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Manic-depressive psychosis
M
a n i c - d e p r e s s i v e p s y c h o s i s is a n affective disorder
producing periodic disruption of apparently n o r m a l
moods by pathological depression or elation.
Although a single m a n i c state i n a lifetime is not u n c o m m o n ,
m a n i c - d e p r e s s i v e illness is u s u a l l y seriously disabling, h a r d to
u n d e r s t a n d , a n d often difficult to treat. Before the advent of
mood-stabilizing drugs, the most effective treatment w a s E C T ,
w h i c h is still occasionally u s e d i n dangerous crises a s a life
saving strategy. Impressive anti-depressive a n d a n t i - m a n i c
medication, a n d compelling evidence for a genetic component
i n the illness, have focussed attention on biological aspects of
the disorder. E v e n w h e n allowing for s u c h genetic influences a s
a n e c e s s a r y c a u s a l factor, there exists a n equally compelling
c a s e for the parallel study of developmental psychology if a
sufficient c a u s a l explanation is to be found.
P s y c h o a n a l y s t s have long contributed to the u n d e r s t a n d i n g
of factors involved i n the predisposition to m a n i c - d e p r e s s i o n ,
to the precipitation of episodes, a n d to its p s y c h o d y n a m i c s .
A b r a h a m (1911, 1924) a n d F r e u d (1917e [1915]) laid the foun
dations for the u n d e r s t a n d i n g of the n a t u r e of pathological
135
136 UNIMAGINABLE STORMS
NICOLA
First session
Nicola is depressed and withdrawn and sits motionless in her
chair. She is dressed in pyjamas and dressing gown and has
bandages on her wrists from a recent suicide attempt She had
smuggled a razor-blade onto the ward and cut herself badly.
This was one of many attempts and followed an incident in
which another patient had set fire to herself resulting in serious
harm. This had activated a hypomanic response in Nicola,
followed the next day by depression and suicidal behaviour.
The following excerpt begins 5 minutes into the interview and
finishes 15 minutes before the interview ends.
, . . Pause . . .
* * *
Second session
* * *
Third session
The following day. Nicola, MJ, and the ward psychiatrist are
present.
* * *
Fourth session
Two days later. Nicola strides into the room, grinning.
Nicola: You don't m i n d if I smoke, I hope? Is there a n a s h t r a y
around? No a s h t r a y ? O h dear. 111 have to throw it on the
floor. [Sits down.] What are you grinning about?
MJ: Well, your grinning is very sad, actually.
Nicola: My grinning isn't sad. I'm quite happy.
M J : I think you Ye trying to make yourself feel happy so you
won't feel s a d , really.
Nicola (shouts and points]: Why didn't you come a n d see me
at 1:15? And why couldn't I go over to the Institute?
MJ: Good question. Have you got any ideas?
Nicola: B e c a u s e I've r u n away, of course.
M J : We didn't have enough n u r s e s to make sure that you
wouldn't r u n away. So I've had to come to see you here [on a
locked ward].
Nicola: Well, that's a shame. I'm sure you didn't enjoy the
trip.
M J : I think it would be easier for you to think that I didn't
want to come a n d see you than to think that I actually did
want to come to see you.
Nicola gets up and walks round the room.
M J : I understood that you wanted to speak to me on the
telephone.
Nicola [shouts]: Yes I did.
MJ: Could you try sitting down for a minute?
Nicola sits.
MJ: Do you remember . . .
Nicola: I don't know what I wanted to say now. I've forgotten.
M J : Your mood h a s changed. You weren't quite so excited
then a s you are . . .
Nicola [shouts]: I'm NOT excited. T h i s is a myth. [Gets up,
walks around.] I m u s t have a n ashtray. C a n you get me a n
a s h t r a y ? [Walks around looking for an ashtray.]
MANIC-DEPRESSIVE PSYCHOSIS 147
* * *
In the following, sixth session Nicola has come down from this
mood of pathological elation and is barely able to speak.
148 UNIMAGINABLE STORMS
Sixth session
Three days later. Nicola sits crumpled and withdrawn.
Nicola: No.
M J : Do you try to remember, or is it that you try not to
remember?
. . . Pause . . .
* * *
Follow-up