A half-century of participant observation in psychiatry. Part II: Affective disorders. / Pól wieku obserwacji uczestniczacej w psychiatrii. Czesc II. Choroby afektywne.

The last half-century, thanks to the efforts of outstanding researchers, brought about great progress in the pathogenesis and clinics of affective illnesses. The catecholamine and serotonin hypothesis delineated in the 1960s have retained significant merit. Since the 1990s, the theories have pointed on excessive immune activation and impairment of neuroplasticity under stress. Since the 1970s, asystematic subclassification of unipolar and bipolar affective disorder has proceeded. Epidemiological studies of the last half-century indicated a significantly higher prevalence of depression compared with previous decades. The 21st century brought evidence for agreater frequency of various forms of bipolar affective disorder. During the last 50years, the etiopathogenesis, diagnosis and treatment of affective disorders were my favorite and fascinating clinical and research topics. This initiated in 1970 when I began my work in the Department of Psychiatry, Medical Academy in Poznan, on account of the introduction of lithium salts for the treatment of these disorders. In 1976-1977, I received afellowship of the National Institutes of Health at the University of Pennsylvania in Philadelphia and participated in research that elucidated the mechanism of lithium transport across cell membranes. I carried out the studies on the pathogenesis of affective disorders for more than 40 years afterward. They concerned abnormalitiesof transport across cell membranes, the activity of stress system, excessive pro-inflammatory activation, molecular genetics, dysfunctions of cognition and neurotrophins, especially the brain-derived neurotrophic factor (BDNF). Atthe beginning of the 21st century, I coordinated two Polish epidemiological projects DEP-BI and TRES-DEP. For my research on bipolar disorders, I received many international awards. I am also the author of the book The faces of manic-depressive illness which had three Polish editions as well as English and Russian versions.

From Charcot's descriptions to the current understanding of neuropsychiatric symptoms in multiple sclerosis.

Neuropsychiatric disorders in multiple sclerosis have been known since the original clinicopathological description by Charcot in the late nineteenth century. Charcot, in the last decades of his life, became involved in the field of neuropsychiatry. This produced a battle between rival schools in the era that still echoes to this day. Charcot's intuition, including the line of thought of Babinski, one of his most famous disciples, was that there was a connection between mood disorders and many of the diseases of the nervous system. Medicine's concern with establishing a relationship between mood disorders and disease stems from the ancient and middle ages with references found in the Hippocratic doctrine. However, it was only in the second half of the nineteenth and early twentieth century, with Charcot's discoveries, that this discussion was established in a structured way, laying the foundations of neuropsychiatry.

[The "price" of creativity? Predictive and protective factors in the suicide of Sylvia Plath].

An increasing number of studies deal with the potential correspondence between suicidal behaviour and creativity nowadays. Psychobiographical analysis of the life of well known artists may help the better understanding of this phenomenon. In the present study predictive and protective factors of suicide are presented through the case of the well known suicidal poet and writer, Sylvia Plath. The most important predictive factors of suicide in her case are: affective disorder, comorbid anxiety disorder, prior attempt of suicide, and also her seriously affected personality, that mainly appears in her affective dependence. Her life events, both causes and effects of these, are also predisposing suicide. The early loss of her father, ambivalent relation with her mother and her marriage foredoomed to failure are the most significant of them. Although she used to write since her early childhood, the constant fluctuation of her psychological state had serious effect on her ability to write and also her motivation, both being an additional source of stress, due to her performance pressure. The fear of the acceptance of her works could also lay to increased amount of stress and anxiety on her sensitive personality. Her tragical life events, her psychiatric illness and her relentless templets towards herself could cause such a pressing stress, that neither creation, nor motherhood (the most important protective factor for women) could predominate. Neither moving to England, nor her last confessional book, "The Bell Jar" could cure her many kind of wounds, and these factors together lead to the suicide.

[Psychiatric disorder of Sylvia Plath].

Sylvia Plath was one of the most famous American poets in the twentieth century. Plath was diagnosed with depression after her first suicide attempt when she was 20 years old. Her major depression (without psychotic symptoms) recurred several times. Plath never had a manic episode, but there were probable hypomanic periods in her life. She died by violent suicide when she was 30. Sylvia Plath took a bottle of sleeping pills and stuck her head in a gas oven. Several factors may have contributed to Plath's psychiatric disorder and suicide. The author reviews the etiological factors and course of psychiatric disorder based on the Unabridged Journals of Sylvia Plath and the literature. Her family history was positive and her premorbid personality was vulnerable to depression. There were histrionic, narcissistic and borderline features in her personality. The probable diagnoses of Plath were bipolar II. affective disorder and mixed personality disorder.

From Charcot's descriptions to the current understanding of neuropsychiatric symptoms in multiple sclerosis / Das descrições de Charcot à compreensão atual dos sintomas neuropsiquiátricos na esclerose múltipla

ABSTRACT Neuropsychiatric disorders in multiple sclerosis have been known since the original clinicopathological description by Charcot in the late nineteenth century. Charcot, in the last decades of his life, became involved in the field of neuropsychiatry. This produced a battle between rival schools in the era that still echoes to this day. Charcot's intuition, including the line of thought of Babinski, one of his most famous disciples, was that there was a connection between mood disorders and many of the diseases of the nervous system. Medicine's concern with establishing a relationship between mood disorders and disease stems from the ancient and middle ages with references found in the Hippocratic doctrine. However, it was only in the second half of the nineteenth and early twentieth century, with Charcot's discoveries, that this discussion was established in a structured way, laying the foundations of neuropsychiatry.

RESUMO Os distúrbios neuropsiquiátricos na esclerose múltipla são conhecidos desde a descrição clínico-patológica original de Charcot no final do século XIX. Charcot nas últimas décadas de sua vida se envolveu no campo da neuropsiquiatria. Isso produziu uma batalha de escolas rivais na época que ainda ecoa até hoje. A intuição de Charcot, incluindo a linha de pensamento de Babinski, um de seus discípulos mais famosos, foi a teoria correta da conexão entre os transtornos do humor e muitas das doenças do sistema nervoso. A preocupação da Medicina em estabelecer uma relação entre transtornos do humor e doenças vem das idades antiga e média, com referências encontradas na doutrina hipocrática. No entanto, foi apenas na segunda metade do século XIX e início do século XX que, com as descobertas de Charcot essa discussão foi realizada de maneira estruturada, estabelecendo os fundamentos da neuropsiquiatria.

Mood disorder in the personal correspondence of Robert Burns: testing a novel interdisciplinary approach.

Robert Burns has long been recognised as someone who experienced episodes of melancholia, but no detailed, systematic and objective assessment of his mental health has been undertaken. We tested a novel methodology, combining psychiatric and literary approaches, to assess the feasibility of using Burns's extensive personal correspondence as a source of evidence for assessing the presence of symptoms of a clinically significant mood disorder. We confirmed the potential of this approach and identified putative evidence of episodes of depression and hypomania within the correspondence. While not conclusive of a formal diagnosis of bipolar disorder, this work highlights a need for further systematic examination of Burns's mental health and how this may have influenced his work.

Lithium Clinics in Berlin and Dresden: a 50-Year Experience.

Although lithium's serendipitous discovery as a medication for depression dates back more than 200 years, the first scientific evidence that it prevents mania and depression arose only in the 1960s. However, at that time there was a lack of knowledge about how to administer and monitor lithium therapy safely and properly. The lithium clinics in Dresden and Berlin were remarkably similar in their beginnings in the late 1960s regarding patient numbers and scientific expertise without being aware of one another due to the Iron Curtain separating Germany into a western and eastern part until 1990. In what were initially lithium-care programs run independently from one another, the lithium clinics embedded in academic settings in Dresden and Berlin represent a milestone in the history of psychopharmacological treatment of affective disorders in Germany and trailblazers for today's lithium therapy. Nowadays, lithium's clinical applications are unquestioned, such as its use in strategies to prevent mood episodes and suicide, and to treat depression. The extensively documented knowledge of lithium treatment is the fruit of more than 50 years of observing disease courses and of studying side effects and influencing factors of lithium prophylaxis. Its safe and proper administration-in determining the correct indication, baseline and follow-up examinations, recommended dosages, monitoring, or the management of side effects-is well established. Subsequently, both national and international guidelines continue recommending lithium as the gold standard in treating patients with unipolar and bipolar disorders.

A brief history of polarity in mood and its diagnostic evolution.

BACKGROUND: We reviewed the historical development of diagnostic nomenclature and classification systems of mood disorders. METHODS: A literature search in PubMed and Google Scholar was performed using multiple search terms. Also, the criteria and classification of various mood disorders were reviewed and compared across all editions of DSM. We also reviewed several books and the references of the found articles. RESULTS: This review describes the historical development of the concepts and diagnostic nomenclature of mood disorders, including the encompassing of most of the now major depressive disorder under the prior manic-depressive illness. Additionally, we examine how mood disorders have been developed, classified, and split into subcategories historically until the current classification. We observed that the modern nosology (DSM-5) leans a bit more toward a spectrum approach. CONCLUSIONS: The pendulum has swung a bit from splitting toward lumping. The current diagnostic system blurs some of the boundaries between bipolar and unipolar disorders, as in the case of changing nomenclature to "mixed features" in both types of illnesses. This is supported by many experts (and some studies) who advocate for the spectrum concept in mood at the phenotypic level. The spectrum concept is more supported by evidence and further examination driven by both unconfined clinical observations and biological anchor points and markers to scientifically examine the zones of rarity and boundaries between disorders. This would be more fruitful than the arbitrary DSM number of criteria or episode durations and the artificial separation of manic-depressive illness.

The genealogy of major depression: symptoms and signs of melancholia from 1880 to 1900.

How deep are the historical roots of our concept of major depression (MD)? I showed previously that psychiatric textbooks published in 1900-1960 commonly described 18 characteristic depressive symptoms/signs that substantially but incompletely overlapped with the current DSM (Diagnostic and Statistical Manual of Mental Disorders) MD criteria. I here expand that inquiry to the key years of 1880-1900 during which our major diagnostic categories of manic-depressive illness (MDI) and dementia praecox were developed. I review the symptoms of depression/melancholia in 28 psychiatric textbooks and 8 other relevant documents from this period including monographs, reviews and the first portrayal of melancholia Kraepelin in 1883. Descriptions of melancholia in the late nineteenth and twentieth century textbooks closely resembled each other, both reporting a mean of 12.4 characteristic symptoms, and emphasizing core features of mood change and alterations in cognitive content and psychomotor behavior. The detailed monographs, reviews and the early description of Kraepelin were more thorough, reporting a mean of 16.6 of these characteristic symptoms. These nineteenth century texts often contained phenomenologically rich descriptions of changes in mood and cognition, loss of interest and anhedonia and emphasized several features not in DSM including changes in volition/motivation, posture/facial expression and derealization/depersonalization. In the early nineteenth century, melancholia was often defined primarily by delusions or as the initial phase of a unitary psychosis transitioning to mania and then dementia. By 1880, the concept of depression as an independent mood disorder with characteristic symptoms/signs and a good prognosis had stabilized. Kraepelin incorporated this syndrome into his diagnostic concept of MDI, changing its name to 'Depressive States', but did not alter its underlying nature or clinical description.

Marketing Masked Depression: Physicians, Pharmaceutical Firms, and the Redefinition of Mood Disorders in the 1960s and 1970s.

This article investigates the redefinition of depression that took place in the early 1970s. Well before the introduction of the third edition of the Diagnostic and Statistical Manual of Mental Disorders, this rather rare and severe psychiatric disorder hitherto treated in asylums was transformed into a widespread mild mood disorder to be handled by general practitioners. Basing itself on the archives of the Swiss firm Ciba-Geigy, the article investigates the role of the pharmaceutical industry in organizing this shift, with particular attention paid to research and scientific marketing. By analyzing the interplay between the firm, elite psychiatrists specializing in the study of depression, and general practitioners, the article argues that the collective construction of the market for first-generation antidepressants triggered two realignments: first, it bracketed etiological issues with multiple classifications in favor of a unified symptom-oriented approach to diagnosis and treatment; second, it radically weakened the differentiation between antidepressants, neuroleptics, and tranquilizers. The specific construction of masked depression shows how, in the German-speaking context, issues of ambulatory care such as recognition, classification, and treatment of atypical or mild forms of depression were reshaped to meet commercial as well as professional needs.

Emotional Mental Imagery as Simulation of Reality: Fear and Beyond-A Tribute to Peter Lang.

This article pays tribute to the seminal paper by Peter J. Lang (1977; this journal), "Imagery in Therapy: Information Processing Analysis of Fear." We review research and clinical practice developments in the past five decades with reference to key insights from Lang's theory and experimental work on emotional mental imagery. First, we summarize and recontextualize Lang's bio-informational theory of emotional mental imagery (1977, 1979) within contemporary theoretical developments on the function of mental imagery. Second, Lang's proposal that mental imagery can evoke emotional responses is evaluated by reviewing empirical evidence that mental imagery has a powerful impact on negative as well as positive emotions at neurophysiological and subjective levels. Third, we review contemporary cognitive and behavioral therapeutic practices that use mental imagery, and consider points of extension and departure from Lang's original investigation of mental imagery in fear-extinction behavior change. Fourth, Lang's experimental work on emotional imagery is revisited in light of contemporary research on emotional psychopathology-linked individual differences in mental imagery. Finally, key insights from Lang's experiments on training emotional response during imagery are discussed in relation to how specific techniques may be harnessed to enhance adaptive emotional mental imagery training in future research.

[Müller-Hegemann's classification of depressions of 1964 as a proposal for a conceptualization of affective disorders: A critical review]. / Müller-Hegemanns Systematik der Depressionen von 1964 als Vorschlag zur Konzeptualisierung der affektiven Störungen. Eine kritische Analyse.

Against the background of current discussions on the classification of psychiatric disorders, this study analyses and discusses the East-German psychiatrist Dietfried Müller-Hegemann's concept of a clinical classification of depressions of 1964.In his paper, Müller-Hegemann differentiated between two main forms of depression, namely the "vitally tinged depression" (= melancholy), found mainly in the depressive phases of the manic-depressive disorder, and the "depressive disgruntlement" (= dysthymia) seen in "reactive and neurotic depression", "involutional depression", and in the depressive states in psychopathic personalities. Due to a lack of sufficient biological evidence, Müller-Hegemann refrained from a purely etiological differentiation.His proposal is significant in so far as it provided a classification that could easily be used in clinical practice, and at the same time, by pointing to the traditional concept of melancholy and by calling for a differentiated psychopathology, anticipated aspects of topical interest.

Tempering Madness: Emil Kraepelin's Research on Affective Disorders.

This essay examines some of the research practices and strategies that the German psychiatrist Emil Kraepelin (1856­1926) deployed in his efforts to account for the significance of emotions in psychiatric illnesses. After briefly surveying Kraepelin's understanding of emotions and providing some historical context for his work in the late nineteenth century, it examines three different approaches that he took to studying emotions. First, it discusses his work in experimental psychology and his use of so-called artificial insanity to study affective disorders. It then turns to his clinical research, exploring his particular interest in the course and outcome of psychiatric disorders and then showing how those concerns related to his nosological delineation of manic depressive illness. Finally, it considers briefly how he attempted to expand his "clinical gaze," turning it outward onto larger, nonhospitalized populations in an attempt to study subclinical forms of affect or temperaments. The article argues that the inadequacies and limitations of his own experimental and clinical research practices contributed to his evolving understanding of affective disorders. In particular, they led him to expand and differentiate his understanding of manic-depressive illness so as to take greater account of premorbid symptoms or temperaments.

Joseph Haydn's encephalopathy: new aspects.

With increasing age, Joseph Haydn complained of progressive forgetfulness preventing him from composing for about the last 8 years of his life. He spent his days more and more inactive and immobilized, suffering from a disabling gait disturbance. Still, most biographers consider diffuse atherosclerosis and congestive heart failure to be reasons for Haydn's medical condition and physical decline during the last years of his life. A more sophisticated and detailed inspection of documents and sources, however, leads to the diagnosis of subcortical vascular encephalopathy (SVE), caused by progressive cerebral small vessel disease. Important features of the disease are mood changes, urinary symptoms, and in particular a characteristic gait disturbance, while dementia is only mild and occurs later in the course. Haydn was severely disabled by the symptoms of SVE for several years and often reported difficulties in the completion of his last oratorio "Die Jahreszeiten" (The Seasons). Subsequently, the disease prevented him from composing another large oratorio, "Das jüngste Gericht" (The last judgement), which had been already drafted. Finally, the progress of SVE stopped his long career as a composer and conductor at the age of 73 years.

Unipolar mania: a necessary diagnostic concept.

In the classification of mood disorders, major depressive disorder is separate from bipolar disorders whereas mania is not. Studies on pure mania are therefore rare. Our paper reviews the evidence for distinguishing pure mania (M) and mania with mild depression (Md) from bipolar disorder. Two large epidemiological studies found a prevalence of 1.7-1.8% of M/Md in adolescents and adults. Several clinical follow-up studies demonstrated good stability of the diagnosis after a previous history of three manic episodes. Compared to bipolar disorder, manic disorder is characterised by a weaker family history for depression, an earlier onset, fewer recurrences and better remission, and is less comorbid with anxiety disorders. In addition, mania is strongly associated with a hyperthymic temperament, manifests more psychotic symptoms and is more often treated with antipsychotics. Twin and family studies find mania to be more heritable than depression and show no significant transmission from depression to mania or from mania to depression. Cardiovascular mortality is elevated among patients with mood disorders generally and is highest among those with mania. In non-Western countries, mania and the manic episodes in bipolar disorder are reported to occur more frequently than in Western countries.