The Stages of Mania
`A Longitudinal Analysis of the Manic Episode
`Gabrielle A. Carlson, MD, and Frederick K. Goodwin, MD, Bethesda, Md
`
`The progression of symptoms during an acute manic episode was
`studied retrospectively in 20 bipolar manic-depressive patients
`whose diagnosis was reconfirmed at follow-up. Three stages were
`delineated, the most severe of which was manifested by bizarre be-
`havior, hallucinations, paranoia, and extreme dysphoria. Despite
`symptoms that might have otherwise prompted a diagnosis of schiz-
`ophrenia, patients appeared clearly manic both earlier in the course
`and later as the episode was resolving.
`The level of functioning was ascertained at follow-up and com-
`pared statistically with the level of psychotic disorganization during
`the acute manic episode; no relationship was found. The advantages
`of using a longitudinal view of a psychotic episode as a diagnostic
`tool
`is discussed.
`
`In the course of longitudinal studies of manic-depres¬
`sive illness during the past seven years we have
`frequently observed periods during the patient's manic
`episode when his symptoms appeared to be indistin¬
`guishable from those of acute schizophrenia. Because of
`the recent availability of lithium carbonate for the acute
`and prophylactic treatment of mania,1·2 the task of recog¬
`nizing this illness and differentiating it from schizophre¬
`nia has assumed renewed importance.
`We have attempted to investigate systematically the
`course of the manic episode in 20 patients who by strict
`diagnostic criteria were considered on admission to have
`manic-depressive illness, who had a complete manic epi¬
`sode at some time during hospitalization, and in whom the
`diagnosis of manic-depressive illness was confirmed on
`follow-up. The date reviewed suggest that the occurrence
`of "schizophrenic-like" symptoms during the manic epi¬
`sode in some patients does not differentiate them diag-
`Accepted for publication Oct 11, 1972.
`From the Section on Psychiatry, Laboratory of Clinical Science, National
`Institute of Mental Health, Bethesda, Md.
`Reprint requests to Clinical Research Unit, Section on Psychiatry, Labo-
`ratory of Clinical Science, National Institute of Mental Health, 9000 Rock-
`ville Pike, Bethesda, Md 20014 (Dr. Goodwin).
`
`nostically or prognostically from manic patients without
`such symptoms.
`
`Methods
`Prior to admission to either of two metabolic research units at
`the National Institute of Mental Health (NIMH), patients were
`screened for primary affective disorder by at least one psychia¬
`trist and a psychiatric social worker. Patients were referred by
`private psychiatrists or mental health clinics, generally from the
`Washington, DC, area. The referral sources were aware of our
`group's interest in affective illness and of the free inpatient treat¬
`ment available at NIMH. More specifically, referrals were stimu¬
`lated by the availability of lithium carbonate through our pro¬
`gram.
`Twenty consecutively admitted patients were selected for this
`study on the basis of having participated in an ongoing follow-up
`reexamination of manic-depressive patients and having had at
`least one complete manic episode during hospitalization. A com¬
`plete manic episode is one in which patients proceed from a de¬
`pressed or normal mood state, thru mania, and returning to a de¬
`pressed or normal state while hospitalized, so that the entire
`course was observed. The manic episodes under study averaged
`four weeks in duration. The total length of hospitalization (aver¬
`aging four months) was longer than is usual for affective illness—a
`consequence of the fact that the research protocols involved long
`periods off medication. In addition, some patients were kept in the
`hospital through more than one manic or depressive episode.
`The diagnosis of bipolar affective disorder was based on a his¬
`tory of relatively good premorbid adjustment, a history of previ¬
`ous episodes of mania and depression, no history of personality
`deterioration, and symptoms compatible with the diagnosis of
`mania or depression at the time of admission.3 Though not re¬
`quired for the diagnosis, patients frequently had a family history
`of affective disorder. Special care was taken to exclude patients
`whose histories were suggestive of schizophrenia, particularly pa¬
`tients with any of Schneider's first-rank symptoms of schizophre¬
`nia (experiences of alienation, thought insertion, thought with¬
`thought broadcasting, persistent feelings of
`influence,
`drawal,
`complete auditory hallucinations, and delusional perceptions).4
`Hospital Study.—The manic episode was first identified by using
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`
`Table 1.—Excerpts From Daily Nursing Notes, Including Patient Verbalizations
`Stage II
`Stage I
`like talking" and does so,
`Hypersexual, bizarre (wearing 3 dresses
`'Now I feel
`increasing intrusiveness and irri¬
`at a time), screaming, angry, delusion;
`tability, flight of ideas, restless;
`in control but frightened that other
`"I'm not feeling so depressed."
`patients are against her; grandiose,
`incessant talking.
`
`'I'm going higher than a Georgia Pine.
`I'm going to fly tonight. I could
`kill you."
`
`Pacing, manipulative, religious; says he
`can't trust people; crude, hypersexual,
`assaultive; wants to be King Kong;
`grimaced and postured as if anguished;
`felt "life on the unit is designed to
`test my tolerance."
`
`Hyperactive, pressure of speech, sarcastic,
`playful; "I'm having a ball."
`Talks of spending $3,000,000.
`
`Took bath in nightgown, yelling, crying,
`laughing, throwing food, threatening,
`combative.
`
`"I'm excited but I don't think I'm
`worried about anything." Later,
`"You'd rather have me on top of the
`table than under it wouldn't you?"
`Somewhat labile, good frame of mind,
`very busy.
`
`Talking about big plans for Christmas
`party; very loud, profane, almost
`assaultive, slightly paranoid, very
`inappropriate telephone use (calling
`people to solicit money.)
`Hypersexual, hyperverbal, hyperactive,
`suspicious; very angry, assaultive,
`obscene; banging urinal on door; wanting
`to use phone to buy stocks._
`
`Stage III
`Very frightened, talking and crying
`constantly, pacing. "I'll never get
`out." "I have cat eyes. He crawls
`around inside me and he can't stand
`the light." Profane, hypersexual, un¬
`cooperative. "Oh please let me die.
`I can't take it anymore." "National
`Institute of Hell."
`Much pacing, grimacing, and bodily shak¬
`ing; slaps self on arms; afraid of
`dying. "They're going to cut out my
`heart." Afraid of being given TNT;
`thought there was special meaning
`when his doctor pointed a finger at
`him; running up and down hall making
`animalistic noises.
`Throwing things, exposing herself, try¬
`ing to escape, parading around in
`flimsy pajamas crying, "even God has
`given up" and later, "I'm dying. The
`radioactivity has made my hair
`straight." Voided on the seclusion
`room floor.
`
`global mania ratings for each patient; these global ratings were
`obtained twice daily by consensus of the nursing research team.
`This method of evaluation, originally designed to measure depres¬
`sion,5 has been revised to include a global mania item." The epi¬
`sode was analyzed if the mania rating averaged at least 4 over
`three consecutive days (equivalent to a moderate degree of mania,
`ie, hypomania).
`Additional corroboration of the manic nature of the episode was
`obtained from the psychiatrists' and nurses' written descriptions
`of the patient's affect, psychomotor activity, and cognitive state.
`Using these daily written observations, we recorded the sequence
`of symptoms from the beginning to the end of the episode, specifi¬
`cally following longitudinal changes in affect, behavior, and cogni¬
`tion. Both the nurses who originally recorded the observations and
`we who reviewed the clinical data were blind to all research or
`therapeutic medications given to these patients.
`Follow-Up Study.—Follow-up data described in detail elsewhere
`(Carlson GA et al, unpublished data) were obtained independently
`through two-hour systematic interviews with the patient and
`most significant family member available (spouse, sibling, or par¬
`ent) without prior knowledge of the patient's course during hospi¬
`talization. A 200-item questionnaire was used which focused on
`job status, changes in family and social relationships, mental
`status, further hospitalization, and the status of psychiatric treat¬
`ment. The degree of return to premorbid level of function was as¬
`sessed by scoring each patient's job status, social function, and in¬
`terpersonal relationships at the time of interview as compared to
`those parameters before the first episode of manic-depressive ill¬
`ness. The scoring method was the following:
`Areas of Functioning Rated at Follow-Up
`Job Status
`4—Return to the same or better job with same
`
`responsibilities
`3-Return to full-time work but in position of
`lesser status
`2-Employed irregularly or works around the home
`1—Sustained unemployment
`Interpersonal and Family Relationships
`4—Patient and family satisfied
`3—Family less satisfied but tolerant
`2-Family dissatisfied but together
`1—Family disruption due to illness
`Social Function
`4—Normal social function
`3-Some social withdrawal
`2—Moderate social withdrawal
`1-Complete social withdrawal
`Mental Status
`4-Completely normal
`3-Very mild affective symptoms
`2—Obvious affective symptoms
`1—Symptoms requiring constant care
`These points were totaled and the patients were ranked from
`best to worst functioning. These rankings and the rankings of the
`severity of the acute manic episode (as measured by the extent of
`progression towards psychotic disorganization) were compared
`using Spearman's rank order correlation technique.
`
`Results
`Patients had an average age of onset of first episode at
`28 years with a mean of 4.4 manic episodes and 2.2 depres¬
`sive episodes over an average of 12.3 years. These de¬
`mographic data are summarized below:
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`
`15
`
`12
`
`9
`
`Dysphoria
`tr
`O-
`
`IT
`
`,,
`
`/
`
`Mania
`
`
`
`
`
`e1
`rr
`"co
`a>coe
`
`3
`
`Hospital
`Days
`
`93
`
`95
`
`A little
`pressured
`speech,
`somewhat
`tangential,
`hyperactive,
`happy
`
`Brought too
`many clothes
`from home,
`paranoid,
`hyper-religious,
`hyperverbal,
`pacing,
`numerous
`telephone
`calls,
`grandiose
`
`Quieter.
`Still paranoid
`but more cooperative,m°re organized,
`overtalkative
`restless,
`seductive,
`hypersexual,
`still
`manipulative,
`depressed
`still angry,
`makes telephone
`calls
`
`Appropriate,
`realistic,
`showing concern
`for
`others
`
`Hyperverbal,
`delusional,
`"has x-ray
`vision,"
`talking with
`dead father,
`panicked—
`afraid he
`might
`blow
`up, labile,
`suspicious,
`sexually preoccupied
`occasionally disoriented
`unable to complete a
`thought, very angry
`Fig 1.—Relationship between stages of a manic episode and daily behavior ratings (patient 69).
`
`Demographic Data
`Men, 10
`Women, 10
`Sex
`Age of onset
`Average 28 (range 17 to 57)
`No. of episodes Average 6.6 (range 1 to 20)
`1 to 3 episodes 8 patients
`4 to 6 episodes 4 patients
`7 episodes
`8 patients
`(including 2 patients
`or more
`with frequent, severe,
`alternating manic and
`depressive episodes)
`Frequency of episodes
`Mania—4.4 per patient
`Depression-2.2 per patient
`Duration of illness
`Average 12.3 years (range
`3 to 31 years)
`Family history of affective disorder (either parent, sibling
`or both treated for or incapacitated by a depressive episode,
`manic episode, or both): 15 patients (75%)
`Depression immediately prior to index mania: 6 patients
`(30%)
`
`These demographic data are similar to those derived
`from other studies of manic-depressive patients,3 suggest¬
`ing that our patients are not atypical with respect to re¬
`lapse frequency, duration of illness, and so forth.
`The patient's longitudinal course was divided into three
`stages based mainly on the predominant mood: in stage 1
`euphoria predominated, in stage 2 anger and irritability
`prevailed, while stage 3 was dominated by severe panic.
`In all 20 patients the initial phase of the manic episode
`was characterized by increased psychomotor activity
`which included increased initiation and rate of speech and
`increased physical activity. The accompanying mood was
`labile but euphoria predominated, although irritability be¬
`came obvious when the patient's many demands were not
`instantly satisfied.
`The cognitive state during the initial stage was charac¬
`terized by expansiveness, grandiosity, and overconfi-
`though sometimes tan¬
`dence. Thoughts were coherent
`gential. Also frequently observed during this stage were
`increased sexuality or sexual preoccupations, increased in-
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`Hospital
`Days
`
`13
`
`Stage I
`Talking and
`laughing more,
`more irritable,
`seductive,
`said she was
`having ideas that
`might get her into
`trouble
`
`Stage II
`Sarcastic, angry, hyperactive,
`overly pleasant
`and cheerful, manipulative,
`carrying around
`clothing, records, etc,
`"Happy Easter to you all,
`scratch, scratch,"
`provocative, suspicious,
`constant flow of chatter,
`grandiose, uncooperative
`
`Stage I
`Pleasant, overly
`cheerful, slightly
`hyperverbal, bought
`many things,
`carrying around
`quince blossoms,
`occasionally
`irritable and
`sarcastic
`
`Fig 2.—Relationship between stages of a manic episode and daily behavior ratings (patient 15).
`
`terest in religion, increased and inappropriate spending of
`money, increased smoking, telephone use, and letter writ¬
`ing. Some of the patients were aware of the mood change
`on some level and described the feeling of "going high,"
`having racing thoughts, and feeling like they were in an
`airplane. At this stage patients were not out of control.
`The second or intermediate stage was also observed in
`all patients. During this period the pressure of speech and
`psychomotor activity increased still
`further. Mood, al¬
`though euphoric at
`times, was now more prominently
`characterized by increasing dysphoria and depression. The
`irritability observed initially had progressed to open hos¬
`tility and anger, and the accompanying behavior was fre¬
`quently explosive and assaultive. Racing thoughts pro¬
`gressed to a definite flight of
`ideas with increasing
`disorganization of
`the cognitive state. Preoccupations
`that were present earlier became more intense with ear¬
`lier paranoid and grandiose trends now apparent as frank
`delusions.
` ß final stage was seen in 14 of 20 patients (70%) and
`was characterized by a desperate, panic stricken, hopeless
`state experienced by the patient as clearly dysphoric, ac¬
`companied by frenzied and frequently even more bizarre
`psychomotor activity. Thought processes that earlier had
`been only difficult to follow now became incoherent and a
`definite loosening of associations was often described. De¬
`lusions were bizarre and idiosyncratic; hallucinations were
`present in six patients; disorientation to time and place
`
`was observed in six patients during this stage; and three
`patients also had ideas of reference. The diagnosis of
`schizophrenia, at least as described by Bleuler,7 was most
`often entertained at this state. (Schizophrenia, according
`to Bleuler, was "characterized by a specific type of think¬
`ing, feelings and relation to the external world," and in¬
`cluded many nonspecific symptoms and a variable progno¬
`sis. We, however, are using the narrower concept of K.
`Schneider,4 and none of his first-rank symptoms were ob¬
`served in these patients at any time during their hospital¬
`ization.) Quotes from patients in each of the three stages
`appear in Table 1.
`The clinical material on which the staging was based is
`illustrated in Fig 1 to 3 which present individual patient
`data showing the progressive changes in the nurses' rat¬
`ings of mania, psychosis, and dysphoria (an average of the
`ratings for depression and anxiety) along with clinical
`vignettes and quotes. This material emphasizes the fol¬
`lowing points: (1) the mania ratings rise first, followed
`closely by the psychosis ratings; (2) the dysphoria rating is
`always fairly high, but as mania and psychosis increase so
`does dysphoria; (3) stage III, the most intense stage, is
`represented on the graph as a concatenation of the peaks
`of mania, psychosis, and dysphoria not observed in stage
`II patients.
`While the sequence of symptom progression was re¬
`markably consistent, the rate of acceleration was variable.
`Some patients progressed to stage III in hours, others
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`
`Ili¬
`
`ce
`CD
`CO
`
`e
`°
`
`Dysphoria, j-,
`
`XD-.
`
`Mania V'
`-4—^^^ -!^-·"
`
`•
`
`Hospital Days
`
`20
`
`'
`
`Psychosis
`
`Stage I
`
`Stage
`
`Stage
`
`Stage II
`
`Stage
`
`Distractable,
`racing thoughts,
`joking, intrusive,
`happy, can't concentrate,
`impulsive,
`hyperverbal,
`singing
`
`More manic and
`hyperverbal,
`hyperactive,
`impulsive, much
`pressure of speech,
`still responding
`to limits, racing
`thoughts, paranoid,
`grandiose, labile
`
`No sleep, religious
`delusions,
`"hearing God"
`fragmented, restless,
`confused,
`disruptive, loud,
`more talkative,
`severely agitated,
`"Going downhill at
`190 MPH," singing
`loudly, crying
`Fig 3.—Relationship between stages of a manic episode and daily behavior ratings (patient 72).
`
`Coherent, tired,
`still paranoid,
`difficulty
`concentrating,
`racing thoughts,
`depressed, labile
`
`Labile, numerous
`phone calls, feels
`good, laughing and
`joking, hyperverbal,
`irritable, changing
`moods quickly,
`insightful
`delusions and
`hallucinations
`
`took several days. All of the stage III patients, even the
`six most psychotic, passed through earlier stages where
`their symptoms were typically manic. In their decelera¬
`tion phase they again passed through stages in which they
`appeared more typically manic. Delusions and hallucina¬
`tions disappeared as mood returned to normal. Although
`treatment with antimanic agents hastened the return to a
`normal mood state, the disappearance of symptoms fol¬
`lowed the same course in both spontaneously remitting
`and treated patients.
`Hyperactivity, extreme verbosity, pressure of speech,
`grandiosity, manipulativeness, and irritability, ie, the ma¬
`nic symptoms most frequently reported in other studies,3 s
`were found in all patients. Table 2 shows the prevalance of
`symptoms. Examples of some of the delusions,
`ideas of
`reference, and bizarre behaviors are illustrated in the pa¬
`tients' quotes in Table 1. Examples of the hallucinations
`were "hearing the theme from Rawhide," "hearing the
`hallelujah chorus from the Messiah," "seeing a box open
`with beautiful flowers emerge," "seeing a kaleidoscope of
`colors running together," and "talking to my dead daugh¬
`ter."
`No significant relationship between the severity of the
`acute manic episode and the level of function to which the
`patients returned during the follow-up period were shown
`by Spearman's rank order correlations technique.
`Follow-up data per se are discussed in detail elsewhere.
`However no patient at the time of discharge or follow-up
`showed signs of persistent delusions or hallucinations. All
`
`patients showed insight, recognizing themselves as hav¬
`ing been ill and requiring help for their illness. Four pa¬
`tients who showed an abnormal mental status at the time
`of follow-up had a mental status compatible with affec¬
`tive disorder, not schizophrenia. Those patients who ex¬
`hibited symptoms of stage III mania had no greater fre¬
`quency of relapse or abnormal mental status at the time
`of follow-up than did stage II manic patients.
`Comment
`We have presented longitudinal clinical data on the se¬
`quence of symptoms occurring during the manic episodes
`of 20 patients admitted with the diagnosis of manic-de¬
`pressive illness based on the criteria of Winokur et al.3
`None of Schneider's4 first-rank symptoms of schizophrenia
`was revealed by history or observed on admission. Six of
`the patients, however, at the peak of their manic episodes
`became grossly psychotic with disorganized thoughts, ex¬
`tremely labile affect, delusions, hallucinations, and brief
`ideas of reference. Because of these symptoms the diag¬
`nosis of schizophrenia was sometimes entertained.
`Reference to schizophrenia-like psychotic symptoms oc¬
`curring during manic episodes can be found in some of the
`older literature."11 The current view as reflected in recent
`textbooks of psychiatry is that mania is a syndrome in
`which euphoria predominates and behavior and pre¬
`occupations are really secondary to the prevailing mood.
`For example, Arieti,12 Noyes and Kolb,13 and Freedman
`and Kaplan14 have briefly paraphrased Kraepelin's de-
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`
`Table 2.—Classical and "Atypical" Symptoms
`in 20 Manic Patients
`Patients Manifesting
`Symptoms, %
`100
`100
`100
`100
`100
`100
`90
`90
`80
`75
`75
`(25)
`(65)
`(20)
`(15)
`
`Symptoms
`Hyperactivity
`Extreme verbosity
`Pressure of speech
`Grandiosity
`Manipulativeness
`Irritability
`Euphoria
`Mood lability
`Hypersexuality
`Flight of ideas
`Delusions
`Sexual
`Persecutory
`Passivity
`Religious
`Assaultiveness or
`threatening behavior
`Distracti bi Iity
`Loosened associations
`Fear of dying
`Intrusiveness
`Somatic complaints
`Some depression
`Religiosity
`Telephone abuse
`Regressive behavior
`(urinating or defecating
`inappropriately; exposing
`self)
`Symbolization or gesturing
`Hallucinations (auditory and
`visual)
`Confused
`Ideas of reference
`
`75
`70
`70
`70
`60
`55
`55
`50
`45
`
`45
`40
`
`40
`35
`20
`
`scription of "delirious" mania10 but it is presented as a
`variant of the normal clinical picture in mania, given little
`emphasis, and may consequently be rarely recognized.
`Redlich and Freedman,15 and Slater and Roth16 emphasize
`that delusions are part of the grandiosity seen in mania.
`Only Henderson and Gillespie17 describe in some detail the
`bizarre and frenetic picture possible in severe mania, but
`they add that it is rarely seen.
`Before somatic treatments were available, psychiatrists
`had the opportunity to observe the natural history of the
`manic episode and their clinical descriptions and reports
`of the incidents of psychotic symptoms are of interest.
`Kraepelin's9 description of three types of mania are per¬
`haps the most thorough: acute mania, delusional mania,
`and delirious mania. His descriptions of these latter two
`types bear clear similarities to the clinical picture de¬
`scribed here. Thus in delusional mania, paranoid delusions
`and hallucinations prevail, while in delirious mania hallu¬
`cinations are numerous and the mood changes from eu¬
`phoria to "anxious, despairing thoughts of death," psy¬
`chomotor activity is "senseless" and "raving," patients
`"pass their motions under them, smear everything, make
`impulsive attempts at suicide, take off their clothes," and
`articulations are incoherent. Kraepelin, however, does not
`
`provide a longitudinal picture of the episodes he describes
`under the three "types" and it is not clear whether the
`acute "delusional" and the "delirious" descriptions apply
`to separate populations or to different phases in the same
`patients as we have described here.
`Some studies which have attempted to relate the pres¬
`ence of psychotic symptoms in mania to the clinical condi¬
`tion at follow-up are summarized in Table 3.
`Rennie, in his follow-up from the predrug era,1" has de¬
`scribed some psychotic symptoms in his manic-depressive
`patients. Although he does not say what percentage of
`those having hallucinations or delusions were manic or de¬
`pressed, he does give some examples of hallucinations, eg,
`"see something white," "saw and heard God and the an¬
`gels," "saw trees glitter like gold," "saw dead father,"
`they've got me now," "heard God's
`"heard voices say,
`voice," etc (hallucinations similar to those verbalized by
`our patients). He also described bizarre behavior which in¬
`cluded grimacing, smearing, "fear with screaming of
`being killed," posturing, spitting, wetting, soiling, refus¬
`ing medication, hoarding, and mannerisms. He concluded
`that the depth of psychosis had no relation to the clinical
`status at follow-up since 76% of those recovered had been
`"seriously psychotic."
`Lundquist,11 in 1945, discussed the symptoms of con¬
`fusion and hallucinations occurring during the acute
`phase of the first manic episode in relation to the outcome
`of manic-depressive illness. He found that the duration of
`untreated manic episodes was shorter in patients with
`confusion, while the duration of the episode did not seem
`to be related to the presence of hallucinations.
`Astrup et al,18 while not clarifying which of their pa¬
`tients had mania or depression as their predominant mood
`at admission, felt that the presence of ideas of reference,
`paranoia, passivity, or symbolism during the acute episode
`was a poor prognostic sign because more patients with
`those symptoms in their study had a chronic schizophrenic
`course. Again, the presence of hallucinations did not nec¬
`essarily correlate with outcome.
`Langfeldt,19 on the other hand,
`found that some pa¬
`tients diagnosed as schizophrenic because of Astrup's
`"poor prognostic" symptoms on their first admission, go
`on to have manic-depressive course. The clinical descrip¬
`tions of both these populations sound very similar and one
`can only conclude that the presence of Astrup's "poor
`prognosis" symptoms is in no way pathognomonic or even
`diagnostic of schizophrenia.
`Winokur et al,3 studying a population of manic patients
`very similar to ours, recorded the prevalence of symptoms
`in 100 directly observed manic episodes. In this study, and
`in an earlier one of 31 manies,8 they note that delusions
`(persecutory, passivity, sexual, religious, and depressive),
`hallucinations, posturing, and symbolism may occur in
`mania even though these features are often considered
`symptoms of schizophrenia. Finally, Lipkin et al20 re¬
`ported three patients with paranoid delusions, bizarre be¬
`havior, and excitement who were first diagnosed as schizo¬
`phrenia or paranoid state, but who later responded to
`lithium carbonate. In the brief case histories presented,
`the authors record but do not emphasize the occurrence of
`typical "manic" symptoms preceding the onset of a dis-
`
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`Table 3.—Psychotic Symptoms in Manic Patients,
`Review of the Literature
`% Patients
`
`Perse¬
`Passivity
`cutor
`Ideas of
`No
`Delusions Delusions Delusions Reference
`
`Incoher-
`enee
`
`Symbol-
`ism
`
`Halluci-
`nations
`
`No
`Halluci-
`nations
`
`Confu-
`sion
`
`65
`
`15
`
`23
`
`22
`
`48
`
`38
`
`19
`
`24
`
`25
`
`27
`10
`
`52
`
`16
`
`52
`
`20
`
`70
`
`40
`
`23
`
`38
`
`28
`
`15
`
`84
`
`40
`
`55
`62
`
`30
`
`22
`
`13
`
`60
`
`45
`38
`
`70
`
`35
`
`58
`
`23
`
`Follow-Up Studies
`NIMH (1972)
`20 patients
`with complete
`manic episodes
`Astrup (1959)18
`96 manic-depressives
`No. of manies not
`specified
`77 recovered
`13 chronic schizophrenic
`Winokur (1969)3
`100 manic episodes in
`61 patients
`Clayton & Winokur (1965)"
`31 patients
`Rennle (1942)10
`208 patients (66 manies)
`Lundquist (1945)"
`95 recovered manies
`
`organized, agitated, paranoid psychotic state.
`There are several possible explanations for our findings
`of a higher incidence of psychotic symptoms during mania
`than is generally emphasized in the literature. Our study,
`in contrast to others, included only patients hospitalized
`with a complete manic episode rather than patients who
`had already been manic for some time before hospitali¬
`zation. The inclusion of patients admitted to the research
`unit when the episode was already beginning to subside
`would have increased the proportion of "nonpsychotic" to
`"psychotic" patients.
`Furthermore, because of our interest in studying the
`natural phenomenonology of mania, drug treatment was
`not instituted in the earlier phases as it would be in most
`other settings. Thus, the full clinical picture is more likely
`to unfold. This suggests one reason that the observations
`of Kraepelin,9 Lundquist,11 and Rennie1" from the predrug
`era are in reasonable agreement with our data. Finally,
`Mendlewicz et al21 have reported that in manic patients
`with a positive family history of affective disorder (ie,
`similar to our patients), almost half had previously been
`misdiagnosed as schizophrenic. They speculate that this is
`the result of a higher incidence of psychotic symptoms
`during mania and therefore the tendency to misdiagnose
`schizophrenia in patients with more psychotic manias.
`The course of the illness and response to medication in
`these patients has been no different from those parame¬
`ters in groups of manic patients reported in the litera¬
`ture.1 All 20 patients eventually received lithium carbon¬
`ate in a double-blind fashion and showed an antimanic
`response; 40% of the most disturbed were treated simulta¬
`neously with phenothiazines for the acute episode. Despite
`the phenothiazines, manic episodes re¬
`continuation of
`curred when lithium carbonate was replaced by a placebo.
`Moreover, ultimate withdrawal of phenothiazines with
`lithium carbonate maintenance was accomplished without
`return of symptoms. In addition, a prophylactic benefit of
`
`lithium carbonate was observed in all the stage III pa¬
`tients and in all but one of the stage II patients, a success
`rate comparable to that reported in the literature.1·22
`Do the data presented here suggest that these cases
`should be classified as "schizo-affective" psychosis? The
`meaning of this question awaits further clarification of
`what constitutes this diagnostic category. Clayton et al23
`have presented evidence that the "schizo-affective" psy¬
`choses can be reasonably considered variants of manic-de¬
`pressive illness. Our data are compatible with such a view,
`and we realize that others may choose to diagnose the pa¬
`tients discussed as schizo-affective.
`We have, however, presented clinical and therapeutic
`reasons as well as historical precedents to support the con¬
`clusion that they are manic. Whether or not these patients
`ultimately will become chronic schizophrenics also cannot
`be assessed. The average duration of illness thus far is
`only 14 years. In Astrup's "atypical" cases, chronic schizo¬
`phrenia became obvious anywhere from one to 52 years
`after onset of initial psychiatric symptoms.18 It seems that
`a conclusive diagnosis cannot be made because of the
`evidently long age of risk for the late-developing schizo¬
`phrenias.
`Although to our knowledge no one has systematically
`examined the sequence, progression, and significance of
`symptoms over the course of the entire manic episode it¬
`self, there are several reports examining the onset and
`early phases of the episode. Bunney et al24 describe three
`phases occurring in the first ten days following the switch
`into mania. They note the progression of behavior from
`euphoria, irritability, and hyperactivity to more psychotic
`behavior. Their emphasis is on the "switch process" itself,
`however, and the more psychotic symptoms were not high¬
`lighted since they usually occur later in the course of the
`illness.
`Both Cohen13 and Henderson and Gillespie17 have noted
`that delirious mania may follow earlier stages of mania or
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`begin acutely. We found even in those cases with a fairly
`abrupt onset of severe mania, the earlier stages were pres¬
`ent even though transient. To recapitulate then, although
`the sequence of symptom appearance is rather consistent,
`the rate of progression of mania varies considerably in
`different individuals.
`This study has demonstrated that cross-sectional obser¬
`vations are not always reliable in making a diagnosis, and
`that the presence during mania of symptoms sometimes
`thought of as schizophrenic (eg, hallucinations, paranoid
`delusions, and ideas of reference) should not necessarily
`rule out the diagnosis of affective disorder. Finally, even
`when such symptoms are present they apparently do not
`distinguish that population of patients from those without
`psychotic symptoms in terms of subsequent functioning.
`
`The ability to distinguish mania from schizophrenia
`during the acute psychotic episode has both practical and
`importance. The therapeutic modalities for
`theoretical
`both the treatment and prophylaxis of mania now in¬
`cludes lithium carbonate, a medication probably con-
`traindicated in schizophrenia.25 Furthermore, the lack of
`clarity concerning proper diagnostic boundaries has often
`clouded the interpretation of the psychobiological data in
`affective illness. The use of longitudinal sequential analy¬
`sis of changing symptom patterns, rather than simple
`cross-sectional enumeration of symptoms, should result in
`increased diagnostic clarity.
`
`The nursing staff of 4-West contributed valuable behavioral observations
`and ratings; Martin Matzen and Eloise Orr provided t