Melancholic Mysteries

Once I was a young physician, taking on for half a century ago, melancholy proved to be a rare condition, or at least a condition that was seldom diagnosed, which is not quite the same thing. In its acute forms it was unmistakable. Patients that might to all seems have everything to endure could turn their faces to the wall, nearly literally when their beds had been adjacent to a wall; they might even suffer with Cotard’s syndrome, even the delusional belief that they had or were nothing, which their bodies had rotted off, which they were in the very last phases of impoverishment even when they had millions in the bank. I remember a patient who told me that he was dead and that all that remained with him had been that the gangrenous hint of his nose. No rational argument might convince him that he was mistaken. Electro-convulsive treatment (ECT) attracted very quickly to his usual condition, a successful and prosperous businessman.
It was impossible to not conceive of him as having been ill, pure and easy. However, what about lesser forms of melancholy and human distress? When did distress, understandable from the patient’s circumstances, become disease? There was in the moment a lively polemic between people who thought that gloomy mood had a bimodal, and people who thought it had a unimodal, distribution. Individuals who thought that there was a bimodal distribution split melancholy into endogenous (that’s to say, originating from the sufferer’s constitution) and reactive (that’s to say, originating from the patient’s response to his circumstances). The former tended to be, but was not necessarily, more acute, intense and bizarre compared to the latter; they all admitted that circumstances, in certain circumstances, could lead to acute depression, to an evident disgust with life and also to suicide.
Lately, there was a similar playful polemic between people who thought that high blood pressure has been bimodally distributed and people who thought that it was unimodally distributed. In the bimodal model, there were a separate group of those who suffered from an as yet undiscovered illness that resulted in extremely severe hypertension, whilst everybody else had blood pressures that were distributed around a mean.
It’s now generally accepted that people who thought in unimodal distributions, either of mood and blood pressure, won the debate. Personally, I believe that is right in the event of blood pressure, however, wrong in the case of melancholy. Once you have seen melancholia, as it was called, you can’t confuse it for depression of mood, however prolonged. But I am quite old-fashioned.
In the last twenty five years, diagnosis of depression has become so prevalent that up to a sixth of adults in western countries are taking antidepressants–or even alleged anti-depressantsas critics might say. The term unhappiness has nearly been excluded from the lexicon, and no one complains of it; if they complain in any way, it is of melancholy.
The issue remains, addressed within this book without definitive answer (because none can be given), as to whether the greater variety of individuals diagnosed, or even self-diagnosed, as suffering from depression represents a true increase in the incidence of this illness, better comprehension of a condition that has been always there but dismissed, or perhaps a cultural fashion.
It’s short and succinct, the author writes obviously without resort to jargon to give his writing a false atmosphere of profundity, also he is undogmatic in a field not lacking from dogma and dogmatists. He’s clearly read a excellent deal about the topic, and in general his reasoning is solid. This is not to say I would concur with all his judgments, but not one of these is indefensible.
By way of example, I think he is much too generous to in general psychoanalysis and Freud particularly. This Freud was frequently acute in his observation of mankind is accurate, but so were La Rochefoucauld and Lichtenberg (a higher proportion of the moment, actually, and considerably more pithily). Even fortune tellers tend to be intense observers of their customers, but these acuteness doesn’t require the huge superstructure of theory that Freud claimed to own erected on the basis of supposed observations, but really on these of preconceptions encouraged (as by now has been pretty well-established) by a considerable resort to mystification and outright lies about the results of his remedy. Far from having been an aid to understanding, psychoanalysis has traditionally exerted an obfuscating impact both on doctors and physicians, and has been pointed out several times before was conducted professionally nearly as a religious cult, complete with heresies, heretics, heresiarchs, excommunications and anathemata, by which signs or truth had little to do. The observation that gloomy adult patients have frequently had emotionally deprived childhoods (if true) is just one that could be produced with no psychoanalytic theory whatsoever.
One of the issues of melancholy as an object of study is that there are no straightforward biological markers to differentiate cases from non-cases. A few endocrinological conditions mimic melancholy, and some medicines undoubtedly cause it. In the excellent majority of cases, but there are no quantifiable physiological modifications, except those brought about by the symptoms themselves: in melancholy, symptoms and disease are just one, at least in the current condition of knowledge.
The author is anxious to prevent false dichotomies: genetic vs ecological, physical versus mental, social versus individual, endogenous versus reactive. It’s rarely in medication, he says, that the causes of a disorder are both necessary and adequate; Koch’s famous postulates are not often satisfied even in relatively easy circumstances, let alone in something as complex as melancholy.
Although he says that scorn is not useful to understanding history, he is somewhat scornful of the concept that there’s a moral dimension to melancholy. At no moment does he consider that a conscious effort to become resilient, by way of example, might play a useful function in preventing depression: he believes that a willingness to acknowledge and accept psychological vulnerability is unequivocally an advance. Oftentimes, it might well be ; however, it being so would be perfectly compatible with a rapid increase in melancholy on a public foundation.
The author doesn’t (in my opinion) sufficiently look at the cultural importance of the replacement of this term unhappiness by melancholy in common parlance. The technical effect is considerable. A miserable person should either set up with his urgency, or examine the reasons for this and attempt to change either himself or his or her circumstances. The depressed person is announcing himself ill and placing the responsibility on somebody else to treat him. In present medical circumstances, where doctors have hardly any time for each patient (and much of that consumed with inputting data, or pseudo-data, on a pc ), a prescription is the most likely result.
The author suggests that people who downplay or deny the seriousness of melancholy tend to use the term character flaw to accounts for its apparently increasing incidence. However, is there anything as personality defect?The pills prescribed might or might not assist; if they do, it might or might not be because of a real antidepressant effect. Oftentimes, but they don’t work, even as a placebo (that they might even act as a nocebo, a concept that makes no appearance in this book). Fortunately for the physician, maybe less so for the patient, there are many unique dosages and many unique pills that may be tried before all pharmacological therapy possibilities are exhausted. A sort of pas de deux may occur between the physician and patient lasting several months, by that time the feelings of melancholy may have remitted in almost any circumstance.
But things are far from straightforward. It’s not unusual in medication, at least nowadays, to prescribe medication to a hundred individuals understanding that it will function in only one of these, but never understanding in which . This is the explanation for this prescription of the two antihypertensive drugs and statins, which in almost any individual patient are more likely to cause slight side-effects compared to do some good: even if they do great, it is a very good good really. And precisely because melancholy is so protean, therefore vague and therefore ill-understood, it is not easy to tell that which patient will gain from which therapy. Can there be more rejoicing in heaven over one recovered depressive than more than one-hundred depressives given medication uselessly, as well as harmfully? I don’t actually think there’s, or may be, even a definitive answer.
The author suggests that people who downplay or deny the seriousness of melancholy tend to use the term character flaw to accounts for its apparently increasing incidence. However, is there anything as personality flaw? When there’s not, does that not rather empty all human life of ethical importance, as critics of this over-diagnosis of melancholy says it does? Really, the author almost implies that the usage of term personality flaw might be considered–a personality flaw.
However, the situation is complex. I remember a person of minein her early seventies, that for approximately twenty years had been lacking energy, had loved nothing, and had sat about moping. As in everybody’s life, there were factors that could plausibly describe her distress. No remedy functioned; she stayed the same. I was about to write off her because character-defective if I prescribed an monoamine oxidase inhibitor for an old-fashioned medication that requires the patient to abjure particular foods to prevent a potentially dangerous reaction. In my great surprise and pleasure, but also to my own shame at having nearly written off her because character-defective, she recovered her joie de vivre, began to play the piano and became vivacious. I found it hard to feel that this was a mere placebo response: why this kind of response so late in the afternoon? It’s easy to write off people as poor personalities, which is not to say that there are no such men and women.
The story I have just told would not surprise Professor Sadowsky since he’s got a complex and sophisticated instead of a simplistic and primitive view of melancholy. He’s fair-minded rather than polemical, however there are omissions. There is surprisingly little mention of suicide from the book; he doesn’t tackle the issue of how to differentiate between a plausible and a true cause of a psychological illness. After all, everybody has a reason to be miserable but not everybody is miserable, even though his reason to be miserable is quite strong.
I am pleased to say, but that Professor Sadowski is a worthy follower of Hamlet: he doesn’t disdain or hate efforts to explain man’s condition, but doesn’t think either that the core of the mystery is about to be phased out.