Bipolar disorder: building the path of return to the ideas of Kraepelin

Transtorno bipolar: a construção do caminho de retorno às idéias de Kraepelin

LETTERS TO THE EDITORS

Bipolar disorder: building the path of return to the ideas of Kraepelin

Transtorno bipolar: a construção do caminho de retorno às idéias de Kraepelin

Dear Editor,

Kraeplin (1921) described a wide spectrum of cases of mania and hypomania ranging from euphoric episodes up to predominantly dysphoric or mixed presentations with symptoms of depression.¹ However, in the middle of the 20^th century, influential psychoanalytical writings focused on the euphoric cases of these episodes. Post-hoc interpretations of Kraepelin's ideas led to the adoption of the term 'bipolar' which implies that mania and hypomania are opposite poles of depression.² Many authors suggest that a return to the concepts developed by Kraepelin would be advantageous.² However, there are some criticisms to the widening of the concept of BD.³ Recent advances (to some extent referring to the original descriptions of Kraeplin)¹ expanded bipolarity to a broader spectrum.⁴

From a pragmatic standpoint, we believe that the adoption of the concept of a bipolar spectrum may be rather premature. Even using the standard DSM-IV nomenclature, the lag between the initial symptoms of the disorders and the diagnosis of bipolar illness is usually of about one decade, across different countries.^5-6 A worrying scenario would be "an overenthusiastic" adoption of the bipolar spectrum in the international nomenclature, not matched by the necessary re-education of health care professionals. The descriptions made by Kraepelin derived from careful observation, which was systematic and longitudinal. Would such sophisticated psychopathology be feasible within the managed care era? We believe that there is a lot to be done in order to bridge the advances made in the psychopathological appraisal of bipolar patients and the adoption of operational criteria to classify patients suffering from the 'soft spectrum' of the Bipolar Disorders.

Should we return to Kraepelin? This seems the right thing to do. However, its important to pave this returning path with sound evidence, and continuing medical education programs.

Fernando Kratz Gazalle, Flávio Kapczinski

Psychiatry Research Unit, Post-Graduate Psychiatry

Program, and Bipolar Disorders Program,

University Hospital, Universidade Federal do

Rio Grande do Sul (UFRGS),

Porto Alegre (RS), Brazil

References

1. Kraeplin E. Manic-Depressive Insanity and paranoia, translated by Barclay RM. Edinburgh, Scotland: Livingstone; 1921.

2. Vojta C, Kinosian B, Glick H, Altshuler L, Bauer MS. Self-reported quality of life across mood states in bipolar disorder. Compr Psychiatry. 2001;42(3):190-5.

3. Baldessarini RJ. A plea for integrity of the bipolar disorder concept. Bipolar Disord. 2000;2(1):3-7.

4. Katon WJ. The depressed patient with comorbid illness. In: Program and abstracts of the 154th. Annual Meeting of the American Psychiatric Association; 2001 May 5-10. New Orleans, Louisiana, USA: Industry Symposium; part 2, 43B.

5. Lish JD, Dime-Meenam S, Whybrow PC, Price RA, Hirschfield RM. The National Depressive and Manic-Depressive Association (DMDA) survey of bipolar members. J Affect Disord. 1994;31(4):281-94.

6. Gazalle FK, Andreazza AC, Kauer-Sant'Anna M, Santin A, Kapczinski F. Early diagnosis in bipolar disorder. Rev Bras Psiquiatr. 2005;27(1):83-4.

Financing: None

Conflict of interests: None

Publication Dates

• Publication in this collection
  24 Mar 2006
• Date of issue
  Mar 2006