Historical and Contemporary Understandings of Bipolar Disorder

Medical History of Bipolar Disorder

Throughout history, mania and depression have been noted by doctors, philosophers, writers, and more recently lawyers. The earliest written accounts of depression were recorded in ancient texts of the Mesopotamian era dating from the second millennium B.C. Depression also appears in the writings of medical luminaries from the ancient Greek and Roman civilizations, such as Hippocrates and Galen. Mania is harder to pinpoint in ancient works because the term was used broadly, roughly equivalent to today's use of the words insane or psychotic. In that time period, clear accounts of bipolar disorder, a combination of the two symptoms depression and mania in the same person have yet to be found.

For nearly a millennium after the fall of the Roman Empire, the Greek Humoral Hypothesis prevailed as the theory of the cause of depression and mania. The humoral hypothesis asserted that 'melancholia' (depression) was caused by a body fluid known as black bile, while 'mania' (insanity) was caused by another fluid called yellow bile.

The idea of and debate about a relationship between mania and melancholia can be traced back to at least the 2nd century A.D. Although Soranus of Ephedrus (98-177 A.D.) described mania and melancholia as distinct diseases with separate origins, he acknowledged that others considered melancholia a form of mania. The earliest written descriptions of a bipolar relationship between mania and melancholia are attributed to Arataeus of Cappadocia, an eclectic medical philosopher who lived in Alexandria somewhere between 30 and 150 A.D. Arataeus is recognized as having authored most of the surviving texts referring to a unified concept of manic-depressive illness, viewing both melancholia and mania as having a common origin in 'black bile'.

Not much else is noted about the relationship between the two until about the 17th century, when Richard Napier, a British physician, wrote extensively about psychiatric mental health conditions and may have described manic-depressive illness. He did not use the words manic depression or bipolar disorder, but referred to a disorder in which two mood states existed in a cycling pattern within one individual.

By the middle 19th century publications like Phillipe Pinel's Treatise on Insanity (1806) and John Haslam's Observations on Madness and Melancholy (1809) had reintroduced the concept of bipolar disease back into Western medicine. On January 31, 1854, Jules Baillarger described to the French Imperial Academy of Medicine a biphasic mental illness causing recurrent shifts between mania and depression. Two weeks later, on February 14, 1854, Jean-Pierre Falret presented a similar description to the Academy. This illness was designated folie circulaire ('circular insanity') by Falret, and folie ? double forme ('dual-form insanity') by Baillarger.

By the late 19th century, multiple descriptions and case studies of bipolar mental illness were being published across Europe and, as well, the clinical pattern of manic depression had been described within medical textbooks. In his 1896 German-language textbook, Emil Kraeplin provided a definitive clinical description for bipolar disorder. He writes, "Manic-depressive insanity...includes on the one hand the whole domain of so-called periodic and circular insanity, on the other hand simple mania, [and] the greater part of the morbid states termed melancholia." Kraeplin categorized and studied the natural course of untreated bipolar patients. He noted in his patient observations that in between phases of mania and depression, there were relatively symptom-free intervals in which the patient was able to function normally. For his definitive description, Emil Kraeplin is considered to be the father of the modern conceptualization of bipolar disorder.

By the middle 20th century, medical journals were publishing informed speculation concerning the origins of bipolar illness, specifically, describing the likelihood that bipolar depression ran in families. In 1952, The Journal of Nervous and Mental Disorders published an article analyzing heritability behind the disorder. This study, offering a statistical analysis of family generational data, showed a heightened incidence of bipolar disorder symptoms among biological relatives, providing evidence for a biological and more specifically genetic mode of transmission.