Wednesday, January 25, 2012

The sequence of mood changes in Manic-Depressive illness

After seeing a number of manic-depressive patients I have found that there is a typical sequence to their mood changes.

First there is a high spirited sense of triumph and superiority that is so overabundant that it spills into enjoyment of others miseries and inferiority. This is based on a burst of self confidence and appreciation  - and well justified for manic-depressive folks are generally beautiful people with superior looks, attractive bodies and quick mind - of one' excellent attributes. The person is completely self centered and feels no hesitation in thinking of the death of anybody who crosses one's path.

This phase is followed by emergence of guilt and anticipation of punishment. These two negative emotions are clearly relate to the earlier joy at the plight and inferiority of others. The anticipation of punishment - forewarning of pain - creates great anxiety. To control the anxiety and guilt - guilt itself is kind of anxiety (anticipation of punishment from one's conscience) - all kinds of obsessive thinking and rituals emerge in those whose preferred mode of defense is obsessive, while in the hysterics, body aches and pains emerge to assuage the guilt (through suffering). These obsessive/hysterical symptoms are kind of repentant activities. If the fear of punishment is not placated by these obsessive/hysterical maneuvers, the patient resorts to actually punishing herself - the most favored way to torture is to start dreading the impending poverty which sometimes becomes frank delusions that one soon will be a destitute homeless bag-lady. The psychodynamics behind punishing oneself even before fate (parents) does lies in the following reasoning: let me punish myself which will placate my parents and avert their wrath from falling upon me. When self-torture goes way beyond one's capacity to handle, the person goes into frank depression and ceases partaking of all enjoyments and all activities. The excessive delight at one's superiority during the manic phase is now fittingly punished with the belief that one is utterly worthless.

Today a patient of mine, who I have been seeing for over 15 years, and who has classic manic-depressive illness, and who was in good remission for a long time, came with the complaint that she is very shaky and her son stated that her manic-depressive confusional state is round the corner. When patient was asked as to what could be causing this sudden deterioration, she said that a friend of hers, who she has known for years, and with whom she rode every morning to go to dialysis had died.

When asked how had she died, the patient's face showed a triumphant pleasure. This was certainly against her good sense and perhaps without even her knowledge. She followed it up with the following statement, "She got a kidney transplant. But it did not last for even 2 months. She died. She would have been better off not getting it." I could feel her secret joy at the death of someone who had got the kidney transplant while she had not. But mixed with it was the sadness at her friends death and guilt over the triumph.


  1. Can these mood changes(from mania to depression) not be easily explained by nuero-transmitter/


  2. There is a psycho-physical parallelism. Physical events happen at the physical level and at some particular point of complexity their psychical counterpoint emerges. Only a fraction of the psychical events reach consciousness, the majority of it happen behind the scene in the unconscious.
    What I describe above is what I have observed in manic-depressive patients from what they are consciously able to tell me, what I see in their behaviors, and what I have inferred as to be present in their unconscious psychical life on the basis of the former two.
    As to how they correlate with the changes in the ups and downs of neurotransmitters I have little interest. The study of neurotransmitters and how they influence the psychic events is at an infantile stage and explains hardly anything.