Mood disorders: «Napoleons are no longer to be found»

Affective (emotional) disorders of the psychotic level used to be called manic-depressive psychosis (MDP). In 1957, the German psychiatrist Carl Leonhard divided them into two types based on genetic differences: bipolar (with manic and depressive episodes) and unipolar (with only one type of seizure). This approach formed the basis for the description of the ICD-10 (International Classification of Diseases, 10th revision) of manic-depressive psychosis, called bipolar affective disorder (BAD).

The incidence of bipolar disorder is 0,6-0,9% with a female predominance (1:1,2), and these differences persist in most countries. BAD begins more frequently in late adolescence, with a peak in the 20s and 30s. The mechanisms underlying the disease are still not well understood; the main attention of scientists is directed to the study of the activity of neurotransmitters (norepinephrine, dopamine and serotonin). It is the “amine hypothesis” of affective disorders that is now dominant.

How does disorder occur?

The clinical picture of the disorder is characterized by repeated (at least two) episodes in which there is a change from a depressive state to a manic state or vice versa. Between attacks there is a complete recovery.

In most cases, attacks alternate, although some patients may experience a «unipolar» course, that is, only manic or only depressive episodes. As the disease progresses, the phases become more frequent, but personality changes are not detected even with a long course of the disease.

Often the onset of bipolar disorder is provoked by a serious stressful situation, and in addition, the use of psychoactive substances. Often this disease, especially in manic episodes, is accompanied by alcohol abuse.

The «fashion» of this topic and the recognition of many famous people suffering from this disease is due to the interest in some uniqueness, the strangeness of their illness. However, it is important not to forget that this is a severe mental disorder with difficult selection of treatment, which a person is forced to continue throughout his life.

How it looks from the side

With a diagnosis of bipolar affective disorder, the syndrome can be expressed in varying degrees: from hypomania to mania with psychotic symptoms; from mild depressive episode to severe depression.

A manic episode (mania) is manifested in the fact that patients are excited, verbose, hyperactive, sometimes ridiculously and colorfully dressed. They experience a feeling of vivacity, a surge of energy, a feeling of physical strength, health, and cease to really perceive the existing and previously disturbing painful sensations, which can mislead a doctor of a non-psychiatric specialty.

At the same time, euphoria can be replaced by irritability, especially when the patient’s ambitious plans fail, and dysphoria. In these cases, the episode is called a mixed state. Rapid speech turns into speech confusion, delusional ideas of greatness appear.

It is interesting that you will not meet the previously described «Napoleons» now, but rather «terminators of the Universe» or heroes from the sensational film «The Matrix». It does not make sense to ask the patient questions that would help to find out the cause of the elevated mood. Also unsuccessful are attempts to explain the inappropriateness of his behavior, which can cause dislike for the doctor. Awareness of the disease is completely absent.

Work according to the laws of BAR

Manic states, as well as depression, are now more common in the form of so-called hypomania — this is a mild degree of mania. In this case, the changes in mood and behavior are too long-term and pronounced to be included in this condition in cyclothymia, in which there is a constant slight rise in mood, increased energy and activity, talkativeness, excessive familiarity, increased sexual activity and reduced need for sleep. However, these changes do not lead to serious disruption in the work or social rejection of patients.

Sometimes, instead of the usual euphoric sociability, irritability, increased conceit and rude behavior can be observed. Despite the decrease in concentration and attention, new interests and activities may appear, often associated with excessive spending.

The manic affect is «contagious» for the people around. I saw a patient who held a high management position in a large company. During periods of rise in her emotional state (manic episodes), all the people subordinate to her worked «tirelessly», did not sleep, practically did not eat. In her depressive periods, subordinates, on the contrary, did nothing.

After their boss left for another job, the team continued to work «according to the laws of the BAR.» Only after they were disbanded into different departments, each of them returned to his usual mood, but everyone remembered the former leader with admiration.

«His soul was oppressed by longing»

The Russian writer Vsevolod Garshin (1855–1888) suffered from bipolar affective disorder. Biographers give characteristic descriptions of the phases of his illness. “At the end of 1872, when Garshin had already moved to the last class, that severe mental illness first manifested itself in him, which periodically covered him later, poisoning his life, and led to an early grave.

The first signs of the disease were expressed in a strong excitement and in increased feverish activity. Garshin turned his brother’s apartment into a real laboratory, attaching almost world significance to his experiments, and tried to attract as many people as possible to his studies. Finally, his fits of nervous excitement became so aggravated that he had to be admitted to the hospital.

In 1879, “he developed melancholy. He was in that state of indefinite and painful melancholy, which subsequently came over him every summer and finally brought him to the grave. He couldn’t do anything; he felt a terrible apathy and a decline in strength … Every, the simplest action demanded from him a strain of spiritual strength. His soul was oppressed by constant melancholy.

He changed physically as well; haggard, his voice became weak and sickly, his gait was sluggish; he walked with his head bowed, and it seemed that even walking was an unpleasant and painful labor for him; all spiritual manifestations were painful for him.

If hypomania occurs in many great people and accompanies the intensification of their creative activity, then bipolar affective disorder is a disease in itself more severe and not very common. Vsevolod Garshin described both manic and depressive phases; the last depression ended quite typically — a suicidal attempt.