Brit. J. Psjchiat. (i97@), 127, 78—85

Models of Mania: An Individual By D. R. HEMSLEY

and H. C. PHILIPS

Summary A longitudinal study ofa single case ofmanic-depressive between @

ments

psychiatric

were

made

ratings, reaction on

9 occasions

Case Study

psychosis investigated the relationship

time and two measures

over

a five-month

period.

of autonomic The

number

activity. of slow

Measure

responses

on

the reaction time task increased with increasing depression. Manic periods appeared not to be characterized by a slowing of responses, but rather by an increase in the number of premature responses,

i.e.

those

made

to the

warning

signal.

A derived

performance

index

discriminated

over the complete range from severe depression to severe mania. Increased depression was associated with lower heart rate resting levels, and increasing mania with increased skin conductance levels. An increased frequency of slow reaction times was significantly associated with lower resting heart rate. Skin conductance measures ccrrelated significantly with the number of premature responses made on the reaction time tasks. Some differences in the relationships emerged when data obtained during the administration of lithium were included in the analysis. The results are discussed in relation to both the bipolar and the continuum models of manic-depressive psychosis. The latter model isnot supportedby thepresentinvestigation, sincemanic episodes were not characterized by a more severedeparturefrom normalitythan depressive

episodes

on either the number

of slowed

Irrri@oDuc'noN On the basis of clinical observations it would

findings

depressive psychosis. The prediction would be that variables reflecting changes in activation

(e.g.

1954;

ig@@). However,

Woodworth

and

it is possible

that

the

help

of

changes

in

psychophysiological

responses mediated by the autonomic nervous system and the central nervous system (Duffy,

level would show increments during mania and decrements during depression, the degree of mood shift affecting the clarity of this rela tionship. This hypothesis is consistent with a of the disorder

measures.

optimum levels of activation interact with task complexity to produce an ‘¿inverted U' relation ship between activation and reaction time. Activation levels may also be monitored with

with changes in mood state in cases of manic

view

or autonomic

(Teichner,

Schlosberg,

seem reasonable to hypothesize differences in the level of activation (or ‘¿arousal')correlated

bipolar

responses

1973).

Although

the

intercorrelations

between

these measures on a single occasion are not high (Lacey, 1956), it is well established that they are indicative of changes in activation (Duffy,

Silverman,

1969). Changes in activation or arousal might be monitored in various ways and it is not clear that such measurements all reflect a single

systems depends

arousal continuum.

problems of measurement, individualdiffer

It has been found that reaction time can be used to monitor activation level. Stimuli which

ences, homeostatic mechanisms, psychosis(Claridge,1967).

are known to affect the level of activation, e.g. drugs, fatigue and motivational differences,

Reaction time and manic depressive psychosis

have frequently been reported to influence reaction time, though there are some ambiguous

The relatively gross changes in behavioural activation found in manic-depressive psychosis

1973). The

78

degree of intercorrelation between

on a number

of factors, such as and

possibly

BY D. R. HEMSLEY

might show either a linear or an inverted U relationship with simple reaction time (Figure Ai, Bi). Court (1968, 1972) has proposed a third alternative, suggesting that the beha vioural manifestations of mania and depression

may be superficial and not necessarily of aetio logical significance. Court puts forward a continuum model of manic-depressive psychosis, with mania a more severe departure from normality

than

depression

(Figure

Ci,

Cii).

His arguments are based on clinical, biochemical and psychological data. Although he has brought together a mass of data, some of his conclusions seem faulty (Silverman, 1969). Simple reaction time has been shown to bear a close relationship to the degree of severity of illness and to changes in clinical state (Court, 1964; King, 1969). Court's model suggests that hypomanics

and

manics

should,

as a group,

be slower than normals and depressives. This was confirmed in his i@68 study which corn pared

normals

and

depressed

and

manic

patients on a simple reaction time task, with preparatory intervals ranging from i to i6 seconds. These resultswere criticized by Silverman (1969) on the ground that some of the depressed group had shown no manic episodes

and

might

therefore

have

been

suffering

from a genetically distinct form of depression (Winokur and Clayton, 196g). As Court him self points out, a study which remains to be carried

out to confirm

the continuum

model

measures and manic-depressive

H.

other

C. PHILIPS

79

data on psychophysiological

mediated

by

the

autonomic

responses

nervous

system

need to be considered. There appear to be no recent studies of the psychophysiology of manic depressive psychosis, but there is general agreement that in depression there is a signifi cant

reduction

in basal

sweat

gland

activity,

i.e. low skin conductance (S.C.) (Lader and Wing, 1969; Noble and Lader, 1971a). Re duced

spontaneous

fluctuations

were also rela

ted to retarded depression. Less clear-cut results have been found for the cardiovascular system.

Noble

and

rate unchanged pressed

patients,

Lader

(1971b)

found

pulse

after ECT in a group of de although

forearm

blood

flow

was found to be lower prior to ECT. Lader and Wing (1969), however, found a trend towards higher basal pulse rate in a group of retarded and agitated depressives, compared with nor mals, though

the difference

was significant

only

for the agitated depressives. Hence Court's model is not fully supported by the data from autonomically mediated responses, which are more consistent with bipolar models (Figures Mi, Bii). However, Court (1972) does accept the possibility of some

low arousal measures in mania and depression if Claridge's view (i 970) is correct and the psychoses are characterized by a dissociation of arousal measures. Only with data collected during

mania

can

the

issue

be further

clarified.

is

the repeated testing of a group of patients at differing pointsalongthecontinuum. Psychophysiological psychosis

AND

Aims of present study

The usefulness of the individual case study in psychological research has been discussed by Shapiro(1966).He has distinguished between the observation of particular detailed configura tions of behaviour and the observation of rela tionships between different kinds of phenomena. The present longitudinal study investigated the relationships between mood change, reaction

Court (1968, 1972) also draws on psycho physiological data from studies of skeletal muscleand EEG reactivity tosupporthismodel of manic-depressive psychosis (Whybrow and Mendels,1969).The latter authorshypothesize time and autonomic indices (Skin Conductance an unstable state of the central nervous system and Heart Rate) over a number of cycles in a leading to a disorganized hyper-reactivity in single case of manic-depressive psychosis. depression which iseven worse in mania. The Three possible sets of relationships were implication of this view is that there is a dis suggested by the literature, referred to from sociation of mood state, behavioural indices now on as A, B and C. C corresponds to of activation and psychophysiological measures. Court's continuum model, A and B represent The data they review on skeletal and C.N.S. variants of the bipolar model. The alternatives indices do in part support this view; however, are illustrated diagrammatically. Model A

8o

MODELS OF MANIA:

AN INDIVIDUAL

CASE STUDY

investigation between I.

is a pilot study of the relationship

these

variables

in

manic-depressive

psychosis. I!

METHOD

The subject The patient investigated was a 27-year-old man with a history of marked mood swings between depression and mania. The cycle had begun four

at A (ii)

FIG. A.

years previously following a suicidal attempt.

N

N

E 0@1

During

his depressive periods, he showed depressed mood; he occasionally felt suicidal, but was most charac teristically apathetic, retarded and extremely drowsy. When hypomanic he showed flight of ideas, elation, distractibility and constant restless movements. He

had no hallucinations or delusions, and his cognitive state was unimpaired. The swing between the two B (i)

moods was relatively

B (ii)

FIG. B.

periodicity

four

to

five

weeks.

showing During

a in

patient treatment at the Maudsley Hospital he was diagnosed manic-depressive psychosis—circulartype

I

(2963). Treatment had included antidepressants, pheno thiazines, lithium carbonate (‘Priadel'), haloperidol and ECT. No marked clinical improvement had been achieved, except with ECT. When a course of

m 0

H

tl

C (i)

ECT was given in a depressive phase it appeared to break the cycle for 2 to 3 months, during which time the patient appeared stabilized. The patient was first

C (i@

Fio. C. predicts normal

fast and reliable,

of about

that responses in mania, and

will be faster than slower in depression.

A similar relationship is predicted for auto nomic measures, i.e. arousal higher than normal in mania and lower during depression. Model B suggests that both depression and mania will result in slower responses

than normal,

but no

clear prediction is made as to the relative speeds in mania

and

depression.

Autonomic

indices

seen

during

such

a post-ECT

period.

At this time

both the psychiatrist and the patient himself felt that he was close to his own ‘¿normal' level. During

the

assessment

period

to be described,

the

patient was being given orphenadrine for a residual Parkinsonian

tremor,

night

sedation,

and

occasionally

haloperidol to control hypomanic episodes. Lithium was recommenced

during the last few weeks of this

study. Because of possible effects of this drug on the study, the results have been analysed both with and without those occasionswhen lithium was being taken.

are considered to relate to manic and depressive episodesas in Model A. Model C predicts Procedure reaction

time

in

mania

to

be

longer

than

reaction time in depression, which will itself be longer than reaction time in normality. Auto nomic measures should parallel these changes. The three models suggested do not represent all the possible relationships between the variables under consideration. The present * Court's

model

is not

explicit

in predicting

which

arousal measures might increase in depression and mania, and which might decrease. However, the measures are expected to deviate from normality in the same direction

for both depression and mania.

During a five-month period, the patient was seen on nineteen occasions, at which times mood ratings,

reaction time and psychophysiological data were collected. On three occasions during this period psychophysiological data could not be collected, so that only the two other measures were obtained. This loss was due to technical problems unrelated to

the patient's clinical state. On each occasion the patient completed the reaction time task. This was followed immediately by an assessment of the psycho physiological variables. The patient then had an interview

with

observer rating.

his psychiatrist,

who

completed

the

8r

BY D. R. HEMSLEY AND H. C. PHILIPS

variations

Measures

Ps,chiatric rating: The rating was on a 7-point scale: severely

depressed,

moderately

depressed,

slightly

ment

in activation.

followed

the

Psychophysiological

reaction

time

task

assess

immediately,

and involved a minimum of 15 minutes of seated

depressed, normal, slightly manic, moderately manic,

resting behaviour. After the electrodes to assess HR.

severely manic. This was as used by Coppen ci al. (@@7i). The rating was made independently on each

remain

occasion of testing by one of the authors and by the consultant psychiatrist in charge of the case. The

data was then recorded. An attempt was made to assess responsivity to tones by presenting a series of

inter-rater

reliability

of the scale (rank correlation

and S.C. had been attached, the patient was asked to as still as he could.

auditory

signals

(i,ooo

Ten

minutes

Hz, 85 Db,

of resting

i sec. duration)

in

coefficient) was 0 92 ; this was considered sufficiently

a sequence approximately 6o sees apart. However, a&

high for only one set of ratings

mentioned previously, phasic data proved impossible

subsequent

analysis

to be used in the

to assess. On two occasions the patient pulled off his

of the data.

Although the selection ofthis case was influenced by the relatively unambiguous periods of mania, nor mality and depression, it can be argued that the use

of two unipolar scales for depression and mania would have been more appropriate to allow for the recording of mixed clinical states. Reactiontime: The task was a simple reaction time experiment with a light as a signal. The warning signal was a tone delivered through headphones. The preparatory interval varied from 50 m.secs to 95°m.secs. Inter-trial intervals ranged from 5 to 9

electrodes and period. Sweat gland

headphones activity

during

the

recording

was assessed by utilizing

silver-silver-chloride electrodes attached to the palmar aspect of two fingers on one hand, and recording

resistance on a Grass polygraph throughout.

skin

The data.

were sampled at onset and at the end of the ten minutes of basal activity. These scores were then converted

into log skin conductance

scores were obtained

skin conductance

in each

units. Thus two

session.

fluctuations

The number

were

of

also counted

seconds. Each session consisted of , io trials. There was a reaction time ceiling of45o m.sec. built into the

during the first minute and the last minute of the

apparatus;

tion was that used by Lader and Wing (1966). H.R. was assessed by means of a plethysmo-@

the measure

of slowness taken

in this

study was the number of trials in which this ceiling was equalled or exceeded. It was felt that a more elaborate unjustified

analysis of the reaction time data was in view

of the

relative

crudeness

of the

psychiatric rating.However, the measure does not distinguish between ‘¿slow' and ‘¿omitted'responses.

A measure of premature responseswas also obtained; this represented stimuli

a response

to the warning

signal

rather than to the signal itself.

P@ychophjsiological measures: The psychophysio logical measures taken were H.R. and S.C. during basal state recordings (io-minute period of no

ten-minute

resting

period.

The criterion

of a fluctua.@

graph attached to the ear lobe. The pulse signal produced was converted into a running histogram of heart rate. The data for analysis were selected in the

following way. The highest and lowest heart rate recorded in a io sec. epoch at onset and immediately preceding the end of the ten-minute resting period. were assessed. Consequently for each session: the highest

four scores were derived and lowest heart rates at

both onset and end of the basal period. RESULTS

stimulation).It was found impracticable to assess Reaction time, premature responses and responsivity to stimulation, in addition, for the

following three reasons. During depressive periods, little if any responsivity could be found to fairly

psychiatric ratings

Fig. i indicates the mean number of reaction

intensetones.Lader and Wing (1969)reportsimilar times more than or equal to 450 m.sec. (N) at each point on the psychiatric rating scale. difficulties with retarded depressed patients. Re peated

testing

over

a number

of months

led to an

Fig. 2 indicates the mean number of premature

added confusion: habituation of responsivity. Finally,

responses

there were large practical problems of keeping the

signal, at each point on the psychiatric rating scale.

patient seated with electrodes and earphones on for more than io minutes within a hypomanic phase. All in all, it became necessary to assess only resting data.

(P),

i.e.

responses

As can be seen, it appears

to

the

warning

that the frequency

of slow responses is related to the depressive

The actual measures (S.C. and H.R.) were chosen for their relevance to previous work on depression,

mood swings, whereas the premature vary with the hypomanic episodes.

ease of measurement,

number of observations at each point on the rating scale precludes an analysis of differences

and well-documented

associa

tion with changes (increments and decrements) with

responses The small

MODELS OF MANIA: AN INDIVIDUAL CASE STUDY

82

between mood levels. The correlation between rating and N, over the fifteen drug-free sessions, is —¿036 (n = I 5, NS). This is in the direction of increasing frequency of long reaction times

110

@

90

with

70

increasing

depression.

If the

last

four

sessions, during which the patient was receiving lithium, are included, the correlation rises to —¿o6o(n = ‘¿9, p < o.oi). The correlation between premature responses (P) and mood ratings is significant, whether or

2 A 30 10

not —¿1

0

+1

+2

+3

Psychiatricrating

one

includes

the

final

n = 15, r = +o84 n = 19, r —¿+o8I increasing

mania

four

trials.

With

(p < o.ooi), and with (p < o@ooI). Thus

is significantly

associated

with

the occurrence of premature responses. FIG. I.

It

appears

therefore

that

the

reaction

time

index (N), marks the depressive range, whereas 12

the

10

A

responses

derived

@

sessions

@3

was

—¿08 I (p