The Psychology of Emotion

Morbid and Normal

John T MacCurdy, MacCurdy, John T

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781136298196
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

This is Volume XII of nineteen in a collection of Abnormal and Clinical Psychology. Originally published in 1925, this research stemmed from many discussions about the applicability of psychoanalytic principles to manic-depressive insanity, whether the symptoms could be traced to unconscious mental processes in the same way as Jung had demonstrated it to be possible in dementia praecox and ended up with the general objective moving from that of psychopathological to one of psychological conclusions.

PART I

PSYCHIATRICAL INTRODUCTION

CHAPTER I

THE MANIC-DEPRESSIVE GROUP

A CONVENTIONAL opening to psychiatrical monographs is a tedious discussion of the literature pertinent to the field in which explorations are to be described. The reader will be spared this for the following reasons. It is expected that he will be a technical psychiatrist, a professional psychologist, or a layman interested in psychological problems. In the first case he will have ready access to, or be already familiar with, digests laboriously compiled by experts, whose pens turn with greater facility to such tasks than does mine. If, however, he be either an “academic” or a lay psychologist, his interest will be confined to the text with its clinical material and argument; he will be indifferent to the question of the relative or absolute originality of what he reads. Nevertheless, since psychiatrical and psychological discussions cannot be utterly divorced, since the classificatory and diagnostic problems with which we are to be concerned have important psychological implications—and would otherwise be out of place in this book—for these reasons the non-medical reader must be put au courant with some matters of psychiatrical debate. It is mainly for him that this chapter is written.

Older than medicine and older than recorded history is the observation that madness may be temporary. Of almost equal antiquity is the knowledge that such attacks tend to recur in the same individual and to be of roughly the same type when they do reappear. But it was probably not until psychiatry was sufficiently advanced to be called a specialty, that recognition came of the fact that temporary insanity was apt to be characterized by marked changes in mood, that is, that the patients were morbidly sad, happy, fearful and so on.

Recoverability, recurrence, and emotional disturbance, fundamental generalizations as they are, are still features too vague and too general on which to base a satisfactory classification. Modern efforts have been aimed at the establishment of groups in which a reasonable internal consistency could be found. The first important one of these was in France. Forty-five years ago Falret and Baillarger described what the former termed “Folie Circulaire”, a psychosis¹ in which oscillations occur between elation, or maniacal excitement, and a depressive condition. Such phenomena have since then been observed with such regularity that there can be no doubt that striking alternations of emotional reaction are characteristic of many recoverable psychoses. This is so well recognized that, for “Circular Insanity”, the more pompous term of “Cyclothymia” has become current, while the adjective “cyclothymic” is applied even to personality. One who is given to marked mood swings is spoken of as cyclothymic.

The occurrence during one attack of apparently antithetic emotions would seem to indicate some, if only a pathological, relationship between them. Naturally it was not long before psychiatrists began to say that it was accidental whether the mania and depression occurred in one attack or were separated by a period of normality, or of apparent normality. This extension of the term made it possible to include under this heading all recurrent attacks of emotional insanity: if a severe depression terminated with a short, mild elation, the attack could be called cyclothymic; if the elation were not present at all, it might appear in the next breakdown. Nay, further, an isolated psychosis could be similarly labelled, because with all recurrent disease the first attack is necessarily an isolated one and, in this instance, if the aberration was of an emotional order, one could expect other attacks to appear, justifying the diagnosis. This elasticity robbed circular insanity of its specific meaning, which lay in its implication of alternation, the latter being generalized into mere recurrence. The next phase was a reaction against this looseness. In the last decade of the last century strenuous efforts were made to keep cyclothymia a clinical entity, and clinical research aimed at finding criteria, which might be used effectively to differentiate between true circular insanity and other disturbances that might or might not be periodic, let alone alternating. These were attempts to erect and maintain landmarks on shifting sands.

About the turn of the century Kraepelin began to unravel this Gordian knot by grouping together under the title of “Manic-Depressive Insanity” all periodic, emotional insanities, regardless of whether they were circular or merely recurrent. In 1904, in the seventh edition of his text book, he cut the knot by including simple mania¹. Still later² he brought in most melancholias as well. (These are conditions of anxious depression, often with much hypochondria, occurring mainly in the advancing years of life.) His present standpoint, which is almost universally accepted, may be given most fairly by quoting his own words of introduction to this section in the last edition of his text book.

“Manic-depressive insanity … includes, on the one hand, the whole domain of the so-called periodic and circular insanities and, on the other, simple mania, the majority of the clinical pictures labelled ‘Melancholia’ and also a not inconsiderable number of cases of amentia³. Finally we reckon here certain mild, even very mild, mood nuances, sometimes periodic, sometimes permanent, that are to be viewed on the one hand as preliminary to more severe disturbances, and on the other glide over into the domain of personality make-up. In the course of years I have become more and more convinced that all these phenomena are manifestations of only one pathological process. I grant that a series of subsidiary forms may possibly be built up later, or that individual little groups be entirely split off again; but, if this happens, then according to my view, it is quite certain that those symptoms should not be used as criteria, which up to that time were customarily placed in the foreground.”

At this point a comment may be made parenthetically, which is, I believe, pertinent. The essence of Kraepelinian psychiatry is displayed in this quotation. He begins by formulating a classification of great practical value. Then comes a theoretic generalization that seems sound, namely that all the symptoms are manifestations of one pathological process. But at once a vigilant proprietorship forces an inconsistency. If there be one pathological process it must be the central fact or theory, the ultimate justification of the classification, for which the symptoms are of secondary importance. He proceeds, however, to claim that the classification rests on the presence of certain symptoms that derive their importance from a point of view. Since it is his imprimatur that dignifies these symptoms, he is, in effect, making an appeal to his authority rather than to clinical experience or to the demonstrability of a fundamental pathological process. The significance of this criticism will appear more clearly as we proceed.

The arguments he adduces for the unity of the manic-depressive group are excellent. We find a certain small constellation of aberrations in all forms of manic-depressive insanity, appearing in manifold expressions and combinations, it is true, but persisting side by side with shifting, transitory symptoms. These give a stamp of unity to all cases, although not necessarily pathognomic in any given case. If one is familiar with the type picture he can recognize it in the majority of cases, even at one interview, in spite of the variety of disguises it may assume. Of still greater importance is the experience that all the different syndromes, which are grouped together in manic-depressive insanity, melt off into each other imperceptibly, or may replace each other even during one attack. In the same patient we see changing places, not merely mania and depression, but also states of deepest confusion and irrationality, striking delusional fabrications and, lastly, mild mood variations. Again, there is usually a prolonged, monotonous, emotional background against which is developed a full-blown, circumscribed attack. A further bond between the different clinical pictures is their common prognosis; fast or slowly all the patients recover, and dementia does not appear even after many repeated attacks. Hereditarily too, a close relationship between the different types is to be discovered. One member of a family may have periodic and another circular attacks, or one manic, another depressive and a third confusional episodes, and so on.

In making his sub-divisions of manic-depressive insanity Kraepelin disregards the older groups of “periodic” or “circular”, etc., and proposes three broad types. These are: mania with its symptoms of flight of ideas, feeling of elation and over-activity; depression characterized by sadness or anxiety, with retardation of thought and action; and the mixed conditions where some manic and some depressive symptoms appear side by side, producing a state that can be called neither mania nor depression. We shall have a good deal to say about this classification, for the principles involved transcend the technical problems of psychiatry. It is not merely a matter of hospital expedience but of fundamental, psycho-pathological theory. Before entering into this discussion, however, we must see what Kraepelin concludes as to the basic pathology of these psychoses.

“Manic-depressive insanity occurs in attacks, the appearance of which is, in general, independent of external influence. This fact points to the view that the essential and fundamental cause of the disease is to be sought in a permanent morbid condition, that must also exist during the times when no attacks are present. We assume this most readily when frequent illnesses recur at approximately equal intervals. But when the disease appears only a few times or even once in a life time, its roots have already been growing for a long time or are to be sought in a perversion of psychic life established since youth.”

He admits that in some cases there seems to be an exception to this generalization. They are the psychoses that look as if they were precipitated by exogenous factors. Such accidents are due to alcoholism, syphilis, injuries to the brain, bodily diseases (particularly infections), pregnancy and child-birth. But only a small proportion of the patients show a history of such intercurrent factors, and the same patient, who now seems to have broken down after one of these physical insults, may have had previous attacks in which no external agency was discoverable. A statistically more important group is that in which some mental cause seems to operate. Deaths of relatives and friends are particularly prominent; then there are quarrels, frights, lawsuits, betrothals, threats, house-moving and so on. But here again he finds that many patients seem to have causeless attacks, and that in the same way one psychosis may seem to be precipitated by mental stress, but another come out of the blue. (It may be marked here that our experience fails to confirm this last claim. We always find that something untoward has occurred with which the breakdown is connected, although careful and extensive inquiry may be needed in order to discover what it is. Of course we regard such events as pregnancy and child-birth as having psychological significance, whereas Kraepelin looks on them merely from the physical standpoint.)

So Kraepelin comes to the conclusion that exogenous influences play an inconstant and therefore negligible rôle; a basic predisposition must exist. Statistical demonstration of this appeared in 377 of nearly 1,000 cases in the Munich clinic, such cases showing a history of peculiarities in their free intervals. Sometimes these abnormalities seemed merely to be exaggerated when a definite psychosis appeared, but in others the symptoms of the attack were apparently opposite in nature to the characteristics of the normal life of the patients. A further interesting observation is that other members of the patient’s family might also show these oddities, although these others never broke down.

He does not say how often such temperamental abnormalities appear in families where no psychoses intervened.

His conclusion therefore is that “there are certain predispositions that may be regarded as early stages of manic-depressive insanity. They can exist throughout the entire life as peculiar formations of the psychic personality without further development; but they may also under special circumstances become the point of departure for pathological developments occurring in separate attacks.” He calls these predispositions the “fundamental conditions” (Grundzustände) of manic-depressive insanity. The principal forms that the fundamental conditions assume are a depressive (or anxious) predisposition, a manic, one of emotional excitability, or a cyclothymic tendency. The manic personalities are characterized by flightiness, buoyancy, overconfidence, and superficial judgment. The depressive people worry much, take everything hard, have a pessimistic outlook and have to force themselves into activity. Those with emotional instability over-react to circumstances that are in the slightest degree out of the ordinary: they have hasty tempers, facile tears, and “take on” about anything. The layman would call many of them “hysterical”. The cyclothymics are always either on the crest of the wave or wallowing in the depths.

When Kraepelin comes to discuss the etiology of magic-depressive insanity he says, “The causes of the disease we must look for essentially, so it seems, in the pathological predisposition”. He then proceeds to enumerate the customary factors of heredity, age, sex, chronic physical disease, etc. that may be at the back of this predisposition.

The most impressive evidence he offers is of heredity. A number of authors, agreeing with Kraepelin’s experience, have found hereditary taint in 4–5ths of manic-depressive cases; abnormality was discoverable in the parents of 1–3rd of their patients.

Age seems to be a factor of no small moment. 16.4% of 903 cases showed the first attack between 15 and 20 years of age; 15.3% and 15.4% initiated psychoses between 20 to 25, and 25 to 30 respectively. From then on the frequency of onset declines steadily up to 85 years, with the exception of a slight rise of the curve between 45 and 50. A full 50% begin their psychotic careers before the age of 30. With the exception of the rise between the ages of 45 and 50, the curve follows, roughly, that of the number of survivors in a given population at the different age periods. So, if these were the only attacks from which the patients suffered, there would be nothing very remarkable about these figures. There are a decreasing number of people living from the age of 20 on who may develop manic-depressive insanity. But it is a matter of common psychiatric observation that the younger the patient at the time of the first attack, the greater is the liability to recurrence and the greater is the proportion of subsequent life to be spent in an institution. A man who first breaks down in his teens is liable to many more psychoses, whereas if he is, let us say, 35 years old when the first break comes he has a fair chance of never having another. These impressions receive confirmation from a study of the statistics collected by Pollock¹ from the data gathered in the New York State Hospitals. One is forced to the conclusion that some kind of a constitutional defect exists in manic-depressive insanity, which tends to be checked by the greater elasticity and adaptibility of youth, or comes to expression with the gradual increase of stress and strain as life advances. If one succumbs in spite of the relative freedom from responsibility in youth and of its greater resilience, then it must be assumed that this constitutional weakness is unusually pronounced.

Another interesting point which Kraepelin discusses in connexion with the age factor is the change in proportion of the different types of illness as the years go on. There is a tendency for reduction in the relative number of manias and mixed conditions with a corresponding increase in the proportion of depressions. At the extremes the contrast is striking; up to the age of 20 years, there are approximately an equal number of manias and depressions, but after 60 years there are 4.3 times as many of the latter. Kraepelin, quite rightly, I think, ascribes this both to the effect of physical regression which tends to limit activity, and also to the change of outlook incidental to increasing age.

As to the influence of sex, he points out that women are regularly more affected than men. The slight proportionate differences between the two sexes at different ages and with different types of psychosis are not so striking as the figures just discussed.

Temperamental peculiarities influence the type of psychosis that developes, particularly in the case of depressive personalities which tend to produce a large number of depressions and very few manic states. Manic predispositions are followed by more manias, but, strangely enough, by still more depressions. As Kraepelin points out, however, one may regard these predispositions, not as causal factors, but as symptoms of an existing disease.

These factors all have to do with the manic-depressive constitution, whatever it may be. In addition there are the exogenous factors of alcohol, syphilis, head injuries, bodily disease, pregnancy and child-birth. They all seem to play a subordinate rôle, as Kraepelin says. As to physical basis of the actual attacks, he has to admit that we are completely in obscurity. He discusses the hypotheses that have been advanced in favour of vasomotor or metabolic changes, auto-intoxication and endocrine disturbances. Speculation outweighs evidence heavily in this field.

Now where does all this argument get us to in the end? The inexpedience of trying to maintain, as unrelated psychoses, simple manias, simple depressions, “periodic”, recurrent, and cyclothymic attacks seems fully proved. His proof of the existence of a common thread running through a...

Table of contents

• Cover Page
• Half Title page
• Series page
• Title Page
• Copyright Page
• Dedication
• Preface
• Contents
• Part I Psychiatrical Introduction
• Part II Psychological Introduction
• Part III The Stupor Reaction
• Part IV The Involution Melancholias
• Part V Manic States
• Part VI Anxiety States
• Part VII Depression
• Part VIII Perplexity States
• Part IX Psychiatric Conclusions
• Part X Data for a Theory of Emotions
• Part XI Psychological Conclusions
• Glossary
• Index