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Chapter 2 of Manic Depressive Disease, Clinical and Psychiatric Significance, by John D. Campbell, MD, copyright 1953:

 

 

 

 

Cycloid Personality

 

 

one of the principles upon which modern psychiatry is built is that individuals with a particular temperament are more susceptible to a certain psychosis.  The significance of the prepsychotic personality, as we have observed, was recognized by Hippocrates and Aretaeus.  Schizophrenia, for instance, usually occurs in the introverted, seclusive personality type, known as schizoid, whereas manic-depressive psychosis is more likely to develop in the outgoing, friendly cycloid personality.  This principle at once, of course, acknowledges the relative, as well as the inherent nature, of these mental aberrations, and emphasizes the importance of basic personality in the etiology.  Furthermore, it is axiomatic that he who cares to understand manic-depressive psychosis, should be thoroughly conversant with the material from which the illness springs.  The diagnosis of a stuporous, maniacal or inaccessible patient, for instance, may depend upon knowledge of the patient’s fundamental traits.

 

discussion of terms

 

The term cycloid personality is an overall or general appellation, indicating all forms of the prepsychotic manic-depressive personality.  The cycloid personality may occur in one of three forms, with innumerable gradations and mixtures between the three.  First, is the hypomanic personality, the overactive, jovial, friendly, talkative and confident individual who, if he becomes psychotic, usually develops the manic form of manic-depressive psychosis.  (The term hypomanic is also sometimes used to describe mild manic attacks of manic-depressive psychosis.)  Second, is the depressive type, the worried, anxious, thoughtful, sorrowful, individual who, if he becomes psychotic, usually develops the depressive form of manic-depressive psychosis.  The third form of the cycloid personality is the cyclothymic personality who may have mixed traits, or be euphoric and friendly at one time, and depressed and pessimistic at another, and who may develop either a manic or depressive reaction, or swing from one into the other.  It is important to realize that the manic reaction, melancholia, hypomanic reaction, cyclothymia personality, cycloid personality, depressive personality and periodic insanity, are all a part of the same disease process, and that any one of these may change into any other.  The more we observe these variations of the cycloid personality, the more flexible we realize them to be, and the more we appreciate a general term, such as cycloid.  Despite the great variety of terms, the student will observe that the manic-depressive process is a homogeneous, undulating, but consistent, personality deviation, which may be observed in many individuals long before a psychosis occurs.

 

historical note

 

The relationship between the cycloid personality and manic-depressive psychosis was discussed by Reiss, Kretschmer, Bleuler, Kraepelin, Bowlby and others.  Reiss, in 1910, described the prepsychotic temperament of individuals who developed manic-depressive psychosis, and classified them into (1) depressive temperament; (2) manic temperament; (3) irritable temperament; and (4) cyclothymic temperament.  Kretschmer, in 1925, published his book, “Physique and Character” in which he discussed the physical and personality aspects of both the schizoid and cycloid personalities.  The asthenic type, slender with a long neck, thin chest, long extremities, tapering fingers and a delicate skin, was said to occur in 46 per cent of schizophrenic patients.  He stated that the opposite type, the pyknic, with short neck, average height, thick chest, short limbs and thick muscles, was present in 84.6 per cent of patients with manic-depressive psychosis.  In the same work Kretschmer analyzed the prepsychotic personality of patients, linking the psychologic attributes to the physical traits, thus emphasizing the constitutional basis of personality.

 

As a result of his observations Kretschmer concluded that the prepsychotic personality of the manic-depressive patient conformed to a definite pattern; it was he who designated this the cycloid personality, and distinguished it in physique and temperament from the schizoid personality.  Although Kretschmer noted that some cycloids are friendly, overactive, jovial and sociable, while others are slow, serious, agreeable and sorrowful, he applied the same term to both varieties.  His reasoning in doing this is beautifully summed up in the following statement: “Men of this land have a soft temperament which can swing to great extremes.  The path over which it swings is a wide one, namely between cheerfulness and unhappiness....  Not only is the hypomanic disposition well known to be a peculiarly labile one, which also has leanings in the depressive direction, but many of these cheerful natures have, when we get to know them better, a permanent melancholic element somewhere in the background of their being....  Goethe’s mother, a woman of the sunniest hypomanic temperament, gave her servants the strictest orders never to tell her anything unpleasant, so greatly did her emotions need this artificial protection from themselves.

 

We ought not, therefore, to describe cycloid individuals, even apart from intermediate grades, as simply hypomanic, or simply depressive.  For in many hypomanics there is hidden a small depressive component, and in the majority of cycloid melancholies there is a vein of humour.  The hypomanic and melancholic halves of the cycloid temperament relieve one another, they form layers or patterns in individual cases, arranged in the most varied combinations.”

 

Kretschmer also observed a marked tendency for this type to occur in certain families.  Bleuler and other workers readily accepted the indisputable observations made by Kretschmer, except that Bleuler applied the term syntonic instead of cycloid.

 

kraepelin on cycloid personality

 

Kraepelin, in 1913, also made a study of the prepsychotic manic-depressive personality, emphasizing the hereditary factors, the continuity between the various forms of the manic-depressive process, and the good prognosis even when the patients become psychotic.  Under the heading of “Fundamental States,” Kraepelin, in his book, discusses the depressive temperament, the manic temperament and the cyclothymia temperament.  He indicates the chronic, worrying disposition of the depressive personality, his “susceptibility to the cares, the difficulties, and the disappointments of life,” and adds: “Every task stands in front of them like a mountain....  They are distrustful, regarding themselves as nature’s stepchildren, are not understood by their surroundings, and they like to occupy themselves with thoughts of death, even already in childhood’s years.”  Kraepelin mentions the feeling of guilt, the unreasonable fear of failure, sentimental outlook, sexual squeamishness, overconscientious attitude, excessive anxiety, and indecision, we so often observe in the depressive personality.  Their lack of self-confidence causes them, he says, to avoid examinations and thus withdraw more and more from association with people.  Suicide, he mentions, is a frequent thought in the minds of these individuals.  Such somatic complaints as nervous exhaustion, dull pressure sensation in the head, palpitation, headaches, impotence, nervous dyspepsia and insomnia, he states, are often complained of by these depressive personalities.

 

Kraepelin continues: “the morbid picture here described is usually perceptible already in youth, and may persist without essential change throughout the whole of life.”  He then mentions the exacerbations, the fluctuations and recurrences, and adds: “It is exactly the fluctuations of the state progressing imperceptibly to real attacks which point to the inner relationship of the depressive temperament with manic-depressive insanity.”

 

Kraepelin’s description of the manic temperament in his chapter on “Fundamental States” goes too far over into the hypomanic or outright manic picture but here again he shows excellent insight into his subject: “The intellectual endowment...  is for the most part mediocre, sometimes even fairly good, in isolated cases excellent.  They acquire, however, very imperfect and unequal knowledge, because they show no perseverance in learning, do not like exerting themselves, are extraordinarily distractible, and seek to escape in every way from the constraint of a systematic mental training....  Their understanding of life and the world remains superficial...  the remembrance of former events fleeting, colored by partiality, and falsified by numerous personal additions;...  judgment is hasty and shallow....  The mood is permanently exalted, careless, confident.  The patients put an extremely high value on their own capabilities and performances, boast with the most obvious exaggeration.  They wholly lack understanding for the morbid imperfection of their temperament....  They are convinced of their superiority to their surroundings....  Toward others they are haughty, positive, irritable, impertinent, stubborn....  They are usually ready for jokes, even for self-derision, for conversation and pastimes of all kinds and for all sorts of tricks.  Now and then once in a way anxious or mournful moods also may temporarily be present.”  (Author’s italics)

 

Kraepelin continues his description of the hypomanic thus: “The slightest forms of disorder lead us to certain personal predispositions still in the domain of the normal.  It concerns here brilliant, but unevenly gifted personalities with artistic inclinations.  They charm us by their intellectual mobility, their versatility, their wealth of ideas, their ready accessibility and their delight in adventure, their artistic capability, their good nature, their cheery, sunny mood.  But at the same time they put us in an uncomfortable state of surprise by a certain restlessness, talkativeness, desultoriness in conversation, excessive need for social life, capricious temper and suggestibility, lack of reliability, steadiness, and perseverance in work, a tendency to building castles in the air and scheming, occasionally unusual activities.  Now and then one possibly hears also of periods of causeless depression or anxiety, which usually are traced back to external circumstances, overwork, disappointments.  This experience, as also the further circumstance, that we very often see the parents, brothers and sisters, or children end in suicide, in mournful moodiness, or fall ill of definite manic-depressive insanity, suggests to me that that kind of strongly-developed sanguine temperament is to be regarded as a link in the long chain of manic-depressive predispositions.”  Throughout his book, Kraepelin constantly reminds us that not only are the various phases of the disease all a part of a single entity, but that we may look for similar manifestations in other members of the patient’s family.

 

Of the “irritable temperament” Kraepelin states as follows: “The patients display from youth up extraordinarily great fluctuations in emotional equilibrium and are greatly moved by all experiences, frequently in an unpleasant way.  While on the one hand they appear sensitive and inclined to sentimentality and exuberance, they display on the other hand great irritability and sensitiveness.  They are easily offended and hot tempered, they flare up, and on the most trivial occasions fall into outbursts of boundless fury....  The patients are positive, always in the mood for a fight, endure no contradiction, and therefore, easily fall into disputes with people round them, which they carry on with great passion....  In the family also they are insufferable, capricious, threaten their wives, thrash their children, have attacks of jealousy.  The coloring of mood is subject to frequent change...  they shed tears without cause, threaten suicide, bring forward hypochondriacal complaints, go to bed.  At the time of the menses the irritability is usually increased.”

 

Finally, regarding the cyclothymic temperament, Kraepelin states: “It is characterized by frequent, more-or-less regular fluctuations of the psychic state to the manic or to the depressive side.  It was found only in three to four per cent of our patients, but without doubt in reality is much more frequent, as it is the invariable introduction to the slightest forms of manic-depressive insanity which run their course outside of institutions, and frequently leads to them by gradual transitions.”

 

Kraepelin understood the manic-depressive process, and its connection with the “fundamental states,” more thoroughly than any other observer, before or since, with the possible exception of Kretschmer.  With such graphic descriptions of the cycloid personality, which so accurately fit our patients today, it is surprising that modern psychiatry has neglected this important personality type.  Unfortunately, the description of the cycloid personality has become so scant that it is often completed by stating that the individual is an extrovert, or that he is subject to mood swings.  Even Kraepelin, however, failed to show the connection between the depressive personality and clinical medicine, a task which is left to the modern psychiatrist with his great opportunities in the general hospital.

 

description of cycloid personality

 

It has been the writer’s custom to describe abnormal personality types under the four major inherent traits, intelligence, conscience, emotional stability, and psychosexual development, and two secondary char­acteristics, sociability and special modes of adjustment.

 

Intelligence.  While the schizoid personality and the psychopathic personality are conspicuously abnormal, the cycloid often goes unrecognized in everyday life.  The inconspicuous nature of the cycloid personality indicates the close similarity between this type and the normal.  For instance, the intelligence of the cycloid is average, or moderately greater than normal; furthermore, his mental processes are not well suited to eccentric, abstract, or theoretical thinking, but are much more adapted to the practical affairs of life.  Due to a relative degree of psychomotor retardation, the depressed cycloid thinks slowly and often reaches decisions laboriously.  The mental processes of the hypomanic, on the other hand, are quick and usually efficient, characterized by increased psychomotor activity.

 

The cycloid’s strong feeling of insecurity, associated with normal intelligence, make of him a hard worker, a plugger; the depressive is a slow, meticulous, conscientious worker, while the hypomanic is aggressive, often brilliant, perhaps an opportunist, whose abnormal drive and energy are directed toward more and more accomplishment.  Indeed, this combination of traits, insecurity plus normal intelligence, probably accounts for the fact that the cycloid usually is found in the upper brackets of society, economically and socially.

 

Conscience.  The cycloid personality is inherently a conscientious individual.  While the life of the depressive is virtually dominated by his conscience, the hypomanic is constantly aware of this censor which guides his daily activities.  Many of the cycloid’s psychic and emotional reactions, his peculiar complexes, scruples, phobias and feelings of guilt, stem from his abnormal endowment of conscience.  The cycloid’s conscientious attitude is often reflected in his choice of occupation.  Teaching school, preaching, practicing medicine, holding public office, working as executive of a large company, as president of a bank, or serving as secretary of a union or other organization, are a few of the kinds of work which inevitably attract the cycloid, particularly the depressed type.

 

In concluding the subject of conscience, it should be noted that the cycloid’s conscientiousness is intimately related to his emotions and will be found to vary from one cycloid to another, and from time to time in the same cycloid individual, determined to a great degree by the emotional reaction.  The hypomanic, for instance, with his optimistic outlook, is not so troubled by his conscience, while the same individual, in a depressive swing, has morbid thoughts of remorse.  Like everything else in the cyclothymic process, the emotional reaction seems to set the pattern.

 

Emotional Reaction.  The mood swings, usually described as the chief characteristic of the cycloid personality, are not always conspicuous, certainly not in the regular undulations most of us were taught in our courses in psychiatry.  Indeed, depending upon mood swings alone to diagnose the cycloid personality would be very misleading.  Some cycloid personalities are mildly hypomanic throughout life, some mildly but consistently depressed, while others show definite mood swings from one phase to another.  Female cycloids suffer depressive swings particularly just prior to or during the menses.  Some cycloids are hardly aware of mood swings while for others they are transiently disabling.  When conspicuous, the patient usually has apt descriptive terms, such as the following: “I am either way down in the dumps or up in the skies;” one patient marked on the calendar the days she was “up” and the days she was “down,” so she could determine whether life is worth living.  Chronically depressed cycloids often say, “life has always been sad for me.”  The hypomanic, usually exuberant, optimistic and loquacious, often hides away during a depressive swing, becomes intoxicated, or makes other attempts to run away from himself, as well as from the environment, until the melancholic reaction passes.  Kretschmer gave us a good description of the typical cyclothymic personality: “The temperament of the cycloids alternates between cheerfulness and sadness, in deep, smooth, rounded waves, only more quickly and transitorily with some, more fully and enduringly with others.  But the mid-point of these oscillations lies with some nearer the hypomanic, and with others nearer the depressive pole.”

 

Insecurity, stemming from an inherent feeling of inadequacy and lack of confidence, secondary to a depressive mood, is a complex emotion, goaded by anxiety, apprehension and a desire to be wanted and needed.  This feeling of insecurity not only drives the individual on to more accomplishment, but it also accounts for many of the conflicts in the patient’s social and family life.  Unreasonable and pathologic ambition, selfishness and jealousy result from strong feelings of insecurity.

 

Anxiety is just as strong and important in the cycloid as in the psychoneurotic personality.  Sensitiveness and self-consciousness, which lead to the development of ideas of reference, are other important emotional reactions in the cycloid.  It will be observed later how depression, sensitiveness and ideas of reference constitute the basis for delusional thinking in the psychotic phase of the manic-depressive process.  Based upon an unrelenting conscience, the cycloid, from early years, is plagued with latent ideas of guilt and feelings of remorse.  As the manic-depressive process goes through its exacerbations these feelings of guilt and remorse may develop into delusions of a similar nature.  Nervous tension, sensitiveness to noise, tendency toward insomnia, and a low threshold to irritability are other traits which reflect the nature of the cycloid’s nervous system.

 

Psychosexual Development.  There is a sexual deviation in the cycloid personality, on a physiologic basis, characterized by an increase and diminution of sexual desire and satisfaction, varying with the phases of the psychosomatic process.  The depressive cycloid is often deficient in libido and may for this reason be late in becoming married.  The depressive cyclothymic state in women is one of the chief causes of relative frigidity in that sex.  The female depressive personality often states that although she has been married for years, she has never experienced an orgasm.  When a psychotic episode ensues the female depressive not infrequently concludes (and the physician too often concurs or encourages this idea) that the “nervous breakdown” is due to sexual incompatibility with the present spouse.  Marital discord, separations, infidelity and divorces occur because of insufficient sexual desire and the erroneous conclusion that better sexual relations could be had with another partner.  The fact that an occasional depressive patient has excessive libido will be discussed further in the chapter on autonomic disturbances.

 

The impression that the relative impotency or frigidity in the depressive is on a physiologic basis is indicated by the common observation that the same individual, in a hypomanic or manic reaction, is sexually aggressive, and often promiscuous in his sexual habits.  Here again, marital discord often results from the hypomanic patient concluding that his sexual partner is insufficient for his needs.  As Kraepelin stated: “Sexual excitability is increased and leads to hasty engagements, marriages by the newspaper, improper love adventures, conspicuous behavior, fondness of dress, on the other hand to jealousy and matrimonial discord.  Several of my patients displayed in excitement homosexual tendencies.”  A female manic-depressive patient in the author’s practice, usually respectable and discreet, during the incipient stage of a manic reaction, insisted upon going to a dance every night, and eventually seduced a neighbor’s husband who became infatuated with her euphoria, enthusiasm and sexual stimulation.

 

There is very little sexual perversion among cycloids but it is not at all unknown.  Most writers (Bowlby, Bond and Partridge) have remarked upon the scarcity of homosexuality among manic-depressives but the writer’s records contain at least a dozen such cases.  Interestingly enough, the homosexuality in these patients seems to be an independent process, having little or no relationship to the inevitable mood swings of the emotional disease.  Quite naturally, such a patient occasionally attempts to explain the depressive reaction as a result of the abnormal sexual practices but several were also subject to manic swings which could not be so explained.  When first observed, some of these patients were diagnosed “homosexual panic” but subsequent observation proved the emotional swings to be an independent process, and that the patients were basically cycloid in temperament.  Asocial sexual behavior is unusual among cycloids.

 

Sociability.  At no level in his make-up is the cycloid personality so consistent and meaningful as in his social adjustment.  It is here that we feel so keenly the continuity of the cyclothymic process, whether we are dealing at the moment with a hypomanic or a depressive, whether the individual is in the relatively mild cycloid state, or in a marked psychotic episode.  The inherent tendency for the cycloid to have a feeling for, and an understanding of, his fellow man, is a trait we can follow throughout his many cyclothymic reactions.  Kretschmer had this to say regarding the cycloid’s social drives: “They feel the necessity to speak out, to laugh out, and to have a good cry.  They seek by the nearest and most natural way, i.e., indulgence in human society, what will bring their spirits into satisfactory motion, rejoice them and lighten them....  For this reason the average cycloid man, especially in the quiet central region, has a sociable, friendly, realistic and accommodating feel about him.  Because his temperament swings with that of the milieu, there is for him no sharp distinction between I and the outside world, no principle of withdrawal, no burning desire to correct according to firmly-held rules, no tragically exacerbated conflict, but a life in things themselves, a giving up of himself to the external world, a capacity for living, feeling and suffering with his surroundings.”

 

The cycloid personality is almost always a friendly, sociable individual.  The hypomanic is particularly affable, garrulous, extroverted and genial.  At times he may become boisterous, mischievous and even obnoxious, but his friends know him as the “life of the party.”  He is often carefree in his manner, extravagant in his habits, and anxious to put on a show.  While he is quick to make friends and can usually laugh off any embarrassing situation, the hypomanic is flighty, fickle and subject to jumping about for variety and excitement.  The hypomanic’s friends are sometimes forced to desert him because of his extravagant habits or his obstinate disposition, especially when crossed.  It is usually his family who must cope with the practical problems of living.

 

The depressive cycloid is also attracted to people and loves companionship, but lacks the erratic manner of the hypomanic.  The depressive prefers a quiet social gathering, avoids noisy crowds and abhors ostentation.  In fact, he often worries for fear people will think he is pompous or trying to live above his station.  The depressive is thoughtful, sympathetic, considerate, sensitive and often apologetic in his relations with his neighbors.  Although sensitive, the depressive cycloid rarely becomes seclusive as does the schizoid.  The physician will often resent the cool aloofness of the schizoid, the critical and sarcastic attitude of the psychoneurotic, but be favorably impressed by the cordiality, humility and graciousness of the cycloid, particularly the depressive type.  As Kretschmer put it: “The... depressives have some soft quality in their moodiness.  If the psychic flow is not hampered by a high degree of repression, one usually has a sympathetic feeling for them, one can always say something friendly to them when occasion arises, in spite of all their despair; they long for encouragement, and, as the obstructions fall away, they have an impulse to express themselves; and when their trouble gives way to treatment, they are unassuming, friendly and grateful.  Patients in whom the obstruction is overpowerful often actually complain very loudly at their own lack of warm, kindly feeling for men and things, a sign that this feeling is their very life element; and in spite of their subjective consciousness of obstruction, when seen objectively, in comparison with a schizophrenic, they still seem affable and kind-hearted.”

 

Special Modes of Adjustment.  Every individual has adopted some compensatory mechanism, some special mode of adjustment which serves to replace or compensate for those factors which are deficient or absent in his own personality.  The schizoid, with his pathologic shyness, seeks a lonely life or an existence which does not bring him into close competition with other persons.  The inadequate psychopath seeks by means of unethical methods to adjust his poorly integrated personality.  The cycloid personality can sometimes be recognized, not so much from the positive factors previously described, as from the special methods of adjustment which the individual has unwittingly discovered to give himself more ease and security in his environment.  Church work, Red Cross, soliciting funds for various charitable or public enterprises, serving his community without pay—all these reflect the cycloid’s insecurity and sharp conscience.  A compulsive tendency toward work and accomplishment has already been mentioned as a compensatory mechanism in the life of the cycloid.  The depressed cycloid may become socially ambitious, or the hypomanic aggressive, as a mode of adjustment for their feeling of insecurity.  Both the hypomanic and the depressive may resort to alcohol as a special mode of adjusting a nervous, tense, anxious insecure personality.  These various modes of escape, compensation or adjustment often reflect, like a mirror, the underlying personality traits of the cycloid.

 

illustrative cases of cycloid personality

 

There are numerous instances of cycloid personality, as there are of psychoneurosis and schizoid personality, who never consult a physician.  There are many other such patients, because of somatic or emotional dysfunctions, who do consult a physician and are treated for nervous tension or such equivalents as gastritis or migraine.  These patients are often recognized by the general physician and internist to be suffering with an emotional illness, and are helped considerably by a patient, understanding attitude, reassurance and mild sedation.  Some remain mildly depressed and clinically ill, without being psychotic, for varying periods of time, while others manifest repeated episodes, some of which could technically be classified as mild psychoses.  Unfortunately, too many of these individuals with episodic or prolonged nervous and depressive reactions, are given a diagnosis of psychoneurosis, the true nature of the reactions not being recognized.  From among this group an occasional patient is referred to the psychiatrist, usually because of some particularly disturbing factor, such as intractable headache or insomnia, suicidal attempt, threatened divorce or excessive alcoholism.  The patient may be mildly and transiently psychotic or simply in an exaggerated state of the cyclothymic personality.  The following illustrative cases were chosen because they are fairly typical of the nonpsychotic or prepsychotic cyclothymic reactions.

 

case 366.  J. M. M., age 38, who was born on a farm, completed the ninth grade at 17, and worked on a construction job, as a truck driver, manager of a grocery and market, and finally became owner of his own wholesale produce and fruit business.  For years he had operated this business, arising at 4:00 A.M.  and working 12 to 16 hours per day.  J. M. was married at 23 years of age to a girl of 18; after living together 15 years they were separated, but not divorced, two months before consulting the psychiatrist.  The patient had had the usual childhood diseases; no serious injuries; appendectomy (for chronic appendicitis) in 1943; tonsillectomy (to relieve tension in throat) in 1946; virus pneumonia in 1947.  He admitted drinking heavily several years before, but only occasionally at the time of the examination.  The patient’s father had died at 57 of a heart attack; his mother was alive and in good health; she had one brother who had been in the state hospital for 10 or 12 years, diagnosis dementia praecox.

 

Coming for the psychiatric examination on May 17, 1948, the patient stated that for three or four years he had been very nervous, tense, unable to relax; restless and unable to concentrate properly; he suffered with frontal and occipital headaches, with pulling sensations in the neck muscles.  Insomnia had been an intermittent symptom.  He had hot flushes at times, hands perspired excessively and his heart would speed up, especially during meals.  He admitted that he was more irritable, impatient and sensitive than formerly, that he had no patience with anyone.  At times, he would become depressed, almost tearful, barely able to control his emotions.  In discussing his marital problem, he admitted being irritable, losing his temper, and at times being unreasonable in his relations with his wife.  She had said to him, in fact, “something has come over you.”  The patient was sensitive and irritable, but denied both ideas of reference as well as hallucinations by name and description.

 

For four years the patient had been consulting doctors, first for headaches and nervousness, more recently for gastrointestinal disturbances and moodiness.  He had had every imaginable test performed and tried various suggested treatments without avail.  A diagnosis of hypercholesterolemia, hypochlorhydria and avitaminosis was made by one internist, but nothing was done to diminish the patient’s anxiety and nervous tension.  He had had three negative gastrointestinal series performed.  One psychiatrist to whom he was finally referred began to search his past life for the cause of his “neurosis,” but accomplished nothing.  The patient was a matter-of-fact, prosaic individual, neither introspective nor demonstrative in a psychoneurotic manner.

 

J. M. was a serious, hardworking worrying type of man who had never allowed himself a reasonable amount of recreation.  His only relaxation in adult life had been obtained through alcohol but, realizing he was becoming an alcoholic, the patient had stopped drinking on his own accord.  He liked people and readily earned their friendship but on account of his nervousness, was unable to take part in social gatherings or other exciting events.  For several years J. M. had narrowed his life down to work, sleep (which was erratic) and worry.  This man was distinctly of a depressive temperament, his wife complaining that “he had never gotten any fun out of life.”  On the other hand, she quickly defended him as being dependable, likeable and kind, except when he was emotionally upset.  Prior to the onset of his present illness, the patient had made rare visits to a doctor, nor had any physician who examined him, except one psychiatrist, considered him to be neurotic.  This patient responded favorably to conservative treatment which will be discussed in detail in a subsequent chapter.

 

case 2.  Mrs. Louise K., age 21, was attending college with her husband, an ex-soldier.  Daughter of a chemist, Louise had completed high school at 16, with very good grades, and had worked in a laboratory prior to entering college.  She was an aggressive, insecure, conscientious, worrying type of person, but obstinate and temperamental.  She smiled normally, made friends easily and liked to be with people.  She was married at 19 to a man 27; the only serious problem encountered in the marriage was that the patient had become pregnant soon after marriage and she was afraid she would not be able to continue her college course.  The patient and her husband were not only carrying heavy college courses, but they were also supervising a church rooming-house on the campus.

 

Louise K. had had most of the childhood diseases, including diphtheria; menstrual periods began at 13 and had been regular until the onset of the present illness when they became scant and delayed.  She had had a tonsillectomy at 14 years of age.  Although the family history was described as free of nervous and mental diseases, the examiner interviewed the patient’s father later and observed that he possessed an insecure, anxious, depressive type of personality.  Although he denied having experienced any outright “nervous breakdowns,” he showed an understanding of his daughter’s illness which could not have been obtained otherwise than by actual experience.

 

The patient dated the onset of her nervous condition to about one year previously when she had spontaneously aborted a three or four months pregnancy.  A month later, she returned to college and her household duties, not allowing herself, as she later realized, sufficient rest.  During the ensuing year she became progressively more irritable and nervous; losing her temper, crying and blaming herself for not being a good wife.  She was tired all the time, lacked energy, but had been able to sleep fairly well.  Although she had frequently lost her temper with her husband, she admitted that he was just and patient, usually giving her the benefit of the doubt.  Louise described guilt complexes about keeping her house immaculate; it seemed that the more depressed and nervous she became, the more meticulous she had to be in her duties.  Since she was majoring in home economics, and there were fellow students in her home, she felt that she must carry on her housekeeping absolutely above reproach.  Although it was not her responsibility, the patient began to worry and fret over the habits of several younger co-eds living in her house.  These things, she recognized, as “borrowed troubles,” but declared she could not dispel them from her mind.  She admitted hypersensitiveness and, although there had been no ideas of reference, she felt insecure and jealous toward her husband’s family.  After they came to visit, the patient would lose her temper, say mean things and, on one occasion, had thrown a stack of dishes on the floor.  Fear of insanity had troubled her some, particularly since she could not concentrate on her school work satisfactorily.

 

It is to be noted that the patient retained a good insight throughout her illness: she blamed herself for misunderstandings with her husband and realized that the guilt feelings, projections and anxieties were not logically founded.  She improved nicely on conservative office treatment, consisting of superficial psychotherapy, mild sedation, intravenous vitamins and rest.  After a few weeks she appeared brighter, less worried and depressed, and could speak with a smile and more spontaneity.

 

Discussion.  These two cases illustrate mild cyclothymic reactions of the depressed type, not of sufficient depth to designate as psychoses.  Such individuals may have two, three or a dozen such reactions, in a lifetime.  Basically, depressive cycloids, these patients nearly always experience an exacerbation of the depressive swing with only an occasional hypomanic reaction.  Neither of these patients, nor other similar cases, can rightfully be called psychotic, but this phase is as much a part of the manic-depressive process as are the truly psychotic reactions.  Indeed, there may be days in the lives of these individuals during which, if they were examined, they would likely be diagnosed as being beyond the realm of sanity.  Observing a large number of patients of this kind over a period of time reveals the fact that this is the material from which truly manic-depressive psychosis arises.  Furthermore, an occasional manic reaction helps to substantiate this conclusion.

 

It will be noted that the symptoms of these cyclothymic reactions, as well as the symptoms of manic-depressive psychosis, are classifiable into three categories: autonomic disturbances, emotional dysfunction, and psychic symptoms.  The two cycloids described in this chapter, for instance, had symptoms chiefly involving the autonomic and emotional spheres.  Neither of these patients showed a great deal of psychic aberration, although they did manifest latent evidences, such as marked sensitiveness, psychomotor retardation and jealousy.  Mental symptoms are rare in the cycloid personality phase while they are prominent in the far-advanced psychotic cases, such as are observed in the state hospital.

 

The second patient described, Mrs. Louise K., had symptoms chiefly in the emotional sphere—one of Kraepelin’s “irritable temperament” cases—with few somatic complaints.  Cyclothymic patients with autonomic disturbances as the chief complaints are usually treated by the general physician.  A patient may have autonomic disturbances dominating the illness in one depression and, a few years later, in another depression, emotional or psychic symptoms may constitute the chief complaints.  As a general rule, however, the cyclothymic episodes in the same patient more-or-less repeat themselves in the quality of symptoms as well as in the degree of the depression. 

 

 

 

fig.  1.  Relative Proportion of Autonomic, Emotional, and Psychic Symptoms in Cyclothymic Reactions.

 

 

Using the principle that all the symptoms of cyclothmic reactions, whether prepsychotic or psychotic, fall into three types, the student will find a helpful scheme in the diagnosis as well as in the understanding of the symptomatology.  The accompanying diagrams (Fig. 1) illustrate that this triad of symptoms—autonomic, emotional and mental—always present in the manic-depressive process, vary in degree from patient to patient.  For instance, the symptoms of the first patient, J. M. M., a cycloid personality, may be represented by Diagram A.  Here we observe a preponderance of autonomic disturbances (somatic complaints), accompanied by a large proportion of emotional dysfunction, and only a small degree of (latent) psychic symptoms.  Patients of this kind are usually treated by the general physician or internist.  Diagram B illustrates the situation in the second patient, Mrs. Louise K., who had a predominance of emotional disturbance with a smaller proportion of autonomic dysfunction, but more evidence of psychic deviation than was present in the first patient, J. M. M.  Diagram C illustrates the proportion of autonomic, emotional and psychic symptoms present in the great majority of patients with mild manic-depressive psychosis, depressed type, the chief subject of this volume.  Diagram D represents the symptomatology of a severe case of manic-depressive psychosis, the type of patient usually observed in the state hospital; the majority of the symptoms are psychic, about one-fourth are emotional, and there is usually only a small percentage of autonomic disturbances in these far-advanced depressions.  If the reader will refer back to these diagrams as he peruses the subsequent chapters, he will appreciate more and more the significance and value of this scheme.

 

cycloid personalityhypomanic type

 

The hypomanic cycloid differs from the depressive in that he rarely suffers with autonomic disturbances or somatic complaints.  Indeed, the physiologic functions seem to be smoother than normal in the hypomanic.  An illustrative case at this point will help to contrast the hypomanic with the depressive cycloid.

 

case 507, David R., age 37, was observed by the writer intermittently over a period of five years.  David’s mother had manifested manic-depressive emotional reactions most of her life, having experienced both manic and depressive episodes, requiring hospitalization on two occasions.

 

Although David R. had a position as clerk with a large corporation, he spent his spare time selling insurance.  Being a person with an extraordinary amount of energy and ambition, this avocation afforded him an outlet for his excess zeal and enthusiasm.  While he was friendly, smiling, congenial, one could never feel that David R. possessed much depth or discernment.  His light-hearted emotional reaction seemed to drive him along at a shallow level, never seeking a deeper understanding of life or people.  He laughed easily, talked a great deal, but always avoided a serious, introspective discussion of himself.  Occasionally, when particularly enthused or amused, he would almost lose control of himself in a paroxysm of laughter.  His mind was full of ideas regarding his work: letters to be written, new angles to be studied and clients to be interviewed.  In addition to his two jobs the patient served as a leader of a Boy Scout troop, did church work, and spent considerable time helping neighbors who were ill or needed advice.  He took correspondence courses which he hoped would make him an expert in the insurance business.  He was obsessed with plans for the future, talking about his many activities—all of which it could easily be seen helped to counteract his strong feeling of insecurity.

 

On several occasions the patient had become enthused over a new project, making changes which interfered with his vocational advancement.  Once, for instance, when his usual hypomanic personality suffered a transient depressive swing, he resolved to carry out a life-long ambition to become a minister.  He gave up his job, sold his home, and moved to another city in order to enroll in a theological seminary.  Fortunately, after a few months, he found the work too strenuous and returned to his former occupation without a serious emotional reaction.  On another occasion, after experimenting with a combination of acetylsalicylic acid and belladonna, he became unduly excited and enthused over a patent for a new headache powder which he knew would make him rich.  His frustration resulting from the failure of this project was relieved when he was offered a position with another insurance company which required, however, that he move to another city.  He described his new job as one which would give him unlimited opportunities.  When this position failed to work out as well as he expected he became critical and bitter toward his superiors, resigning in a fit of temper.  As usual, he had built up strong hopes and plans in his own mind, founded upon his abnormal euphoria and enthusiasm, and really was not justified in blaming others.  Following each of these incidents, the patient became mildly depressed, but always snapped back quickly, showing a remarkable ability to rationalize his errors and compensate for his defeats.

 

While David R. would occasionally manifest anxiety and nervous tension, usually these symptoms were covered up by an exterior of buoyancy, laughter, or exuberant speech.  Pessimism, or even plain sober thinking, was rarely allowed to linger in his thoughts.  When business was poor he bored his listeners with superficial optimism, that this wouldn’t last, etc.  When business was good his spirits rose in proportion, causing the observer to feel uneasy for fear the patient might become too successful and then too euphoric.

 

That these various characteristics were not simply personal peculiarities, and that they were truly a part of the cyclothymic process, was proved when the patient actually did experience a manic episode of manic-depressive psychosis.  This reaction, precipitated by his wife’s confinement, was accompanied by the usual increased psychomotor activity, flight of ideas, excitement, euphoria and grandiosity.  When admitted to a private hospital the patient was noisy, boastful, antagonistic, uncooperative, and threatening homicide as well as suicide.  As with all manics, a depressive coloring could be detected in the patient’s manner and speech.  He felt remorseful that he could not do more for his wife at the time that she needed him most, but this emotion was dispelled immediately by overactivity and pressure of other ideas.  The patient showed a rapid improvement with electroshock treatment, being away from his work only two months.  The writer has observed this patient at fairly regular intervals over a period of six years and feels that he is a good example of the hypomanic type of cycloid personality.

 

differential diagnosis

 

In a subsequent chapter the differential diagnosis between manic-depressive psychosis and other psychoses will be discussed, but here we shall consider the differential diagnosis between the cycloid personality and other abnormal personality types.  The recognition of the various basic personality types is one of the most helpful aids in the practice of psychiatry.  Many psychiatric patients are so disturbed, or uncooperative, at the time of the examination “that a satisfactory study is not possible, but by obtaining an account of the individual’s basic personality, one may determine whether a patient is a mental defective, a schizoid or a cycloid personality.  A psychopathic personality, for instance, in a psychotic reaction may behave like a manic-depressive patient in a manic phase; likewise, one of the writer’s depressive patients from a rural community gave every appearance of being a mental defective in a psychotic episode; scrutiny of the underlying personalities, however, usually sheds light on the true situation.  Furthermore, the psychosis may change from day to day, but the basic personality goes on throughout life.

 

Mental Deficiency.  Since the cycloid’s intelligence is nearly always normal or above, it would appear that this personality type should not be confused with the mental defective.  Actually, it does happen in unusual instances that the dull depressive personality is assumed to be mentally retarded.  Psychomotor retardation, always present in some degree in depressive reactions, retards the thinking to such an extent that the patient may simply appear to be stupid.  An illustrative case is given in Chapter 10.

 

Psychopathic Personality.  The irritable, argumentative, litigious type of hypomanic, involved in family discord at home and unable to adjust satisfactorily at work, often presents the superficial appearance of a psychopathic personality.  The hypomanic, especially when drinking, is quick to take offense, start an argument, demand his rights and project his own deficiencies on others.  While the hypomanic is a restless, often obnoxious, egocentric person, close scrutiny of his personality usually reveals an insatiable desire for accomplishment and group approval, which is not a feature of the psychopath’s make-up.  The hypomanic is friendly, likeable, often slap-dash, and sometimes overbearing, but always capable of attracting friends.  Kraepelin said of this type: “Already at school they are insubordinate and disorderly, ring-leaders in all disturbances of the peace; they play truant, run away, do not get on anywhere, have to change their school, fail in examinations, because of their aversion to thorough and persevering study.  They stand military discipline very badly, neglect cleanliness and order, overstay their leave, are remiss in service, resist authority, and are, as a rule, often punished, when it is not recognized that they are ill.  At the same time an important part is played by the sexual instinct which awakens early and is very active, and which leads them to debauchery....  The influence of alcohol is usually still more unfavorable, to which, in general, they yield themselves without resistance.”

 

The basic difference between the psychopath and the hypomanic cycloid is essentially one of conscience.  Even in his erratic and poorly timed actions, the hypomanic can be observed to work toward a goal, some kind of worthwhile accomplishment, whereas the psychopath is less meaningful, more destructive and not nearly so interested in accomplishment.  Both may be irregular, impulsive, spasmodic workers, but there is a difference in attitude toward the vocation.  The cycloid usually adheres to orthodox occupations whereas the psychopath prefers off-color jobs.  Although talkative, cocky, bombastic and erratic, the cycloid’s personality contains a certain philanthropic attitude which is lacking in the antisocial psychopath.  Both are capable of making friends but the cycloid is more able to keep friends.  A history of a previous depressive or manic episode, or a positive family history, often aids in making the decision.  A longitudinal study of the patient’s life, if he is a psychopath, will usually reveal significant information.  This subject will be discussed again in the chapter Manic-Depressive Psychosis, Manic Type.  The depressive type of cycloid personality is rarely confused with the psychopath.

 

Schizoid Personality.  The differential diagnosis between manic-depressive psychosis and schizophrenia is occasionally very difficult and may depend upon determining the basic personality of the patient as cycloid or schizoid.  This differentiation cannot be so easily solved as to say that one is an extrovert and the other an introvert.  There are some quiet, depressive cycloids, who appear to be lonely and introverted, while there are overactive schizoids who may be confused with hypomanics.  As a rule, the cycloid personality, depressive or hypomanic, is an out-going, friendly individual who makes a warm, smooth, unobtrusive impression upon others, while the schizoid is an introverted, rigid, suspicious individual who immediately arouses a feeling of discomfort in a new acquaintance.  The schizoid possesses several conspicuous traits, such as loneliness, conscientiousness, daydreaming, poor sexual desire and lack of humor which are consistent in this personality type.  The cycloid, on the other hand, is less peculiar, in that he possesses no distinguishing characteristics not also found in other personality types.  Hence, the schizoid is often considered an odd or queer individual, while the cycloid often goes unrecognized, in everyday life.

 

The schizoid may be quite intelligent, often more so than the average cycloid, but his mind turns toward abstract, theoretical subjects which hold little interest for the practical cycloid.  In conscience, the schizoid is overendowed, even to the point of becoming a fanatic, while the cycloid is conscientious, but usually makes use of accepted outlets for the expression of this trait.  The cycloid personality, as well as the stock from which he springs, is more productive, or successful, in the everyday affairs of the world; the cycloid mixes well and is interminably at work while the schizoid makes an almost chronic maladjustment.  The schizoid, who often presents a dull emotional reaction, does not manifest the emotional swings typical of the cyclothymic personality.  Psychosexually, the cycloid again more nearly approaches the normal, while the schizoid is not only immature but is skittish, and more susceptible to primitive, abnormal drives in this sphere.  The schizoid marries late, if at all, while the hypomanic is sexually aggressive, and the depressive is only moderately retarded sexually.  In all attributes, it readily can be observed, that the cycloid is more like our conception of the normal than is the schizoid.

 

Bowlby stated that there are four traits which, in association, occur only in the cycloid personality.  These—“steady worker,” “practical,” “few good friends,” and “quietly sociable”—are often found in association in the cycloid but never in the schizoid.  Kretschmer considered diligence, capability, and capacity for hard work as characteristic of the depressive personality.  While the schizoid may be cold and distant, the depressive, although glum and sensitive, likes people and cannot bear not to be liked by them.  A concluding statement from Kretschmer will help to differentiate the depressives from the schizoids: “They (the depressives) may be differentiated from the corresponding schizoids in that there is no internal antipathy, no hostile turning away from human society, to be found in them, but at the most there is a certain melancholy, and, occasionally, anxiety and a tendency to a feeling of inferiority.  If one seeks their company, they are friendly, natural and approachable....”

 

These two personality types under examination present entirely different appearances.  The cycloid is often overfriendly, making sincere inquiries regarding the physician, while the schizoid remains aloof and often suspicious.  Here is a quote on this subject from a previous work of the author’s: “During a brief examination the schizoid may perspire freely, yawn, exhibit mannerisms, or make superficial attempts to put himself at ease.  He is obviously trying to be nonchalant but cannot succeed, as he feels too strongly the gaze of the examiner.  The latter, as Tillman points out, is placed in the awkward position of embarrassing his patient simply by looking at him.  Tillman states: ‘If the examiner feels bored or obscurely annoyed by the registrant and if he is struck by vagueness, uncertainty, and evasive tendencies the examiner should be especially on his guard and should objectively ascertain his subjective response to the registrant (patient) because quite likely he is dealing with a schizoid personality’.”

 

Differentiation between manic-depressive psychosis and schizophrenia will be discussed in the chapter devoted to differential diagnosis.

 

Psychoneurosis.  One of the writer’s chief purposes in the present volume is to establish the cyclothymic process, in all of its variations, as an independent entity from psychoneurosis.  Many individuals in a cyclothymic reaction, are still being classified as psychoneurotic, resulting in errors in therapy.  In fact, the careless use of the term “neurotic,” to apply to schizoids, cycloids, homosexuals, alcoholics and almost every other personality type, is one of the major errors and sources of confusion in modern psychiatry.  In an effort to show that practically all psychiatric entities, even schizophrenia and manic-depressive psychosis, are secondary to environmental and dynamic factors, the psychoanalytic school has first classified these entities with psychoneurosis and then applied dynamic interpretations.  In order to frustrate this pernicious thinking, which has its influence throughout the field of psychiatry, we must establish more definite criteria for differential diagnosis.  Many workers have noted the similarity between cyclothymic reactions and psychoneurosis and duly warned the profession regarding this.  Kraepelin stated that numerous cyclothymic patients are classified as hysterical because of the occurrence of “fainting fits and attacks of giddiness, as well as fully developed hysterical convulsions.”  Bleuler stated that cycloid “patients often complain of all sorts of weaknesses, black spots before the eyes, roaring in the ears, headache and other paresthesias.  The beginning of the disease often gives the impression of neurasthenia, as do the milder forms during the entire course.

 

Yaskin emphasized the feeling of unreality as an important point in differential diagnosis; it does not occur in psychoneurosis.  Noyes states: “The sense of inadequacy, abnormal fatigability, depressive ideas and apprehension that may accompany mild forms of the depressive or mixed type, particularly in the early stages, are often misinterpreted as symptoms of neurasthenia, of a compulsion neurosis or of an anxiety state.”

 

The psychoneurotic and cycloid personalities are distinctly opposed; knowing the basic traits the diagnostician should not confuse these conditions.  The cycloid is an outgoing, usually likeable individual while the psychoneurotic is egocentric and anoerotic, as the psychoanalysts would say; one is generous, the other selfish.  Whereas the cycloid is masochistic, always thinking of punishments for himself, the neurotic is sadistic or anxious to inflict pain upon others, either physically or mentally.  The cycloid personality is modest and unassuming, the psychoneurotic craves attention and is aggressive; the former is humble and appreciative, the latter is depreciative; the cycloid is tolerant and just, while the neurotic is intolerant and dogmatic; one is sorrowful, the other is satirical and critical.  While the cycloid is forgiving in his basic impulses, the psychoneurotic is resentful and nurses grudges.  The cycloid is shy and sensitive while the neurotic is sensitive but exhibitionistic.  One is ashamed of his symptoms when they arise, and tries to cover them up, the other is more likely to use his symptoms to an advantage.  While the cycloid will blame himself for his morbid state, saying “I should have more will power,” the neurotic rationalizes more freely, projecting his inadequacies upon others.

 

Thus, we readily see that the neurotic is a more primitive, immature person basically while the cycloid assumes a more adult or tolerant outlook upon life.  The physician at once has a kindly feeling toward the cyclothymic personality, but is forced on his defensive in dealing with the neurotic.  The latter blames the physician, by subtle innuendo, that the treatment is not obtaining results while the cycloid blames himself when improvement is not forthcoming.  The mood swings in the cyclothymic are endogenous and less influenced by circumstances, while the flights in mood in the neurotic are more fickle and obviously related to incidents in his daily life.  The cycloid is often sorrowful, remorseful and truly a sensitive person, while the neurotic, although sensitive, is more given to assuming affected injured feelings.  Both are subject to anxiety and phobias, a subject to be discussed in more detail later.

 

Autonomic disturbances also occur in both conditions, but the autonomic dysfunction in the neurotic, like the emotional dysfunction, is more of a lifetime disturbance, aggravated at times by environmental or circumstantial factors, while in the cyclothymic the autonomic disturbances are more deep seated, or endogenous, as are the emotional disturbances.  As shall be observed later, the autonomic dysfunction in manic-depressive disease is an endogenous disturbance, closely associated with the emotional aberration, and not influenced nearly so much by the environment as in the case of psychoneurosis.

 

The inexperienced should be warned against attempting to distinguish psychoneurosis from cyclothymic reactions upon the basis of severity of symptoms.  Designating mild manic-depressive reactions as psychoneurotic, simply because the patients do not manifest psychotic behavior, reflects a poor understanding of underlying personality constitution.  Furthermore, calling the mild phases “psychoneurosis” and the severe episodes “psychosis” has resulted in another erroneous deduction in psychiatry, i.e., that psychoneurosis can change into a psychosis.  Many psychiatrists, for instance, who fail to recognize manic-depressive psychosis in its milder phases, believe that an individual may have psychoneurosis this year and manic-depressive psychosis next year, or the year afterward.  A thorough knowledge of the manic-depressive process proves that the in­dividual was on both occasions in cyclothymic reactions, one being mild, the other severe.

 

On the other hand, the psychoneurotic patient may manifest such erratic thinking and bizarre behavior that the observer is quite convinced that he is witnessing a severe psychosis.  The answer, again, is to know the basic personality so well that one may recognize the underlying attitude and motives behind any particular statement or pattern of behavior.  In psychoneurosis, for instance, there is nearly always an ulterior, selfish motive behind an apparently insane reaction.  Erratic behavior of the manic-depressive patient, on the other hand, is more likely to be based upon self debasement, euphoria or depression.  In differential diagnosis one cannot rely upon the severity of the reaction for many mild manic-depressives would be called psychoneurotic, while many severe psychoneurotics might be designated schizophrenic or manic-depressive.  Besides, this approach would be comparable in medicine to calling a mild case of bronchitis a cold and a severe case tuberculosis, without implicating other significant symptoms.

 

TABLE 1

 

differential diagnosis between mild manic-depressive disease, depressive type, and psychoneurosis

 

Manic-depressive                                                                                            Psychoneurosis

Triad of autonomic, emotional and mental disturbances Autonomic and emotional disturbances

Basic cycloid personality

   out-going

   generous

   friendly

   masochistic

   modest, unassuming

   humble

   appreciative

   tolerant

   sorrowful

   forgiving

   just

Basic psychoneurotic personality

   egocentric

   selfish

   anoerotic

   sadistic

   craves attention

   aggressive

   depreciative

   intolerant

   satirical and critical

   resentful

   dogmatic

Shy and sensitive Exhibitionistic
Ashamed of symptoms May use his symptoms
Suffers quietly More demonstrative
Occipitocervical headache with drawing in neck Band-like headache
Blames himself for his illness More rationalization and projection
“Woozy” feeling in head Dizziness
Morbid outlook More changeable—not so depressed
Cries without cause Cries because of various small factors in environment
Not precipitated by environmental factors Often precipitated by environmental factors
Feelings of unreality No feelings of unreality
Ideas of reference Ideas of reference are rare
Endogenous feeling of guilt Exogenous feeling of guilt
Truly depressed Not seriously depressed
Truly sensitive Affected injured feelings
Illusions and misinterpretations None
Anxiety and phobias Anxiety and phobias
Psychotic Not psychotic

Preoccupation with death

More concerned with life
History of previous attacks More continuous
Suicidal Rarely suicidal
Family history of similar depressions or mania Family history less specific
Not appreciably improved by psychotherapy Definite improvement by psychotherapy
Definitely improved by ECT Not improved by ECT

 

 

Such are the essential differences between the basic personality types, cycloid and neurotic, not considering for the moment the severe degrees of each condition.  The accompanying table gives the student a quick resume of the contrasting characteristics between the cycloid and psychoneurotic personalities.  At this point a psychoneurotic patient is described so that this type may be compared with the three examples of cycloid personality previously described.

 

Grace McD., age 24, surgical nurse, was referred to the psychiatrist by a resident physician in the hospital where the patient had worked for two years.  He reported that he had treated the patient intermittently for various physical complaints, and emotional upsets; that she had been pre-occupied with her health, requesting daily blood counts and keeping a careful record of these, in spite of the fact that they had all been normal.  After reading an article on amebic dysentery, the patient had insisted upon having daily stool examinations.  Although the stools had been negative for amebae, she had demanded that the physician give her a series of emetin hydrochloride injections.  The physician had attempted to analyze the patient’s personality, in accordance with his psychiatric training, but she had become so dependent upon him that he sought psychiatric consultation.

 

Grace McD. had been an orphan who was adopted by a kindly couple, and had always had a strong attachment and dependence upon her foster-mother.  (Apparently, it was after the death of this parent two years before, that the patient’s neurosis had reached the clinical stage.) The patient completed high school at 15 and nurse’s training at 19; she then set out to get a B. S. degree, explaining retrospectively, “I just had to get above the heap.”  She was a very insecure, industrious individual, attending college courses in her spare time, but unable to cope with the strain she brought upon herself.  Thin in stature, walking with a mannish gait, speaking in a quick, high-pitched voice and exhibiting several petulant gestures, the patient betrayed considerable immaturity even upon superficial examination.

 

During the previous two years, while attached to the hospital as a nurse, the patient had been on the sick list “half of the time,” according to the referring physician.  She had been treated for pylorospasm, diarrhea, vasomotor rhinitis, frontal headaches, tachycardia and other symptoms indicative of a hypersensitive autonomic nervous system.  However, the chief problem seemed to center around the patient’s personality maladjustment.  During the examination it was noted that the patient maintained a superior, critical, suspicious and sarcastic attitude, quick to rationalize her own position.  She discounted previous conflicts with other persons merely as “misunderstandings.”  When questioned regarding so many admissions to the hospital during the previous two years, she explained, “that was because somebody couldn’t diagnose an appendix.”  The appendix referred to had been removed during one of her episodes of gastroenteritis and had proved to be normal; the “somebody” who had failed to diagnose this allegedly inflamed appendix was the house physician toward whom the patient had markedly ambivalent feelings.  The history showed that her somatic illnesses had always occurred after an argument with a fellow-worker, after being criticized by the manager of the hospital, or when her feeling of insecurity was intensified by not receiving sufficient attention from the house physician.

 

At times, when speaking of the referring physician, the patient used his surname with a derisive tone; at other times she spoke of him almost affectionately.  She admitted having consulted him on various occasions, not only regarding her health, but also regarding her personal affairs.  She admitted taking advantage of this physician’s professional interest in her by writing him friendly notes, or arranging unnecessary consultations after hours.  She attempted to drag him into her personal arguments with other nurses, of whom she was jealous, and would blame him in a childish manner when he refused to take her side.  The patient was capable of developing fair insight into her somatic symptoms, as well as her neurotic reasoning, but this insight was ephemeral and always quickly smothered by resentments, ambivalent feelings and projection.  Rationalization, jealousy, hatred, insecurity and fear crowded out any reasonable thinking, except for brief moments, such as when talking over her situation calmly with the psychiatrist.

 

There were other complaints, such as nightmares and a complex about having been an adopted child, which reflected her anxiety and insecurity.  She seemed incapable, as are many neurotic persons, of accepting help and encouragement from anyone without developing some feeling of ambivalence or resentment.  (There was not the wholesome, grateful, philanthropic attitude which we observe in the cycloid.)  On her next job, for the patient was soon discharged, the neurotic traits again frustrated the patient’s attempt at a satisfactory adjustment.  Here again, she sought help and encouragement from her physician-employer, and again began to involve the physician in her personal affairs.  Having obtained his interest in her as a “case,” the patient began “testing my luck,” as she admitted, “to see how much he would take off of me.”  She made herself thoroughly disliked by other personnel by criticizing them to their employer whenever she saw an opportunity to do so.  Her anxiety and insecurity drove her on to bolder methods of gaining attention and superiority, using any trick which seemed to work at the moment.  She eventually became more irritable, petulant and critical at her work, taking full advantage of the fact that her employer was interested in her readjustment.

 

In a letter to the psychiatrist at this time the patient stated that her employer, in attempting psychotherapy, had advised her that her frustration in life was due to resentment of her father who had deserted her.  While he was working out this questionable dynamic interpretation of her case, she was rapidly building a situation similar to the one involving her previous physician.  She wrote: “I like Doctor Blank very much—he is one person above all others I can trust.  I think he would do anything possible to help me.  He sort of takes the place of parents for me, but another spell of trying to irritate him would finish me.”  Within a few days she failed to report to work, admitting frankly that she did this to see how interested he was in her as an individual.  Following her discharge from this position, the patient suffered a brief situational depression, showing no guilt or remorse, but blaming everyone in the hospital except her former employer for whom she still felt both attachment and resentment.

 

From her next hospital position the patient wrote the psychiatrist that she was in a “real hole now, reeking with politics—the doctors are a bunch of jackasses.”  A month later she wrote, “I had to get out of that place—the strain of doing everyone else’s work was too much—I was blamed for everything.”  She emphasized in her letter: “There was no Doctor Blank there either who tried to understand and help.”  Again, she had been suffering with diarrhea, tachycardia and insomnia.  As the petulance and critical attitude increased, the environmental problems increased, and as the latter became worse, the anxiety and autonomic disturbances were aggravated.  Such beautiful examples of rationalization, projection, ambivalence, jealousy and resentment are rarely observed in any other than the psychoneurotic individual.  The contrast between this case and the three cycloids previously described is so great that further discussion does not appear necessary.

 

 

 

 

   

 

 

 

 

 

 

 

 

 

 

 

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