History and evolution of the concept
The earliest descriptions of polar affective states—"melancholia" and "mania"—date back to the works of Hippocrates. However, the realization that these syndromes are cyclical stages of a single disease only emerged in the mid-19th century thanks to J.-P. Falret and J. Baillarger.
Emil Kraepelin made a fundamental contribution to nosology. He included manic-depressive psychosis (MDP) in the classification as an independent entity and grouped it together with dementia praecox (schizophrenia) into the category of endogenous disorders. Kraepelin identified a crucial diagnostic criterion: unlike schizophrenia, MDP does not lead to dementia and pronounced personality changes, even after multiple relapses.
The boundaries of the disease were debated for a long time. For instance, conditions combining features of schizophrenia and MDP ("favorable psychoses") were eventually classified as a separate schizoaffective disorder. Kraepelin also ultimately included involutional melancholia—late-life depression with anxiety and nihilistic delusions, but without manias—within the framework of MDP.
Clinical presentation and course characteristics
The core of the disease is the periodic occurrence of manic and depressive syndromes. There are no consistent patterns in their alternation: mania can precede depression or develop immediately as the patient emerges from it.
- Age of onset: The disease can manifest at any time, but most commonly starts in youth (after 20 years) and adulthood. In cases of late diagnosis, histories often reveal mild juvenile episodes of hypomania or subdepression that did not require treatment.
- Nature of episodes: The disease is autochthonous (independent of external causes) in nature. Emotional stress may trigger only the very first episode, whereas subsequent exacerbations develop against a background of complete well-being.
- Intermissions (lucid intervals): Between phases, all psychopathological disorders resolve completely, and no negative symptoms develop.
Influence of biorhythms
Affective psychoses demonstrate a close connection with the patient's biological rhythms:
- Seasonality: Exacerbations most frequently occur during transitional seasons—spring and autumn.
- Connection with the menstrual cycle: In women, episodes often correlate with specific phases of the cycle.
- Diurnal fluctuations: Most clearly observed in mild depressions. Immediately after morning awakening, the severity of depression peaks, while patients experience relief by evening. Because of this pattern, the majority of suicide attempts occur in the early morning hours.
Epidemiology and classification (ICD-10)
In the International Classification of Diseases (ICD-10), all affective disorders except organic ones are grouped under class F3 to avoid debates about their etiology. The fourth character in the code reflects the severity of the condition and the presence of psychotic symptoms. The main categories are:
- F30 — manic episode;
- F31 — bipolar affective disorder;
- F32 — depressive episode;
- F33 — recurrent depressive disorder.
The nosological independence of unipolar depression and bipolar psychosis is still debated. There is yet no robust genetic proof for their complete separation. Epidemiological statistics vary due to differing methodologies. In Russia, MDP is strictly distinguished from schizoaffective disorder (which occurs twice as often). The morbidity rate in Russia is traditionally estimated at 0.45–0.49 per 1,000 population, whereas foreign schools, which include mild forms in their statistics, report figures up to 12 per 1,000.
Briefly: answers to topical questions
What disorders are included in the F3 class of affective disorders according to ICD-10?
The F3 class of affective disorders according to ICD-10 includes the following nosological entities:
- F30 — manic episode;
- F31 — bipolar affective disorder;
- F32 — depressive episode;
- F33 — recurrent depressive disorder;
- F34 — persistent mood disorders (cyclothymia, dysthymia);
- F38 — other mood disorders;
- F39 — unspecified mood disorder.
What is the average duration of the manic and depressive phases in bipolar disorder?
The average duration of a typical depressive episode in bipolar affective disorder ranges from 2 to 6 months. Manic episodes are usually shorter than depressive ones, though in some cases they can last up to several months. An important feature is that between phases, all psychopathological manifestations resolve completely, and the lucid intervals (intermissions) can range from very short to several years.
What symptoms make up the classical manic triad?
The classical manic triad includes the following main symptoms:
- Elevated mood (hyperthymia) — very good mood accompanied by inflated self-esteem and optimism;
- Accelerated thinking (tachypsychia) — acceleration of thought processes;
- Psychomotor agitation — goal-directed motor activity where, due to marked distractibility, tasks are rarely seen through to completion.
What symptoms make up the classical depressive triad?
The classical depressive triad consists of the following symptoms, which are directly opposite to the manic ones:
- Depressed mood (hypothymia) — sharply lowered mood, complaints of anguish, despondency, and anxiety;
- Slowed thinking (associative retardation or ideational retardation) — impoverished speech, prolonged deliberation when answering, difficulty comprehending;
- Motor retardation (psychomotor retardation) — rigidity, slowness, up to the development of complete immobility (depressive stupor).
Which drug groups are used for the prophylaxis of phase switching in bipolar affective disorder?
For the prevention of phase switching in bipolar affective disorder during the intermission period, mood stabilizers are used. These include the following drug groups:
- Lithium salts — are the drugs of choice, requiring monitoring of target blood concentration (0.6–0.9 mmol/L);
- Anticonvulsants (antiepileptic drugs) — include valproic acid salts, carbamazepine, topiramate, and lamotrigine.
To remember E. Kraepelin's main criterion, use the phrase: "Phases pass, personality remains." Unlike schizophrenia, in bipolar disorder, the psyche recovers after an episode without a defect.
Class and exam questions
Can endogenous depression be distinguished from reactive depression?
In practice, this is difficult. Reactive depression occurs exclusively in response to severe psychological trauma and typically does not recur. In endogenous depression, the first episode may also be triggered by stress, but the subsequent course becomes cyclical and autochthonous.
What is the difference between bipolar and schizoaffective disorder?
Schizoaffective disorder includes symptoms of both affective phases and an endogenous process disease (schizophrenia). In Russian psychiatry, these pathologies are strictly differentiated.
At what time of day are patients in the depressive phase most vulnerable?
The maximum severity of anguish and the highest risk of suicide are observed in the early morning hours (immediately upon waking).
What else to study on this topic
- Clinical structure of depressive and manic syndromes
- Schizoaffective disorder: criteria and differences from bipolar psychosis
- Involutional melancholia: features of late-life depressions
- Persistent mood disorders (cyclothymia and dysthymia)
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