Manic-Depressive Psychosis

MANIC-DEPRESSIVE PSYCHOSIS The main syndromes included in the concept of M.-d. p. are mania and melancholia (see). Until the turn of the 20th century, psychiatry considered these as completely independent and essentially opposite pathological entities. In addition to simple manias and melancholias, recurrent and periodic forms were distinguished, which were included in the large group of 'periodical insanity.' These subdivisions continued to exist even after French psychiatrists Falret and Baillarger almost simultaneously, in 1852, described cases of regular alternation of mania and melancholia, either in the form of a continuous cycle of both forms (circular psychosis - folie circulaire; Falret) or in the form of an interrupted chain separated by free intervals of manic and depressive pictures, giving such a periodic psychosis its characteristic 'two-faced' nature (folie à double forme; Baillarger). These facts, which clearly indicated an internal affinity between both psychotic states, did not, however, receive proper patho-clinical interpretation at that time. Accordingly, in the following decades, much effort was spent on finding differential diagnostic criteria between simple manias and simple melancholias on the one hand, and recurrent, periodic, and circular forms on the other. But the task proved impossible. Over time, it had to be recognized that it was completely impossible to determine the nature and further course of mania (resp. melancholia) by observing only the first attack of the disease or having before one a patient with an unknown anamnesis; in other words, the symptomatic identity of simple periodic and circular attacks was established. Moreover, as further anamnestic and catamnestic data accumulated and were statistically processed, the comparative rarity of single episodes of mania and melancholia became increasingly clear. Recurrences of the illness and circular forms were noted much more frequently. Almost simultaneously with this, attention was drawn to the fact that such patients, even during periods free from the disease, exhibit a peculiar emotional instability, suggestibility, and unmotivated fluctuations in mood, i.e., that manic and depressive states require a special soil or constitution for their development. This became particularly clear as the number of outpatient observations of a large contingent of borderline states, characterized by a tendency to not sharply expressed fluctuations in mood and general biotonia, increased, and these received the name cyclothymia on the proposal of Kahlbaum. A review of all these facts led to their inclusion in one large group with the main characteristic feature - extreme instability of the affective sphere and the comparative benignity even of severe disorders, allowing a favorable prognosis to be made in each individual case. This generalization was made by Kraepelin in the 5th edition of his textbook (1896). After several years of comprehensive discussion and collection of additional materials, the new doctrine gained general recognition, and the name M.-d. p. became firmly established in science. However, at present, its boundaries have significantly expanded, encompassing a whole range of pathological conditions, so that it is already customary to speak not of M.-d. p., but of something broader - the manic-depressive circle. Kraepelin himself admits that M.-d. p. is not a single pathological process (nosological unit), but represents a complex group, however originating from one root, with blurred boundaries between individual forms (group of affective psychoses). But in its original form [along with another synthetic construction, Kraepelin's group of early dementia (dementia praecox)], the concept of M.-d. p. played a huge role in the scientific systematization of clinical material. It led to the formulation and partial resolution of a whole range of essential problems of psychopathology, genetics, the doctrine of constitutions, marking a significant progress in theoretical and practical psychiatry of the first quarter of the 20th century. Distribution. Diseases included in the manic-depressive circle (and among them, M.-d. p. in its basic forms) belong to the fairly common disorders. According to Kraepelin's data, patients with M.-d. p. constitute 10-12% of all admissions to the hospital; according to Deny and Camus, among the total number of patients in the female department of the Salpêtrière, there are 17.3% of manic-depressive cases. According to reports of hospitals in the USSR (Kazan regional infirmary, Tomsk, Odessa, Leningrad 1st psychiatric hospital named after Forel, according to data from the clinic of the Military Medical Academy and other institutions of the republic), the percentage of manic-depressive patients averages 12-a figure little different from the statistical data of Western European and American hospitals. However, it should be assumed that these numerical values do not establish the actual prevalence of the disease, since a significant number of mild cases, borderline and combined forms escape registration. Etiology. Sex. Women get sick more often than men. According to Kraepelin, the number of women constitutes about 70% of all cases. The same figures have been published by other authors (Walter, Rehm, Bumke, I. Lange). According to the latest calculations by Rüdin, for every 100 men there are 148 women. The predominance of women may be associated with generative processes, with the lesser stability of the endocrine apparatus and the greater affective lability of the female psyche. - Age. In early childhood, the disease is rarely noted. The number of cases increases as puberty approaches. Starting from 15-16 years, the disease curve rises rapidly. Its maximum height is concentrated in the age group of 21-30 years. Later, a certain decrease in the curve is observed, which, approaching the beginning of the involutionary period (36-40 years), rises again, then to give a slow decrease with old age. The nature of the attacks changes with age. In almost half of the cases, the disease begins with depression; as age increases, the percentage of initial depressions grows, and their severity increases; if the first depressive attack falls at the 4th or 5th decade (even independently of involutionary processes), it usually manifests in a more severe form. The exact opposite is observed in mania. As age increases, the number of first manic attacks is observed less and less frequently, and the attacks become milder. However, particularly severe cases sometimes occur here . - Race plays a far from clarified role. A long time ago, a tendency to melancholic states was noted among German tribes (Swabians, Saxons) and among Scandinavian peoples (high suicide rate). Pilcz and Kraepelin pointed to the increased predisposition of Jews; this is confirmed by Warsaw statistics by Urstein. The Slavic race also gives a high morbidity rate. Opinions regarding primitive peoples differ. Among the native population of South Africa, a relatively high percentage of manic-depressive cases has been established. - Profession. Bumke expresses the opinion that in cultural strata, M.-d. p. is more common than in relatively less cultural ones (in contrast to schizophrenia). However, such a 'class' predisposition is not proven in any way. Only fragmentary data are available regarding professional pathology of M.-d. psychosis. Instead of a direct influence of the profession, it is often possible to assume the reverse relationship, i.e., the influence of the manic-depressive constitution itself on a person's choice of occupation, with a preference for forms of labor that require emotional stress and constant communication with people. Manic-depressive constitution. Among the etiological factors, the first place is occupied by the peculiar 'mental makeup' characteristic of a person before the illness, as well as in the intervals between attacks (prepsychotic personality). The same makeup also characterizes most other members of this family (blood relatives), who, however, may never develop a psychosis. M.-d. p. is a constitutional and hereditary disease. This position is one of the most established facts of theoretical psychiatry. People with a manic-depressive constitution are prone to unmotivated, long-lasting shifts in mood and general biotonia in the direction of excitement and depression. Among recent authors, Kretschmer gave the most detailed characterization of the manic-depressive constitution ('cycloid temperament'). People belonging to this category are sociable, friendly, keenly feel the good and bad sides of reality and in general accept life as it is. Among them, several types are distinguished. 1) Pure euphoric (hypomanic type), 'sunny natures', cheerful, sociable, good-natured, optimists, interested in everything, somewhat superficial. The talent of these people is above average in half of the cases.

They represent considerable social value, although they often do not carry out their plans to the end, getting sidetracked, and thus do not justify expectations. 2) The second type includes self-confident people, 'who know their own worth,' irritable. With average abilities, they always strive to penetrate the front ranks. Sociability and skill in dealing with people help them in this. But they have no perseverance in anything, and with an abundance of diverse ideas, great distractibility (physiological prototype of 'flight of ideas' - see below). Their irritability can cause violent outbursts, but it is devoid of aggressiveness. In others, however, the tendency to struggle is a predominant character trait: they persistently defend their rights, representing numerous transitions to paranoid and querulant types. This variety has no special social value; on the contrary, under certain circumstances it is dangerous (Reichardt). 3) The third category includes the constitutionally depressive type: somewhat insecure people, with a feeling of inferiority, heavy, unable to experience joy directly and showing a tendency to experience unpleasant life events more deeply and for longer periods. The largest part of these constitutionally depressive natures represents social value, distinguished by high intellect and good talents. 4) Cyclothymics - people who show long-term fluctuations between elevated well-being and creative uplift on the one hand, and depressed mood and psychomotor retardation on the other. They always experience one of these phases. Individual variations here are extremely numerous. Such are the subdivisions of cyclothymic types. Attempts to determine the comparative prevalence of these groups have not yielded complete and convincing results (Krepel, Kahn). But whatever the subtype to which cyclothymic temperament people belong, all have a common characteristic feature: orientation toward real life, and their affective experiences as if resonate in tune with surrounding events, and thoughts resonate in tune with the main mood. They have no detachment from life and no inner fragmentation. Bleuler defined the basic property of their psyche as syntony. This is their essential difference from the qualitatively opposite type - detached from real life, directed toward oneself, fragmented within oneself schizoid temperament. - In the vast majority of cyclothymics, a pyknic body build is observed (according to the latest data from Andreev, the correlation coefficient is +0.45). This discovery by Kretschmer has received universal confirmation. The pyknic type is close to Sigaud's digestive type and the arthritic habitus of older authors. An essential addition to Kretschmer's characterization of the cyclothymic-pyknic constitution is the peculiarities of the psychomotor sphere in individuals of this type, established by Russian authors (Gurevich, Ozeretsky, Zislin, Sukhareva). They are distinguished by general motor giftedness, rhythmic movements, expressive facial expressions, and so on (for more details - see Human Motorics). Cyclothymic-pyknic individuals are prone to metabolic disorders of a certain order: obesity, gout, diabetes, etc. Tuberculosis is not characteristic of them; they are prone to arteriosclerosis; apoplexy is more often observed in them (also in their relatives). According to Gilyarovsky and Nastyukova, the manic-depressive constitution is in some way related to the tendency to cancer. Heredity. Direct predisposition from one parent, who in turn comes from a cyclothymic family, is often observed, and it is often possible to establish the presence of M.-d. p. in several consecutive generations, so one can think of a dominant type of inheritance (Wimmer, Lenz). But this is not a general law. M.-d. patients also come from apparently healthy parents and in turn produce healthy children - the disease skips a generation, a fact indicating a more complex nature of the type of inheritance. As an example of direct inheritance, one can cite the genealogy of the famous Russian writer Garshin, who suffered from manic psychosis, in whose family the psychosis existed in four generations. Rudin thinks of a trimeria with one dominant and two recessive traits. According to Yudin, M.-d. p. occurs if a cyclothymic core (dominant) is added with two recessive features, in the form of either two schizoid genes or one schizoid gene with the addition of obsessive or fantastic elements. One of the most vivid proofs of the involvement of a schizoid gene is the fact that children of M.-d. patients are often schizophrenics (Yudin). In any case, recent research has clearly shown that the genetic core of M.-d. p. cannot be regarded as something closed, and scientific research is aimed at decomposing this core into more elementary idiotypes (Kahn) or gene radicals. Somatic causes. If the main role in the origin of M.-d. p. belongs to endogenous-constitutional factors, one cannot however deny a certain etiological significance to a number of exogenous-somatic factors. A connection between psychosis and organic brain lesions (head injuries, vascular diseases), with infectious diseases [pneumonia, influenza (Lange)] has been described. However, caution is necessary in evaluating such relationships. Schultes describes identical diseases in two twins, in one of which the onset of psychosis coincided with a head injury, which thus was a chance occurrence, which however, had the disease of the other brother not been established, could have impressed as a clearly causal factor. Among the etiological factors of primary importance, the generative processes of the female organism should be mentioned: menstruation, pregnancy, childbirth, lactation, the climacteric period. These facts undoubtedly indicate the enormous importance of biochemical relationships for the occurrence of M.-d. p., the psychopathological signs of which must be considered only as the most conspicuous manifestations of some other, extremely essential processes in the depths of the tissues. From this point of view, one must also consider the significance of infections, which apparently sometimes give a push to those specific metabolic disorders that can be assumed as the basis of M.-d. p. Mental causes. The experience of the imperialist war showed that despite the associated psychological traumas and emotional stress, the number of M.-d. cases during.

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this time did not increase. This fact makes one treat with skepticism the indications of patients (and their relatives) on this or that psychological moment (a heavy loss, a court verdict, resettlement from one's accustomed place, etc.) as the cause of the illness. However, psychological factors do play a role in some cases of M.-d. p. Where the influence of psychological factors can be proven, they speak of psychologically provoked depression (I. Lange); closely related to it are reactive forms (Lange), arising on the special soil of constitutional depression (see below). Symptomatology and clinic of the main forms of M.-d. p. Prodromal symptoms. The more than probable assumption that M.-d. p. represents a general disease of the organism finds confirmation, among other things, in the existence of a whole series of prodromal phenomena of a neuro-somatic nature. Patients complain of poor appetite, constipation, tightness in the chest, headaches, a feeling of general fatigue, and sleep disturbances. Prodromal phenomena are especially noticeable in the morning and somewhat subside by evening; sometimes they quite quickly (within several days or even hours) lead to the typical picture of a developed attack of melancholia or mania. In the first case, neuro-somatic phenomena intensify and multiply, in the second they disappear, replaced by a general feeling of physical health and increased energy.-Depressive phases. The general neuro-somatic and mental depression of the patient is reflected in the external appearance of the patient. The head is lowered, the face is pale, the facial expression is listless or sorrowful, the eyes express fatigue, humiliation, anxiety, worry, fear, despair. In the psychopathological picture, the following "triad" of symptoms appears: 1) depressed mood with gloomy thoughts, 2) slowing of associative processes, 3) psychomotor retardation. Depending on the severity of the attack, melancholic ideas may vary in content. Everything that previously interested and tied one to life-family, work, entertainment-now evokes only sad thoughts. Memories of past life are tendentiously selected with the exclusion of anything joyful and cheerful. The evaluation of the present and oneself is colored in a sharply negative tone. The future is depicted as difficult, gloomy, terrible, inspiring mortal fear; there appears a desire to escape from life-suicidal tendency. On such an affective background, overvalued (in mild and moderate cases) or delusional (in more severe cases) ideas form and persist. Patients accuse themselves of mistakes and crimes (delusion of self-accusation), say that in them is embodied everything sinful, dirty and criminal (delusion of self-abasement), consider themselves infected with serious and incurable diseases-cancer, syphilis (hypochondriacal delusion), are convinced that they are being watched as criminals, that they are going to be arrested, executed (delusion of persecution), sometimes express the thought not only of their own destruction, but also of the destruction of close people, all people in general_gthe whole world, which has already ceased to exist (nihilistic delusion) (see Delusion). Slowing of associative processes is subjectively experienced as difficulty in any mental activity. Experimental-psychological studies in such cases establish more or less pronounced lengthening of reaction time [instead of 0.1-0.3 sec. 2-3 sec., whole tens of sec., up to complete absence of reaction (Gutman)]. Intellectual retardation is experienced as extremely heavy, as a complete loss of capacity for work, "feeble-mindedness", "death of the personality", "mental collapse", etc.-Psychomotor retardation gives a picture of slowing of all motor reactions: the patient has difficulty speaking, moving, performing the most elementary acts of daily life (getting up, washing, etc.). Sometimes motor retardation is the predominant element of the entire depressive picture: these are stuporous forms of melancholia (see Stupor).-Especially severe are depressive states colored by the affect of fear and premonition of impending disaster. The feeling of anxiety and inexpressible mental heaviness sometimes takes on the character of a purely somatic phenomenon: in the chest there is felt a peculiar compression, a special kind of feeling of pressure in the heart area (the so-called precordial anxiety, anxietas praecordialis). The anxious torment of a purely physical nature is experienced by many patients in other parts of the body: in the abdomen, shoulders, upper and lower extremities. Such patients often cannot remain calm, pace about, wring their hands, moan (agitated melancholia).-Among the important basic elements of the depressive state, thoughts and tendencies toward suicide have enormous practical significance. Suicide attempts often occur at the very beginning of the illness. In some patients this tendency persists throughout the depressive period. The attempts made are in most cases serious: the patient jumps from a 5-6th floor window, into a stairwell, takes a strong poison, shoots oneself, etc. It is practically important to note the danger of suicide in those periods when retardation is still little expressed (beginning of the attack) or is rapidly decreasing (period of recovery). Cases of suicide immediately after discharge from the hospital are not uncommon; therefore, whatever the condition of the "recovering" melancholic, it never hurts to give the patient's relatives instructions on the necessity of supervision. The act of suicide can happen even in the best organized institution: in the ward, in the presence of staff. Special vigilance is necessary in the morning hours, when depression (as a rule) is most strongly expressed. Dangerous are those cases where rapidly growing affect of gloom and fear, breaking through retardation, gives a flash of violent excitement with destructive tendencies (raptus melancholicus). Extremely tragic in their consequences »b 23

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There are cases of suicide with the preliminary killing of close people (children, wife), which the melancholic wants to free from the dangers and horrors of life.--For somatic phenomena in depression, see below. Manic phases. The manic state is the complete opposite of the depressive one. Here a completely different 'triad' of main features comes to the forefront: 1) elevated joyful mood with cheerful thoughts, 2) facilitated shift of associative processes, and 3) speech and motor excitement (see Hypomania). Everything around acquires in the eyes of the patient a special charm and attractiveness. Recovered patients later report that in normal periods of their lives they did not even approximately experience such a feeling of general well-being, lightness, and complete happiness ('this cannot be expressed in words'). In more severe cases, the facilitation of associative processes leads to complete fragmentation of thoughts. The patient is unable to stop on anything and think it over. Attention jumps from subject to subject, the logical course of thought is disrupted. All impressions immediately cause chains of secondary images that have only a superficial relation and similarity to the original representation: the goal-directedness of thought is lost (symptom of distractibility). Such incoherence of thinking (incohaerentia idearum) in severe forms turns into the so-called 'flight' or 'whirl of ideas' (fuga idearum). Experimental-psychological research does not, however, reveal any objective acceleration of reaction time corresponding to the slowing down, sometimes observed in depressions.-The elevated mood and accelerated flow of thoughts find their expression in the third cardinal feature of the manic state-in the excitement of the motor-volitional sphere. The speech of patients is hasty, disorderly, facial expression is lively and varied, movements are fast, impulsive, unexpected. If the patient has not yet been placed in a hospital, he visits acquaintances all day, talks incessantly, goes to institutions, submits projects, makes plans, spreading around him noise, fuss, and disorder. While preserving the external aspect of mental activity, in such cases a 'delusion of actions' comes to the forefront. A manic patient placed in a hospital quickly becomes the center of the ward and department, pesters everyone, laughs, gestures, shouts out disorderly, sings, undresses, dances. Attention is drawn to the absence of a feeling of fatigue (this circumstance incidentally makes prolonged simulation of mania impossible). Besides pleasant emotions, affects of sharply negative nature are sometimes observed: impatience, irritability, anger, and marked aggressiveness appear. Arising episodically with any more or less pronounced manic excitement, these affects in a number of cases color the entire picture of the manic phase: the patient swears, breaks glass, smashes furniture, attacks others (mania gravis, m. furiosa). In severe cases, delusional ideas of various content appear (manic delusion). The latter are always in full accordance with the generally elevated mood, increased self-esteem, or with the affectively negative elements of the manic complex (irritability, anger, etc.). Patients express ideas of greatness, wealth, power, which are however distinguished by their variability and instability. Ideas of erotic content are common: women think that they are the object of courtship and desire of all men without exception; men consider themselves 'irresistible,' talk about an impending marriage with a famous beauty, singer, etc. In other cases, ideas of a clearly paranoid nature arise, explained by the fact that the excited patient, naturally not receiving satisfaction for his claims, easily comes into conflict with surrounding chance passersby or officials, which he interprets as intrigues, persecution, injustice (bribery) of judges, etc. On this basis arises a special variety of 'litigious insanity'-the type of manic querulant. In some cases, as remnants of a recently experienced depressive phase, hypochondriacal ideas are observed. The patient complains of painful sensations in the back, in the heart, stating that he has tabes, arteriosclerosis, etc. Characteristic for these cases is a specifically manic coloring of such complaints: patients suffer less from hypochondriacal fears than they use this topic for noisy verbal outbursts or for visiting the doctor, which is prompted in them by a vague feeling of illness. Hallucinations are not typical for manic states, but sometimes illusory perceptions are observed on the basis of hasty identifications and conclusions. In very severe cases, there are disturbances of consciousness, confusion; the latter sets in due to the extreme acceleration of associative processes and the abundant influx of illusory images. Mixed states. In the long-described classical cases of mania and melancholia, the combination of disorders of intellectual, affective, and motor order is usually stable and homogeneous, i.e., either an expansive or a depressive state, spreading simultaneously to all areas of psychological functioning. Experience shows, however, that such pure cases are comparatively rare. More often, instability or heterogeneity of the clinical syndrome is observed: 1) daily fluctuations of mood from morning depression to evening excitement; 2) spontaneous breakthroughs of the clinical picture with contrasting elements (e.g., minutes and hours of euphoria on the background of depression); 3) prolonged coexistence in the psychopathological picture of status praesens of heterogeneous elements from both manic and depressive phases. The syndromes designated in point 3, the so-called mixed states (Mischzustande), were first described by the school of Kraepelin (Weygandt). Here the following com-

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combinations. 1) Maniacal mood--euphoria with intellectual and motor inhibition. Patients lie or sit quietly with a satisfied and calm expression, slowly answer questions, and move slowly. This state is designated as manic stupor. It usually develops from syndromes of ordinary manic excitement or appears at the end of melancholic attacks, when melancholy has already disappeared, euphoria has appeared, but general inhibition still persists. Such forms were, before Kraepelin, mostly classified in the group of catatonia. 2) Manic excitement--euphoria with intellectual excitement but motor inhibition. Patients experience flight of ideas, but due to speech inhibition, they can only provide information about it after the attack has ended. Such inhibition of mania sometimes externally differs little from true manic stupor. Patients sometimes have a rich inner life, experiencing vivid optical images. Sometimes instead of euphoria, emotional excitement is expressed as fear (angstliche Manie - manic fear). 3) Intellectual inhibition and euphoria in combination with motor excitement give a picture of so-called unproductive mania. Patients give the impression of being internally depleted; all their statements are poor in content, stereotyped, and their behavior is monotonous, but due to euphoria it takes on the character of childish absurdity, strongly resembling schizophrenic pictures. However, the complete accessibility of patients without difficulty reveals their belonging to the syntonic type (to the manic-depressive circle). 4) Depressive mood with flight of ideas and internal excitement, so-called agitated melancholia (m. agitata), which is often based on a tense melancholy combined with fear, continuously giving motor discharges to the periphery: patients are constantly in motion, pace about, cry, groan, harm themselves, and inflict injuries. Acute flashes of agitated depression (iap.tus melancholicus) were described above. A peculiar form is the combination of flight of ideas with general inhibition; here the associative processes are greatly slowed down in tempo, while retaining all the features of fugae idearum (distractibility and superficiality of thinking, etc.). Complex forms of mixed states can be recognized as such only when it is possible to trace their origin from typical manic-depressive pictures or when the patient's history reliably contains classic circular phases. However, the outcome of the disease in mixed states is often not as favorable as in pure forms. Some authors assume that mixed forms are genetically the most complex, and that the atypicality of their pictures depends precisely on these additional pathological moments. Here, too, schizoid features are most frequently observed, sometimes schizoid and epileptoid features. Reactive forms. On the basis of the manic-depressive constitution under the influence of psychological factors (psychic trauma), as well as in some other psychopathic constitutions, syndromes arise that are close in their characteristics to M.-d. p. The following variants are distinguished here. 1) The content of melancholic ideas, initially connected with a psychotraumatic factor, gradually loses this connection, transforming into typically endogenous delusional productions (banal ideas of self-debasement, sinfulness, etc.). This is psychically provoked melancholia (Lange). 2) The depressive syndrome after psychic trauma occurs in a patient with constitutional depression (Reiss), and the content of melancholic ideas does not go beyond the original experience; inhibition is not expressed at all or is very slight (true reactive depressions; Lange). Here the depressive syndrome might not have occurred if there had been no occasion, but even with the presence of this occasion, the subject could have remained healthy if he did not have the corresponding constitution (Bumke). Similar pictures are encountered on a completely different basis, outside the manic-depressive circle. In these latter cases, interesting from a differential-diagnostic point of view, instead of true depression, embitterment, egoism, withdrawal, continuous irritation of one's emotional wound, etc., come to the forefront. The prepsychotic personality of such patients is densely colored with schizoid traits. Lange proposes to designate such forms as psychogenic depression. Psychically conditioned (reactive) manias are rarely observed (in hypomanic subjects who have suddenly become rich; Bonhoffer, Bumke), in cases of intense fear (Angstmanie Schneider), when a special kind of cheerfulness and motor excitement serve as a means to drown out unbearable horror. Of practical importance is the sometimes hidden, fully matured decision to commit suicide that lies deep within such manic syndromes ('laughing mania'). Somatic phenomena in M.-d. p. do not present pathognomonic signs. One of the most characteristic phenomena must be considered the fluctuation in weight: decrease in both phases, especially in the depressive phase, and increase during recovery. These fluctuations have important prognostic significance. The fluctuation in weight apparently depends not only on irregularities in nutrition but also on deeper internal causes connected with the organic essence of the disease. Investigation of metabolism has been carried out repeatedly. According to Bekhterev and Omorokov, a decrease in oxidative processes is noted in both phases; slowed metabolism has also been confirmed by American authors (Gibbs, Lemke). The slowdown concerns water, gas, partly protein, and sugar metabolism. These facts indicate that the disorder of the affective sphere is by no means the most essential phenomenon in the complex symptom-complex of M.-d. p. According to Lange, the Abderhalden reaction also provides some reference points: in mania, the thyroid gland plays a role, in melancholy--the liver (Ewald, Jacobi). Nevertheless, endocrinological theories are extremely unstable and unreliable. Attempts to reduce the acute phases of psychosis to increased irritation of the parasympathetic nervous system and other assumptions about the role of vegetative-endocrine apparatus represent a priori considerations. The facts in this field have not yet been brought into a system. In acute phases, menstruation often ceases (Protopopov, Hanse), sexual desire decreases (however, in some cases of climacteric depression, an increase in libido is noted). Disorders in the activity of the adrenal glands have been described (melanoderma, Damaye, Muratov). However, the fragmentary reports in the literature about such facts do not yet justify Krasser's attempts to explain the entire M.-d. p. as a consequence of a secretory disorder of the chromaffine system (Lange). Extremely typical for depressive syndromes are severe disturbances of digestion (persistent constipation). Disturbances of sleep are just as frequent, not always explainable psychologically (by tension of melancholic thoughts, fear, etc.), since sleep is sometimes disturbed in simple inhibition and apathic states. In some cases of depression, on the contrary, lethargy is observed, resembling narcoleptic attacks (Antimov, Kannabich). Sometimes insomnia has the significance of a prodromal symptom. The disturbances of sensitivity are numerous and varied: hyperesthesias, paresthesias, pains in the head, back, chest, etc. All the listed phenomena sometimes show a clearly cyclical course in the absence of any significant disturbances from the psychic side. This gives some authors reason to single out a special purely somatic form of manic-depressive psychosis--somatic cyclothymia (Pletnev). Essence and pathogenesis of M.-d. psychosis. A number of hypotheses have been proposed to explain the essence of the disease. Meynert at one time reduced melancholic pictures to constriction of cerebral vessels, and manic pictures to their dilation. This theory is again put forward by Thalbitzer. Reichardt assumes localization of the basic process in the brain stem. Ewald considers M.-d. p. as a disease of temperament. If one assumes that the normal temperament is the result of the equilibrium of functions of two glandular groups (stimulating and inhibitory), subject to special brain centers, then the hypomanic temperament (resp. mania) receives its explanation as a consequence of hyperfunction of the stimulating glands (in melancholy--the reverse). Attempts have also been made to reduce the essence of M.-d. p. to more basic, purely biological phenomena. Thus, the Russian psychiatrist Antimov (at the end of the 19th century) compared the periodic depression of patients with the winter hibernation of animals, and the manic exaltation--with the spring awakening in the animal and plant world. The same idea (independently of Antimov) was expressed by Lange (1928). Some indication of the actual kinship of the phenomena mentioned is the periodic hibernation as an equivalent of depression in some cyclothymics (Kannabich). Pure forms of M.-d. p. undergo numerous distortions depending on the influence of a number of endogenous and exogenous moments.

Among the first, the so-called critical periods of life are of great importance, especially the climacteric, during which extremely severe and prolonged melancholic pictures with complex symptoms often arise (involutional melancholia). Kraepelin, who initially considered involutional melancholia as an acute form, later (after Dreyfus's follow-up study) unconditionally included it within the framework of M.-d. p. (as an example of a 'mixed state'). Kraepelin's viewpoint, which for a time gained wide circulation, underwent substantial criticism from Bumke, Kleist, and others. These authors attribute completely independent etiological significance to disturbances in the chemical processes of tissues in the involutional period of human life, assigning only a secondary role to the manic-depressive constitution. Furthermore, psychological factors are also assigned considerable importance. Seelert places involutional melancholia in an intermediate position between endogenous depressions and organic depressions of arteriosclerotic and senile types. In view of the diversity of pictures, courses, and outcomes presented by involutional melancholia, it is necessary to conclude that we are dealing with a collective group. It includes completely pure manic-depressive cases, but also depressive symptom complexes of other, complex-genetic origin: from the paranoid, schizophrenic, obsessive, hysterical, and organic circles. This circumstance greatly complicates prognosis, which in each individual case of involutional depression must be derived from a detailed analysis of all clinical, constitutional, and genetic data (Mauz, Kant, Lyusternak, Andreev). Furthermore, a whole series of exogenous factors often complicates manic-depressive syndromes. Alcohol and infections cause delirious states (Bonhoffer); heart diseases impose an hypochondriacal coloration on depressions, causing severe anginal phenomena (Romberg, Gaupp).-Individual paranoid traits are observed in simple cases of mania, melancholia, and cyclothymia. The catathymic (see Catathymia) origin of such ideas is often easily detectable. Paranoid suspicion is especially understandable in more advanced age, when feelings of worthlessness, even under physiological conditions, give rise to corresponding thoughts. But more persistent paranoid pictures not related to catathymia are also encountered. It is therefore necessary to admit that M.-d. p. in itself contains the prerequisites for paranoid delusion formation. However, the theory once put forward by Specht S17 about the complete identity of paranoid and circular mechanisms is not justified by the facts. Sometimes, however, the presence of a special predisposition must be recognized, especially when all phases of the illness in a given patient had a paranoid coloration (some cases of 'acute paranoia' of Gannushkin). What this predisposition consists of is still unknown. There is reason to speak of a special paranoidic constitution, which, however, is not something uniform, but contains genes of different origins. Apparently, schizoid heredity and schizophrenic mechanisms play a role here (Bleuler, Hoffmann, Yudin, Geyer, Galachyan, etc.).-It is often necessary to observe manic-depressive phases with genuine, sharply expressed schizophrenic traits. Such combined psychoses are observed in persons representing various deviations from the pyknic body type (asthenics, dysplastics; Mauz). The premorbid personality of these patients also shows schizoid elements. For a long time, the problem of such composite psychoses presented a stumbling block for clinicians. After the work of the Tübingen school (Kretschmer, Gaupp, Mauz, Hoffmann), the requirement for a strict separation of clinical material according to individual diseases has lost its obligatory nature. The combination of manic-depressive and schizoid constitutions, hereditarily demonstrable in a whole series of cases, completely explains the superimposition (Legierung) of one symptomatological picture on the other. The following formulation by Mauz is fundamentally important: 'Schizophrenia on the one hand and M.-d. p. on the other are for us not eternally fixed disease entities, but biologically grounded and having precise characteristic basic types, between which numerous transitions exist.' This position of constitutionally oriented modern psychiatry fully illuminates and the frequently encountered combination of manic-depressive pictures with hysterical and obsessive phenomena (globus, seizures, obsessive ideas, anankasms).-The admixture of hysterical reactions (everywhere encountered as psychogenic layers) - 'hysterical-melancholia' of former authors (Friedmann)-does not require special consideration. More complex is the question of the combination of M.-d. p. with phenomena characteristic of 'obsessive-compulsive neurosis' (psychasthenia R. Janet). Some authors (Jastrowitz, Bonhoeffer, Heilbronner, Aschaffenburg, Kanabik and especially Stocker) see the psychogenesis of obsessive ideas in the depressive affects themselves and include these symptoms in the M.-d. p. group. However, it is known that the obsessive-compulsive syndrome is also observed in schizophrenia. But besides this, this phenomenon also occurs completely independently as a special, highly characteristic constitutional symptom complex. Genetic studies (Hoffmann, Yudin) allow for the identification of a special type of psychasthenic constitution (Yudin), which, along with the cyclothymic temperament, can be part of the more complex type of psychopathic organization inherited by the individual. Course and outcomes. The course of M.-d. psychosis presents enormous diversity. It may be said that each patient has his own, characteristic picture (Reichardt). However, several of the most frequently encountered typical variants may be noted. 1) A hypomanic predisposition runs continuously through the person's entire life. 2) A depressive predisposition runs continuously through the person's entire life (during which either no fluctuations are observed at all, or only minimal fluctuations in one direction or the other are observed). 3) Throughout life (or over some long segment of it), there are more noticeable wave-like fluctuations from depression to excitement and back-cyclothymic course, circular psychosis. 4) One or the other of the phases (manic or depressive) occurs once in the life (rare cases of simple mania, simple melancholia). 5) A certain periodic syndrome is characteristic of the given patient, i.e. a) only manic phases, b) only depressive phases, c) only the regular alternation of both, d) always the same mixed state. 6) Different phases occur in the patient without any regularity throughout life (e.g. 8-10 mild depressions and one severe mania or mild manic attacks and a single deep melancholia or finally approximately equal numbers of depressive and manic periods). 7) Individual phases occur at more or less regular intervals (periodically) or at completely irregular intervals (recurrent, intermittent attacks) sometimes with very long pauses. The duration of each phase varies within very wide limits. The average duration of phases is generally considered to be 8-9 months. However, there occur (especially frequently in the involutional period of life) depressive states lasting several years (3-4-5 and even more), on the other hand, short phases of 2-3 weeks, 1-2 days are observed. Outcomes. As a general rule, each phase of M.-d. p. (if there is no circular course) ends in recovery, and the patient returns to his original temperament (hypomanic, depressive, etc.). Such an outcome is especially typical for persons with a clearly expressed pyknic-cyclothymic constitution. Various admixtures-paranoid, obsessive, etc.-make the course irregular and greatly complicate prognosis. As a general rule, it may be recognized that the prognosis is the more unfavorable the more sharply heterogeneous constitutional-morphological types: asthenic, dysplastic, etc., appear in the patient's physical structure. Despite the fundamentally benign nature of manic-depressive diseases in general, it is necessary to note a number of significant circumstances that to some degree darken the favorable prognosis. Thus,