Journal of Affective Disorders 45 (1997) 117–126

Invited Review

Dysthymia and cyclothymia: historical origins and contemporary

development

Peter Brieger*, Andreas Marneros

Psychiatric Hospital, Martin Luther University, Halle-Wittenberg, Germany

Received 25 October 1996; received in revised form 26 March 1997; accepted 26 March 1997

Abstract

The aim of this article is to review and put in their historical context today’s data, methodologies and concepts concerning
subaffective disorders. The historic roots of dysthymic and cyclothymic disorders — part of the subaffective spectrum — are
essentially Greek, but the first use of the word ‘dysthymia’ in psychiatry was by C.F. Flemming in 1844. E. Hecker
introduced the term ‘cyclothymia’ in 1877. K.L. Kahlbaum (1882) further developed the concepts of hyperthymia,
cyclothymia and dysthymia — with possible subthreshold symptomatology — in 1882. After Kraepelin’s rubric of
‘manic-depressive insanity’, the term ‘dysthymia’ was widely forgotten, and ‘cyclothymia’ became ill defined. Nowadays the
latter term is used in three, partially contradictory, senses: (1) a synonym for bipolar disorder (K. Schneider), (2) a
temperament (E. Kretschmer) and (3) a subaffective disorder (DSM-IV, ICD-10). A renaissance of subaffective disorders
began with the development of DSM-III. Therapeutically important research has focused on dysthymic disorder and its
relationship to major depressive disorder, while cyclothymic disorder is relatively neglected; nonetheless, operationalized as
a subaffective dimension or temperament, cyclothymia appears to be a likely precursor or ingredient of the construct of
bipolar II disorder.  1997 Elsevier Science B.V.

Keywords: Dysthymic disorder; Cyclothymic disorder; Temperament; History of psychiatry; Review article

1. Introduction atry has known such disorders under different names

With the advent of DSM-III (1980), the constructs
of ‘dysthymic disorder’ and ‘cyclothymic disorder’
have received growing attention. Both diagnoses are
now included in DSM-IV (1994) and ICD-10 (1992)
and constitute a part of what contemporary authors
call ‘subaffective disorders’ (Akiskal, 1981). Psychi-
*Corresponding author. Tel.: 1 49 (0)345-557 3681; fax: 1 49
(0)345-557 3500; e-mail: peter.brieger@medizin.uni-halle.de.
for a much longer period. Knowledge of these
historical roots is essential to better appreciate why
today’s concepts and questions — whether
dysthymia is better accounted for as a personality
disorder or an affective disorder — have such great
impact clinically and scientifically. Transatlantic
debates have taken place, particularly about
dysthymia (see, for instance, Burton and Akiskal,
1990), without an in-depth consideration of the
origins of these concepts. Therefore we would like to

0165-0327 / 97 / $17.00  1997 Elsevier Science B.V. All rights reserved.

PII S0165-0327( 97 )00053-0
118 P. Brieger, A. Marneros / Journal of Affective Disorders 45 (1997) 117 – 126
review the historical developments of cyclothymia
and dysthymia.
The methodology for such historical reviews in
psychiatry has rarely been addressed. German Ber-
rios (1996) explains how the history of psycho-
pathology can be seen from at least three different
viewpoints. For our topic this would mean asking
firstly, how the terms ‘cyclothymia’ and ‘dysthymia’
have been used in the past (historical and compara-
tive etymology); secondly, how behaviour and symp-
toms have changed over the years (behavioural
palaeontology); and finally, how the underlying
concepts have changed in this time (conceptual
history). In the present review, we will stress
etymological and conceptual development.
2. Before the 19th century
The melancholic temperament has been of great
importance in human sciences from before Hippoc-
rates and Aristotle to Walter Benjamin and beyond
(Jackson, 1986). The humoral theory saw black bile
as the cause of melancholia. The famous, frequently
quoted text that begins with the question: Why are
all extraordinary men ‘melancholics’? has been
attributed to Aristotle (Tellenbach, 1983; Klibansky
et al., 1964). Robert Burton’s Anatomy of Melancho-
¨
ly and Albrecht Durer’s famous etching Melencolia I
are fine examples of how baroque and renaissance
artists saw melancholia and the melancholic tempera-
ment not, or not only, as an illness, but also as a
disposition for certain positive abilities, e.g. for a
‘clearer mind’. The Greek word ‘dysthymia’ literally
means ‘being of bad mood’ and is still in use in
modern Greek today with exactly the same meaning.
Hippocrates (460–377 BC) stated that melancholia
consists of phobia and dysthymia (Leibbrand and
Wettley, 1961). It is beyond the scope of this article
to delve further into the question of how melancholy
and mood disorders were understood before the 19th
century (Klibansky et al., 1964; Jackson, 1986;
Berrios, 1996), but obviously temperamental forms
of depression were well known, although one has to
be very cautious in comparing the Greek, Renaiss-
ance, 19th century and modern usages of such terms
as ‘melancholia’, ‘dysthymia’ and ‘mania’. One of
the first authors to briefly describe ‘cyclothymic’
mood changes was William Cullen (1710–1790),
who wrote in his First Lines of Practice of Physic
(1786) ‘‘that the same state of the brain may in
moderate degree give melancholy; in a higher, that
of mania which melancholia so often passes into’’
(quoted by Jackson, 1986). A few years later Es-
quirol was one of the first psychiatrist to recognize
affective illness as a distinct mental disorder, which
he called ‘lypemanie’ (Esquirol, 1820).
3. The early 19th century: first use of
‘dysthymia’ in psychiatry
Carl Friedrich Flemming (1799–1880), who knew
Esquirol’s ideas well, was the first psychiatrist to
speak of ‘dysthymia’, although a German pathologist
named Stark (1838) had used the term before him to
separate disorders of mood from those of the will
(dysbulias) and intellect (dysnoesias). Flemming
(1844) exemplifies very well the changes psychiatry
went through in the mid-19th century. He never held
an academic position. At 24 years of age he was
appointed director of an asylum which he first had to
plan and build, which he then went on to do in a
modern manner. At the age of 55 years Flemming
retired — the reasons are not clear, but might have
had to do with some sort of disappointment with
growing conservatism. Flemming founded the first
successful psychiatric journal in German, the Al-
lgemeine Zeitschrift fur ¨ Psychiatrie. Influenced by
‘faculty psychology’, he first distinguished between
‘anoesia’ (disorders of intellect), ‘dysthymia’ (dis-
orders of mood) and ‘mania’ (disorder of both
intellect and mood), and described different clinical
subforms of dysthymia, including ‘bright’ and
‘cheerful’ ones, as well as ‘dark’ and ‘gloomy’
forms. In general Flemming saw his diagnosis of
dysthymia in the tradition of Esquirol’s concept of
‘lypemanie’. Interestingly, he renounced his diagnos-
tic system some 15 years later (Flemming, 1859) and
criticized all attempts to create such systems for lack
of scientific proof. Subsequently, he (Flemming,
1876) reintroduced four diagnoses as sufficiently
confirmed by clinical research. Following Kahlbaum,
two of them were ‘katatonia’ and ‘hebephrenia’,
while the other two are derived from French psychi-
 P. Brieger, A. Marneros / Journal of Affective Disorders 45 (1997) 117 – 126
atry: ‘paralytic megalomania’ and a form of circular
insanity, which Flemming translated into German as
‘Zirkel–Wahnsinn’, and where he obviously referred
to the work of Falret (1851) and Baillarger (1854)
without mentioning them by name.
Flemming’s changes from a theory-based diagnos-
tic system to the rejection of all theory and then to a
system based on clinical observation were strongly
influenced by the writings of Kahlbaum (1863). This
psychiatrist, who spent most of his life as director of
a private hospital and worked only for three years at
a university, published a fundamental book on
psychiatric classification in 1863. He reviewed ear-
lier systems of classification extensively, and came
to the conclusion that they were based merely on
theory and did not sufficiently consider clinical
observation and course; he therefore questioned their
value. Being an excellent observer and clinician,
Kahlbaum distinguished between total and partial
disorders of the soul. The total disorders he com-
pared to Griesinger’s and Neumann’s concept of
‘unitary psychosis’. One subform he called ‘varietas
circularis’, in line with Falret’s and Baillarger’s
concepts of circular insanity, while his partial dis-
orders of the soul resembled the French concept of
‘monomanie’. Like Stark, the latter disorders he
subdivided into disorders of mood (dysthymia),
disorders of intelligence (paranoia) and disorders of
the will (diastrephia). For reasons that are not
entirely clear (Katzenstein, 1963), Kahlbaum’s writ-
ings were initially little appreciated and did not have
a substantial influence on psychiatry until the turn of
the century.
To recapitulate, three important developments
took place around the mid 19th century:
• Flemming was one of the first psychiatrists to
make a distinction between affective disorders,
which he termed ‘dysthymias’, and nonaffective
disorders.
• Kahlbaum showed the limited value of theory-
based systems of classification and proposed the
classification of mental diseases according to
clinical observation and course.
• Baillarger and Falret described Folie a` Double
Forme and Folie Circulaire, the cyclical forms of
insanity. The two had a rather emotional argu-
ment, recently summarized in masterly fashion by
119
Pichot (1995), about which of them had truly
been the first to ‘discover’ circular insanity.
Simultaneously, important touchstones were being
laid for today’s concepts of dysthymia and
cyclothymia. It is important to note that the cases
these authors described in their writings were, almost
without exception, patients of asylums who, due to
their illness and social circumstances, suffered un-
favourable courses and had very little in common
with today’s largely ambulatory subaffective pa-
tients.
4. ‘Cyclothymia’: first uses of the concept
In the second half of the 19th century quite a few
treatise dealing with the concept of circular insanity
were published, e.g. by Ludwig Meyer (1874) and
Pick (1899). On re-reading Meyer’s descriptions,
however, it become clear that his circular cases had
what today we would consider first-rank symptoms,
so that we might diagnose those patients as suffering
from schizo-affective disorder (Marneros and
Tsuang, 1990).
The earliest use of the term ‘cyclothymia’ for a
distinct mood disorder is to be found in the work of
Kahlbaum’s pupil Ewald Hecker (1877), who re-
ported patients whom nowadays we would probably
describe as having bipolar I disorder or full-blown
manic-depressive illness. Quite a different view is
put forward in a little noticed article by Kahlbaum
(1882). Looking at severity and course, Kahlbaum
makes a clear distinction between ‘typical insanity’,
which may also have circular features, and the so-
called ‘partial disorders of the soul’, namely hy-
perthymia, cyclothymia and dysthymia, which have a
favourable course. This is somewhat reminiscent of
today’s use of the concept of subaffective disorders
(Akiskal, 1981, 1994b; Akiskal and Akiskal, 1992).
Kahlbaum wrote that these disorders may be so mild
that they do not necessarily require hospitalization or
medical treatment at all. From his article, however, it
is also clear that he would have included most other
forms of affective disorders under the rubrics of
‘dysthymia’, ‘cyclothymia’ and ‘hyperthymia’, con-
ditions that today we would consider major depres-
sion, mania and bipolar disorder. Nevertheless, the
120 P. Brieger, A. Marneros / Journal of Affective Disorders 45 (1997) 117 – 126
idea that cyclothymia could present with mild or
even subthreshold symptomatology was taken up by
other authors, e.g. Hecker (1898) and Hoche (1897).
At the turn of the century, then, the situation was as
follows:
• Affective disorders, including their mild ambulat-
ory forms, were being recognized both scientifi-
cally and clinically.
• Depressive and bipolar courses of affective dis-
orders appear to have been described.
• The terms ‘cyclothymia’ and ‘dysthymia’ were in
use by some authors both in the narrow and broad
sense.
5. Kraepelin’s revolution
The classification of psychiatric disorders changed
totally in the years between 1895 and 1915.
Kraepelin’s dichotomy of ‘dementia praecox’ and
‘manic-depressive insanity’, which was influenced
by the ideas of, amongst others, Kahlbaum and
Moebius, permanently changed psychiatric nosology.
Kraepelin, 1909-1915 dropped ‘dysthymia’, but re-
tained the term ‘cyclothymia’ for mild forms or for a
predisposition (‘Konstitution’) for manic-depressive
insanity. He undoubtedly had the concept of a
continuum from mild, subclinical forms to full-
blown disorders in mind. Interestingly, although
Kraepelin did not retain dysthymia as a terminology
for the depressive constitution, he gave a vivid
description of its psychopathology (Kraepelin, 1909–
1915):
‘‘Beginning with adolescence ( . . . ) they show a
certain sensitivity for life’s sorrows, grieves and
disappointments. Everything is burdensome for
them ( . . . ). Each task stands before them like a
mountain ( . . . ). Their whole course of life is
strongly influenced by their suffering. ( . . . ) They
feel weak, without energy ( . . . ). Sleep is normal-
ly insufficient; these patients have a great urge for
sleep, but they fall asleep very late ( . . . ), in the
morning they do not feel refreshed but tired ( . . . )
and only during the day do they reach a fair state.
The illness described here normally first manifests
itself during adolescence and may persist without
major changes throughout life.’’
These patients are identical to those described in
contemporaneous work (Akiskal, 1983), and would
certainly fulfil the DSM-IV criteria for dysthymic
disorder, especially the criteria in its appendix (APA,
1994). Modern research has confirmed several of
Kraepelin’s observations: dysthymia often begins in
adolescence (early onset) and has a chronic course
(Kovacs et al., 1994), it is associated with low
functioning and low well-being (Hays et al., 1995),
and typical depressive cognitive patterns can be
observed (McCullough et al., 1994). Kraepelin re-
ported the familial aggregation of all forms of manic-
depressive insanity, including that of dysthymia
(Maier et al., 1992; Klein et al., 1995), and knew
that severe melancholia may develop on the basis of
a ‘constitutional dysthymia (Verstimmung)’ — an
idea reminiscent of present concepts of ‘double
depression’ (Keller and Shapiro, 1982).
Kraepelin’s impact was tremendous, but as early
as in 1911 Homburger criticized that cyclothymia
was too often diagnosed and therefore had degener-
ated to a wastebasket diagnosis, like hysteria and
neurasthenia before it. Generally, however,
cyclothymia became a synonym for mild or subclini-
cal forms of manic-depressive insanity. One of the
most comprehensive publications at that time was a
lecture before the American Medico-Psychological
Association in 1910 by Smith Ely Jeliffe, who gave a
masterly review of the German and French literature
on cyclothymia and presented ‘cyclothemias’ as the
mild forms of the manic depressive constitution
(Jelliffe, 1911). Opponents of Kraepelin’s concepts,
amongst them Adolf Meyer (1927), repeatedly criti-
cized Kraepelin for condensing all forms of affective
disorders into the concept of manic-depressive in-
sanity. It is noteworthy too that Kraepelin (1920)
himself displayed some skepticism regarding his
diagnostic system in his later years. Nonetheless,
several modern authors (e.g. Akiskal et al., 1977,
1979; Depue et al., 1981; Akiskal, 1992, 1996b)
have presented data and arguments in favour of
Kraeplin’s continuum hypothesis from cyclothymia
(as a subaffective disorder) to bipolarity (as full-
blown manic-depressive insanity).
 P. Brieger, A. Marneros / Journal of Affective Disorders 45 (1997) 117 – 126
6. E. Kretschmer and K. Schneider — two very
different concepts of ‘cyclothymia’
The succeeding decades witnessed a development
in German psychiatry which has led to confusion up
to the present: Kurt Schneider and Ernst Kretschmer
formulated concepts of cyclothymia which they both
saw in the tradition of Kraepelin, but in reality their
respective concepts were contradictory. The reason
might have had to do with the fact that the term
‘cyclothymia’ was always somewhat vague and ill-
defined in Kraepelin’s writings: he did not clearly
delineate the ‘constitutional’, ‘subclinical’ and ‘full-
blown’ forms.
Kretschmer (1921) worked intensively on a theory
that connected physique, constitution, temperament,
character and mental illness. His findings, as ex-
¨
pounded in Korperbau und Charakter (Physique and
Character, 1921) were influential for some time, but
are now mainly of historical value, primarily because
his attempt to link temperament to a certain type of
‘pyknic’ physique was not supported by later re-
search. Nonetheless, Kretschmer’s ideas have clearly
influenced the modern concept of subaffective dis-
orders. He described a cyclothymic temperament
with frequent mood shifts which could be found in
normal individuals, but which had some relation to
manic-depressive illness, as he saw a continuous
transition from temperament to psychosis.
Kurt Schneider (1946) vehemently rejected the
idea of a continuum from normality to psychosis. He
saw a differential typology of two endogenous
psychoses ‘cyclothymia’ and ‘schizophrenia’, which
had no causal relation to personality or temperament.
His book on psychopathology proved so successful
that in many parts of the world the term
‘cyclothymia’ has become a synonym for manic–
depressive illness, and the former meaning of a ‘mild
or constitutional form’ is lost. Schneider is of
importance to the field of subaffective disorders for a
different reason. In his concept of ‘psychopathic
personality’, he atheoretically conceptualized ‘psy-
chopaths’ as special forms of abnormal personalities,
which were merely ‘variants of the norm’
(Schneider, 1923). With this definition, he profound-
ly influenced modern concepts of personality dis-
orders. From clinical observation he described ten
types of psychopaths. Three of these have distinct
121
affective traits: depressive, hyperthymic and emo-
tionally labile psychopaths. He always stressed,
however, that his definition of psychopathic per-
sonality was by no means ‘self-evident’, but was a
mere matter of convention. In other words, diagnos-
tic thresholds for such personality disorders were
deliberate and derived from clinical necessities. The
diagnoses of depressive, hyperthymic and emotional-
ly labile psychopathic personality had nothing to do
with cyclothymia as Kurt Schneider understood it:
He always considered psychopathic personalities to
be a variant of the norm and not an illness.
7. Dysthymia: 1900–1970
The term ‘dysthymia’ played a minor role in 20th
century psychiatry until the 1970s. Some authors
(e.g. Weitbrecht, 1952), used ‘endo-reactive
dysthymia’ to describe forms of depressions that
were perceived as being located half-way along a
continuum between endogenous and reactive depres-
sions. A few other authors — e.g. E. Kahn (1928),
and K. Leonhard (1968) — included the term in their
classifications of psychopathic personalities to de-
scribe persons who suffered chronically from dis-
turbed or irritable mood. With the influence of
psychodynamic psychiatry the diagnosis of neurotic
(or psychogenic) depression was of greater impor-
¨
tance (Volkel, 1959) during this period and over-
shadowed dysthymia.
8. A change of paradigm in affective research:
1960–1980
Around 1960 when, with the discovery of antide-
pressant medication, another diagnostic revolution
was shaping up, affective disorders were diagnosed
according to not very systematic distinctions between
assumed organic, endogenous, reactive and neurotic
etiology, as reflected in the various diagnoses of
affective disorders in ICD-9 (WHO, 1978). The
following 15 years led to a totally new approach to
affective disorders. Firstly, research by Angst
(1966), C. Perris (1966) and Winokur et al. (1969)
122 P. Brieger, A. Marneros / Journal of Affective Disorders 45 (1997) 117 – 126
reminded psychiatrists of the relevance of the long
neglected distinction between unipolar and bipolar
disorders introduced by the so-called ‘hirnpathologi-
sche’ (brain-pathological) school in the tradition of
C. Wernicke, K. Kleist and K. Leonhard (Neele,
1949; Leonhard, 1957). Secondly, a series of influen-
tial articles in the late 1960s and the 1970s (e.g.
Paykel, 1971; Winokur and Morrison, 1973; Akiskal
and McKinney, 1975; Kendell, 1976) showed the
shortcomings and the lack of reliability of the
contemporary diagnostic strategies (e.g. ICD-9 and
DSM-II) for affective disorders. Therefore, opera-
tional diagnostic criteria such as the RDC and DSM-
III were being prepared. One profound controversy
in the development of the DSM-III was whether the
diagnosis ‘neurotic depression’ should be included.
Two studies (Akiskal et al., 1978; Klerman et al.,
1979) had shown how problematic its diagnostic
validity and reliability were. Thus in 1979, the
preparation committee for DSM-III agreed on the
diagnosis ‘dysthymic disorder (neurotic depression)’,
which represented a compromise between neo-
Kraepelinian and psychodynamic psychiatrists
(Bayer and Spitzer, 1985). The diagnosis was listed
under the chapter mood disorders with the ICD-9
number for neurotic depression (300.4), although it
was strongly influenced by the criteria of ‘intermit-
tent depression’ (RDC: Spitzer et al., 1978). Akiskal
(1983) tried to differentiate subforms such as ‘subaf-
fective dysthymia’ (an antidepressant responsive
form) and ‘character-spectrum disorder’ (nonrespon-
sive to antidepressants), but this question is still open
today (Anderson et al., 1996). Nonetheless, there is
wide agreement that dysthymia is a disabling chronic
form of a mood disorder that is in principle treatable
with pharmacotherapy (Kocsis et al., 1996; Thase et
al., 1996) combined with psychotherapy. Following
further work by Akiskal et al. (1977) and others
(Spitzer et al., 1978), the diagnosis ‘cyclothymic
disorder’ was also included in DSM-III under the
chapter ‘mood disorders’. Later ICD-10 followed
this development, although one slight conceptual
difference between ICD-10 and DSM-IV is that the
former lists dysthymic and cyclothymic disorder
under a common heading that stresses their chronic
courses, while the latter focuses on the bipolar–
unipolar distinction and therefore assigns the two
disorders to two different parts of the classificatory
scheme for affective disorders.
9. Discussion: what can we learn from history?
The monograph by Georges Dreyfus (1907) on
Melancholia, published with a foreword by
Kraepelin, brought 19th century concepts of melan-
cholia to an end: the author wrote in his literature
review that in 19th century psychiatry ‘‘almost every
author named psychoses according to his convictions
without any regard to former concepts’’. Aren’t we
sometimes in danger of forgetting that some of our
supposedly new concepts are in fact anything but
new? As we have already indicated, many of
Kraepelin’s conclusions have been supported by
recent research. The same applied to other German
authors who lived in the first half of this century. A
recent important study (Akiskal et al., 1995) showed
prospectively that patients who switched from unipo-
lar to bipolar II displayed high mood lability, day
dreaming and high energy-activity, widely in agree-
ment with how Kretschmer had portrayed the
cyclothymic temperament. Also a connection be-
tween ‘artistic temperament’ (Jamison, 1994) and
bipolar mood disorders has been postulated at least
since the early 20th century, when Homburger
(1911) suggested distinguishing between hyper-
thymia and mania in cyclothymic patients, because
hyperthymia is associated with higher productivity,
while mania leads to a loss of quality. Hyperthymia,
not recognized in current official diagnostic systems
(e.g. ICD-10, DSM-IV), has received even less
attention than cyclothymia in the current literature;
an exception is a descriptive paper by Akiskal
(1992).
Having reviewed the history of ‘subaffective
disorders’ in light of present knowledge, we come to
the following conclusions:
• Although the terms ‘cyclothymia’ and
‘dysthymia’ had been introduced some years
earlier (Flemming), the development of the con-
cept of subaffective disorders principally began
with Kahlbaum, who described the putative sub-
clinical forms ‘cyclothymia’, ‘hyperthymia’ and
‘dysthymia’. The long history of such a concept
can be seen as supporting its validity.
• Early onset, chronic course, familial aggregation,
dysfunctional cognitive features, double depres-
sion and other features of dysthymia can already
be found in the writings of Kraepelin.
 P. Brieger, A. Marneros / Journal of Affective Disorders 45 (1997) 117 – 126
• The excessively broad concept of manic-depres-
sive insanity (Kraepelin) and the subsequent
research of E. Kretschmer and K. Schneider led to
conceptual confusion. Not only was the unipolar /
bipolar distinction lost, but also the word
‘cyclothymia’ acquired three different meanings:
1) synonym for manic-depressive illness (K.
Schneider); 2) nonpathological temperament that
may predispose to the development of affective
psychoses (and is connected to a certain type of
‘pyknic’ physique; E. Kretschmer); 3) synonym
for mild or constitutional forms of bipolar illness
(Kahlbaum, DSM-IV, ICD-10).
One must be aware of this conceptual confusion.
For example, only 10 of the several thousand ab-
stracts of lectures, communications and posters at the
10th World Congress of Psychiatry contain the words
‘cyclothymia’ or ‘cyclothymic disorder’ (Visotsky et
al., 1996). Six of these 10 abstracts, however, use it
merely in the Schneiderian sense as a synonym for
bipolar disorder and only 4 use it to mean a
subaffective disorder. Apart from the historical
bifurcation of the meaning of cyclothymia, it is
likely that contemporary psychiatrists, especially in
North America, might substitute atypical mood-labile
depression and borderline personality for
cyclothymic disorder (Akiskal, 1994b; Akiskal et al.,
1995).
A lack of familiarity with the historical literature
in psychiatry may obstruct scientific progress. This
seems to have happened at least twice in the history
of subaffective disorders. Firstly, Kahlbaum’s ob-
servations were not noticed by most authors of the
late 19th century. Secondly, Kraepelin’s concept of
manic-depressive insanity became too influential, so
that the bipolar / unipolar distinction was widely
forgotten until the research of Angst, Perris, Winokur
and others in the 1960s — with the exception of the
Wernicke–Kleist–Leonhard school, which did not
gain much acceptance. Although the unipolar / bipo-
lar dichotomy is now entrenched in official nosology
(DSM-IV, ICD-10), for some authorities (Akiskal,
1996b; Goodwin and Jamison, 1990), the pendulum
may now be moving back to Kraepelin’s broader
concept.
Attempts to diagnose affective disorders have been
made at least since the times of Esquirol and before.
Diagnostic systems based on clinical observations
123
instead of theory are meaningful and tend to endure
over time (Kahlbaum, Kraepelin), especially if the
researchers themselves are flexible enough to adapt
to new findings, as was certainly true for Kraepelin.
Other diagnostic systems with a more theoretical and
less flexible background quickly became outdated.
To a certain extent, we can ask ourselves to what
extent the present ‘diagnostic revolution’ with the
wide acceptance of DSM-IV and ICD-10 is again
such a victory of empiricism over theory.
Nevertheless, we retain some doubts whether the
diagnostic criteria for cyclothymic disorder truly
meet such standards of skeptical clinical observation
(Howland and Thase, 1993; Brieger and Marneros,
1997). Many problems with the diagnosis, especially
its high comorbidity with bipolar II disorder, prompt
us to reconsider its validity.
The question of where the border lies between
‘normal’ personality, ‘abnormal’ personality and
‘illness’ may nowadays sound wearisome and aca-
demic. However, the concept of ‘disorder’ does not
constitute a sufficient answer, and for subaffective
disorders, which by definition often present outside
of psychiatric treatment settings, this question is of
great importance. The solution could be a dimension-
al instead of a categorical assessment of subaffective
disorders, seeing such disorders on an affective
continuum (Akiskal, 1996a; Brieger and Marneros,
1997). Subaffective disorders could possibly play a
role in changing our diagnostic attitudes from cate-
gorical to dimension, but the consequences of such a
change could be far-reaching. For instance, Akiskal
(1994a) has recently provided a clinical perspective
on major depressions arising form dysthymic and
cyclothymic foundations. This author (Akiskal,
1995) has also written provocatively on the theoret-
ical and neurobiologic implications of the tem-
perament-affective illness continuum model.
Although the DSM-IV and ICD-10 classifications
of mood disorders are now rather similar and have
reasonably good reliability, many psychiatrists with
an interest in psychopathology feel uncomfortable
with their ‘simplicity’, especially concerning the
diagnoses ‘major depression’ and ‘dysthymic disor-
der’. On the other hand, new studies — particularly
psychopharmacological investigations — lend con-
vincing support to the concept of dysthymia as a
mood disorder (Akiskal, 1996a). Clinically and sci-
entifically it is necessary to clarify the concept of
124 P. Brieger, A. Marneros / Journal of Affective Disorders 45 (1997) 117 – 126
cyclothymic disorder. This means firstly that the
term should be used only for subaffective disorders,
and not for the entire clinical spectrum of bipolar
disorders. Secondly, further research is clearly indi-
cated to prove its discriminant validity from bipolar
II (Cassano et al., 1992; Akiskal et al., 1995). In his
important book on personality and mood disorders,
Hubertus Tellenbach (Tellenbach, 1983) quoted
Toynbee’s sentence ‘‘The price of quantification is
the ignoring of uniqueness.’’ This dilemma certainly
also applies to subaffective disorders.
Acknowledgments
The authors wish to thank Hagop S. Akiskal for
his advice. The Halle Dysthymia Research Group is
partly supported by a grant of the Deutsche Fros-
chungsgemeinschaft (DFG Ma 915 / 6-1).
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