Lecture 7: The concept of affective disorders: historical evolution and current controversies

Question 1

What’s the difference between affective disorder (Maudsley) and mood disorder?

Answer 1

• Mood disorder: underlying or longitudinal emotional state

- Affective disorder: external expression of emotion observable to others

Question 2

Since which historical period do we have account of depression?

Answer 2

• Cave paintings
• Early greek literature (mania)
• Bible: King Saul

Question 3

Who proposed that emotional disorders were an extension of existing character traits?

Answer 3

Arataeus of Cappadocia

Question 4

Which organs controlled all emotions, according to Galen?

Answer 4

heart and liver

Question 5

Make a brief recount of the understanding of affective disorders from the 17th to 19th centuries

Answer 5

• Robert Burton: melancholy could be cured with diet, sleep, music, meaningful work, talking to a friend
• Delasiauve: depression as a psychiatric symptom
• Shift from melancholia affecting brilliant men to affecting women
• Depression = melancholia
• Manic depressive illness:
• Baillarger (folie a double forme)
• Falret: mania and depression as different stages of disease (folie circulaire)
• Griesinger: mental disorders as somatic
• Kahlbaum: cyclothymia and dystyhimia
• Kraepelin: “manic depressive insanity”
• Separated psychotic illnesses from each other (e.g., manic-depressive illness - clearly separated from dementia praecox)
• Major depression: involutional melancholia

Question 6

Make a brief recount of the understanding of affective disorders from the 20th century up to 1977

Answer 6

• Kurt Schneider: proposed endogenous and reactive depression, but concepts were controversial - disputed by Mapother in 1926. Controversy betwen Roth (Newcastle) and Kendall (IoP and Edinburgh)
• Kleist (1937) and Neele (1949): bipolar vs unipolar/monopolar depression and mania
• Angst (1966): bipolar vs depression
• Freud:
  • linked melancholia to mourning (objective loss leads to subjective loss w/ severe melancholic symptoms, compromising the ego)
  • life experiences as predisposing
• Meyer: mental disease as a reaction of biogenetic factors to psychosocial influences. Also that use depression > melancholia
  • His work lead to DSM-I (manic-depressive reaction)
• Leonhard: first coined the terms Bipolar and Unipolar
• Jung: 1975 distinction between mania and hypomania. Bipolar II added to the DSM-IV.
  Fieve and Dunner also published an article stating only manic individuals need hospitalisation

Question 7

Name some first-generation antipsychotics

Answer 7

• Chlorpromazine
• Haloperidol
• Fluphenzazine
• Thioridazine

Developed between 1930-1960

Question 8

Name some second generation (atypical) antipsychotics

Answer 8

• Clozapine
• Zotepine
• Amisulpride
• Risperidone
• Olanzapine
• Quetiapine
• Ziprasidone
• Asenapine
• Aripiprazole

These were developed from 1970 to the 2000s

Question 9

Name some important researchers in the development of treatments for affective disorders

Answer 9

• Kline: pioneer - antidepressants

- Cerletti and Bini: electricity to stimulate seizures (ECT)

Question 10

Why are Foucault and Scull relevant to psychiatry?

Answer 10

• Idea of mental illness as a social construct, product of industrialisation and capitalism ⇒ propose moral treatments

Mental illness as a product of industrialisation and capitalism

Question 11

Name some limitations of modern classifications of mental disorders

Answer 11

• Not free of theory
• Reliability higher than validity
  
  • Reliability is good in research, poor in clinical settings
  • Validity: only for a few categories
• Not better than clinical knowledge and experience
• Transcultural limitations
• Dimensions are categorised
• Syndromes = Diseases

Question 12

Which are some characteristics of mixed bipolar episodes?

Answer 12

• Severe mood disturbance
• Correlates with higher comorbid substance use disorders, suicidal ideation and attempts, and psychosis
• Less frequent remission/high risk of recurrence
• Poorer response to some medications

Question 13

Make a brief recount of the understanding of affective disorders from prehistory to medieval periods

Answer 13

• Possibly in cave paintings
• Mania: reported in early Greek literature
• Ancient Greece:
  • Hippocrates (mental functioning: brain, melancholia: lasting fears),
  • Arataeous of Cappadocia: melancholia: dull without cause, proposed premorbid personality. Later (1st century): previously euphoric patients have tendency to melancholy
  • Galen: affliction of brain or heart/liver

• Islamic Golden Age:
- Avicenna: melancholia as depressive type w/ suspicions and phobias

Question 14

Describe some key points Johann Christian Reil (Professor of Medicine at University of Halle) made about Psychiatry

Answer 14

Key points:

Anyone can get mental diseases
Highlighted the need for an anti-stigma campaign
Mental health disorders may cause somatic disorders

Treatment should aim for free intervals (prevention) and place the individual without high expressed emotion
Psychotherapy is an equivalent therapy

Also stated:

a) Psychiatry is a pure medical specialty (no room for philosophers)
b) Only the best physicians shall become psychiatrists
c) Medical psychology for the needs of physicians should be included in medical training
d) Psychiatry, psychosomatics and medical psychology are closely allied

Question 15

What did Hippocrates aim to do?

Answer 15

Classify mental disorders (paranoia, epilepsy, melancholia and mania)

Hippocrates attributed mental functioning to the brain

He also introduced the idea of wellbeing - that doing productive activities could boost your mental health “walking be your medicine”

Question 16

Describe what Aretaeus of Cappadocia contributed to the commentary on affective disorders?

Answer 16

He explored the role of pre-morbid personality (that those who became manic may be initially labile or irritable and those who were depressed had a tendency for low mood in their premorbid state)

Aretaeus also latterly in the medieval period described the pattern of bipolar illness (from mania to depression)

Question 17

What did Avicenna describe about depressive disorders?

Answer 17

The 11th century Persian physician stated that during depressive illnesses those may become suspicious and develop phobias

His book was The Canon of Medicine

Question 18

In the late medieval period outline some trends in affective disorders?

Answer 18

Psychological problems also entailed legal and religious issues.

Witch-hunting - Malleus Maleficarum “of no cause could be found and it did not respond to traditional treatment it was caused by the devil”

Palm-reading and astrology - the importance of celestial bodies on health led to the term “lunatic”

While social philosophers dissented, they were largely outnumbered

Question 19

Outline some key contributions from 17th to 19th centuries

C17th - “Era of Reason and Observations”

Reformation 15-17-1648 (split of protestants and catholic churches) - Church lost its grip over medical and philosophical thought

Answer 19

Depression:
- Robert Burton (monk in 17th century) wrote the anatomy of melancholy which highlighted the role of diet, meaningful experiences and social support

Discrepancies in belief about the cause of depression:

• Heinroth - believed sin played a role
• Pinel - hospital reformer whoa advocated a humanitarian approach
• Galen - believed skull or abdomen shape played a role
• Esquirol - stated the importance of social or psychological factors

Question 20

Who first used depression when describing a psychiatric symptom?

Answer 20

Louis Delasiauve

Followed by Emil Kraepelin

Question 21

Outline some influences to manic-depressive illnesses in 17th-19th centuries

Answer 21

(Fr) Jules Baillarger - Folie a Double Forme

(Fr) Jean-Pierre Falret - La Folie Circulaire (mania and melancholia follow with continuity and regularity)

Germany:

(W Griesinger - Mental disease were somatic and disorders of the brain (integrate the mentally ill with society))

K L Kahlbaum - cyclothymia

Question 22

Outline some contributions of Emil Krapelin to Affective Disorders?

Answer 22

• Separated manic-depressive illness from dementia praecox (Schz)
• Manic-depression - more benign than Schz
• Patients have a FHx
• There is an episodic course

Stated there was a unifying concept of affective disorders

Question 23

Give some names of people who contibuted to the use of Lithium as a mood stabiliser?

Answer 23

John Cade (Australian Psychiatrist) - used Lithium in Guinea Pigs and tx symptoms similar to mania

Mogens Schou (Prof of Biological Psychiatry in Denmark) - use of Lithium to prevent relapse in manic-depressive illness

Question 24

Outline some contibutors to the field of ECT

Answer 24

Ladislas Meduna - observed that in epilepsy or schizophrenia patients on post mortem there was over/under brain growth. After this mediation used to try and initiate seizures (camphor then Metrazol). Ladislas Meduna believed Epilepsy and Schz were antagonistic disorders.

Ugo Cerletti and Lucio Bini in 1938 - 1st used electricity to generate seizures

Question 25

Outline some historical challenges to Psychiatry?

Answer 25

1. Birth of patient movements
2. Nazi and Soviety Psychiatry
3. 1960’s prominent anti-psychiatrists - Cooper, Szasz, Laing, Foucalt
4. Challenges from clinical psychology
5. Rosenhan Experiement
6. Critical Psychiatry

Question 26

Give some limitations of modern classifications of mental disorders?

Answer 26

Poorly linked to pathophysiology

Not free of theory - if theory incorrect so will diagnosis

Reliable > valid

Not transculturally applicable

Categorise dimensions - may not be categorical

Could negatively impact education and training