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After reading this article you will learn about:- 1. Factors of Manic-Depressive Disorders 2. Psychological Explanation of Manic-Depressive Disorders 3. Studies 4. Treatments.
Factors of Manic-Depressive Disorders:
i. Biological Factors:
The need for a biological explanation of manic-depressive psychoses arises from the fact that once the disorder is in the process, it continues automatically and completes the full course unless otherwise controlled by drugs and other medicines. The biological factors of manic-depressive psychoses include hereditary, constitutional, neurophysiological and biochemical factors.
(a) Hereditary explanation:
In a study of M.D.P. patients Slater (1944) noted that in about 15 per cent of the cases, brothers and sisters, parents and children of manic-depressive patients also suffered from M.D.P. Rich (1969) confirmed the hereditary explanation when they found that 20 per cent of the mothers of 347 cases suffer from M.D.P.
Thus they concluded that children from M.D.P. parents have normally higher probability for M.D.P., than only the fathers suffering from M.D.P. Kallman (1958) in his study of identical twins found when one twin suffered from M.D.P., the other also suffered.
Kraepelin pointed out that 0 to 80% of the cases of M.D.P. can be attributed to hereditary disposition. The advocates of hereditary explanation viewed that M.D.P. is transmitted from parents to the offspring’s through a single dominant gene transmission.
In all these studies, however the effect of early environment and learning has not been controlled. So it would be just erroneous to conclude that M.D.P. is due to the hereditary predisposition alone. Thus, Coleman (1981) concludes. “The precise role of heredity is far from clear, although it seems realistic to consider it an important interactional factor in the total picture.”
(b) Constitutional explanation:
Kretehmer viewed that picnic type of personality generally suffer from M.D.P. He categorized the short, bulky people with thick neck and broad face as having picnic type of personality.
According to Meyer, Hock, Kinby, Bluler and others, psychesthenic people characterised by moods, swinging from elation to depression generally suffer from M.D.P. They may be quite brilliant, talkative and aggressive people who may take the affairs of life ordinarily or who may have a gloomy outlook towards life and take little matters quite seriously.
(c) Neurophysiological explanation:
Certain earlier investigators reveal that manic reaction is a state of excessive excitation and weakened inhibition of the higher brain centre and depressive reactions occur due to excessive inhibitions.
The interest in the area developed by the work of Pavlov led to the possibility of the fact that imbalance in the excitatory and inhibitory processes may predispose some people towards change of moods such as mania and depression.
According to Engel (1962) the central nervous system is apparently organised to mediate two opposite patterns of responses to mounting needs, the first is an active goal oriented pattern directed towards gratification of needs from external sources. The second is a defensive pattern aimed at reducing activity and thereby increasing the barriers against stimulation and conserving the energies.
Manic reaction seems to be an exaggerated form of the first response pattern, while the second response pattern may be attached to depression. So motor retardation of the depressive and psychomotor activities of the manic do suggest polar opposites in neural functioning.
ii. Biochemical Factor:
Metabolic disorders of the catecholamine are well proved in the M.D.P. It has been found that abnormality in indocolamine metabolism is related to depression. Schildkrant (1970) viewed that depression may be associated with a deficiency in brain norepinephrine and the manic behaviour shows an excess of norepinephrine.
In support of his theory he argued that psychoactive drugs which increase mood tend to produce an increase in norepinephrine at synapses, but those which produce depressed mood cause a reduction of this biochemical.
When the neurotransmitter substance is of appropriate amount, it allows normal neural transmission. But when it exceeds the normal level, the nerves are excited too frequently leading to manic stage. On the contrary, it is below the normal level, the neurons are unable to respond to the normal impulses resulting in depression and inactivity.
Duke and Nowicki (1979) report that “Research on antidepressant medications and their mode of action contributed much support to the catecholamine hypotheses. Different types of antidepressant drugs work in different ways to affect the presence of norepinephrine.
For example, a group of antidepressant drugs called monoamine-oxidase (MAO) inhibitors check the actions of the enzyme that metabolizes norepinephrine, thereby elevating the concentration of this neurotransmitter at the synapses.
It is further pointed out that lithium carbonate, a currently widely used drug in the treatment of manic depressive psychoses reduces the flow of norepinephrine at brain synapses and this in turn decreases the hyper responsively of the nervous system and slow down neurotransmission to a relatively normal level.
It is true though, that the information about the function of neurotransmitters is based on animal research, some studies on mental patients have also confirmed the above facts. Kety (1975) found high levels of norepinephrine in the urine of manic patients and low level in depressive patients.
Subsequent investigations conducted by Maas, Fawability and Dekirmenjian (1972) have proved that with successful treatment of antidepressants there is increase in the level of catecholamine in depressive patients and this finally brings them back to the normal condition.
In-spite of the empirical findings in support of the biochemical explanation, M.D.P. and particularly neurotransmitter variations as the cause of M.D.P., the biochemical explanation only proves that the neurotransmitter variations exist, but it is not able to explain the cause of neurotransmitter variations in M.D.P. patients.
Duke and Nowicki also opine that the catecholamine hypotheses by itself does not seem to explain adequately the biochemistry of affective psychoses.
Research has also highlighted the fact that deficiency in indoleamine metabolism is related to depression. But at the same time, serotonin levels have also been found in lower degree than normal in manic patients as in psychotic depression. The presence of lower amount of serotonin in both manic and depressive patients makes this explanation very complicated and confusing.
However, Kety (1975) slates that “a deficiency of serotonin at central synapses is an important genetic or constitutional requirement for affective disorder, permitting what might otherwise be normal and adaptive changes in norepinephrine activity and the resultant mood states to exceed the homeostatic bounds and progress in an un dampened fashion to depression or excessive elation.”
Duke thus concludes “Thus variations in mood in affective psychoses would be attributable specifically to norepinephrine variation, but the predisposition to overreaction in the form of extreme variation would be the result of a genetic lack of the dampening effects of serotonin. This intriguing hypothesis is yet to be tested fully enough to make suitable evaluation possible.”
Psychological Explanation of Manic-Depressive Disorders:
Freud and other psychoanalysts have attempted to give a psychological explanation of manic depressive psychoses. Currently, learning theorists have tried to explain the causes of affective psychoses through life experience, learning and various other psychological events.
Psychoanalyst, Karl Abraham (1948) was of opinion that ambivalent, ego centric people are more prone to affective psychoses. They in-fact are incapable of expressing one feeling in the absence of another.
They are unable to express pure love which leads to feelings of pure impoverishment. How this impoverished feeling arises? It is the function of fixation at the oral stage of psychosexual development; caused by an ambivalent attitude towards the mother. The person fixated at the oral stage develops the tendency to be terrifically dependent upon other people.
In the opinion of Duke and Nowicki (1979) “Such people grow up being unable to relate adequately to love objects and experience intense frustration while trying to obtain gratification from them. In reaction to problems in relating to others, in later life they regress to the oral level and relate to themselves with the same love hate ambivalence. Sometimes they hate themselves (depression) and sometimes they love themselves (Mania).”
Freud viewed that the behaviour of grieving was similar to that of depression. He viewed that depressed people mourn the loss of their own egos just as distressed people mourn the loss of their near and dear ones.
The ego of the patient has already strongly, identified with the loved object itself and when the loved person is lost or the individual looses the love of his most beloved, he strongly feels the loss and this leads to depression. He also experiences guilt of real and imagined sins against the person lost.
Freud further opined that depression represented a turning inward of aggressive feelings that may have been felt toward another person. People, who are unable to channelize their aggression in proper ways, experience a deep sense of despair and it may lead to suicide since the aggression turns inward.
To add to this, Kendal also found that in societies where aggression is permitted, there is a lower incidence of depression.
According to Meyer (1948) Manic depressive psychoses is a reaction to stressful condition involving both biological and psychological components which serve both as defective and compensatory nature. Such reactions are accepted as protective mechanism to protect the individual or relax the stress to bring about recovery.
Areiti (1969) reviewing a large number of studies concluded that reaction pattern to stress may be classified into 3 types.
1. Death of a loved one.
2. Failure in interpersonal relationship.
3. A severe disappointment or set back in work to which an individual has devoted his life. All these precipitating conditions involve loss of something that has great value for the individual.
Manic reactions are in fact responses to escape one’s difficulties by flights to reality. There are evidences to show that in severe stress situations the individual attends more parties and tries to forget the broken love affair, or tries to escape anxiety by being overactive and over busy.
Thus, hyperactivity is found in the manic patient. Several ego analysts like Jacobson (1953) have found the key cause of depressive psychoses in the loss of self-esteem.
Jacobson thus writes “Manic depressive manifests a particular kind of infantile narcissistic dependency on their love object. What they require is a constant supply of love and moral support from a highly valued love object, which need not be a person, but may be represented by a powerful symbol, a religious, a political or scientific causes or an organisation………………… as long as their belief in this object lasts they will be able to work with enthusiasm and efficiency.”
Such people, according to Jacobson underestimate their loved object.
When the loved object is lost or threatened depression associated with low self image of the undervalued ego occurs. A normal individual when depressed takes recourse to constructive activities designed to reduce the threat to self esteem. Either one may lower his level of aspiration or through the use of some defences he may try to change his perception to events.
But the depressed person instead of taking recourse to constructive activities or adjusting his goals, a feeling to helplessness and depression occurs. On the other hand, the manic reactions are the results of excitement around the belief that the unrealistic goals are being solved, though they are not solved in reality.
The role of environment and family has also been emphasised in predisposing an individual to depression. By setting examples and models through one’s own actions the children may directly be motivated to show similar type of behaviour. About 80 per cent of these cases have been reported having adverse life events precipitating this pathological conditions.
Studies on Manic-Depressive Disorders:
According to Beck (1967) there is a positive relationship between feelings of guilt, shame and unworthiness over past work and depression. But similar findings are not found in the patients of non-western culture as reported by Venkoba Rao (1973) who reviewed the studies on the depressive patients in Africa, Japan, Philippine, Iraq and China, Bangladesh and Pakistan.
Among the Indians, he said, the Hindus showed less shame and guilt. Venkaba Rao further states that the incidence of depression has been found to have decreased in the U.S.A. In U.K. and Canada, marginal increase has been reported on the basis of hospital admission, the prevalence of all forms of depressions found to be 3% while it is 12% in India.
He further reports that the incidence of depressive psychoses is relatively higher in North India in comparison to South India perhaps because of the rituals in South India.
Treatment of Manic-Depressive Disorders:
i. Hospitalization:
A manic or depressed person may need hospitalization when there is risk to his own-self or others when the family environment is disturbing for the patient or when a need for shock treatment is required. Also the need for hospitalization occurs when the patient does not take food for days together and needs to be tube fed.
Currently, use of antidepressant drugs have however, reduced the need for hospitalization. But in severe cases hospitalization cannot be avoided. Hospital further provides better physical care to the patient, removes disturbing home influence, acts as a protective measure against suicide and other responsible behaviours.
ii. Physical Rest:
Some patient also gain by sleep than by sleep therapy. Rest in some cases seems to be the best medicine for every type of mental disease.
iii. Psycho-Chemotherapy:
Wide application of chemical treatment for depressive and manic patient has greatly reduced the percentage of admission in hospitals. Antidepressant drugs such as imipramine are generally used for the treatment of depressive patients.
Proper dosage is determined through trial and error adjustment. Use of electric shock in M.D.P. patients has decreased due to the wide application of antidepressants. Through antidepressant drugs also uncooperative patients have become more responsive to psychotherapy.
Drugs for depression have been available since 1950s. But only in the 1970s lithium carbonate has been used effectively for treating manic patients and to prevent their occurrence. As a rule, lithium carbonate must be administered under careful medical supervision.
iv. Electro Convulsive Shock Therapy:
ECT is extremely effective in treating severely depressed patients. It however has better effect on manic symptoms.
Many psychiatrists are of opinion that it is better to begin ECT than to wait for antidepressant drugs to be effective.
In the absence of any specific form of treatment, time acts as the great healing agent and the disease runs its course and terminates within a few months.
However, successful treatment of mental disease depends to a great extent upon the personality make up and experience of the psychiatrist.
In India there is very little provision for dealing with such cases. In future, therefore efforts should be made for the successful treatment of the M.D.P. patients not in urban areas alone but also in the rural section of the country.