1. 2 Historical Roots in Medicine and Ancient Times Print

Presentations of Bipolar disorder were described by the ancient Greeks. It was observed and described not only by physicians like Hippocrates and Aretaeus, but also by philosophers and poets. Angst and Marneros (2001) review the historical evolution of the concept of bipolar disorder from ancient to present times.

The first physician to actually observe and describe in detail the features of Bipolar disorder is (Aretaeus, 150 AD) of Cappadocia in his two books ‘On the Aetiology and Symptomatology of Chronic Diseases’ and ‘The Treatment of Chronic Diseases’. Although like Hippocrates he emphasised the biological bases of mental illness, he also pointed out the role of psychological factors especially for depression. He distinguished between a biologically caused depression (melancholia) and a “reactive depression”. Apart from the hypotheses he made regarding the cause of the disorder, he also made interesting observations regarding the interplay between melancholia and mania, which highlight the mixture of bipolar symptoms.

‘‘ . . . I think that melancholia is the beginning and a part of mania . . . The development of a mania is really a worsening of the disease (melan-cholia) rather than a change into another disease. . . In most of them (melancholics) the sadness became better after various lengths of time and changed into happiness; the patients then developed a mania’’. Aretaeus of Cappadocia (150 AD)

Aretaeus observations of the two primary phases of bipolar disorder emphasised their development over time and the complex interplay of bipolar symptomatology. The emphasis on the variability of bipolar symptomatology as the primary feature of the disorder has continued to appear through out the academic literature on bipolar disorder.

Plato, on the other hand, observed and highlighted the role of psychological factors in mania. In his book “Phaedrus” he distinguished between two kinds of mania; one characterised by mental strain that arises from a bodily cause of origin (what would nowadays be considered dysphoric mania), and a second divine or inspired mania with Apollo being the source of “inspiration” (euphoric mania). Plato made further distinctions between psychogenic manias, which he called “inspirations”. These were the “prophetic inspiration”, the “erotic inspiration” (sent by the god of love, Eros), and “protreptic inspiration” (sent by the muses) that makes men sing. Such observations further set the ground for investigating different causal factors of bipolar symptoms and also contemporary knowledge with regards to the factor structure of mania (Cassidy et al., 2001).

Contemporary medical accounts of bipolar disorder by physicians in the 18th century continued to describe the longitudinal associations between melancholia and mania but did not see this as one single condition. According to (Angst and Marneros, 2001) it was the French psychiatrist Jean-Pierre Falret (1854) who recognised bipolar disorder as an entity on its own by calling it “folie circulaire”, and describing it as an entity that is “characterized by a continuous cycle of depression, mania and free intervals of varying length”, Jean-Pierre Falret (1854).

Our 20th century descriptive and diagnostic understanding of Bipolar disorder is primarily the end product of the work of German psychiatry, in particular Emil Kraepelin who made the distinction between manic depressive illness and schizophrenia (Kraepelin, 1919).

Kraepelin made the distinction based on his careful prospective observation of the symptoms course and the prognosis of the two disorders. He considered schizophrenia as an illness with a deteriorating course, in contrast to bipolar disorder that was characterised by an episodic course and overall a better prognosis. Kraepelin was also one of the first modern physicians to advance the method of Bipolar Life-Charting as he kept detailed graphical records/charts of his patients’ illness course.

Nevertheless, the clinical significance of sub-syndromal symptoms in bipolar disorder was first put forward by a non-organic psychoanalytically trained psychiatrist, Karl Abraham. Even though Karl Abraham (1911, 1924) is often considered the father of the manic-defence hypothesis, which was a psychoanalytic insight/hypothesis proposing that mania is a defence against depression, he should also be credited for his early observations on the presence of sub-syndromal symptoms during “free intervals”, what we nowadays call inter-episode periods.

In his 1924 monograph, “Manic Depressive states and the pre-genital of the libido”, he wrote: “For we find that the patient who is liable to periodic fits of depression and exaltation is not really perfectly well during his “free interval”. If we merely question such patients rather closely we learn that during long intervals of this kind they pass through depressive or hypo-manic states of mind from time to time” (p.423, 1924) Predictably, as an early psychoanalyst trained to observe personality functioning he even gave some insight into the differences in the characters of bipolar patients during these “free interval” periods.

“But what is specially interesting to the analyst is the fact that in all cycloid illnesses the patient is found to have an abnormal character-formation during his “free interval”; and that this character-formation coincides in a quite unmistakable way with that of the obsessional neurotic” (p. 423, 1924)

Of course given the nature of his psychoanalytic work and the fact that he based most of his theories on six case studies, Abraham did not attempt to make any links between his observation on sub-syndromal symptoms or the “abnormal” character formation during well periods and the course of the disorder.

 

key references

Angst, J. & Marneros, A. 2001. Bipolarity from ancient to modern times: conception, birth and rebirth. J Affect Disord, 67, 3-19.

Aretaeus 150 AD. On the Aetiology and Symptomatology of Chronic Diseases.

Cassidy, F., Pieper, C. F. & Carroll, B. J. 2001. Subtypes of mania determined by grade of membership analysis. Neuropsychopharmacology, 25, 373-83.

Kraepelin, E. 1919. Dementia Praecox and Paraphrenia.(1896) Translated by RM Barclay. Chicago: Chicago Medical Books.

Abraham, K. 1911. Notes on the psycho-analytical investigation and treatment of manic-depressive insanity and allied conditions. Selected Papers, 137-56.

Abraham, K. 1924. A short study of the development of the libido, viewed in the light of mental disorders. Selected Papers, 418-501.