Descriptive Psychopathology: The Signs and Symptoms of ...

207 Chapter 8: Disturbances in emotional experienceto ecstasy and irritability to rage. Intense emotion colors thinking and the patientis expansive, loudly and dramatically expressing a sense of great self-importance.Outlandish dress and self-decoration occur. Kraepelin offers a photograph of oneof his manic patients, corsage in his lapel, smoking a cigar and a pipe simultaneously.He carries a baton with which, we are told, he insists on conducting otherpatients in song.When emotional expression is labile, periods of despair, apprehension andtearfulness intermingle with euphoria. These intense “mixed” states are not distinctforms of mania; they are mania.The intense emotion of acute mania is associated with increased arousalthat elicits hyperactivity. Flooded with racing, multiple lines of thinking andgreat energy, the patient rushes from one chore to the next. Anything that catcheshis eye is immediately attended to. At its height frenzy occurs. Psychosis ispresent.The patient’s many thoughts are expressed in a torrent of speech. When thispressured speech is substantial, it is difficult to interrupt the patient, whotypically becomes angered by attempts to lead him back to the examiner’squestion or nursing care effort. Such patients are unpleasant and can be dangerous,often requiring temporary seclusion, where the reduced external stimulationmodulates their excitement. When emotional expression is mixed, hyperactivityand press of speech yield to periods of psychomotor slowing. When slowing issevere, stupor and catatonia ensue. Table 8.3 displays the psychopathology seenin acute mania. The numbers in parentheses indicate the proportion of acutelyhospitalized manic patients found to have the feature. 43 Nearly 50% will also havea history of alcohol abuse. Acute mania is similar in presentation worldwide. 44Patient 8.2 is an acute manic patient described by Taylor and Abrams. 45Patient 8.2A 69-year-old woman was brought to the hospital in restraints by the police.She had entered a restaurant, threatened the patrons, and demanded $500 000from the owner. In a prior similar episode she was said to have paranoidschizophrenia. On admission she was animated and overactive, dressed in abright, theatrical fashion. Her emotional expression was intense and labile.She was euphoric and irritable, with angry outbursts requiring seclusion.Her speech was rapid, pressured, and circumstantial. She spoke constantlyto several hallucinated voices which “provoked” her to speak up for her rightsand to claim her “billions”. She described the voices as clear, continuous, andcoming from two people above her. She believed she was the richest woman inthe world, and that there was a plot to harm her. Lithium monotherapyresolved her mania and she remained well for over a year.