Manic State (is a condition that may be feared to transition)

MANIC STATE is a condition that may be feared to transition into chronic manic state [progressive manic constitution (Nitsche)] with frequent recurrence of manic episodes. In this condition, stereotypy of behavior and generally noticeable mental deterioration gradually develop. That deterioration occurs much more frequently than is generally thought is shown by the observations of Galachyan. Long-lasting mixed states also indicate a less favorable outcome. Attacks in later life are combined with manifestations of cerebral arteriosclerosis, resulting in a complex picture with an unfavorable course. According to some authors (Lange), fluctuations in the affective sphere in manic-depressive patients themselves predispose to vascular diseases (apoplexy). Diagnosis. Typical cases of manic-depressive psychosis do not present particular difficulties. The consonant character of patients, the naturalness and accessibility inherent in cycloids, the main features of manic and depressive syndromes (distractibility, retardation), body build and type of motor activity as auxiliary criteria, hereditary data, and finally similar attacks in the history—all this provides solid points of support for the diagnosis. In differential diagnosis, one should consider 1) organic brain diseases (manic and depressive pictures in progressive paralysis, etc.); 2) some schizophrenic forms that sometimes present great difficulties, since, as Lange's research shows, the presence of even massive catatonic features does not exclude the basic manic-depressive nature of the disease. Sometimes the young age of patients combined with intellectual inadequacy gives purely manic-depressive attacks a pseudo-hebephrenic coloration. Non-productive manias with apparent mental emptiness present considerable difficulties. Depressive states in epilepsy do not last long, showing specifically epileptic features at the same time. Some difficulties may be presented by manic states in Basedow's disease and (in children) by chorea. Prevention and treatment. Eugenic requirements encounter a number of theoretical and practical difficulties. Mostly, manic-depressive psychosis in parents occurred after the offspring had already appeared. Cases are somewhat more frequent where one of the parents had an attack before entering marriage. However, considering the insufficient development of the laws of inheritance of manic-depressive psychosis, there is no possibility of establishing universally mandatory contraindications to childbirth. There is no means of preventing an attack. If the disease has already manifested in childhood, it would be advisable not to rush too quickly with education. The question of contraindications to pregnancy and childbirth presents great difficulties. A depressive state during the first pregnancy (or after the first childbirth) does not yet predetermine the occurrence of attacks under similar conditions. Depression at the beginning of pregnancy is not an absolute indication for abortion. One of the most important questions in the therapy of manic-depressive psychosis is the prevention of suicide. As a general rule, the depressive patient should be placed in a closed institution. Exceptions may be admitted with detailed knowledge of the patient and the unquestionable absence of suicidal tendencies. In severe retardation, the danger of suicide is also relatively small. However, one must always keep in mind the possibility of raptus melancholicus. Moreover, it is precisely these patients (retarded) who feel best in the hospital, where the surrounding environment does not require them to show initiative, since the presence of the disease is confirmed and officially recognized. One should still remember the frequent dissimulation of suicidal tendencies. Sometimes patients with great skill deceive the vigilance of the staff. Thus the old rule—'do not trust any melancholic'—remains in full force.-- In all other respects, treatment proceeds according to general psychiatric principles. Bed rest is beneficial, warm baths and especially (for insomnia and manic excitement) prolonged baths (of the so-called Dauerbad type). More specific water treatment procedures have no importance. Among medicinal substances in depressive states (affects of fear and cardiac anxiety), opium takes first place (three times a day from 10 to 40 drops of opium tincture); in manic states, it is advisable to use small doses of hypnotics for a long time (e.g. Veronal 0.2x5, changed after a week with Sulfonal 0.2x5 pro die). Psychotherapy in manic-depressive psychosis consists of careful and patient listening to the patient's complaints, a compassionate attitude of the physician, repeated indications of curability, etc.