Catatonia and Melancholia 101
In modern culture, and in medicine, the word depression has no useful meaning anymore. William Styron summed up the diagnosis of “depression” as well as any I have heard:
Melancholia… was usurped by a noun (Depression) with bland tonality and lacking any meaningful presence, used indifferently to describe an economic decline or a rat in the ground…The Swiss-born psychiatrist Adolf Meyer had a tin ear for the finer rhythms of English and therefore was unaware of the semantic damage he had inflicted by offering “depression” as a descriptive noun for such a dreadful and raging disease. Nonetheless, for over seventy-five years the word has slithered innocuously through the language like a slug, leaving little trace of its intrinsic malevolence and preventing, by its very insipidity, a general awareness of the horrible intensity of the disease…
While it is convenient for quickly naming, treating, and (most importantly) billing, the global term depression has little actual utility in understanding a person’s lived experience. The truth is that the modern diagnosis of “depression” was designed to make research easier, not to give deeper insight into the nature of the illness. Before the universal acceptance of this meaningless term, there were many different flavors of lived experience, unique patterns and clusters of symptoms with many different names. That was ok when the treatment was complex and personalized psychoanalytic treatments, but studying how each of them was affected by Prozac would have been impossible. Therefore, as we transitioned to a pharmaceutically driven field of psychiatry, we needed to find the common features and ignore the individual lived experience. We turned what would have been a 10 page case formulation into a 9 symptom checklist.
Unfortunately, all “depression” isn’t the same, and our patients have suffered because of the narrative. There has also been a recent fracture in the system with the National Institute of Mental Health (NIMH) coming into direct conflict with the American Psychiatric Association (APA) over these “diagnoses”. The NIMH would have researchers only study symptom clusters in their Research Domain Criteria (RDoC), with its leadership in direct conflict with the APA’s Diagnostic and Statistical Manual (DSM) regarding trial funding. However, the RDoC symptom clusters are no less arbitrary, and no more reflective of the lived experience of patients than the DSM.
I cannot describe the majority of the different disorders that now fall under the depression moniker, but there are two that modern research has shown are fundamentally different. They are neither defined by sadness nor worrying. They are much more often associated with neurologic illnesses. They have clear laboratory and imaging biomarkers, though the clinical diagnosis is far more useful than the blood testing. Most importantly, the treatments are fundamentally different. They are the diagnoses of Catatonia and Melancholia.
Melancholia was originally considered a medical illness like any other. The body slowed down, as did the mind. Sure, there was often sadness, but for many the word sad didn’t really apply. It was as if the color had left the world. It was a sudden shift of demeanor, as if the core structure of the brain’s emotional and perceptual centers had changed. It was as if part of the patient had died, leaving a shell behind. It was often caused by some life transition, putting it squarely in the field of psychiatry, but the appearance and experience of it was more like the depression seen in hypothyroidism, a toxic exposure, or a withdrawal syndrome than bereavement. It is also more likely to be misdiagnosed as a dementia or other chronic medical illnesses than many of the other forms of depression. It is less responsive to standard antidepressants and more likely to have complex components like muscle pain, abdominal complaints, or cognitive decline.
Catatonia was even more misplaced, with early categorization under Schizophrenia rather than depression, though most modern catatonia theorists would say it is more like a mood disorder than a primary thought disorder. Specifically it is more like the old melancholia diagnosis, with similar biomarkers and treatment responses. However, Catatonia is even more of a physical illness with features that look a lot more like parkinson’s disease or even a severe infection than other mood disorders. Consequently, it is also often seen by neurologists who sign off quickly saying it is psychiatric, though many psychiatrists still feel uneasy that medical causes haven’t been fully investigated. It is often what I like to call a “not it” diagnosis. Everyone seems to place the responsibility on someone else to treat it.
Unfortunately, everyone is right. The psychiatrist is correct that many cases of catatonia are associated with a medical syndromes such as delirium, infection, medication toxicity, or even encephalitis. The neurologist is right that after looking for life threatening causes, the core treatment is usually given by and monitored by psychiatry. I have the unpopular opinion that psychiatry and neurology should have never been separate fields of medicine. However, now that they are two separate fields, these diagnoses that land in-between the fields requires much closer coordination in the diagnosis and treatment.
Read more articles on these disorders, and if you are a medical professional you should read the following articles and books. However, if you have been told by a neurologist that your loved one is not moving, moving in very bizarre ways, or rapidly declining because of a psychiatric problem, and the psychiatrist insists that the problem seems like a medical emergency, there is a good chance that catatonia or melancholia are playing a role. Contact us if you would like a consult today!
