The melancholia of everything completed!

Allee im Park von Schloss Kammer, Gustav Klimt, 1912

Psychotic depression meets criteria for melancholia

The manifestations of depressed mood, family history and course of illness, laboratory test findings, and response to treatments are indistinguishable for those with and those without evidence of psychosis. Clinical vignettes are consistent with the view that psychotic depression is a severe form of melancholia and not a distinct entity.

Cotard syndrome as an example of psychotic depression

Delusions reported by patients are variable and often elaborate, enticing poets and scholars alike. An author’s name has been applied as an eponym in descriptions of some dramatic delusions. Patients who avowed the nihilistic delusion of ‘‘being dead’’ or having ‘‘no brain, nerves, chest or entrails, and was just skin and bone’’ met criteria for the de´lire de ne´gation, now recognized as the Cotard syndrome. Identified in the late nineteenth century, it is often reported among manic-depressive patients. Ananalysis of 100 cases reported in the literature found 89% of the patients to be depressed, the others suffering from various brain disorders. The most common nihilistic delusion concerned the body (86%), existence (69%), and immortality (55%). Co-occurring anxiety, guilt, and hypochondriacal delusions were frequent.
The appearance of delusions of negation even in the presence of a mood disorder syndrome does not preclude the possibility that the condition is the result of structural brain disease, and Cotard syndrome is also described in patients after brain injury.

Depression with catatonia or stupor is severe melancholia

When a depressive mood disorder is expressed in repetitive speech, repetitive movements, mutism, negativism, or other motor signs of catatonia, the differentiation from a structural dementia is diYcult.106 Catatonia in melancholic patients may be associated with such profound psychomotor retardation that it appears as stupor. Indeed, undiagnosed stupors (comas) that meet criteria for catatonia are an occasional feature of hospitalized patients on general medical and neurological services. Melancholic patients often exhibit catatonic features of prolonged fixed
postures (catalepsy). They pay little attention to their surroundings, stare into space, speak sluggishly or not at all, and look and move as if under the influence of sedatives. They are insensitive to painful stimuli and may be incontinent. The syndrome of catatonia is no longer considered a feature of schizophrenia alone, but is associated with depressive and manic mood disorders, and toxic and general medical disorders.

The close association between melancholia and catatonia was described by Karl Kahlbaum. In his patient descriptions, the motor signs of catatonia developed after melancholia had been fully expressed. Catatonia was also described in manic states, a finding that has been confirmed in the prominence of catatonia in the manic phases of manic-depressive disorders.
Melancholia is often associated with catatonia and one or the other syndrome may dominate at any one time. The overlap of syndromes suggests a commonality in the sites of brain dysfunction.