The psychoses which are brought together under this classification
include mental disorders which at first glance would appear to be of
very wide variation, namely, conditions of maniacal excitement and
those of depression. Further consideration, however, reveals the very
evident reasons why they should be united as sub groups under the one
head. The fact that these two mental states of seemingly opposite
characteristics often appear alternately in the same individual, that
in certain cases of each type there is a wave like feature in the
nature of the attack and the frequency with which they tend to recur,
together with other points of similarity in respect to duration,
prognosis, etc., tend to point to their very close relationship.
Kraepelin was the first to draw attention to these facts and advocate
the present convenient and widely accepted classification of these
disorders.
The outstanding feature is the disturbed emotional state which
dominates and overshadows all other symptoms and is fundamentally
the same whether expressed through the excitement of mania or the
depression of melancholia.
=Etiology.=—Heredity is considered an important factor. Various
authorities claim to have demonstrated direct hereditary influences in
as many as eighty per cent and more of cases. Individual predisposition
resolves itself into a matter of constitution and temperament in which
there seems to be a greater tendency among those who are subject to the
emotional extremes.
Early adult life is by far its most frequent period of onset, though
it may arise also somewhat later. In certain cases the beginning
of the disorder dates from some psychic or emotional shock. Just
what importance these factors have as causes is little known since
other cases develop in which the constitutional element alone seems
responsible and no immediate exciting cause can be demonstrated.
The osteopathic viewpoint emphasizes the all important influence of
spinal lesions as exciting factors. In individuals who have a tendency
to this reaction their presence disturbing the cerebral circulation and
nutrition may act as the direct causative factor.
=Manic Phase.=—The manifestation of this condition is brought about
by the release of the inhibiting influences which normally govern all
psychic function. Various terms as hypomania, acute mania, delirious
mania, etc., have been used to differentiate the different degrees in
which the symptoms appear.
In the milder types we find the following symptoms present. There is
a marked feeling of well being. The patient, having lost sight of his
personal limitations, feels a consequent exalted opinion of himself.
His conduct is often rather boisterous, he talks a great deal, often
swearing and using obscene language. He is inconsiderate of others and
tries to impose his will upon those about him. There goes with this a
certain unstability of the emotional tone as manifested by the quickly
changing feeling of good humor, irritability and anger. There is a
rapid flow of ideas with a marked loss in the ability to concentrate
and direct thought. The ideas which pass through the mind do not
coordinate themselves toward a definite goal, but deviate from the
course of consecutive thinking by any passing association. Again there
is a restlessness and activity beyond all normal bounds. The individual
feels strong physically and mentally. The appetite is unusually good
and if activity is not too extreme there may be a gain in weight. The
period of sleep is diminished and the feeling of fatigue is reduced.
In the more exaggerated cases the flight of ideas becomes more marked,
the associations are more rapid and superficial and the attention is
focused but momentarily. Illusions and delusions may be present due
to the imperfect preceptions from inability to concentrate attention
and from abnormal associations. Rhyming speech, disconnection of
phrases and even apparent incoherence are often present. The state
of mind may be such that the patient tears his clothing, breaks up
furniture, jumps, dances and shouts and often will not take time to
eat. The most extreme cases which refuse food over some period of time
progress rapidly to exhaustion and measures to conserve strength become
imperative.
=Depressive Phase.=—In this phase of the disorder are encountered
manifestations which are in direct contrast to those presented in
the manic phase. In place of the exalted emotional state there is a
depression. There is a tendency to worry over trivial matters of the
daily routine and of instances in past life. Introspection is the
predominant mental attitude and the whole outer world is colored by
the inner feeling of worry and uncertainty. Replacing the rapidity
of thought in the manic phase there is a distinct slowing of mental
processes in the depressive phase. Thinking is more difficult and
labored, questions are answered slowly and with an apparent effort and
there is usually a tendency to avoid social life.
Again replacing the excessive activity in mania the depressions show
a retarded action. There is disinclination or disability toward any
effort either motor or mental. The patient feels weak and incapable of
effort, the body assumes a bent attitude and the facial expression is
one of despondency. The appetite is usually impaired with resultant
loss of weight, the bowels are sluggish, the period of sleep reduced.
In the more exaggerated cases the retardation may be complete.
Introspection is carried to the degree where the patient tries to
take unto himself the responsibility for all the sin in the world.
He himself is the arch sinner and he feels himself the subject of
punishment by divine wrath in a manner in which no other individual
was ever punished. Also the introspection tends to produce various
hypochondriacal ideas. The patient may feel that he has contracted
some incurable disease and that certain bodily functions have ceased
operating.
Mental processes become not only retarded and difficult, but actually
painful, a symptom which has been termed psychalgia. Suicidal
tendencies are also quite frequently present.
In extreme conditions the patient may become so retarded in thought and
activity that he apparently receives no stimulus from the outer world.
He lives in a more or less stuporous state, even requiring that food be
administered by tube.
=Circular Insanity and Mixed Forms.=—In addition to the conditions in
which simply mania or melancholia are manifest there are certain cases
which show variations and combinations of these forms. A common type
is that in which there is an alternation of the manic and depressed
conditions. The patient may pass directly from one state into the
other, or there may be an intervening period of lucidity. The term
circular insanity has been applied to this type. Other variations
are those in which there are recurrences of the manic or depressive
attacks often at more or less regular intervals, each recurrence being
a practical repetition of the preceding.
There is also possible a considerable intermingling of the
characteristics of the two types. In the manias may occur difficulty
of thinking, passing feelings of depression and even almost stuporous
conditions. In depressions there can exist a marked degree of
restlessness and activity and a rapidity in the flow of ideas.
=Prognosis.=—The outlook for recovery from the individual attack is
good. The attack may last from a period of days to one of a number
of months and recovery comes with rarely any evidence of mental
deterioration. There is a tendency to recurrence of the trouble.
In fact recurrence is the rule rather than the exception. In the
osteopathic handling of these cases it has been the endeavor to
demonstrate that the correction of lesions had a tendency to lessen
the duration of the individual attack and reduce the tendency to
recurrence. Judging from the experience thus far gained in the
observation of cases under treatment during the attack and the
comparative few recurrences reported both of these aims have been
attained.
=Treatment.=—The osteopathic measures are aimed at the correction of
the spinal lesions, especially those located in the upper dorsal and
the cervical regions. Some reflex effects from lesions in more remote
areas may have their influence so that it is wise to look to the
correction of any other structural variations when present.