A GROUP OF BENIGN CHRONIC PSYCHOSES: PROLONGED MANIC EXCITEMENTS : With a Statistical Study of Age, Duration and Frequency in 2000 Manic Attacks

1. A historical survey of the literature bearing on prolonged manic excitements is given. This brings out that fully described cases of prolonged manic excitements are scarce (some are to be found in the literature on "late recoveries") and that there is little agreement among different authors as to the nature, outcome, and clinical evaluation of these conditions. The view seems to prevail that there are conditions of "chronic mania" which are essentially incurable; that other cases of prolonged manic excitements are in every respect the same as acute manic attacks; that still other prolonged excitements of manic nature really belong to the schizophrenic group.

2. Six cases of prolonged manic excitement of from five to eleven years duration are reported. Four of these patients had either previous or subsequent manic attacks; in two patients the prolonged excitement was the only attack; no patient had depressive attacks, either before or after the prolonged excitement. One patient had two attacks of prolonged manic excitement, each of six years duration.

3. As to outcome of the prolonged attack: three cases recovered; two cases died during the attack (one from a heart disease, the other as the result of an accident); one is still sick. The three recovered cases had later manic attacks.

4. The onset of the prolonged attack occurs in mature or advanced age: in four cases at fifty or over (fifty, fifty-one, fifty-eight, and sixty); in one at thirty-eight, and in one at thirty-four.

5. The premorbid personality of the six cases shows a "positive charge in mood and activity": they are very active and persistent, talk a great deal, have many friends, are ambitious and of a jolly optimistic nature. The first patient is of definitely hypomanic temperament, and in his development shows a similarity to the cases described by Nitsche as "progressive manic constitution."

6. All cases were free from "growth disorders" (Wertham). In only three cases was the anthropological type ascertained; all three belonged to the pyknic type in its most pronounced form.

7. After prolongation of the manic psychosis the patients tended to show:

(a) A more and more marked tendency to fluctuations, with relatively quieter periods intervening.

(b) A reduction in overactivity and intellectual productivity with tendency to a certain monotony and automaticity.

(c) Appearance of delusional ideas, transient and impressing one as showing a diminution of intellectual discernment.

8. The patients of this study after years of profoundly psychotic behavior preserve well the integrity of their personality and show very little or no diminution of their intellectual and affective faculties.

9. Conditions favorable to the occurrence of prolonged manic attacks are: (a) The existence of a manic constitution combined with what may be termed (b) an increased "psychobiological rigidity."

The existence of a manic constitutional element (a) in these cases is evidenced by (1) the recurrence of manic attacks with absence of depressive attacks; (2) a "positive charge in mood and activity," which Ewald speaks of as "high biotonus."

Manic attacks occur in individuals with a certain rigidity (b) of the whole personality. There seem to be three factors which alone or in conjunction with one another bring about or increase this psychobiological rigidity.

(1) Onset at maturity or advanced age. The importance of the age factor in the development of prolonged manic attacks is also borne out by the fact that a relatively considerable number of prolonged manic attacks is recorded in the literature on mania of advanced age (Molin de Teyssieu, H. Meyer, Ducosté).

(2) Evidence of characterological rigidity in the premorbid personality. This is noted in five of the six patients.

(3) Pronounced reduction of intellectual equipment. This is noted in two patients.

10. A seventh case of prolonged manic excitement is reported which represents a transition to the group of chronic manic excitements of circular type. This patient had one previous depression, the age of onset was relatively early (thirty-one), he was emotionally very unstable as a child, and in the course of the psychosis the elation became less continuous and there was an alternating course with periods of mild depression between the states of excitement.

11. In a series of manic attacks of 1000 male and 1000 female recovered manic-depressive patients who were first admissions to the New York civil State Hospitals, the variation in the duration of manic attacks, the frequency of chronicity and the relationship between age and duration of the attack were studied.

(a) Duration.-The duration period in which the largest number of cases occurs is about 120 days (4 months). The average duration of all manic attacks was 241.7 days (34.5 weeks). There is a continuous decline in the number of cases as the duration increases, from 120 days on. The decrease is steady and gradual until the duration of about one year and ten months is reached; from then on the cases are very infrequent (Figs. 1, 2, 3). The distribution according to duration of attacks in male and female patients is very similar to the distribution for the combined group.

(b) Frequency.—There is a slight preponderance of chronic attacks in women. The frequency of cases with a duration of over five years, the group to which belong the cases of this study, as compared with the frequency of cases with shorter duration, is about eight pro mille.

(c) Age.—The average age at admission of the 2000 cases is thirty-two years. The peak of the distribution according to age is between twenty and twenty-five. Then the curve decreases rapidly and steadily as the age periods increase (Fig. 4).

12. There is a definite biological correlation between age and duration of first admissions of manic patients. This is shown by frequency polygons showing the distribution of cases according to age (Fig. 5), and by a comparison of the average ages of the duration groups (Table 1). The average age at admission of the group with duration under one year is thirty-one years; that of the group with duration of five years and over is forty years. This statistical result confirms the conclusion derived from the clinical study of the prolonged manic excitements here reported, that age is one of the most important demonstrable factors entering into the development of prolonged manic excitements.

13. There are evidently different groups of psychoses with prolonged manic excitements. The group isolated and described here as cases of benign chronic psychoses has distinct constitutional and clinical features and may serve as a point of orientation for further investigation of prolonged excitements in affective psychoses and of chronic excitements in general. Practically, its recognition is of importance because these cases are frequently wrongly interpreted. On account of the long duration, the intense outbursts on paranoid lines, the great impulsiveness and the contrary attitude, the patients are apt to be diagnosed as paranoid psychoses, as schizophrenic psychoses, as paraphrenia, or as involutional psychoses of unfavorable type.

14. From the study of this material and from scattered cases recorded in the literature, it seems possible to single out a distinct group of benign chronic manic excitements which consists of infrequent cases arising on the foundation of a manic constitution with a tendency to recurring acute manic attacks, an affinity to the pyknic body type, a tendency to the onset of a chronic condition in mature or later life, absence of depressive attacks or circular phenomena, reduction in the manic overactivity with tendency to fluctuation, absence of pronounced signs of deterioration and a potential possibility of recovery from the chronic attack.