Aretaeus On Bipolar Disorder

I remember reading The Americanization of Mental Illness four year ago when it was written and being generally impressed by its thesis. Every culture has “culture-bound syndromes” (I recently pointed out puppy pregnancy syndrome as an especially horrifying example) and with American hegemony we risk declaring that America’s forms of mental illness are “real mental illness” and everyone else’s forms are just a weird local variation. Sometimes it’s neat to learn that what you thought were laws of nature are merely your own culture’s idiosyncrasies.

On the other hand, sometimes it’s nice to learn you were actually right about everything.

Aretaeus of Cappadocia was a 1st century AD Greco-Roman physician who is notable for describing bipolar disorder almost exactly as it is described today. He says: “It appears to me that melancholy is the commencement and a part of mania” and goes on to describe symptoms of the disorder.

I have in front of me the bipolar chapter of both Aretaeus’ De causis et signis acutorum morborum and of the modern Mood Disorder Questionnaire, an instrument used for diagnosing bipolar. I’m going to go through the MDQ questions and see how many I can match to sentences in Aretaeus:

“Do you ever feel so good or hyper you are not your normal self?”

Aretaeus: “And they with whose madness joy is associated, laugh, play, dance night and day”

“…or so hyper it got you into trouble?”

Aretaeus: “They become silly, and doing dreadful and disgraceful things”

“Do you feel so irritable that you start fights or arguments?”

Aretaeus: “They are suspicious, irritable without any cause…others have madness attended with anger; and these sometimes rend their clothes and kill their keepers, and lay violent hands upon themselves. This miserable form of disease is not unattended with danger to those around.”

“Do you feel much more self-confident than usual?”

“Aretaeus: [They] sometimes go openly to the market crowned, as if victors in some contest of skill”.

“Do you get much less sleep than usual, but find that you don’t miss it?”

Aretaeus: “When [tending] to cheerfulness, they are in excellent spirits; yet they are unusually given to insomnolency”

“Do you find that you talk much more than usual?”

Aretaeus: “But the modes are infinite in those who are ingenious and docile,–untaught astronomy, spontaneous philosophy, poetry truly from the muses”

“Do you find you are much more interested in sex than usual?”

Aretaeus: “At the height of the disease they have impure dreams, and irresistible desire of venery.”

“Do you find that spending too much money gets you in trouble?”

Aretaeus: “[They can become] simple, extravagant, munificent, not from any virtue of the soul, but from the changeableness of the disease.”

…and six in the Mood Disorder Questionnaire that I couldn’t find a good analogue for in Aretaeus, but which seem to be in accordance with the spirit of his piece. So I will give Aretaeus a 7/13 or so on mania.

II.

Moving on to depression, we have the Patient Health Questionnaire-9, probably the most commonly used depression screening tool today.

“Do you feel little interest or pleasure in doing things?”

Aretaeus: “The understanding is turned…to sorrow and despondency only.”

“Trouble falling asleep, or sleeping too much”

Aretaeus: “And they also become peevish, dispirited, sleepless, and start up from a disturbed sleep.”

“Feeling tired or having little energy”

Aretaeus: “The patients are…unreasonably torpid, without any manifest cause: such is the commencement of melancholy.”

“Poor appetite, or overeating”

Aretaeus: “But if the disease go on to increase, they are voracious and greedy in taking food, for they are watchful, and watchfulness induces gluttony…But if any of the viscera get into a state of inflammation, it blunts the appetite and digestion.”

“Being so fidgety and restless that you have been moving around a lot more than usual”

Aretaeus: “Wherefore they are affected with madness in various shapes; some run along unrestrainedly, and, not knowing how, return again to the same spot.”

“Thoughts that you would be better off dead, or of hurting yourself”

Aretaeus: “If the illness become more urgent – hatred, avoidance of the haunts of men, vain lamentations; they complain of life, and desire to die.”

I’m giving him 6/10 on the depression side.

III.

So on mania and depression combined, Aretaeus gets 13/23 of the same criteria we use today, which is not bad at all.

I admit that some of the analogies are a little forced, but I think any knowledgeable person reading Aretaeus’ book would have to admit he is generally on the ball with his description of bipolar, not only in gestalt but also in many of the individual symptoms.

His theories of pathogenesis and treatment are, of course, totally off-base. I think he thinks they’re caused by warm or cold or dry or wet weather and imbalances in the four humors? But that goes with the territory.

What impresses me is that people with bipolar disorder in ancient Rome seem to have behaved a lot like people with bipolar disorder today.

And that seems like pretty solid evidence that this disorder, at least, is firmly biologically grounded and not culture-bound.

(which we already knew. Bipolar is very heritable and seems to occur about equally in all nations and cultures. But it’s nice to have confirmation.)