Very common at the beginning of psychoses, melancholy ideas may persist through the entire duration of the disease, as in involutional melancholia.

The principal varieties are:

(A) Ideas of humility and of culpability. The latter are also called ideas of self-accusation;

(B) Ideas of ruin;

(C) Hypochondriacal ideas;

(D) Ideas of negation.

(A) Ideas Of Humility And Of Culpability

The patient considers himself a being good for nothing, wretched, undeserving of the attention bestowed upon him, and accuses himself of imaginary faults or crimes. Often he will seek out from his past life some insignificant act to which he will attribute extreme gravity: he stole some apples when he was a boy, or he forgot to make the sign of the cross once upon entering a church. The idea of the crime committed entails also ideas of merited punishment: he expects every instant to be arrested, put to death, cut to pieces, thrown into hell, etc.

(B) Ideas Of Ruin

These are frequent in senile dements; the patient believes himself to be without any means, bereft of everything; his clothes will be sold; some day he will be found dead of starvation on a public road.

(C) Hypochondriacal Ideas

These concern the subject himself, involving either the physical sphere - the stomach is obstructed, the spinal marrow is softened, the entire organism is affected by an incurable disease - or the psychic sphere, constituting psychic hypochondriasis: the mind is paralyzed, the intelligence is destroyed, the will power is annihilated.

Hypochondriacal ideas are sometimes dependent upon an actual diseased condition which, however, is falsely interpreted by the patient (Hypochondria cum materia).1

(D) Ideas Of Negation

In some cases these concern the subject himself, and are then nothing but hypochondriacal ideas pushed to an extreme: the brain, the heart, etc., are destroyed, the bones are replaced by air, the body is nothing but a shadow without a real existence. In other cases they are referred to the external world: the sun is dead, the earth is nothing but a shadow, the universe itself exists no more (metaphysical ideas of negation).

1 Pick. Zur Lehre von der Hypochondrie. Allg. Zeitscher. f. Psychiat, 1903, Nos. 1-2.

2 Seglas. Lecons cliniques, p. 276. - Cotard. Du delire des negations. Arch, de neurol., 1882. - Arnaud. Sur le delire des negations. Ann. m6d. psychol., Nov.-Dec. 1892. - Seglas. Le delire des negations. Encycl. des Aide-mem. - Trenel. Notes sur les idees de negation. Arch, de neurol., March, 1899. - Castin. Un cas de delire hypo-chondriaque a forme evolutive. Ann. m6d. psych., June, 1900.

By a singular process, apparently paradoxical, hypochondriacal ideas and those of negation give rise to ideas of immortality and of immensity. The patient, feeling himself, on account of the destruction of his organs, placed beyond the laws of nature, concludes that he cannot die and that he is condemned to suffer eternally; or, dismayed by the form and monstrous dimensions of his body, he imagines himself obscuring the atmosphere, filling the world, etc.

The general features of melancholy delusional states are the expression of psychic inhibition and of the painful emotional tone which constitute the basis of the melancholy state.

The following is a summary of the chief characteristics of these states, according to the admirable study of Seglas:

(a) Melancholy delusions are monotonous; the same delusions are constantly repeated, the inhibition allowing but little formation and appearance of new ideas.

(6) These states are humble and passive. The patient accuses no one but himself, and submits without resistance to the ill-treatment which he believes himself to have deserved.

(c) As to localization in time, the delusions are referred to the past and to the future: the patient finds in the past the imaginary sins which he has committed, and foresees in the future the chastisements which are to be inflicted upon him. In this respect melancholy delusional states are in contrast with persecutory delusional states. The persecuted patient localizes his delusions chiefly in the present. The persecutions of which he complains are actual.

(d) From the standpoint of its development the melancholy delusional state is centrifugal. The trouble begins with the patient and extends gradually to his friends, his country, and the entire universe, who suffer through his faults.

(e) The melancholy delusional state is secondary, that is to say, it is the consequence of sadness and of psychic pain. It shares this characteristic with most of the other delusional states which are generally but the expression of the emotional tone of the subject.1

Melancholy delusions may have two grave consequences which we shall many times have occasion to emphasize: suicidal tendency and refusal of food.

Ideas Of Persecution

Like melancholy ideas, ideas of persecution are of a painful character. But while the melancholiac considers himself a culpable victim and submits beforehand to the chastisements which he believes he has merited, the subject of persecution is convinced of his innocence and protests and defends himself.

Ideas of persecution may be divided into two groups, according to whether or not they are accompanied by hallucinations.

Those of the first group are associated with hallucinations generally of an unpleasant character, among which auditory verbal hallucinations and hallucinations of general sensibility are most prominent. After a certain time the phenomena of physic disaggregation supervene: motor hallucinations, autochthonous ideas, reduplication of the personality, etc.

In the second group are ideas of persecution peculiarly associated with false interpretations; any chance occurrence is ascribed by the patient to malevolence; he sees in everything evidences of hostility against him, and attributes to the most ordinary and unimportant facts and actions a significance which is as grave as it is fanciful. This form of ideas of persecution is frequent at the onset of certain psychoses; it also constitutes the basis of an affection known as paranoia or reasoning insanity.

1 Seglas. Legons cliniques.

Some patients do not know their persecutors. Others accuse particular persons or societies (Jesuits, Freemasons). Still others bear their hatred towards some certain individual who is, in their eyes, the instigator of all the injurious procedures of which they are the victims, "the great master of the persecutions," as one such patient once said.

Of all delusions those of persecution are the most irreducible and are held by the patients with the firmest conviction. Almost always the patients resent to have them disputed. In themselves these delusions do not have an invariable influence upon the prognosis, excepting that, in a very general way, they are of more serious import than melancholy ideas.

Of all delusions these also present the greatest tendency to systematization and to progressive evolution. A perfect persecutory delusional system should comprise:

(a) A precise idea of the nature of the persecutions;

(6) An exact knowledge of the persecutors, of their aim, and of the means employed by them;

(c) A plan of defense in harmony with the nature of the delusions.

In the examination of cases with persecutory ideas one should always attempt to determine these points, on account of their great practical importance.

Ideas Of Grandeur

Ideas of grandeur appear chiefly in demented states and are often of a particularly absurd nature, bearing the stamp of mental deterioration. The patients are immensely rich, all-powerful; they are popes, emperors, creators of the universe. Generally they naively claim these pompous titles without being at all concerned by the flagrant contradiction existing between their actual state and their ostensible almightiness. A general paralytic was once asked: "If you are God, how, then, does it happen that you are locked up? " " Because the doctor refuses to let me go," he replied simply. It is not rare to see a pseudo-pope obey without a murmur the orders of hospital attendants and assist with the best possible grace in the most menial labor.

Often the patient's attire is in harmony with the title: uniforms of the oddest fancy, multicolored tinsels, numerous decorations, etc.

When the mental deterioration is less pronounced, as, for instance, in certain cases of dementia praecox, the subject shows more logic in his conduct. He assumes an air of dignity, avoids all association with the other patients, and declines with a contemptuous smile all suggestion of employment.

Ideas of grandeur are also met with in certain acute psychoses, as in mania, for instance, and in certain forms of systematized delusional states without mental deterioration (Paranoia originaire of Sander).