The mixed and atypical forms are of special importance, as they occupy the middle ground between the classical types of manic-depressive insanity and dementia praecox. It is here that difficulties arise and errors in diagnosis are made. They have never received sufficient attention until recently. In practice many of these have undoubtedly been classed with the dementia praecox group. The first of these as described by Kraepelin is depressive or anxious mania—characterized by a depressive mood with anxiety and excitement and, at the same time, a flight of ideas. The patients are distractible, observant of everything in their surroundings, and complain that thoughts obtrude themselves upon them. Some have a mania for scribbling. Often there are delusions of persecution, sin, and hypochondriacal ideas. The mood is one of anxiety or despair. Impulsive acts are occasionally observed. They are inclined to weep, wring their hands, pull out their hair and throw themselves on the ground.
Instead of a flight of ideas there may be poverty of thought and retardation with excitement—an "excited depression." The patients may be very wordy and monotonous in expression but are entirely clear as to their surroundings. The mood is anxious and tearful, often with delusions. There is a considerable excitement, but not of such a stormy character as in the depressive or anxious mania.
Mania with poverty of thought, an "unproductive" form, shows a more cheerful mood but without a flight of ideas. This form Kraepelin speaks of as a common one. Speech is monotonous and expressionless. The patients present almost an appearance of feeblemindedness, although exceedingly variable and changeable. The mood is cheerful and sometimes irritable. The excitement is shown by jumping around, making faces, etc., but without any occupational activity. This alternates with periods of quiet when but little is said. They show no desire to occupy themselves in anything useful. Sudden outbursts of violence often occur.
Stuporous, almost cataleptic forms with occasional delusions of a hypochondriacal type, fairly well oriented and with a clear sensorium, are spoken of as "manic stupor." This is interrupted by excitement and violence, with laughter, witty remarks and even eroticism. They often have a clear memory of all occurrences. This stuporous type may appear suddenly in an ordinary manic attack, or take place between excitements and depressions.
In the course of an ordinary depression a flight of ideas may also replace the usual retardation—"depression with flight of ideas." The delusions are interspersed with cheerful thoughts and the patients show certain activities and an interest in their surroundings, although still depressed and hopeless. When they begin to talk they complain of an inability to control their thoughts. There is an inhibition of speech but not of thought. They may be quite prolific in writing, and may show a characteristic flight of ideas. This condition often merges into genuine excitement.
Kraepelin also speaks of an inhibited or "retarded mania," showing a cheerful mood with flight of ideas and psychomotor retardation. These eases are excited, distractible, inclined to witticisms with "klang associations," but lie quietly in bed. He believes that there is an inner tension manifesting itself at times in acts of violence. Kraepelin also speaks of various other mixtures of depression, anxiety and excitement. Specht has described an "irascible mania" (Zorntobsucht) and Stransky a bashful mania (verschämte Manie). Dreyfus has described a partial inhibition or retardation (partiellen Hemmung). Hecker is responsible for a "grumbling" or faultfinding variety of mania (nörgelnden Formen der Manie). In any event, Kraepelin's conceptions constitute a distinct advance and have materially clarified a much involved confusion of entities which seem to warrant complete differentiation. His views have, of course, not been universally accepted. The English school of psychiatrists has been slow in expressing its approval of his theories. No textbook of late years has appeared, however, in this country that has failed to recognize the manic-depressive psychoses practically as Kraepelin originally described them.
The psychological mechanisms of manic-depressive insanity have been studied exhaustively by Karl Abraham and other psychoanalysts. He looks upon retardation as a symbol of death and interprets it as a defensive reaction, the patient taking refuge in a retarded state to avoid contact with the outer world. The ideas of poverty associated with depressions he considered as symbolic of an inability to love and occurring in individuals who have not obtained sexual gratification in a normal way. When repression is no longer possible mania ensues and the patient enters upon a new existence, all instinctive inhibition being lost. The flight of ideas he looks upon as a reestablishment of infantilism. He suggests these views, however, as tentative. The delusions of the manic-depressive psychoses have been interpreted as an expression of repressed complexes. White[278] would explain these mechanisms as follows:—"Manic-depressive psychosis is the type of extroversion reaction. That is, the patients instead of turning within themselves (introversion) try to escape their difficulties (conflict) by a 'flight into reality.' This flight into reality is the manic phase of the psychosis with its flight of ideas, distractibility and increased psychomotor activity during which the patient seems to be at the mercy almost of his environment having his attention diverted by every passing stimulus. The great activity can be understood as a defense mechanism. The patient appears, by his constant activity to be covering every possible avenue of approach which might by any possibility touch his sore point (complex) and so he rushes wildly from this possible source of danger to that meanwhile keeping up a stream of diverting activities. He is at once running away from his conflict—into reality—and trying to adequately defend every possible approach.... This method I have described as a 'flight into reality' which is the characteristic of the manic phase, while the failure to deal adequately with the difficulty is manifested by the depression of the depressive phase. In the depression the defenses have broken down and the patient is overwhelmed by a sense of his moral turpitude (self-accusatory delusions). This sense of being sinful is the conscious appreciation of tendencies which should have been left behind to become a part of the historical past (the unconscious) in the course of the development of the psyche but which still demand expression.... The benign character of the manic-depressive group of psychoses is explained because of their extroverted mechanism. Reality is the normal direction for the libido and because the direction is normal they more readily result in recovery."
The American Psychiatric Association, in its manual designed for the assistance of hospitals for mental diseases in the compilation of statistical data, makes the following suggestions as to the delimitation of the manic-depressive psychoses:—
"This group comprises the essentially benign affective psychoses, mental disorders which fundamentally are marked by emotional oscillations and a tendency to recurrence. Various psychotic trends, delusions, illusions and hallucinations, clouded states, stupor, etc., may be added. To be distinguished are:
"The manic reaction with its feeling of well-being (or irascibility), flight of ideas and over-activity.