1. DEPRESSION: AN HOMOGENEOUS AREA ?

One of my patients, during a psychotherapeutic session, compared her present depression with the depression she experienced some years ago, at the beginning of the therapy:

This is the sadness that lives the one who is out of depression and looks at the past. I am sad for the consequences of my depression … I am depressed but, at the meantime, I am looking at my depression.

The depression I suffered some years ago was desperation, a heavy, severe sensation, spreading towards the future. I felt trapped. I got stuck in it, forever. It was like a bubble that went up and burst before my face, like a rotten plague spot. Something poisoning my life, something stinking of methane: an old familiar, toxic sensation. And I felt that it was going to be the same, forever.

This clinical sketch could offer the opportunity to consider several aspects of depression, for example the difference between sadness and depression. In this paper, however, my intent is:

• to underline the difference between major depression and melancholia, in particular from the point of view of the patient’s subjective experience;
• to consider the different points of view from which the subject looks at his depressive phenomenon.

Today, my patient looks at her depression and realizes the limitations that this disorder imposed on her life. Before, on the contrary, she fell into an increasing state of desperation, where she was totally immersed. A state with no limits in time, lived as never-ending, timeless and unchangeable. She was living this condition without the possibility to look at it from outside. The impossibility to look at one’s own depressive condition is characteristic of severe depressive condition: XIX century European psychopathology named it melancholic depression. In time, the term melancholia took on many different meanings, so that "the melancholia of past eras encompassed much more than modern conception of depression" (Radden, 2003, p. 39). In the first half of XIX century, melancholia became a specific clinical syndrome in European psychopathology. For the modern nosography (DSM), on the contrary, melancholia is a by-product or sub-species of Major Depressive Episode classified as Major Depressive Episode with melancholic features. Nosography of depression, from DSM-III (1980) on, made every grass a beam, lumping all depressive disorder into a major depression group, instead of distinguishing it in different kinds (Radden,1996). DSM considers only quantitative differences amongst depressive disorders, on the basis of the severity of the disorder and its duration. This kind of logic was grounded on the illusion that all depressions were to be successfully treated by psychopharmacology, regardless of their specific clinical features and of the different kinds of the patient’s subjective experience. In DSM-III, this view was based on "drug cartography" (as Jennifer Radden called this trend): a tentative of remapping psychiatric categories based not on symptom clusters but on psychopharmacological effect. In this perspective, depression is any condition that antidepressants alleviate. But the illusion that antidepressant could heal every depression proved groundless.

Today we know that "patients meeting the DSM criteria for Major Depression vary widely in severity, pathophysiology and treatment response" (Taylor, Fink, 2008, p.2). Yet, we know that

- the diagnosis of depression is not stable in time (Kessing, 2005);

- the course of the disorder varies more than expected. Moreover, the same patient may display different forms of depressive experiences in different times: Oquendo called this phenomenon "pleomorfism" (Oquendo et al., 2004);

- a considerable proportion of depressions chronicizes (Weissman,Klerman,1977;Keller,1992; Beekman et al.,2002) often resulting in enduring psycho-social deficit (Goldberg et al.1995; Martìnez - Aran et al.,2004; Geddes et al.,2004);

a considerable proportion of depressions resists to psychopharmacological treatment (Burrows et al.,1994; Stimson et al., 2002)

another proportion of depressions partially responds to pharmacological treatment (Judd et al.,2000)

For all these reasons, the area of depression cannot be considered an homogenous area. "The DSM diagnostic criteria (for Major Depressive Disorder) - Taylor and Fink (2008 p. 3) write - are non-specific, blurring boundaries between melancholia and other depressive mood disorder and confounding diagnoses. The major depression construct has poor validity". In order to develop a more profound and specific comprehension of depressive disorders and organize more specific and adequate treatments, it is necessary to introduce some distinctions among different kinds of depression. In particular, "if contemporary clinicians do not recognize the subjectively melancholic person living behind the objectively depressed clinical presentation - Brendell writes (2003, p.55) - they might fail to diagnosis and treat person in respectful, empathic, and individualized manner". Behind the objectively depressed clinical presentations we can find people who live different depressive experiences. We have to reconstruct and comprehend these experiences in order to treat depressive disorders at best. By reversing the trend that led to the present inflation of a generic depressive disorder diagnosis, we must look back at the contributions of European phenomenological psychopathology in the field of depression in general and melancholy in particular. Concerning Major Depressive Episode with melancholic features, DSM-IV states that the essential feature of this condition is loss of interest in all, or almost all, activity: there is a near-complete absence of the capacity for pleasure, not merely a diminuition. One of the most preminent characteristic is thedistinct quality of depressed mood: it is experienced by individuals as qualitatively different from sadness experienced during bereavement or non-melancholic depressive episode.

What I want to emphasize is that when DSM speaks of melancholic features, it considers only a qualitative aspect. Melancholic depression has a distinct quality: quantitative instruments cannot measure this qualitative feature. But what does distinct quality mean? This can be verified – DSM suggests – by asking to the patient to compare the quality of the current depressed mood with the mood experience after the death of a loved done. A suggestion that takes in account Freud’s research program of Mourning and Melancholia (1917): "we will try to throw some light on the nature of melancholia by comparing it with the normal affect of mourning" (p.243). At that time, melancholic depression was considered the paradigm of depression par excellance and the touchstone for mourning physiological depression.

What clinical features of melancholia Freud was referring to? The impression – Freud wrote – is to be facing a puzzle

"because we cannot see what it is that is absorbing him so entirely …. An extraordinary diminuition in his self-regard, an impoverishment of his ego on grand scale. In mourning it is the world which has become poor and empty; in melancholia it is the ego itself" (Freud, 1917, p. 246).

Yet:

"the distinguishing mental features of melancholia are a profoundly painful dejection, cessation of interest in the outside world, loss of the capacity to love, inhibition of all activity, and a lowering of the self-regarding feeling to a degree that finds utterance in self-reproaches and self-revilings, and culminates in a delusional expectation of punishment" (ivi,p. 244).

This way, Freud defined the characteristics of melancholia described by European classic psychiatry from the point of view melancholic’s subjective experience. Swiss psychiatrist Eugen Bleuler wrote: patients indulge in complaining about their feeling of having no feelings; everything looks colorless and foreign to them....facial mimicry expresses pain, despair, anxiety; movements get difficult, slow, weak; limbs get heavy as lead; thinking gets inhibited, slow and sluggish. They insist on monotonously on a same point: their sorrow.

Nowadays melancholic depression cannot be considered the paradigm of depression. For DSM it is a sub-species of Major Depressive Disorder. The more widespread form of depression are "atypical" depression of borderline and narcissistic patients. However melancholic depression remains a severe form of depression identifiable in a specific syndrome that has been accurately described and defined. Its specific features are:

• the quality of melancholic mood, which originates without any (apparent) motivation;
• the relentement or inhibition of mental life and motricity
• the patic-apathy or the the feeling of having no feelings, the painful consciuosness of having no feelings
• a modificaton of the temporality which implies a painful retrospection, pervasive experiences of guilt and self-reproach. In all these experiences come to light – as Schneider wrote – the great topics of human anxiety: the preoccupation for the one’s own soul (delusion-like ideas of guilt and unworthiness), the preoccupation for one’s own body (hypochondriac delusion), the preoccupation for one’s own property (ruin delusion).

Recently Rush e Weissenburger (1994) confirm that psychomotor retardation, non-reactive mood, pervasive anhedonia and quality of mood are identifiable clinical features of melancholic syndrome. To shift our attention from the quantity of depression (how much a person is depressed) to the quality of depression (how a person is depressed) I propose to take into account at least two points:

• the quality of the depressive affect;
• what stance the subject adopts in respect to his affect ?

2. THE QUALITY OF DEPRESSIVE AFFECT

Depressive affect quality in melancholia is quite different from what we find in major depression. DSM nosography mentions this difference, but it does not examine it in depth. What is the real specificity of this different kind of experience? Kaplan and Sadock (1993) write that patients are talking about an ineffable quality of melanchonic experience. First of all this qualitative difference depends on the fact that melancholic experience is quite different from sadness. Sadness encompasses much more than depression: sadness and depression are not synonymous, although sadness is present in depression. French psychopathologist Arthur Tatossian pointed out that normal sadness is an experience (often depending on a loss) diffusing with an halo effect. But sadness does not invade all the people’s mental life. Sadness leaves room for others affects. It is an experience with spatial and temporal boundaries (Tatossian,1979). Sadness is one’s incidental attribute. One keeps the ability to distinguish between himself and his sadness, having consciousness of his sadness. In depressive disorders, sadness, if present, is pervasive, loses its spatio-temporal boundaries, it is not limited to one object and diffuses toward all objects of the whole reality. Like a philosopher's stone on reverse, it transforms all the objects with which it is coming in touch.

In Major Depression with melancholic features this kind of depressive sadness becomes, in the subjective patient’s experience, something different. XIX century European psychopathology described this "something different" as the vital quality of melancholic experience.

A condition that can be described in terms of objective symptoms as psychomotor retardation or inhibition (motor functions and cognitive activity are slowed and stupor may occurs – Taylor, Fink, 2008), non-reactive mood, disturbances in basic body functions and vegetative signs (Taylor, Fink, 2008). From this point of view the vital quality of melancholic depression consists in a painful sensation, difficult to describe that the patient feels as a weight burdening his breast. A somatic sensation crushing and freezing the subject, regardless of every real event of his life. Feeling of heaviness, oppression, narrowness, fatigue, slowing or inhibition of mental life and motricity are the somatic more evident melancholic’s complaints. Something that the German psychopathologist Karl Lehonard (1968) described as "somatic prostration" . But melancholic vital quality of depression cannot be reduced to somatic complaints only. Behind this somatic and behavioral façade, what is the quality of affective experience? Subjectively, vital quality expresses itself as moral sorrow. Something quite different from sadness. Yet, in comparison with normal or depressive sadness, melancholic vital quality of depression consists (paradoxically) in the impossibility to be sad. Impossibility to be sad is only a particular aspect of a more global condition characterized by the painful feeling of having no feelings: the pathetic a-pathy, i.e. a painful absence of pathos. "I am not able to do nothing – a patient says - I cannot feel anything, as if I should have no feelings… I have not the possibility to feel something: no body sensation, no sexual sensation.. no feeling for my wife or for my child" (R. Kuhn, 1987). Tormented by her lack of feeling of love towards her daughters, one of my patient says: "for a mother the more terrible sin is to have no love feelings for her daughters…. This is a terrible guilt …".

The feeling of having no feelings is painfully experienced, as a serious shortcoming, a real guilt. This shortcoming proves to the patient his unworthiness. One’s own indifference is felt as the demonstration of his inability to love, and revealing one’s own falsity and un-authenticity. Stanghellini, in accordance with Tatossian, shows that the core experience in melancholia it is not sadness but a mood global alteration. Mood is a global condition, that is non-intentional in the sense that it has no object, not focused, unmotivated, without any reference to the external world. The German psychopathologist Alfred Kraus (2003) pointed out the specific quality of melancholic’s mood showing that:

• melancholic does not find any reason for his condition
• melancholic cannot take any distance from his mood
• melancholic feels the mood alteration as imposed to him
• melancholic has no influence on his mood
• melancholic is not able to have emotions and cognitions different from melancholic mood
• melancholic cannot feel sadness
• melancholic feels his mood inside his body

The melancholic suffering –Tellenbach (1974) writes – consists essentially in the impossibility to establish a relation with his own mood alteration. It lacks the possibility to feel sadness too. To feel sadness should mean to feel something and so doing to take a stance toward melancholic condition. This possibility is not given to the melancholic.

3. WHAT STANCE THE SUBJECT ADOPTS IN RESPECT TO HIS AFFECT ?

The second point I want to consider deals with the stance the subject adopts toward his depressive experience. In Major Depression the sense of continuity between depressive state and one’s life is more conserved. Melancholic experience, on the contrary, signify a break in the life: a dramatic change erasing the sense of continuity of one’s own life. Melancholic mood get out without the possibility that the subject can give any reason to it. The subject cannot try to inscribe this change in a narrative dealing with his being changed. In front of this radical change in the way he looks at himself and at the world around him the subject is astonished.

This astonishment comes together with a special experience: to have direct access to the truth about himself and his life. It is not the access toa truth, but to the truth: the real, only truth. One’s own real nature is uncovered. Freud too, in Mourning and melancholia underlined the melancholic’s attitude to pick up the truth about himself: "he must surely be right in some way – he wrote - and be describing that is as it seems to him to be …. It is merely that he has a keener eye for the truth" (Freud 1917, p.246). So the melancholic discovers the truth about himself: he is guilty, unworthy, condemned for ever, without appeal. The whole his life is recreated in his mind in the light of this ruthless truth: he has been always false, insincere, and lying. As my patient says: "I could appear to others right, honest or normal. But really I am false, throwing dust in the others’ eyes". Melancholic experience so brings to the radical revelation of one’s shameful, wretched, guilty and unworthy nature. "Also when I was fine – my patient says – I pretended to be different from what I really was. I really was different. I was insincere and false". So melancholic experience opens a tear in the obvious, normal perspective one has around himself and his world. This revealed "truth" affects the melancholic and sometimes can kill him (Lambotte, 2003).

Regardless of major depression, where the subject can try to formulate some narrative reconstruction of the relationship between loss and depression, giving to himself some reason for his depression, melancholic does not know if he has lost something, neither what he has possibly lost. His impression is to have gained a privileged point of view from which to look at the real truth about himself and his life. From the point of view of consciousness, the difference between major depression and melancholia pivots on the relationship between phenomenal consciousness, pre-reflective consciousness and reflective self-consciousness, in the sense of narrative self-constitution as Shaun Gallagher (2000) pointed out.

Pre-reflective consciousness does not seem to be directly implied in melancholia. On the contrary melancholic’s phenomenal consciousness – regardless major depression – is occupied by experience that sound as definitive conclusion: "I do not feel any feeling!", "I am guilty", "I am unworthy" or "I am dead", in the extreme case of Cotard’s syndrome. Melancholic’s phenomenal consciousness so is characterized by definitive conclusions. Nothing that can help him to reduce his suffering. In major depression, on the contrary, sadness is pervasive but in some degree opened to meaningfulness. And meaningfulness perhaps means working through.

The more significant difference between major depression and melancholia concerns the role of reflective self-consciousness. A consciousness mediated by reflexion, in which one’s experience of himself is objectified so to permit the development of a narrative identity. This particular aspect of melancholic consciousness is marked by an impasse: the narrative becomes fixed. In his subjective experience, the melancholic feels that his condition is irreparable, fixed. He is no longer in touch with others, with the world, and with the normal way to live time. In melancholia all is blocked. The loss of freedom is total. Neither regret is possible: the revelation of the melancholic truth leaves no room for hope (Fuchs,2001).

The melancholic truth is a subjective experience, felt from inside in an absolute manner and unquestionable, which has the character of autoevidence. It is not a possible narrative reconstruction but it is the real truth: the narrative par excellance in which many melancholic’s fragments of life are recollected. In front of the Truth, one cannot adopt a stance. One can only to be subjugated, to be absorbed from it. For this reason, melancholic’s experience – as Alfred Kraus pointed out – is a consciousness modification with which the subject cannot establish no relation. Melancholic is his disorder, condemned – in his subjective experience – to a condition of profound loss of freedom. Major depression – taking a Lucrezio’s powerful imagine in De rerum natura – is a shipwreck with Spectator. One’s phenomenal consciousness to be depressed is part of reflective self-consciousness in search of a narrative which could give meaninfulness to his depression. If major depression is ashipwreck with Spectator, melancholy resembles a shipwreck without Spectator (Stanghellini, 2004) where the possibility of feeling sadness and depressed becomes an important therapeutic target.