INVOLUTION MELANCHOLIA
In 1896 Kraepelin first definitely outlined his views on dementia
praecox, to which he assigned hebephrenia, although he did not at
the time include katatonia in his delimitation of that disease. He
also described melancholia in his fifth edition, classifying it as
an involutional or retrograde presenile process (Das Irresein des
Rückbildungsalters). He had not as yet formulated his theory of the
manic-depressive psychoses although he described manic and depressive
forms of periodical constitutional disorders. In 1899 he discarded the
mania and melancholia of other writers altogether or rather included
them in his new manic-depressive group, but still retained melancholia
as a distinct entity occurring in the involutional period of life only.
As has already been shown, melancholia is a term which had been used
for centuries and in a general way applied to depressions of any and
all types. Kraepelin's manic-depressive psychoses and dementia praecox
very largely destroyed the integrity of this old-time conception. It
has been shown, furthermore, that depressive states often constitute
an integral part of the picture of general paresis. Symptomatic
depressions more or less distinct in character have been associated
with a number of somatic diseases. Senile psychoses, epilepsy,
various organic conditions, the psychoneuroses and the psychopathic
personalities have depressive manifestations well recognized and
readily classifiable.
Kraepelin, however, pointed out the fact that there was another group
still unaccounted for—the anxious depressions of later life, which
he included under the designation of involution melancholia and which
did not belong to the manic-depressive group. This he described as
being preeminently a depression associated almost always with anxiety
and fear as prominent symptoms. Accompanying this condition there
are usually ideas of poverty, sin, or impending danger of some kind.
Delusions of self-accusation are quite common. Anxious restlessness
or agitated excitement is to be expected in a majority of the cases.
There is usually no clouding of the consciousness, although, as Hoch
expresses it, "the mental horizon may be more or less narrowed to the
depressive ideas." The memory as a rule is not impaired. Hallucinations
of sight and hearing are often present. Somatic delusions of a
hypochondriacal nature occur. Insomnia is usually marked. The tendency
of the disease is towards deterioration. Retardation and psychomotor
inactivity are not to be expected. Melancholia is to be differentiated
from manic-depressive insanity by the prominence of anxiety and
apprehension, the absence of any retardation or psychomotor inhibition,
the unusual frequency of self-accusation with ideas of sinfulness, the
clearness of the sensorium, the comparatively unfavorable prognosis and
the great frequency of suicidal impulses. The age, and the absence of
previous attacks, is, of course, exceedingly important in arriving at
a diagnosis. The onset of the disease is usually between the ages of
forty and sixty, but not infrequently it begins with the menopause in
women, and Kraepelin states that sixty per cent of the cases occur in
the female sex. He found a history of defective heredity very common.
The precipitating factor is often some mental shock, the illness
or death of friends, or disasters of various kinds. No distinctive
pathology of the disease has been described by Kraepelin. He was
uncertain as to the rôle played by arteriosclerosis in its etiology.
Diefendorf[283] reported that about one-third of the cases made complete
recoveries; twenty-three per cent were able to return to their previous
surroundings; twenty-six per cent terminated in an advanced state of
deterioration and nineteen per cent died within a period of two or
three years.
In 1907 Dreyfus,[284] at that time an assistant of Kraepelin's, made
an elaborate study of the cases previously diagnosed as involution
melancholia in the Heidelberg clinic. During a period of fourteen
years, a total of seventy-nine were reported. A thorough investigation
by Dreyfus showed that two-thirds of these had made complete recoveries
or improved to such an extent as to be able to go home. Only eight per
cent showed a marked mental deterioration. He also found that over
half of the series had more than one attack, usually depressions.
One-third of the patients died and were thus eliminated from further
consideration. The duration of the attack was over three years in
one-third of the cases reviewed. Fifteen per cent recovered in from
three to five years, nine per cent in from six to eight years, and
eight per cent in from ten to fourteen years. He was of the opinion
that after a careful study of the hospital records the symptoms found
could all be explained on the basis of manic-depressive insanity,
usually of a mixed form. Kraepelin had reported that forty-nine per
cent of his cases deteriorated mentally. Dreyfus reduced this on
further observation to only eight per cent. On analysis he found, in
many instances, brief periods of manic elation, sometimes only a matter
of hours or a few days, evidences of excitability, manic suggestion in
the eagerness of the patient to communicate his troubles to others,
and inhibitory processes indicated by a lack of interest, loss of
affection or even difficulty of thinking. Dreyfus concluded that the
depressions of late years were not so common as had been supposed and
that a sufficient knowledge of their history showed that they had
usually exhibited previous attacks. He thought that the long duration
of the disease probably led to erroneous ideas as to its termination in
deterioration.
Kirby[285] is of the opinion that Dreyfus based some of his findings on
insufficient evidence, as shown by his published case records:—"In
a considerable number of other cases the author's conclusion that
manic-depressive symptoms were present is based on extremely meagre
data. As an illustration one case may be referred to briefly. A man
fifty-three years old had an agitated depression lasting over two and
one-half years and terminating in recovery. The case record contains
no statement of any objective inhibition or feeling of subjective
insufficiency, neither are there any statements regarding flight
of ideas, or unusual loquacity. The diagnosis, however, is made of
manic-depressive insanity, with partial psychomotor inhibition and
flight of ideas. The assumption that these symptoms existed is based
entirely on the retrospective account from the patient, obtained three
years after recovery from the psychosis. He then declared that during
the attack he could not think calmly; it seemed that one thought
"knocked the other down," one thought "hunted after the other." He also
described a feeling as if there were a cap on his head, as if he were
nailed down. These retrospective statements are interpreted to mean
that there was partial psychomotor inhibition and flight of ideas. In
many other cases the reasoning is just as forced and the deductions
based on equally insufficient grounds.... The author's aim was to see
if the symptoms present fitted into certain schematic formula and thus
the analysis became rather a search for diagnostic signs supposed to
characterize a definite form of disease. Such a method leads away from
consideration of the mental disorder as a whole; a few minor features
are emphasized in the picture and because the patient recovers these
are raised to diagnostic importance—a little feeling of insufficiency
or a slight change of mood in a disorder which ends in recovery are
seized upon as evidence that a special kind of disease exists; as a
matter of fact, we would hardly miss just such symptoms in many other
psychoses. There is no attempt to get below the surface, to understand
the evolution of the disorder, or to use the facts in the development
in formulating the prognosis."
In the introduction to the book written by Dreyfus in 1907, Kraepelin
nevertheless expressed the opinion that "These results show that
for the most of these disorders which have been designated as
melancholia there now exists no sufficient reason to separate them
from manic-depressive insanity." This at the time was looked upon as
definitely settling the fate of the melancholia concept and it was
abandoned by some. As a general rule, however, the psychiatrists of
this country seem to have accepted Kraepelin's original description
of the disease as being thoroughly justified. To use White's words,
"Many psychiatrists still believe, although Kraepelin himself accepts
Dreyfus' conclusions, that there is still a place for involution
melancholia distinct from the manic-depressive group."
In his eighth edition Kraepelin[286] discusses melancholia as a
presenile condition and reviews the whole situation in considerable
detail. He shows that symptomatic considerations alone did not guide
him in his original conception of the disease. A great deal of weight
was attached to prognosis and certain forms were separated out and
differentiated from manic-depressive because they tended towards
mental enfeeblement. He calls attention to the fact that Thalbitzer
disputed the integrity of melancholia in 1905, classifying it as a
manic-depressive reaction. After reviewing the findings of Dreyfus he
admits that the conclusions of the latter are in the main correct and
that involution melancholia as originally described cannot be retained
as a definite entity. "The significant fact still remains," he says,
"that single attacks of depression are disproportionately common in
the involution period." Hübner, for instance, found twenty-one single
attacks of melancholia after the fiftieth year of age to only two
single attacks of mania. "The appearance of depressions, therefore,
through the revolutions of this period of life seems to be favored
to a special degree." He again states that he is unable to determine
what rôle is played in the involutional depressions by beginning
arteriosclerosis or the onset of senile conditions. He concludes,
however, that a form of depression, earlier described as melancholia,
is still to be separated from the manic-depressive psychoses although
not entirely clear as to its significance or exact delimitation.[287]
These are the most severe and rapidly fatal forms of anxious
excitements, as a rule developing suddenly and included now in his
presenile group. "These cases are anxious, restless, sleepless,
self-accusatory and show delusions of persecution." The delusional
ideas are depressive, extravagant and hypochondriacal. "They have
offended everybody; are eternally damned; Satan is coming and will take
them; he is out there. Nature has changed, everything is different, no
mercy can come from heaven; there are ghosts in the house; the patients
find themselves in the infernal regions, are surrounded by hostile
powers, are in a bewitched castle. They will be carried away, thrown
into a fiery furnace, their arms and legs cut off, have their throats
cut in the presence of a thousand students, and be buried alive. They
have a cancer in the stomach, the husband is insane or has had a
stroke." Suicidal attempts are frequent. Sometimes grandiose ideas are
expressed, accompanied by hallucinations. Apprehension and orientation
are usually not disturbed. This is ordinarily followed by a period of
violent excitement with agitated wringing of the hands, striking the
breast, tearing the hair, etc. Confusional conditions with clouding may
appear, often terminating shortly in a pneumonia, erysipelas or heart
failure. According to Nissl, widespread and well marked changes are to
be found in the brain at autopsy. There is an extensive destruction
of ganglion cells, although that cannot be definitely associated with
the symptoms of the disease. Kraepelin leaves the question open as to
whether this should be looked upon as some form of "acute delirium"
such as manifests itself in the course of various psychoses. The
disease is usually one of the sixth decade of life, much more common in
the female sex, and cannot without further information be definitely
excluded from the involutional processes. He concludes his discussion
by saying that these conditions probably "have some relation to the
similar delirious senile forms to be discussed later." This is, of
course, a decided modification of his original views, although it
is quite clear that he still feels that there is an involutional
depression, now included, however, in the presenile group.
In his chapter on manic-depressive insanity three years later
Kraepelin[288] referred to this question again as follows:—"Under these
circumstances I thought at first that the involutional depressions
described as special clinical forms, melancholia in the narrower sense,
which seemed to show essential differences in its general
characteristics, course, and to a certain extent in the history of its
development, should be separated from manic-depressive insanity. At the
same time I was aware of the fact that in a considerable number of the
involutional depressions, both on account of their clinical form and
their association sooner or later with manic states, their connection
with manic-depressive insanity could not be questioned. I therefore
made an effort to establish a practical differentiation, entirely
without satisfactory results. Further experience has demonstrated, as
was shown in the discussion of the presenile psychoses, that they do
not constitute grounds for the separation of melancholia. Deterioration
is explained by the development of senile or arteriosclerotic changes.
Some cases were of long duration, showing manic symptoms before
recovery. The frequency of depressions in advanced years we have
learned to be a legitimate development of the involutional period of
life. The substitution of anxious excitement for volitional inhibition
has proved to be an occurrence which is found in advancing years in
those cases which had an attack of the ordinary form in the decade
before (as shown in our cases 1 and 2). Hübner has, moreover, made
the observation that melancholia may show retardation in one attack
and not in the next. There remains, therefore, no adequate reason for
differentiating the involutional depressions heretofore described as
melancholia from manic-depressive insanity."
Kehrer[289] has made a careful analysis of the facts brought out
by Kraepelin's statistical diagram showing the various age groups
represented by his manic-depressive cases. "From the fifteenth year
of life, at which age manic and melancholic attacks are most frequent
(about twenty-five per cent), the curve of the manic attacks falls
steadily (with only two important rises at the thirty-fifth and the
forty-fifth years) until it becomes less than five per cent at the
seventieth year, while the curve of the melancholic conditions with
equal constancy increases (with the exception of the fifty-fifth
year only), especially between the forty-fifth and fiftieth years,
from fifty-two to seventy-four per cent and finally to eighty per
cent. On the other hand, the curve of the manic first attacks falls
steadily from 28.5 per cent at the twentieth year to 3.5 per cent at
the sixtieth, with a slight increase at fifty from 12.7 per cent to
13.4 per cent, while in the male sex the same curve shows no further
increase after the thirtieth year, when it reaches its maximum (33.8
per cent) and even shows a particularly sharp fall, from 22.2 per
cent to 5.9 per cent, between the fiftieth and sixtieth year....
Based on this diagram Kraepelin concluded that the depressions of the
involutional period, which did not show special symptoms of some other
disease entity, could not be differentiated from those of the earlier
periods of life."
Specht,[290] Hübner and Stransky have subscribed to these views.
Stransky expressed the opinion that "there is nothing in the form
of these depressions, either with or without anxiety, by which they
can be distinguished from those recognized as manic-depressive
insanity and that neither the course nor the age of onset offer any
convincing argument for their clinical independence." Rehm, on the
other hand, held that there were depressions of the involutional
period of life corresponding to Kraepelin's melancholia and not
belonging to manic-depressive insanity. He described these as lacking
the constitutional taint and characterized by a slow onset, without
previous attacks, fatigability, outspoken egocentric conduct,
hypochondriacal delusions of the deteriorative type and the appearance
of hallucinations. Bleuler,[291] Bumke, Seelert, Albrecht and others
still hold to the integrity of involution melancholia as a distinct
entity. "These forms," as Bleuler expresses it, "have as a rule a much
more protracted course. They progress slowly for one or two years,
continue to be mild, reaching their height in several years, and
decline slowly to their final conclusion. The inhibition is obscured
by great restlessness, genuine agitated forms are common, they tend to
recidivism much less than the others and show also much less heredity."
Albrecht, in 138 cases of functional psychoses of the involutional
period, only thirty-two of which were in men, diagnosed eighty-two as
genuine involution melancholia. In none of his cases did he find an
isolated attack of mania in that period of life. He differentiates this
condition from agitated melancholia, leaving the question open as to
whether this constitutes a pernicious form or is a presenile disease.
According to Bumke, psychic causes are more prominent in involution
melancholia than in the manic-depressive psychoses, the duration is
longer and they do not make such complete recoveries, the most common
termination being a depressive mental enfeeblement, with despondency
and an anxious hypochondriacal mood. For the genetic interpretation of
climacteric melancholia as well as the other involutional forms the
intimate association, according to Bumke, of endogenous with exogenous
factors is the point of greatest importance. "Involution only brings
the barrel to an overflow; it only adds exogenous to the individual
endogenous momentum so that the sum total leads to the outbreak of a
manifest psychosis." Seelert goes still further with the endogenous
exogenous theory of Bumke. "It depends on the type of the association
whether the organic anxiety psychosis, a melancholia or the depression
of a manic-depressive insanity develops in the later period of life.
In one the endogenous factors predominate, in the other the exogenous
and in melancholia (in its narrower sense) the two maintain a balance."
Although, as has been noted, no characteristic pathological changes
have been associated with involutional melancholia, a condition to
which attention was called by Adolf Meyer should be referred to here.
In 1901, in an article in "Brain" on "The Parenchymatous Systemic
Degenerations mainly in the Central Nervous System" he proposed the
name "Central Neuritis" for a terminal affection previously described
by Turner in 1899 and occurring more frequently perhaps in involutional
melancholia than in any other psychosis:—"This alteration has
been found to occur in peculiar forms of end stages of depressive
disorders, near or after the climacteric period, alcoholic-senile
and alcoholico-phthisical cachectic states, idiocy, and perhaps also
general paralysis (Turner's case). Ordinary infectious and cachectic
states do not, however, appear to form an important link in the
causes."[292] The mental condition is usually anxious, agitated and
apprehensive, often terminating in a delirium followed by a stupor.
The disease may last for a few days ending in death or may recover
after several weeks. It is accompanied by progressive weakness, loss
of weight and wasting, a slight rise of temperature, and in many cases
attacks of diarrhea. Characteristic are muscular tension with rigidity,
twitching movements, incoordination and jactitation of the limbs.
The reflexes are usually increased. The onset is often quite sudden,
usually in the fourth, fifth or sixth decade of life. At autopsy a
striking condition, described as axonal alteration, is found in the
"Betz" and other large ganglion cells generally. The cell body
is somewhat swollen, the stainable substance is reduced to a
structureless powder and the nucleus is dislocated and appears
conspicuously in the periphery. There is also some "Marchi"
degeneration of the fibre tracts in the motor areas. The regions
involved, according to Meyer,[293] are "the cortico-thalmic connections
of the motor areas, the auditory radiation, the forceps, the pyramids,
the fillet, the restiform body, and to a lesser degree, the posterior
column of the cord, the intersegmental elements, and the segmental
efferent motor elements."
In view of the attitude of the psychiatrists of this country as shown
by numerous expressions of opinion, the statistical committee of the
Association felt justified in retaining involution melancholia in its
classification of psychoses for the present and collecting data for
further consideration. The following suggestions were offered as to its
delimitation:—
"These depressions are probably related to the manic-depressive group;
nevertheless the symptoms and the course of the involution cases are
sufficiently characteristic to justify us in keeping them apart as
special forms of emotional reaction.
"To be included here are the slowly developing depressions of _middle
life and later years_ which come on with worry, insomnia, uneasiness,
anxiety and agitation, showing usually the unreality and sensory
complex, but little or no evidence of any difficulty in thinking. The
tendency is for the course to be a prolonged one. Arteriosclerotic
depressions should be excluded.
"When agitated depressions of the involution period are clearly
superimposed on a manic-depressive foundation with previous attacks
(depression or excitement) they should for statistical purposes be
classed in the manic-depressive group."
In view of the history of the development of the conception of this
psychosis an analysis of the hospital statistics on this subject is
of unusual interest. We now have reports of over seventy thousand
first admissions based almost entirely on the classification at
present used by the Association. In 49,640 first admissions to the
New York hospitals during a period of eight years there were 1,351
cases diagnosed as involution melancholia—2.72 per cent of the
total. During 1918 and 1919, when the Association's classification
was followed in detail, these hospitals showed 480 cases, or 3.45 per
cent of 13,588 first admissions. Twenty-one public institutions in
fourteen other states reported 378 cases, or 2.06 per cent of 18,336
admissions. Two and twenty-five hundredths per cent of the admissions
to the Massachusetts state hospitals in 1919 were cases of involution
melancholia. Reports from forty-eight different state hospitals show
that involution melancholia constituted 2.53 per cent of over seventy
thousand admissions. This shows a remarkable similarity in standards of
diagnosis as far as this psychosis is concerned.