A Brief History of Bipolar Disorder

Patient Expert

I'm hard at work right now on a book on bipolar. This would supplant the one that came out nearly nine years ago, based on a manuscript I turned in ten years ago.

This time, I'm going the self-publishing route, a series of short books (I see six, right now), that will add up to a rather large one. So it occurred to me: Why don't I, from time to time, report what I'm working on?

Right now, I'm putting together two chapters that trace the evolution of our modern understanding of mood disorders. The story begins with Emil Kraepelin, who coined the term, manic-depression. In 1921, he wrote:

Manic-depressive insanity ... includes on the one hand the whole domain of so-called periodic and circular insanity, on the other hand simple mania, the greater part of the morbid states termed melancholia and also a not inconsiderable number of cases of amentia.

In other words, manic-depression also included unipolar depression. Plus "colorings of mood" that bled into personality.

Kraepelin is regarded as the father of diagnostic psychiatry, but by the time the American Psychiatric Association decided to compile a diagnostic bible, Freud was the dominant force in the US.

The DSM-I of 1952 and its successor the DSM-II of 1968 both preserved the general shape of Kraepelin's manic-depression, but they overlaid it with a thick layer of Freudian muck. Their assumption was that mental illness was the result of an individual failing to adapt to his or her environment.

These "reactions" had as much to do with personality, social setting, and the stresses of dealing with life as with any biological cause.

These DSMs proved of no practical value to clinicians, who showed a greater enthusiasm for treating neurosis, anyway. Nevertheless, these documents are well worth reading, if only to provide an insight into the sheer complexity of what we have to cope with.

In 1974, the APA appointed Robert Spitzer of Columbia University to head up the DSM-III task force. By this time, psychiatry was suffering a major public image problem and the Freudians were in retreat.

For guidance, Spitzer turned to the one university psychiatric department not dominated by Freudians, Washington University in St Louis. Two years before, a small group later referred to as "neo-Kraepelians" came up with the "Feighner Criteria," based on symptom checklists.

The lists describing depression and mania landed on the pages of Spitzer's DSM virtually intact, but not as part of manic-depression. Replacing it was "bipolar disorder," which did not include unipolar depression.

Back in the 1950s, the German psychiatrist Karl Leonhardt had come up with valid reasons for making the separation. George Winokur, one of the authors of the Feighner Criteria, also endorsed the split. The catch was that the DSM-III made the distinction without showing the relation between unipolar and bipolar.

Even those supporting a unipolar-bipolar split appreciated that one condition overlapped the other along a single spectrum. Basically, we have a class of unipolar patients who have more in common with their bipolar cousins than with their fellow unipolars.

In essence, bipolar and a good deal of unipolar is driven by its cyclic and recurrent nature, not as the isolated episodic phenomena the DSM would lead you to believe.

This is no mere esoteric quibbling. Frederick Goodwin, co-author with Kay Jamison of Manic-Depressive Illness, makes the point that thanks to the DSM, we have a whole class of patients we have never studied and don't know how to treat.

In theory, a future edition of the DSM should have rectified these oversights, but this never happened. By then, Spitzer's DSM was a runaway success. Bipolar became frozen in time.

In 1994, the DSM-IV highlighted hypomania and wrapped it in "bipolar II," but this only created the false impression that psychiatry was creating a new illness out of thin air.

Even today, clinicians resist the bipolar II diagnosis, thus consigning their patients to years of needless suffering on the wrong treatments.

The DSMs III and IV regarded mixed episodes as rare occurrences, and narrowly restricted its criteria. Mixed episodes, of course, are part of what binds bipolar to unipolar. Kraepelin, naturally, saw mixed episodes as common, and went to great lengths describing its many presentations.

In 2013, in the one thing it did right, the DSM-5 acknowledged the reality of mixed episodes and restored something of a Kraepelian perspective. Nevertheless, 35 years later, we have a DSM that is a virtual copy-and-paste of the DSM-III.

Kraepelin is rolling in his grave.