{"id":17062,"date":"2011-12-09T11:00:04","date_gmt":"2011-12-09T16:00:04","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=17062"},"modified":"2011-12-09T11:26:07","modified_gmt":"2011-12-09T16:26:07","slug":"melancholia","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/12\/09\/melancholia\/","title":{"rendered":"melancholia…"},"content":{"rendered":"\n

from SG<\/font><\/strong><\/u><\/a>:"I would be grateful if you would consider a thorough posting on what you’ve seen as melancholia. I think I’ve followed your postings faithfully and you’ve made me aware that not all MDD is the same but I’d really like your opinion on what I believe you term melancholia.<\/em>"<\/p>\n

The term, Melancholia [literally black bile] comes from antiquity and describes a state of painful dejection, famously portrayed in Albrecht Dü<\/span>rer’s wood-cut shown on the leftt. In a variety of incarnations, the term has been used over the years to describe a particular kind of depressed state, often dichotomized with all other forms of depression. Most people trained in psychiatry in my era and before were taught [and accepted] that there were two forms of depression – the terms were endogenous depression<\/em> and exogenous depression<\/em>, but there have plenty of other synonyms for each. The controversy is that the DSM-III and all of its later iterations did not separate the depressions into two groups, or in fact, into groups at all. All depressions were included under the term Major Depressive Disorder. Reasons? The usual suspects – lack of evidence-based<\/em> or measurement-based<\/em> this and that. Who really knows?<\/p>\n

Depression is a communicative emotion. When you meet a person who is depressed, you can usually see it and are drawn to comment on it, "You look really down." It’s quickly the topic of the encounter, and one is drawn to think and ask about "why?" – why is this person depressed? Some patients know the answer, or have an idea about it. Even those  who don’t know<\/em>, at least understand the question. Patients with Melancholic Depression may or may not have something to say in response, but it doesn’t seem relevant. There’s not a why<\/em>, at least not one that makes any sense. What they say isn’t really an explanation of the depression, it’s a part of it. In Melancholia, there’s a timeless quality – the patient doesn’t so much connect with a before<\/em> and a during<\/em>. The patient I mentioned earlier [as precisely as possible…<\/font><\/a><\/strong><\/u>] kept saying things like "I think I’ve always been…" or "I never been …" He was a person I’ve seen in the community a number of times when he was perfectly fine, but even in the presence of someone who’d been around him when he was obviously happy and enjoying himself, he couldn’t relate to ever having felt anything other than his Melancholy.<\/p>\n

Melancholic Depression isn’t only pervasive in time, it’s pervasive in all dimensions. There’s a saying "there’s a black dog over there" meaning that there’s no escape from the feeling, and the interviewer quickly feels that because everything the patient says simply reiterates the state of depression. The interview goes nowhere, because there’s no place other than the depression to go. Likewise, the Melancholic person doesn’t relate to the words that we usually use to describe depression like sadness<\/em>. I used the word "blue" in talking to this man, and he said "not blue – more like black." Later he said "not really sad" and "it’s not like grieving." The way such statements are usually understood is that Melancholic patients are describing a feeling unlike anything that occurs naturally in life. We all know what sadness feels like and can be empathic with depression of the usual variety, but there’s not a similar connection with Melancholy. The Melancholic is not describing something we’ve personally ever felt [and knows it]. <\/p>\n

Self-attacking, self-flagellating, guilt, shame, low self esteem are all phrases used to describe the negative perception of the depressed person. In Melancholia, it seems to also have a different quality, though this is more how these patients seem to me than something I’ve read. They think the are bad<\/em>, like a noun. But it’s not bad<\/em> as in evil, it’s bad<\/em> like "that pear has gone bad" eg rotten<\/em>. And it’s often that they are bad<\/em> because<\/u> they are Melancholic – not because of things done or not done before. In the case in point, he said that he was bad<\/em> because he didn’t want to work, get out of bed, be with his daughter, be any fun, etc. Something like being a rotten apple that would spoil the other apples in the barrel.<\/p>\n

There’s more. The physical symptoms [sleep, appetite, diurnal variations, etc.] are prominent [see below]. There’s often a family history [Depressions, Manic Depressive Illness, Alcoholism, Suicides]. The patient may have had previous episodes of depression or comorbid<\/em> alcoholism or alcohol problems. This is the clinical presentation of the Depressive Episodes in Manic Depressive Illness. Melancholic Depressives respond to Antidepressants regularly and are particularly responsive to ECT. Almost anyone who has talked about Melancholia over the ages has presumed Melancholia to be a biological disease. At the time I was in training, this was called Endogenous Depression, contrasted with Exogenous Depression – depressions related to life and personality. Like many other psychiatrists, I still essentially believe that schema, knowing full well that it hasn’t been proven<\/em>.<\/p>\n

Melancholia is not a topic I consider my area of  expertise. I saw a lot of Melancholic Depression in training and on the faculty [1974-1986], but very few cases thereafter. Most of the later cases were like the man mentioned earlier, people that came my way via routes other than my private office. Psychoanalysts who do mainly psychotherapy don’t get referred such patients [but that doesn’t seem to have stopped me from commenting]:<\/div>\n