17 janvier 2009

Das Absurde am Leben macht es erst erträglich.


Le jour des morts, Adolphe William Bouguereau, 1859.


The descriptions of melancholia over millennia by medical authorities, writers, and public figures have face validity. The recognition led to the inclusion of ‘‘melancholia’’ in some form in all psychiatric classification systems. This heritage regards melancholia as a disorder in mood accompanied by perturbations in circadian and ultradian rhythms. Psychomotor disturbance is always present, expressed as agitation or inactivity, slowness of movement and speech, catatonia, or stupor. Ruminations of despondency and death dominate the suVerer’s waking thoughts. Suicide is all too frequent.

Melancholia is the classic depressive mood disorder. Psychotic depression, manicdepressive depression, puerperal depressions, and abnormal bereavement are part of the melancholia picture. Diverse disease processes, such as endocrinopathies and seizure disorder, induce it. It is recognized worldwide and at all ages, becoming most prominent in older adults. Melancholia is less recognized in young children, but that omission may be a distortion of classification.

Despite its long history, the position of melancholia in psychiatric taxonomy is unclear. Traditionally it was considered a distinct illness. More recently it has been viewed as a stage of illness, not fundamentally diVerent in pathophysiology from other depressive illnesses. Which view is correct?

The historical record clearly presents melancholia as a distinct disorder of mood that is present from its onset. Simple retardation was considered a mild form. There appears gradually a sort of mental sluggishness; thought becomes diYcult; the patients find diYculty in coming to a decision and in expressing themselves. It is hard for them to follow the thought in reading or ordinary conversation. They fail to find the usual interest in their surroundings.

The process of association of ideas is remarkably retarded . . . they have nothing to say; there is a dearth of ideas and a poverty of thought . . . It is hard to remember the most commonplace things. They appear dull and sluggish, and explain that they really feel tired and exhausted . . .
Melancholia was viewed as a distinct disease, not a stage of illness. The milder features occurring at the onset of an episode were considered as typical of melancholia as were its most severe symptoms. By contrast, the historical record does not recognize most of the depression syndromes in the present classifications, although some diagnoses, such as abnormal bereavement and postpartum depression, can be seen as variants of melancholia. Other Diagnostic and Statistical Manual (DSM) depression options, such as dysthymia and adjustment disorder, have unclear meaning or validity.

Depressive-like states are classified by severity or episode duration into major and minor categories on the assumption that all have the same pathophysiology. This assumption lacks proof and the mixing of the variations in depressive illnesses, like the mixing of apples and oranges in discussing fruits, clouds the traditional face of melancholia.

06 janvier 2009

A lembrança da dor ainda é a dor, a lembrança da felicidade já o deixou de ser.


La Douleur, Jacques Louis David, 1770.

En la forest de Longue Attente

En la forest de Longue Attente
Mon povre cuer tant se garmente
D'en saillir par aucune voye
Qu'il ne lui semble pas qu'il voye
Jamais la fin de son entente.

Desconfort le tient en sa tente
Qui par telle façon le tente
Que j'ay paour qu'il ne se forvoye
En la forest de Longue Attente.

Espoir en riens ne le contente
Comme il souloit, pour quoy dolente
Sera ma vie, ou que je soye,
Et si auray, en lieu de joye,
Dueil et Soussy tousjours de rente

En la forest de Longue Attente.


Gilles des Ormes 1438-1500

Le monde est un chaos, et son désordre excède tout ce qu'on y voudrait apporter de remède.


Der Kuß, Gustav Klimt, 1907.

Melancholia defined by a specific event

Clinicians often ascribe etiologic significance to a special event preceding an episode of mood disorder, but the causal association is not established and the depressive illnesses that occur under such circumstances do not diVer from classical melancholia.
Descriptions of postpartum melancholia, vascular or late-life depression, abnormal bereavement, and seasonal depression are examples of disorders labeled according to the presence of hypothecated precipitants.

The circumstances assumed to be precipitants do not alter the typical features of the melancholic syndrome, the characteristic laboratory findings, or the treatment response. The melancholic syndromes are indistinguishable in characteristics and to the extent known, in their biology. It is confusing for clinicians and inhibiting of scientific assessments to separate patients with episodes of illness that meet the criteria for melancholia simply because the episodes are associated with a specific circumstance. Adverse events are commonly associated with emerging disease, but a myocardial infarction is no less a heart attack for occurring amidst personal turmoil, and neither is depressive illness.

Abnormal bereavement is melancholia

The DSM psychiatric classification includes abnormal bereavement as a specified form of depressive mood disorder. The dying and death of a loved one is traumatic. About half of women and 10% of men over age 65 have had a spouse die. By age 85, over 80% of women and 40% of men have had a spouse die. Although grief may persist for several years and one-third of widowed older persons initially meet DSM criteria for major depression, the common signs of depression rarely last beyond several weeks. Features persisting past 1 month after the death are associated with continuing mood disorder. Suicide remains a persistent risk. The clinical dilemma is the uncertainty of whether these prolonged symptoms reflect the circumstances and the patient’s personality, or are signs of an illness that requires treatment.
Abnormal bereavement is not distinguishable from melancholia, and the DSM criteria for it could easily be used as descriptors of melancholia. Sleep architecture and immune functions are disturbed in the normal bereaved, and their morbidity and mortality rates are high.
While disturbances in general medical health do not distinguish melancholia, the dexamethasone suppression test may be helpful as normal grieving is not associated with high cortisol levels and non-suppression. Four weeks following the death of a parent, children and adolescents have normal cortisol functioning. In one study of bereavement, however, 39% were non-suppressors. These patients had many melancholic features and were suicidal, clinically meeting criteria for melancholia as well as abnormal bereavement.

Identifying a syndrome of abnormal bereavement is unnecessary. The literature offers no defining characteristics that would distinguish this form of melancholia from any other. When bereavement is followed by a severe depressive illness and the illness meets criteria for melancholia, the illness warrants treatment for melancholia.

Features of abnormal bereavement

Sustained and non-reactive mood disturbance
Psychosis
Marked psychomotor impairment
Failure to regain level of pre-death social functioning within 2 months
Preoccupation with worthlessness and desire to die
Suicide attempt