Theories of the Forms

(In my last post, I promised to share bits of the writing I've been doing about madness, and have largely failed to live up to that promise. But here's a short version of what will eventually be a far longer essay. Or, a first draft of a short version, of same. There are probably typos and errors and I apologize).


In 1854, at a conference of the Académie de Médecine in Paris, a scuffle broke out between two eminent psychiatrists over the proper name of a new illness. It began with Jules Baillarger, already famous for his innovations in the treatment of depression, rising before the assembly to read his latest paper. He had identified a new madness, he announced. Despite similarities, this disease was not merely a variant of the depressive personality, but a separate and far more severe condition. He called it folie á double forme. The double-form insanity.

The trouble began when Baillarger described the symptoms. Patients of the double-form would experience intense periods of depression, often accompanied by suicidal ideation, he said. But at other times they would take on the character of the lunatic. They would become grandiose, delusional, and violent. Some even suffered paranoid hallucinations. One member of the audience began to feel a little paranoid himself. Jean-Pierre Falret had presented his own paper the year before on precisely the same condition. Baillarger was stealing “his” illness, the circular insanity, folie circulaire.

Both psychiatrists ultimately confessed that the condition they were describing was already well-documented by the time of the conference. But both maintained they had achieved new insight into its causes and consequences. Baillarger maintained that his double-form insanity emerged from an irresolvable conflict between “chained” traumas in the patient’s mind. Falret insisted that the circular insanity presented in unrelated episodes and that each must be treated independently. Baillarger wrote that his illness was incurable, but could be managed. In 1864, Falret published the results of a multiyear study: in fact, the disease resulted, inevitably, in dementia and death. (It is believed now that a number of his patients in fact suffered from neurosyphilis.) The two men were “not without a little vainglory,” wrote one contemporary, and the conflict, at bottom, appeared to be over the naming rights. A double form, or a single circle? Legacies depended on such distinctions.

The true father of this illness didn’t give it a name. But during the reign of Nero, Aretaeus of Cappadocia wrote of patients who were “unreasonably torpid, without any manifest cause”, prone to sorrow and self-doubt, who the next day were in “excellent spirits”, speaking “untaught astronomy, spontaneous philosophy, and poetry truly from the muses.”  They sometimes go openly to the market crowned, as if victors in some contest of skill, wrote Aretaeus. But this was the sign of danger. Soon after, he said, they are suspicious and irritable. They “rend their clothes and kill their keepers and lay violent hands upon themselves.” The disease, he said, is “not unattended with danger to those around.” Wherefore they are affected with madness in various shapes, he says, some run along unrestrainedly and, not knowing how, return again to the same spot. Return again to sorrow, then joy, then suspicion and delusion and rage.

Emil Kraepelin called it manisch-depressives Irresein. The manic depressive psychosis. He distinguished it from démence précoce—schizophrenia—only in that this disease appeared to be episodic. This distinction would stand until the 21st century, when genetic research established that these two diseases were not so different as Kraepelin believed.

Diagnostic and Statistical Manual of Mental Disorders, first edition, 1952, called it “manic-depressive illness.” They later shortened this to “manic-depression.” In 1980, editors of the third edition renamed the illness “bipolar disorder”, on the recommendation of reformers who believed this name to be less stigmatizing. Now we distinguish between forms: bipolar type one. Like schizophrenia in bursts. Bipolar type two: More common, less severe except for suicides, with “hypomanic” episodes distinguished from pure mania. Bipolar type 3 or cyclothymia. Moodiness. At some point you must wonder what we’ve chosen to pathologize.

Now each type comes with a grab bag of accessories. Bipolar with or without psychotic features. Bipolar of pure mania or hypomania or dysphoric episodes, called “mixed,” and considered the most dangerous kind. Slow cycling. Constant cycling. Intermittent cycling. Rapid cycling. Schizoaffective disorder, bipolar type. From the double-form madness we derived madness in limitless forms, diagnoses built up from appended limbs, more heft than weight, the kind that may take a full line in a spiral notebook to write out no matter how small you make the letters (I’ve tried it), a diagnosis like: schizoaffective disorder of the bipolar type, rapid-cycling, with mixed episodes and associated psychosis. That’s a proper name. That’s what you call it.

That’s the diagnosis I had on file when I checked myself into an emergency room in Chicago, unable to decide whether I wanted to pace or weep or scream or dispense with the endless fastidious medication regimen entirely and return to clarity of my delusions somewhere in the wilderness. When I was discharged, over twenty-four hours later and sedated into the cold of New Year’s Eve’s Day, the release paperwork listed the reason for my visit. Mood problem. That too is as good a name as any for what’s wrong.