A Contribution to The Aetiology of Manic-Depressive Insanity (1940)

 Section II
 Hereditary and Constitutional Factors

Selection of the Material

 Any attempt to obtain, with the help of the ordinary type of investigation possible with human subjects, results which will have some correspondence with Mendelian laws immediately presents a great number of difficulties. These difficulties are particularly well‑marked in the case of a psychiatric material. An important one is the difficulty of ascertaining whether the material investigated is uniform. Schulz has drawn attention to the errors likely to be caused by lack of uniformity of material in the case of schizophrenia and has proposed a statistical method by which an appropriate test may be made. The circumstances in the case of manic‑depressive insanity are no less complicated than in the case of schizophrenia. If one does not examine the clinical material with sufficient care it is easy to include among pure manic‑depressive psychoses psychogenic depressions, arteriosclerotic affective psychoses, and even recurrent schizophrenias. In order to avoid these sources of error I attempted to select a manic‑depressive material which would correspond to the most purely endogenous type of the psychosis, i.e. patients who had constantly recurrent attacks of illness of which each single attach ended in complete recovery. I had indeed hoped at first to find a sufficient number of patients in whom the illness showed a clear rhythm, and who ould perhaps form a distinct group with a particular mode of inheritance. This hope, however, was doomed to be disappointed, for although patients of this kind were to he found their number was much too small to allow of any reliable statistical results being obtained. Accordingly I determined to accept as propositi all manic.‑depressives who fulfilled the following conditions.

    1. They should. have the first attack before the fiftieth year.

    2. They should have at least one clear manic and one clear depressive attack, alternatively three manic or three depressive attacks, all clearly separated from one another and ending in complete recovery.

    From the 2,500 or so cases diagnosed as manic‑depressive in the Kraepelin clinic between the years 1903 and 1922 and from a further 500 cases which were put at my disposal by Dr. Ast, the Director of Eglfing Hospital near Munich, I was able to find 315 such patients. Of these, 114 were childless. They were not further investigated by me, except by examination of the collected records of every case, and were used only for Section I and for the statistics on the incidence of psychosis among the parents. In a further 41 cases it was impossible to get into touch with the relatives of the patient, although in some of these detailed in‑­formation was available in the records. I preferred to exclude them all from the statistics on the children. In the remaining 160 families I received information by personal investigation of 167 separate relatives and by the return of 62 questionnaires which were sent out for filling in. This information was provided by 172 children and 57 other relatives. In practically every case these communications served as a supplement to information already in the possession of the Institute.

    The material of 201 families with children had to be reduced still further, for diagnostic reasons. Follow‑up accounts were obtained for all these 201 propositi and, furthermore, whenever one of the summarized accounts of the card‑index mentioned symptoms which could be regarded as atypical of manic‑depressive psychoses, the original medical records of the Psychiatric Clinic and of all other hospitals in which the propositus had been a patient were obtained. This caution proved to be justified. Twenty of these 201 "manic‑depressives" had to be excluded, as the diagnosis ap­peared to be incorrect. The majority of these twenty excluded cases seemed to be in fact schizophrenics, but there were a few in which the diagnosis was rather one of psychopathy or organic illness. In a few, no certain diagnosis could be made, in spite of the detailed accounts available. In a further 43 cases, the histories showed a mixture of so‑called manic‑depressive and schizo­phrenic symptoms, or typically manic‑depressive symptoms being suc­ceeded by a defect‑state such as one finds after schizophrenic illness, or atypical schizophrenic‑like psychoses recurring in phases from which there was good recovery, or symptoms which in one form or another raised a suspicion of schizophrenia. There remained therefore 138 who were probably true manic‑depressives; of these 30 belonged to the above‑mentioned group of 41 cases whom I had to exclude from the statistics on the children because of incomplete information. Even this material of 138 cases is not quite uniform clinically. Many cases show a number of atypical qualities, such as irritability, reserve, etc., which, however, may be determined rather by character peculiarities than by the psychosis.

    I divided these 138 propositi into two groups: 84 "A" propositi, and 54 "B" propositi. The "A" group includes 65 cases with complete information on the children, the "B", 43. Clinic­ally, the "B" group consists of cases showing any variety of atypical symptoms; the "A" propositi showed in my opinion no marked deviation from the classical picture of the psychosis, no symptoms which could not be directly related to the psychosis and its underlying personality structure. The case material at the end of the thesis will show ho I have divided these two groups one from the other. Summarizing, one may say that the atypical symptoms shown by the "B" group could be classified as follows:

    I. Constitutional and characterological anomalies, psychogenie factors, e.g. irritability, suspicion, a paranoid attitude toivards the environment (to a certain degree), coarseness and vio­lence of speech and behaviour, certain rather bizarre types of be­haviour in states of excitement, indifference, lack of interest, vacancy of expression, apathy, hypochonth'iasis, compulsive phenomena, affcted and theatrical forms of behaviour and expression, hysterical fits, mental defect, and in general the signs of a psychopathic personality, insofar as it could be read from the case records.

    II. Exogenic factors: signs of arteriosclerosis, delirium, confusion, etc.

    III. Hallucinations.

    IV. Schizoid and schizophrenic‑like symptoms: ideas of re­ference (of being filmed, electrified, etc.), bizarre ideas of grandeur, maliciousness to others, grimacing, stereotyped move­ments, echopraxia, automatic obedience, a stiff or posed attitude, flexibilitas cerea, affectiess stupor, impulsive laughing or cry­ing, inadequate affect. To the objection that patients who show such symptoms as the above can be no true manic‑depressives, I would refer the reader to the case material in the last section of the thesis. Each of the patients concerned showed only one or two such symptoms, and then only as a rule in one of several attacks of illness.

(1) Z. ges. Neurol. Psychiat. (1934) 151