THE Brief History of Manic Depressive Insanity (Bipolar Disorder)- from Hippocrates to DSM-5

Author’s Note: Author does not claim to be either a researcher or a historian of Bipolar Disorder or any other form of Mental Illness. The quest for history of Bipolar Disorder, earlier known as Manic Depressive Insanity came from the desire to understand the rubrics and nuances of this type of madness which the author suffers from. Mistakes in the narrative show ignorance of the author who would like those experienced to throw more light on the matter

 

History of “mania” and “melancholia” is supposedly first systematically described by Hippocrates (460-337 B.C.) using anatomical explorations of Pythagoras, Alcmaeon, and Empedocles of Crotona and on his own clinical observations of these extreme expressions of mood.

 However there was lack of clarity as to how these two extremes were linked within one person and how these changing emotional states were expressed as a disease of mind. It was Arteaeus of Cappadocia in the 1st century A.D. who first linked mania and melancholia by introducing his concept of spectrum on the assumption that melancholia and mania had the same etiology coming from the brain dysfunction. More specifically he postulated mania as the worsening condition as well as phenomenological counterpart of melancholia.

Concept of mania and melancholia and link between the two were re-examined in  the 19th century giving birth to the “modern” manic depressive insanity or bipolar disorder. First salvo was fired in 1851 by Jean-Pierre Falret who described a new psychiatric disorder encompassing both mania and depression, characterized by continuous cycle of depression, mania and free intervals of uneven lengths between two extremes. He called it- “Folie Circulaire”. (Circular insanity). Also Jules Baillarger talked of “folie à double forme” (insanity of double form where mania and melancholia change into one another without requirement of free interval between two) in contrast to Falret’s description which would include those with a long interval between the two mood states.

 

In 1863, Karl Kahlbaum classified psychoses into nosological framework, duly delineating clinical symptoms, the disease course and outcome, brain pathology and etiology. Based on symptoms and outcome, he described two way classification-one with limited disturbance  (“Vecordia”) with continuous but remitting course and the other that represented complete disturbance of the mind (“vesania”) a progressive disease with changing symptoms. He also added Cyclothymia as a form of circular insanity.

But it was father of modern psychiatry Emil Kraeplin  who in 1999 and in subsequent works, drawing inspiration from both Kahlbaum and Falret, surmised all dysfunctions of mood and  brought out two distinct classifications-Dementia Praecox” and “Manic-Depressive Nnsanity” (also including recurrent melancholia), now known as schizophrenia and bipolar disorder, respectively. The Kraepelinian dichotomy in manic-depressive insanity, described full spectrum of mood dysfunctions which potentially could be present in single episodes of mania or depression or in multiple recurrent episodes of both. Post Krapelin further substantive work was also done by his contemporary Bleurer

Post Kraeplin, in last hundred twenty years the researches have been taken forward by many researchers but Kraeplin model remains a robust one till date.

 

ICD 6 and DSM 1: In the modern era, the first step to categorize mental-disorders started with the sixth version of International Classification of Diseases (ICD-6) of WHO in 1948 and first version of Diagnostic and Statistical Manual of Mental Disorders (DSM-1) of American Psychiatric Association. DSM-1. 

“DSM-1 called manic-depressive insanity a form of psychotic disorder “characterized by varying degree of personality integration and a failure to test and evaluate correctly external reality in various spheres”. DSM-1 classification postulated three states- mania, depression and others. The manic type was akin to modern definition of mania, “elation or irritability, with over talkativeness, flight of ideas, and increased motor activity”. The depressive types were akin to what today is described as Major Depressive Disorder-“severe depression of mood, with mental and motor retardation and inhibition and in some cases much uneasiness and apprehension. Perplexity, stupor or agitation too also was described as key depressive symptoms”. Also in other type it explained mixed states or cycling-, “marked mixtures of manifestations of manic and depressive phases (mixed type), or those cases where continuous alternation of the two phases occur (circular type)”.

 

Thus DSM-1 for the first time provided symptoms of mania, depression and their tendency to remit and recur. Interestingly, it also listed illusions, delusions and hallucinations as possible additions to the diagnosis, but today such psychotic features in manic are not present in all bipolar patients.

 

DSM 2: With the advent of DSM 2 in 1968, classification of manic-depressive insanity changed from “Psychotic disorder” to “ The Affective disorder”. Its nomenclature too changed to “manic-depressive illness” and it was defined as disorders marked by severe mood swings and a tendency to remission and recurrence. It was divided into three major subtypes: manic type, depressed type, and circular type.

 

Manic type in DSM 2 was categorized as one with episodes only characterized by excessive elation, irritability, talkativeness, flight of ideas, and accelerated speech and motor activity. It talked of occurrence of brief periods of depression sometimes in this subtype but these were not considered true depressive episodes. Depressive types was categorized as one exclusively consisting depressive episodes characterized by severely depressed mood and by mental and motor retardation progressing occasionally to stupor often with uneasiness, apprehension, perplexity and agitation. It further added that when illusions, hallucinations, and delusions (usually of guilt or of hypochondriacal or paranoid ideas) did occur, they had to be attributed to dominant mood disorder and because it was a primary mood disorder, this psychosis differed from the psychotic depressive reaction, which was more easily attributable to precipitating stress. It considered cases incompletely labeled as “psychotic depression” to be classified here instead of under psychotic depressive reaction

 

DSM-II described Manic Depressive Illness circular type as one to be distinguished by at least one attack of both a depressive episode and a manic episode. It was here that both manic and depressed types are combined into a single category. In DSM-I these cases were diagnosed under “Manic depressive reaction, other” but were more clearly amplified in DSM 2 as manic-depressive illness circular and manic depressive illness circular depressive

 

It is important to note that in DSM,-I manic-depressive insanity diagnosis was strongly influenced by prevalent psychodynamic approach with no sharp distinction between normal and abnormal states. All disorders were considered reactions of the personality to psychological, environmental, and biological factors, with mental disorders existing on a continuum of behavior. This construct largely was followed also by DSM 2.

 The radical change- DSM-3

It was DSM-3 in 1980 that brought about a radical change in the perspective when biomedical approach replaced hitherto psychodynamic conceptualization, making way for a clear distinction between normal and abnormal behaviors and reformulating psychiatric illnesses in terms of empirical research and statistical knowledge.

DSM III also introduced other fundamental changes- it changed the name of Manic-Depressive Insanity to Bipolar Disorder, separated uni-polar and bipolar depression as two distinct types of illness, it introduced concept of Hypomania, emphasized polarity of mood, for the first time made difference between adult and pediatric bipolar disorder construct and introduced family history as additional diagnostic tool.

These changes echoed tireless pioneering works of Keist (1950) on uni-polar versus bipolar manic-depressive sub-types; Leonhard (1957) coining the word bipolar disorder and his elaboration of polarity concept and further elaboration thereof these concepts by Angst and Perris (1960’s) and finally Akiskal (1980) work of broad bipolar spectrum

DSM-3 also introduced rigor to the diagnostic criteria which in case of manic episode now included:

“ increase in activity (either socially, at work, or sexually) or physical restlessness; more talkative than usual or pressure to keep talking; flight of ideas or subjective experience that thoughts are racing; inflated self-esteem (grandiosity, which may be delusional); decreased need for sleep; distractibility, i.e. attention is too easily drawn to unimportant to irrelevant stimuli; excessive involvement in activities that have high potential for painful consequences which is not recognized, e.g., buying-sprees, sexual-indiscretions, foolish business investments, reckless driving”

 

These criteria look like present day diagnostic-criteria.

DSM-III also prescribed for the first time that for diagnosis as manic attack at least three of above symptoms were needed for a duration of one week, for most of the time, though an episode would meet criteria regardless of duration if  hospitalization was required, also if only irritable mood was present and then four symptoms were required. The criteria also detailed symptoms which would preclude a manic episode diagnosis and points to other more appropriate diagnoses if schizophrenic symptoms are present (i.e., hallucinations or bizarre behavior).

Some more incremental improvements to diagnostic-criteria were introduced with in DSM-III-R with research findings about  mood disorders and disorders of childhood and adolescence and also for the first time got added bipolar subtype classifications such as bipolar disorder-mixed, bipolar disorder-manic, bipolar disorder-depressed, bipolar disorder-not otherwise specified, and Cyclothymia.

DSM-IV (1994) retained the manic episode diagnostic-criteria of DSM-III/DSM-III-R including the fact that for Bipolar-I diagnosis at least one manic episode of seven days duration of severity sufficient to cause “marked impairment in psycho-socio-occupational functioning and/or needing hospitalization must have happened.

DSM IV- TR (2000)

In this revision Bipolar disorder is characterized by more than one bipolar episode. snd it provides 3 types of  bipolar disorder:

1. Bipolar 1 Disorder, in which the primary symptom presentation is manic, or rapid (daily) cycling episodes of mania and depression.
2. Bipolar 2 Disorder, in which the primary symptom presentation is recurrent depression accompanied by hypomanic episodes (a milder state of mania in which the symptoms are not severe enough to cause marked impairment in social or occupational functioning or need for hospitalization, but are sufficient to be observable by others).
3. Cyclothymic Disorder, a chronic state of cycling between hypomanic and depressive episodes that do not reach the diagnostic standard for bipolar disorder (, pp. 388–392).

Manic episodes here are characterized by:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:
(1)increased self-esteem or grandiosity
(2)Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) more talkative than usual or pressure to keep talking
(4) flight of ideas or subjective experience that thoughts are racing
(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
(6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
(7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)”

 

Finally comes the DSM-5 (2013), the latest diagnostic criteria for Bipolar Disorderr-

Criteria for bipolar disorder: The criteria for diagnosing specific types of bipolar disorder  provided in Diagnostic and Statistical Manual of Mental Disorders (current version DSM-5), published by the American Psychiatric Association are as follows.

  • Bipolar Disorder I: is considered to be one where the patient has had at least one manic episode preceded by or followed by hippomanic or major depressive episodes. Mania brings significant psycho-social- occupational impairment, often requires hospitalization and/or is accompanied with psychotic attack (break from reality).
  • Bipolar II disorder.It characterizes at least one major depressive episode lasting at least two weeks and at least one hippomanic episode lasting at least four days, but no major manic attack. Major depressive episodes and unpredictable changes in mood and behavior can cause distress or difficulty in areas of life.

Note: Bipolar II disorder is not a milder form of bipolar I disorder, but a separate diagnosis. While the manic episodes of bipolar I disorder is often severe and dangerous, individuals with bipolar II disorder are usually depressed for longer periods, which can cause significant impairment.

  • Cyclothymic disorder: One or two years of numerous periods with hypo-mania symptoms (less severe than a hypo mania episode) and periods of depressive symptoms (less severe than a major depressive episode) in children or teen-agers . During that time, symptoms are present at least half the time and never go away for more than two months. Symptoms cause significant distress in important areas of life.
  • Other types.These include, for example, bipolar and related disorder due to another medical condition, such as Cushing’s disease, multiple sclerosis or stroke. Another type is called substance and medication-induced bipolar and related disorder.

The DSM-5 has specific criteria for the diagnosis of episodes of mania and hypomania-

  • An episode of mania is one with distinct period of abnormally and persistently elevated, expansive or irritable mood that lasts at least one week (or less than a week if hospitalization is necessary). The episode includes persistently increased goal-directed activity or energy.
  • An episode of hypomania is characterized with a distinct period of abnormally and persistently elevated, expansive or irritable mood that lasts at least for four consecutive days.

Also for an episode to be diagnosed as mania or hypomania during the period of disturbed mood and increased energy at least three or more the following symptoms ( four if mood is only irritable) must be present and represent a noticeable change from  usual behavior:

  1. Inflated self-esteem or grandiosity
  2. Decreased need for sleep
  3. Unusual talkativeness
  4. Racing thoughts
  5. Distractibility
  6. Unusually increased goal-directed activity at home, social set up, school, college or work or sexual over activity or agitation
  7. Overindulgence in unusual activities with have potential for painful consequences — for example unrestrained buying sprees, sexual indiscretions or foolish business investments

 

In addition to be considered as episode of mania following additional conditions must be fulfilled-

  • The mood disturbance must be severe enough to cause noticeable difficulty at work, at school or in social activities or relationships; or to require hospitalization to prevent harm to yourself or others; or to trigger a break from reality (psychosis).
  • Symptoms are not due to the direct effects of something else, such as alcohol or drug use; a medication; or a medical condition.

 And for being considered an episode of hypomania following additional criteria-

  • The episode brings a distinct change in mood and functioning of the patient that is not characteristic of him when the symptoms are not present, and the change is enough for others to notice.
  • The episode isn’t severe enough to cause significant difficulty at work, at school or in social activities or relationships, and it doesn’t require hospitalization or trigger a break from reality.
  • Symptoms are not due to the direct effects of something else, such as alcohol or drug use; a medication; or a medical condition.

Criteria for a major depressive episode

In Bipolar Disorder, mania/hypomania is necessarily preceded or succeeded by a phase of major depressive episode. DSM-5 also lists criteria for diagnosis of a major depressive stage, as per which a depressive episode must involve prevalence of five or more of the following symptoms over a minimum period of two weeks either based on feelings of the patient or observation of someone else. Also at least one of the symptoms must be either depressed mood or loss of interest or pleasure. Signs and symptoms include-

  • Depressed mood most of the day, nearly every day, such as feeling sad, empty, hopeless or tearful (in children and teens, depressed mood can appear as irritability)
  • Markedly reduced interest or feeling no pleasure in all — or almost all — activities most of the day, nearly every day
  • Significant weight loss when not dieting, weight gain, or decrease or increase in appetite nearly every day (in children, failure to gain weight as expected can be a sign of depression)
  • Either insomnia or sleeping excessively nearly every day
  • Either restlessness or slowed behavior that can be observed by others
  • Fatigue or loss of energy nearly every day
  • Feelings of worthlessness or excessive or inappropriate guilt, such as believing things that are not true, nearly every day
  • Decreased ability to think or concentrate, or indecisiveness, nearly every day
  • Recurrent thoughts of death or suicide, or suicide planning or attempt

To be considered a major depressive episode-

  • Symptoms must be severe enough to cause noticeable difficulty in day-to-day activities, such as work, school, social activities or relationships
  • Symptoms are not due to the direct effects of something else, such as alcohol or drug use, a medication or a medical condition
  • Symptoms are not caused by grieving, such as after the loss of a loved one

Other signs and symptoms of bipolar disorder-

Signs and symptoms of bipolar I and bipolar II disorders may include additional features-

  • Anxious distress having anxiety, such as feeling keyed up, tense or restless, having trouble concentrating because of worry, fearing something awful may happen, or feeling one may not be able to control oneself
  • Mixed State meeting the criteria for a manic or hypomanic episode, but also having some or all symptoms of major depressive episode at the same time
  • Melancholic features having a loss of pleasure in all or most activities and not feeling significantly better, even when something good happens
  • Atypical features experiencing symptoms that are not typical of a major depressive episode, such as having a significantly improved mood when something good happens
  • Catatonia not reacting to one’s environment, holding  body in an unusual position, not speaking, or mimicking another person’s speech or movement
  • Peripartum onset bipolar disorder symptoms that occur during pregnancy or in the four weeks after delivery
  • Seasonal pattern (seasonally affective disorder or SAD) a lifetime pattern of manic, hypomanic or major depressive episodes that change with the seasons
  • Rapid cycling having four or more mood swing episodes within a single year, with full or partial remission of symptoms in between manic, hypomanic or major depressive episodes
  • Psychosis severe episode of either mania or depression (but not hypomania) that results in a detachment from reality and includes symptoms of false but strongly held beliefs (delusions) and hearing or seeing things that aren’t there (hallucinations)

 

Symptoms in children and teens

The same DSM-5 criteria used to diagnose bipolar disorder in adults are used to diagnose children and teenagers. Children and teens may have distinct major depressive, manic or hypomanic episodes, between which they return to their usual behavior, but that’s not always the case. And moods can rapidly shift during acute episodes.

 

Symptoms of bipolar disorder can be difficult to identify in children and teens. It’s often hard to tell whether these are normal ups and downs, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder. And children who have bipolar disorder are frequently also diagnosed with other mental health conditions. The most prominent signs of bipolar disorder in children and teenagers may include severe mood swings that are different from their usual mood swings.

 

 

 

 

 

 

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