hours.
This cycle continued for 11 years. Bunney, Murphy, Goodwin and Borge (1972) have also cited the case of a woman patient who shifted between mania and depression every 48 hours for a period of 2 years. Such cases are not common though.
The patient in the circular type thus experiences mania and depression in a cyclic order. There even may be a gap of normality when the patient shows normal behaviour. This is suddenly followed by a second attack when the patient may experience severe elation and excessive happiness. Interestingly, in some other cases the patient may go to sleep with depression and get up with manic episode.
In the circular types, at first there is mild depression with subjective uncertainty, slight restlessness, mild elation over successful work, then depression again of greater duration followed by elation. Elation periods are characterised by aggressiveness, frequent irritability and pronounced erotic tendencies.
During the depressive period, there is intense depression with suicide attempts. The patient may lie on the bed, immobile. A dull depressed expression may be marked on his face.
A middle aged man made a lot of fortune during the manic period. He was over active and very enthusiastic. He would be talking and talking all the while. Sometimes he would dress himself in the most funny manner.
At times, he would put on a garland and go to the doctor’s clinic. However, when depressed, he never comes out of his house. He felt like ending his life, but could not gather the courage to lift the phone to call the doctor for advice. Kraepelin (1937) has described the mixed state as a combination of manic and depressive state.
He differentiated 6 principal types:
1. Maniacal stupor
2. Agitated depression
3. Unproductive mania
4. Depressive mania
5. Depression with flight of ideas
6. A kinetic mania.
According to Kraepelin these conditions not only occur singly in the course of either an acute excitement or an acute depression, but as transition stages during the changes from excitement to depression. The essential picture of the mixed stale is an elated mood with restlessness, alertness and talkativeness.
Then it shifts to a state of distress and depression accompanied by mutism. At the beginning of the attack, the association of mutism with a slightly happy smiling mood and free movements constituted a fairly typical example of the mixed state.
The physical symptoms of the mixed state are as follows:
1. Disorder of sleep,
2. Loss of appetite.
Control of these two factors is the key stone of treatment particularly in the acute phase. The manic patient is so restless, so distractible and so busy that he has no time either to sleep or to eat, whereas the depressive patient is so tormented by upsetting ideas and feels so unworthy that he does not consider himself entitled to any food that is offered to him.
It has been observed that practically most depressive cases have a high blood pressure while in the maniac, the blood pressure is reduced. But this has not been confirmed by scientific findings.
The findings of a clinical study conducted on the patients of a Metabolic research ward at the National Institute of Mental Health, Bethesda, Maryland, by a group of investigators led to the anticipation that a biological switch mechanism may be factor in sudden cyclic shifts from depression to mania.
With the assumption that “something must be happening in the body as well as the mind” of such patients, the above investigators studied biochemical changes in six manic-depressive patients, who with one exception were not on medication.
A brief but marked elevation in a biogenic amine in the urine of the depressed patients on the day of the switch was noted. Patients with the most rapid onset of mania also showed the most marked elevation in this biogenic amine on the switch day. The investigators also presumed the role of identifiable environmental stresses played a part.
However, they were not able to recognize such stresses in the change out of mania. This impression was supported in an additional study of patients switching from mania into depression as well as depression to mania.