The Bipolar Spectrum

Byline: M. Reddy "Shrink it to Broaden it to Shrink it to Broaden it. " ! Melancholia is the beginning and a part of Mania…. The development of Mania is really a worsening of the disease (Melancholia) rather than change into another disease. (Aretaeus of Cappadocia, 100 AD). Mania is Primary, with Depression being the consequence of preceding Mania, which means the Recurrent Unipolar subgroup of MDI does not really exist since all depressive presentations are preceded by a manic presentation. (Koukopoulos, 2006). That Happiness and Sadness, the two normal and very common emotions of every human being, constitute the core clinical features of a disease, Manic Depressive Illness (MDI), remains a fascinating, though disturbing, fact. The magnification of joy and worry, two poles of the normal emotional spectrum, reaches such gigantic proportion necessitating treatment. The clinical presentation varying between the two poles, often alternating, naturally reveals itself as a spectrum disorder of conditions and related temperaments. For Eugene Bleuler a patient was predominantly schizophrenic or predominantly manic-depressive in the spectrum of psychosis. But Emil Kraeplin, father of classification in modern psychiatry, segregated the two major psychotic illnesses into Manic-depressive insanity and Dementia praecox. By 1913, Kraeplin brought virtually all of the major clinical forms, which had *Episodic or Periodic course *Benign prognosis *Family history of MDI, under the diagnosis of Manic -Depressive illness (MDI) in which he included Bipolar Disorders (BD) and Recurrent Depressive Disorders. The Bipolar Spectrum concept can be approached from two different ways: *Manic - Depressive Spectrum: Continuum between Bipolar and Unipolar *Bipolar Spectrum: Restricted to BD with continuum between Full blown illness (BD I) to Milder illness to Temperament traits (Cyclothymia ……). Understanding the concept of Bipolar/Manic Depressive Spectrum demands a brief journey into the history dating back to the last quarter of 19th century. SHRINK IT - 1875-1925 [Figure 1]{Figure 1} The Northwest Wales asylum, opened in 1848, catered to a specific geographic location of the population and had admission of 3172 patients from 1875 to 1924. As depicted in the graph, mania as percentage of all admissions was 60% in 1885 which got "Shrunk" to around 20% in 1920. "In 1885, the diagnosis of mania referred to any state of OVERACTIVE INSANITY. Around 1900, primarily in response to Kraeplin's impact, the use of mania as a diagnosis in North Wales began to fall (limited only to episodic illness with benign course) progressively to about 4% in 1924. [1]" BROADEN IT: 2nd quarter of 20th century "Manic Depressive insanity…. includes on one hand the whole domain of periodic and circular insanity, on the other hand simple mania, the greater parts of the morbid states termed Melancholia" (Emil Kreaplin, 1924). [INLINE:1] The unifying "Broadening"concept of MDI, which brought together all the mood disorders, separating from Dementia Praecox, was based on *Episodic, recurrent course of illness *Benign course and outcome. SHRINK IT (again): 2nd half of 20th Century Move forward to the 3rd quarter and the first half of the 4th quarter of 20th century. The Kreaplinian concept of MDI was considered "too inclusive" and in 1957 Karl Leonhard proposed the concept, propagated later by the works of Angst, 2002,[2] and Perris, of dividing the MDI into two sub groups: Bipolar and Unipolar, the only difference being presence/absence of mania. The Broad MDI concept was "shrunk again" by separating BD group away from the unipolar group. The term bipolar was introduced in DSM III in 1980 and in ICD 10 in 1992; since then the unipolar and BD are categorized as two separate diagnostic entities in the classificatory system. …