By Lisa Hermsen
I procrastinated with the opening for this blog post. I have been researching and writing about the historical contexts of the word “mania” for years now. During procrastination, writers do odd things – bake quiche, clean ceiling tiles, alphabetically arrange their books. While I was in this mode, deliberating about the tone and context for what’s to come, I decided, perhaps impulsively, to tear up my stained stairway carpet. It was late. And I had a mess. When I called my mother for advice on the best course of action, she suggested I hang up immediately and call my psychiatrist.
I do not recognize myself as a maniac. And yet, I am one.
For most of its history, the word “mania” denoted a general madness – a raging fury. Aretaeus of Cappadocia (150-200 CE) in his Chronic Diseases, described mania as a condition marked by excess: “they with whose madness joy is associated, laugh, play, dance night and day, and sometimes go openly to the market crowned, as if victors in some contest of skill; this form is inoffensive to those around. 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.”
Aretaeus’s maniac, who “may become wholly mad and run unrestrainedly, roar aloud, flee the haunts of men and go to the wilderness to live by himself,” informs descriptions of mania from classical medicine to nineteenth-century psychiatry. This conventional representation of the maniac—raving, furious, and excessive—was captured in a familiar and widespread illustration by Sir Charles Bell in his Essays on the Anatomy of Expression in Painting (1806). Bell intended this portrait to render “ferocity amid the utter wreck of the intellect.”
Bell’s cowering, physically restrained personification of “Madness” reflects a remarkably stable tradition of imagining and depicting mania as exaggerated human forms seemingly devoid of all reason and devolved into full derangement. From classical Greek texts to nineteenth-century psychiatry, mania came into being as a condition of excess, embedded in the layering of text upon text, image upon image. Associated with a general category of madness, mania came to be used interchangeably in English with such words as “lunacy” or “insanity” to describe the agitated, furious, and sometimes rageful insane. But while lunacy and insanity have, for the most part, disappeared from contemporary clinical discourse, mania has been incorporated in clinical vocabulary. Mania is a contemporary diagnosis and an emotional disorder, a pole on the affective spectrum.
The general category of madness, of which mania was a part until 1800, was transformed when the classical notion of a single madness with various manifestations was replaced by a classification system with clinical diagnostic criteria. In his book Of Mental Diseases Treated With Respect to Medicine, Public Health, and Forensics (1838), The French psychiatrist Etienne Esquirol (1772-1840) moved away from classical notions of mania by distinguishing it from general madness. Esquirol, “the crown prince of reformed psychiatry”, emphasized an important and enduring distinction: that mania was not an intellectual disorder, but an emotional one.
However, while Esquirol’s classification system might have signaled radical change in early psychiatry, the symptomatic descriptions of the disorder used for purposes of diagnosis are quite familiar. His classification therefore also marks what has been described as a “bridge,” transporting deep-rooted notions of madness into current clinical diagnostic criteria for mania. Esquirol offered this symptomology:
“In mania, the multiplicity, rapidity, and incoherence of ideas, together with the defect in the power of attention, exalt the passions of the maniac, occasion errors of judgment, corrupt his desires, and impel him to determinations more or less strange, unusual or violent” (378).
His description of the admission of one patient, Madame A, to his hospital in 1813, while clothed in the vocabulary of clinical diagnosis, recalls familiar notions of madness:
“At the period of her admission into the hospital Salpêtrière, Mad’e A . . . has numerous hallucinations, utters abusive and threatening language, and deals blows upon all around her. The patient breaks everything within her reach, tears her clothing, goes naked, rolls upon the ground, sings, dances, vociferates, and rejects the aliments that are offered her.”
Esquirol transcribed a general condition into a specific syndrome, but one that remained characterized by major abnormalities of affection, including exalted states, inattention, impulsivity, rapid speech and thought, euphoric behaviors, and artistic but incoherent language.
The methods of observation and the classification system culminated in new understandings of mania as a mood or affective disorder. Esquirol emphasized the importance of careful observation to ensure correct classification, as when he made notes about Md’e A’s “emaciation, the swarthy hue of the skin, the contraction of the muscles of the countenance, the knit brow, the commissures of the lips convulsively raised, the eyes sunken, often injected and haggard, and the animated, although doubtful look, give to the physiognomy of this maniac, a character which perfectly expresses the disorder and exaltation of her ideas and affections.” Nevertheless, the figure of the maniac in observation and classification continued to enact furious, mischievous, violent, whimsical, ridiculous, excitable, passionate, sexual, noisy, and foolish performances. This history of continuity has been supported by medical historians, such as Andrew Scull, who suggested that even towards the close of the eighteenth century, mania still wore its earlier garb.
Although medical textbook classification systems multiplied chaotically and were adopted in piecemeal fashion with only touches of consensus, mania remained a disorder of mood diagnosed by its symptomology. Emil Kraepelin’s Compendium der Psychiatrie, in 6th edition by 1899, is an important continuation of this narrative because it is considered still to be the basis for the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), the leading guide for psychiatric diagnosis. Kraepelin’s Clinical Psychiatry laid the foundations for manic-depressive disorder, or what we recognize now as bipolar disorder. When Kraepelin began writing about mania in his work on Manic Depressive Insanity, he noted that mood was mostly exalted in mania. In this lively excitement, mania had the “peculiar coloring of unrestrained merriment.” He noted that:
“patients cannot sit or lie still; they run back and forth, dance about, turn handsprings, sing, shout, and prattle incessantly, make all sorts of gestures, tear off clothing, pull down the hair, clap the hands, smear the person or the room with grotesque designs.”
Below is a photograph of one such individual who ornamented himself with torn strips of clothing.
The recent and controversial DSM-V (2013) outlines the classical understanding of mania and notes that criteria for contemporary bipolar disorder show little difference from criteria for the manic-depressive disorder described in the nineteenth century. The “essential feature” is that of “elevated, expansive, or irritable mood.” Other symptoms described include grandiose delusions, rapid or pressured speech, racing thoughts, increased activity, and impulsive behavior, including sexual promiscuity, spending sprees, and reckless driving. Examples of manic behaviors are all too familiar. The authors state that “Speech is sometimes characterized by jokes, puns, amusing irrelevancies, and theatricality, with dramatic mannerism, singing, and excessive gesturing.” While individuals may become flamboyant, some “may become hostile and physically threatening to others.”
As we enter a new age of neuropsychiatry, professionals are emphasizing the associations between mood disorders and regional structural brain abnormalities: limbic portion of basal ganglia and brainstem structures. The New Oxford Textbook of Psychiatry, a leading guide for today’s students and clinicians, lists “heightened mood, more and faster speech, quicker thought, brisker physical and mental activity levels, more energy with a corresponding decreased need for sleep, irritability, perceptual acuity, paranoia, heightened sexuality, and impulsivity” among the diagnostic criteria for bipolar disorder.
Whilst medical genealogies of ideas are attractive, we should listen to German Berrios, a prominent medical historian, who warns against reading instances of mania from the past through the lens of the present. He has noted that what might have been denoted as “mania” in the first century AD bears little reliable relation to the disorder classified as bipolar and the defining manic episodes.  His assertion that no plausible history of “mania” can be written leads him to argue that such historical examinations could be histories merely of words.
Little comfort for us maniacs. How could the remnants of classical madness, entangled in clinical mania, not be discomforting for us? Descriptions of mania continue to highlight excessive euphoria or extreme rage, with dangerous impulsive activity. Of course, the past is always and everywhere confronted with the everyday present.
But to claim that such depictions of madness have vanished or have been replaced by more reasonable clinical encounters of illness is to make it even more difficult for me to evaluate my symptoms (or lack thereof). What does it mean that I started an impulsive massive home improvement when I ought to have been studiously writing instead?
Lisa Hermsen is associate professor of English at the Rochester Institute of Technology. She is the author of Manic Minds: Mania’s Mad History and Its Neuro-Future (Rutgers UP, 2011).
 Aretaeus, The Extant Works of Aretaeus, The Cappadocian. Edited and translated by Francis Adams. Boston: Milford House, 1972. p. 302.
 For a longer discussion with additional texts, see Manic Minds: Mania’s Mad History and Its NeuroFuture (Rutgers, 2011).
 Esquirol, Etienne. Mental Maladies : A Treatise on Insanity. Philadelphia: Lee and Blanchard, 1845.
 Shorter, Edward. A History of Psychiatry. 1997. p.13.
 Esquirol, Etienne. Mental Maladies : A Treatise on Insanity. Philadelphia: Lee and Blanchard, 1845.
 Scull, Andrew. Social Order/Social Disorder: Anglo-American Psychiatry in Historical Perspective (Berkeley: University of California Press, 1989), 58.
 First published in 1883, the Compendium was edited consistently, through its definitive 6th edition.
 Kraepelin, Emil. Manic Depressive Insanity and Paranoia. 1921.
 Gelder, Michael, Nancy Andreasen, Juan Lopez-Ibor, and John Geddes. Eds. New Oxford Textbook of Psychiatry (Oxford: Oxford Univ. Press, 2009).
 G. E. Berrios, “Classic Text No.57: Of Mania: (from Bucknill and Tuke, 1858),” History of Psychiatry 15.1 (2004): 109; Berrios, “Mood Disorders.” in A History of Clinical Psychiatry: The Origin and History of Psychiatric Disorders, ed., by German Berrios & Roy Porter (London: Athone Press, 1995), 384-408.
 Various clinicians and historians have attributed more or less significance to the origin of the concept in Aretaeus and its subsequent evolution to its status as a modern medical term. See also: S. Kotsopoulos, “Aretaeus the Cappadocian on Mental Illness,” Comprehensive Psychiatry 27.2 (1986): 171-179.