Aretaeus On Bipolar Disorder

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

“Trouble falling asleep, or sleeping too much”

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

“Feeling tired or having little energy”

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

“Poor appetite, or overeating”

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

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

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

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

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

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


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

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

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

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

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

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

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18 Responses to Aretaeus On Bipolar Disorder

  1. The faster you talk to and also answer, the stronger
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  2. Paul Torek says:

    I seriously doubt that bipolar disorder is roughly equally common in all nations and cultures. The diagnosis rate in the United States has certainly not remained constant, especially in certain age groups. Now, you might say that this is a matter of diagnosis, not prevalence. But that’s still evidence of a large cultural component: for instance, when does a certain pattern of behavior become a “problem”?

    On a related note, starvation is significantly heritable, insofar as bodies differ in their reactions to calorie deprivation. But it’s not obvious that this has significant implications for the best ways to treat starvation.

  3. Jed says:

    Before the Protestants got hold of it, sloth (“slowth”) was the emotional state of not wanting to do anything, rather than idleness per se. Dante’s description of hell-for-the-slothful uses imagery straight out of a Zoloft commercial: black clouds, breathlessness, drowsiness, turbid water, and weight. Mixed in with them are the wrathful, who trample the slothful into the fens of Styx while tearing one another to pieces. The circle above them houses hoarders and prodigals, who abuse each other in a kind of Sisyphean joust. The pair of pairings is unique in the Inferno, and the narrative underlines it by packing all four groups into a single canto.

    There are a lot of quibbles. But you can tell a convincing story: Florence circa 1300 generated enormous amounts of new wealth. Sooner or later some of it would have made its way into the hands of unstable young men. Flame-outs would have been more spectacular then, because money was more concentrated, there was less to buy, and everybody knew everybody else. So someone like Dante would have gotten a good long look at some common pathologies.

    But you do have to look askance at a guy whose response to the great 20th century tyrants would begin, “At least you didn’t charge any interest.”

  4. Joe from London says:

    Have you tried running this experiment on a few diseases you do consider to be culture-bound? I’m not sure which ones you place in that category, but it might be an interesting experiment.

    • Brian says:

      Wikipedia lists several culture-bound syndrome among subpopulations of the US (mostly the South), but nothing common to mainstream American culture or Western culture in general. So that’s not very helpful.

      What would we expect a culture-bound syndrome in the West to look like? There’s a lot of variation in symptoms between the ones Wikipedia lists, but they all appear in the local popular culture in a more or less medicalized form; many are linked to social pressures or have some sort of genital focus; spontaneous movement seems to be a theme.

  5. Doug S. says:

    Apparently, characters in Charles Dickens’s novels often suffered from various conditions that we now have names for. The most famous example is that one character in The Pickwick Papers suffered from the symptoms of sleep apnea, long before anyone knew what sleep apnea was – the first description of sleep apnea in modern medical literature was in 1952. And Ebenezer Scrooge may have suffered from Lewy body dementia.

    Going back further than Dickens but not as far as ancient Greece, Shakespeare’s Hamlet appears to have bipolar disorder.

    I have no idea if Don Quixote has a real-world mental disorder or not, though.

  6. Gunlord says:

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

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

    At the same time, though, isn’t it possible that there may be a lot of mental diseases with biological groundings that didn’t exist in other times or cultures? For instance, just off the top of my head, something like, I dunno, video game addiction might have gone unrecognized in Rome, since video games didn’t exist yet. I guess it might have had an analogue in some other compulsive behavior back then, though…

    • Doug S. says:

      Compulsive gambling, maybe. I once heard that the Romans were very into gambling…

      • Jed says:

        The Athenians chose leaders by drawing lots. It made sense to them because serving in the army was how you qualified for office, war between cities was fairly common, and in a phalanx almost half your protection comes from the shield of the guy to your right. So before you could be chosen, someone had to bet their femoral and carotid arteries on you.

        Not that it mattered. It’s a lesson that bears repeating: bad politics comes from bad incentives, not bad people.

  7. Douglas Knight says:

    Thanks! I care a lot about ancient Greek views on bipolar disorder. PS – you inconsistently spell Aretaeus. Should be A before E.

  8. Yogonath says:

    Scott, I am leaving this comment here because you made the Apophemi post un-commentable. Since I am not going to get into the dirty bits of the argument, I hope you will not mind too much.

    When you wrote thousands of words first to steel-man and then to attack Reactionary bloggers, I, like many others, was puzzled as to why you’d devote so much effort to a pretty obviously inconsistent and extremely insular ideology. But you wrote (if memory serves) that you thought their out-there ideas still held discussion value as radical thought experiments. That was fair enough, and besides, even if you had been wrong, time you enjoyed wasting isn’t wasted, as the saying goes.

    Now you’re doing the same with social justice warriors. I can easily see a similar motivation applying – that at the heart of all the bullying and circle-jerking you believe there is a core of valuable ideas. However, I have a different question… no, a different concern now: why would you debate people that make you utterly miserable? If you could entertain their ideas and their unreserved hostility with detachment, without feeling personally affected, that would be one thing; but you acknowledged that you can’t, and more importantly you showed it throughout your post. At several points I could almost see you cringing (in the original meaning of the word) as you wrote it, and it made me cringe (in the Reddit meaning) in response.

    You don’t owe those people anything. And anything you might gain by debating their ideas, you could still gain by having debates with people who grant you the benefit of basic respect and humanity. If the Reactionaries, instead of addressing the points you made (however poorly), had been whining at you about their God-given right to call you “demotist faggot” whenever you disagreed with them, would you have directly engaged them and linked their responses?

    • Cyan says:

      Also commenting here in regards to the Apophemi response, although my comment is really really(!) inconsequential. FWIW one doesn’t need to own a horse to learn horse-back riding or even compete in horse shows. Stables that offer lessons usually have a stock of ponies on which kids can learn; horse owners will lease horses to competitive riders without horses of their own.

      It’s still bloody expensive, but it’s within reach of the non-rich.

      • gwern says:

        Stables that offer lessons usually have a stock of ponies on which kids can learn

        I did this in high school, actually. It was a lot of fun.

    • Andrew says:

      Comments aren’t closed on that post due to a misclick or a software bug, you know. If you’ve got something super-important to say to Scott, I imagine he’d rather you email him. If you’ve got something super-important to say to the internet, I imagine he’d rather you at least say it somewhere else.