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we have the picture of the depressive and the manic phases of manicdepressive disorder. The two phases are opposed, not in the sense that one is a phase of excitement and the other a phase of passivity or calmness, but rather in the sense that the one is a phase of exaltation and the other a phase of depression. Exaltation, not excitement, is the true opposite of depression. Excitement may accompany depression; most strikingly in the condition known as agitated melancholia. And in many cases of melancholia or depression there is a certain amount of excitement expressed by restless wandering to and fro, lamentations, insomnia, dreaming and vivid, perhaps hallucinatory, imaginings1. The characteristic mark of the depressed phase is that the patient takes a low, a depressed, view of himself, declares that he is a miserable sinner, a wretched useless creature; that he has committed dreadful imaginary crimes and expects corresponding treatment in this world and in the next; that he is incapable of coping with the world by reason of moral and physical deficiencies of the most varied kinds.
On the other hand, in the exalted phase the patient displays an attitude of lofty superiority, an exaggerated belief in his own capacities, there is nothing he cannot achieve; he feels and therefore believes that physically and mentally he is a superman. His excitement is an excitement of a particular kind; it is not specifically amorous, or fearful, or curious, or altruistic2; it is the excitement of an intensified self-assertion, unbalanced, unchecked by any effective self-criticism or by deference to any other person. The patient busies himself with ceaseless boastful talk or great plans, he explains his case to his physician with the utmost confidence in his own view and writes grandiose letters to persons of exalted station3.
1 Prof. Bleuler writes: "In excited depressions...the agitation is nothing but the expression of anxiety and with it the other centrifugal functions are plainly retarded." Only the English translation of his Textbook is available to me: but it is probable that the word translated as 'anxiety' (according to the unfortunate custom of English psychiatrists) is 'Angst.' Clearly Bleuler means 'fear.' Fear is the main ground of excitement in depressed states.
2 Nor is it a general hyperexcitability of all nervous functions. Such general hyperexcitability we see in Graves' disease or in any condition of hyperthroidism; it differs widely from the excitement of the manic patient.
* Prof. Bleuler (in his Textbook of Psychiatry) claims manic-depressive insanity as one of the 'affective psychoses,' and writes of it the following passages which support, I think, the view I suggest: "The manic invariably estimates his own worth much too highly, the melancholic infinitely too low"; and "In Euphoria the turgor vitalis is naturally raised; a patient, who in a state of melancholia is a broken up individual, may appear twenty years younger the next day, when he has merged into a manic mood, and then present a vigorous bearing and a good appearance. All vegetative functions adapt themselves to the situation.
How then does the patient in these two phases, the exalted and the depressed, differ from the normal man? The normal man takes a sober balanced critical view of himself and of his relations to the world; and he does this in virtue of the constant interplay of two fundamental tendencies of his instinctive nature, namely the tendency to self-assertion and the tendency to submission. These two tendencies are the principal tendencies incorporated in his sentiment of self-regard1. In the man of normal disposition and development, these two tendencies are constantly at work during all self-conscious reflection. The one prompts him to attempt any line of action that may seem in any way attractive, to regard himself as capable of all achievements, as superior to all other men in all respects. And when the promptings of this tendency carry him to success, whether actually or merely in imagination, his satisfaction takes the special form which we call 'joy,' or, perhaps more properly, 'elation.'
The other tendency, the submissive tendency, on the other hand, prompts him to defer to others, to be docile, to submit and obey, to take a lowly view of himself and all his capacities and achievements; to bow down beneath hard blows and to suffer in silence. And the normal man's estimate of himself, varying as it does from time to time, even from moment to moment, according as one or other of these two tendencies predominates, is the product of the co-operation and reciprocal influence of these two opposed tendencies. Normally they work together as the twin impulses of the sentiment of self-regard, each checking and moderating the influence of the other; each liable in turn to be called out in greater strength than the other by appropriate circumstances.
The essence of my suggestion towards a theory of the manic-depressive disorder is that the disorder results from the upsetting or disturbance of the normal balance and co-operation of these two impulses within the sentiment of self-regard.
There are three ways in which we can suppose this balance to be upset in favour of one or other of the two impulses. First, external circumstances may be such as greatly to favour one relatively to the other. For example, a run of bad luck, of lack of success, of mistakes
The exalted person usually has a good appetite and effective metabolism"; and he writes of "cyclo-thymics in whom periods of energetic euphoria alternate with despondent impotence."
1 For an account of the nature and development of the sentiment of self-regard, I refer the reader to my Social Psychology.
and rebuffs, may nip all the incipient stirrings of the self-assertive impulse and evoke again and again in the present, as well as retrospectively and prospectively, the submissive impulse. Or the converse may happen. Secondly, changes of the bodily metabolism may have similar effects. We know that bodily freshness and vigour are favourable to the working of the self-assertive impulse; while fatigue and exhaustion and debility are unfavourable to it and favourable to the submissive impulse. And it is altogether probable that, just as the sex-instinct and the fearinstinct have their hormones and endocrine secretions which are stimulated by, and in turn favour, the activity of the corresponding instinct, so also each of these two instincts of the sentiment of self-regard has its specific hormone. If that is the case, then it may happen that one or other of these two hormones may be formed in excess, owing to what we may call accidental disturbance of the metabolic order; or that one of them is formed in less than the normal amount. In either case the balance of action between the two tendencies would be upset. Thirdly, the seat of the disorder may be within the structure of the selfregarding sentiment itself; there may occur within it something of the nature of a dissociative process that prevents the due reciprocal influences between the two impulses. Before considering this last possibility, I describe a case which seems to me to be one of simple morbid elation produced in the first of the three ways suggested above as possibilities.
A professional man in middle life of good heredity had shown no previous trace of instability. His history would justify classing him with the cyclo-thymic type. He had, when young, suffered some periods of very mild depression and apathy, such as might be called merely prolonged moods of discouragement. And at other times he had displayed an almost excessive activity and energy, working extremely hard in preparation for examinations and achieving athletic feats that required tremendous endurance and energy. He became actively engaged in a Presidential campaign. He had long been keenly interested in politics and certain planks of his party's platform; but he had never before taken an active part in electioneering, whether State or Federal, and had never spoken in public. He approached his new task with considerable diffidence; but he very soon found that he was an effective campaign orator. He was immensely pleased, stimulated and elated by his success. He worked with extreme enthusiasm and energy. He sought and seized every opportunity for addressing public gatherings. At first his colleagues in the particular local campaign were full of admiration; but
after some days they were obliged to communicate with his relatives and ask them to remove him from the scene. For his conduct had begun pass the bounds of the normal and the decorous, and he was beginning to make himself a nuisance to them. He angrily resented all their suggestions to the effect that he needed a rest and had done his share; he was utterly impervious to their arguments and persuasion. Instead of taking a long night's rest after his hard day's work, he would get up very early in the morning and, appearing at the window of his hotel bedroom, would gather a crowd in the street by his animated and somewhat strange behaviour and deliver to them a fiery address, freely exchanging jokes and pleasantries with his auditors. As he afterwards put it, he felt like a god; for he could sway his audience as he wished, evoking enthusiastic agreement and applause. Such admiring response from public gatherings is, as we know, strong drink for any man. Even men long and gradually accustomed to such successes suffer a kind of intoxication on occasions of this sort; and, as with drugs, they acquire a morbid craving for ever new and larger doses; they cannot live without the limelight.' And to this hitherto quiet and retiring professional man the 'intoxication' went to the point of throwing him off his balance. He was brought home by the exercise of much tact and patience. He refused to submit to medical examination, declaring that he had never before been so fit and strong. One experienced physician who saw him was inclined to diagnose the case as one of lightning general paresis. He was continually elated and voluble, but extremely irritable: the least opposition provoking violent anger and scorn. He insisted on attending a local political meeting in support of his Presidential candidate: and, though he was prevented from taking any leading part in it, he behaved as though he were in command of the meeting, threatening to punch the heads of all interrupters. The least shortcoming in the behaviour of others, e.g. in a police officer or a street-car conductor, would provoke from him an angry lecture on the due performance of duty. With patient humouring he gradually quieted down and after a few days became his normal self. He has shown no further sign of instability during the ensuing five years and has been wise enough to abstain from all active participation in electioneering.
The foregoing case was, I submit, one of morbid elation produced by excessive stimulation and excessive gratification of the self-assertive tendency. I have no doubt that, if any forcible restraint had been applied, or any attempt made to confine him in a hospital, the excitement would have increased and he would have presented the picture of
a full-blown maniacal excitement1. It is not impossible, I think, that, if such aggravation of the condition had occurred, it might have left the increased susceptibility to incoordination within the sentiment of selfregard which, I suggest, is the ground of manic-depressive alternations of exaltation and depression.
Before describing another case which seems to fit well with my suggestion, I adduce some further theoretical considerations in support of it. The predominant emotion of the manic condition is elation; but another emotion is so commonly displayed to excess, sometimes so dominating the scene, that it might be regarded as a characteristic of the condition, namely anger. This fact may be seen to be entirely in harmony with my hypothesis, if we consider the conditions that evoke anger. The anger impulse is normally evoked by any thwarting of any other strong impulse 2. Therefore, if any one instinctive impulse becomes abnormally intensified, we may expect to find also an increased irritability or rather irascibility. But the self-assertive impulse is peculiarly apt to occasion anger; because it is so constantly in play in all social relations, and can suffer thwarting, not only through the overt actions of others, but through a mere word or gesture or facial expression, or even through mere passivity or indifference, a lack of submissive response on the part of others. The persons who are most irascible are in the main those whose course of life has favoured the development of the selfassertive tendency at the cost of the submissive tendency. It is for this reason that the retired colonel or general has become in fiction the accepted type of extreme irascibility, especially the retired colonel of the Indian army. He has figured in a thousand and one stories as the man who, in spite perhaps of a kindly and benevolent disposition, grows red in the face and breaks out with strong language at the slightest opposition to his opinions or thwarting of his wishes. Such irascibility has been commonly ascribed to the liver; but the effects of tropical climate on the liver are of secondary importance. Such a man has spent the greater part of his life in a position where, surrounded by submissive subordinates, it is his duty and his pleasure to issue commands that are unquestioningly obeyed.
Anger, then, is a secondary feature of mania. So long as the manic patient gets his own way, he is pleasant and often witty and amusing.
1 Fortunately I was able to be with him continuously during the few days when the excitement was at its height; if that had not been possible, it would have been necessary to commit him.
2 Cp. my Social Psychology, p. 59.