Descriptive Psychopathology: The Signs and Symptoms of ...

375 Chapter 16: An evidence-based classificationand perhaps other undefined conditions (e.g. some anxiety disorders). The sameis true for adjustment disorder, depressive type. 10 Separating these conditionsfrom melancholia facilitates their further delineation.MelancholiaRecognized for centuries, melancholia was understood to encompass depressiveand manic phases as a single disease. Recent classifications degrade the constructwith non-specific diagnostic criteria blurring boundaries between melancholiaand other conditions that share depressive features, while they exaggerate thedelineation of unipolar and bipolar categories. 11The poor validity of the present classification of depressive illness is demonstratedin numerous studies. For example, in an examination of co-morbidity intwins and the occurrence of future episodes to externally validate the DSMdepression criteria, the number of symptoms (the hallmark of the criteria), theirduration, and resulting impairment did not predict the presence of depressiveillness in a co-twin or future episodes in the proband. 12 Another study foundDSM criteria to have poor agreement with core features of melancholia derivedfrom cluster and similar analytic techniques. 13Swelling population prevalence rates from 6 to 8% in the 1960s to over 10% formen and 20% for women today reflect the artificially low threshold for thediagnosis of major depression. 14 One Swedish study reports rates of almost27% for men and a staggering 45% for women, but only 8 men and 9 womenof over 2000 subjects were identified as having a “serious” depressive illness. 15The inflation of depression base rates has profound and adverse effects on geneticresearch and healthcare policy.Syndrome delineationThe melancholia syndrome is confirmed by over 70 multivariate analyses ofpatient and community samples of depressed persons. The studies find sampleheterogeneity with a melancholia group most clearly delineated. About half ofhospitalized depressed patients are identified as melancholic. The few studies thatdo not report sample heterogeneity and a recognizable melancholia syndromehave been challenged and re-interpreted. 16The defined syndrome is characterized by three symptom clusters, all presentearly in an episode. An abnormal emotional state is always present and is dominatedby unremitting apprehension and overwhelming gloom. Unlike non-melancholicdepressive disorders, the abnormal emotional state has a life of its own and is notreactive to pleasurable circumstances. Psychomotor disturbance is always present.Motor functions and cognitive activity are slowed and stupor and catatonia may