Second edition

06.qxd 3/10/08 9:34 AM Page 217
Hyperactivity
Hyperactivity, which might just as well be termed pressure
of activity, follows from the patients’ grandiosity and
increased energy. Patients may enter into business arrangements
with unbounded and completely uncritical enthusiasm.
Ventures are begun, stocks are bought on a hunch,
money is loaned out without collateral, and when the family
fortune is spent, manic patients, undaunted, may seek
to borrow more money for yet another prospect. Spending
sprees are also quite typical. Clothes, furniture, and cars
may be bought; the credit card is pushed to the limit, and
another one is obtained; checks, without any foundation in
the bank account, are written with alacrity. Kraepelin
noted that such a patient is swelled by a ‘need to get out of
himself, to be on more intimate terms with his surroundings,
to play a part’. It causes him:
to change about his furniture, to visit distant
acquaintances, to take himself up with all possible
things and circumstances, which formerly he never
thought about. Politics, the universal language,
aeronautics, the women’s question, public affairs of
all kinds and their need of improvement, give him
employment. A physician advertised about ‘original
sin, Genesis, natural selection and breeding’. Another
patient drove about in a cab and distributed pictures
of the saints. The patient enters into numerous
engagements, suddenly pays all his business debts
without it being necessary, makes magnificent
presents, builds all kinds of castles in the air, and
with swift enthusiasm precipitates himself in daring
undertakings much beyond his powers. He has 16,000
picture post-cards of his little village printed. . . .
STAGE II MANIA: ACUTE MANIA
Kraepelin (1921)
The transition from hypomania to acute mania is marked by
a severe exacerbation of the symptoms seen in hypomania
and by the appearance of delusions, typically delusions of
grandeur. Kraepelin noted, ‘The patient asserts that he is
descended from a noble family, that he is a gentleman; he
calls himself a genius, the Emperor William, the Emperor of
Russia, Christ; he can drive out the devil. A patient suddenly
cried out on the street that he was the Lord God . . . ’.
Delusions of persecution may also occur, especially in
patients with irritability. Patients may assert that their failures
are not their own but the result of treacheries and
betrayals by family members or business colleagues. They
are persecuted by those jealous of their grandeur; they are
pilloried and crucified by their enemies. Terrorists have set a
watch on their houses and seek to destroy them before they
can ascend their thrones. Occasionally, in addition to these
delusions, there may be transitory hallucinations. Grandiose
patients may hear a chorus of angels; persecuted patients
may hear the resentful muttering of the envious crowd.
6.3 Mania 217
With the intensification of hypomanic symptoms and
the appearance of delusions, the overall behavior of these
patients may become quite extravagant. Kraepelin noted
that patients may:
run out of the house in a shirt, go to church in a
petticoat, spend the night in a field of corn, give away
their property, disturb the service in church by
screaming and singing, kneel and pray on the street,
fire a pistol in the waiting-room, put soap and soda in
the food, try to force their way into the palace, throw
objects out at the window. A female patient jumped
into the carriage of a prince for a joke . . . A male
patient appropriated the property of others in taverns.
Another appeared in the court of justice in order to
catch a murderer.
STAGE III MANIA: DELIRIOUS MANIA
Kraepelin (1921)
The transition to delirious mania is marked by the appearance
of confusion, more hallucinations, and an intense
exacerbation of all the symptoms seen in stage II. There
may be a dream-like clouding of consciousness and
patients may become unaware of where they are; incoherence
may appear and, as described by Kraepelin, ‘Their linguistic
utterances alternate between inarticulate sounds,
praying, abusing, entreating, stammering, disconnected
talk, in which clang-associations, senseless rhyming, diversion
by external impressions, persistence of individual
phrases, are recognized’. Hallucinations become prominent,
and as further described by Kraepelin, ‘The patient
sees heaven open, full of camels and elephants, the King,
his guardian-angel, the Holy Ghost; the devil has assumed
the form of the Virgin Mary. The ringing of bells is heard,
shooting, the rushing of water, a confused noise; Lucifer is
speaking; the voice of God announces to him the day of
judgment, redemption from all sins’.
With this evolution into stage III, overall behavior
becomes very fragmented, and patients may ‘become stupefied,
confused, bewildered’, they may:
dance about, perform peculiar movements, shake
their head, throw the bedclothes pell-mell, are
destructive, pass their movements under them, smear
everything, make impulsive attempts at suicide, take
off their clothes. A patient was found completely
naked in a public park. Another ran half-clothed into
the corridor and then into the street, in one hand a
revolver in the other a crucifix.
Etiology
Kraepelin (1921)
The various causes of mania are listed in Table 6.4, in which
they are organized into several groups. The first group is