Descriptive Psychopathology: The Signs and Symptoms of ...

213 Chapter 8: Disturbances in emotional experienceMelancholics are much addicted to biting their nails, picking their fingers, or any pimple orabrasion ... the attending pain is unheeded.Not to be outdone, Kraepelin describes:The total absence of energy is very specially conspicuous. The patient lacks the spirit andwill-power, like a wheel on a car, which simply runs but in itself has no movement or drivingpower. He cannot rouse himself, cannot come to any decision, cannot work any longer, doeseverything the wrong way about, he has to force himself to everything, does not know what todo. A patient declared that he did not know what he wanted, went from one thing to another.The smallest bit of work costs him an un-heard-of effort; even the most everyday arrangements,household work, getting up in the morning, dressing, washing, are only accomplished with thegreatest difficulty and in the end indeed are left undone. Work, visits, important letters,business affairs are like a mountain in front of the patient and are just left, because he doesnot find the power to overcome the opposing inhibitions. If he takes a walk, he remainsstanding in the house door or at the nearest corner, undecided as to what direction he shalltake; he is afraid of every person whom he meets, of every conversation; he becomes shy andretiring, because he cannot any longer look at any one or go among people. 68When this state of severe psychomotor retardation worsened, stupor wasrecognized. When hallucinations and delusions emerged, melancholia graviswas defined. When persecutory delusions were prominent, paranoid melancholiawas diagnosed. Fantastic melancholia was identified when hallucinations becameintense experiences with visual and auditory phenomena merging into spirits,monsters, body parts, wild beasts, and the devil, and other hallucinatory phenomena(e.g. tastes of soap, excrement; odors of rotting flesh, mildew).Hammond wrote about the onset of “simple melancholia”:The patient is indisposed to either physical or mental exertion, he shuns the companionshipof others, is averse to speaking, frequently remains silent for hours, and if forced to respondto questions put to him does so in the fewest possible words, and without change ofcountenance ... his conversation is entirely in regard to himself, of his horrible feelings,his despair, his weariness of life, and the unhappy hours he passes, his mind filled with themost dreadful thoughts ...His eyes are scarcely raised to look at those who address him, andthe most exciting events do not engage his attention. The pupils are dilated, the browscontracted, the corners of the mouth drawn down, his whole aspect that of a person plungedin the deepest sorrow. (Hammond, 1883, p.562)Delirious melancholiaDelirious melancholia is a severe episode characterized by clouding of consciousness,delusions and hallucinations, and catatonic features including mutism,immobility with posturing, and automatic obedience alternating with “anxiousresistance”. Stupor alternates with restlessness, agitation, and hand-wringing,