The Early History of Bipolar Disorder
As might be expected, the early history of bipolar and other mental disorders is not pretty, but rather a testimony to ignorance, misunderstanding, and fear. Consider that in 300 to 500 CE, some people with bipolar disorder were “euthanized,” according to Cara Gardenswartz, PhD, who is in private practice in Beverly Hills, California, with specific expertise in bipolar disorder and in its history.
“In the earliest days of documentation, these people were viewed as ‘crazy’ [or as] possessed by the devil or demons,” says Dr. Gardenswartz. Their treatment or punishment, she explains, included restraint or chaining; their blood was let out; they were given different potions; or electric eels were applied to the skull — “much in the way witches have been treated in various cultures. In fact, witchcraft was often used to try and ‘cure’ them.”
“Less is known about bipolar disorder from 1000 to 1700 CE, but in the 18th and 19th centuries, we adopted a healthier overall approach to mental disorders,” says Gardenswartz.
How Our Understanding of Bipolar Evolved
Consider these developments in the evolution of bipolar disorder, which was observed and studied in the second century by physician Aretaeus of Cappadocia, a city in ancient Turkey. In his scholarly work, On Etiology and Symptomatology of Chronic Illnesses, Aretaeus identified mania and depression; he felt they shared a common link and were two forms of the same disease.
The ancient Greeks and Romans coined the terms “mania” and “melancholia” and used waters of northern Italian spas to treat agitated or euphoric patients — and, in a forecast of things to come, believed that lithium salts were absorbed into the body as a naturally occurring mineral. In 300–400 BCE, the ancient Greek philosopher Aristotle had thanked “melancholia” for the gifts of artists, poets, and writers, the creative minds of his time.
But in the Middle Ages, people living with mental illness were often thought to be guilty of wrongdoing. Their illness was viewed as a manifestation of bad deeds.
In 1621, Robert Burton — English scholar, writer, and Anglican clergyman — wrote what many deem a classic of its time, a review of 2,000 years of medical and philosophical “wisdom”: The Anatomy of Melancholia, a treatise on depression that defined it as a mental illness in its own right. In 1686, Swiss physician Théophile Bonet named “manico-melancolicus” and linked mania and melancholia.
Measurable progress was made in the early 1850s when Jean-Pierre Falret, a French psychiatrist, identified folie circulaire or circular insanity — manic and depressive episodes that were separated by symptom-free intervals. He broke substantial new academic ground when he chronicled distinct differences between simple depression and heightened moods. In 1875, because of his work, the term “manic-depressive psychosis,” a psychiatric disorder, was coined. Scientists also credit Dr. Falret with recognizing a genetic link associated with this condition.
The Discovery of Mixed States and Cycling
“We owe the categorization of bipolar disorder as an illness to Falret,” write Jules Angst, MD, and Robert Sellaro, of Zurich University Hospital in Switzerland, in their September 2000 paper, “Historical Perspectives and the Natural History of Bipolar Disorder,” published in Biological Psychiatry.
“It is remarkable how Falret’s description of symptoms and hereditary factors are so similar to descriptions found in present-day books and journals,” writes Erika Bukkfalvi Hilliard of Royal Columbian Hospital in British Columbia, in her 1992 book Bipolar Disorder, Manic-Depressive Illness. “Falret even encouraged physicians to diversify medications used in the treatment of manic-depressive illness in the hopes that one of them might one day discover an effective drug therapy.”
Dr. Angst and Sellaro note that concurrently in 1854, French neurologist and psychiatrist Jules Gabriel François Baillarger used the term folie à double forme to describe cyclic (manic-depressive) episodes. Dr. Baillarger apparently also recognized a distinct difference between what we now know as bipolar and schizophrenia.
In their treatise, the Swiss specialists detail more specifics about the face of an emerging illness, particularly as it relates to “mixed states.” They write, “The history of the concept of mixed states [symptoms of mania and depression occurring simultaneously] … were probably already known at the beginning of the 19th century and named ‘mixtures’ … and ‘middle forms.’”
A 1995 paper by French psychiatrist T. Haugsten, “Historical Aspects of Bipolar Disorders in French Psychiatry,” also traces the term “mixed states’ to Falret’s son, psychiatrist Jules Falret.
“At the end of the 19th century, in spite of the contributions of Falret, Baillarger, and [German psychiatrist Karl Ludwig] Kahlbaum (among others), most clinicians continued to consider mania and melancholia as distinct and chronic entities with a deteriorating course,” José Alberto Del Porto, Paulista School of Medicine of the Federal University of São Paulo, states in a research paper published in Brazilian Journal of Psychiatry. However, the acceptance of this theory would not prevail forever.
The Shift From Manic Depression to Bipolar Disorder
German psychiatrist Emil Kraepelin (1856–1926) is one of the most recognizable names in the history of bipolar. He is sometimes referred to as the founder of modern scientific psychiatry and psycho-pharmacology. He believed mental illness had a biological origin and he grouped diseases based on classification of common patterns of symptoms, rather than by simple similarity of major symptoms, as those who preceded him had done.
This forward-thinking specialist suggested that a specific brain or biological pathology was at the root of psychiatric illnesses. Dr. Kraepelin felt that the classification system needed revising, and so he did.
In the early 1900s, after extremely detailed research, he formulated the separate terms “manic-depression” and “dementia praecox,” the latter later named schizophrenia” by Eugène Bleuler (1857–1940). Widespread use of the term “manic depression” prevailed until the early 1930s — it was even used until the 1980s and 1990s, and some people prefer it to this day.
Also during the early 1900s, neurologist and psychoanalyst Sigmund Freud broke new ground when he used psychoanalysis with his patients with manic depression: biology then took a back seat. He believed childhood trauma and unresolved developmental conflicts played a role in bipolar disorder.
In the early 1950s, German psychiatrist Karl Leonhard, and colleagues began the classification system that led to the term “bipolar,” differentiating between unipolar and bipolar depression. Gardenswartz notes that “once there was a difference between bipolar and other disorders, individuals suffering from mental illnesses were better understood, and in turn — along with the progress in psychopharmacology — were able to receive better treatment.”
The term “bipolar” logically emphasizes “the two poles” of mood episodes, according to the prominent late psychiatrist Robert L. Spitzer, MD, who was a major force in developing the modern approach to classifying and diagnosing psychiatric illnesses. People with unipolar depression experience low mood episodes only, while people with bipolar depression experience both depressed and elevated moods in a cyclical manner. (In some cases of bipolar 1 disorder, people have manic episodes only.)
Dr. Spitzer led the task force that wrote the third version — an undeniably major revision — of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). After DSM-III was published in 1980, the reference work became so influential it is often referred to as the “bibIe” of American psychiatry. (Specialists in many other countries use the International Classification of Mental and Behavioural Disorders, or ICD.)
Among the monumental changes in the DSM-III, the term “manic-depression” was dropped and “bipolar disorder” introduced — eliminating references to patients as “maniacs.”
The Debate: Manic-Depressive Illness or Bipolar Disorder?
The third edition of the Diagnostic and Statistical Manual of Mental Disorders, published in 1980, dropped the term “manic depression” and substituted “bipolar disorder.” There are some people — prominent bipolar researcher and memoirist Kay Redfield Jamison among them — who would like to go back to the old name.
In her book Robert Lowell: Setting the River on Fire, Jamison explains that the renaming was “a result of attempts by clinicians and scientists to distinguish between those patients who have a history of both mania and depression from those with a history of depression only.”
She presents several reasons not to “abandon” the term manic-depressive illness, partly so we don’t lose the historical and social dimensions of the phrase. While many find the term “bipolar disorder” less stigmatizing, she acknowledges, she finds it “misleading, rather trivializing.”
Rather, she argues, we should appreciate mania and depression’s association with accomplishments “in the arts, sciences, and other fields of human endeavor” and “understand moods and their aberrations in the context of individual lives and imaginations; the role they have in shaping societies; and the meaning they assume in the human condition.”
The Impact of the DSM-5 on Diagnosis
Further revisions of the DSM over the years have clarified inconsistencies in diagnostic criteria and incorporated updated information based on research findings, according to the American Psychiatric Association (APA). The APA issued the latest edition, DSM-5, in 2013.
Noted American neuroscientist and psychiatrist Thomas Insel, MD, former director of the National Institute of Mental Health, has said that whatever the changes in the DSM over the years, the reference work ensures that clinicians use the same terms in the same way.
Each edition has also reflected changes in philosophy in psychiatric practice. For example, the Substance Abuse and Mental Health Services Administration (SAMHSA) noted that the DSM-5 takes a “lifespan” perspective that recognizes the importance of age and development on the onset, manifestation, and treatment of psychiatric disorders.
When the DSM-5 came out, an editorial in the International Journal of Bipolar Disorders predicted that some of the changes should address an “under-recognition” of bipolar disorders. The chapter traditionally covering “mood disorders” was broken into separate chapters for unipolar depressive disorders and bipolar disorders. In addition to bipolar 1 (“classic” manic-depression), bipolar 2 (depression plus hypomania), and cyclothymic disorder (mood episodes that don’t meet the full diagnostic criteria for either bipolar 1 or 2), the new chapter includes a more flexible category for “bipolar-like phenomena.”
Furthermore, the criteria for diagnosing elevated mood states now includes an emphasis on shifts in energy level and goal-directed activity. The editorial writers felt this would make it easier to distinguish bipolar depressions from unipolar depressions in the absence of a current hypo/manic episode, since notable upticks in energy and activity would be easier for individuals to identify and recall in self-reports.
Advancements in Bipolar Treatment Options
As the labels for psychiatric disorders evolved and changed, so, too, did the range of treatments for those with bipolar disorder, says Gardenswartz. She points to the use of sedatives and barbiturates prior to the 1950s; patients were also institutionalized to separate them from others. Prefrontal lobotomies and early forms of electroconvulsive shock therapy emerged as two more radical treatment options.
“Starting in the mid-1900s, with the advent of psychiatric and antipsychotic mood-stabilizing medications, patients were able to be viewed more as human beings suffering from illnesses that could be treated,” Gardenswartz explains.
Additionally, doctors and the public began to view various health conditions “as the separate entities that they were: schizophrenia, ongoing without breaks or relief from symptoms when untreated; or bipolar, in which people could typically function normally during periods between this cyclical illness.”
A discussion of medications to treat bipolar cannot be complete without acknowledging the work of John Cade, MD, an Australian physician who introduced lithium to the practice of psychiatry in 1949 quite by accident when he observed that lithium urate appeared to calm guinea pigs.
Lithium has since remained one of the most effective medications for those with bipolar disorders, providing a springboard for further research and discovery of biomedical treatments. As the ancient Greeks and Romans suspected, natural lithium can indeed be found in hot springs and there is scientific justification for their historical use as a treatment for bipolar disorder.
Inspired by Dr. Cade, Mogens Schou, MD, Prof. Med. Sci. (1918–2005), continued groundbreaking research into lithium. Dr. Schou was emeritus professor of the Psychiatric Hospital in Risskov, Denmark, and was named honorary president of the International Society for Bipolar Disorders. Schou labeled manic-depression “the national illness” of his country and, in the 1960s, he used lithium on an experimental basis with a group of his patients who experienced mania.
Schou’s work proved that when used properly with monitoring, lithium could be very effective in treating bipolar mood episodes. In no small part because of Schou’s efforts, the U.S. Food and Drug Administration (FDA) finally approved lithium as a treatment for mania in 1970, and in 1974, as a preventive treatment for manic-depressive illness.
Going Forward
There is a lot more work and research to be done to help people diagnosed with Bipolar. While the disease has been present a long time there is still so much we don’t know about the origins of the disease or the best ways to manage it.
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