cyclothymia, a circular mood disorder by ewald hecker* introduction* by christopher baethge,a,b...

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DOI: 10.1177/0957154X030143007 2003; 14; 377 History of Psychiatry

Ewald Hecker Cyclothymia, a Circular Mood Disorder

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* Work on both the introduction and the translation were supported by the Max KadeFoundation, New York, NY, USA (Dr Baethge), by the Bruce J. Anderson Foundation, and theMcLean Private Donors Neuropsychopharmacolgy and Bipolar Disorder Research Fund, Belmont,MA, USA (Dr Baldessarini). Address for correspondence: Ross J. Baldessarini, M.D., MailmanResearch Center, Harvard Medical School, McLean Hospital, 115 Mill St, Belmont, MA 02478-1906, USA. E-mail: [email protected]

a Department of Psychiatry and Psychotherapy, Freie Universitt Berlin, Berlin, Germany.b Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, Bipolar & Psychotic

Disorders Program and International Consortium for Bipolar Disorder Research, McLean Divisionof Massachusetts General Hospital, Belmont, MA, USA.

c Institute of Clinical Psychiatry, University of Parma, Parma, Italy.

Ewald Hecker (18431909) was a collaborator of Karl Ludwig Kahlbaum(18281899). Both worked outside the university and public mental institutions ofGermany. By meticulously observing clinical signs and illness-course, they laidthe groundwork for modern descriptive psychiatry. Their clinical approachinfluenced Kraepelin and continues to dominate psychiatric classification.Hecker popularized several of Kahlbaums syndromal concepts, includinghebephrenia. Another was cyclothymia, a relatively benign form of manic-depressive illness, introduced by Kahlbaum in 1882. It included depressive(dysthymia), hypomanic (hyperthymia), and mixed hypomanic-depressive phases.The Kahlbaum-Hecker syndrome of cyclothymia survives in DSM-IV bipolarII disorder and cyclothymia. An annotated English translation of Heckers1898 paper is provided, with historical notes on Hecker and the significance ofhis work.

Keywords: cyclothymia; Hecker; history of psychiatry; Kahlbaum;psychopathology

History of Psychiatry Copyright 2003 SAGE Publications 0957-154X [200309] 14(3): 377399; 038309

Classic Text No. 55

Cyclothymia, a Circular Mood Disorder

by EWALD HECKER*

Introduction* byCHRISTOPHER BAETHGE,a,b PAOLA SALVATOREb,c and ROSS J. BALDESSARINIb

Vol 14-Pt3-Cl Txt 55-Hecker 28/8/03 5:04 pm Page 1


378 HISTORY OF PSYCHIATRY 14 (3)

In 1898 Ewald Hecker (18431909),who is known for his work onhebephrenia (Hecker, 1871b; Sedler,1985), published a paper on cyclo-thymia. This 1898 report contained adetailed clinical description of anosologic entity first described by KarlLudwig Kahlbaum (18281899) in1882.1 Heckers paper on cyclothymiawas recognized as a seminal contri-bution in Theodor Ziehens (18621950) textbook and by the Americanpsychiatrist, Smith Ely Jelliffe (Jelliffe,1909; Ziehen, 1902). Karl Jaspers inhis landmark book Allgemeine Psycho-pathologie refers to Heckers work oncyclothymia as a fundamental contri-bution, similar to his earlier paper onhebephrenia (Jaspers, 1946).

Both syndromes (hebephrenia andcyclothymia) were initially describedby Kahlbaum and later elaborated byhis junior colleague and collaboratorHecker. Their combined work prepared

the ground for Kraepelins revolutionary psychiatric classification scheme(Berrios and Hauser, 1988). In particular, the Kahlbaum-Hecker concept ofcyclothymia, characterized by recurrent episodes of depression or dysthymiaand periods of hypomania or hyperthymia, was an influential antecedent ofKraepelins manic-depressive insanity (Baethge, Salvatore and Baldessarini,2003).

Kraepelins separation of manic-depressive illness and dementia prcox inthe late 1890s (Kraepelin, 1899) represents a major conceptual step in thehistory of psychiatric thinking, with its fundamental division of disordersmarked primarily by dysfunctioning of mood or of reason. Kraepelins manic-depressive illnesses combined most cases of recurrent, severe, episodicmelancholic depression, many bipolar (manic-depressive) and mixed states,and uncommon cases of recurrent mania (Kraepelin, 1899).

However, by the mid-twentieth century, European psychopathologistsdistinguished a bipolar manic-depressive subgroup from those with recurrent,unipolar depressive illness (Angst, 1966; Perris, 1966). Current standardinternational diagnostic systems (ICD-10 and DSM-IV) further distinguishbipolar types I and II (depression with hypomania) as well as cyclothymiamarked by life-long mood instability (APA, 1994; WHO, 1992).

Diagnostic refinement of bipolar disorders continues to be a lively topic of

EWALD HECKER(from Wilmanns (1924), with permission from

Springer Verlag)



379C. BAETHGE, P. SALVATORE & R. J. BALDESSARINI: INTRODUCTION

research and discussion, encouraged by modern descriptive, epidemiological,genetic and other biological studies, as well as the ongoing quest forimproved treatments for all major affective disorders (Akiskal and Pinto,1999; Atre-Vaidya and Hussain, 1999; Baldessarini, 2000; Howland andThase, 1993; McElroy et al., 1992; Merikangas et al., 1996; Taylor, 1992).Kahlbaums and Heckers publications on cyclothymia mark early contributionsin this continuing tradition of scientific discussions on bipolar disorders.

Because of the historical importance of the cyclothymia syndrome ofKahlbaum and Hecker, and its relevance to current research on bipolardisorder subtypes, we provide here an annotated English translation ofHeckers report on cyclothymia of 1898, together with comments on Heckersbiography, his psychiatric contributions, and on the scientific significance ofthis study.2

Biographical sketch

Information about Heckers life is scarce. Available sources of informationinclude his writings, an obituary by Proebsting (1909) and a chapter aboutHecker by Karl Wilmanns in a book about important German alienists.3

Ewald Hecker was born in Halle an der Saale in Prussia on 20 October1843. His father was an architect. The family moved to Knigsberg in EastPrussia, on the Baltic sea (now Kaliningrad in Russia). In this university cityhe completed his secondary education and began university studies inarchitecture in 1961, but soon decided to pursue a medical degree. Hecompleted medical studies at the University of Knigsberg in 1866 with adoctoral dissertation on tuberculosis (Hecker, 1866). Later that year hemoved to nearby Allenberg in East Prussia to work at the local publicpsychiatric hospital, where Karl Ludwig Kahlbaum worked as a staffpsychiatrist during his brief time in the teaching and clinical faculty at theUniversity of Knigsberg (Baethge et al., 2003; Hecker 1899).

Kahlbaum and Hecker became friends as well as close professional associates.Both shared liberal social values and are believed to have been dissatisfiedwith the conservative Prussian politics of the 1860s under the leadership ofOtto von Bismarck, as well as a conservative head of staff at the AllenbergPsychiatric Hospital (Neisser, 1924; Wilmanns, 1924). In 1866 Kahlbaummoved to the town of Grlitz, also in East Prussia, near the present Polishborder, to work at the Reimer Sanatorium, a private psychiatric hospitalwhich was considered to be a leading centre for the care of epileptic patients.Kahlbaum soon became director of this sanatorium (Baethge et al., 2003).Hecker followed Kahlbaum to Grlitz in 1867 where they worked togetheruntil 1876. In 1868 Kahlbaum married Heckers cousin, and in 1871 Heckermarried Henriette Leonhard (18461900), a friend of this cousin. They hadtwo daughters, Else and Helene, and one son, Waldemar.

Hecker wrote about that period (in his obituary of Kahlbaum): I have




experienced ten perfect years of working together, in mutual struggles andworries with him [Kahlbaum]. Our relations became truly brotherly whenKahlbaum married a cousin of mine in 1868. (Hecker, 1899; translation bythe authors)

Undoubtedly, the years in Grlitz were of decisive importance for Heckersprofessional development. Kahlbaum had opposed the theory of unitarypsychosis and had published a new classification of psychiatric disorders in1863. Moreover, he was the leading proponent of the then-revolutionaryclinical method with its emphasis on meticulous cross-sectional, descriptivepsychopathology and close longitudinal observation of illness-course asfundamentals in the diagnostic process. At the time of Kahlbaum andHecker, both descriptive psychopathology and long-term observation werenew concepts in psychiatry. This innovative approach attracted manytalented young psychiatrists to Kahlbaum. In addition to Hecker, severalimportant figures in German psychiatry of the late nineteenth centuryworked with Kahlbaum at Grlitz, including Hallervorden, Ziehen, andCassierer (Neisser, 1924).

Janzarik wrote about German academic psychiatry at the end of thenineteenth century and considered Kahlbaums position as an academicoutsider at a remote provincial hospital:

[. . .] the further development of psychiatry was determined by the clinicalmethod of the outsider whose arguments werent backed by an academicposition and who considered himself just like Kraepelin later on as apure clinician. It was not properly recognized at that time, but the periodbetween Griesinger and Kraepelin was the epoch of Kahlbaum. (Janzarik,1979: 54; original italics; translation by the authors)

One gets a glimpse of the atmosphere at the Kahlbaum clinic from a statementthat his predecessor, Riemann, made about his reasons to hand overleadership of his clinic to Kahlbaum: I finally found the right purchaser; hegets up at four oclock in the morning to start his work and he prepares hiscoffee himself. He shall have my clinic! (Hecker, 1899: 127; translation bythe authors)

However, this style might not have been attractive to everyone. In the early1880s Kahlbaum had offered Kraepelin, who was 28 years younger, aposition at his clinic. Kraepelin rejected the offer for reasons that areuncertain. However, he reports in his autobiography that his fatherly friend,the University of Leipzig psychologist Wilhelm Wundt (18321922), stronglyadvised against Grlitz, by rhetorically asking why Kraepelin would want tojoin this personal slavery (Hoff, 1994). Heckers personality was quitedifferent from Kahlbaums. In his obituary of Kahlbaum, Hecker describeshim as stern and unapproachable at times, but adds that he had a winningmanner in close personal contact (Hecker, 1899). Hecker was Kahlbaumsrepresentative in the Grlitz clinic. When the director took a years leave to




pursue studies of neuroanatomy and neuropathology at the Universities ofVienna and Prague in 18751876, Hecker led the clinic (Wilmanns, 1924).

In 1876 Hecker was offered the medical directorship of a psychiatricsanatorium in Plagwitz in Silesia. He remained there for five years, bringingmany reforms to the organization and clinical operations of the institution. In1881 he purchased his own sanatorium on the Rhine in Johannisberg, wherehe could promote his own ideas about psychiatric care. In 1891 he movedagain, to Wiesbaden near Frankfurt am Main to develop a new sanatorium.Here, he lived with his patients in a spacious mansion for nearly two decadesuntil 1908, shortly before his death.4 Heckers wife died in 1900, and hesurvived until 11 January 1909, dying at the age of 65 from pneumoniafollowing a series of strokes.5

Hecker is described as a kind, warm, modest and socially conscious personwhose interests were not limited to psychiatry. Wilmanns writes that Heckerwas very unassuming and sacrificed himself to his patients. Hecker also tookchild-like joy in inventions. For example, he designed a matchbox thatprovided one match at a time, and a container that issued one calling card ata time. Although he rarely travelled or took vacations, he once went toSwitzerland with his patients, using a travelling bag with many compartmentsof his own design (Wilmanns, 1924).

Heckers psychiatric career and contributions

Hecker is known for his influential report on hebephrenia (Hecker, 1871b) a disorganized form of chronic idiopathic psychotic illness often arising inyouth. This disorder was first recognized by Kahlbaum among paediatricpatients at Grlitz and reported as early as 1863 (Kahlbaum, 1863). Theconcept was later incorporated into Kraepelins dementia praecox andBleulers schizophrenia (Bleuler, 1911; Kraepelin, 1899).

In addition to his work on hebephrenia, Hecker refined and promotedseveral other concepts of Kahlbaum. In order to qualify for his academicappointment at the University of Knigsberg in 1863, Kahlbaum prepared amonograph on a revolutionary psychiatric classification system (Berrios,1996; Brunig and Krger 2000; Kahlbaum, 1863). Referring to this classicmonograph, Hecker wrote about Kahlbaums clinical method of descriptivepsychopathology, based on direct observation of many carefully describedcases followed over time, as a basis for proposing novel diagnostic categoriesof psychiatric illnesses (Hecker, 1871a; 1877). Kraepelin was influenced bythis work and later wrote that, in preparing his classification scheme and hisconcept of manic-depressive disorder, he was indebted to Kahlbaum and toHecker (Kraepelin, 1918). The clinical method continues as a foundation ofmodern international psychiatric nosology that is the basis of both ICD-10and DSM-IV (Berrios and Hauser, 1988).

Heckers 1898 report on cyclothymia translated below was published one




year before Kahlbaums death and was his last report based on Kahlbaumsideas. In his obituary of Kahlbaum, Hecker stated that he would have likedto elaborate more of his influential colleagues ideas, but that Kahlbaumoften made this difficult by planning to write more himself than he was ableto do. Wilmanns, Heckers biographer, suggests that Kahlbaums lack ofgenerosity [Engherzigkeit] contributed to the paucity of publications byHecker based on Kahlbaums ideas (Wilmanns, 1924). Kahlbaum indeedwrote little and would probably be even less well known today were it not forHeckers elaboration of several of his innovative concepts.

Heckers elaborations and refinements of Kahlbaums ideas represent onlya small proportion of about 30 scientific works that he published between1866 and 1900. His output peaked at Grlitz, with four articles in 1871.Many of Heckers papers developed from his lectures. They covered a widerange of interests, including forensic topics, the organization and administrationof psychiatric hospitals, treatment of sleep disturbances, and even moreesoteric subjects such as the nature of laughter (Hecker, 1868, 1873, 1887,1897, 1900). Interestingly, during his own lifetime, two of Heckers publicationswere translated into English. One was on Sleep and dreams (1871c); theother, in 1885, was entitled The causes and first symptoms of mentaldisease (Kreuter, 1996).

In later years, when Heckers private clinics in Johannisberg and Wiesbadenwere visited mainly by patients with non-psychotic ailments, he became moreinterested in neuroses. Between 1892 and 1894 he published three papers onthe diagnosis and treatment of anxiety and neurasthenia. These reportsreceived considerable attention during Heckers lifetime, indicating that hewas not merely an expositor of Kahlbaums ideas. In 1895 Sigmund Freudwrote in one of his early papers on the anxiety neurosis:

I call this syndrome anxiety neurosis, because all its components can begrouped round the chief symptom of anxiety, because each one of themhas a definite relationship to anxiety. I thought that this view of thesymptoms of anxiety neurosis had originated with me, until an interestingpaper by E. Hecker (1893) came into my hands, in which I found thesame interpretation expounded with all the clarity and completeness thatcould be desired. Nevertheless, although Hecker recognizes certainsymptoms as equivalents or rudiments of an anxiety attack, he does notseparate them from the domain of neurasthenia, as I propose to do.(Freud, 1962)

Heckers remarkably modern views of psychiatric disorders were sometimesnot accepted by contemporary academic psychiatrists. In addition, he was avery progressive clinician for his time. For example, perhaps even more thanKahlbaum, he was dedicated to minimizing the use of coercive measures. InAllenberg, Hecker tried to eliminate the use of the strait-jacket and otherforms of physical restraints, but succeeded only when the clinic director was




away on a prolonged medical leave of absence. Kahlbaum and Heckersuccessfully modernized the sanatorium in Grlitz, including minimal use ofphysical restraints, as Hecker later did at his own hospital in Plagwitz, oftendespite the reluctance of his staff. In addition, Hecker introduced work-therapy, greatly improved the physical environment at Plagwitz, and madeavailable concerts, plays and other social events. Hecker even employedpatients in his household (Wilmanns, 1924).

Hecker was a dedicated therapist who employed hypnosis and psycho-therapy in his treatment, in keeping with his shifting clinical interest frompsychotic illnesses to anxiety, neurasthenia, hysteria and cyclothymia.Although Hecker had a medical view of mental illness, his clinical approachto the mentally ill shared many characteristics of milieu therapy and of themoral treatment movement that had emerged throughout Europe and Americain the early nineteenth century (Shorter, 1997); his psychologically-basedtreatment of ambulatory and less severely ill patients anticipated thepsychotherapy movement emerging in the early twentieth century with theAustrian, Swiss and German psychoanalytic movement.

Hecker remained a practising clinical psychiatrist throughout his professionalcareer. However, in 1907, at the age of 64, the Prussian government awardedhim the honorific title of Professor, even though he had never held auniversity post. Heckers career path, based on life-long practice withinsmall, private mental hospitals, was very similar to that of Kahlbaum. Thiscareer path may well have limited the influence of both men on the trainingof psychiatrists of their time and this may explain why, during the pasthundred years, academic psychiatrists have tended to ignore them or fail toappreciate their work. It is also noteworthy that many of the clinical as wellas conceptual ideas held by both Hecker and Kahlbaum also seem to havebeen ignored by their own contemporaries in university clinics and publicmental institutions.

According to Proebsting and Wilmanns, there was a proposal to offerHecker an academic chair of psychiatry at a Prussian university, butChancellor Otto von Bismarcks Secretary of Education, Robert Victor vonPuttkammer (18281900), blocked the proposal, presumably on politicalgrounds. Hecker, whose liberal uncle had been convicted for high treason,had attracted Puttkammers attention by vigorously supporting a liberalpolitical party (Freisinnige Partei) that opposed the conservative and nationalisticpolicies of Bismarcks government (Proebsting, 1909; Wilmanns, 1924).Though plausible, this account of Heckers lack of a senior universityposition should be viewed with caution, since the evidence on which it isbased is circumstantial. It appears possible, too, that Kahlbaums andHeckers opposition to the ruling theory of unitary psychosis [Einheitspsychose]may have contributed to their disfavour by more theoretical academicpsychiatrists of their era.

During Heckers early career, academic psychiatry in Germany was in its




earliest years. The chair taken by Wilhelm Griesinger (181768) at theUniversity of Berlin in 1865 was the first regular psychiatric professorship inGermany (Janzarik, 1979). At that time, when the leading clinical conceptwas Neumanns and Griesingers unitary psychosis [Einheitspsychose], Germanacademic psychiatry was a stronghold of the application of neuropathology.This approach was aimed at localizing psychiatric disorders as braindisorders rather than at developing descriptive psychopathology and othermore clinical approaches.6 Kraepelin, who was considerably younger thanboth Kahlbaum and Hecker and also considered himself a clinician ratherthan a neuroscientist, adopted the clinical method of Kahlbaum and Heckerand brought it to the attention of academic psychiatry. Nevertheless, it isinteresting to note that what turned out to dominate nosology and clinicalpractice in the next century was developed outside university psychiatry bypsychiatrists like Hecker and Kahlbaum.

Heckers article, Cyclothymia, a circular mood disorder

Heckers 10-page paper of 1898 contains a lively description of the clinicalfeatures of cyclothymia, and therefore makes it easy for the reader to imaginesuch patients.7 This descriptive presentation contrasts strikingly withKahlbaums 1882 lecture and paper on cyclothymia. Kahlbaums was atheoretical contribution aimed not only at presenting cyclothymia as a newnosological concept, but perhaps even more at challenging the ruling theoryof mental unity [unity of the soul]. Kahlbaum provided a sophisticatedaccount of basic psychopathological issues at that time, but with very littleinformation about the clinical characteristics of cyclothymia (Baethge et al.,2003; Kahlbaum, 1882). Moreover, Kahlbaums report is perhaps excessivelyscholarly and employs a complex style that is hard to follow. For this reason,Heckers contribution filled a gap in the presentation of the cyclothymiaconcept as a novel clinical entity.8

Typically for his time, Hecker did not present numbers or statistics. Hedid not apply any psychometric measurements and rating scales. Instead, thepaper is an example of meticulous psychopathological observation, carefulclinical judgement, and consideration of current literature. At the beginningof his report, Hecker refers to Kahlbaum as the originator of the cyclothymiaconcept as one of several novel syndromes within Kahlbaums classificationsystem of 1863, as well as bearing similarities to the cyclothymia and periodicdepression later described by Kraepelin and the Danish author Carl GeorgLange (see the translation, and Translators Note 2).

Hecker pictured cyclothymia as a nosological entity characterized by periodicmood swings between moderate exaltation and dysthymic depression. Thesestates do not usually lead to psychiatric hospitalization, although thesuicidality associated with dysthymia might require protective interventionsincluding hospitalization. Hecker emphasizes that core features of dysthymia




are inhibition, hopelessness and nonspecific somatic complaints, andparticularly a tendency to criticize and be querulous. In the hyperthymic state(Hecker does not use the term hypomania later popularized by Kraepelin),patients display an elevated mood, an accelerated thought process; they feeland may be more capable and skilful in different ways, and may squandermoney or become boisterous or hypersexual. Interestingly, in the hyper-thymic phase the irritability and querulousness may remain. Table 1 providesa summary of the major symptoms of cyclothymia described by Hecker.

Hecker states that the course of cyclothymia is unpredictable, withdifferent patterns of duration and periodicity, including what today might beregarded as mixed states and rapid cycling. However, he stresses the generallygood long-term prognosis, in contrast to other more severe and pervasivepsychiatric disorders, such as general paralysis of the insane or Kahlbaumsvesania typica circularis (a more severe, manic-depressive-like, disorder thatwould include todays severe bipolar disorder of poor outcome, schizo-affective disorder, and other forms of episodic psychotic illness). Hecker thendifferentiates cyclothymia from other psychiatric disorders, including melan-cholia, general paresis, hysteria, and neurasthenia. He ends up with theadvice not to treat the dysthymic phase of the disorder aggressively, andrecommends opium as well as hypnosis for dysthymia and tepid baths forboth dysthymic and hyperthymic states.

In many points, the cyclothymia of the Grlitz School is closer to todaysconcept of bipolar II disorder (recurring major depression with hypomania)rather than to the less well-defined modern concept of cyclothymia (Briegerand Marneros, 1997). Moreover, Hecker says that, despite a lack ofdelusions and other psychotic features, the symptoms of cyclothymiasometimes exceed hypomanic levels and lead to functional impairment.Therefore, some of his cyclothymia patients might be diagnosed today withbipolar I disorder.

Although historic diagnostic concepts such as that presented here areprecedents of the current standard international classification systems andare basically their roots it is important to note that it is somewhat artificialto force Kahlbaums and Heckers cyclothymia into current diagnoses.Instead, differences in classification systems point to the fact that diagnosticconcepts are cultural phenomena that may change over time. At the level ofsymptomatology, however, it is interesting to see that various aspects ofHeckers cyclothymia are pertinent to several psychopathological phenomenathat remain lively topics of study today. These include subsyndromal mooddisorders, dysphoric mania and mixed affective states, hypersomnia duringdepression, rapid cycling, and even the harmful potential of antidepressanttreatment of bipolar patients. For example, mixed manic-depressive(dysthymic-hyperthymic) states are not included in bipolar II syndromeaccording to DSM-IV, but are considered possible and even characteristicacross the spectrum of bipolar disorders, as Hecker, Weygandt and Kraepelin,




TABLE 1. Features of cyclothymia reported by Hecker

Dysthymic phasePsychic inhibition, loss of interest, reduced communication or workGeneral weakness and anergyDulling of thoughts, inner numbnessSadness, hopelessness, wearinessSuicidal thoughts and actionsFacial inexpressivenessSocial withdrawal, indifferenceAmbivalenceAnxietyIntense feeling of being unwellSomatic complaintsTense feeling in chest and head, headachesWeight lossIncreased sleepCritical or querulous tendencyExaggerated guilt, some false beliefs*No delusional ideas or misperceptions

Hyperthymic phaseElevated mood, irrepressible cheerfulness* Accelerated thinking and responsiveness to stimuli Restless activityAnimated expressivenessExaggerated self-confidence, grandiosity, arrogance*Increased creativity, improved capabilitiesTendency to criticize, irritabilityPseudorationality (folie raisonnante or madness with reason)*Eroticized relations with strangersIrritabilityUrge to spend moneyUnusual behaviour, out-of-characterBoisterousness, joking, tricksReduced self-control, impulsivity Tendency to lie, drink, and antisocial behaviour Reduced need for sleep

Course of illnessUsually present for medical assessment when depressed*Hyperthymia often unrecognized by patient or clinician Unpredictably episodic with relatively healthy intervals High inter- and intra-individual variability of course Episode duration varies from days to yearsDaily fluctuations of mood and behaviour within episodesMixing of excited and depressive featuresLack of progressive worsening to a defect state* Need for hospitalization rare Behaviour changes arise from altered mood

* Features also (or only) noted by Kahlbaum.




as well as some modern authors, suggest (APA, 1994; Dilsaver, Chen, Shoaiband Swann, 1999; Salvatore et al., 2002).

Heckers description of somatic symptoms, hypersomnia, and psychomotorinhibition in the dysthymic phase of cyclothymia and his explicit differentiationof the dysthymic phase of cyclothymia from genuine melancholia point tocurrent discussions about bipolar depression. Akiskal and his collaborators havefound anergy, hypersomnia and somatization to be symptoms of depressionin a group of patients suffering from bipolar II and an even broaderspectrum of bipolar-like illnesses (Akiskal et al., 1985; Akiskal et al., 2000).They also found a high frequency of antisocal acts and substance abuse bysuch patients. Moreover, in the first contemporary study that defined bipolarII disorder, Dunner and colleagues reported substantial suicidality amongsuch patients (Dunner, Gershon and Goodwin, 1976). All these signs andsymptoms had been reported by Hecker in cyclothymia.

On the other hand, Hecker appears to have been a victim of the spirit ofhis times (Shorter, 1997, 3142) in declaring that cyclothymic patients hadpresumably genetically-determined dyssocial tendencies [sittlicher Defect].Hecker may correctly have recognized a heightened familial risk for affectivedisorders and antisocial behaviour among cyclothymic patients, but heprovided no data to suggest whether substance abuse, marital problems orcriminal behavior were present in excess in such families.

ENDNOTES

1. See Kahlbaum (1882). For a detailed introduction and an annotated English translation ofKahlbaums classic text, see Baethge et al. (2003).

2. An unannotated English translation of Heckers paper on cyclothymia, along with a briefintroduction (Koukopoulos, 2003), was published during the preparation of this report,underlining growing interest in the history of the concept of bipolar disorders

3. The most comprehensive account of Heckers life is that by Wilmanns (1924), Englishtranslation in Berrios and Kraam (2002). Heckers publications are listed in Kreuter (1996).Several of Heckers papers are included in the Reference list below.

4. The original name of the sanatorium was Heilanstalt fr Nervenkranke. It was in Wiesbaden atNo. 4 Gartenstrasse, which today is Steubenstrasse (Hessisches Hauptstaatsarchiv, Wiesbaden,2 December 2002).

5. On 12 January 1909 a short notice of Heckers death appeared in the local daily newspaper(Wiesbadener Tagblatt). Hecker died at 12.30 p.m. on 11 January, according to an obituary noticepublished by the Hecker family in the same issue of the newspaper. Hecker was buried on 14January at the old cemetery in Wiesbaden, in a tomb with his wife. The tombstone had beenprepared by Heckers son, Waldemar, in 1902 (Buschmann, 1991).

6. It was not unusual at that time to work in a private or in a state non-university hospital and tocontribute to academic discussions. The journal Allgemeine Zeitschrift fr Psychiatrie, publishedfrom 1844 to 1949, was a forum for clinicians, whereas Griesinger as the leading figure ofneuropathology-based psychiatry founded Archiv fr Psychiatrie und Nervenkrankheiten in 1868;this was published until 1983 (Janzarik, 1979). Hecker generally published in clinically orientedjournals (among others, three times in the Allgemeine Zeitschrift fr Psychiatrie). However, he alsopublished one paper in Archiv fr Psychiatrie und Nervenkrankheiten.

7. Heckers paper appeared in Zeitschrift fr praktische Aerzte. This journal, published in Frankfurtam Main, was aimed at general practitioners; it had various titles, and this one was used from1896 to 1900.




8. Hecker had introduced the word cyclothymia into psychiatric terminology in 1877 in a paper onclassification and diagnosis (Hecker, 1877: 607). Brieger and Marneros (1997) provide adetailed historical account of the concepts of cyclothymia, referring to the very differentmeanings that this term had in the past. Moreover, they emphasize that mild forms of bipolarmood disorders had been noticed before Kahlbaum and Heckers time. And, almost at the sametime as Hecker, the German psychiatrist Hoche wrote a treatise on milder forms of periodicmadness (Hoche, 1897). For the historical development of the bipolar concept, see Angst andMarneros (2001), Berrios and Hauser (1988) and Pichot (1995).

REFERENCES

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Akiskal, H. S., Bourgeois, M. L., Angst, J., Post, R., Mller, H. J. and Hirschfeld, R. (2000) Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum ofbipolar disorders. Journal of Affective Disorders, 59, S5S30.

Akiskal, H. S., Walker, P. W., Puzantian, V. R., King, D., Rosenthal, T. L. and Dranon, M. (1985)Bipolar outcome in the course of depressive illness: phenomenologic, familial, andpharmacologic predictors. Journal of Affective Disorders, 5, 11528.

Angst, J. (1966) Zur tiologie und Nosologie endogener depressiver Psychosen. Eine genetische, soziologischeund klinische Studie (Berlin: Springer Verlag).

Angst, J. and Marneros, A. (2001) Bipolarity from ancient to modern times: conception, birth andrebirth. Journal of Affective Disorders, 67, 319.

APA (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV) (Washington,DC: American Psychiatric Association).

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Baethge, C., Salvatore, P. and Baldessarini, R. J. (2003) On Cyclic Insanity by Karl LudwigKahlbaum, M.D., 1882: translation and commentary. Harvard Review of Psychiatry, 11,7890.

Baldessarini, R. J. (2000) A plea for the integrity of the bipolar concept. Bipolar Disorders, 2, 37.Berrios, G. E. (1996) Classic Text No. 25: Die Gruppirung der psychischen Krankheiten, Part III,

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cyclothymia, a circular mood disorder by ewald hecker* introduction* by christopher baethge,a,b...

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