Descriptive Psychopathology: The Signs and Symptoms of ...

210 Section 3: Examination domainsDelirious (Bell’s) mania 53Luther Bell first systematically described delirious mania in 1849 as an acutemania with fever and delirium. Kraepelin described delirious mania as anuncommon, rapidly emerging state characterized by extreme excitement, hallucinationsand delusions (often fantastic and grandiose), clouding of consciousness,lability of mood with shifts from exaltation to despair to simultaneousmoods, and catatonic features including posturing with waxy flexibility, andecholalia and echopraxia. Periods of stupor, excitement, and despondency werefollowed by a gradual resolution. Kraepelin maintained that the more intense themanic attack the shorter its duration. 54 Delirious mania with its commonlyassociation catatonia has been described repeatedly. 55Cyclothymia and the manic-depressive spectrum (“soft bipolar spectrum”)The image of manic-depression is of dramatic episodes of illness interspersedwith periods of quiescence. Episodes of mixed symptomatology or of substantialfrequency are also recognized. Long-standing, low-grade features, however, werealso defined by Kraepelin in the nineteenth century and re-affirmed by Akiskal80 years later. 56 These “affective temperaments” are the earliest and most subtleexpressions of manic-depression and include cyclothymia and traits identifiedas dysthymic, hyperthymic, and irritable. The various presentations of manicdepressionthat have been artificially separated into bipolar I, II, rapid cycling,seasonal, and mixed disorders and other low-grade forms constitute a manicdepressivephenotypic spectrum.Cyclothymia is characterized by gradual and modest mood swings lastingweeks or months. When the mood is elevated, the person is extroverted, outgoing,cheerful, optimistic, impulsive, restless, talkative, and uninhibited. Theneed for sleep is reduced and appetitive behaviors increase, the latter oftenleading to interpersonal and social indiscretions. When the mood is depressed,the person is irritable and short-tempered, lethargic and inactive and over-sleeps,taciturn, shy, unsure, pessimistic, and slow in thinking. Table 8.4 displays thebehavioral patterns observed in patients with cyclothymia.Hyperthymia is characterized by continuous overtalkativeness, extroversion,being uninhibited, bombastic, optimistic, restless, meddlesome, vigorous, needingonly a few hours of sleep nightly, and cheerfulness to the point of hypomania.Such persons are “hard workers, hard drinkers, and hard players”. Dysthymia ischaracterized by hypersomnolence, brooding, anhedonia, self-blame, passivity,and indecisiveness. The irritable condition is characterized by being hypercritical,brooding, complaining, dysphoric, restless, sarcastic, irritable, and choleric.In children with manic-depression, episodes are less distinct and sufferersexhibit many spectrum features. Problematic distractibility, rage attacks, and severe