Manic-Depressive Illness

   (Bipolar Disorder)

   Before 1850, numerous physicians had commented on the alternation of mania and melancholia. In 1844, Karl Wigand Maximilian Jacobi (1775–1858), chief physician of Siegburg asylum in Germany, noted that "Exaltation and depression stand in the most intimate reciprocal relationship with each other, alternate together, and appear often mutually, if not with absolute regularity, to trigger each other" (The Main Forms of Mental Disturbances [Die Hauptformen der Seelenstörungen], I, p. xxxii). In 1844, Carl Friedrich Flemming (1799–1880) gave the alternation a name, as a separate entity, saying "[Between melancholy and mania] there is not infrequently a connection of each to the other, called Dysthymia mutabilis, in which first the one, then the other presents" (General Journal of Psychiatry [Allgemeine Zeitschrift für Psychiatrie], 1844, p. 129). Yet, Flemming’s distinction was forgotten.

   Circular insanity (1850). In 1850, Jean-Pierre Falret gave a lecture to the Paris Psychiatric Society in the course of which he mentioned "circular insanity" (la folie circulaire); the lecture was briefly summarized in 1851 in the Paris Hospital Gazette (Gazette des hôpitaux). Three years later, in 1854, Jules-Gabriel-François Baillarger (1809–1890), who taught the course on mental illness at the Salpêtrière hospice, gave a lecture on "madness in double form" (la folie à double forme), in which he claimed that, "There are not two diseases here but one single, that the two apparent episodes are only two phases of one sole episode" (p. 370). Upon seeing this, the outraged Falret rushed his own thoughts on the matter into print in order to claim priority. Baillarger said that the alternation of mania and melancholia represented, in fact, a distinct illness, and that Falret’s description failed to recognize this novelty but rather just gave a name to the long familiar alternation of two separate illnesses. Both authors were quite gloomy about prognosis, Baillarger saying that the patients never really recovered even in apparent intervals, and Falret that the alternations occurred in an almost mechanical manner continually throughout life. See Falret’s paper and Baillarger’s heated response in the Bulletin de l’Académie de médecine, 1854. Baillarger’s original paper, "De la folie à double forme," appeared in 1854 in the Annales médicopsychologiques. In the view of Pierre Pichot, the priority belongs to Falret not only because he came first but he also because he highlighted the importance of clinical course ("évolution") in the description of independent disease entities. "Seen in this perspective, the birth of bipolar disorder is more than a picturesque episode illustrating the occasional smallmindedness of brilliant scientists. It can be considered as a decisive episode in the history of psychiatry" (European Psychiatry, 1995, p. 9). Cyclothymia (1882). In an article on "circular insanity" in the Friend of the Insane (Der Irrenfreund), Karl Ludwig Kahlbaum, now owner of a private nervous clinic in the Prussian town of Görlitz, coined the term "cyclothymia" for a form of circular insanity that did not go progressively downhill, unlike "vesania typica circularis," that several earlier writers had described; cyclothymia affected mainly the emotional realm of the mind rather than intelligence and drive. "Thus we may differentiate strictly between a circular insanity that does not lead to terminal dementia and that keeps within the boundaries of the emotions, and a circular insanity that even in the stage of exaltation represents a primary impairment of all aspects of mental life and in further stages of confusion and dementia leads to complete mental degeneration." Kahlbaum suggested the term "cyclothymia" for the former (p. 155). The term stuck for many observers: Kurt Schneider seldom talked of manic-depressive illness but rather "cyclothymia."

   Manic-depressive illness (das manisch-depressive Irresein) (1899). In the sixth edition of his textbook, Emil Kraepelin brought all the affective disorders—depression, Manic-Depressive Illness (Bipolar Disorder) mania and "mixed forms"—into the single diagnostic category of manic-depressive illness. As he wrote in Psychiatry (Die Psychiatrie), "Manic-depressive insanity . . . includes on the one hand the entire area of so-called periodic and circular forms of insanity; on the other hand it includes most of the hitherto separately treated simple manias. In the course of the years I have become increasingly convinced, that all of the above mentioned clinical pictures are only aspects of a single disease" (p. 359). Only involutional melancholia remained outside this framework. Henceforth, all cases of affective disorders would , in the Kraepelinian world, considered as constitutionally predisposed "MDI."

   Manic-depressive illness arises from predisposing personality attitudes (1921). Ernst Kretschmer (1888–1964), then a staff psychiatrist in the department of psychiatry at Tübingen University, ventured the idea in his 1921 book, Body Type and Character (Körperbau und Charakter), that mood disorders, especially manic-depressive illness, arose from "cycloid temperaments" (zykloide Temperamente). Certain body types corresponded as well to this kind of "diathesis." "We indicate as schizoid and cycloid the abnormal personality types that fluctuate between health and illness, and that give rise to the basic psychological symptoms of the schizophrenic and the circular psychoses." The basic constitutional type, or diathesis, of the manic-depressive was "sociable, kindly, friendly, easy-going [gemütlich]." And the body type on which such a constitution rested was mainly "pyknic," meaning a big frame with a "soft, wide face on a short massive neck" (that so many of the male patients of this physical type seemed to have big stomachs as well may have been more attributable to the Swabian diet than to ancestry) (pp. 27, 115–116 of the seventh edition, published in 1929). (See Psychosis: Emergence: Kretschmer’s constitutional psychoses [1921].) The book went through many editions.

   Manic-depressive illness seems to consist of separate diseases: bipolar and unipolar disorders (1957). On the basis of many years of longitudinal research on outcome and family history, in 1957 Karl Leonhard (1904–1988), then professor of psychiatry at Erfurt University, published The Classification of the Endogenous Psychoses (Die Aufteilung der endogenen Psychosen). (See Wernicke–Kleist–Leonhard Pathway.) On grounds of family history and phenomenology, he demonstrated that unipolar depression and manic-depressive illness are different diseases. For Leonhard, there was a "pure melancholia" distinguished from the "pure depressions," of which latter he subdivided five forms. He borrowed Kleist’s term "bipolar" illness for manic-depressive illness and revived Kleist’s concept of single-polar illness for pure depressive illness and pure mania. (Kleist had used the term "unipolar," which Leonhard called "monopolar.") (On Kleist, see Wernicke–Kleist–Leonhard Pathway.)

   In 1964, writing in the Acta Psychiatrica Scandinavica, Carlo Perris (1928–2000), a member of the psychiatry department of Umea University in Sweden, changed Leonhard’s term "monopolar" back to Kleist’s term "unipolar." The first family data in this project were published by former team member Edda Neele (1910–) in 1949. (The notion that unipolar and bipolar disorders differed on grounds of family history was confirmed in 1966 in separate publications by Jules Angst at the Burghölzli in Zurich (Zur Ätiologie und Nosologie endogener depressiver Psychosen [The Etiology and Classification of Endogenous Depressive Psychoses]) and by Perris in an article in a supplement of Manic-Depressive Illness (Bipolar Disorder) the Acta Psychiatrica Scandinavica. Perris: "Moreover, the results of our investigation seem to indicate a specificity in the heredity of depressive psychoses. This is supported by the high morbidity risk for the same form of illness and the low for the other one within each group" (p. 41).

   See Schizophrenia: Recent Concepts: much "schizophrenia" turns out to be manic-depressive illness (1978).

   DSM-III renames manic-depressive illness "bipolar disorder" (1980). The third edition of the DSM series said that bipolar disorder, formerly known as manicdepressive illness, was a subtype of major affective disorders, along with major depression. Within biopolar disorder, DSM distinguished among: "bipolar—mixed," meaning recently the full symptom picture of both mania and major depression, "intermixed or rapidly alternating every few days"; "bipolar—manic," meaning recently a manic episode; and "bipolar—depressed," meaning currently depressed with a past history of a manic episode at some point.

   DSM-III also accepted "cyclothymic disorder," reviving Karl Kahlbaum’s term, but meaning alternating periods of depression and hypomania not severe enough to meet the criteria of major depression or the manic picture.

   DSM-III-R (1987) did not change DSM-III in any important way in this area.

   DSM-IV (1994) subdivided bipolar disorder into bipolar I disorder and bipolar II disorder. Bipolar I meant mainly mania plus mixed episodes; bipolar II meant mainly major depression plus hypomanic episodes.