Gin S. Malhi: A critical analysis of concepts in psychiatry.
Gin S.Malhi and Erica Bell:Fake views: Cyclothymia. Ditering disorder
Edward Shorter’s comment
Gin Malhi and Erica Bell now continue their Demolition Derby of DSM diagnoses. Regarding cyclothymia, they find DSM confused on the questions of chronicity and severity of this disorder, which, in DSM lingo, is part of “bipolar disorder.”
How to sort this out? Maybe, rather than being a subgroup of bipolar disorder, cyclothymia has several interpretive threads in the German diagnostic traditions, which Malhi and Bell invoke, and from which so much of today’s psychiatric nosology flows.
There are actually three Germanic traditions in “cyclothymia”:
1. Karl Kahlbaum’s initial conception in 1882 of the diagnosis as minor league “circular disorder.” Kahlbaum said that major-league circular disorder, “Vesania typica circularis,” went relentlessly downhill. Cyclothymia fluctuated. Kraepelin substantially agreed with Kahlbaum and said that “Cyklothymie” occurred typically between major episodes of Manic-Depressive Insanity, and that it wasn’t, actually, a real psychiatric disease (Kraepelin 1913). He gave it one paragraph.
2. Kurt Schneider, who assumed the professorship of psychiatry in Heidelberg after the Second World War and was an important psychopathologist, didn’t like Kraepelin’s term “manic-depressive insanity” and called it “Cyclothymie.” This tradition elevates cyclothymia to a big illness, a “showstopper," as Mickey Nardo called these.
3. The tradition of considering cyclothymia a character disorder, comparable to “depressive personality.” The landmark here is Ernst Kretchmer's (professor of psychiatry in Tübingen) Körperbau und Charakter (1921), which proposed the “cycloid temperament," fluctuating in and out of circular psychosis.
The whole mood basin contains so many currents which flow back and forth that all three of these traditions are probably correct. Yes, cyclothymia can be seen as a variant of “bipolar disorder,” at least by all those who regard bipolar disorder as a separate disease and dismiss the concept of “the mood basin.” Cyclothymia can also be seen as intercurrent with major episodes of depression and mania-hypomania. And finally, it can also be seen as quotidian changes in personality, blowing hot one day and cold the next. This is believed to be quite common, and not necessarily needy of treatment.
So, the Malhi-Bell discussion opens the whole can of worms of mood disorders: How many are there and how do we classify them? Sentiment is gaining ground for dismantling “bipolar disorder” as a separate disease and throwing it back into the Kraepelinian "mood basin” of manic-depressive insanity and its cousins. There is something to be said for this.
Kraepelin E. Psychiatrie, 8th ed. III, 1913, p. 1349.
Kretschmer E. Körperbau und Charakter: Untersuchungen zum Konstitutionsproblem und zur Lehre von den Temperamenten. Berlin: Springer. 1921.
July 23, 2020