Manic Hills Depressive Slopes
Until today
None of them understood
Neither me
Nor my elevator heart
We went down
We went up
With the women
Some got off on the first floor
Some got off on the fifth floor
But know that the bills I paid were in cash.
Ömer BUGAY
Observations regarding mood disorders have appeared throughout human history, in different eras, in different societies, in various mythologies, and in both ancient and newer monotheistic religions. For approximately 2500 years, they have been described as one of humanity’s most common illnesses. In prehistoric religious texts and in Greek and Latin works, patients who experienced severe depression and episodes of agitation are described. Homer used the word “mania” (from Greek, meaning anger and wrath) in the Iliad.
Gilgamesh, the hero of the “Epic of Gilgamesh,” one of humanity’s earliest epics that spread from Mesopotamian lands such as Akkad, Assyria, and Sumer throughout the world, can be evaluated as a person who displays mood disorder.
King Gilgamesh is an extroverted, lively, cheerful, affectionate mythological hero who becomes easily and quickly emotional, frequently shows mood swings, loves and is loved, worries and becomes angry. He is sociable. He is active. He enjoys relationships with women, eating, and drinking. He sees himself as successful and superior and constantly strives to prove this. He easily establishes contact with people, becomes attached to them, and when he loses them, he becomes bored, saddened, and falls into depression.
After the death of Enkidu – who was first an enemy and then a friend – Gilgamesh became dull, uninterested, and unwilling; his appetite was disturbed. He did not eat, he did not drink, he did not sleep at night, he did not talk to anyone during the day, he did not leave his room, and when he did, he began to wander alone in the mountains and plains. Gilgamesh, who did not want to believe that Enkidu had died, began talking with the creatures he saw in his dreams in order to fill Enkidu’s absence. When he became distressed and overwhelmed, he tore his hair and his clothes. Wherever he wandered, he searched for Enkidu and continually called out to him. Crying, he chanted a lament for him;
Listen to me
I shed tears for my friend
I moan like a mourning woman
I cry for my brother.
In the 400s BC, Hippocrates was the first to use the term “melancholy” for the appearance of sleeplessness, not eating, sadness, and hopelessness, and he attributed this to black bile. At the same time, with the scientific approach of his era, he initiated the naming and classification of mental disorders and illnesses, and this has continued to develop up to the present. Throughout the ages, in all naming and classification systems, mood disorders have appeared under various headings.
Hippocrates (460–377 BC) linked human mood with bodily fluids, and defined different temperaments (moods) as “Sanguine Temperament, Phlegmatic Temperament, Melancholic Temperament, and Choleric Temperament.” He grouped mental and nervous diseases and symptoms into six groups and included “mania” among sudden mental illnesses without fever.
With the term “melancholy,” meaning “black bile,” Hippocrates defined a disease picture that appears in melancholic personality structures and temperaments as a result of disturbances in the liver and bile ducts, characterized by sluggishness, lack of interest, lack of motivation, sleeplessness, anxiety, feelings of inadequacy, and suicidal thoughts.
His contemporary Plato (424–347 BC) argued that mental illnesses arose from nature and supernatural forces and pointed to gods as the cause. He defined four distinct types of melancholy caused by the wrath of gods such as Apollo, Dionysus, and Eros.
Celsus (in the 100s AD), in his book called “De Medicina” (“On Medicine”), described all bodily illnesses from head to toe, and included melancholy and mania among head diseases, thereby establishing for the first time a structural association between this illness and the brain and central nervous system.
The idea that the tendency to depression and mania was based on a physiological disorder was widely accepted in the ancient Greek literature. It was described in Aristotle’s book “Problemata” and in Galen’s writings. Galen (131–201 AD), influenced by Aristotle’s book “On the Soul,” in which the logical human soul was explained along with the functions of the vegetative and animal souls and their connection with life, further developed these philosophical views and paved the way for theories that have survived to the present day. Furthermore, he was influenced by Hippocrates, who brought scientific views to the explanation, naming, and classification of personality structures and mental and nervous diseases in the ancient Greek literature. Like Hippocrates, Galen divided human temperament into four groups according to the bodily fluids that are most abundant in the body and affect the personality: Sanguine, Phlegmatic, Melancholic, and Choleric. Later, under the influence of his anatomical research on animals and humans, he established a link between personality structure and disease and added two more classifications. Among these six classifications, “Melancholy” appears under the heading “Those Due to Disturbances of Bodily Fluids,” with various symptoms. “Mania,” on the other hand, was placed under the heading “Those Due to the Disturbance of Mental State.”
In the 600s AD, during the early period of the Byzantine Empire, Alexander collected “Melancholy and Mania” under four subgroups in his classification, and divided melancholy into types according to where blood accumulated in the head and throughout the body.
Aegina (625–700 AD) defined, alongside mental illnesses due to natural causes in which melancholy and mania were included, types of melancholy that were attributed to “the devil seizing the human soul.”
In the Middle Ages, one of the best descriptions of mental depression was made by Ibn Sina (Avicenna), who provided interesting case examples. In his book “The Canon,” Ibn Sina grouped mental disturbances and illnesses into fifteen groups. After these years, Thomas Aquinas appeared on the scene with his research. He focused on the concepts of “Vegetative, Animal, and Rational Soul State,” which were introduced by Aristotle and developed by Razi, in the formation of mental disturbances and illnesses. He argued that slowing in mental development, epilepsy, febrile illnesses, lethargy, mania, melancholy, and clouding of consciousness arose from natural causes, while hallucinations and thought disturbances occurred under the influence of supernatural forces and the devil.
With the Renaissance beginning after 1450, the human being came to be seen as the focal point of the universe. The influence of religion and supernatural forces decreased in science, medicine, and art, and humans began to be examined in a more accurate and realistic way.
In France, Fernel (1497–1558) divided mental disturbances and illnesses into three groups based on causes that disrupt the membranes, structure, and ventricles of the brain, and included melancholy and mania within this grouping. Another researcher in France, Boissier de Sauvages (1706–1767), grouped all diseases into ten categories and, in the eighth group, described mental disturbances and illnesses, including “Dementia, Mania, and Melancholy.” In 1621, in England, the book “The Anatomy of Melancholy” described the classification and definition of illnesses.
In England, Timothy Bright’s book “Melancholy” was published in 1586 (editor’s note: historically 1586), and in this book Bright divided melancholy into two subgroups: natural and unnatural melancholy. He stated that “natural melancholy” was caused by black bile, and that in the formation of “unnatural melancholy,” disorders of black bile, blood, and lymph played a role. The author also identified the signs and symptoms of melancholy and drew attention to the fact that disturbances of mood such as absent-mindedness, dullness, sorrow, sadness, pessimism, distress, and uneasiness were at the forefront.
Paracelsus (1493–1541), in the Renaissance period, moved away from Galen’s traditional understanding and introduced chemistry into medicine. In his book “Diseases That Destroy Human Thought and Reason,” he described and classified mental disturbances and illnesses, placing acute mania in the category of hereditary diseases, and dividing melancholy into different types in which he attributed a role to supernatural forces.
Paolo Zacchias (1584–1659), who conducted research in the field of Forensic Medicine, divided illnesses into three groups: “Mental Depression and Insufficiency, Non-Febrile Mental Illnesses, and Febrile Mental Illnesses,” and placed “Mania” within these three groups.
Burton, in his book, defined various types of melancholy and described the signs, symptoms, and differential diagnosis of “Melancholy Originating from the Brain” and “Melancholy Originating from the Body” as well as illness anxiety disorder.
Philippe Pinel (1745–1826), in France, reviewed and grouped all the previously proposed naming and classification systems. Within these groups, he placed mania, melancholy, dementia, and intellectual disability, and stated that these illnesses arose as a result of structural disorders.
In Germany, Griesinger put forward the view that “mental disturbances are brain diseases.”
He argued that there was only one mental illness that he called “insanity.” According to this, all signs, symptoms, and complaints are different manifestations of a single underlying illness. This illness has two stages; in the first stage it is treatable. In the second stage, treatment is impossible. Mania, melancholy, and monomania are in the first stage, while dementia and chronic mania are in the second stage. From a descriptive perspective, Griesinger described three reaction types: depression, mental excitement and agitation, and mental decline. Griesinger’s ideas had a great impact and left a significant mark. Because Griesinger’s classification is both close to today’s terminology and relevant to our topic, it is worth presenting it here.
Sınıflandırması Şöyledir;
A-Mental Emotional Depression State
- Hypochondria
- Melancholy
- Stagnant melancholy
- Melancholy with aggressive, destructive tendencies
a-Melancholy with suicidal tendency
b-Melancholy with homicidal tendency
- Melancholy associated with increased mental obsessions and agitation
B-Mental Excitement (Manic) State
- Mania
- Monomania
C-Mental, Intellectual Weakness State
- Chronic mania
Griesinger’s work in Germany is quite close to present-day diagnoses and definitions. In nearly the same years, around 1820, Esquirol in France classified mental disturbances and illnesses similarly to Pinel, but defined two new disease pictures called “Monomania and Lypemania.” According to Esquirol, the term Monomania was used to describe excessive passions, while Lypemania was used to describe depressions accompanied by thought disorders.
Baillarger and Falret, in 1851, in France, independently of each other yet at almost the same time, accepted the illnesses that showed clinical pictures of mania and melancholy as suddenly beginning diseases as two different manifestations of a single illness. At the same time, they drew attention to the fact that this illness was more frequent in women and related to heredity.
The comprehensive definition and classification of affective disorders were later carried out first by Kahlbaum and then by Kraepelin.
Kahlbaum (1828–1899) in Germany defined the terms “Dysthymia” and “Cyclothymia” and classified mood disturbances falling within the scope of these terms. He reviewed and evaluated the research and studies of especially German and French physicians who had grown up before and during his time. As can be seen from these studies, it is Emil Kraepelin who, for the first time in 1883, in a 400-page summary book, published a classification and definition that distinguished mania and melancholic psychosis from other illnesses. In this book, Emil Kraepelin emphasized the organic causes of mental and nervous diseases. Especially after the 1900s, psychogenic factors were added to the causes of this illness and it was also addressed in this direction.
Sigmund Freud (1865–1939), the founder of psychoanalysis, focused on the psychodynamics of depressions in his work “Mourning and Melancholia” written in 1917 and emphasized the importance of “loss of the loved object” in depressions. While Freud underlined the importance of mental experience in depressions, on the other hand, he also emphasized that a chemical-physiological cause might play a role in the formation of depressions. Many psychoanalysts following Freud focused on the psychodynamics of this illness and took the issue beyond its purely physiological and biological aspects. One of these is Adolf Meyer. Meyer (1866–1950) introduced a multidimensional, dynamic approach to the definition and classification of this illness along with other mental disturbances and illnesses.
The view of defining and classifying mental illnesses according to their causes, which started with Kraepelin, continued to influence later classification systems. One of these is the “Würzburger” classification, prepared by a commission in Germany in 1930 and accepted by the German Psychiatric Association in 1933. The approaches of Kraepelin and Würzburger in definition and classification influenced the classifications used for many years in the USA, Germany, France, and other Western countries.
From the 1930s to the late 1960s, the Uzman-Aksel classification used in our country grouped illnesses according to their causes, modes of development, and clinical pictures. “Manic-Melancholic Psychosis” was classified under the heading “Cyclophrenia” and it was stated that different clinical pictures called “Mania, Melancholy, and Mixed Form” were gathered under three subheadings. After the second half of the twentieth century, the influence of descriptive psychiatry decreased. Especially in the USA, mental disturbances and illnesses were defined and classified as reactions. The approach of the DSM-I Diagnostic and Statistical Manual, first published in 1952, to mental disturbances and illnesses was in this direction. In this period, significant differences emerged between the diagnostic and classification systems in the USA and those in Europe. Especially in the diagnosis and classification of schizophrenic reaction and manic-depressive reaction, different approaches and interpretations were observed.
In the USA, the diagnostic and classification criteria for schizophrenic reaction were kept broad, and those for manic-depressive reaction were kept narrow; in Europe, the opposite was done. In DSM-II published in 1968, Kraepelin’s approach was influential. The reaction approach was abandoned and instead diagnostic criteria based on research were developed.
DSM-III published in 1980 and DSM-III-R published in 1987 continued this approach and placed emphasis on classification based on diagnostic criteria.
The terms “Unipolar” (UP) and “Bipolar” (BP) disorder used today were coined by Karl Kleist and were later used by his students Neole (1949) and Leonhard (1957).
Psychodynamic Approach to Manic-Depressive State
Manic-Depressive Psychoses have always had a place in dynamic psychiatry, dynamic psychology, and psychoanalysis, and they have been the subject of attempts to understand them. However, analytically speaking, mania has lagged behind depression in terms of explanation, examination, and study. This is not surprising. At the root of all manic phenomena lies an excessive increase in self-confidence. In the manic period, insight is wholly or partially lost. This makes it impossible to work with patients in the manic period.
The first person to evaluate the phenomenon of Manic-Depressive Psychosis within the framework of psychoanalysis was Abraham, a student of Freud. In 1912, Abraham compared melancholic depression with normal mourning, and observed that in both situations the person experiences a loss, but while the person in mourning is preoccupied with the lost person, the depressive person is writhing in feelings of guilt. Abraham interpreted the depressive mood as a regression to the oral-sadistic stage.
In later years (1959), Gutheil stated that depression has a distinctive feature that differentiates it from normal sadness and sorrow, and put forward that depression consists of the combination of sadness and pessimism. According to Gutheil, pessimism is the most important element that differentiates depression from normal sadness. The conviction that what is happening to the person at that moment will also happen in the future, or that the situation the person is in will not change, is the fundamental belief of depression (Gutheil, 1959). Gutheil’s observation is based on the statements of patients with mood disorder problems who receive treatment either as outpatients or inpatients. It is observed that in outpatients, in the period we may call the pre-depressive period, they use statements such as “I have started to become pessimistic, as if I will never get better, I will never recover,” and these statements are almost signals of their depressive periods.
In his famous paper entitled “Mourning and Melancholia,” Freud agreed with Abraham’s ideas and explained that in mourning, the loss corresponds to the death of an object, whereas in depression, since the lost object has been incorporated into the ego, the person experiences an internal loss in his inner world. According to him, the sadism directed toward the lost object is turned toward the internalized love object in depression. The concept of “internalization” that Abraham developed in this explanation laid the groundwork for Freud’s development of the concept of the “superego.” In 1923, Freud mentioned that such a mechanism of internalization was the only way for the ego to renounce an object. In his book “The Ego and the Id” published in the same year, he stated that melancholic patients have a ruthless superego and that they experience feelings of guilt arising from aggressive tendencies directed toward their loved ones.
Freud also addressed the phenomenon of mania and defined this state as a fusion between the ego and the superego. According to Freud, the energy spent on the ongoing conflict between these two personality components is used for pleasure in mania. Freud also emphasized that this fusion occurs in “biologically determined cyclical periods.”
After Abraham and Freud, other important contributions to this topic include the views of psychiatrists and psychoanalysts such as Rado, Klein, Bibring, and Arieti.
According to Rado, melancholy is “a hopeless plea for love.” The ego tries to protect itself from the punishment it expects from its parents by punishing itself. In doing so, it repeats the familiar ritual of “crime-punishment-forgiveness.” According to Rado, this is a symbolic repetition of the experiences in the infant’s world in which anger is identified – hunger – the appearance of the mother’s breast, and the subsequent satisfaction. Rado further developed Freud and Abraham’s views on the internalization mechanism in depression. According to him, the internalized object is divided into two parts (splitting). The good part, which the child wants to be accepted and loved, remains in the superego, while the bad part, which the child does not like and even wants to destroy, is turned into a part of the ego.
Melanie Klein, on the other hand, accepts manic-depressive states as a reflection of the failure to develop positive, good internalized objects in infancy. In other words, depressive individuals are people who have not been able to move beyond the depressive position that is normally and temporarily experienced in infancy. For this reason, they continually grieve for the good and beloved objects that they believe they have destroyed as a result of their own destructiveness and greed in infancy. As a result of this destructiveness, while they experience longing for the lost object on the one hand, they believe on the other hand that they are being persecuted by the negative internalized objects that remain. In other words, depressive individuals feel worthless because they have turned their internalized positive parental imagos into persecutors as a result of their own destructive impulses and fantasies.
According to Klein, manic defenses such as omnipotence, denial, devaluation, and idealization provide protection against the pain of longing for lost loved objects. These reactions can provide the person with relief in three ways: 1) rescuing and repairing the lost love objects; 2) rejecting ties with negative objects; 3) denying excessive dependence on love objects. Through manic defenses, the person attempts to deny his aggressive and destructive tendencies toward others, and the resulting cheerful and happy appearance is in fact the opposite of the reality of his life. Idealizing someone or displaying contemptuous and belittling attitudes toward others allows the person to deny his need for relationships. According to Klein, manic defenses symbolize the desire to triumph over the parent and to reverse the parent-child relationship. This desire for triumph leads to feelings of guilt and depression. According to Klein, this also explains why some people experience depression after success and promotion.
Bibring, who agrees with the view that explains depression as aggression turned toward the self, argues that depression arises from the tension between ideals and reality (1953). Bibring mentions three different types of narcissistic expectations, each intensely experienced and used as criteria in the behavior of depressed individuals: being a valuable and loved person, being a strong and superior person, and being a good and loving person. However, the ego’s awareness that it cannot achieve these criteria causes the person to feel weak and helpless and to fall under the dominance of the depressive state. Bibring explained that in some cases helplessness can lead to self-directed aggression, but that this can occur only as a secondary situation. According to him, any narcissistic frustration or injury that embraces a person’s self-esteem can lead to the emergence of clinical depression. For Bibring, the tension is not experienced between the ego and another mental structure, but within the ego itself. Depression arises when the ego partially or completely withdraws its self-esteem because it cannot meet its own expectations, while at the same time continuing these expectations with the same intensity. According to Bibring, mania is a secondary reaction that compensates for the flow of depression or an expression of the effort to meet narcissistic expectations through fantasy.
Arieti (1977) also put forward views parallel to Bibring’s, and there are common aspects between the two approaches. In both, the depressive person is evaluated as someone who experiences helplessness in the face of a goal that cannot be achieved. These individuals are so rigid that they cannot think of or accept any alternative other than their dominant goal.
Of course, the explanations in the literature regarding the clinical entity known as bipolar mood disorder are not limited to those mentioned here. Many rich explanations and opinions have been proposed on this subject, and research and observations have been presented. Thus, although these efforts have not been able to fully prevent attempts to explain this condition solely with biological approaches, at least they have slowed them down. It can be noticed that in the psychoanalytic approach, disease pictures such as depression and melancholy have been focused on more and understood better. However, the same cannot be said for mania. As mentioned above, the difficulty of following cases in this period during and after the attack may be a factor. Still, it can be thought that both phases of this illness should be examined and understood outside purely biological approaches. This field has been significantly broadened especially by those who adopt a biological approach, and nowadays this diagnosis is used for many psychiatric and even psychological conditions. Moreover, this diagnosis has been subdivided into subgroups and has been rather widely atomized.
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