Involutional melancholia
Encyclopedia
Involutional melancholia or involutional depression is a traditional name for a psychiatric disorder affecting mainly elderly or late middle-aged people, usually accompanied with paranoia
. It is classically defined as "depression of gradual onset occurring during the involutional years (40-55 in women and 50-65 in men), with symptoms of marked anxiety, agitation, restlessness, somatic concerns, hypochondriasis, occasional somatic or nihilistic delusions, insomnia, anorexia, and weight loss."
(1907) was the first to describe involutional melancholia as a distinct clinical entity separate from the manic-depressive psychosis
, arguing that 'the processes of involution in the body are suited to engender mournful or anxious moodiness'.. Right up until 'the seventh edition of his textbook Kraepelin considered involutional melancholia as a separate disease', of acquired origin, but (partly in response to Dreyfus) 'he decided to include it in the eighth edition under the general heading of manic depressive insanity'.
Dreyfus (1907) had challenged Kraepelin's concept of an acquired origin, maintaining it to be endogenous in origin - although 'a recent statistical study of Dreyfus's old series has also shown that his conclusion that the natural history of involutional melancholia was no different from that of depression affecting younger subjects was wrong'.. Kirby (1909) described it as a distinctive syndrome, as did Hoch and MacCurdy in 1922. Titley (1936) described the premorbid personality and narrow range of interests, etc., Kallman (1959) found incidence of schizophrenia in the families of such patients.
Debate about causation - endogenous or environmental - as well as clinical entity continued into the late twentieth century. Some contend that whereas 'involutional melancholy was conceptualized as an acquired rather than constitutional disorder, these ideas have not survived careful scrutiny'. R. P. Brown in 1984 maintained that 'there is insufficient evidence to view involutional melancholy as a separate clinical entity', but at the same time that 'clinical characteristics of patients with unipolar endogenous depression may be influenced by age'.
and hypochondriacal delusions. The late onset of the disorder was matched with a prolonged course with poor prognosis
and/or deterioration, in the absence of treatment.
Electroconvulsive therapy
may also be used. Mid-century, there was a consensus that the technique indeed 'yields the best results in the long-lasting depressions of the change of life, the so-called "involutional melancholias", which before this form of treatment was introduced often required years of hospitalization'. The 21st century also records 'an excellent and rapid clinical response found in melancholia of recent onset...in older rather than younger patients' with ECT
considered that 'psychoanalytically, not much is known about the structure and mechanism of involutional melancholias; they seem to occur in personalities with an outspoken compulsive character of an especially rigid nature. In the climacterium the compulsive defensive systems fail'.
Paranoia
Paranoia [] is a thought process believed to be heavily influenced by anxiety or fear, often to the point of irrationality and delusion. Paranoid thinking typically includes persecutory beliefs, or beliefs of conspiracy concerning a perceived threat towards oneself...
. It is classically defined as "depression of gradual onset occurring during the involutional years (40-55 in women and 50-65 in men), with symptoms of marked anxiety, agitation, restlessness, somatic concerns, hypochondriasis, occasional somatic or nihilistic delusions, insomnia, anorexia, and weight loss."
Literature review
Emil KraepelinEmil Kraepelin
Emil Kraepelin was a German psychiatrist. H.J. Eysenck's Encyclopedia of Psychology identifies him as the founder of modern scientific psychiatry, as well as of psychopharmacology and psychiatric genetics. Kraepelin believed the chief origin of psychiatric disease to be biological and genetic...
(1907) was the first to describe involutional melancholia as a distinct clinical entity separate from the manic-depressive psychosis
Psychosis
Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...
, arguing that 'the processes of involution in the body are suited to engender mournful or anxious moodiness'.. Right up until 'the seventh edition of his textbook Kraepelin considered involutional melancholia as a separate disease', of acquired origin, but (partly in response to Dreyfus) 'he decided to include it in the eighth edition under the general heading of manic depressive insanity'.
Dreyfus (1907) had challenged Kraepelin's concept of an acquired origin, maintaining it to be endogenous in origin - although 'a recent statistical study of Dreyfus's old series has also shown that his conclusion that the natural history of involutional melancholia was no different from that of depression affecting younger subjects was wrong'.. Kirby (1909) described it as a distinctive syndrome, as did Hoch and MacCurdy in 1922. Titley (1936) described the premorbid personality and narrow range of interests, etc., Kallman (1959) found incidence of schizophrenia in the families of such patients.
Debate about causation - endogenous or environmental - as well as clinical entity continued into the late twentieth century. Some contend that whereas 'involutional melancholy was conceptualized as an acquired rather than constitutional disorder, these ideas have not survived careful scrutiny'. R. P. Brown in 1984 maintained that 'there is insufficient evidence to view involutional melancholy as a separate clinical entity', but at the same time that 'clinical characteristics of patients with unipolar endogenous depression may be influenced by age'.
Characteristic symptoms
Involutional melancholy's 'course was chronic, with agitation, depersonalization and delusions of bodily change and guilt' featuring strongly, but 'without manic features'. Symptoms of fear are also considered to occur, as well as despondencyDepression (mood)
Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behaviour, feelings and physical well-being. Depressed people may feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, or restless...
and hypochondriacal delusions. The late onset of the disorder was matched with a prolonged course with poor prognosis
Prognosis
Prognosis is a medical term to describe the likely outcome of an illness.When applied to large statistical populations, prognostic estimates can be very accurate: for example the statement "45% of patients with severe septic shock will die within 28 days" can be made with some confidence, because...
and/or deterioration, in the absence of treatment.
Treatments
Involutional melancholia is classically treated with antidepressants and mood elevators.Electroconvulsive therapy
Electroconvulsive therapy
Electroconvulsive therapy , formerly known as electroshock, is a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Its mode of action is unknown...
may also be used. Mid-century, there was a consensus that the technique indeed 'yields the best results in the long-lasting depressions of the change of life, the so-called "involutional melancholias", which before this form of treatment was introduced often required years of hospitalization'. The 21st century also records 'an excellent and rapid clinical response found in melancholia of recent onset...in older rather than younger patients' with ECT
Psychoanalysis
Otto FenichelOtto Fenichel
Otto Fenichel was a psychoanalyst of the so-called "second generation".Otto Fenichel started studying medicine in 1915 in Vienna. Already as a very young man, when still in school, he was attracted by the circle of psychoanalysts around Freud...
considered that 'psychoanalytically, not much is known about the structure and mechanism of involutional melancholias; they seem to occur in personalities with an outspoken compulsive character of an especially rigid nature. In the climacterium the compulsive defensive systems fail'.
Further reading
- Moses R. Kaufmann, "Psychoanalysis in Late-Life Depression", Psychoanalytic Quarterly vi (1937)