Duration of compulsory treatment of a person with TIR. Manic phase of affective psychosis. The course of manic-depressive psychosis

The human psyche is a complex system, and failures can sometimes occur in it. Sometimes they are minor and corrected by several visits to a psychologist, but sometimes the problems can be much more significant. One of the serious mental disorders that require specialist monitoring is manic-depressive psychosis.

A distinctive feature of this disease is the alternating manifestation in a person of certain affective states: manic and depressive. These states can be called opposite, because manic-depressive psychosis is also called bipolar affective disorder.

Why do people get bipolar disorder?

It is believed that manic-depressive psychosis (MDP) is due to heredity: this is due to some disturbances in the transmission of nerve impulses in the hypothalamus. But, of course, it is quite difficult to determine this in advance, especially if the disease was not transmitted from the previous generation, but from more distant relatives. Therefore, risk groups were identified, among which cases of the onset of the disease are especially frequent. Among them:

Constant stress on the psyche. It can be a job associated with negative emotions, or a difficult situation in the family - in a word, everything that day by day puts a person out of balance.
Hormonal disruptions.
Adolescence.
Experienced violence - moral or physical.
Presence of other mental illnesses.

Another characteristic feature of the disease is that, despite the tendency to emotionality and nervousness prescribed for women, it occurs precisely in females.

Signs of bipolar affective disorder

As already mentioned, for such a disease as manic-depressive psychosis, two "poles" are characteristic, two states - manic and depressive. Therefore, the symptoms of each of the phases should be described separately.

Manic stage

During this phase of bipolar disorder, the patient feels a sense of elation, joy, memory improves, and a desire to interact with the outside world arises. It would seem, and where are the symptoms of the disease? But still, the manic phase of such a disease as manic-depressive psychosis has some signs that make it possible to distinguish a painful state of the psyche from ordinary cheerfulness.

Increased desire for risk, getting adrenaline. This may include gambling, extreme sports, the use of alcohol, psychoactive substances, etc.
Restlessness, agitation, impulsivity.
Fast, slurred speech.
A prolonged, unconditioned feeling of euphoria.
There may be hallucinations - both visual and auditory, tactile.
Not quite adequate (or completely inadequate) perception of reality.

One of the main disadvantages of this condition is the commission of rash acts, which in the future can aggravate another stage of the disease - the depressive phase. But it happens that a manic syndrome exists in a person by itself, without the onset of depression. This condition is called manic psychosis, and it is a special case of unipolar disorder (as opposed to bipolar, which combines two syndromes). Another name for this syndrome is hypomanic psychosis.

depressive phase

Depression follows the manic phase of psychosis, during which the patient is extremely active. The following symptoms are characteristic of the depressive stage of the disease:

Apathy, slow response to environmental stimuli.
Low mood, craving for self-flagellation and self-abasement.
Inability to concentrate on anything.
Refusal to eat, talk even with loved ones, unwillingness to continue treatment.
Sleep disorders.
Slow, incoherent speech. The person answers questions automatically.
Headaches and other symptoms that indicate the impact of depression on physical health: nausea, dizziness, etc.
Perception of the surrounding world in gray, boring colors.
Weight loss associated with loss of appetite. Women may experience amenorrhea.

A depressive state is dangerous, first of all, with possible suicidal tendencies, a person closing in on himself and the inability to carry out further treatment.

How is TIR treated?

Manic-depressive psychosis is a disease that requires very competent and complex treatment. Special drugs are prescribed, in addition, psychotherapy is used, as well as conservative therapy.

Medical treatment

If we talk about the treatment of psychosis with drugs, then we should distinguish between drugs designed for a long course and drugs, the main purpose of which is to quickly relieve the symptoms of a painful mental state.

Strong antidepressants are used to relieve acute depressive states. However, treatment with antidepressants must be combined with mood stabilizers, otherwise the patient's condition may destabilize. As for the manic phase, here you will need medications that will help normalize sleep, remove overexcitation. You will need antipsychotics, antipsychotics, and all the same mood stabilizers.

Long-term treatment is designed not only to remove the consequences of affective states, but also to stabilize the patient's condition during periods of "calm". And in the long term, and completely minimize the manifestations of the disease. These are, again, sedatives, antipsychotics, tranquilizers. The treatment of manic-depressive psychosis also often involves the use of lithium carbonate: it has a pronounced anti-manic effect, removes the excited state.

Psychotherapeutic methods of treatment

Although medications play a huge role in the recovery of a person with bipolar disorder, other therapies are needed. Including the need for a person and psychological help. The following are widely used in this regard:

Cognitive therapy. At this stage, a person needs to find out what in his behavior aggravates his condition. This will help avoid similar patterns of thinking in the future.
Family therapy. Helps in establishing contacts with other people, especially with relatives and friends.
Social therapy. It involves, first of all, the creation of a clear daily routine, which will allow you to regulate the time of work and rest, not allowing you to overstrain unnecessarily or worsen the patient's condition in any other way.

General therapy

In the intervals between depressive and manic phases, conservative methods of treatment are used that contribute to relaxation, mood stabilization and overall strengthening of mental and physical health. Electrosleep, physiotherapy, massage, hydromassage, etc.

In conclusion, it is worth noting that although manic-depressive psychosis is a rather dangerous disease for a person, if treatment is started in a hospital on time, the patient may well return to normal life. And of course, in addition to medicines and procedures, the support of loved ones is very important in this situation. The same applies to illnesses such as depression or hypomanic psychosis.

(hypomanic) and depressive, as well as mixed states, in which the patient has symptoms of depression and mania at the same time (for example, melancholy with agitation, anxiety, or euphoria with lethargy, the so-called unproductive mania), or a rapid change in symptoms of (hypo)mania and (sub)depression.

These states periodically, in the form of phases, directly or through "bright" intervals of mental health (the so-called interphases, or intermissions), replace each other, without or almost without a decrease in mental functions, even with a large number of transferred phases and any duration of the disease.

Historical information

For the first time as an independent mental disorder, bipolar affective disorder was described almost simultaneously in the year by two French researchers J. P. Falret (under the name "circular psychosis") and J. G. F. Bayarzhe (Baillarger) (under the name "insanity in two forms). However, for almost half a century, this mental disorder was not recognized by the psychiatry of that time, and E. Kraepelin () owes its final separation into a separate nosological unit. Kraepelin introduced the name for this disorder affective insanity, which has been generally accepted for a long time, but is now considered outdated and scientifically incorrect, since this disorder is by no means always accompanied by psychosis, and both types of phases (both mania and depression) are also not always observed in it. In addition, the term "manic-depressive psychosis" is offensive and stigmatizing in relation to patients. Currently, the more scientifically and politically correct name for this mental disorder is "bipolar affective disorder", abbreviated as BAD. Until now, in psychiatry of different countries and different schools within the same state there is no single definition and understanding of the boundaries of this disorder.

Prevalence

Etiology and pathogenesis

The etiology of bipolar affective disorder is still not clear. There are two main theories trying to explain the causes of the development of the disease: hereditary and autointoxication (endocrine imbalance, disturbances in water and electrolyte metabolism). As in schizophrenia, post-mortem brain samples show changes in the expression of certain molecules, such as GAD67 and reelin, but it is not clear what exactly causes them - a pathological process or medication. Searches are underway for endophenotypes to more confidently detect the genetic basis of the disorder.

Clinical picture, course

The debut of bipolar affective disorder occurs more often at a young age - 20-30 years. The number of phases possible in each patient is unpredictable - the disorder can be limited to only one phase (mania, hypomania or depression) in a lifetime, it can manifest only manic, only hypomanic or only depressive phases, or their change with correct or incorrect alternation.

The duration of the phases ranges from several weeks to 1.5-2 years (3-7 months on average), the duration of the "light" intervals (intermissions or interphases) between the phases can range from 3 to 7 years; The “light” gap may be completely absent. The atypicality of phases can be manifested by a disproportionate severity of core (affective, motor and ideation) disorders, incomplete development of stages within one phase, inclusion in the psychopathological structure of the phase of obsessive, senestopathic, hypochondriacal, heterogeneous delusional (in particular, paranoid), hallucinatory and catatonic disorders.

The course of the manic phase

Manic phase It is represented by a triad of main symptoms: increased mood (hyperthymia), motor excitation, ideator-psychic (tachypsychia) excitation. There are five stages during the manic phase.

The hypomanic stage (F31.0 according to ICD-10) is characterized by an elevated mood, a feeling of spiritual uplift, physical and mental vigor. Speech is verbose, accelerated, the number of semantic associations decreases with an increase in mechanical associations (by similarity and consonance in space and time). Moderately pronounced motor excitation is characteristic. Attention is characterized by increased distractibility. Hypermnesia is characteristic. Moderately reduced sleep duration.
The stage of severe mania is characterized by a further increase in the severity of the main symptoms of the phase. Patients continuously joke, laugh, against which short-term outbursts of anger are possible. Speech excitation is pronounced, reaches the degree of a jump of ideas (lat. fuga idearum). Expressed motor excitation, pronounced distractibility lead to the impossibility of having a consistent conversation with the patient. Against the backdrop of a reassessment of one's own personality, delusional ideas of greatness appear. At work, patients build bright prospects, invest in unpromising projects, design insane designs. Sleep duration is reduced to 3-4 hours a day.
The stage of manic frenzy is characterized by the maximum severity of the main symptoms. Sharply motor excitation is erratic, speech is outwardly incoherent (in the analysis it is possible to establish mechanically associative connections between the components of speech), consists of fragments of phrases, individual words or even syllables.
The stage of motor sedation is characterized by a reduction in motor excitation against the background of persistent elevated mood and speech excitation. The intensity of the last two symptoms also gradually decreases.
The reactive stage is characterized by the return of all the components of the symptoms of mania to normal and even a slight decrease in mood compared to the norm, mild motor and ideational retardation, and asthenia. Some episodes of the stage of severe mania and the stage of manic frenzy in patients may be amnesic.

The course of the depressive phase

depressive phase It is represented by a triad of symptoms opposite to the manic stage: depressed mood (hypothymia), slow thinking (bradypsychia) and motor inhibition. In general, bipolar disorder is more often manifested by depressive states than by manic states. There are four stages during the depressive phase.

Patients lose their appetite, food seems tasteless (“like grass”), patients lose weight, sometimes significantly (up to 15 kg). In women, periods of depression disappear (amenorrhea). With a shallow depression, diurnal mood swings characteristic of BAD are noted: health is worse in the morning (they wake up early with a feeling of melancholy and anxiety, are inactive, indifferent), in the evening their mood and activity increase slightly. With age, anxiety (unmotivated anxiety, premonition that “something is about to happen”, “inner excitement”) takes an increasing place in the clinical picture of depression.

The initial stage of depression is manifested by a mild weakening of the general mental tone, a decrease in mood, mental and physical performance. Characterized by the appearance of moderate sleep disorders in the form of difficulty falling asleep and its superficiality. All stages of the course of the depressive phase are characterized by an improvement in mood and general well-being in the evening hours.
The stage of increasing depression is already characterized by a clear decrease in mood with the appearance of an anxiety component, a sharp decrease in physical and mental performance, and motor retardation. Speech is slow, laconic, quiet. Sleep disturbances result in insomnia. A marked decrease in appetite is characteristic.
The stage of severe depression - all symptoms reach their maximum development. Severe psychotic affects of melancholy and anxiety, painfully experienced by patients, are characteristic. Speech is sharply slow, quiet or whispered, answers to questions are monosyllabic, with a long delay. Patients can sit or lie in one position for a long time (the so-called " depressive stupor"). Characterized by anorexia. At this stage, depressive delusional ideas appear (self-accusation, self-abasement, own sinfulness, hypochondria). It is also characterized by the appearance of suicidal thoughts, actions and attempts. Suicidal attempts are most frequent and dangerous at the beginning of the stage and at the exit from it, when there is no pronounced motor inhibition against the background of severe hypothymia. Illusions and hallucinations are rare, but they can be (mainly auditory), more often in the form of voices reporting the hopelessness of the state, the meaninglessness of being, recommending suicide.
The reactive stage is characterized by a gradual reduction of all symptoms, asthenia persists for some time, but sometimes, on the contrary, some hyperthymia, talkativeness, and increased motor activity are noted.

Options for the course of the depressive phase

simple depression - a triad of a depressive syndrome without delirium;
hypochondriacal depression - depression with affective hypochondriacal delusions;
delusional depression (" Cotard's syndrome") - depression with the presence of nihilistic delirium (the patient claims that he is missing one or more of the internal organs, there is no any part of the body) or delusions of his own negative exclusivity (the patient claims that he is the most terrible, an incorrigible criminal, will live forever and suffer forever, etc.);
agitated depression is characterized by the absence or weak severity of motor retardation;
anesthetic depression is characterized by the presence of the phenomenon of painful mental insensitivity (lat. anesthesia psychica dolorosa), when the patient claims that he has completely lost the ability to love loved ones, nature, music, has lost all human feelings in general, has become absolutely insensible, and this loss is deeply experienced as an acute mental pain.

Options for the course of bipolar affective disorder

periodic mania - only manic phases alternate;
periodic depression - only depressive phases alternate;
correctly-intermittent type of flow - through "light" intervals, the manic phase replaces the depressive, the depressive - manic;
incorrectly intermittent type of flow - through “light” intervals, manic and depressive phases alternate without a strict sequence (after the manic phase, the manic phase may begin again and vice versa);
double form - a direct change of two opposite phases, followed by a "light" gap;
circular type of flow - there are no "light" gaps.

The most common types of flow are irregularly intermittent and intermittent depression.

Differential Diagnosis

Conducting a differential diagnosis of BAD is necessary with almost all types of mental disorders: neuroses, infectious, psychogenic, toxic, traumatic psychoses, oligophrenia, psychopathy, schizophrenia.

Treatment

The treatment of bipolar disorder is challenging, as it requires a detailed understanding of psychopharmacology.

Since the discrete course of psychosis, as opposed to the continuous course, is prognostically favorable, the achievement of remission is always the main goal of therapy. To stop the phases, “aggressive psychotherapy” is recommended in order to prevent the formation of “resistant states.

depressive phase

Of decisive importance in the treatment of the depressive phase of bipolar disorder is an understanding of the structure of depression, the type of course of bipolar disorder in general, and the patient's state of health.

In contrast to the treatment of unipolar depression, in the treatment of bipolar depression with antidepressants, it is necessary to take into account the risk of phase inversion, that is, the transition of the patient from a depressive state to a manic state, and more likely to a mixed one, which can worsen the patient's condition and, more importantly, mixed states are very dangerous in terms of suicide. So, with monopolar depression, tricyclic antidepressants cause hypomania or mania in less than 0.5% of patients. In bipolar depression, and especially in the structure of bipolar disorder type 1, the phase inversion to mania on tricyclic antidepressants is more than 80%. In BAD type 2, inversion occurs less frequently, but in the form of the occurrence, as a rule, of mixed states. It should be noted that most often mania is caused by irreversible MAO inhibitors and tricyclic antidepressants, and selective serotonin reuptake inhibitors cause phase inversion much less frequently. Therefore, we will consider the most progressive and modern methods of treating the depressive phase of bipolar disorder. The decisive role is played by antidepressants, which are selected taking into account the characteristics of depression. In the presence of symptoms of classic melancholic depression, in which melancholy comes to the fore, it is advisable to prescribe balanced antidepressants that occupy an intermediate position between stimulants and sedatives, such as paroxetine (as studies show, among drugs of this class, SSRIs, more than others suitable for classic melancholic depression), clomipramine, which belongs to tricyclics and is one of the most powerful blood pressure, citalopram, venlafaxine, fluvoxamine, etc. If anxiety and anxiety come to the fore, then sedative blood pressure is preferred: mirtazapine, mianserin, trazodone, amitriptyline. Although the anticholinergic effects of tricyclic antidepressants are often considered undesirable, and they are especially pronounced with amitriptyline, many researchers argue that the m-anticholinergic effect contributes to the rapid reduction of anxiety and sleep disturbances. A special group of depressions are those when anxiety and lethargy are present at the same time: sertraline showed the best result in treatment - it quickly stops both the anxiety-phobic component and melancholy, although at the very beginning of therapy it can increase the manifestations of anxiety, which sometimes requires the appointment of tranquilizers. With adynamic depression, when ideational and motor retardation come to the fore, stimulating blood pressure is preferable: irreversible MAO inhibitors (currently not available in Russia), imipramine, fluoxetine, moclobemide, milnacipran. Citalopram gives very good results in this type of depression, although its effects are balanced, not stimulating. In depression with delusions, olanzapine showed efficacy comparable to the combination of haloperidol and amitriptyline, and even slightly outnumbered those sensitive to therapy, and tolerability was much higher.

Treatment with antidepressants must be combined with mood stabilizers - mood stabilizers, and even better with atypical antipsychotics. The most progressive is the combination of antidepressants with such atypical antipsychotics as olanzapine, quetiapine or aripiprazole - these drugs not only prevent phase inversion, but also have an antidepressant effect themselves. In addition, it has been shown that olanzapine makes it possible to overcome resistance to serotonergic antidepressants: a combined drug - olanzapine + fluoxetine - Symbyax is now being produced.

Manic phase

The main role in the treatment of the manic phase is played by mood stabilizers (lithium drugs, carbamazepine, valproic acid, lamotrigine), but for the rapid elimination of symptoms, there is a need for antipsychotics, and priority is given to atypical ones - classical antipsychotics can not only provoke depression, but also cause extrapyramidal disorders, to which patients with bipolar disorder are especially predisposed and, especially, to tardive dyskinesia - an irreversible disorder leading to disability.

Causes of Bipolar Disorder

Most experts agree that there is no one global reason why a patient develops bipolar disorder. Rather, it is the result of several factors that influence the appearance of this mental illness. Psychiatrists identify several reasons why bipolar disorder develops:

genetic factors;
biological factors;
chemical imbalance in the brain;
external factors.

As for the genetic factors that influence the development of bipolar disorder, scientists have made certain conclusions. They conducted several small studies using the method of studying personality psychology on twins. According to doctors, heredity plays an important role in the development of manic-depressive psychosis. Individuals with a blood relative who suffers from bipolar disorder are more likely to be diagnosed with the disease in the future.

When it comes to biological factors that can lead to bipolar disorder, experts say that brain abnormalities are often observed when examining patients diagnosed with bipolar disorder. But so far, doctors cannot explain why these changes lead to the development of a serious mental illness.

A chemical imbalance in the functioning of the brain, especially with regard to neurotransmitters, plays a key role in the occurrence of various diseases, including bipolar disorder. Neurotransmitters are biologically active substances in the brain. Among them, in particular, the most famous neurotransmitters are distinguished:

dopamine;
norepinephrine.

Hormonal imbalance can also trigger the development of bipolar disorder with a high degree of probability.

External or environmental factors sometimes lead to the formation of bipolar disorder. Among environmental factors, psychiatrists distinguish the following circumstances:

excessive alcohol consumption;
traumatic situations.

Symptoms of Bipolar Disorder

The symptoms during the manic stage are as follows:

a person feels like the ruler of the world, feels euphoric and too excited;
the patient is self-confident, he has an excessive sense of his own importance and an increased self-esteem prevails;
doctors note a distorted perception in the patient;
a person is distinguished by rapid speech and an excess of phrases;
thoughts come and go at a high speed (the so-called jumps of thought), eccentric statements are uttered; patients sometimes even begin to translate some strange thoughts into reality;
during the manic stage, a person is sociable, sometimes aggressive;
the patient is able to commit risky acts, there is a promiscuous sex life, alcoholism, he can use drugs and participate in dangerous activities;
a person can carelessly handle money and spend it excessively.

Symptoms during the depressive stage of bipolar include the following:

the patient feels despondency, despair, hopelessness, sadness, and his thoughts are gloomy;
in severe cases, the patient is visited and he may even take certain actions to carry out the intended;
doctors note insomnia and sleep disorders;
the patient often experiences anxiety over trifles;
the personality is often overwhelmed by guilt about all events;
the depressive phase of bipolar disorder is reflected in food intake - a person eats either too much or too little;
patients report weight loss or, conversely, weight gain;
the patient complains of fatigue, weakness, apathy;
a person has impaired attention;
the patient easily gives in to irritants: noise, light, smells, reacts to tight clothes;
some patients are unable to go to work or study;
a person notices that he has lost the ability to enjoy activities that used to bring joy.

Psychosis

Both during the manic and depressive stages of bipolar disorder, a patient can experience psychosis, when a person cannot understand where the fantasies are and where the reality in which he is.

The symptoms of psychosis in bipolar disorder are as follows:

illusions;
hallucinations.

Clinical depression or major depressive disorder

Clinical depression is often seasonal. It used to be called seasonal affective disorder. There are mood swings depending on the time of year.

Symptoms of bipolar disorder in children and adolescents:

sudden change of mood;
bouts of anger;
outbursts of aggression;
reckless behaviour.

It is important to remember that manic-depressive psychosis is treatable and exists. The symptoms of this mental illness can be reduced with the right approach, and thus the person will return to normal life.

Diagnosis of Bipolar Disorder

A psychiatrist or psychologist, when making a diagnosis of bipolar disorder, is guided by his previous work experience, his observations, conversations with family members, colleagues, close friends, teachers, as well as knowledge of the secondary signs of this mental illness.

First, it is necessary to study the physiological state of the patient, make a blood and urine test.

Experts distinguish three common types:

1) The first type of bipolar disorder, the so-called expression of emotions in the mirror

There must be at least one episode of the manic stage of bipolar disorder or a mixed phase (with a previous depressive stage). Most patients have experienced at least one depressive stage.

In addition, in this case it is important to exclude clinical affective disorders that are not associated with manic-depressive psychosis, for example:

schizophrenia;
delusional disorder;
other mental disorders.

2) The second type of bipolar disorder

The patient experienced one or more episodes of depression and at least one episode of hypomanic behavior in manic-depressive psychosis.

A hypomanic state is not as severe as a manic state. During the hypomanic stage, the patient sleeps little, is assertive, easy-going, very energetic, but is able to carry out all his duties normally.

Unlike the manic stage of bipolar disorder, doctors do not observe symptoms of psychosis or megalomania during the hypomanic stage.

3) Cyclothymia

Cyclothymia is a mental affective disorder in which the patient experiences mood swings ranging from indistinct depression to hyperthymia (sometimes there are even episodes of hypomania). Hyperthymia is a persistent elevated mood.

In general, such mood swings in cyclothymia are a mild form of manic-depressive psychosis. Mild depressive mood is often observed.

In general, a patient with symptoms of cyclothymia feels that his condition is quite stable. At the same time, other people notice his mood swings, ranging from hypomania to a manic-like state; then depression may occur, but this is hardly a major depressive disorder (clinical depression).

Treatment for Bipolar Disorder

The goal of treatment for bipolar disorder is to reduce the frequency of manic and depressive episodes as much as possible, as well as significantly reduce the symptoms of the disease so that the patient can return to a normal course of life.

If the patient does not receive treatment, and the symptoms of the disease remain, then this can last for one year. If the patient is undergoing treatment for manic-depressive psychosis, then improvement usually occurs in the first 3-4 months.

At the same time, mood swings still remain a hallmark of patients diagnosed with bipolar disorder who are undergoing treatment. If the patient regularly communicates with his doctor and goes to a meeting, then such treatment is always more effective.

Treatment for bipolar disorder usually involves a combination of several therapies, including medication, exercise, and counseling.

Nowadays, a patient is rarely hospitalized with symptoms of manic-depressive psychosis. This is only done if he could harm himself or others. Then the patients are in the hospital until improvement occurs.

Lithium carbonate is most often prescribed for a long time to reduce mania and hypomania. Patients take lithium for at least six months. You must strictly follow the instructions of the psychiatrist.

Other types of therapy for bipolar disorder include the following methods of influencing the patient:

anticonvulsants;
neuroleptics;
valproate and lithium;
psychotherapy;

Anticonvulsants are sometimes prescribed to help a person in the manic stage of bipolar disorder.

The antipsychotics are aripiprazole, olanzapine, and risperidone. They are prescribed if a person behaves too restlessly, and the symptoms of the disease are severe.

When are valproate and lithium carbonate prescribed? Doctors use this combination of drugs for fast cycling.

Rapid cycling is a form of bipolar disorder where the patient has 4 or more episodes of mania or depression per year. This condition is more difficult to treat than varieties of the disease with less frequent attacks, and requires a special selection of drugs. According to some studies, more than half of patients suffer from this form of the disease.

In general, a sign of rapid cyclicity is unbalanced behavior in a person diagnosed with “manic-depressive psychosis” all the time, and the norm has long been absent from his behavior. In such cases, psychiatrists prescribe valproate in combination with lithium. If this does not bring the desired effect, the doctor recommends lithium carbonate, valproate and lamotrigine.

The goal of psychotherapy is to:

relieve the main symptoms of bipolar disorder;
help the patient to realize the main provoking factors that lead to the disease;
minimize the impact of illness on relationships;
identify the first symptoms that indicate a new round of the disease;
look for those factors that help to stay normal the rest of the time.

Cognitive Behavioral Therapy is teaching the patient how to use psychological self-help and a form of family therapy. Psychiatrists educate the patient and family members about how to avoid exacerbation of bipolar disorder.

Interpersonal (or interpersonal) therapy also helps patients with depressive symptoms. Interpersonal psychotherapy is a type of short-term, highly structured, specifically focused psychotherapy. It is based on the working principle of "here and now" and is aimed at resolving the problems of the current interpersonal relationships of patients who suffer.

Compared to the avalanche of studies on endogenous depression, studies on mania are surprisingly few in number. This is partly due to the fact that manic states are several times less common than depressive states, their treatment is less differentiated, since there are no specific anti-manic drugs, except for lithium salts, and neuroleptics are most often used to treat mania. Hypomanic states are less likely to come to the attention of a psychiatrist than mild depression, since patients are not burdened by them and consider themselves completely healthy. Therefore, they refuse treatment, and due to increased activity, they do not have time for examination. With severe mania, the doctor no longer has time to conduct research, since in these cases it is difficult to keep the patient without immediate treatment. Finally, the symptomatology of the manic phase is simpler than that of other psychoses and therefore seems less promising for new discoveries.

Clinic

Since the time of E. Kraepelin, the clinic of mania has often been described as a mirror reflection of depression with the opposite sign: the depressive triad includes melancholy, mental and motor retardation, and mania is characterized by an elevated mood, an accelerated pace of thinking, and motor excitation. With moderate mania, the appearance of patients changes; facial expressions become lively, eyes shine, speech is accelerated, movements are fast, patients look rejuvenated, they are active, energetic. The mood is elevated, the past and, most importantly, the future appears in a rainbow color, the patient is full of optimism, there is a feeling of strength, attractiveness (especially for women), unlimited possibilities. If depression is characterized by anhedonia, loss of interest, closeness to all positive, and in severe depression - and negative experiences associated with the external situation, then in mania the patient is able to experience joy because of every little thing, reacts sharply to all external events, notices everything , ready to intervene in everything, strives for communication. Surrounding and especially recently found friends seem to be wonderful, charming people (relatives sometimes cause irritation, as they try to limit the activities of patients, inappropriate contacts, unjustified spending of money). During the period of mania there is an improvement in memory. So, a 65-year-old patient with a long course of affective psychosis (43 years) and a significant decrease in memory in remission in a hypomanic state remembered the smallest details of life in besieged Leningrad, as well as a number of episodes during severe affective attacks, which, as the doctors assumed, she completely amnesiac.

If it is especially difficult for a patient with depression to make decisions, to make a choice, then with mania, categorical judgments appear, decisions are made without reflection and attempts are immediately made to put them into practice. Serious problems facing patients seem simple, easily resolved. Combined with the disinhibition of drives, this sometimes leads to ill-considered actions that can become the subject of painful experiences and ideas of guilt when depression sets in. Sometimes one can only guess about a shallow manic state suffered in the past only by the unexpected ease with which a restrained and modest person entered into intimate relationships, broke off old stable relationships, trying to start new ones, changed jobs or places of study, etc.

Elevated mood is one of the main components of a manic syndrome. In English literature, the term "euphoric mood" is often used to refer to it. This term seems to be unfortunate, since euphoria means high spirits, characterized by contentment, complacency, ease of perception of life, uncritical judgments and can arise as a result of intoxication, unexpected luck, and sometimes with severe overwork. Euphoria is not accompanied by the vital sensation of strength, energy, cheerfulness, clarity of thought characteristic of mania (the latter refers to mild manic states). In this sense of vitality, the manic affect differs from euphoria or situational joy, just as vital melancholy differs from ordinary sadness, sadness, grief. In its purest form, manic affect is characteristic of "solar mania": depending on the severity of the mania, it manifests itself in a range from a slight increase in mood to an ecstatic feeling of happiness.

In some patients, manic affect is combined with anger and irritability. Anger is manifested either by short flashes that occur when the patient's wishes and intentions are opposed or disagreed with him, or is permanent, present throughout the entire phase (“angry”, “irritable”, “groaning” mania). Often anger and irritability are quite labile. They come on easily but subside relatively quickly. Usually, a manic patient's outburst of anger is easily prevented or extinguished by diverting his attention to another subject, simply joking, or continuing to maintain a benevolent tone. Occasionally it happens that a manic patient tries to hit the doctor, but this, as a rule, indicates the psychiatrist's lack of ability to feel the patient's condition rather than the directed aggressiveness of the patient.

Much less often, manic affect is combined with anxiety. In patients with MDP, this only happens during rapid phase changes, usually during the transition from depression to mania. Sometimes such a state is combined with slight confusion, some misunderstanding of the surrounding situation. As a rule, the duration of such episodes is no more than a few days or hours. They are pronounced and prolonged in patients with schizoaffective psychosis.

Thinking is characterized by an accelerated pace and increased distractibility, switchability. With moderate mania, there is distractibility by external associations, with severe mania, to a greater extent by internal ones. In typical cases, the acceleration of the pace of thinking and distractibility develop in parallel. As the severity of the mania increases, the pace of thinking accelerates and, at the height of the attack, it can take on the character of a jump of ideas. At the same time, the speech of patients is disorganized to an even greater extent than thinking, since the patient does not have time to finish a phrase, even a word, since the speed of speech inevitably lags behind the pace of thinking and the speed of changing ideas. With the extreme severity of the disease state, the so-called mania furibunda, thinking is characterized by a "whirlwind of ideas", disorganization, up to a complete lack of understanding of the situation, which is perceived fragmentarily. Speech becomes incoherent, the patient is in a disorderly, chaotic movement, the face is inflamed, the voice is broken, hoarse.

Usually manic affect, accelerated thinking and distractibility correspond to each other in severity. However, sometimes the speed and especially the switchability of thinking lag behind the rest of the symptoms of a manic syndrome. It seems that it is in these cases that angry mania arises: if usually a manic patient, encountering opposition, gets irritated, but is immediately distracted by another topic or action without even having time to express dissatisfaction, then a patient with relatively torpid thinking cannot be distracted so quickly and a reaction of anger and irritation develops.

Indeed, among patients with angry mania, there are more often persons with previous organic brain lesions and personality changes of an organic type, as well as a group of patients with bipolar TIR, among whose relatives there were epileptics, and they themselves had features of epileptoidness in the intermission. However, we could not reliably confirm this observation, since there were often patients with typical solar mania, with obvious signs of organic damage to the central nervous system, and according to P. Dalen (1965), in patients with bipolar MDP, neurological, EEG- and PEG studies revealed a rather severe neurological pathology. Obviously, this issue requires further careful study.

It seems that ideas of grandiosity, which used to be given great importance as an important diagnostic criterion for mania, have become less common and diminished in recent decades. Perhaps this is due to intensive therapy, perhaps it is the result of pathomorphosis, which is also observed in delusional states of a different origin. In some cases, it is difficult to distinguish whether certain actions and statements of the patient are due to ideas of grandeur or frivolity inherent in mania, a desire to joke, have fun and lack of self-control.

So, one patient managed to get into the dressing room of the theater, take a hussar uniform intended for some kind of operetta. Having changed into it, he went to the place where the motorcade of the head of one of the eastern states was supposed to pass. Dressed in an unusual bright uniform, he stopped a passing car, explained to its owner that he was a bodyguard and head of security for the arriving guest, but his car broke down. Having transplanted the driver, he himself got behind the wheel and rushed along the avenue in front of the cortege at high speed. Soon he crashed the car, and during the arrest it became clear that he was mentally ill. Once in the hospital, he explained that he was well aware that he was not an officer of the special services, but he was just having fun and wanted to "throw something out."

In the same way, when decorating themselves with medals, sham orders, etc., patients are not necessarily convinced of their merit or high rank. They just want to draw attention to themselves, stand out from the crowd. Sometimes such behavior has a peculiar character of a semi-game: on the one hand, the patient understands that he is not a hero, a great poet or general, but on the other hand, having entered the role, he begins to partially believe in it.

In general, with moderate mania, activity is purposeful and productive, and only in a rather serious condition does it lose it. A characteristic sign of motor excitation in mania is the absence of fatigue or its insignificance in comparison with the expenditure of physical energy that accompanies the patient's activity. Sleep disturbance up to insomnia is also characteristic of mania, and, unlike insomnia in depressive patients, it does not cause fatigue and weakness in the morning, a feeling of "lack of sleep". Among other manifestations of mania, an increase in libido, sympathotonia (increased heart rate, respiration, etc.) are noted, but it is often considered as a consequence of motor excitation.

Thus, the main signs of mania are high spirits, an increase in the level of interests and sociability (with severe mania, poorly differentiated), disinhibition of drives, and psychomotor agitation. The latter requires clarification, since, as P. A. Ostankov noted in his monograph “Phases of Mania”, a manic patient is characterized not so much by excitement as excitability. If he is kept in isolation, in complete rest, the level of arousal may decrease, but as soon as he gets into an environment where there are many irritants, the manic symptoms begin to increase.

This factor is sometimes not taken into account at discharge from the hospital: it seems that the manic symptoms are almost completely stopped, the behavior has become quite ordered, and hypomania manifests itself only in a slightly elevated mood. However, after a few days, the manic excitement builds up again, leading to re-hospitalization. Usually, the deterioration of the condition is explained by spontaneous relapse, alcoholism, discontinuation of medication, if supportive therapy was prescribed, etc. However, most often the reason is that after returning home, having met a lot of people, starting vigorous activity, the patient is exposed to a mass of irritants, which, given the increased excitability characteristic of mania, leads to an increase in psychomotor arousal, which even more pushes the patient to increase the number of contacts, expand the field of activity, etc.

As a result, a vicious circle is formed, leading to a rapid increase in the intensity of the disease. That is why, the earlier the treatment of the manic phase is started, the more effective it is and the faster it is possible to stop the manifestations of mania, since the process of “self-unwinding” of symptoms can be stopped at its initial stage. In contrast, depression responds best to treatment in the second half of the phase.

The psychopathological picture of atypical manic phases approaching clinically to mixed states is much more complicated. In these cases, elevated mood is combined with short-term periods of anxiety or alternates with them. Sometimes patients for a short time begin to complain about various difficulties and failures and even cry, then the mood rises again or anger, irritability arise, threats, swearing, and complaints fall upon the medical staff. After a while, the patient laughs again, talks about his virtues, pours out promises of various benefits, etc. In general, periods of high mood or high mood combined with anger predominate in duration. All these mood changes occur against the background of speech and motor excitement, only occasionally replaced by short periods of calm, a sharply accelerated pace of thinking and distractibility. Such conditions often occur during prolonged multi-month phases, and manifestations atypical for mania gradually increase, reaching a maximum in the middle or in the second half of the attack.

Atypical manic symptoms also occur in shorter phases, but usually in patients with many years of MDP and a large number of depressive and manic states. Often these patients had organic diseases of the nervous system, brain injuries in the past, and neurological pathology is detected during the examination. Older patients with such manifestations of mania usually have severe cerebral atherosclerosis. Obviously, the long course of affective psychosis contributes to the more rapid development of atherosclerosis, which was noted by E. Kraepelin. Such atypical manic states resemble mania in senile patients: emotional lability, elements of anxiety, etc., however, they differ in a much greater intensity of affective disorders and resistance to therapy.

As you know, the onset of depression the patient feels and realizes before others begin to notice it. With the development of mania, the situation is the opposite: the patient considers himself "healthier than ever", and relatives immediately recognize the beginning of the phase. However, in children, people around and even parents often mistake manifestations of mania for "bad behavior" or "childish gaiety."

Manic states in children are much less studied than depression, perhaps because they are less common. The age when formalized, harmonious in terms of symptoms of mania occurs is considered to be 20 years. However, E. Kraepelin (1904), describing patients with manic-depressive psychosis, noted that in 0.4% of the patients he observed, the disease began before the age of 10 and was expressed in a manic state. The possibility of mania in preschool age is still disputed by many researchers, although such early depressive states are now recognized. Descriptions of individual patients or small groups (2 ... 4 cases) are published. It is believed that manic states in children are similar to adult mania, but the symptoms of this disease in children have a number of features.

W. Weinberg and R. Brumback (1976) consider euphoria, excitability or agitation, hyperactivity, verbosity (“flow of speech, speech pressure”), flight of thoughts, ideas of superiority, sleep disturbances, distractibility as mandatory signs of a manic state in children. Elevated mood - the first of the three main symptoms that determine the manic state of adults, in children is not the main diagnostic sign, since childhood is generally characterized by cheerfulness and gaiety. However, in a manic state, this high spirits reaches a particularly high level; besides, it is vital, i.e., the gaiety of the children is inexhaustible, it does not fade from fatigue or the opposition of adults. Another affect - anger - is rare in manic children (correspondingly, angry mania is also rare).

If the increase in mood is hardly noticeable, but other manifestations of mania are present, then this type of manic state is referred to as "excited mania" [Lomachenkov AS, 1971].

Children in a manic state sometimes give the impression of being foolish. It must be remembered that most children in a good mood are prone to jokes, playfulness, even buffoonery, clowning. With an increase in mood, these features should not in all cases be regarded as heboid with the assignment of the disease to schizophrenia. Capturing the attitude of others to his buffoonery, a quick reaction, restructuring, a change in the content of statements distinguish a clowning manic child from a foolish schizophrenic, who, with visible cheerfulness, is much more autistic and monotonous. And yet it is often difficult to give a correct assessment of this shade of foolishness.

As you know, the heboid syndrome is characterized by a pronounced disorder of desires, which manifests itself in gross sexual perversions, a sadistic desire to hurt others, getting pleasure from causing pain or causing disgust and disgust with their actions in relatives (for example, these children rummage through garbage cans, bring home and they lay out various garbage in some special order on the carpet or collect worms and cut them into pieces with scissors at the dinner table, etc.).

Attraction disorders in children in a manic state are devoid of perversity, gross heaviness and monotony. Appetite is increased, pugnacity, aggressiveness - also, but everything is subject to rapidly changing streams of ideas, distractibility does not allow anything to be completed. A child can eat 1.5 kg of sausages at once, several cans of jam, but in another situation he does not remember food during the day; can cause serious injury to a random offender, but not notice the hail of blows that fell upon him.

In a manic state, if it has reached an extreme degree, despite disinhibition, an accelerated train of thought, children retain their usual self-service habits, elements of upbringing, cultural skills; in a geboid state, personality changes, emotional flatness and perversion begin to appear very soon.

Heboid syndrome occurs in children of school age. At a younger age from R / 2 years [Kovalev V.V., 1985], the manic state must be differentiated from the hyperactivity syndrome (hyperkinetic), which is expressed in a complex of behavioral disorders, including general motor restlessness, restlessness, fussiness, an abundance of unnecessary movements, lack of focus actions, impulsiveness of actions, increased affective excitability, emotional lability, inability to sustained concentration of attention [Golubeva V. L., Shvarkov S. B., 1981]. Most often, this condition manifests itself in preschool and primary school age.

It differs from mania in the absence of a stable joyful mood, quickness of thinking. Manic children tenaciously capture the details of their surroundings until they are distracted by some next impression; hyperactive children have constantly reduced working capacity, slow pace of thinking, their memory is usually reduced. Although distractibility leads to a decrease in school performance, manic children, in the face of a general background of poor study, can suddenly give a brilliant answer, speak out brightly and witty. In a hypomanic state, when distractibility has not yet reached a significant degree, performance in oral subjects even improves (due to self-confidence, the rapid emergence of associations, children seem "wiser", their mental life is richer).

A child with hyperkinetic syndrome, like a hypomanic one, is always on the move, wakes up early and falls asleep late, takes one thing or another, hands constantly twist something, roll it on the table, stamp their feet or they chat with them; everything that lies on the doctor's table is picked up, examined without much understanding of the essence, shifted from place to place. With their fussiness, they annoy other people, conflicts arise. There is no joyful animation with which a manic child infects others.

Hyperkinetic syndrome occurs in children as a long-term consequence of organic brain damage, often minor, i.e., minimal brain dysfunction, and gradually smoothes out after 14 ... 15 years. There is no phase during the course of the disease, but periodic worsening of symptoms can occur under the influence of external concomitant hazards (somatic diseases, mental stress), which can give the impression of emerging manic phases.

Thus, the definition of manic syndrome in children presents significant difficulties. It occurs both in MDP and in periodic schizophrenia or schizoaffective psychosis. Since there is a lot of atypicality in the structure of the manic state in children (folly, behavioral disorders), only a thorough study of the characteristics of thinking allows us to decide in which disease mania arose. Thinking in mania is accelerated, speech lags behind the flight of thoughts and often gives the impression of being broken, therefore, in order to get a correct idea of \u200b\u200bthinking, it is necessary to return to the question asked several times, to examine against the background of the action of tranquilizing substances, neuroleptics - then structural disorders of thinking, the presence of which it was difficult to guess when the patient was agitated, long-winded. The following case history may serve as an example.

Vova K. First admission to the hospital at the age of 12. History: mood swings in the mother. The boy grew up active, sociable, studied well. 2 months before hospitalization, he was in a pioneer camp, became sad, stopped participating in general activities, did not sleep well, thought that his school work was “bad”, he could not cope with the study of the German language. The mother took the boy home, and a week later his usual cheerful tone was restored. He was again sent to the camp for the next shift, by the end of his stay there his mood worsened, he “burned in his chest”, he thought that he would not be able to become a real helper for his mother, since school was not going well. He believed that such a mood arose after a meeting with his mother, who shared with him the difficulties that arose in relations with colleagues. I went to school, but, having studied for two days, on the third I could not force myself to get up in the morning, I was withdrawn and gloomy. In the department - a typical depressive state with a good analysis of experiences: "dreary", horror at the thought that "he has become stupid, his memory has disappeared", "ashamed in front of his mother", "did not live up to expectations." He constantly returns to the idea that he will not be able to master the German language according to the school curriculum. As a result of treatment with amitriptyline, the state changed, became more animated, became talkative, then the mood improved, in the department here and there his sonorous voice was heard, he told something, taught someone, was good-natured, laughed witty, but kindly at those around him , began to strive to return to school, it seemed that he would master everything, there was no need to just waste time. The appearance changed: the hair was carefully combed to one side, the bangs were wetted, the corner of the handkerchief was sticking out of the pocket, the sports trousers were rolled up, giving the appearance of shorts. The speech was at an accelerated pace, but it seemed logical. Once, he casually mentioned that something had happened to his vision, but he could not understand what it was because of the verbosity in the explanations. In connection with this, the boy (although before that nothing gave reason to doubt the diagnosis of MDP) was interviewed after the administration of Seduxen, when the distractibility decreased, and then several more times carefully at different stages of the reduction of the manic state. It turned out that already in the period of the second depression, thoughts arose that a friend of his mother, whom he had previously disliked, was acting on him. Now he experienced some kind of influence on himself, which either accelerated or slowed down his thoughts, or the imperative words “Get up! sit down! These sudden risings during a conversation attracted attention before, but were considered a manifestation of motor excitement. One day, "alien thoughts" appeared when I was sitting at the doctor's desk in the intern's room and looking out the window. The setting sun illuminated the background of the opening landscape, it seemed that what was far away was brighter than close objects; this, together with "other people's thoughts," seemed to be the result of the mother's friend's witchcraft. With an accelerated pace of thinking, the boy could not retell everything at once, there was not enough time to put everything into complete phrases, and he only declared to the doctor: “something is happening with vision.” Subsequently, after several affective phases, personality changes in intermissions and an increase in delusional symptoms confirmed the diagnosis of schizophrenia (8-year follow-up).

If there are no changes in thinking, delirium, the diagnosis helps to make a rapid emotional and volitional impoverishment, which manifests itself even during a manic rise in mood and activity.

Igor Ch., born in 1967. I fell ill at the age of 11, suffered a short, rather typical depression. He got to the hospital a month later in a state of excitement: he is cheerful, he has a mischievous smile on his face, his voice is sonorous, he gets to know everyone at once, easily puts up with various procedures, injections, a ban on leaving the ward, remains in a great mood, bows to the doctors, takes help nurses in cleaning, immediately finds a replacement among other guys, orders, does not take offense if he hears an angry remark in response, speech is fast; often does not finish the phrase, uses interjections or some meaningless exclamations for expressiveness, but does not go beyond the bounds of decency; in behavior, statements, the intellect and culture of a boy of his age and upbringing are manifested. Two years later, in the same manic state - obscene language on every occasion; if he starts a fight, he does not take into account those who are trying to keep him, turns over the furniture, not noticing that he has hit the doctor, pushes the nurses aside, still talks a lot, but the statements are monotonous. By the age of 18, the disease loses its phase character, a specific emotional-volitional defect grows, it is almost constantly in hospitals, disability of the II group is established.

These examples show that the nosological qualification of a manic state during the first attack can be difficult. Only after several manic phases have passed, the nature of remissions and the complication or persistence of symptoms in the phases allow us to stop at a specific diagnosis. We know of two patients who fell ill at the age of 14, who, by coincidence, were examined especially carefully at each exacerbation, since they came to the attention of interested specialists. They changed their diagnosis 3...4 times, until in one case they settled on schizophrenia, in the other - on MDP.

The following example illustrates a typical childhood course of TIR.

Dima G., born in 1970. Her grandmother had a history of unspecified affective postpartum psychosis. Mother's pregnancy and childbirth - without pathology. In terms of the pace of psychomotor development, he did not lag behind the age norms. He grew up active, read a lot, was fond of chess, studied at a music school. Two years before the onset of psychosis, he suffered from a cold, complicated by "infectious-allergic myocarditis", was registered with a rheumatologist, but the diagnosis of rheumatism was not confirmed. He became mentally ill acutely in the first days of September 1981. He was inadequately upset by the insult (fought with a boy, he hit him on the head), his mood was lowered for several days, he became tearful, asked questions if he would die, felt a lack of air, could not sleep. After 4 days, the state changed, he became excited, belligerent, aggressiveness was combined with cheerfulness, he talked a lot, difficulty falling asleep was replaced by complete insomnia. After treatment with haloperidol, the condition returned to normal, but a month later, when the manic phase began again very quickly, he was hospitalized for the first time. On the night of admission, he slept only 2 hours after the injection of Diphenhydramine. All the time he speaks loudly, answering questions, adding jokes to the answer, sometimes repeating the words of the interlocutor, rearranging them and making comic accents and gestures, rhymes, pronounces excerpts of poems, quotes classics of literature. His eyes sparkle, his voice, ringing at first, became hoarse by morning. He is always on his feet in the ward, he invites everyone to play chess with him, but he does not finish the game, he switches to billiards. He invariably says about his well-being and mood that it is “beautiful”. Despite the treatment with haloperidol and chlorpromazine, only on the 11th ... 12th day the condition improved, by the 15th day the symptoms of mania disappeared. After 2 weeks, he became lethargic, his face dimmed, then he began to say that it was difficult to think, thoughts were slow, “the head does not work well”, everything faded around, the guys had “swollen faces”, “everyone is crying so much that he himself wants to cry.” The depressive state lasted 5 days, after coming out of it the boy began to take lithium carbonate, which he still receives. Soon there was another episode of high spirits, the boy did not even pay attention to the fact that his home leave was canceled in connection with this, he was pleased with everything, talkative. Subsequently, no clinically pronounced affective fluctuations occurred for 3/2 years. The boy returned to his school, to all his former hobbies. He studies well, he moved to the 9th grade. Has many friends, actively participates in the extra-curricular life of the school.

Thus, the diagnosis of MDP in this case was confirmed by a four-year follow-up.

Manic-depressive psychosis (circular psychosis, cyclophrenia) is manifested in typical cases by recurring manic and depressive phases. Attacks of the disease are usually separated by periods of complete mental health (intermissions). Women make up 70% of all patients with manic-depressive psychosis.

Despite long-term studies, the cause of this psychosis is still not clear enough, however, in 80% of cases, a hereditary burden with data, as well as other mental illnesses, is revealed.

The manic phase is manifested by three main clinical signs: increased, joyful mood, acceleration of intellectual processes, speech and motor excitement. These symptoms typically determine the patient's condition throughout the manic phase. Everything around is drawn to the patient in attractive colors, attention does not linger for a long time on unpleasant events that are even directly related to the patient. Patients do not take into account the mood of others and therefore often become tactless, importunate, elevated mood and reduced criticism are accompanied by a reassessment of their own personality. Ideas of greatness are usually reduced to boastful, unsystematized and changing in content statements about one's own talent, wit, external attractiveness, great physical strength, etc. There may be an improvement in memory for the past, accompanied by a violation of memorization. In this state, patients often make unreasonable and unrealistic promises, commit theft, embezzlement to satisfy the numerous desires that arise. The manic state is also accompanied by disinhibition and increased drives (food, sexual). Of particular importance is sexual arousal, manifested in sexual promiscuity. Sexual disinhibition is aggravated by the intake of alcohol.

According to the severity of the manic syndrome, there are: a mild (hypomanic) state, a pronounced manic state described above, and a sharp manic excitement (fury), in which a state of confusion may develop, accompanied by aggressive, destructive actions directed at everything around.

The depressive (melancholic) phase is, as it were, the opposite of the manic phase in terms of clinical manifestations: it is characterized by a low, dreary mood, slowness of intellectual processes and psychomotor retardation. Longing can become "hopeless", accompanied by subjective feelings of indifference to the health and fate of their loved ones, which patients are especially hard on, tormented by thoughts of their own callousness, callousness. The depressive phase is characterized by delusional ideas of self-accusation, self-abasement, sinfulness, the content of which can be determined by an overvalued attitude to minor misconduct in the past. Patients often make suicide attempts, which are all the more unexpected for those around them, the less pronounced the clinically depressive state of the patient and the more carefully suicidal thoughts and intentions are dissimulated.

It is also possible the so-called extended suicide - the killing of members of one's family, and then suicide. Patients commit such acts in order to “save everyone from the coming torment or shame”, in the inevitability of which they experience unshakable painful confidence. Psychomotor retardation can sometimes be interrupted unexpectedly by a melancholy frenzy, which manifests itself in a sharp excitement with a desire to injure oneself: patients try to throw themselves out of the window, beat their heads against the wall, scratch and bite themselves.

Mixed states are often found in the clinic of manic-depressive psychosis. They are characterized by a certain combination of manic and depressive features in one patient and occur more often during the transition from one phase to another. Depending on the combination of components of various phases, inhibited, unproductive mania, manic stupor, etc. are distinguished.

Cyclothymia is a mild, mild form of manic-depressive psychosis and is more common than its severe forms. Symptoms are not sharply outlined, which makes it difficult to timely recognize the disease.

In the hypomanic phase, patients, due to a slightly elevated mood, desire for activity, verbal animation, interfere with others, are undisciplined, take absenteeism, show a tendency to waste, revelry, sexual promiscuity.

In the depressive phase of cyclothymia (subdepressive state), patients experience some depression, melancholy, decreased performance, lethargy, which is accompanied by a decrease in activity and labor productivity. There is a tendency to self-accusation, they often make suicide attempts, for those around them in most cases unexpected, since no one noticed the disease before.

The course of the disease and prognosis. The frequency of the phases is very diverse, which makes it difficult to predict the further course of the disease. The duration of attacks ranges from several months (one or two) to a year or more. The prognosis of a single attack is favorable. The attack ends with recovery without any mental defect.

clinical observation. Subject V., 34 years old, is accused of hooligan actions.

He grew up and developed without peculiarities, by his nature from childhood he was cheerful, kind, sympathetic, but quick-tempered. There were unmotivated fluctuations in mood towards a lower one. At the age of 22, without any apparent external reason, for several days he was depressed, melancholy, sought solitude, began to say that he was not coping well with the assigned work, and expressed thoughts of suicide. This state lasted about a month and was replaced by an elevated mood, when he became boastful, laughed out loud, handed out his things to his neighbors, made unnecessary purchases in stores, visited restaurants that he had hardly gone to before, began to build a garage without having a car. Didn't go to psychiatrist. Gradually, the mental state returned to normal, the mood leveled off. About three years later, a depressed mood with lethargy developed again. There was no desire to go to work, to communicate with others. He began to avoid family and friends. He was placed in a psychiatric hospital, where he stayed for 3 months, and was discharged with a diagnosis of "manic-depressive psychosis, depressive phase." After being discharged, he continued to work. After 3 years, the mood became elated, I felt a surge of "physical and mental strength", I decided to "earn a lot of money", I left for the neighboring region, where I got a job in a carpenter brigade. However, after a few days, without explaining anything to others, he left his things and returned to his place of permanent residence. There was an increased mood, verbosity. As can be seen from the materials of the criminal case, in a state of alcoholic intoxication he went to his acquaintances, began to make incomprehensible claims to them, cursed obscenely, and was aggressive. When detained by police officers, he was excited, sang loudly, recited poetry.

During the forensic psychiatric examination, no pathology was found in the internal organs and the nervous system. Oriented correctly, willingly enters into a conversation. He starts talking immediately, without further questions. He is verbose, easily distracted, jumps from one thought to another, gesticulates in a sweeping manner. He does not consider himself sick. No health complaints. He calls himself a man of moods. He says that life seems beautiful to him, he wants to sing, dance. In the department, he is mobile, talkative, interferes in the conversations and affairs of others. When questioned about the offense, he willingly talks about what happened, reads poems in which he jokingly outlines his life. It is not critical to the current situation.

By the decision of the forensic psychiatric expert commission, he was recognized as suffering from a chronic mental disorder in the form of manic-depressive psychosis. With regard to the act incriminated to him, committed in the indicated morbid state, he was declared insane. Compulsory treatment in a general psychiatric hospital was recommended.

Forensic psychiatric evaluation. Manic-depressive psychosis often presents difficulties in terms of forensic psychiatric evaluation. Difficulties arise when forensic psychiatric experts have to determine the extent of the patient's affective (emotional) disorders. If the patient has an exacerbation of the disease with the development of a psychotic attack (both depressive and manic) during the period related to the act incriminated to him, the ability to adequately assess his mental state and the current situation is lost, to critically comprehend the essence and consequences of his actions, to control his behavior generally. In a state of manic excitement, patients can insult others, commit aggressive actions against them, and various ridiculous acts. Due to the increased sexual excitability in such states, these individuals can commit indecent acts and rape. Along with this, the occurrence of perversions (exhibitionism, homosexual tendencies, etc.) is possible, which were not characteristic of patients before and which disappear along with an attack of the disease. Socially dangerous acts committed during a psychotic attack entail insanity. With a less pronounced manic state (for example, with cyclothymia), patients can enter into illegal transactions, commit embezzlement, and violate labor discipline. They often end up in a forensic psychiatric examination as victims.

In the depressive phase of manic-depressive psychosis, patients are less likely to get a forensic psychiatric examination. Usually they are accused of criminal negligence, sometimes banal theft. They tend to attempt suicide or extended suicide. These actions are usually committed in a state of psychotic depression, when against the background of a depressed mood, a feeling of deep melancholy, depressive delusional ideas of self-accusation and self-abasement, suicidal thoughts arise, delusional thoughts of depressive content (that life has come to a standstill, the world is collapsing, therefore relatives, especially children, need kill to get rid of torment). Patients who have committed socially dangerous acts during a period of psychotic depression are also recognized as insane.

Post-mortem forensic psychiatric examination in connection with suicide often reveals that people who committed suicide without any external reason had a depressive phase of manic-depressive psychosis.

In cases where the patient has already left the psychotic state by the time the expert decision on insanity is made, and the signs of mental illness are at the subclinical level, it is advisable to recommend that this person be prescribed compulsory outpatient observation and treatment by a psychiatrist. In order to prevent re-offending, such patients should, at the very first symptoms of a new psychotic phase of manic-depressive psychosis, be placed in psychiatric hospitals on the principles of involuntary hospitalization, followed by the resolution of relevant legal issues.

Persons who have committed offenses in the "bright interval" (the state of intermission) are recognized as sane.

In civil proceedings, it is also often necessary to resolve expert issues in relation to persons suffering from manic-depressive psychosis. These persons, being in the manic or hypomanic phases, can make property transactions, housing exchanges, and marry. If such civil acts are committed during the psychotic phase, then a conclusion is made that the patient, due to his mental disorder, could not understand the meaning of his actions and manage them during that period, and the concluded legal acts are considered invalid.

Great difficulties arise in the examination of persons suffering from cyclothymia (a mild form of manic-depressive psychosis). In these cases, a thorough analysis of objective data on the condition of the subject at the time of the offense and the characteristics of the course of the disease as a whole is required. The solution to the issue of sanity in these cases is determined by the depth of the observed disorders of the mental state, which in the same patient at different cyclothymic phases can be different.