History of Psychiatry

http://hpy.sagepub.com Cyclothymia, a Circular Mood Disorder

Ewald Hecker History of Psychiatry 2003; 14; 377 DOI: 10.1177/0957154X030143007 The online version of this article can be found at: http://hpy.sagepub.com/cgi/content/abstract/14/3/377

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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* by
CHRISTOPHER BAETHGE,a,b PAOLA SALVATORE b,c and ROSS J. BALDESSARINI b
*

Ewald Hecker (18431909) was a collaborator of Karl Ludwig Kahlbaum (18281899). Both worked outside the university and public mental institutions of Germany. By meticulously observing clinical signs and illness-course, they laid the groundwork for modern descriptive psychiatry. Their clinical approach inuenced Kraepelin and continues to dominate psychiatric classication. Hecker popularized several of Kahlbaums syndromal concepts, including hebephrenia. Another was cyclothymia, a relatively benign form of manicdepressive 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 bipolar II disorder and cyclothymia. An annotated English translation of Heckers 1898 paper is provided, with historical notes on Hecker and the signicance of his work. Keywords: cyclothymia; Hecker; history of psychiatry; Kahlbaum; psychopathology

* Work on both the introduction and the translation were supported by the Max Kade Foundation, New York, NY, USA (Dr Baethge), by the Bruce J. Anderson Foundation, and the McLean Private Donors Neuropsychopharmacolgy and Bipolar Disorder Research Fund, Belmont, MA, USA (Dr Baldessarini). Address for correspondence: Ross J. Baldessarini, M.D., Mailman Research Center, Harvard Medical School, McLean Hospital, 115 Mill St, Belmont, MA 024781906, USA. E-mail: rjb@mclean.org

Department of Psychiatry and Psychotherapy, Freie Universitt Berlin, Berlin, Germany. Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, Bipolar & Psychotic Disorders Program and International Consortium for Bipolar Disorder Research, McLean Division of Massachusetts General Hospital, Belmont, MA, USA. c Institute of Clinical Psychiatry, University of Parma, Parma, Italy.

a b

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In 1898 Ewald Hecker (18431909), who is known for his work on hebephrenia (Hecker, 1871b; Sedler, 1985), published a paper on cyclothymia. This 1898 report contained a detailed clinical description of a nosologic entity rst described by Karl Ludwig Kahlbaum (18281899) in 1882.1 Heckers paper on cyclothymia was recognized as a seminal contribution in Theodor Ziehens (1862 1950) textbook and by the American psychiatrist, Smith Ely Jelliffe (Jelliffe, 1909; Ziehen, 1902). Karl Jaspers in his landmark book Allgemeine Psychopathologie refers to Heckers work on cyclothymia as a fundamental contribution, similar to his earlier paper on hebephrenia (Jaspers, 1946). Both syndromes (hebephrenia and cyclothymia) were initially described EWALD HECKER by Kahlbaum and later elaborated by (from Wilmanns (1924), with permission from his junior colleague and collaborator Springer Verlag) Hecker. Their combined work prepared the ground for Kraepelins revolutionary psychiatric classication scheme (Berrios and Hauser, 1988). In particular, the Kahlbaum-Hecker concept of cyclothymia, characterized by recurrent episodes of depression or dysthymia and periods of hypomania or hyperthymia, was an inuential antecedent of Kraepelins manic-depressive insanity (Baethge, Salvatore and Baldessarini, 2003). Kraepelins separation of manic-depressive illness and dementia prcox in the late 1890s (Kraepelin, 1899) represents a major conceptual step in the history of psychiatric thinking, with its fundamental division of disorders marked primarily by dysfunctioning of mood or of reason. Kraepelins manicdepressive illnesses combined most cases of recurrent, severe, episodic melancholic depression, many bipolar (manic-depressive) and mixed states, and uncommon cases of recurrent mania (Kraepelin, 1899). However, by the mid-twentieth century, European psychopathologists distinguished a bipolar manic-depressive subgroup from those with recurrent, unipolar depressive illness (Angst, 1966; Perris, 1966). Current standard international diagnostic systems (ICD-10 and DSM-IV) further distinguish bipolar types I and II (depression with hypomania) as well as cyclothymia marked by life-long mood instability (APA, 1994; WHO, 1992). Diagnostic renement of bipolar disorders continues to be a lively topic of

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research and discussion, encouraged by modern descriptive, epidemiological, genetic and other biological studies, as well as the ongoing quest for improved treatments for all major affective disorders (Akiskal and Pinto, 1999; Atre-Vaidya and Hussain, 1999; Baldessarini, 2000; Howland and Thase, 1993; McElroy et al., 1992; Merikangas et al., 1996; Taylor, 1992). Kahlbaums and Heckers publications on cyclothymia mark early contributions in this continuing tradition of scientic discussions on bipolar disorders. Because of the historical importance of the cyclothymia syndrome of Kahlbaum and Hecker, and its relevance to current research on bipolar disorder subtypes, we provide here an annotated English translation of Heckers report on cyclothymia of 1898, together with comments on Heckers biography, his psychiatric contributions, and on the scientic signicance of this study.2 Biographical sketch Information about Heckers life is scarce. Available sources of information include his writings, an obituary by Proebsting (1909) and a chapter about Hecker by Karl Wilmanns in a book about important German alienists.3 Ewald Hecker was born in Halle an der Saale in Prussia on 20 October 1843. His father was an architect. The family moved to Knigsberg in East Prussia, on the Baltic sea (now Kaliningrad in Russia). In this university city he completed his secondary education and began university studies in architecture in 1961, but soon decided to pursue a medical degree. He completed medical studies at the University of Knigsberg in 1866 with a doctoral dissertation on tuberculosis (Hecker, 1866). Later that year he moved to nearby Allenberg in East Prussia to work at the local public psychiatric hospital, where Karl Ludwig Kahlbaum worked as a staff psychiatrist during his brief time in the teaching and clinical faculty at the University 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 dissatised with the conservative Prussian politics of the 1860s under the leadership of Otto von Bismarck, as well as a conservative head of staff at the Allenberg Psychiatric Hospital (Neisser, 1924; Wilmanns, 1924). In 1866 Kahlbaum moved to the town of Grlitz, also in East Prussia, near the present Polish border, to work at the Reimer Sanatorium, a private psychiatric hospital which 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 together until 1876. In 1868 Kahlbaum married Heckers cousin, and in 1871 Hecker married Henriette Leonhard (18461900), a friend of this cousin. They had two daughters, Else and Helene, and one son, Waldemar. Hecker wrote about that period (in his obituary of Kahlbaum): I have

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experienced ten perfect years of working together, in mutual struggles and worries with him [Kahlbaum]. Our relations became truly brotherly when Kahlbaum married a cousin of mine in 1868. (Hecker, 1899; translation by the authors) Undoubtedly, the years in Grlitz were of decisive importance for Heckers professional development. Kahlbaum had opposed the theory of unitary psychosis and had published a new classication of psychiatric disorders in 1863. Moreover, he was the leading proponent of the then-revolutionary clinical method with its emphasis on meticulous cross-sectional, descriptive psychopathology and close longitudinal observation of illness-course as fundamentals in the diagnostic process. At the time of Kahlbaum and Hecker, both descriptive psychopathology and long-term observation were new concepts in psychiatry. This innovative approach attracted many talented young psychiatrists to Kahlbaum. In addition to Hecker, several important gures in German psychiatry of the late nineteenth century worked with Kahlbaum at Grlitz, including Hallervorden, Ziehen, and Cassierer (Neisser, 1924). Janzarik wrote about German academic psychiatry at the end of the nineteenth century and considered Kahlbaums position as an academic outsider at a remote provincial hospital:
[. . .] the further development of psychiatry was determined by the clinical method of the outsider whose arguments werent backed by an academic position and who considered himself just like Kraepelin later on as a pure clinician. It was not properly recognized at that time, but the period between 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 statement that his predecessor, Riemann, made about his reasons to hand over leadership of his clinic to Kahlbaum: I nally found the right purchaser; he gets up at four oclock in the morning to start his work and he prepares his coffee himself. He shall have my clinic! (Hecker, 1899: 127; translation by the authors) However, this style might not have been attractive to everyone. In the early 1880s Kahlbaum had offered Kraepelin, who was 28 years younger, a position at his clinic. Kraepelin rejected the offer for reasons that are uncertain. However, he reports in his autobiography that his fatherly friend, the University of Leipzig psychologist Wilhelm Wundt (18321922), strongly advised against Grlitz, by rhetorically asking why Kraepelin would want to join this personal slavery (Hoff, 1994). Heckers personality was quite different from Kahlbaums. In his obituary of Kahlbaum, Hecker describes him as stern and unapproachable at times, but adds that he had a winning manner in close personal contact (Hecker, 1899). Hecker was Kahlbaums representative in the Grlitz clinic. When the director took a years leave to

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pursue studies of neuroanatomy and neuropathology at the Universities of Vienna and Prague in 18751876, Hecker led the clinic (Wilmanns, 1924). In 1876 Hecker was offered the medical directorship of a psychiatric sanatorium in Plagwitz in Silesia. He remained there for ve years, bringing many reforms to the organization and clinical operations of the institution. In 1881 he purchased his own sanatorium on the Rhine in Johannisberg, where he could promote his own ideas about psychiatric care. In 1891 he moved again, to Wiesbaden near Frankfurt am Main to develop a new sanatorium. Here, he lived with his patients in a spacious mansion for nearly two decades until 1908, shortly before his death.4 Heckers wife died in 1900, and he survived until 11 January 1909, dying at the age of 65 from pneumonia following a series of strokes.5 Hecker is described as a kind, warm, modest and socially conscious person whose interests were not limited to psychiatry. Wilmanns writes that Hecker was very unassuming and sacriced himself to his patients. Hecker also took child-like joy in inventions. For example, he designed a matchbox that provided one match at a time, and a container that issued one calling card at a time. Although he rarely travelled or took vacations, he once went to Switzerland with his patients, using a travelling bag with many compartments of his own design (Wilmanns, 1924). Heckers psychiatric career and contributions Hecker is known for his inuential report on hebephrenia (Hecker, 1871b) a disorganized form of chronic idiopathic psychotic illness often arising in youth. This disorder was rst recognized by Kahlbaum among paediatric patients at Grlitz and reported as early as 1863 (Kahlbaum, 1863). The concept was later incorporated into Kraepelins dementia praecox and Bleulers schizophrenia (Bleuler, 1911; Kraepelin, 1899). In addition to his work on hebephrenia, Hecker rened and promoted several other concepts of Kahlbaum. In order to qualify for his academic appointment at the University of Knigsberg in 1863, Kahlbaum prepared a monograph on a revolutionary psychiatric classication system (Berrios, 1996; Brunig and Krger 2000; Kahlbaum, 1863). Referring to this classic monograph, Hecker wrote about Kahlbaums clinical method of descriptive psychopathology, based on direct observation of many carefully described cases followed over time, as a basis for proposing novel diagnostic categories of psychiatric illnesses (Hecker, 1871a; 1877). Kraepelin was inuenced by this work and later wrote that, in preparing his classication scheme and his concept of manic-depressive disorder, he was indebted to Kahlbaum and to Hecker (Kraepelin, 1918). The clinical method continues as a foundation of modern international psychiatric nosology that is the basis of both ICD-10 and DSM-IV (Berrios and Hauser, 1988). Heckers 1898 report on cyclothymia translated below was published one

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year before Kahlbaums death and was his last report based on Kahlbaums ideas. In his obituary of Kahlbaum, Hecker stated that he would have liked to elaborate more of his inuential colleagues ideas, but that Kahlbaum often made this difcult by planning to write more himself than he was able to do. Wilmanns, Heckers biographer, suggests that Kahlbaums lack of generosity [Engherzigkeit] contributed to the paucity of publications by Hecker based on Kahlbaums ideas (Wilmanns, 1924). Kahlbaum indeed wrote little and would probably be even less well known today were it not for Heckers elaboration of several of his innovative concepts. Heckers elaborations and renements of Kahlbaums ideas represent only a small proportion of about 30 scientic works that he published between 1866 and 1900. His output peaked at Grlitz, with four articles in 1871. Many of Heckers papers developed from his lectures. They covered a wide range of interests, including forensic topics, the organization and administration of psychiatric hospitals, treatment of sleep disturbances, and even more esoteric subjects such as the nature of laughter (Hecker, 1868, 1873, 1887, 1897, 1900). Interestingly, during his own lifetime, two of Heckers publications were translated into English. One was on Sleep and dreams (1871c); the other, in 1885, was entitled The causes and rst symptoms of mental disease (Kreuter, 1996). In later years, when Heckers private clinics in Johannisberg and Wiesbaden were visited mainly by patients with non-psychotic ailments, he became more interested in neuroses. Between 1892 and 1894 he published three papers on the diagnosis and treatment of anxiety and neurasthenia. These reports received considerable attention during Heckers lifetime, indicating that he was not merely an expositor of Kahlbaums ideas. In 1895 Sigmund Freud wrote in one of his early papers on the anxiety neurosis:
I call this syndrome anxiety neurosis, because all its components can be grouped round the chief symptom of anxiety, because each one of them has a denite relationship to anxiety. I thought that this view of the symptoms of anxiety neurosis had originated with me, until an interesting paper by E. Hecker (1893) came into my hands, in which I found the same interpretation expounded with all the clarity and completeness that could be desired. Nevertheless, although Hecker recognizes certain symptoms as equivalents or rudiments of an anxiety attack, he does not separate them from the domain of neurasthenia, as I propose to do. (Freud, 1962)

Heckers remarkably modern views of psychiatric disorders were sometimes not accepted by contemporary academic psychiatrists. In addition, he was a very progressive clinician for his time. For example, perhaps even more than Kahlbaum, he was dedicated to minimizing the use of coercive measures. In Allenberg, Hecker tried to eliminate the use of the strait-jacket and other forms of physical restraints, but succeeded only when the clinic director was

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away on a prolonged medical leave of absence. Kahlbaum and Hecker successfully modernized the sanatorium in Grlitz, including minimal use of physical restraints, as Hecker later did at his own hospital in Plagwitz, often despite the reluctance of his staff. In addition, Hecker introduced worktherapy, greatly improved the physical environment at Plagwitz, and made available concerts, plays and other social events. Hecker even employed patients in his household (Wilmanns, 1924). Hecker was a dedicated therapist who employed hypnosis and psychotherapy in his treatment, in keeping with his shifting clinical interest from psychotic illnesses to anxiety, neurasthenia, hysteria and cyclothymia. Although Hecker had a medical view of mental illness, his clinical approach to the mentally ill shared many characteristics of milieu therapy and of the moral treatment movement that had emerged throughout Europe and America in the early nineteenth century (Shorter, 1997); his psychologically-based treatment of ambulatory and less severely ill patients anticipated the psychotherapy movement emerging in the early twentieth century with the Austrian, Swiss and German psychoanalytic movement. Hecker remained a practising clinical psychiatrist throughout his professional career. However, in 1907, at the age of 64, the Prussian government awarded him the honoric title of Professor, even though he had never held a university post. Heckers career path, based on life-long practice within small, private mental hospitals, was very similar to that of Kahlbaum. This career path may well have limited the inuence of both men on the training of psychiatrists of their time and this may explain why, during the past hundred years, academic psychiatrists have tended to ignore them or fail to appreciate their work. It is also noteworthy that many of the clinical as well as conceptual ideas held by both Hecker and Kahlbaum also seem to have been ignored by their own contemporaries in university clinics and public mental institutions. According to Proebsting and Wilmanns, there was a proposal to offer Hecker an academic chair of psychiatry at a Prussian university, but Chancellor Otto von Bismarcks Secretary of Education, Robert Victor von Puttkammer (18281900), blocked the proposal, presumably on political grounds. Hecker, whose liberal uncle had been convicted for high treason, had attracted Puttkammers attention by vigorously supporting a liberal political party (Freisinnige Partei) that opposed the conservative and nationalistic policies of Bismarcks government (Proebsting, 1909; Wilmanns, 1924). Though plausible, this account of Heckers lack of a senior university position should be viewed with caution, since the evidence on which it is based is circumstantial. It appears possible, too, that Kahlbaums and Heckers opposition to the ruling theory of unitary psychosis [Einheitspsychose] may have contributed to their disfavour by more theoretical academic psychiatrists of their era. During Heckers early career, academic psychiatry in Germany was in its

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earliest years. The chair taken by Wilhelm Griesinger (181768) at the University of Berlin in 1865 was the rst regular psychiatric professorship in Germany (Janzarik, 1979). At that time, when the leading clinical concept was Neumanns and Griesingers unitary psychosis [Einheitspsychose], German academic psychiatry was a stronghold of the application of neuropathology. This approach was aimed at localizing psychiatric disorders as brain disorders rather than at developing descriptive psychopathology and other more clinical approaches.6 Kraepelin, who was considerably younger than both Kahlbaum and Hecker and also considered himself a clinician rather than a neuroscientist, adopted the clinical method of Kahlbaum and Hecker and brought it to the attention of academic psychiatry. Nevertheless, it is interesting to note that what turned out to dominate nosology and clinical practice in the next century was developed outside university psychiatry by psychiatrists like Hecker and Kahlbaum. Heckers article, Cyclothymia, a circular mood disorder Heckers 10-page paper of 1898 contains a lively description of the clinical features of cyclothymia, and therefore makes it easy for the reader to imagine such patients.7 This descriptive presentation contrasts strikingly with Kahlbaums 1882 lecture and paper on cyclothymia. Kahlbaums was a theoretical contribution aimed not only at presenting cyclothymia as a new nosological concept, but perhaps even more at challenging the ruling theory of mental unity [unity of the soul]. Kahlbaum provided a sophisticated account of basic psychopathological issues at that time, but with very little information about the clinical characteristics of cyclothymia (Baethge et al., 2003; Kahlbaum, 1882). Moreover, Kahlbaums report is perhaps excessively scholarly and employs a complex style that is hard to follow. For this reason, Heckers contribution lled a gap in the presentation of the cyclothymia concept as a novel clinical entity.8 Typically for his time, Hecker did not present numbers or statistics. He did not apply any psychometric measurements and rating scales. Instead, the paper is an example of meticulous psychopathological observation, careful clinical judgement, and consideration of current literature. At the beginning of his report, Hecker refers to Kahlbaum as the originator of the cyclothymia concept as one of several novel syndromes within Kahlbaums classication system of 1863, as well as bearing similarities to the cyclothymia and periodic depression later described by Kraepelin and the Danish author Carl Georg Lange (see the translation, and Translators Note 2). Hecker pictured cyclothymia as a nosological entity characterized by periodic mood swings between moderate exaltation and dysthymic depression. These states do not usually lead to psychiatric hospitalization, although the suicidality associated with dysthymia might require protective interventions including hospitalization. Hecker emphasizes that core features of dysthymia

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are inhibition, hopelessness and nonspecific somatic complaints, and particularly 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 feel and may be more capable and skilful in different ways, and may squander money or become boisterous or hypersexual. Interestingly, in the hyperthymic phase the irritability and querulousness may remain. Table 1 provides a summary of the major symptoms of cyclothymia described by Hecker. Hecker states that the course of cyclothymia is unpredictable, with different patterns of duration and periodicity, including what today might be regarded as mixed states and rapid cycling. However, he stresses the generally good long-term prognosis, in contrast to other more severe and pervasive psychiatric disorders, such as general paralysis of the insane or Kahlbaums vesania typica circularis (a more severe, manic-depressive-like, disorder that would include todays severe bipolar disorder of poor outcome, schizoaffective disorder, and other forms of episodic psychotic illness). Hecker then differentiates cyclothymia from other psychiatric disorders, including melancholia, general paresis, hysteria, and neurasthenia. He ends up with the advice not to treat the dysthymic phase of the disorder aggressively, and recommends opium as well as hypnosis for dysthymia and tepid baths for both dysthymic and hyperthymic states. In many points, the cyclothymia of the Grlitz School is closer to todays concept of bipolar II disorder (recurring major depression with hypomania) rather than to the less well-dened modern concept of cyclothymia (Brieger and Marneros, 1997). Moreover, Hecker says that, despite a lack of delusions and other psychotic features, the symptoms of cyclothymia sometimes exceed hypomanic levels and lead to functional impairment. Therefore, some of his cyclothymia patients might be diagnosed today with bipolar I disorder. Although historic diagnostic concepts such as that presented here are precedents of the current standard international classication systems and are basically their roots it is important to note that it is somewhat articial to force Kahlbaums and Heckers cyclothymia into current diagnoses. Instead, differences in classication systems point to the fact that diagnostic concepts are cultural phenomena that may change over time. At the level of symptomatology, however, it is interesting to see that various aspects of Heckers cyclothymia are pertinent to several psychopathological phenomena that remain lively topics of study today. These include subsyndromal mood disorders, dysphoric mania and mixed affective states, hypersomnia during depression, rapid cycling, and even the harmful potential of antidepressant treatment of bipolar patients. For example, mixed manic-depressive (dysthymic-hyperthymic) states are not included in bipolar II syndrome according to DSM-IV, but are considered possible and even characteristic across the spectrum of bipolar disorders, as Hecker, Weygandt and Kraepelin,

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TABLE 1.

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Features of cyclothymia reported by Hecker

Dysthymic phase Psychic inhibition, loss of interest, reduced communication or work General weakness and anergy Dulling of thoughts, inner numbness Sadness, hopelessness, weariness Suicidal thoughts and actions Facial inexpressiveness Social withdrawal, indifference Ambivalence Anxiety Intense feeling of being unwell Somatic complaints Tense feeling in chest and head, headaches Weight loss Increased sleep Critical or querulous tendency Exaggerated guilt, some false beliefs* No delusional ideas or misperceptions Hyperthymic phase Elevated mood, irrepressible cheerfulness* Accelerated thinking and responsiveness to stimuli Restless activity Animated expressiveness Exaggerated self-condence, grandiosity, arrogance* Increased creativity, improved capabilities Tendency to criticize, irritability Pseudorationality (folie raisonnante or madness with reason)* Eroticized relations with strangers Irritability Urge to spend money Unusual behaviour, out-of-character Boisterousness, joking, tricks Reduced self-control, impulsivity Tendency to lie, drink, and antisocial behaviour Reduced need for sleep Course of illness Usually 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 years Daily uctuations of mood and behaviour within episodes Mixing of excited and depressive features Lack of progressive worsening to a defect state* Need for hospitalization rare Behaviour changes arise from altered mood * Features also (or only) noted by Kahlbaum.

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as well as some modern authors, suggest (APA, 1994; Dilsaver, Chen, Shoaib and Swann, 1999; Salvatore et al., 2002). Heckers description of somatic symptoms, hypersomnia, and psychomotor inhibition in the dysthymic phase of cyclothymia and his explicit differentiation of the dysthymic phase of cyclothymia from genuine melancholia point to current discussions about bipolar depression. Akiskal and his collaborators have found anergy, hypersomnia and somatization to be symptoms of depression in a group of patients suffering from bipolar II and an even broader spectrum of bipolar-like illnesses (Akiskal et al., 1985; Akiskal et al., 2000). They also found a high frequency of antisocal acts and substance abuse by such patients. Moreover, in the rst contemporary study that dened bipolar II disorder, Dunner and colleagues reported substantial suicidality among such patients (Dunner, Gershon and Goodwin, 1976). All these signs and symptoms had been reported by Hecker in cyclothymia. On the other hand, Hecker appears to have been a victim of the spirit of his times (Shorter, 1997, 3142) in declaring that cyclothymic patients had presumably genetically-determined dyssocial tendencies [sittlicher Defect]. Hecker may correctly have recognized a heightened familial risk for affective disorders and antisocial behaviour among cyclothymic patients, but he provided no data to suggest whether substance abuse, marital problems or criminal behavior were present in excess in such families.
ENDNOTES 1. See Kahlbaum (1882). For a detailed introduction and an annotated English translation of Kahlbaums classic text, see Baethge et al. (2003). 2. An unannotated English translation of Heckers paper on cyclothymia, along with a brief introduction (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), English translation 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 at No. 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 notice published by the Hecker family in the same issue of the newspaper. Hecker was buried on 14 January at the old cemetery in Wiesbaden, in a tomb with his wife. The tombstone had been prepared 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 to contribute to academic discussions. The journal Allgemeine Zeitschrift fr Psychiatrie, published from 1844 to 1949, was a forum for clinicians, whereas Griesinger as the leading gure of neuropathology-based psychiatry founded Archiv fr Psychiatrie und Nervenkrankheiten in 1868; this was published until 1983 (Janzarik, 1979). Hecker generally published in clinically oriented journals (among others, three times in the Allgemeine Zeitschrift fr Psychiatrie). However, he also published one paper in Archiv fr Psychiatrie und Nervenkrankheiten. 7. Heckers paper appeared in Zeitschrift fr praktische Aerzte. This journal, published in Frankfurt am Main, was aimed at general practitioners; it had various titles, and this one was used from 1896 to 1900.

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

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