Periodic and circular insanity

• Part 1: A beautiful child
• Part 2: Periodic and circular insanity
• Part 3: Accident prone
• Part 4: A healthy productive life
• Part 5: Major therapeutic advances
• Part 6: Rebecca Riley
• Part 7: The bipolar brain is miswired
• Part 8: A tale of two psychiatrists
• Part 9: A devastation beyond belief

In 1854, two French psychiatrists, Jules Baillarger and Jean Pierre Falret, within a few days of each other delivered lectures to the French Imperial Academy of Medicine on episodes of depression and mania alternating in the same individual, a condition which Baillarger named "folie à double forme" and which Falret called "folie circulaire." This precipitated a bitter dispute as to which man had priority, a dispute that lasted as long as both men lived. Emil Kraepelin, who is widely regarded as the father of biological psychiatry, divided all mental disorders into two categories: dementia praecox and manic-depressive insanity. "Dementia praecox" corresponds more or less to our modern notion of schizophrenia (along with with syphilitic dementia, or "general paralysis of the insane" as it was then known, thrown in). He divided "manic-depressive insanity" into three categories: melancholia, simple mania, and "periodic and circular insanity." The latter came to be known as "manic-depressive illness," and in 1966, Swedish psychiatrist Carlo Perris used the term "bipolar" to describe patients suffering from this condition. The first pharmacological treatment for manic-depressive illness, and indeed for any specific psychiatric diagnostic category, was lithium salts. Lithium, the lightest metal on earth, was discovered by the Swedish chemist Johan August Arfwedson in 1817. The word "lithium" literally means "rock stuff"--not a terribly informative name, but there you are. The antimanic properties of lithium were discovered in the 1940's by John Cade, an Australian psychiatrist and WWII Japanese POW camp survivor, who followed up on a chance observation that lithium urate had a tranquilizing effect on guinea pigs. After being injected, these rodents became apathetic and unresponsive, not even bothering to right themselves after they were placed on their backs. After testing lithium on himself and being satisfied that it produced no untoward effects, Dr. Cade administered it to nineteen of his patients and found that it helped those suffering from mania but not other kinds of mental illnesses, such as schizophrenia or depression. Lithium was approved by the FDA for treatment of mania in 1971. Two years later, psychiatrist Ronald Fieve, an early champion of lithium therapy, told the National Observer "Lithium preserves normal mental and physical functions and seems to get at the core of the illness by correcting basic biochemical processes."

David Healy is a medical doctor and the author of Mania: A Short History of Bipolar Disorder. In a telephone interview he stated that the antimanic effects of lithium go beyond a mere tranquilizing effect. "The antipsychotics and anticonvulsants are used a lot for mania because they're clearly sedating and they can kind of knock manic behavior on its head," he explained. "Lithium is quite different from that point of view. When the manic behavior responds to lithium it seems to do so without the patient being heavily sedated. So I think there is a more distinct anti-mania with that than all of the other drugs." The means by which lithium exerts its antimanic effects remains unknown. The lithium ion has no known function, in any living thing. As with any drug, lithium carries the risk of toxic effects. These include abdominal cramps, nausea, vomiting, diarrhea, tremor, fatigue, ataxia, slurred speech, cognitive impairment, skin eruptions, weight gain, hypothyroidism, irreversible kidney damage, and sudden cardiac death (one of the first group of patients Dr. Cade gave the drug to died from lithium poisoning, something he never got around to mentioning in his published accounts). The National Institute for Clinical Excellence guidelines recommend patients given lithium therapy be tested for lithium plasma levels every three months, in addition to testing for kidney and thyroid functioning every six months. Many people with bipolar disorder are prescribed atypical antipsychotic drugs, notably risperdone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), olanzapine (Zyprexa), ziprasidone (Geodon), and clozapine (Clozaril). So-called "antipsychotic" drugs originally were called "neuroleptics," a term which means "that which seizes the neuron," because the effects of these drugs mimic those of brain damage. Thorazine, the first of the neuroleptic drugs, was introduced into the United States in 1954. Henri Laborit, a young French naval surgeon who was the first to use this drug in human patients, touted the drug as "a medicinal lobotomy." From the beginning, it was clear that any diminution of psychotic symptoms associated with these drugs was due to a general blunting of the affect, rather than any specific antipsychotic action. The term "atypical" is a marketing term rather than a pharmaceutical one, as there is no convincing evidence of any consistent differences between "typical" and "atypical" antipsychotics, either in terms of efficacy or safety. Both "typical" and "atypical" antipsychotics are associated with a dizzying array of toxic effects, including tardive dyskinesia, a disfiguring, socially-isolating condition characterized by lip-smacking, grimacing, bizarre postures, and uncontrollable movements of the tongue. As many as forty percent of long-term users of antipsychotic drugs may develop tardive dyskinesia. There is no cure.

Other toxic effects of these drugs include neuroleptic malignant syndrome, dysphagia, hypersalivation, massive weight gain, diabetes, seizures, blood clots, stroke, sudden cardiac death, atrophy of the brain, and something called "rabbit syndrome." The long-term use of anti-psychotic drugs is correlated with a drop in life expectancy measured not in years but in decades. Before the modern psychopharmaceutical era, bipolar disorder was a rare condition. It was also virtually unknown among children. Krapelin analyzed data from 903 cases of affective disorders and found that only 0.4% began before the age of ten. In an additional 2.5%, the age of onset was between ten and fifteen years. This was all affective disorders, not just bipolar. In 1931, psychiatrist Jacob Kasanin reported that out of some 1900 children admitted to Boston Psychopathic Hospital every year, only two or three were suffering from "affective psychosis." Again, this was all affective disorders, not just bipolar. And in 1960, psychiatrists James Anthony and Peter Scott reviewed the literature and found only three cases of prepubescent children suffering from bipolar disorder which, in their judgement, were not open to charges of misdiagnosis. All this began to change when the psychopharmaceutical industry began dosing large numbers of children with stimulants and antidepressants. The first harbingers of the gathering storm appeared in the 1970s. Next: Part 3: "Accident prone" List of Sources

• Healy, D. 2008. Mania: A Short History of Bipolar Disorder. Johns Hopkins University Press.
• Pichot, P. 2004. Circular insanity, 150 years on. Bulletin of the National Academy of Medicine 188:275-284.
• Krapelin, E. 1921. Manic-Depressive Insanity and Paranoia. E.S. Livingstone, Edinburgh.
• Cade, J. 1949. Lithium salts in the treatment of manic excitement. Medical Journal of Australia 2:349-352.
• Shah, D.K. 1973. Manic-depressives: Hope in a drug. National Observer 7 July 1973.
• Johnson, F.N. 1984. The History of Lithium Therapy. Macmillan.
• Valenzuela, E.S. 1998. Blaming the Brain. Free Press.
• Leucht, S. and J.M. Davis 2011. Are all antipsychotic drugs the same? British Journal ofPsychiatry 199:269-271.
• Kasanin, J. 1931. The affective psychoses in children. American Journal of Psychiatry 10:897 926.
• Anthony, J. and P. Scott 1960. Manic-depressive psychosis in childhood. Child Psychology andPsychiatry 1:53-72.