An Introduction to Manic-Depressive Illness
Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, Second Edition by Frederick K. Goodwin and Kay Redfield Jamison chronicles the medical treatment of manic and depressive episodes, strategies for preventing future episodes, and psychotherapeutic issues common in this illness. In the excerpt below the authors introduce their second edition.
It has been 17 years since the publication of the first edition of this text; they have been the most explosively productive years in the history of medical science. In every field relevant to our understanding of manic-depressive illness—genetics, neurobiology, psychology and neuropsychology, neuroanatomy, diagnosis, and treatment—we have gained a staggering amount of knowledge. Scientists and clinicians have gone an impressive distance toward fulfilling the hopes articulated by Emil Kraepelin in the introduction to his 1899 textbook on psychiatry. Those who treat and study mental illness, he wrote, must first, from bedside observation, delineate the clinical forms of illness; they must define and predict its course, determine its causes, and discover how best to treat and then ultimately prevent insanity. Psychiatry, he argued, was a “young, still developing science,” and it must, “against sharp opposition, gradually achieve the position it deserves according to its scientific and practical importance. There is no doubt that it will achieve the position—for it has at its disposal the same weapons which have served the other branches of medicine so well: clinical observation, the microscope and experimentation.” Kraepelin was right, as usual. And he was remarkably astute in his observations and predictions about the immensely complex group of disorders collectively known as manic-depressive illness.
Manic-depressive illness magnifies common human experiences to larger-than-life proportions. Among its symptoms are exaggerations of normal sadness and joy, profoundly altered thinking, irritability and rage, psychosis and violence, and deeply disrupted patterns of energy and sleep. In its diverse forms, manic-depressive illness afflicts a large number of people—the exact number depending on how the illness is defined and how accurately it is ascertained. First described thousands of years ago, found in widely diverse cultures, manic-depressive illness always has fascinated medical observers, even as it has baffled and frightened most others. To those afflicted, it can be so painful that suicide seems the only means of escape; indeed, manic depressive illness is the most common cause of suicide. We view manic-depressive illness as a medical condition, an illness to be diagnosed, treated, studied, and understood within a medical context. This position is the prevailing one now, as it has been throughout history. Less universal is our diagnostic conception of manic-depressive illness, which evolved as we were writing both editions of this book. Derived from the work of Kraepelin, the “great classifier,” our conception encompasses roughly the same group of disorders as the term manic-depressive illness in European usage. It differs, however, from contemporary concepts of bipolar disorder. Kraepelin built his observations on the work of a small group of nineteenth-century European psychiatrists who, in their passion for ever finer distinctions, had cataloged abnormal human behavior into hundreds of classes of disorder. More than any other single individual, Kraepelin brought order and sense to this categorical profusion. He constructed a nosology based on careful description, reducing the categories of psychoses to two: manic-depressive illness and dementia praecox, later renamed schizophrenia. It is to Kraepelin, born in the same year as Freud, that we owe much of our conceptualization of manic-depressive illness. It is to him that we owe our emphasis on documenting the longitudinal course of the illness and the careful delineation of mixed states and the stages of mania, as well as the observations that cycle length shortens with succeeding episodes; that poor clinical outcome is associated with rapid cycles, mixed states, and coexisting substance abuse; that genetics is central to the pathophysiology of the disease; and that manic-depressive illness is a spectrum of conditions and related temperaments.
Kraepelin’s model consolidated most of the major affective disorders into one category because of their similarity in core symptoms; presence of a family history of illness; and, especially, the pattern of recurrence over the course of the patient’s lifetime, with periods of remission and exacerbation and a comparatively benign outcome without significant deterioration. Kraepelin viewed mania as one manifestation of the illness, not as the distinguishing sign of a separate bipolar disorder as it is regarded in today’s American (and increasingly worldwide) diagnostic practice.
The European and American concepts of manic depressive illness began to diverge almost immediately after Kraepelin’s ideas became widespread in the early years of the twentieth century. Europeans, adhering to a traditional medical disease model, emphasized the longitudinal course of the illness in both research and clinical work. Ever pragmatic, Americans wanted to treat the illness with the techniques at hand, which at that time were derived from the “moral treatment” movement in mental hospitals and the emerging dynamic therapies based on psychoanalytic theory. Research and clinical efforts in the United States thus slighted clinical description and genetics and turned instead to the psychological and social contexts in which the symptoms of the illness occurred. Exploration of the linkages between clinical typology and family history led to the formulation of the bipolar–unipolar distinction, by which manic-depressive patients were grouped according to the presence or absence of a prior history of mania or hypomania. First proposed by a German, Karl Leonhard, the distinction was elaborated by other Europeans, such as Jules Angst and Carlo Perris, and by the Washington University group in St. Louis, Missouri, the neo-Kraepelinians who gave impetus to the new concern for an etiology-free, description-based diagnostic system in the United States.
The bipolar–unipolar distinction represented a logical refinement of the already well-defined Kraepelinian model, with its emphasis on recurrence and endogeneity. As useful as the distinction is in both research and clinical contexts, it proved to be problematic when applied to the much broader American conception of affective disorders. The bipolar subgroup was clearly defined, but the other component of Kraepelinian manic-depressive illness—endogenous, recurrent unipolar depression—was obscured by its confusion with other affective disorders. In American usage, unipolar disorder came to mean any mood disorder that was not bipolar, regardless of its severity or course. Although the third edition of the Diagnostic and Statistical Manual (DSM-III) clarified the situation somewhat by requiring that criteria for major affective disorder be met before the bipolar–unipolar distinction is drawn, a diagnosis of unipolar disorder was still broader than the Kraepelinian concept since it did not require a prior course of illness. Even the DSM-III/IV category of recurrent depression is overly broad, requiring only two episodes in a lifetime.
Our own struggle to confine and limit the focus of the first edition of this text followed a course similar to the larger historical one. We started with a framework of Kraepelinian manic-depressiveillness, that is, recurrent major affective illness with and without mania. Later, we focused more excusively on bipolar disorder as a way of imposing workable boundaries on the scope of our efforts. Once thoroughly immersed in the subject, however, we became increasingly convinced that isolating bipolar disorder from other major depressive disorders and unduly emphasizing polarity over cyclicity (as do DSM-III and DSM-IV) prejudges the relationships between bipolar and unipolar illness and diminishes appreciation of the fundamental importance of recurrence. By the end, we had returned to a position close to where we began, convinced of the value of the original unified concept of manic-depressive illness, albeit with a special emphasis on the bipolar form. Scientific and clinical advances of the past two decades have only added to the strength of our belief that, as important as polarity is, cyclicity or recurrence is fundamental to understanding manic-depressive illness. This conviction is made clear in the second edition’s new title: Manic Depressive Illness: Bipolar Disorders and Recurrent Depression. Genetic findings will have the ultimate etiologic and diagnostic say, of course, but in the interim we think a broader rather than narrower concept of the illness is warranted by the data; we also think it is heuristically most valuable.