Delusional Melancholia

All varieties of melancholy delusions are encountered in this affection: ideas of culpability, of humility, of ruin, hypochondriacal ideas, and ideas of negation. It is not uncommon for persecutory ideas to occur in combination with the melancholy ideas.

Hallucinations are not frequent. The least rare are, according to Seglas, those of vision and of the muscular sense. Those of hearing, taste, and smell are occasionally met with, while those of general sensibility are altogether exceptional.

Illusions of all sorts are, on the contrary, frequent. They often assume the form of mistakes of identity.

Finally, delusional interpretations are constant. The patient hears the noise of hammer-strokes in the vicinity and thinks a scaffold is being built for him. He hears the sound of voices in the street and thinks the mob is going to. seize and lynch him, etc.

The reactions are usually in harmony with the melancholy state and with the nature of the delusions. Sometimes, under the influence of anxiety which in many cases accompanies the delusions, the reactions assume an exclusively automatic character; it is to be noted that negativism is not uncommon.

The following case illustrates both delusional and anxious melancholia:

Margaret L., fifty-eight years old. - Paternal and maternal heredity: father was alcoholic, died of disease of the liver; mother eccentric, unduly irritable; maternal aunt committed suicide. - The patient has always been nervous and sensitive. She has been, however, of normal intelligence and always attended properly to the work of her home and family. She has two daughters, respectively thirty and twenty-five years old, both normal. Menstruation ceased two years ago.

The mental symptoms began with a state of general depression and discouragement. On being invited to a christening of a little boy she refused to go, giving as her reason that life is a burden and that there is no cause for rejoicing in the birth of a child. After several weeks she began to show very marked uneasiness and a little later delusional interpretations. She saw wagons passing by the house loaded with various objects, furniture, bedding, barrels, sacks of flour; she heard the drivers cracking their whips; all this alarmed her greatly and she asked her husband whether all this did not signify that she was to be thrown out of the house and left to starve to death. She noticed also that the neighbors looked at her queerly whenever she met them. At the same time physical symptoms appeared: complete loss of appetite, headache, insomnia. About two weeks later, namely, March 20, 1900, she developed an idea of self-accusation. About twenty-five years ago she lost a little daughter from croup.

Did not this child die because its mother had left it one day with its feet wet? This idea at first had the character of an imperative idea; the patient knew it was false and tried to drive it away; it, however, grew more and more dominating and was finally accepted by the patient as true: the imperative idea had become a fixed idea. The psychic pain increased steadily. New delusions sprang up, the first one, however, still remaining active. On April 12 the patient went to the police headquarters carrying a bundle of clothing; this, she said, was for the poor girls who had been robbed of everything and thrown out in the street. At the same time she begged the police authorities to send men to protect those unfortunate women whom the Prussians were about to ravish.

On being taken to a sanatorium she did not cease to wail and to lament, first accusing herself, as formerly, of the death of her little girl, later of the illness of her husband, who really did have heart trouble. Gradually the delusions grew. She claimed she had brought upon her relatives such disgrace and misery that they all committed suicide; the letters which she is supposed to receive from them are false; no doubt this is done to console her; everybody has been too good to her; such a nasty creature should have her head chopped off. There she is, well fed and housed, and warmly dressed, yet they know well that she has no money to pay for all this. But this cannot last; pretty soon the day will come when they will put her out to go and beg. She developed a few hallucinations of sight, of hearing, and of muscular sensibility: several times she saw before her a pool of blood; also several times she heard the voices of her children crying: "Bread! Give us bread!" Finally she complained of an inner voice coming from her breast, which made her say against her own will: "Slut! slut!" She cried loudly, begging to be put to death; has made repeated attempts to commit euicide; from April 21 to October 30 five such attempts were counted, three of which were by hanging.

For a time she refused food; after being tube-fed for two days, she began to eat again, although with much difficulty.

Considerable emaciation. Tongue coated. Breath very foul. Constipation. Slight trace of albumen in the urine.

Such is the fundamental and habitual state of the patient. The anxiety, without being ever entirely wanting, presents, however, periods of exacerbation, so that the patient at times shows the typical picture of anxious melancholia. During such paroxysms the patient seems to be literally suffocating. She seems to be striving to throw off a weight from her chest; she pulls her hair, strikes herself in the face, and scratches at the walls of her room until her fingers bleed. When her agitation is at its height it is impossible to obtain from her a response to any question. She merely utters inarticulate cries or repeats in a low, scarcely audible voice: "My God! . . . My God! ..." Her consciousness is then evidently profoundly affected and it seems that even delusions at such times disappear under the influence of the psychic pain and anxiety.

Toward the latter part of November, 1900, the general condition of the patient improved. Her appetite became better. The delusions persisted and the patient continued her lamentation, but the reactions became less pronounced. Little by little the delusions also became less active. A certain degree of mental activity returned. Toward the middle of December the patient was able to do some manual work. She returned home, completely cured, February 6, 1901. At the present time (1905) she is still perfectly well.

Prognosis

Melancholia may terminate in: (a) Complete recovery, 67%;

(6) Dementia due to the development of cerebral arteriosclerosis, 8%;

(c) Death, 25% which may be due to:

(I) Suicide, which is the more likely to occur the more pronounced the psychic pain and the less marked the inhibition. The melancholiac may commit suicide at any period of his illness, even during convalescence, when on account of a real or fictitious gaiety, supervision over him is relaxed;

(II) Melancholic wasting, the principal factors of which are intense sadness, anxiety, agitation, sleeplessness, and insufficient alimentation occasioned by a poor condition of the digestive tract, a delusion, or a suicidal idea;

1 Dreyfus, Loc. cit., p. 269.

(III) Some complication the occurrence of which is favored by the defective nutrition of the tissues: pneumonia, influenza, tuberculosis.

The duration of the affection is very variable, from several weeks to a few years.

Treatment

The principal indications are:

To watch the patient with a view to the prevention of suicide;

To support his strength;

To calm agitation if there is any;

To pay special attention to the alimentation.

The first three indications are admirably fulfilled by rest in bed.

Forced alimentation is often necessary to fulfill the fourth.

Psychic pain may be efficaciously combated by the administration of opium in increasing doses. One may start with 15 minims of the tincture per day, increase to 60 minims or more, and then gradually reduce the quantity to the initial dose before discontinuing the treatment.

Finally, continuous warm baths may be of service in the agitated forms.