Depressive phase of bipolar disorder. Depressive state (depressive phase) What is the manic phase
What is Bipolar Disorder?
Everyone is familiar with mood swings. There are days when we feel depressed, when we experience tension and our self-consciousness is, as it were, “broken”. And on the contrary, a person who is deeply in love is in a state of euphoria, experiences a spiritual uplift, any work argues on the wave of a cheerful and carefree mood.
When a person falls ill with bipolar, or in other words, manic-depressive disorder, these mood swings go far beyond the norm and do not correspond to real life circumstances. Mood swings cover states from deeply depressive to deeply manic, with a full range of painful manifestations. Symptoms of mania include, for example. unusually high spirits (euphoria) and high self-esteem, increased performance, reduced need for sleep, insomnia, lack of a sense of distance and speech pressure. Symptoms of depression, in turn, include despondency, indifference, lack of interest in simple things that usually bring joy, a tendency to obsessive thoughts, a pessimistic attitude about the future, sleep disturbances, early awakening, or an increased need for sleep.
Patients feel abandoned to the mercy of their moods and, above all, at an early stage of the disease, they believe that these drops are difficult to influence from outside. Recurring phases of manic- depressive syndrome often cause a deep spiritual wound both to the sick themselves and to those close to them.
Some of the specific aspects of bipolar disorder will be discussed below and its particular internal dynamics will be characterized. Then the types and causes of the disorders will be discussed.
Specific Aspects of Bipolar Disorders
- Loss of sense of time: In contrast to general mood swings, there is a loss of sense of time in bipolar disorder. Depression seems eternal and inevitable, it always has been and always will be; a correspondingly infinite feeling of despair. Mania is experienced as an inexhaustible source of energy; accordingly, overestimation of one's strengths and risky behavior become unlimited. It is impossible to distinguish the actual change of phases of the disease.
- Re-adaptation problem: If you take a closer look at people with bipolar disorders, you can see their tendency to readjust. In the process of their socialization, they have learned to meet other people's expectations and live according to the criteria of other people, without asking unnecessary questions. They try very hard to please everyone. They are not aware of their own scope and they do not have developed strategies for behavior in conflict situations. In depression, this dilemma becomes apparent and may even be exacerbated and caricatured. Mania manifests itself in an attempt to behave in an unconventional way, but the feeling of liberation in this case actually remains internally empty and develops into a disease.
- Meaning of a sense of self-worth: People with bipolar disorder, like all people, have their own life history. Her periods have a beginning and an end, with or without treatment. The symptoms of a disease evolve, just as the capabilities and strategies to deal with it evolve. To make it clear, we can make this comparison with money accounts: Someone who has a lot of money in a savings account will not suffer financial ruin if there is no money in a checking account. The one who used all the reserve funds is left without a loan. And if he exceeds the balance of the bank account, he will be forced to pay high interest. Money is a sense of self-worth. Of course, self-empowering experiences, attention, love, and events that enhance self-worth are protective, while the opposite is harmful. These factors are not limited to any one period of life or the time preceding the disease. They have importance for treatment, which is why we wonder how we so rarely avoid resentment in the process of treatment.
- Interactions: Obviously, there is a difference in how we gain or lose our sense of self-worth: Some people get irritated faster when the account runs out of money, others bet and win. The emotional battery discharges and charges at different rates. The interaction of social perceptions, emotional experiences, and the impulse control mechanism can be more or less direct. Accordingly, the amplitude of one's own emotionality and predisposition to pronounced phases increase. People with bipolar disorders not only get offended faster, they also become highly receptive and react faster, using their full energy balance.
- Typical thought patterns / internal dynamics of the psyche: Depressive thought patterns lead to significant distortions in the perception of personal and other people's achievements: failures are attributed to oneself, and successes to others. Plans are almost inevitably thwarted. Anticipation of failure mimics a sense of independence, but more and more leads to despair. In manic phases, these distortions work in the opposite direction.
During the period of treatment, it is necessary to figure out how to inspire a person with hope for recovery, without reassuring him only superficially, as this will rightfully be perceived as a mockery. Treatment should restore the sense of time. by the most natural way this is achieved in self-help groups or during special group therapy: In the other patient, one sees precisely that phase that is not currently manifesting in oneself at the moment. Through the development of polarity, a person acquires greater mobility, with a central tendency of evaluation.
The task of long-term maintenance therapy is not to bring adaptation to a normal state, but to help you create your own criteria, critically approach the expectations of strangers, find a place for your unusual manifestations or desires in everyday life, not postponing them for the case of manic behavior.
The primary task of symptomatic and long-term treatment is to prevent new grievances and help to survive old ones, to reveal and direct the internal forces of the body for treatment, and to strengthen and maintain family relationships and social ties.
In the process of treatment, it is necessary to tune the patient to such interactions so that he himself can regulate them.
This mechanism should be reversed: The first steps of treatment should be constantly evaluated critically, patiently and calmly, until they become so small that the success of the treatment is inevitable. In this case, group discussions with the participation of "experienced" patients can be useful.
Helping the relatives of the patient (individually or in groups) will bring therapeutic benefits to the patients themselves. Working with bipolar patients without the involvement of loved ones (individually or jointly) is a medical mistake.
The concept of a “biological defect” allows better justification of strategies drug treatment than the simplified and incorrect theory of direct causality. At the same time, the patient and the attending physician must also think about more complex causes, as well as use individual and social opportunities. The doctor's prescriptions are already quite complicated: Antidepressants are not always effective, they do not act immediately, they increase the risk of suicide for a short time, and for an indefinite period the risk of going into a manic state. Prevention of episodes does not protect even half of patients from relapse. And the antimanic effect of neuroleptics has significant side effects stronger than other drugs. Thus, both a positive attitude towards medicines and the cooperation of doctors and patients are tasks that need to be addressed together. It is all the more important that medical prescriptions form an integral part of the general culture of psychotherapeutic treatment; without this culture, doctor's appointments, although necessary, are hardly acceptable.
The mutual influence of mental, social and somatic factors is so complex that it is hardly possible to speak of a motivated implementation of various monotherapies.
bipolar affective disorder
BAD is a disease of unstable mood.
One of two and a half diseases of the group of endogenous mental disorders, which also includes schizophrenia.
The outdated name "manic-depressive psychosis" is much more descriptive of the yin and yang/west and east/plus and minus of this disease: depression and mania, but it had to be changed due to the lack of yang minus in some patients and the presence of a more accurate name, which does not carry the word “psychosis”, which is terrible for others.
Synonyms: TIR, circular psychosis, cyclophrenia; "bipolar disorder", "BD", "MDI". Not to be confused with a bar where they drink.
The course of the BAR looks like riding up and down the roller coaster of mood, with periodic hanging on the peaks and bottoms, where you either rejoice beyond measure, or, accordingly, kill yourself. These are serious psychiatric conditions in the form of recurrent long-term episodes of marked mood disturbance that are widespread and associated with disability and mortality. They run the gamut from debilitating depression to rampant mania, leading to relationship breakups, poor performance at work/school, and even suicide. Bipolar disorder usually develops in late adolescence or early adulthood, but often goes unrecognized, and then people suffer for years until they are noticed and treated.
Because of the many variations in severity and the unspecified origin of bipolar symptoms, the concept of "bipolar spectrum disorders" is often used, including cyclothymia. According to DSM-IV, there are 4 types of such disorders:
- A single episode of mania (or mixed) is enough to make a diagnosis of type 1 disorder (BARI); a depressive episode is optional (but usually not long in coming).
- The second type (BARI II), which is more common, is characterized by at least one episode of hypomania and at least one depressive episode.
- Cyclothymia requires several episodes of hypomanic episodes followed by depressive episodes that do not fully meet the criteria for major depressive disorder.
- randomness of thoughts - a person thinks quickly and a lot, he swarms in his head various ideas, forming an infertile mess up to delirium;
- distractibility - due to the chaos in the head mentioned above;
- reduced need for sleep - patients sleep for 3-4 hours a day without a feeling of lack of sleep or any discomfort;
- irritability (to the point of rage) along with assertiveness and lack of a sense of distance, although some patients may be simply euphoric and pretentious;
- increased efficiency - comes from the desire to realize everything that the sick head is busy with;
- inflated self-esteem with unreasonable confidence in their own abilities, which often leads to problems such as wastefulness, unsafe sex, drugs and provocative behavior.
- Depressed mood - constant melancholy, nothing pleases, life seems meaningless, even when everything is fine in the family and at work.
- Mental retardation - there are few thoughts in the head, the person answers questions after a long pause.
- Motor retardation - the movements of a person in depression are slowed down, he can lie in bed in one position for days and not move.
The basis of the concept is that there is a low-level mood cycling that may look like a character trait to the observer, but, nevertheless, interferes with the normal functioning of the patient. If a person clearly gives the impression of suffering from some type of bipolar disorder, but does not fit the given diagnostic criteria, then a diagnosis of unspecified bipolar disorder is made.
Everyone has mood swings: depression, a feeling of tension for a couple of days, and short-term mental ups and downs to the level of euphoria are familiar to everyone, but everything changes when BAD comes.
The classic version of this disorder, when manic and depressive episodes follow each other, is extremely rare - more often there is either underhypomania with depression, or only depression in general.
Depressive phases are much less productive in outward manifestations than manic phases, and last three times as long; they manifest themselves like any other depressions: despondency, depression, lack of interest in the outside world, pessimism and others (), which in the end can lead to not the best consequences without proper therapy: about 50% of patients made at least one suicide attempt () .
It is worth remembering that depression is not like ordinary sadness: a person will refuse any activities, not talk to anyone, sit / lie in one position for a long time, suffering about his worthlessness and meaningless life. In milder cases, there may be a dependence of mood on the time of day, which will improve in the evening, but in general, this condition will last not a week or two, but more than a month.
The catch for doctors and patients is that distinguishing depression in bipolar (bipolar) from ordinary (unipolar) depression is quite difficult without a clear analysis of the patient's mood in the past, which may well have been hypomanic episodes that he did not remember. Not all antidepressants are suitable for bipolar depression, and mood stabilizers must be used with them so that a successful exit from a depressive state does not provoke mania or a change in the type of disorder to a fast-cycling one (4 or more depressive / manic episodes per year).
If depression can be imagined by anyone, even the strongest person, then it’s more difficult with mania, because the average person associates psychopaths, maniacs (especially sexual ones) and all kinds of affects known from Dontsova’s books with this word.
Bright, active, eccentric - that's how you can describe a man in the stage of mania compared to a light gap. They are euphoric, but at the same time irritable, tactless and intrusive, especially when trying to correct their behavior. If you've ever watched Jack Black movies, then you can imagine it. The topics of one conversation are constantly changing without any particular relationship (“jump of ideas”), emotions are ahead of thoughts, sometimes there are false exaggerations of one’s power, wealth, abilities, up to delusions of grandeur and self-image as a god. In addition to just talking, they impulsively engage in risky activities (gambling, speed driving, drug use, criminal business), without any assessment of the consequences.
A person in a manic phase is not a rapist who runs around with an ax, inarticulate screams and sows panic. He can be called a madman, but the main manifestations of mania are a long-term elevated mood, excessive mental and physical excitement, not due to circumstances or events.
They come with:
It would seem that an ordinary person would be happy to do all this, only now it will be enough for a maximum of a day, and in patients with bipolar disorder this condition lasts a week or more - during such a time you can break a lot of firewood. This condition without treatment can last up to 6 months ().
In contrast to the depressive phase, many people enjoy mania, experiencing euphoria, comparable to the arrival of drugs, which they get addicted to due to this ().
In advanced cases, activity rises beyond the limit, erasing the connection between the level of mood and behavior: frenzied excitement appears (delirious mania), in which, without life-giving therapy, it is possible to win a box from physical exhaustion. It's nice that cases of unipolar mania (without depressive episodes) have not yet been described ().
Everything is the same, but several times weaker. It is easy to confuse a person in hypomania with an active extrovert, and vice versa: they are energetic, work hard, gush with ideas (often meaningless) and annoy everyone; the difference is that extraversion is a character trait that practically does not change over time, and hypomania can increase to mania or alternate with a normal state and depression.
Alternating hypomania (without episodes of mania) and depression is referred to as the disorder of the second, most common, type. BAD II is much more difficult to diagnose than type 1 because hypomanic episodes can simply be periods of elevated mood and successful productivity that people are unaware of and slow to report to doctors. If you've ever quit smoking, you're familiar with the feeling of elation in the first weeks - that's what hypomania is.
In hypomania, productivity and performance really and clearly increase, it is in it that many famous people with BAD find their inspiration ().
Sometimes BAD surprises in the form of simultaneous mania and depression (mixed type): a person is completely sad and hopeless, but at the same time feels an incredible surge of energy (); now this mixed form is referred to as an unspecified disorder (NOS - not otherwise specified).
The term "dysphoric mania" is used to describe patients in whom classic manic symptoms are combined with marked anxiety, depression, or anger. Although these symptoms tend to appear at more advanced stages of the disease and are therefore directly correlated with the severity of the disease, in some patients they are transient, and then they can be described as "dysphoric", "mixed", "irritable-paranoid" or even " paranoid-destructive."
Cyclothymia
Cyclothymic disorder is now considered as a light version of BAD with chronic numerous episodes of unstable mood, recorded for more than two years in a row, but not up to the level of full-fledged depression or mania (). Often, patients with cyclothymia are presented with the second type of disorder to start, since it is difficult to immediately assess the severity of the phases.
People with an unstable mood will have to suffer until the problem is solved for about ten years - this is the average period between the first episode of the disease and the diagnosis (). As with many other mental disorders, a person with MDP is usually brought in for a consultation by relatives, because manic episodes are pleasant for many patients (and hypomanic ones in general), and in depression they don’t care at all, what kind of doctors are there.
The good news is that with proper selection of drugs, compliance with their use and good psychotherapy, mood can be stabilized for a very long time. long term, or at least reduce the severity of manifestations, even considering that the disease is chronic.
Due to the easy conversion of depression to mania or rapid cycling disorder in the guidelines for the treatment of acute depression in bipolar disorder, the initial use of antidepressants is not recommended, and the use of mood stabilizers is preferred: the first line of therapy includes Quetiapine, Lithium and Valproate.
Diagnosis of Bipolar Affective Disorder
Bipolar affective disorder (BAD) is a mental illness that is characterized by a change in affective states (depression and mania). It is dangerous that a person ceases to control behavior and loses criticism of what is happening. During mania, people spend money, take out loans, give away property, make grandiose plans, and never go through with anything. In depression, all motivation is lost, a person can lie in bed for weeks, unable to go to work and take care of loved ones. With timely treatment to specialists, bipolar affective disorder, symptoms of depression and mania are well controlled.
A person with bipolar disorder must carefully follow the doctor's recommendations in order to stop the onset of an attack in time.
Also in the literature you can find an outdated and not included in the modern classification of the name - manic-depressive psychosis. Symptoms and signs depend on the phase.
The duration of the depressive phase is from 2 to 6 months, the manic phase is usually somewhat shorter - 3-4 months. Not all patients believe that arousal, increased productivity, reduced need for sleep is a disease. Therefore, they often do not tell the doctor about it, and they take the disorder for “pure” depression and prescribe inadequate treatment.
The light interval between attacks - intermission - has a different duration. The treatment is aimed precisely at making the intermission as long as possible, better - for life.
The depressive phase is also called bipolar depression. Symptoms of this phase include:
Bipolar affective disorder (manic-depressive psychosis) is diagnosed by a psychotherapist or psychiatrist. For an accurate diagnosis, it is important to collect the most complete history of the life of a person and his family.
The main signs of the manic phase (mania):
- An increase in mood is causeless joy, carelessness, unshakable optimism even in difficult moments, when a person, for example, has lost a close relative.
- Acceleration of thinking and associations - the patient jumps from one topic to another, speaks so quickly that sometimes his speech cannot be made out.
- Increased motor activity - a person in mania cannot sit still: he rushes to help everyone, dances, sings, takes on several things at the same time, but most often does not bring anything to the end.
Signs of manic-depressive psychosis
Let us consider in more detail the complaints of bipolar affective disorder (BAD), or manic-depressive psychosis (MDP). Symptoms of the disease are determined by the phase.
Patients in the depressive phase complain of a depressed mood, a physical feeling of melancholy - pain, pressure, constriction in the region of the heart, chest, and sometimes the stomach. A person is no longer interested in what is happening around, forgets about work and hobbies. Appetite disappears, food becomes tasteless, which leads to significant weight loss. Sleep is disturbed - early morning awakenings and daytime sleepiness are characteristic. Decreased sex drive. There are complaints about the loss of emotional attachment to loved ones, to children. A person ceases to enjoy life, and in advanced cases, the instinct of self-preservation is violated, which is accompanied by suicidal attempts.
In advanced cases of the disease, the instinct of self-preservation is violated in patients - this leads to suicidal attempts.
In a manic state, people are active, they interfere in everything, they make different plans. But purposefulness is lost, distractibility increases - a person does not bring anything to the end. Motor excitation grows, self-esteem takes off, the patient discovers new abilities, talents (which objectively he does not have). In this state, rash actions are committed, a person can take a loan, buy unnecessary things, give away property and distribute money to strangers. He becomes very sociable, increases sexual desire. A person practically does not sleep (2-3 hours a day), but gets enough sleep, looks younger than his years.
A mixed state is a manic depression, the symptoms of which will be the replacement of one or more elements of depression with a sign of mania. For example, a depressed person walks excitedly around the room, wringing his hands, not finding a place.
Methods for diagnosing bipolar affective disorder
Diagnosis of BAD is carried out by a psychotherapist or psychiatrist. Diagnostic methods:
Often there are difficulties in differential diagnosis. Unfortunately, there is no blood count or sign on CT, MRI, which could confirm the diagnosis of "bipolar disorder". Therefore, a detailed conversation with a psychotherapist or psychiatrist is the main diagnostic method that cannot be neglected, much less try to make a diagnosis on your own.
Mood disorders are not specific features of a manic-depressive syndrome. Symptoms of depression and mania occur in schizophrenia, schizoaffective disorder, and acute polymorphic psychotic disorder.
Sometimes, in addition to an inadequately elevated or depressed mood, a person is sure that he is being persecuted, his thoughts are being read, his body is being controlled, threatening or commenting “voices” are heard in his head. Based on such symptoms, the doctor may suspect that the patient has schizophrenia or schizoaffective disorder, which are "hidden" behind depression or mania. In this case, the psychiatrist is helped to make a diagnosis by the Neurotest (shows an increase in inflammatory markers in the blood in schizophrenia) and the Neurophysiological test system (registers deviations from the norm in a person's reactions to physiological stimuli - sound, light).
Already at the stage of diagnosis, the doctor prescribes treatment - drug therapy (antidepressants, antipsychotics, mood stabilizers, tranquilizers). Psychotherapy, which is carried out in individual, family and group formats, contributes to the extension and consolidation of results in intermission. Read more about the treatment of bipolar affective disorder.
Teacher, nurse, programmer: the most depressing professions
Today, psychologists are increasingly talking about depression as a disease characteristic of people with irregular schedules, unhealthy eating habits, and an inability to effectively deal with stress. On the other hand, some of us are more at risk of developing depressive moods than others. And an important factor in this sense becomes a sphere of activity.
Health.com cites research that suggests certain professions are more depressing. And if you are at risk, then it will be useful for you to know about this in order to be more attentive to your mental health.
10. Sales consultant
In tenth place are people who work in the field of sales - cashiers, sales assistants and personal shoppers in chain stores. There are a number of reasons why this job can contribute to depression: the need to constantly contact people (here, as we remember, the rule “the client is always right” works here), resolve conflict situations during the day, constantly be on your feet and, in addition, not forget to smile, even when you don’t feel like doing it at all.
9. Accountant
The work of an accountant or a financial analyst is stress, stress and more stress (moreover, related to money). Most of us can't stand even the family budget, to be sure, when a person is forced to do this every day. Accountants have such a big responsibility for other people's finances that sometimes it goes off scale - and then depression becomes difficult to avoid. Add to this the feeling of guilt that these people experience when, for one reason or another (and sometimes not dependent on the accountant), someone loses their money or receives it later than originally planned.
8. Programmer
We live in an era personal computers, smart phones and Google search. Now let's imagine that you are sitting in the office and working, but suddenly something goes wrong. Who do you contact? It is likely to the system administrator. Constant revisions are the norm for programmers. As well as unhealthy eating, sedentary work and in most cases isolation from other people, which also does not benefit mental health.
7. Personal assistant
Traditionally, people working as personal assistants have to have high stress tolerance - this is necessary to cope with tasks that they are forced to perform at any time of the day and night. Plus, it is these people who are on the “front line” between the leader and subordinates, and they have to look for an approach to both one and the other side. And, of course, if something goes wrong, then the personal assistant who “understood” or “wrote it wrong” will remain to blame.
The demand for teachers is constantly growing, but the relatively low wages and the need to communicate with difficult teenagers lead to the fact that not all who graduated from pedagogical universities go to work in schools. Of course, teaching is not a profession, but a vocation. That is why teachers often resolve conflicts that arise between children, take each child's concerns to heart, perceiving them as their own, and at the same time take work home. All this leads to permanent fatigue from professional overload, and it, in turn, provokes the development of depression.
5. Artist/Writer/Journalist
These creative specialties often involve irregular wages, the need to work to "deadlines" and long hours of isolation, which, coupled with the low ability of some people to control themselves, can lead to mood swings, and subsequently depression. At the same time, studies show that it is among creative people that the risk of bipolar affective disorder (BAD) is high - a disease that manifests itself in the form of manic, depressive or mixed states.
4. Doctor/nurse
Doctors, nurses and hospital attendants are professions that people enter who tend to leave others more than themselves. Medical professionals may have extra hours and days when a person's life is literally in their hands. In other words, stress accompanies their every action, and at home they sometimes fail to switch off. Let's add to this the general psychological atmosphere - every day, representatives of the professions see pain, suffering, illness and death. And they also deal with relatives of patients who have to report not the most pleasant news.
3. Social worker
The fact that the profession of a social worker is in the top three is not surprising. Close contact with affected adults or children invariably leaves an imprint on the personality of the person, and belonging to the bureaucracy, which implies paperwork, can make this work truly unbearable. Both in terms of general perception, and in terms of stress, leading to apathy and depression.
2. Waiter
Even higher than social workers are the people who serve food at your favorite restaurants. If we are not talking about a luxurious place, then the staff of the establishment receives a relatively small salary when they need to communicate with the very different - and sometimes complex and aggressive - customers. In addition, during the day the waiter serves a huge number of people, each of whom has the right to comment on his work. All this is extremely exhausting, and the lack of energy and motivation are the first steps towards a depressive syndrome.
1. Nanny / nurse
And, finally, the first place - the study showed that the most depressing professions are nannies and nurses. A typical day in this case may include feeding, bathing, entertainment, as well as constant and peremptory care for a person who cannot fully cope with those everyday activities that we usually do “on the machine”. However, the clients with whom one has to work, in most cases, cannot express joy or gratitude, as they are either too sick or too small to do this. It is important to understand that the lack of positive reinforcement is one of the most common causes of withdrawal, dissatisfaction with one's own life and depression.
The Two Sides of Bipolar Disorder
Bipolar affective disorder is one of the most common mental illnesses today, characterized by a relapsing course with alternating episodes of mania and depression. In some cases, both of these forms occur at the same time. Previously, such a state in psychology and psychiatry was called manic-depressive psychosis. Since the boundaries of the definition of the described personality disorder vary, it is difficult to talk about reliable data on its prevalence.
In fact, bipolar affective disorder is two absolutely opposite poles of violations of the psycho-emotional state of a person. And although frequent mood swings may be characteristic of many healthy people, the pathology will be discussed when such swings reach extreme limits, and states of mania and depression continue for a long period of time.
Historical background: manic-depressive psychosis was first described as an independent pathology by French researchers in 1854, but for a long time was not recognized by psychiatrists of that era. The disease received its current name "bipolar affective disorder" only in the early nineties of the twentieth century.
Main reasons
Why manic depression occurs is still unclear to scientists. However, it was possible to establish a connection between the development of the disease and a genetic predisposition, although the pathology cannot be called hereditary in the literal sense of the word. According to scientists, bipolar disorder may arise due to defects in the genetic circuits responsible for the regulation of conductors of nerve impulses in the brain. Statistics also show that such a syndrome is very common among blood relatives. An interesting fact is that sometimes even adopted children of parents with bipolar personality disorder also acquire the disease. Most likely, this is due to a certain way of upbringing in specific families. The probability of developing pathology in identical twins is very high.
Bipolar affective disorder can be caused by neurotransmitters (special elements that conduct nerve signals) in the brain. With a decrease in the number of neurotransmitters, the production of serotonin, the so-called joy hormone, is disrupted. In addition, chronic stress can influence the development of bipolar personality disorder. At the same time, stress does not have to be associated with a bad event, since even very pleasant moments can knock a person out of psychological balance.
Generally. Each person can be more or less vulnerable and predisposed to mental disorders. However, manic-depressive psychosis occurs when the predisposition is paired with another factor, such as frequent stress.
Phases and symptoms
The first episode of bipolar personality disorder most often occurs in young people in their twenties and thirties, but initial symptoms can occur in both childhood and old age. All subsequent episodes of the disease occur from time to time in the form of phases of mania and depression, between which there may be periods in which the person feels normal.
Scheme of alternation of manic and depressive phases
The frequency of alternating exacerbations and remissions is highly variable. In some people, the disorder manifests itself exclusively in manic phases, in others only depressive phases, in others, both phases alternate or occur together. The older a person becomes, the shorter the duration of the remission phases.
Bipolar affective personality disorder can occur in the following scenarios:
Manic depression is almost always characterized by the sudden onset of a manic phase. It can last a couple of weeks or several months. Based on medical statistics, average The duration of one episode is about twelve to sixteen weeks. Depressions are characterized by a more protracted course - approximately six to eight months. In some patients, the depressive phase may last more than one year. Any, even insignificant at first glance, is capable of provoking the development of either phase. stressful situation or psychological shock.
Features of the course of the first phase
The stage of mania in bipolar affective personality disorder in the course of its course goes through five main stages, characterized by certain symptoms:
hypomanic stage. The patient is characterized by good spirits and excellent mood. A person begins to talk quickly and verbosely, often get distracted and sleep less;
Thus, the stage of mania is characterized by three main clinical manifestations: elevated mood, ideator-psychic and motor excitation. In clinical psychology, the severity of the course of a manic syndrome is assessed using a special Young's mania scale.
Features of the flow of the second phase
The depressive phase in bipolar disorder is characterized by the opposite clinical picture: bad mood, motor and mental retardation. This phase also goes through several stages:
Initial stage. The patient's mental tone gradually begins to weaken, the mood becomes depressed, and mental and physical activity decreases. Sleep can become superficial. What is typical for this stage of depression is an increase in the patient's psycho-emotional mood in the evenings;
There are several options for the course of the depressive phase in bipolar mental disorder. It is likely that this will be a simple depression, not accompanied by delusional states, or hypochondriacal depression with affective delirium. Also, people with bipolar personality disorder have delusional depressive states (Cotard's syndrome), agitated depression with motor inhibition of varying severity, or anesthetic depression, characterized by the absence of any emotional manifestations in a person.
Risk factors
According to medical data, bipolar disorder is more common in men, while women are more likely to suffer from a unipolar form of the disease. Risk factors for the development of a pathological condition in women include periods of hormonal imbalance, for example, during menopause or during pregnancy, as well as during menstruation. Manic-depressive psychosis is several times more common in those women who have suffered postpartum depression.
Various external factors can provoke bipolar affective disorder. These factors include stress, unfavorable conditions in the family and at work, alcohol and drugs, etc. As already mentioned, heredity also plays an important role in the pathogenesis of the disease.
There is an opinion that manic-depressive psychosis is especially characteristic of certain personality types. So, the risk group includes people with a melancholic and statothymic type, focused on pedantry, order in everything and responsibility.
How does it manifest itself in children?
Bipolar affective disorder is quite common in children aged six years and older, as well as adolescents. According to statistics, approximately one third of children and adolescents with depression have bipolar personality disorder. As a rule, in children with this disease, the transition from mania to depression occurs quite quickly, and the child's behavior can be described as rather unpredictable. Attention deficit disorder, increased anxiety and hyperactivity only complicate the condition.
Children with bipolar affective disorder are unable to concentrate and focus on a specific task, and therefore often do not have time in their studies. They find it difficult to find mutual understanding with adults and peers, thoughts of suicide often arise, which can develop into actual suicide attempts. It is these teenagers who show the greatest tendency to addiction to alcohol and drugs.
The course of pathology in children has some differences from that in adults. Usually periods of mania are not very pronounced in a child, sometimes mania can manifest itself only in a constant and persistent denial of existing norms and rules, excessive irritability and capriciousness. There is a frequent polar change of mood. The child becomes overly active and may overestimate own possibilities. Also, sleep disturbances, talkativeness, and the absence of any self-preservation instinct are often observed.
Some children, on the contrary, withdraw into themselves, become passive, sad and lethargic. Their appetite decreases, which leads to rapid weight loss. With all the above symptoms, the child should be shown child psychologist who will be able to recognize manic-depressive psychosis, distinguishing it from other diseases and mental disorders, and prescribe effective therapy.
The main difficulty in bipolar disorder in children and adults is the difficult diagnosis. There are cases when the disease is diagnosed only after a few years from the moment the patient has the first symptoms. The recurrence rate averages two episodes every one to two years, although it happens much more frequently in some people.
Manic-depressive psychosis (MDP) refers to severe mental illness that occurs with a succession of two phases of the disease - manic and depressive. Between them there is a period of mental "normality" (light interval).
Table of contents:Causes of manic-depressive psychosis
The onset of the development of the disease can be traced most often at the age of 25-30 years. Relative to common mental illnesses, the level of MDP is about 10-15%. There are 0.7 to 0.86 cases of the disease per 1000 population. Among women, pathology occurs 2-3 times more often than in males.
Note:the causes of manic-depressive psychosis are still under study. A clear pattern of transmission of the disease by inheritance was noted.
The period of pronounced clinical manifestations of pathology is preceded by personality traits - cyclothymic accentuations. Suspiciousness, anxiety, stress and a number of diseases (infectious, internal) can serve as a trigger for the development of symptoms and complaints of manic-depressive psychosis.
The mechanism of the development of the disease is explained by the result of neuropsychic breakdowns with the formation of foci in the cortex hemispheres, as well as problems in the structures of the thalamic formations of the brain. The dysregulation of norepinephrine-serotonin reactions, caused by a deficiency of these substances, plays a role.
V.P. Protopopov.
How does manic-depressive psychosis manifest?
Symptoms of manic-depressive psychosis depend on the phase of the disease. The disease can manifest itself in a manic and depressive form.
The manic phase can proceed in the classic version and with some features.
In the most typical cases, it is accompanied by the following symptoms:
- inadequately joyful, exalted and improved mood;
- sharply accelerated, unproductive thinking;
- inadequate behavior, activity, mobility, manifestations of motor excitation.
The beginning of this phase in manic-depressive psychosis looks like a normal burst of energy. Patients are active, talk a lot, try to take on many things at the same time. Their mood is upbeat, overly optimistic. Memory sharpens. Patients talk and remember a lot. In all the events that take place, they see an exceptional positive, even where there is none.
Excitation gradually increases. The time allotted for sleep decreases, patients do not feel tired.
Gradually, thinking becomes superficial, people suffering from psychosis cannot focus their attention on the main thing, they are constantly distracted, jumping from topic to topic. In their conversation, unfinished sentences and phrases are noted - "language is ahead of thoughts." Patients have to constantly return to the unsaid topic.
The patients' faces turn pink, facial expressions are overly lively, active hand gestures are observed. There is laughter, increased and inadequate playfulness, those suffering from manic-depressive psychosis talk loudly, scream, breathe noisily.
The activity is unproductive. Patients simultaneously "grab" a large number of cases, but none of them is brought to a natural end, they are constantly distracted. Hypermobility is often combined with singing, dancing, jumping.
In this phase of manic-depressive psychosis, patients seek active communication, intervene in all matters, give advice and teach others, and criticize. They show a pronounced reassessment of their skills, knowledge and capabilities, which are sometimes completely absent. At the same time, self-criticism is sharply reduced.
Increased sexual and food instincts. Patients constantly want to eat, sexual motives clearly appear in their behavior. Against this background, they easily and naturally make a lot of acquaintances. Women are beginning to use a lot of cosmetics to attract attention to themselves.
In some atypical cases, the manic phase of psychosis occurs with:
- unproductive mania- in which there are no active actions and thinking is not accelerated;
- solar mania– behavior is dominated by an overjoyful mood;
- angry mania- anger, irritability, dissatisfaction with others come to the fore;
- manic stupor- manifestation of fun, accelerated thinking is combined with motor passivity.
In the depressive phase, there are three main signs:
- painfully depressed mood;
- sharply slowed down pace of thinking;
- motor retardation up to complete immobilization.
The initial symptoms of this phase of manic-depressive psychosis are accompanied by sleep disturbance, frequent nocturnal awakenings, and the inability to fall asleep. Appetite gradually decreases, a state of weakness develops, constipation appears, pain in the chest. The mood is constantly depressed, the face of patients is apathetic, sad. The depression is on the rise. Everything present, past and future is presented in black and hopeless colors. Some patients with manic-depressive psychosis have ideas of self-accusation, patients try to hide in inaccessible places, experience painful experiences. The pace of thinking slows down sharply, the range of interests narrows, symptoms of “mental chewing gum” appear, patients repeat the same ideas, in which self-deprecating thoughts stand out. Suffering from manic-depressive psychosis, they begin to remember all their actions and give them ideas of inferiority. Some consider themselves unworthy of food, sleep, respect. It seems to them that doctors are wasting their time on them, unreasonably prescribing them medicines, as unworthy of treatment.
Note:sometimes it is necessary to transfer such patients to forced feeding.
Most patients experience muscle weakness, heaviness throughout the body, they move with great difficulty.
With a more compensated form of manic-depressive psychosis, patients independently look for the dirtiest work. Gradually, the ideas of self-accusation lead some patients to thoughts of suicide, which they can fully translate into reality.
Most pronounced in the morning, before dawn. By evening, the intensity of her symptoms decreases. Patients mostly sit in inconspicuous places, lie on beds, like to go under the bed, because they consider themselves unworthy of being in a normal position. They are reluctant to make contact, they respond monotonously, with a slowdown, without further ado.
On the faces there is an imprint of deep sorrow with a characteristic wrinkle on the forehead. The corners of the mouth are lowered down, the eyes are dull, inactive.
Options for the depressive phase:
- asthenic depression– patients with this type of manic-depressive psychosis are dominated by ideas of their own soullessness in relation to relatives, they consider themselves unworthy parents, husbands, wives, etc.
- anxious depression- proceeds with the manifestation of an extreme degree of anxiety, fears, bringing patients to. In this state, patients may fall into a stupor.
In almost all patients in the depressive phase, the Protopopov triad occurs - palpitations, dilated pupils.
Symptoms of disordersmanic-depressive psychosisfrom the side internal organs :
- dry skin and mucous membranes;
- lack of appetite;
- in women, disorders of the monthly cycle.
In some cases, TIR is manifested by dominant complaints of persistent pain, discomfort in the body. Patients describe the most versatile complaints from almost all organs and parts of the body.
Note:some patients try to mitigate complaints to resort to alcohol.
The depressive phase can last 5-6 months. Patients are unable to work during this period.
Cyclothymia is a mild form of manic-depressive psychosis.
There are both a separate form of the disease and a lighter version of TIR.
Cyclotomy proceeds with phases:
How does TIR work?
There are three forms of the course of the disease:
- circular- periodic alternation of phases of mania and depression with a light interval (intermission);
- alternating- one phase is immediately replaced by another without a light gap;
- unipolar- the same phases of depression or mania go in a row.
Note:usually phases last for 3-5 months, and light intervals can last several months or years.
Manic-depressive psychosis in different periods of life
In children, the onset of the disease may go unnoticed, especially if the manic phase dominates. Juvenile patients look hyperactive, cheerful, playful, which does not immediately allow us to notice unhealthy traits in their behavior against the background of their peers.
In the case of the depressive phase, children are passive and constantly tired, complaining about their health. With these problems, they quickly get to the doctor.
In adolescence, the manic phase is dominated by symptoms of swagger, rudeness in relationships, and there is a disinhibition of instincts.
One of the features of manic-depressive psychosis in childhood and adolescence is the short duration of the phases (average 10-15 days). With age, their duration increases.
Treatment of manic-depressive psychosis
Therapeutic measures are built depending on the phase of the disease. Severe clinical symptoms and the presence of complaints require the treatment of manic-depressive psychosis in a hospital. Because, being depressed, patients can harm their health or commit suicide.
The difficulty of psychotherapeutic work lies in the fact that patients in the phase of depression practically do not make contact. An important point of treatment during this period is the correct selection antidepressants. The group of these drugs is diverse and the doctor prescribes them, guided by his own experience. Usually we are talking about tricyclic antidepressants.
With dominance in the status of lethargy, antidepressants with analeptic properties are selected. Anxious depression requires the use of drugs with a pronounced calming effect.
In the absence of appetite, the treatment of manic-depressive psychosis is supplemented with restorative drugs
In the manic phase, antipsychotics with pronounced sedative properties are prescribed.
In the case of cyclothymia, it is preferable to use milder tranquilizers and antipsychotics in small dosages.
Note:quite recently, lithium salt preparations were prescribed in all phases of MDP treatment, at present this method is not used by all doctors.
After leaving the pathological phases, patients should be included in various activities as early as possible, this is very important for maintaining socialization.
Explanatory work is carried out with relatives of patients about the need to create a normal psychological climate at home; a patient with symptoms of manic-depressive psychosis during light intervals should not feel like an unhealthy person.
It should be noted that, in comparison with other mental illnesses, patients with manic-depressive psychosis retain their intelligence and performance without degradation.
Interesting! From a legal point of view, a crime committed in the TIR aggravation phase is considered not subject to criminal liability, and in the intermission phase - criminally punishable. Naturally, in any state suffering from psychosis are not subject to military service. In severe cases, disability is assigned.
The content of the article
Manic Depressive Psychosis Part 2Clinical picture of manic-depressive psychosis
Affective insanity is a mental illness clinical sign which are manic, depressive and mixed phases, alternating without a definite sequence. A characteristic feature of this psychosis is the presence of light interphase gaps (intermissions), in which all signs of the disease disappear, a complete restoration of a critical attitude to the transferred painful condition is observed, premorbid characterological and personal properties, professional knowledge and skills are preserved. The nosological independence of manic-depressive psychosis is recognized by most authors. Its non-psychotic form (cyclothymia) in clinical terms is a reduced (weakened, outpatient) variant of the disease.Prevalence
Patients with manic-depressive psychosis make up about 10-15% of the number of patients hospitalized in psychiatric hospitals (E. Kraepelin, 1923). Modern researchers tend to classify manic-depressive psychosis as a rare form of endogenous psychosis. Thus, the incidence of this psychosis in women is 0.86 per 1000 people, men - 0.7 (V. G. Rotshtein, 1977). It has been established that the ratio of the incidence of women and men with manic-depressive psychosis is 2-3: 1, respectively.Manic-depressive psychosis predominantly affects people of working age who are well adapted in many ways. According to epidemiological studies (V. G. Rotshtein, 1977), about 50% of patients with this profile have higher and secondary education, 75.8% of able-bodied patients are engaged in creative and skilled work. The social danger of patients is determined by the fact that they can commit offenses in the manic phase of psychosis and suicidal acts in the depressive phase. Various forms of suicidal activity, as shown by the literature data (A. M. Ponizovsky, 1980) and the results of our observations, are detected in approximately 50-60% of patients with manic-depressive psychosis and cyclothymia, actual suicide attempts in 10-25%. In general, the suicidal risk in this form of psychosis is 48 times higher than in the general population (A. G. Ambrumova, V. A. Tikhonenko, 1980).
Domanifest signs of manic-depressive psychosis often manifest themselves in the form of symptoms of surgical, therapeutic, skin, neurological and other diseases. Therefore, patients are treated for a long time in medical institutions of various profiles. Due to errors in diagnosis, patients with manic-depressive psychosis for a long time (sometimes 3-5 years) do not go to a psychiatrist, which gives the problem of this disease a serious economic sound (V. F. Desyatnikov, 1979).
Manic phase
In a typical form, the manic phase consists of the so-called manic triad: morbidly elevated mood, accelerated flow of thoughts and motor excitement. The leading sign of a manic state is a manic affect, manifested in an elevated mood, a feeling of happiness, contentment, well-being, an influx of pleasant memories and associations. It is characterized by an aggravation of sensations and perceptions, an increase in mechanical and some weakening of logical memory, superficiality of thinking, lightness and unproductiveness of judgments and conclusions, ideas of overestimating one's own personality, up to delusional ideas of grandeur, disinhibition of drives and weakening of higher feelings, instability, ease of switching attention .Depending on the severity of these symptoms, mild, severe and severe manifestations of the phase are distinguished, as well as stages - hypomanic, mania and manic frenzy (I. I. Lukomsky, 1968). Prior to the widespread introduction of psychotropic drugs into psychiatric practice, during the manic phase, a sequential change of the following stages was usually observed: hypomania, severe mania, manic frenzy, motor sedation and the reactive stage (P. A. Ostankov, 1911). Early initiation of treatment, which is characteristic of modern therapy for manic phases, usually prevents a further increase in manic affect and stops the process at the stage of hypomania. It is practical to distinguish three stages in the development of the manic phase: initial (non-psychotic level), culminating (psychotic level) and reverse development (non-psychotic level).
The manic phase typically begins with a change in self-awareness, an experience of cheerfulness, a surge of energy, a feeling of physical strength, health and attractiveness. The patient ceases to perceive the unpleasant sensations that disturbed him earlier. Cases of spontaneous recovery from somatic diseases are noted. The patient's mind is filled with pleasant memories and optimistic plans. Unpleasant events of the past are forced out. The patient does not notice the real and expected difficulties, he perceives the environment in bright, rich colors, his taste and smell sensations are exacerbated. Some strengthening of mechanical memory is noted: the patient remembers forgotten addresses, phone numbers, movie titles, easily remembers current events, names. Within 1-2 days, he remembers the names of all the clinic staff.
Speech in patients is expressive, loud; thinking is lively and quick, intelligence improves, but judgments and conclusions are superficial and often playful. Typically, an increased desire of patients for activity is an increase in its volume with a decrease in its productivity. Patients willingly, without hesitation, join in new cases, expand their circle of interests and acquaintances, sign up for various sections, take on any assignments, but do not complete the work begun. There is a weakening of higher feelings - tact, distance, subordination, duty, and in parallel with this - an increase in drives, primarily sexual. Patients become cheeky, dress in bright clothes, use eye-catching makeup, visit entertainment establishments, enter into casual intimate relationships.
In a hypomanic state, patients retain awareness of the unusual nature of the changes taking place with them and the ability to some correction of their behavior, purposefulness of actions. Critical attitude towards their condition in patients in the climax stage disappears, they cannot cope with professional and domestic duties, are not capable of correcting their behavior Most often, patients are hospitalized in a psychiatric hospital during the transition of the initial stage to the climax. Elevated mood in patients is manifested in laughter, recitation of poetry, dancing and singing. Ideational excitation is assessed by patients as "abundance of thoughts", "fast running of thoughts". Thinking is accelerated, specific associations based on random connections predominate; they quickly change, one thought does not end yet, another begins. In thinking, surrounding events are more often reflected, less often - memories of the past. In speech production, ideas of reassessment are characteristic: patients talk about their organizational, acting, literary, linguistic and other abilities. They willingly read their poems, take up the treatment of patients, “speak” in front of students, give orders to health workers. Increased physical activity manifested in restlessness, interference in the affairs of medical staff, aggressiveness, attempts to escape from the hospital. At the height of the culminating stage, in a state of manic frenzy, patients are inaccessible to contact, extremely excited, viciously aggressive. Their speech is confused, separate semantic parts fall out in it, which makes it similar to schizophrenic fragmentation and creates certain differential diagnostic difficulties in distinguishing manic-depressive psychosis from schizophrenia (I. I. Lukomsky, 1968; T. F. Papadopoulos, I. V. Shakhmatova-Pavlova, 1983). Delusional ideas of grandeur, often of megalomaniacal content, are characteristic.
At the stage of reverse development of the phase, periods of short-term motor calm are accompanied by the appearance of criticism and are interspersed with more prolonged states of motor excitation. Gradually increases the duration of "calm" periods and decreases - states of excitation. After a complete exit from the phase, patients may still experience short-term hypomanic episodes for a long time.
It should be noted that depending on the dominance in clinical picture The manic phase of one of the symptoms of the manic triad is distinguished by "sunny" mania, mania with a jump in ideas, and angry mania. With "solar" mania, an elevated mood, gaiety, and a joyful coloring of affect predominate; witty remarks and jokes of patients, combined with gentleness and gentleness, infect others with fun. With mania with a jump in ideas, an accelerated flow of associations, verbosity and verbosity come to the fore, which makes it impossible to conduct a dialogue with patients. For angry mania with hyperactivity, increased desire for activity, restlessness and resistance to others, the “symptom of ill-treatment” is especially characteristic - patients believe that the medical staff mistreats them, restricts their legal rights, etc.
depressive phase
It is characterized by the "depressive triad": low mood (depression), mental-speech and motor retardation, sometimes reaching the degree of a stuporous state. There are also depressive coloring of sensations and perceptions, some sharpening of memory for subjectively unpleasant events of the past, delusional ideas of self-accusation and self-abasement, vital anguish, anxiety, mental anesthesia, sad facial expressions, a decrease in the volume of purposeful activity, weakening of drives, refusal of treatment and food, weakening of activity. attention. In addition to complaints of a senestopathic, algic and vegetative nature, Protopopov's somatic triad is typical for the depressive phase - tachycardia, mydriasis, constipation, as well as a moderate increase blood pressure, dry mucous membranes and skin, weight loss, anorexia, dysmenorrhea, lack of tears. These symptoms in a manic state are expressed to a lesser degree.There are several stages of the depressive phase, which has a differential diagnostic value.
So, in the initial, non-psychotic stage, somatovegetative disorders and health disorders appear - worsening sleep with early and nocturnal awakenings, decreased appetite, general lethargy, and stool retention. These signs are combined with a “turn to pessimism” (V. F. Desyatnikov, 1979) in the form of hypohedonia, vagueness of perspective, a decrease in creative activity and the preservation of the ability to perform habitual actions, which have characteristic daily fluctuations (most pronounced in the morning). In the future, there is a noticeable decrease in mood, a sense of guilt and one's own inferiority, painful sensations in the retrosternal region - pressure, compression, heaviness, "a stone in the soul"; less often - longing, a feeling of inexplicable anxiety, vague anxiety, uncertainty, indecision, a tendency to doubt, painful introspection, reaching "self-eating", thoughts about the aimlessness and meaninglessness of life.
In the initial stage, awareness of the painful nature of the ongoing changes is preserved, personal reactions to the disease are expressed. Patients are alarmed by their condition, trying to understand its causes, interested in the duration, prospects for treatment, looking for help (anxious-search type of personal reaction).
In patients in the psychotic stage, a critical attitude to painful experiences disappears, the depth of depressive affect increases with a feeling of "longing" in the retrosternal, less often in the epigastric region, which can reach the degree of excruciating physical pain. Patients perceive the outside world as dull and gray, people's faces are sad. It seems to them that time flows slowly or, as it were, stops; the taste disappears, unpleasant sensations emanating from the internal organs are frequent. Patients recall "unseemly" actions, minor offenses inflicted on others, on the basis of which they express self-accusations of immorality, uncleanliness, and crime with delusional steadfastness. They regard the sympathetic attitude of relatives and medical personnel as the result of an error, a delusion; requests to change this attitude to a sharply negative one are typical.
Thinking in patients is usually slowed down, associations are scarce, which they also interpret in a delusional way. Speech is slow, monotonous, poor, with pauses, quiet. The instinctive sphere is depressed, the volume of purposeful activity is narrowed, motor inhibition is accompanied by a feeling of stiffness. Perhaps the development of a depressive stupor.
In the deep psychotic stages of depression, individual perceptual delusions in the form of auditory illusions and delusional ideas of relation can be noted. Thus, a patient with delusional ideas of maternal and marital failure noticed how those around her with remarks, gestures and facial expressions expressed their indignation at the fact that her husband was taking very warm care of her - a "bad mother and wife". A number of authors regard the appearance of symptoms of a non-affective register in the structure of a depressive syndrome as evidence of the schizophrenic nature of depression, while they do not take into account the criteria for classifying such cases as manic-depressive psychosis. These criteria include the thematic unity of affective and paranoid experiences, the appearance of the latter at the height of an affective attack, and their transient nature.
The exit from the culminating stage of depression is often slow, with a gradual attenuation of daily mood fluctuations. During this period, a critical attitude to one's disease may appear in the evening hours and completely disappear in the morning; personal reactions to the disease become noticeable, which requires psychotherapeutic correction.
The clinical picture of the depressive phase is heterogeneous, which served as the basis for the identification of clinical variants of depression. So, depending on the nature of the symptom that prevails in the picture of the depressive phase and determines the appearance of the patient, the following forms of depression are distinguished: sad, melancholic, anesthetic, delusional, agitated, anxious-melancholic, anxious-depressive, hypo- and cyclothymic, hypochondriacal, "matte ”, “petrified”, with derealization and depersonalization, with obsessions, with somatic burden, catatonic, paranoid, simple, complex, typical, atypical, etc. The disadvantage of this classification is the conditionality of the clinical content of the disease and the fuzziness of the boundaries between its various variants.
Most clinicians classify suicidal phenomena as typical symptoms of depression, which can be used to assess the depth and severity of the depressive state. However, suicidal phenomena can also occur in mentally healthy individuals. The research data of A. G. Ambrumova, V. A. Tikhonenko (1980), V. M. Ponizovsky (1980) and our observations show that suicidal phenomena within the depressive phase of manic-depressive psychosis are mainly the result of personal processing of changes, introduced by the disease into the inner world of a person and socio-psychological status, as well as individual symptoms of depression and situational factors.
The course of manic-depressive psychosis
According to E. Kraepelin (1912), manic-depressive psychosis often occurs in people 15-30 years of age, among older people the frequency of its manifestations noticeably decreases, although the first attacks of psychosis after 70 years are not excluded. I. I. Lukomsky (1968) notes that the incidence of this psychosis increases among people over 40 years of age. With a thorough examination of middle-aged and elderly patients, it is often possible to establish that long before the manifestation of psychosis, they experience phase mood swings - from short periods of unreasonable dreary depression and malaise to increased tone, unreasonable optimism and cheerfulness. However, such changes in condition rarely necessitate psychiatric counseling, as it can be easily explained possible reasons their appearance.The first attack of manic-depressive psychosis usually occurs in connection with the impact of any adverse factors (trauma, somatic diseases, infections, intoxications), as well as during crisis periods of development, during the premenstrual and menstrual periods (P. V. Biryukovich et al., 1979). The provocative role of exogeny and mental trauma was also noted by V. P. Osipov (1931), V. A. Gilyarovskiy (1954), A. I. Ivanov-Smolensky (1974). Studying the coincidence of external hazards with the onset of an attack of psychosis, T. N. Morozova and N. G. Shumsky (1963) noted that with deep intermission, the factor provoking another attack occurs in 80% of cases, and with defective one, only in 28%. P. Michalik et al (1980) found that in patients with bipolar manic-depressive psychosis, compared with healthy individuals, there are almost 2 times more somatic diseases, especially cardiovascular, skin, infectious, metabolic diseases. The exacerbation or onset of the disease was preceded by somatic factors in 45% of cases, and as the affective phases relapses accumulate, the number of somatic diseases also increases. According to these authors, 60-year-olds suffering from manic-depressive psychosis have 4 times more somatic diseases than healthy individuals. Some authors have tried to identify specific psychogenic factors that “trigger” depressive phases (S. Puiinski, 1980). Strengthening the role of external factors in the development of the depressive phase, apparently, depends on the age of the patients. So, according to our data (V.P. Linsky et al., 1979), in the group of patients with manic-depressive psychosis with a predominance of middle-aged and elderly people, depressive phases arose as a result of mental trauma in 36% of cases, and among patients with a predominance of persons young age- only 8%. Many researchers believe that as psychosis progresses, the role of external factors decreases, while endogenous factors increase.
From the depressive phase, manic-depressive psychosis begins in 60% of cases, cyclothymia - in 90%, and the psychosis itself proceeds mainly on an outpatient basis. According to averaged data, the bipolar type of flow, characterized by the alternation of manic and depressive phases, is observed in approximately 30% of cases, the monopodar depressive type in 60% and the monopolar manic type in 10%. Recently, attention has been paid to the presence of significant differences between bipolar and monopolar types of depression, which makes it possible to raise the question of the nosological heterogeneity of manic-depressive psychosis (N. Weitbrecht, 1971). In patients with bipolar type of psychosis, psychopathologically aggravated heredity (33%), severe infections and rheumatism suffered in childhood, hyperthymic character, early onset of psychosis, frequent development of phases without previous anxiety states and somatic disorders, duration of phases from 3 to 6 months, are more often observed. a large number of phases, a higher therapeutic efficacy of lithium salts, the possibility of a sharp change in phases during treatment with tricyclic antidepressants, reduced secretion of hydrocortisone (Yu. L. Nuller, 1981; S. Puzinski, 1980).
With a monopolar type of the course of the process, psychopathological heredity is detected in 50% of patients. They are less likely to have severe infections childhood and rheumatism. Neurotic personalities, persons with anxious and suspicious character traits are significantly more common. The disease begins in older people. The phase develops against the background of many years of prodromal phenomena: insomnia, anxiety, somatic diseases, hypochondria. There are fewer phases during life (the duration of the phase is up to 6-9 months), the lower effectiveness of lithium salts and tricyclic antidepressants (Yu. L. Nuller, 1981; S. Puzinski, 1980). In general, bipolarity is regarded as an unfavorable prognostic sign - the disease often proceeds as a continua, especially with manic development at an early age, with a large proportion of psychotic attacks, polymorphism and variability of affective disorders; in men, the bipolar type is more common and its course is more severe. Nevertheless, there are no clear boundaries between the bipolar and monopolar forms of manic-depressive psychosis, as evidenced by the appearance of short-term manic states in in large numbers depressive phases (Yu. L. Nuller, 1981).
Strictly defined patterns in the course of manic-depressive psychosis, the frequency of phases, their sequence and duration, and the frequency of intermissions have not been established. In some cases, one can observe a direct change from one phase to another without a light gap, in others - with a light gap lasting from several hours to several tens of years. The next attack can be either depressive or manic, regardless of the nature of the first attack. The duration of the phases is also different, most often the depressive phases of manic-depressive psychosis proceed for a long time, for several months, sometimes up to a year or more, exceeding the average duration of the manic phases (A. Kgpinski, 1979). The exit from the painful state is usually gradual, with evenly damped daily fluctuations of affect, less often - sudden. According to I. I. Lukomsky (1968), during the period of regression of depressive symptoms, short-term hypomanic states can be observed. After an exit from a painful condition at patients premorbid characterological features, professional skills are completely restored, the circle of interests remains invariable and attachment to relatives and friends remains. However, the classical ideas about the absence of personality changes after attacks of manic-depressive psychosis, according to some authors, do not always correspond to reality. In particular, after bouts of depression, there is a loss of energy potential and a decrease in the threshold of frustration (G. Huber, 1966), which manifests itself in a weakening of initiative and purposefulness, in indecision and a tendency to “revolve in the usual circle” (A. J. Weitbrecht, 1967; St. Rieser, 1969); the preservation of emotional resonance and previous attitudes without the possibility of their implementation is also characteristic (V. M. Shamanina, 1978). The nature of these states is not sufficiently elucidated. Some authors see them as the result of a long-term atypical course of psychosis (V. M. Shamanina), others consider these changes to be manifestations of protracted depressive phases.
Atypical forms of manic-depressive psychosis
These include such conditions in the clinical picture of which symptoms appear that are incompatible with the main affective background and the experiences associated with it (SG Zhislin, 1965). Atypical phases of manic-depressive psychosis are quite common. So, B. A. Kuvshinov (1965) analyzed 1328 case histories and found that atypical phases were diagnosed in 26.7% of cases. Atypical manifestations in the form of delusional ideas of attitude, persecution and influence in the structure of the depressive phase (VP Linsky et al., 1979) were found in 11-12% of women suffering from manic-depressive psychosis. In the works of past years, hallucinations, delusional ideas of relationship, persecution, memory impairment, and disorders of consciousness were described as atypical manifestations of the considered form of psychosis.The reasons for the development of atypical forms of manic-depressive psychosis and the essence of these forms have been studied in two main directions. Some authors (P. B. Gannushkin, 1902; N. N. Timofeev, 1962; R. Tellenbach, 1975; E. S. Paykel et al., 1976; R. Frey, 1977, etc.) explained the atnpicity of this psychosis a mixture of factors of hereditary burden. The interpretation of the essence of the studied psychosis from the standpoint of hereditary conditioning ultimately led to the allocation of "schizoaffective psychosis" - a concept that actually removed the issue of atypical forms of manic-depressive psychosis. Other authors (A. G. Ivanov-Smolensky, 1922; V. P. Osipov, 1923; B. Ya. Pervomaisky, 1959; V. P. Rebrov, 1968) explained the atypical nature of the considered psychosis by the pathological influence of exogenous influences and, in connection with this proposed the term "complicated forms of manic-depressive psychosis". According to their point of view, exogenies (traumas, infections, intoxications, vascular diseases, etc.) can bring additional symptoms to the clinic of psychosis, which, in combination with manic and depressive symptoms, form new, atypical symptom complexes. A complicating factor is recognized on the basis of the most characteristic symptoms for it: hypomnesia, emotional lability, headache - with a traumatic brain injury; syndromes of impaired consciousness, misunderstanding, confusion - with infections, hypertension; visual hallucinations and alcoholic statements - in alcoholism, as well as the results of complex somatic, neurological and laboratory studies.
Sometimes mixed states are mistakenly referred to as atypical forms of manic-depressive psychosis. E. Kraepelin (1923), creating the concept of mixed states, chose the principle of simultaneous combination, mixing of symptoms of depressive and manic triads as the main criterion for their selection. In the possibility of the simultaneous existence of symptoms of depression and mania in one patient, the author saw evidence of the unity of these states and an argument in favor of the nosological independence of manic-depressive psychosis.
Mixed states usually occur during the transition from one phase to another (I. I. Lukomsky, 1968), but can also occur as an isolated psychosis (V. M. Shamanina, 1978). The most common among mixed states are agitated depression (depression with motor excitation), unproductive mania (manic affect without accelerating the flow of thoughts and active excitement), etc.
Latent depression
Latent (masked, somatic, depression without depression, larvated) depression is understood as a condition in which somatic symptoms come first in the clinical picture, and its psychopathological manifestations remain in the background (P. Kielholz, 1973). VF Desyatnikov (1979) includes not only somatic and vegetative, but also mental signs in the circle of obligatory clinical manifestations of latent depression. The possibility of manifestation of the depressive phases of cyclothymia and manic-depressive psychosis under the guise of somatovegetative disorders, the presence of a somatic stage in the development of these diseases, as well as the persistence of somatic disorders in them, were noted by many domestic authors.The problem of latent depression has gained particular importance in the last 15-20 years, due to the increased prestige of psychiatry, the widespread introduction of antidepressants in medical practice, the approach of psychiatric care to the population, and some other factors. Views on the nosological nature of latent depression are contradictory: some authors (V. F. Desyatnikov, 1976; K. Heinrich, 1970; Glatthaar, 1970; G. Hole, 1972; H. Hippius, J. Muller, 1973) attribute it to endogenous circular diseases, others (V. D. Topolyansky, M. V. Strukovskaya, 1986; S. Lesse, 1968; J Glatzel, 1971; P. Schmidlin, 1973; P. Kielholz, 1975) admit the possibility of their psychogenic, organic and endogenous origin .
The clinical picture of somatic manifestations of latent depression may resemble many organic and functional diseases. The nonspecificity of these disorders and their dominant position in the clinical structure of latent depression is one of the main reasons for the long-term examination and unsuccessful treatment of such patients by internists and the late psychiatric diagnosis. No less dangerous in this regard is the opposite trend - a resolute diagnosis of latent depression in patients with rare and sluggish forms of somatic diseases. In this regard, the issue of timely and correct diagnosis of latent depression is of great medical and social importance.
For the differential diagnosis of latent depression and somatic diseases similar to it, criteria are used that are developed taking into account the symptoms of latent depression, its course and response to therapy. Criteria of the 1st group, based on the analysis of the symptoms of depression, V. F. Desyatnikov (1979, 1980) considers the following:
1. Mandatory presence of subdepressive states, which are characterized by diurnal fluctuations with increased intensity at night and before dawn and improvement in the evening.
Subdepressive states within the framework of latent depression are divided into melancholic (close to classical melancholia), hypothymic (moderately low mood with hypohedonia and loss of a sense of perspective), asthenic (with a predominance of mental and physical asthenia), asthenohypobulic (asthenia with a decrease in urges to activity), apathetic-adynamic (with a predominance of indifference and a decrease in mental energy and activity) and fearful (anxiety, apprehension, suspiciousness).
2. The abundance of persistent and diverse somatovegetative complaints that do not fit into the framework of a particular disease. The peculiarity of complaints, their polymorphism, unjustifiedness, persistence, duration, painfulness, topographic atypicality are characteristic.
3. The presence of disorders of vital functions: sleep disorders, menstrual cycle, appetite, potency, weight loss.
4. The appearance of characteristic daily fluctuations in subdepressive states and somatovegetative manifestations.
Criteria of the 2nd group are based on taking into account the characteristics of the course of the disease.
These include:
1) periodicity, undulation of somatovegetative and mental disorders, spontaneity of their occurrence and disappearance, similar violations observed in the past;
2) seasonality (autumn-spring) manifestations of disease attacks; 3) polymorphism of signs, manifested in the alternation from attack to attack of affective and viscerovegetative syndromes.
Differential diagnostic criteria of the 3rd group provide for two main points: the absence of the effect of somatic therapy and the presence of the effect of antidepressant therapy.
Depending on what signs of latent depression (somatic, vegetative or mental) come to the fore in the clinical picture of the disease, V.F. Desyatnikov (1979) identifies five main variants of latent depression: algic-senestopathic, agrypnic, diencephalic, obsessive- phobic and addictive. With any of these options, depressive disorders are mandatory, which form the basis of the disease.
The algic-senestopathic variant occurs in almost 50% of patients with latent depression and proceeds in the form of abdominal, cardialgic, cephalgic and panalgic syndromes. The leading clinical sign of this variant of latent depression is persistent, painful, difficult to describe, migrating pain that is not relieved by analgesics, has a senestopathic color and is accompanied by a variety of unpleasant sensations in the internal organs.
A characteristic sign of the agripnic variant of latent depression is persistent sleep disturbances, manifested in early (night or predawn) awakenings, reduced sleep duration and the absence of the effect of sleeping pills.
The diencephalic variant of latent depression is accompanied by vegetative-visceral paroxysms, vasomotor-allergic and pseudo-asthmatic disorders.
Crises in vegetative visceral syndrome (feeling of a blow, lightheadedness, cardiac arrest and interruptions, swaying, chills, trembling, pain in the heart area, numbness, sweating, weakness, anxiety, fear of death, etc.) are characterized by a predominance of bright subjective disorders in the absence of objective signs of a crisis, the absence of stereotypes and the predominant system of manifestation during their repetition.
For the correct recognition of vasomotor-allergic and pseudo-asthmatic syndromes, the absence of objective signs of organic pathology during examination of the nasal cavity, maxillary sinuses and respiratory tract is important.
In the obsessive-phobic variant of latent depression, obsessive fears, memories, thoughts, counting, along with fear, especially often with the fear of death, predominate.
The addictive version of latent depression is characterized by periods of intoxication in order to relieve feelings of discomfort.
The phases of the disease are pronounced only in some depressive disorders. So, in a severe mental illness - manic depression (bipolar affective disorder), a wave-like alternation of affective states occurs. The disorder is characterized by a change of phases: depressive (with pronounced anxiety, melancholy, lethargy) and manic (with a predominance of hyperactivity, agitation, euphoria).
It has several varieties that differ from each other in cyclicity and duration of phases. In the first variant, the disease proceeds in the form of a protracted depressive episode, which, after a few “quiet” years, is replaced by pronounced manic symptoms. In another group of patients, after many depressive attacks, the manic phase immediately sets in. Some patients may experience only manic episodes. In rare cases, there is a simultaneous presence of both manic and depressive symptoms, which replace each other within a few hours.
Without therapeutic measures, manic-depressive psychosis will progress rapidly, and the time interval between the individual phases will be reduced. Psychiatrists found: the shorter the interval between affective states, the longer and more complex treatment will have to be carried out to achieve stable remission in patients.
Depressive phase: main symptoms
- Dreary, sad mood;
- Irrational anxiety;
- Feeling of "emptiness" in the head;
- Decreased or loss of interest in previously attractive activities;
- Nervousness and irritability;
- excessive anxiety;
- Feelings of helplessness and hopelessness;
- Guilt;
- Increased fatigue, a noticeable decrease in the productivity of activities, a feeling of lack of energy;
- Difficulty concentrating;
- Physical and intellectual retardation;
- Illogical statements, slowing down the pace of speech;
- Lack of appetite;
- Sleep disorders: insomnia, constant feeling of drowsiness;
- Obsessive thoughts about the aimlessness of the future;
- Obsessive ideas of suicide.
In addition to psychological symptoms, often join physical manifestations:
- arrhythmia,
- tachycardia,
- "pressing" and "squeezing" pains in the region of the heart,
- tension headache,
- spastic constipation.
In a particularly severe form of the depressive phase, some patients fall into a stupor: they stop eating, do not respond to the speech addressed to them. They are silent, are in complete immobility.
Manic phase: main symptoms
- physical (motor) excitement;
- irritability, aggressiveness, super-strong emotional reaction to minimal stimuli;
- unnatural, "theatrical", often provocative behavior;
- pathologically "cheerful" mood, causeless, causeless euphoria;
- change in the pace of speech: excessive talkativeness, excessive emotional coloring of the narrated, distortion of reality, endowing with special qualities and properties of ordinary phenomena;
- constant generation of completely new, completely opposite ideas;
- a flash of special interest in previously unattractive events, superficial interest;
- obsessive “activity cravings”: the desire to perform optional, non-urgent, or unnecessary activities.
Unlike bipolar affective disorder, other diseases from the group of depressive states are not characterized by alternation and cyclic change of phases.