Journal of Affective Disorders 73 (2003) 199–205

www.elsevier.com / locate / jad

Special article

Ewald Hecker’s description of cyclothymia as a cyclical mood

disorder: its relevance to the modern concept of bipolar II

Athanasios Koukopoulos*
Lucio Bini Center, Via Crescenzioa 42, 00193 Rome, Italy

Received 22 November 2001; accepted 25 February 2002

1. Historical note
Ewald Hecker (1843–1909) was a disciple of Karl
Ludwig Kahlbaum and his closest assistant for many
years at the Kahlbaum Sanitarium in Goerlitz, Silesia
(Germany). His cousin was Kahlbaum’s first wife.
Their collaboration was extremely fruitful and pro-
duced landmark works on hebephrenia and
cyclothymia. Hecker’s progressive approach to psy-
chiatry, which he recommended to Kahlbaum, com-
bated the coercive methods of his time and placed
the accent on public education to eliminate the
stigma attached to mental illness. Like Kahlbaum, he
never attained a university chair in psychiatry,
perhaps because of his liberal ideas. Instead, he
worked at his own private hospital in Wiesbaden,
which he bought in 1891. Hecker attained a reputa-
tion as hypnotherapist and psychotherapist for pa-
tients with cyclothymia, anxiety and sleep disorders,
anticipating today’s outpatient combination of psy-
chiatry and psychotherapy. He attached such impor-
tance to humane practices that he even accommo-
dated some patients into his home on a temporary
*Tel.: 1 39-06-687-4415; fax: 1 39-06-6880-2345.
E-mail address: a.koukopoulos@flashnet.it
(A. Koukopoulos).
basis until they could be back on their feet. His work
with outpatients and his intimate acquaintance with
them enabled him to make observations which
escaped hospital psychiatrists. His incisive clinical
description and his sophisticated understanding of
psychopathology made Hecker (1898) not only a
forerunner, but also one who anticipated today’s
conceptions of cyclothymia as the basis of bipolar II
disorder (Dunner et al., 1976; Akiskal et al., 1977;
Akiskal et al., 1979; Akiskal, 1981; Depue et al.,
1981; Cassano et al., 1992; American Psychiatric
Association, 1994; Brieger and Marneros, 1997;
Hantouche et al., 1998; Akiskal et al., 2000; Akiskal
and Pinto, 1999). Indeed, he described cyclothymia
as brief depressions with mild excitements of short
duration (measured in days), as well as longer
depressions (lasting weeks to months) and followed
by brief hypomanias. The latter of course correspond
to today’s concept of bipolar II. He proceeded to
provide a superb description of the clinical picture of
bipolar II as we know it today. Even his recom-
mendations not to tamper too much with the depres-
sive phase and instead endeavour to limit the hypo-
manic phase, resonates with contemporary advice
(Akiskal and Pinto, 1999; Wehr and Goodwin, 1987;
Akiskal and Mallya, 1987; Koukopoulos et al., 1990;
Akiskal, 2001)—alas not heeded often enough! The

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200 A. Koukopoulos / Journal of Affective Disorders 73 (2003) 199–205
modernity of Hecker’s remarkable paper prompted
us to translate it. [Only minor clarifications, usually
noted in square brackets, have been added by the
translator or the editor of the Journal of Affective
Disorders. Also, to help the reader, the editor has
structured the paper into sections in accordance with
Journal style. A.K. & H.S.A.]
2. Introduction
In his report on cyclical insanity, which he pub-
lished in ‘‘Irrenfreund’’ in 1882, Kahlbaum distin-
guishes between two forms of cylical psychosis,
which he viewed as differing profoundly from each
other. The first, which he calls ‘‘Vesania Typica
Circularis,’’ is characterized by the frequent recur-
rence of melancholic and manic attacks appearing in
alternation, with a marked tendency towards a state
of deterioration. The second, which he labels as
‘‘Cyclothymia,’’ does not result in a state of confu-
sion and deterioration, not even if it lasts for a
lifetime.
While we may observe an involvement of the
principal functions of psychic life in the first form, in
cyclothymia we only see an oscillation between two
opposing states of mood, namely ‘‘dysthymia’’ and
‘‘hyperthymia,’’ and since intellectual activity is
more or less completely spared, it may be defined as
a pure disorder of mood.
Kahlbaum rightly draws attention to the fact that
cyclothymia manifests itself not infrequently at such
a low-grade intensity that the great majority of cases
do not reach psychiatric hospitals at all. I myself can
confirm from experience, looking back on my former
15-year term as a hospital psychiatrist—and now that
I have been working for the same length of time in
private practice—that I have seen an incomparably
greater number of this kind of patient compared to
the past.
3. Clinical presentation
Virtually all of the [cyclothymics] presented with
a depressive state. The state of excitation—and I
should like emphasize this—had escaped the atten-
tion, in the majority of milder cases, of the patient’s
doctor, his family and friends, and the patient
himself. The patients only became aware of it when I
described the characteristics of this state to them.
Even more often, however, it was the patients
themselves who, having up until that moment con-
sidered them as their ‘‘healthiest’’ periods, were
forced to recognise that they were ill in these periods
also. In one case I examined recently, the family
members, who had had a previous consulation with
me, were still forcefully denying any trace of such
exaltation. But then, when I asked the patient for
some confirmation, he replied with visible relief: ‘‘I
fear that frightful internal agitation even more than
the melancholia, and I try to conceal it from my
family with all my might.’’
I made similar observations with such frequency
that I felt authorised to suppose that at least the
majority of the cases diagnosed as periodic melan-
cholia, that is periodic depressive states, really
belong under Kahlbaum’s cyclothymia. For this
reason, it was of the greatest interest to me to see in
the most recent edition of Kraepelin’s Handbook that
he too views periodic depressive states as an in-
frequent disorder, admitting the possibility that a
certain number of cases he defined as such should in
fact be attributed to a ‘‘cyclical insanity.’’
Kurella recently reported in German a paper by
Professor Lange of Copenhagen entitled ‘‘Periodic
Depressive States and their Pathogenesis on the
Basis of Uric Diathesis.’’ This author argues that the
depressive states he minutely describes are in the
majority of cases [superficially?] similar to epilepsy,
hysteria and all the other forms of neurasthenia. It
was this conclusion which aroused the suspicion that
in Lange’s observations too, we are dealing with
cases of cyclothymia in which the state of excitation
had eluded the physician.
The complete conformity of the smallest details of
the symptoms of the state described by Lange with
those of the depressive phase of cyclothymia leads
me to the almost certain hypothesis—that
cyclothymia, especially in the less severe course,
occurs surprisingly often and represents an unusually
large contingent in psychiatric consultation. It is
nonetheless of particular importance that certain
patients do not go to the doctor because of their real
psychic state, but at first primarily to complain about
a series of physical symptoms, without attaching
 A. Koukopoulos / Journal of Affective Disorders 73 (2003) 199–205
prime importance to the depression, which they only
see as a consequence of the physical ailments they
are suffering from. It happens, then, that the depres-
sive phase of cyclothymia is misdiagnosed and the
patients are wrongly diagnosed as neurasthenic.
Given the fact that precisely in these cases a proper
diagnosis is of particular importance for treatment, I
believe it essential that every doctor, even if he is not
interested in practising psychiatry, should make
himself especially familiar with the milder forms of
the type of disorder presented. The description that
follows should furnish some guidelines.
4. Symptomatology
The principal and fundamental symptom of the
depressive phase of cyclothymia is psychic inhibi-
tion, with a complete lack of hallucinations, and a
fairly highly developed, albeit not always sufficiently
analysed, awareness of the illness. The patients
complain often and primarily of a complete dulling
of thought and sensation, of the fact that they have
lost the ability to perform any intellectual work, to
converse or enjoy themselves. They have the impres-
sion that they are no longer able to work or that they
can only work badly.
They also complain about their indifference to-
wards persons or things which up until then had been
very close to their hearts. They describe their state as
one of inner rigidity, as if a curtain had come down
or a wall erected between them and the world. All
decisions become difficult to make, all actions
become a torment. They have to be pushed into any
action that they take. They would prefer not to see
anyone, and they avoid everyone they know for fear
of having to face a conversation and communicate or
justify their state. Some patients would like to stay in
bed all day to get away from their duties. But others,
despite their illness, manage to control themselves
externally to the extent of preventing their social
circle from noticing anything. Once they begin to
complain to that circle, they are regarded as nothing
more than hypochondriacs. This conclusion appears
all the more justified to the layman when, as
sometimes happens, individual symptoms of the state
of excitation temporarily intrude into the depressive
phase.
201
One symptom is often particularly in contrast with
the apathy and indifference of which the patient
complains: a marked tendency and ability to criticise.
Unlike real melancholics, these patients latch onto
everything, finding a thousand little things unseemly
or bothersome. They moan about imperfections in
the furnishing of their sick room, the service, the
food—albeit not always without reason—but in
contrast with the indifference they complain of
towards the outside world.
Generally speaking these patients perceive their
state as a great torment and they are overwhelmed by
their own lack of courage and hope; they firmly
believe that they will never recover even though they
have come through other attacks of the same kind,
because ‘‘it has never been as bad as this!’’
Dejection and sadness which almost always stem
from their mental state—and only secondarily de-
velop—from it are usually expressed in incessant fits
of weeping, accompanied on occasion by states of
anxiety.
In almost all cases, even when one might not have
expected it because of the appearance of the patient
and the mild degree of melancholy mood, I have
been able to note a more or less intense tendency
towards suicidal thoughts, to such an extent that I
have not observed in other forms of melancholy.
This tendency should not be taken lightly, not even
in the mild cases. Furthermore, I realised that the
patients felt very relieved when they were able to
express themselves openly about this particularly
grievous symptom. Observing this state, one is
spontaneously reminded of a machine in which the
oil has run dry and the gears grind on in laborious
suffering, rasping against one another until they seize
up in pain. By contrast, when the machine is in a
state of excitement it runs on at the highest pitch,
carrying out all its functions with a facility that is out
of the ordinary, and in the milder cases—(to which I
make most reference here)—without anyone noticing
any significant decrease in quality.
Kahlbaum has called the latter state ‘‘hyper-
thymia,’’ as opposed to ‘‘dysthymia’’, because of the
fact that unusually elevated mood is the basic
symptom from which the others stem. Kraepelin uses
the expression ‘‘hypomania’’ and perhaps encompas-
ses better, with this, the more marked forms—just
like Schule, with his definition of ‘‘mania mitis’’ and
202 A. Koukopoulos / Journal of Affective Disorders 73 (2003) 199–205
‘‘mitissima,’’ which bring out with greater clarity the
characteristics of the well-known folie raisonnante
and the mania sine delirio.
Instead of the inhibition that was previously felt,
the course of thoughts is now faster, the perception
of external impressions easier and more immediate,
so the patient appears to be more intelligent, full of
wit and more entertaining than in the healthy days.
As for the increased capacity for criticising, which as
already mentioned may present itself also in the
depressive state, this may now become so strong as
to be considered vexing by the patient himself. It
often betokens itself by an arrogant, mocking smirk.
The elevated mental capacity leads in the majority of
cases to a restless, non-stop activity and dynamism
which develops in the widest variety of directions. It
is not only the stamina of the patient, which appears
greater than that of the healthy days, but the level of
skill and ability that is increased in various ways.
Many, for instance, who had a rather mediocre voice
and in their depressive intervals—were without much
musical talent—now sing not only with great eager-
ness, but also with a better tone of voice and a
livelier expressiveness. Others display, in manual
tasks and their mode of dress, a skill and taste which
they did not formerly possess. And others manifest a
literary bent that was quite alien to them before.
All these characteristics are, as I observed above,
due to the expression of the expansive mood, which
as a rule sweeps over the patient suddenly. All at
once he sees the rosy side of life and at the same
time feels a desire to have others partake in his joy,
to help his fellow men and carry out activities that
frequently bear fruit in the fields of charity and
humanitarian interests. Probably linked to this is an
observation that I made too often to be able to term it
a coincidence, namely that a great number of nurses,
in lay or church-run organisations, suffer from mild
cyclothymia.
While the patient often displays a seductive
amiability towards strangers, an amiability which in
certain cases has slightly erotic traits—one of my
patients, for example, would get engaged in every
phase of excitement only to break off the engage-
ment in the subsequent depressive phase—the
psychic irritability present at the same time often
gets the upper hand at home or in situations that have
become familiar (such as the hospital). This shows
itself as a surprising intolerance, accompanied by a
tendency to create disagreement and to plot, so that
many of these patients are troublesome guests. It
appears absolutely understandable that this state,
when it is barely apparent, is not recognised by the
people around the patient and is regarded as full
mental ‘‘health.’’ But when this state develops
further, a whole series of symptoms appear which
are so marked that, even to a stranger’s eye, there
can be no doubt of the existence of the illness, such
as: spending sprees and wasting money, a tendency
to play silly practical jokes in moments of exaltation,
eye-catching [exhibitionistic] acts (which the patient
defends as natural), abnormally emphasised self-
esteem, aimed at extolling the patient’s abilities, and
a disproportionate ostentation of vanity (for instance,
wearing decorations on inappropriate occasions, or
even the illegal appropriation of titles).
In several cases, patients of mine with such an
intense state of cyclothymic excitation have been
regarded as paralytics [general paresis of the insane]
by laymen and doctors alike. This error appears all
the more comprehensible if we recall the fact that—
as a stigma of their hereditary load—many of our
patients have a ‘‘moral weakness’’, albeit often
barely perceptible, with a tendency to lie, use
alcohol, and frequent loose company, etc. In most
cases, however, the patients maintain a considerable
capacity for controlling their outward behaviour and
preserving full lucidity—factors which make it hard
for observers to assess this state correctly, even in
the most serious cases.
For a doctor familiar with the subject, it is of
course possible in many cases to diagnose
cyclothymia in both the depressive and exalted state
even without prior knowledge of the history of the
patient. Kraepelin himself made the same observa-
tion, only rarely getting the diagnosis wrong [just
based on first contact with the patient].
Of the physical symptoms of cyclothymia, apart
from frequent headaches, the following stand out in
the depressive phase: a tightening of the head and
chest, an empty sensation in the head, often a general
state of weakness, principally recognisable in a
relaxation and fall in the features [of the face], not
due solely to the weight loss which often occurs at
the same time. The hair becomes weak and loses its
shine, and the moustache droops. At the start of the
 A. Koukopoulos / Journal of Affective Disorders 73 (2003) 199–205
phase of excitation, on the other hand, facial features
and posture become vigorous and expressive again (I
already mentioned above the urge to criticise) and
the moustache—together with a renewed attention to
grooming—resumes its natural position with up-
turned ends. In two of my patients, it was this
symptom which alerted me with almost unfailing
certainty to the stereotypical start of the phase of
excitation. In general, it is characteristic that the
individual stages of the change are signalled by such
apparently banal symptoms, so that the physician
may, some time before their reappearance, recognise
and stave off the turnaround in the situation.
Sleep behaves in different ways. Many patients in
the depressive phase are affected by an unmitigated
desire to sleep, while others, particularly those who
are subject to states of anxiety, suffer from insomnia.
The same thing is valid for the states of excitation in
which certain patients present an untroubled working
of all the vegetative functions (appetite and diges-
tion) and have restorative sleep of good quality,
while others have sleepless nights because of rest-
lessness and impulses towards hyperactivity, or they
wake up in the early hours of the morning, without
however feeling any fatigue.
The duration of the episodes is extremely variable.
In some rare cases depression and excitation alter-
nate day after day, while in others each individual
episode lasts for many months, or even years; in
certain cases the individual phases have the same
duration while in others there is no regularity;
sometimes, for years, the same case only presents
depressive phases and then exaltation takes over
again.
Almost always, between the two states, a free
interval of variable duration intervenes. Of particular
importance is the fact that, during the long periods,
there are often short daily variations. In particular,
evening-time improvements in mood are characteris-
tic in the depressive phase.
But there are cases to which Kraepelin draws
special attention, in which ‘‘the depressive and
excitatory manifestations are temporarily mixed in an
indistinguishable way, in which the individual symp-
toms of the various [two] phases appear at the same
time.’’ Cases of this sort are not always easy to
identify clearly, but adequate observation should
always produce the correct diagnosis because the
203
symptoms of the illness are so characteristic in both
phases that they cannot be mistaken if one has some
[clinical] experience, and also because the individual
phases tend to reappear in any case, every so often.
5. Differential diagnosis
5.1. Melancholia
When one has the opportunity to observe both
phases of the patient’s illness, there is virtually no
chance of getting the diagnosis wrong. In cases in
which one sees the patient only in the depressive
phase, and the patient’s medical history does not
offer guidance, we should ask ourselves whether it is
genuine melancholia, initial melancholia, or the
depressive phase of cyclothymia. Militating in favour
of the latter hypothesis is Kraepelin’s observation of
‘‘the increased manifestation of inhibition compared
to the sad and anxious mood of the melancholics’’,
the absence of delusional thoughts, especially those
of guilt or persecution, or the sudden manifestation
of these, without forewarning, as is characteristic in
ordinary melancholia; the desire for sleep seen in
many of these patients, while patients affected by
genuine melancholia always sleep badly; and what is
more, the youthful age at which the disorder starts,
the rapid and benign course of the individual attack
and in particular the presentation of hypomanic
symptoms, whether they be of a passing nature or
whether they are more serious attacks. By this we
mean not only the aforementioned evening improve-
ments and the intrusion of mild excitations, but
above all the need to criticise during the depression.
In certain cases, furthermore, there is a really
surprising tendency towards suicide.
5.2. General paresis
We discussed above the way cyclothymia was
occasionally mistaken for dementia paralitica [gener-
al paresis of the insane]. The latter, in fact, also
presents a preliminary melancholy stage, sometimes
with ill-defined depressive features. To these mani-
festations are very soon added the characteristic
forms of weakness and lack of critical faculties,
completely in contrast with cyclothymia. In a similar
204 A. Koukopoulos / Journal of Affective Disorders 73 (2003) 199–205
way, the same symptoms manifest themselves in an
indistinguishable way in the excited phase of the
paralytic patient.
5.3. Hysteria
Mild cases of cyclothymia with only slight excita-
tion are not infrequently mistaken for hysteria,
especially when the individual phases come in rapid
succession and irregular alternation, or are even
comingled. One believes, in these cases, that one is
dealing with the baseless changes of mood of
hysterics and one takes—vis-a-vis the common
erroneous conviction concerning the real essence of
hysteria—slight moral defects and especially erotic
traits as specific signs of this illness [cylcothymia].
But the complete absence of the cardinal symptoms
of hysteria, namely anaesthesia, cramps, paralysis,
greater suggestibility, etc., provide easy clarification
as to diagnosis.
5.4. Neurasthenia
Mistaking the depressive phase of cyclothymia for
neurasthenia may occur in a handful of special cases.
In the majority of cases, the psychic symptoms of
cyclothymia are so clearly evidenced in their par-
ticularity that the diagnosis is swiftly and surely
made. The presence of phobias and obsessive ideas
indicate neurasthenia. Of decisive significance for
cyclothymia is, of course, periodicity or rather the
circular course. When Loewenfeld, in his well-known
manual, speaks of ‘‘hereditary neurasthenia,’’ defin-
ing it as a periodical form of this disease, he has, in
my view, mistaken it for cyclothymia—also because
cyclothymia is in its aetiology almost without excep-
tion to be attributed to hereditary causes. If at the
same time, as Lange tries to show in his treatise, uric
diathesis also plays a role, I am not yet in a position
to decide because my observations have not been
directed toward the subject up until now. I do know,
however, that some of the cases treated by me were
affected by gout and renal colics. I will naturally pay
particular attention to this fact from now on. It is
well known that some French authors present uric
diathesis as one of the major causes of neurasthenia.
It might very well be possible, considering the
aforementioned frequent misdiagnosis of states of
cyclothymic depression as neurasthenia, that another
such misdiagnosis has taken place in the cases
observed. Lange’s theory might gain credit by way
of this assumption.
6. Prognosis
As for the prognosis of cyclothymia, I personally
do not consider it as absolutely bleak. In the first
place, there are often remissions that last for as long
as 10 years (as in the other cyclic [mood] forms). In
my experience, there is quite often the possibility of
lessening the intensity of the attacks by way of a
targeted treatment. Of particular importance to the
prognosis is, of course, the fact that one can decided-
ly rule out deterioration as an outcome [as opposed
to a proportion of cases with mania].
7. Treatment
It has already been emphasized that only the
smallest proportion of our patients is hospitalized.
Only the truly serious cases, which show an intense
suicidal desire or, rarely, with states of excitation
tending towards grave excesses, will have to be
entrusted to institutions. But because of the fact that
patients are irked by being confined to hospital and
react with even greater manifestations, it is advisable
to grant them the possibility of treatment in a state of
liberty [as outpatients] and not confine them longer
than strictly necessary. Most cyclothymics are re-
ceived in open public structures for ‘‘nerve pa-
tients’’; and the great majority seek treatment from
medical visits. As already mentioned, patients seek
medical help for the most part during the depressive
phase.
In my experience, it is not beneficial for the
overall clinical course if one seeks to shorten the
duration of the depressive phase, pulling the patient
out of this state. The consequence of such treatment
is only to produce a stronger push towards exalta-
tion. The limitation, as far as possible, of the latter
[exaltation] is, I believe, the main task of treatment.
To this end, one should use the depressive state to
inform the patient about the true essence of his
disorder. In this way one puts the patient in a
 A. Koukopoulos / Journal of Affective Disorders 73 (2003) 199–205
position to already control himself better at the start
of the phase of exaltation, so as to be able to then
repress the excitation.
In other cases, it is of course natural that the
patient, freed from the grip of depression, should
now try to enjoy life; and I have observed quite often
how doctors and relatives have supported him in this,
to their own detriment. In the state of excitation one
should protect the patient from further worsening of
the excitation by surrounding him with the greatest
quiet possible, without painful restrictions, by getting
rid of provocations from the outside world and
supplying him with constant, friendly conversation.
In this way one will have an appropriate influence on
the general course and obtain relatively satisfactory
results.
Through methodical opium-based treatment of
depression, galvanisation of the sympathetic nerve,
and lukewarm baths in both states, it is possible to
effectively enhance treatment. By the use of hy-
pnosis, I have also detected and provoked a favour-
able effect on particularly upsetting individual symp-
toms in cases of mild depression.
Acknowledgements
Julia Bracchi and Denis Greenan for help in
translation.
References
Akiskal, H.S., 1981. Subaffective disorders: dysthymic,
cyclothymic, and bipolar II disorders in the ‘‘borderline’’
realm. Psychiatr. Clin. North Am. 4, 25–46.
Akiskal, H.S., 2001. Dysthymia and cyclothymia in psychiatric
practice: a century after Kraepelin. J. Affect. Disord. 62,
17–31.
Akiskal, H.S., Mallya, G., 1987. Criteria for the ‘‘soft’’ bipolar
spectrum: treatment implications. Psychopharmacol. Bull. 23,
68–73.
205
Akiskal, H.S., Pinto, O., 1999. The evolving bipolar spectrum:
prototypes I, II, III, IV. Psychiatr. Clin. North Am. 22, 517–
534.
Akiskal, H.S., Khani, M.K., Scott-Strauss, A., 1979. Cyclothymic
temperamental disorders. Psychiatr. Clin. North Am. 2, 527–
554.
Akiskal, H.S., Djenderedjian, A.H., Rosenthal, R.H., Khani, M.K.,
1977. Cyclothymic disorder: validating criteria for inclusion in
the bipolar affective group. Am. J. Psychiatry 134, 1227–1233.
Akiskal, H.S., Bourgeois, M.L., Angst, J., Post, R., Moller, H.J.,
Hirschfeld, R.M.A., 2000. Re-evaluating the prevalence of and
diagnostic composition within the broad clinical spectrum of
bipolar disorders. J. Affect. Disord. 59 (Suppl. 1), 5s–30s.
Brieger, P., Marneros, A., 1997. Dysthymia and cyclothymia:
historical origins and contemporary development. J. Affect.
Disord. 45, 117–126.
Cassano, G.B., Akiskal, H.S., Savino, M., Musetti, L., Perugi, G.,
Soriani, A., 1992. Proposed subtypes of bipolar II and related
disorders: with hypomanic episodes (or cyclothymia) and with
hyperthymic temperament. J. Affect. Disord. 26, 127–140.
Depue, R.A., Slater, J.F., Wolfstetter-Kausch, H. et al., 1981. A
behavioral paradigm for identifying persons at risk for bipolar
depressive disorder: a conceptual framework and five valida-
tion studies. (monograph). J. Abnorm. Psychol. 90, 381–437.
Dunner, D.L., Gershon, E.S., Goodwin, F.K., 1976. Heritable
factors in the severity of affective illness. Biol. Psychiatry 11,
31–42.
Hantouche, E.G., Akiskal, H.S., Lancrenon, S., Allilaire, J.F.,
ˆ
Sechter, D., Azorin, J.M., Bourgeois, M., Fraud, J.P., Chatenet-
ˆ
Duchene, L., 1998. Systematic clinical methodology for val-
idating bipolar-II disorder: data in mid-stream from a French
national multisite study (EPIDEP). J. Affect. Disord. 50, 163–
173.
Koukopoulos, A., Tundro, A., Floris, G.F., Reginald, D., Minai,
G.P., Tondo, L., 1990. Changes in life habits that may influence
the course of affective disorders. In: Stefanis, C.N., Rabavias,
A.D., Soldatos, C.R. (Eds.), Psychiatry—A World Perspective.
Elsevier, Amsterdam.
Wehr, T.A., Goodwin, F.K., 1987. Can antidepressants cause
mania and worsen the course of affective illness? Am. J.
Psychiatry 144, 1403–1411.
Hecker, E. [in Wiesbaden], 1898. Die Cyclothymie, eine circulaere
Gemuethserkrankung. Zeitschrift fur Practische Artze, 7, 6–15.
American Psychiatric Association, 1994. Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition (DSM-IV). APA
Press, Washington, DC.