Le destin c'est simplement la forme accélérée du temps.

Der Mönch am Meer, Caspar David Friedrich, 1809.

Souvent perçu comme un fondateur de secte froid et intolérant, Jean Calvin, demeure, malgré la quantité et la qualité des ouvrages qui lui sont consacrés, l'une des figures les plus mal connues et les plus mal jugées de l'histoire du christianisme. Il faut dire aussi que Calvin n'a lui-même pas facilité la tâche de ses historiographes en évitant presque systématiquement de se mettre en avant dans ses écrits. Au contraire de Luther qui n'hésite jamais, notamment dans sa correspondance, mais aussi parfois dans ses sermons, à dévoiler ses états d'âme, ses angoisses, ses peines, ses joies et ses aspirations, Calvin ne cherche, toute sa vie durant, qu'à se rendre presque totalement transparent, à s'effacer devant Dieu pour mieux lui rendre justice et se faire exclusivement le vecteur de la Parole.

Ces attitudes opposées sont elles-mêmes le reflet de deux théologies différentes.

Luther est toujours soucieux de faire comprendre à son auditeur ou à son interlocuteur que Dieu est avant tout « Dieu pour toi » : il est plus fécond de s'interroger sur le travail de Dieu, de sa Parole et de son Esprit en chacun de nous que sur l'essence de Dieu lui-même. On pourrait en effet dire qu'avant même d'être un théologien, Luther est un pasteur, qui considère la cure d'âme comme sa principale tâche, et n'hésite donc pas à recourir au témoignage, qui n'est pas un simple étalage de ce qu'il peut vivre, mais plutôt une analyse de sa propre expérience de croyant, convaincu que cela peut être très utile à l'édification et au réconfort des fidèles. Calvin en revanche, toujours troublé par cette énigme qu'est Dieu, saisi par l'incompréhensible grandeur de son amour, cherche à sonder les recoins les plus obscurs de la foi : dès 1534, il rédige un petit traité De Psychopannychia, « par lequel est prouvé que les âmes veillent et vivent après qu'elles sont sorties du corps contre l'erreur de quelques ignorants qui pensent qu'elles dorment jusqu'au jour du jugement ». Paru en latin en 1542 et traduit en français en 1558, ce traité au sujet mystérieux montre le goût de cet intellectuel, proche un temps des humanistes, pour l'énigme théologique.

L'attention particulière portée par Calvin au problème de la prédestination s'inscrit dans cette logique. Mais il faut aussi souligner que si Calvin développe ce thème avec tant de soin, c'est parce que face aux oppositions, il est obligé de préciser sa doctrine. Dans la première édition de l'Institution de la religion chrétienne, paru en 1536, on chercherait en vain un exposé systématique sur la prédestination ; ce n'est que dans l'édition de 1539 que Calvin consacre un chapitre à ce problème, qui ne cessera de grossir au fil des éditions ultérieures de l'oeuvre, jusqu'en 1559. Ce chapitre est complété par deux traités spécifiques, De la prédestination éternelle de Dieu (1552) et La congrégation sur l'élection éternelle (1562).

La Raison c'est la folie du plus fort. La raison du moins fort c'est de la folie.

Francisco de Goya y Lucientes , Perro Semihundido.

Psychotic depression is melancholia

Approximately one-third of melancholic patients are psychotic. Psychotic features in melancholia are reported at all ages, although the recognition of psychotic depression increases with the patient’s age. In some reviews nearly all patients with psychotic depression are melancholic.

In nineteenth-century psychopathology, disorders of thought were identified in patients classified as manic-depressive insanity, involutional and melancholic depression, dementia praecox, and dementia paralytica (neurosyphilis). Psychosis was not pathognomonic for any condition. During the early and mid twentieth century, however, ‘‘first-rank’’ psychotic features (e.g., complete auditory hallucinations, experiences of alienation and control) were associated with the hereditary disorder of dementia praecox, later redefined as ‘‘schizophrenia.’’ The presence of these signs was considered pathognomonic of schizophrenia regardless of the presence of a concurrent mood disorder.

The view that schizophrenia encompassed almost all episodes of psychosis was favored in the USA but not in Europe. Cross-Atlantic diVerences in the prevalence of schizophrenia and of manic-depressive psychosis were reported, and to assess the basis for the discrepancy, a cross-national group of investigators examined patients in the UK and in the USA. Differences in diagnostic perceptions, not national distinctions in populations, best explained the differences in prevalence of the disorders. The broad definition of schizophrenia in the USA materially increased the numbers of patients who were labeled schizophrenic while reducing the
numbers diagnosed with mood disorders.

The place of psychotic mood disorder in psychiatric classification remained unclear. Some considered these states to be more severe forms of manic-depressive illness while others preferred to define them as ‘‘schizoaVective’’ and to include them among the psychotic disorders. One understanding of psychosis in patients with mood disorders derived from the clinical trials of TCAs. Among depressed hospitalized patients treated with imipramine with serum blood levels monitored to assure adequate dosing, some patients failed to respond to imipramine but did respond to ECT. The presence of delusions discriminated the patients who had not improved with imipramine alone. A decade earlier, a large Italian study by De Carolis et al. (1964) had also reported that the psychotic depressed patients had not responded to imipramine but had recovered with ECT. The association between depression, psychosis, poor response to TCAs, and rapid response to ECTwas quickly confirmed and is now widely accepted.

The DSM classifications of 1980 and 1994 still give preference to psychotic features as defining schizophrenia, and they primarily link catatonia with schizophrenia despite its strong association with mood disorder. Psychotic features are recognized as a non-specific psychopathologic phenomenon, appearing within diVerent diagnostic classes, and delusions in a mood disorder are considered signs of severity, not distinctions in pathophysiology, but this classification is only permitted when directly linked to a disturbed mood state. If the patient has delusions that last longer than the mood symptoms or the psychotic features are deemed more pronounced, the schizoaffective diagnosis is preferred and the patient assigned to the psychotic disorders, not mood disorder, category. Nevertheless, for each principal mood disorder – major depressive disorder, bipolar I disorder, and bipolar II disorder, depressed type – the presence of psychosis could be recognized by coding the severity/psychotic/ remission specifier in the fifth digit.

Once a condition of ‘‘psychotic depression’’ or ‘‘delusional depression’’ was recognized, attention was paid to its delineation from other depressive illnesses. Focusing on the motor aspects of melancholia, Parker and Hadzi-Pavlovic (1996) envisioned three forms of depressive illness – psychotic depression, non-psychotic melancholia, and non-melancholic depression.79 They oVered criteria of discrimination by age of onset, degree of cognitive impairment, and prominence of personality and life events. Non-melancholic depression was characterized by early onset of illness, little cognitive impairment, deviant personality traits, and little psychomotor disturbance.

Severity of psychomotor disturbance and cognitive impairment characterized psychotic melancholia. Psychotically depressed patients exhibited more severe psychomotor disturbance, including facial immobility, slumped posture, slowed and limited movements and speech, poverty of associations, and poor responsiveness. Non suppression on the dexamethasone suppression test was recorded in 72% of the patients. The mood was characterized as ‘‘non-reactive.’’ While the distinction was clear between non-melancholic depression and the other two forms of depressive illness, psychotic and non-psychotic melancholia were not shown to be different diseases.

Other authors focused on abnormalities in neuroendocrine and neurocognitive measures, course of illness, familial transmission, and response to treatment as distinguishing psychotic and non-psychotic depression. Among the criteria were greater guilt feelings and psychomotor disturbances, biochemical differences in glucocorticoid activity, dopamine beta-hydroxylase activity, levels of dopamine and serotonin metabolites, severity of sleep measures, and ventricle-to-brain ratios.

Neuropsychological deficits were found to be greater in degree among psychotic depressed patients than among the non-psychotic depressed. None of these efforts identified a clearly distinguishing variable.

In a retrospective examination of patients in Denmark who had a diagnosis of a single depressive episode at their first ever discharge during the period 1994 through 1999, patients were identified as with or without the International Classification of Diseases, 10th edition (ICD-10) diagnosis of melancholia (n ¼ 248 and 293 respectively), and with and without psychosis (n ¼ 1275 and 1639, respectively).

Relapse rates were highest in the psychotic depression group. The groups did not differ in suicide rates or melancholic features. Compared to non-melancholic depressed patients, the melancholic patients were less likely to be diagnosed as having a personality disorder, stress-related disorder, or ‘‘nervous’’ disorder. It is diffcult to recognize the presence of psychosis in melancholic patients. The more severely ill depressed patients are common in referrals for ECT. In an analysis of ECT referrals, only 2/52 patients had been adequately treated for psychotic depression. The authors assumed that, had the referring physicians recognized the presence of psychosis, the medications prescribed would have been more appropriate for psychotic depression.

Other than the recognition of psychosis, no measures distinguish the psychotic and non-psychotic forms of melancholic illness.

La diferencia entre literatura y periodismo es que el periodismo es ilegible y la literatura no es leída

Francisco de Goya y Lucientes, El Aquelarre, 1797.

The scientific evidence fails to distinguish unipolar and bipolar depressive disorders. About 10% of melancholic patients exhibit manic features. The overlap is clearly expressed in the many descriptions of ‘‘mixed’’ and ‘‘spectrum’’ depressive and manic conditions. Patients may exhibit depressive and manic features during the same episode or episodes may recur in cycles, changing from one to another within weeks, days, or even within hours. The depressive state that is identified in a patient with a history of a manic or hypomanic episode cannot be distinguished from the depressive state in a patient without such a history. Neither family history nor course of illness successfully separates the two conditions. Nor does the putative induction of mania by antidepressant drugs assure the separation as the incidence of manic switches is no greater than the natural switch rate; it is sufficiently uncommon as not to be useful as a diagnostic test.

The responses to lithium and to anticonvulsants are cited as justifications for bipolarity. To support such a view, the evidence of the antidepressant efficacy of lithium is minimized, and the control of manic episodes by anticonvulsants maximized. Lithium is both an eVective antidepressant, especially in maintenance therapy, and an effective control for mania. Anticonvulsants are weak mood stabilizers; the treatment algorithms commonly require the polypharmacy of mood stabilizers (often two), antipsychotic, and sedative agents. Yet patients in both the depressive and manic phases of the illness respond rapidly to electroconvulsive therapy (ECT). The neuroendocrine and sleep laboratory tests that demarcate severe depressive mood disorders from other psychiatric disorders are abnormal during both the manic and depressive phases of their illness. The degree of abnormality is apparently less for patients in the manic phases but the difference is not sufficient to support the concept of bipolarity.

Bipolarity as a separate psychiatric disorder is not supported by psychopathology, family studies, laboratory tests, or treatment response. A single disorder of melancholia circumscribes the present knowledge and offers a better model for continuing scientific efforts.

Algunas personas enfocan su vida de modo que vivan con entremeses y guarniciones. El plato principal nunca lo conocen.

Francisco de Goya y Lucientes, El tres de Mayo de 1808, 1814.

Bipolar and unipolar conditions genetically overlap

After the original studies by Leonhard and by Perris reported that familial diVerences between recurrent depressive illness and manic-depressive illness, subsequent family and genetic studies commonly reported an overlap between the two forms of mood disorder, supporting a unitary construct. Both forms of illness occur with increased frequency in the families of patients with manic-depressive illness. When recurrent depressive illness is defined as melancholia, families have an increased risk for manic depression.

Twin studies show this overlap. In an analysis of 30 monozygotic and 37 dizygotic twin pairs, the proband concordance was higher for monozygotic than for dizygotic twins, with heritability estimated at 89%.66 In almost 29% of the monozygotic pairs, one twin had both manic and depressive episodes while the other had recurrent depressive illness. Among the dizygotic pairs 13.5% had a mixed concordance. The investigators tested several liability models and concluded that manic-depressive illness was not simply a more severe form of recurrent depressive illness, but that nevertheless, there was substantial genetic overlap between the twoforms (about 30%) that may represent the risk for depressive illness.

L'unico senso intimo delle cose è che esse non hanno alcun senso intimo.

Distruzione del secondo membro.

§.XIII. A distruzione del secondo membro della successiva principale conseguenza dico, essere pure impossibile che l'acqua sia gibbosa; lo che dimostro così: Sia il cielo dove sono quattro croci, l'acqua dove tre, la terra dove due; ed il centro della terra e dell'acqua concentrica e del cielo sia D. E ritengasi, che l'acqua non può esser concentrica colla terra, se non sia la terra gibbosa in qualche parte sopra la centrale circonferenza, come sa chi è istruito nelle matematiche. Se in alcuna parte s'innalza la circonferenza dell'acqua, e per ciò la sua gibbosità sia nel centro dove è H, quella poi della terra dov'è G; indi si tiri una linea da D ad H, ed un'altra da D ad F; egli è chiaro che la linea da D ad H è più lunga di quella da D ad F; e per questo la sua sommità è più alta della sommità dell'altra: e toccando ciascuna nella sua sommità la superficie dell'acqua, nè oltrepassandola, è chiaro che l'acqua della gibbosità sarà allo insù per rispetto alla superficie dov'è F.

Non essendo quivi adunque ostacolo (se sono vere le prime suppusizioni), l'acqua della gibbosità scorrerà in giù, finchè sarà equiparata al punto D con circonferenza centrale o regolare: e così sarà impossibile che permanga la gibbosità, o vi sia; il che doveva dimostrarsi. Ed oltre a questa principalissima dimostrazione, si può anche per probabilità dimostrare, che l'acqua non abbia gibbosità fuori della regolare circonferenza; perchè ciò che può farsi per un mezzo, meglio è che si faccia per uno, che per più: ma tutto all'opposto può farsi per la sola gibbosità della terra, siccome fra poco sarà dimostrato; adunque non v'ha gibbosità nell'acqua; dacchè Dio e la natura fanno sempre, e vogliono ciò ch'è meglio, siccome appare dal Filosofo dove tratta del Cielo e del Mondo, e nel II della Generazione degli Animali. Quindi risulta chiaro sufficientemente intorno al primo; cioè, essere impossibile che l'acqua sia più alta in alcuna parte della sua circonferenza, vale a dire più lontana dal centro del mondo, di quello che lo sia la superficie di questa terra abitabile: lo che secondo l'ordine era da dirsi primamente.

Conchiude, l'acqua essere concentrica.

§.XIV. Se adunque è impossibile che l'acqua sia eccentrica, come venne dimostrato per la prima figura; e che abbia qualche gibbosità, come per la seconda si è pur dimostrato: ne viene di necessità, che sia concentrica ed equiparata, vale a dire ugualmente in ogni parte della sua circonferenza distante dal centro del mondo; com'è chiaro da sè.

Argomenta al contrario; ed in prima:

§.XV. Ora così ragiono: Tutto ciò che sovrasta ad alcuna parte della circonferenza egualmente distante dal centro, è più lontana dallo stesso centro, di quello che lo sia qualche parte della stessa circonferenza: ma tutti i lidi tanto della stessa Anfitrite, quanto dei mari mediterranei sovrastanno alla superficie del contiguo mare, come scorgesi coll'occhio; dunque tutti i lidi sono più remoti dal centro del mondo, essendo il centro del monde anche centro del mare (come si è veduto), e le superficie littorali essendo parti di tutta la superficie del mare. E come ogni cosa più remota dal centro del mondo è anche più alta, ne consegue che i lidi tutti siano sovrastanti a tutto il mare; e se i lidi, molto più le altre regioni della terra, quelli essendo parti inferiori di questa; lo che dimostrano i fiumi discendenti ai lidi. La maggiore poi di questa dimostrazione viene provata nei Teoremi geometrici; e la dimostrazione è ostensiva, benchè abbia la sua forza, come nelle cose che si sono dimostrate superiormente per impossibili. E così è chiaro del secondo.