Abstract
Introduction
Descriptions of mania and melancholia have intrigued writers for over 2000 years. For example, Plato (quoted by Berrios, 2004) in about 400 BC noted that: ‘the greatest blessings come by way of madness (mania), indeed of madness that is heaven-sent’, and Becker (1978, quoted by Jamison, 1993), when addressing ‘The mad genius controversy’, commented that:
The aura of ‘mania’ endowed the genius with a mystical and inexplicable quality that served to differentiate him from the typical man, the bourgeois, the philistine, and, quite importantly, the ‘mere’ man of talent. . . (page 4)
Jamison (1993), in her autobiographical work Touched with Fire: Manic-Depressive Illness and the Artistic Temperament, also observed that:
Who would not want an illness that has among its symptoms elevated and expansive mood, inflated self-esteem, abundance of energy, less need for sleep, intensified sexuality . . . (page 103)
Early history
Bearing these comments in mind, it is not unexpected that there has been vigorous debate about our evolving conceptualisation of the condition, or more correctly, the conditions we now refer to as the bipolar disorders spectrum.
The etymology of melancholia has been clearly defined as being related to melas, black, and chole, fire. However, that of mania is less clear, and manos, meaning relaxed or loose, and ania, meaning to produce great mental anguish, are probably pertinent.
It is evident that there has been confusion about the meaning of both words and Berrios (2004) noted that each has at times simply meant ‘madness’ as an inclusive term. Indeed, he stated that: ‘It follows that “histories of mania” stretching from the Greeks to the present (e.g. Hare, 1981) are not histories of a “disease” but only the history of a word (Berrios, 1981)’.
Jamison (1993) has reviewed the early history of the disorder, noting that Hippocrates considered mania and melancholia to be separate illnesses, and that Areteus of Cappadocia in the second century AD was thought to have been the first to document that mania and melancholia could occur in the same person over time. In Byzantine times, Alexander of Tralles (c. 575) observed that mania and melancholia could occur in cycles with mixed features, and he wrote that ‘mania is nothing else but melancholia in a more intense form’. Then, in 16th-century Europe, Jason Pratensis (1549) recorded that ‘most physicians associated mania and melancholia (truly dreadful diseases) as one disorder’.
Another historical review by Ritti (1892) in Tuke’s Dictionary of Psychological Medicine placed emphasis on the work of Thomas Willis (1622–1670), famed as the describer of the circle of Willis at the base of the brain, who (quoted by Ritti, 1892) observed that:
. . . after melancholia, we have to treat of mania, which has so many relations to the former, that the two disorders often follow each other, the former changing into the latter, and inversely. The melancholic diathesis, indeed, carried to its highest degree causes frenzy, and frenzy subsiding changes frequently into melancholia (page 215)
Ritti noted further that: ‘The authors of the eighteenth century accepted the theories of Willis without modification or addition. The same is true of the observers of the early part of our century.’
Therefore it is apparent that there had long been a general recognition by physicians that mania and melancholia were related. However, Ritti emphasised that while the association had been well recognised, rather than clinicians considering there to be a specific condition, they ‘saw in it only a transformation of mania into melancholia, and vice versa’.
The French controversy
The credit for describing it as one illness is generally given to either one of two Frenchmen who ‘bitterly disputed as to who had been the first to conceptualise the condition’ (Sedler, 1983). It is of interest to reflect on this controversy.
On 31 January 1854 Jules Baillarger presented a paper at the French Imperial Academy of Medicine entitled ‘folie à double-forme’. However, the following week Jean-Pierre Falret ‘requested to speak in order to “establish his priority in the description of the facts reported by Mr Baillarger”’ (Pichot, 2006).
This occurred on 14 February 1854, when Falret presented a paper entitled ‘folie circulaire’ and it is pertinent to quote from this at length:
At our last meeting, our honorable colleague, Dr. Baillarger, read a paper on a new type of insanity [la folie à double-forme]. I must tell you, Gentlemen, that to me this type of insanity is not new. I have been aware of it for a long time, and for more than 10 years I have described it in my lectures at the Salpêtrière. Many similar cases have been presented by the students there and discussed in our clinical seminars. We even gave it a name because, in our opinion, it is not a mere variant but a genuine form of mental illness. We call it circular insanity [la folie circulaire] because the unfortunate patients afflicted with illness live out their lives in a perpetual circle of depression and manic excitement interrupted by a period of lucidity, which is typically brief but occasionally long lasting. This label of circular insanity has certainly been retained by our students and is common knowledge among the attending staff at the Salpêtrière; indeed, as Esquirol rightly pointed out, many scientific truths are shared by the various divisions of the asylum. I will not call on the testimony of my previous students; no doubt many of them will write on this subject, since teaching involves passing on the opinions, as well as the writings, of the teacher. Here, I will simply note that this form of insanity was positively identified and described by me in the lectures published in the Gazette des Hôpitaux (1850 and 1851) in such a way that it was recognisable to anyone at all perceptive.
Pichot (2004), a respected contemporary French academic psychiatrist, in a review ‘Circular insanity, 150 years on’, noted that Baillarger accused Falret of plagiarism, and that ‘Falret subsequently showed great restraint in the controversy, while Baillarger reiterated and extended his accusations until his death’. Pichot acknowledged that Falret’s description ‘bore little relation to the (very short) previous report that Falret had evoked as proof of his priority’. Nevertheless, he concluded that: ‘An objective study of the printed material not only establishes Falret’s clear priority, but also demonstrates that Baillarger’s accusations of plagiarism are unfounded’ (page 275).
Pichot (2006) also noted that subsequently Baillarger ‘even denied to Falret the paternity of the expression “circular insanity”,’ as the German psychiatrist Griesinger ‘in his textbook of 1845 had in his mention of the incidental alternation of mania and depression in the same patient, used the term “circle” ’. Furthermore, Pichot (2006) noted that in a chapter on ‘History and problems of priority’ published posthumously in 1890, Baillarger ‘reiterated his former arguments, but made now of Griesinger the true precursor of the concept, ending with the venomous remark that his German colleague never presented a claim to priority’.
Notwithstanding Falret’s claim to academic precedence, and Pichot’s strong endorsement of that, it is of interest that in their 1858 textbook, A Manual of Psychological Medicine, Bucknill and Tuke cited Baillarger, but not Falret, and there was no reference to the new terminology. In addition, and of considerably more significance, is the fact that Ritti, a leading late 19th-century French psychiatrist, unequivocally supported the precedence of Baillarger. In the section on ‘circular insanity’ in Tuke’s Dictionary of Psychological Medicine in 1892, in commenting on the description of Baillarger, Ritti referred to Baillarger’s ‘remarkable paper’ and asserted:
This is not the place to enter into the claims of priority which have been advanced ... An impartial examination will make clear his incontestable right to have been the first to introduce this morbid type into Psychological Medicine (page 216)
Ritti’s views cannot be dismissed lightly. He was elected general secretary of the French Société Médico-psychologiques in 1881 and was re-elected each year till his death in 1920. It was noted in an obituary (Cole, 1921) that ‘President after president, in speaking of the services he thus rendered, exhausted the vocabulary of laudatory epithets’. He was also principal editor of the Annales Médico-psychologiques from 1890 and remained so until his death. Cole (1921) commented that: ‘In the ways in which he exercised both his secretarial and editorial functions he was somewhat old-fashioned. He had a great respect for tradition.’
On the other hand, Ritti owed some of his appointments to Baillarger (Walusinski and Bogousslavsky, 2011); he had dedicated his thesis to him (among others); and he succeeded Baillarger as principal editor of Annales Médico-psychologiques (Cole, 1921), as noted above, and his views may have been influenced by these factors.
At the very least it is evident that strong feelings have been aroused, resulting in directly contrasting conclusions regarding academic precedence by two eminent French psychiatrists, separated by 100 years of history.
In addition to commenting on the issue of precedence, Ritti, in his late 19th century review, noted that clinically there could be either a subtle or gradual transition between mania and melancholia and that it could occur in successive oscillations, often with a lucid interval between episodes. He described it as ‘an essentially hereditary affection’; that it ‘often commences with the period of puberty’; and that ‘dementia comes on very late, if at all’.
He also recorded no fewer than 50 subtypes of both melancholia and mania, and the subtypes of mania are presented in Table 1. In addition he noted a number of synonyms for circular insanity, and these are presented in Table 2.
Subtypes of mania (Tuke, 1892).
Synonyms of ‘circular insanity’ (Ritti, 1892).
Although not referred to in the review by Ritti, the now commonly used terms of ‘cyclothymia’ and ‘hypomania’ were described in the late 19th century. Hecker (1877, quoted by Brieger and Marneros, 1997) introduced ‘cyclothymia’ to describe moderate fluctuations of mood, and Mendel (1881, quoted by Malhi et al., 2010) used ‘hypomania’ to denote less severe features of mania.
Kraepelin’s contribution
It was in the last part of the 19th and early 20th centuries that the work of Emil Kraepelin was first published and then held sway, although not without criticism, as will become apparent. Between 1883 and 1926 there were nine editions of his classic textbook, Psychiatry: A Textbook for Students and Physicians, and the evolution of the condition has been described well by Trede et al. (2005).
The term ‘manic-depressive insanity’ was first used in the 6th edition in 1899, when the distinction was made between manic-depressive insanity and dementia praecox. Indeed, it was noted of manic-depressive insanity that ‘even if the illness is prolonged, we do not observe progression into real dementia’.
In that 6th edition in 1899, a number of subtypes of manic-depressive insanity were described, all of which could be periodic, circular or cyclothymic. Kraepelin (quoted by Trede et al., 2005) noted that:
It is not exceptional to see in one and the same clinical course the most dissimilar clinical pictures appearing one after another. All of the diverse forms of manic excitement can take each other’s place in the same and different episodes; this can happen in simple and periodic mania and in circular insanity. These states appear therefore as equivalents, as expressions of very closely related basic states that seamlessly metamorphose into each other ... [W]e find in manic-depressive illness a certain group of clinical manifestations that alternate, and we have no right to trace these endless varieties of clinical pictures back to fundamentally different basic mechanisms (page 171)
Kraepelin’s classification was subjected to intense criticism in the early 20th century, particularly by some English commentators. Drapes (1909) noted that:
No one will deny that Kraepelin is an acute observer, and a most accurate delineator of morbid mental conditions; but he does seem to suffer from a kind of psychopathic colour-blindness which has the effect of making him rivet his attention on one or two special features in a case, and draw deductions from these alone . . . (page 61)
In another paper, Drapes (1908) asserted that:
The fact is, these fanciful so-called ‘varieties’ are all nothing but clinical descriptions of the one disordered mental condition, insanity, while it is passing through certain more or less transitory, or a succession of transitory stages, and to attach a separate style and title to such temporary conditions, or to any combination of them, is nothing but to create confusion in our conceptions of insanity (page 338).
Drapes (1909) concluded that:
Surely we can come to no other conclusion than that there has been an error of judgement on the part of the writer, and that there is no such ‘disease’ as he postulates; or, rather, the very different cases which he describes may be all included under the simple general term of ‘mixed insanity’ . . . (page 63)
In a similar vein, Bolton (1908, page 317) observed that: ‘the writer therefore considers that the maniacal-depressive generalization is untenable as a description of a special kind of mental disease ...’ and, in a comment undoubtedly influenced by the British Empire being at its zenith, he pontificated that:
It is possible, in fact, that in the future foreign psychiatrists, by gradually increasing the breadth of their generalizations, will end where English psychiatrists have begun, by recognizing the unity of mental diseases (page 310)
Not all English authors were as forthright and xenophobic as Drapes and Bolton, and Savage, in his 1907 Lumleian lectures (quoted by Bolton, 1908) observed, in a manner which still resonates well with our uncertain nomenclature, that:
I still believe that what Hughlings Jackson said many years ago is true, viz., that we physicians connected with insanity resemble gardeners rather than botanists; that the fact must be recognized that we classify for convenience rather than on a scientific basis, because in point of fact no such basis, or finality of mode, has as yet been discovered ... (page 311)
Nevertheless, Kraepelin’s descriptions held sway, and by the 8th edition of his textbook the classic features of mania of manic distractedness, flight of ideas, grandiosity, excitement or hyperactivity, and euphoric mood had been described well. Furthermore, Kraepelin (1913, quoted by Trede et al., 2005) was well aware of the potential shortcomings of his classification, and he observed that:
The mixed and transitional states make clear delineations impossible; they obstruct in a very confusing way the uniform understanding of the pure cases . . . These are the cases that push us to widen our knowledge. One should assume that our current understanding about clinical syndromes is far from complete . . . If we will achieve our goal of grasping the true illness-processes through our nomenclature, it will only be if the different ways of delineating them – be it pathological-anatomical, etiological or purely clinical – finally come together. I consider this requirement as the cornerstone of our scientific research on mental illnesses (page 174)
Twentieth century developments
There followed in the 20th century a number of developments. These have been reviewed well by Angst and Marneros (2001), who noted that in a series of studies between 1911 and 1953 Kleist disagreed with Kraepelin’s concept, differentiating between unipolar (‘einpolig’) and bipolar (‘zweipolig’) affective disorders. They also noted that Leonhard developed Kleist’s approach in publications between 1934 and 1957, but they added that ‘Neither Kleist nor Leonhard considered monopolar mania to be a component of bipolar disorders in present-day terms’.
Angst and Marneros (2001) considered that the ‘The “rebirth” of bipolar disorder’ occurred in 1966. The first English language description appears to be that of Perris (1966) in a supplement of Acta Psychiatrica Scandinavica entitled ‘A study of bipolar (manic-depressive) and unipolar recurrent depressive psychoses’. However, in a manner reminiscent of Falret asserting his precedence over Baillarger 150 years before, Angst and Marneros (2001) emphasised that the work of Angst (1966), Zur Ätiologie und Nosologie Endogener Depressiver Psychosen (‘On the Aetiology and Nosology of Endogenous Depressive Psychoses’) had been published ‘first’, and, four lines further on, they noted that the work of Perris was ‘the second’, having been ‘published some months later’. Further descriptions of these and other earlier European contributors are presented in the detailed review of Angst and Marneros (2001).
In the meantime, in the USA in 1952 the American Psychiatric Association used the term ‘manic-depressive reaction’, and in 1968 both the American DSM-II and the ICD-8 referred to ‘manic-depressive illness’.
Another significant development occurred in 1976, when Dunner et al. described bipolar II disorder to distinguish those patients with depression and hypomania from those with depression and severe mania. Since then a plethora of ‘different’ bipolar disorders have been postulated, with ample criticism (Malhi, 2007).
In 1999 Akiskal and Pinto described no fewer than seven subtypes of bipolar disorder ranging from bipolar ½ (schizobipolar) to bipolar IV (depression with hyperthymic temperament, or trait hypomania). Other subtypes have also been incorporated into what is now regarded as the ‘bipolar spectrum’ (Angst, 2007; Phelps et al., 2008). These have included bipolar V, recurrent depression with dysphoric hypomania; and bipolar VI, late onset depression with cognitive decline and mood lability (Ng et al., 2008), and all are recorded in Table 3.
Contemporary subtypes of bipolar disorder. Modified from Akiskal and Pinto (1999).
In addition, Akiskal et al. (2003) referred to ‘“dark” and “sunny” expressions of soft bipolarity’, and Angst et al. (2010) described ‘major depressive disorder with subthreshold bipolarity’. Furthermore, questions have been posed such as those of Perugi et al. (2001): ‘Are atypical depression, borderline personality disorder and bipolar II disorder overlapping manifestations of a common cyclothymic diathesis?’; and Schweitzer et al. (2005): ‘Should bipolar disorder be viewed as manic disorder? Implications for bipolar depression’, all of which confirm our clinical diagnostic uncertainty.
To add to this confusion, and complement the diligence shown by researchers in delineating these conditions, bipolar disorders have even achieved such a place in popular culture that a new phenomenon, ‘I want to be bipolar’, has been described (Chan and Sireling, 2010)!
Implications of contemporary genetic research
Of fundamental importance in psychiatry has been the long held distinction between schizophrenia and bipolar disorders, the ‘so called “Kraepelinian dichotomy”‘ (Craddock and Owen, 2005). In this regard contemporary genetic research has enabled the assumed distinction to be examined in a manner undreamed of by earlier researchers. For example, Lichstenstein et al. (2009) observed that:
The co-morbidity between disorders was mainly (63%) due to additive genetic effects common to both disorders ... These results challenge the current nosological dichotomy between schizophrenia and bipolar disorder, and are consistent with a reappraisal of these disorders as distinct diagnostic entities (page 234)
These findings led Owen and Craddock (2009), to conclude in an Editorial in the Lancet that:
How many distinct disorders it might be useful to recognise, or whether the functional psychoses are better conceptualised as a continuum or as a set of overlapping processes, is not yet known (page 191)
Such a conclusion is consistent with the more recent research of Hamshere et al. (2011), who reported that:
. . . genetic susceptibility influences at least two major domains of psychopathological variation in the schizophrenia–bipolar disorder clinical spectrum: one that relates to expression of a ‘bipolar disorder-like’ phenotype and one that is associated with expression of ‘schizophrenia-like’ psychotic symptoms (page 287)
They concluded that ‘this analysis supports the move in classificatory thinking away from the traditional discrete dichotomous thinking’. Clearly no simple discrete system of classification has yet emerged from contemporary research techniques.
Conclusions
It is fascinating that in some ways the description of these illnesses appears to be going in an historical full circle in terms of the clinical distinction and the utility of that distinction of different clinical syndromes. Indeed, it is not unexpected that there have been papers drawing attention to the similarities between some contemporary subtypes and those referred to in the 19th century literature (Haustgen and Akiskal, 2006; Benazzi and Akiskal, 2006). Given time, perhaps the more than 50 subtypes of mania noted by Ritti (1892) could be re-described in 21st century language!
It is pertinent to reflect on the caution of Phelps et al. (2008) that: ‘Too many overhauls of psychiatric nosology in less than a century could add to diagnostic chaos rather than diminish it’. Furthermore, it is sobering to recall the words of Drapes (1908) written over 100 years ago:
. . . unless our methods of research be developed to such an amazing degree as to enable us to discover the special pathological condition underlying each of the named ‘forms’ of insanity, if we can ever agree as to what are forms – a consummation which I fear is likely to be postponed to the millennium – no rational system of classification will be devised . . . (page 340)
We are now in that new millennium foreshadowed by Drapes, but the advent of sophisticated genetic biological scientific enquiry has not yet settled the nosological debate. Indeed, the emerging complexity resulting from genetic research has almost certainly clarified why there should have been so much, and at times such vehement, academic debate over the last 200 years.
While there remains the possibility of refinements in nosology, it would appear that for the foreseeable future the clinical challenge will remain much as it has for the last two centuries. This is summed up well by Jamison (1993), where she observed:
The clinical reality of manic-depressive illness is far more lethal and infinitely more complex than the current psychiatric nomenclature, bipolar disorder, would suggest. Cycles of fluctuating moods and energy levels serve as a background to constantly changing thoughts, behaviors, and feelings (page 47)
The research challenge also still remains, and it is arguably more complicated than could have been envisaged over a century ago. Indeed, the words of Drapes (1908) a century ago provide a fitting conclusion:
. . . any topic about which men disagree, and which is still the subject of contention and controversy, will always have a certain amount of interest attached to it until the question is finally settled. And everyone will, I think, agree that such is not the case in the present instance, and that by no means the last word has yet been said on the subject of classification (page 341)