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Involutional Melancholia In Males?
Involutional Melancholia In Males? FINN ASKEVOLD
The purpose of this paper is twofold, firstly it will underline the importance of the concept "Masked depression", secondly it will show, on the basis of clinical material, the possibility of an involutional melancholia being present in males parallel to that of females. By masked depression we understand the condition of a patient whose personal sufferings are expressed in somatic terms, while the basis of his complaints is a depressive emotional state not recognized as such by the person himself. Anchersen (1961), Askevold (1969), Geissler (1973). The patient communicates his depression in a somatic symptom language. Lindner (1960), Melgard (1968), Jacobowsky (1961). Consequently it is of great importance both for the general practitioner and for the somatic specialist to interpret this communication correctly. The importance is increased by the fact that these depressions lend themselves very well to treatment with antidepressant drugs, especially when combined with supportive psychotherapy. There has been much controversy regarding the concept of depression. For practical clinical purposes we chose the description by Schwab et al (1973). They list depression as a syndrome consisting of five major dimensions: 1) an affective disturbance with symptoms related to lowered mood, 2) some physical distress with a variety of somatic symptoms, 3) altered type of psychobiological activities such as sleep and appetite, 4) a negative self-evaluation involving lowered selfesteem, self-blame, suicidal ideation and a sense of guilt, 5) an existential dimension typified by pessimism, despair and a gloomy outlook for the future. This multidimensional concept of depression was derived from the works of Freud, Abraham, Rado, Fenichel, Bibring and others. With only slight alteration and translation of the words used, we can describe the same states of mind just as well in the terms of Kraepelin, Bleuler and Kretschmer. I would like to add a few items to point 3, the patterns of psychobiological activity. The sleep pattern in melancholy is the early morning awakening which is almost pathognomonic. (Hawkins et al. (1966), Alsen (1971). Impotency with loss of interest and morning erection and also frigidity in women are important alterations. In the patients' terms it is expressed as "loss of interest" as compared to a previously wellfunctioning sex life. The last item is constipation which Dr. Askevold is from the Psychosomatic Department, Oslo University Hospital, (Rikshospitalet). 170
exceeds the effect of lowered food intake due to anorexia. The masked depressions presenting themselves to the general practitioner may differ somewhat from the classical descriptions of patients in psychiatric institutions. They have less marked psychomotor inhibition, more overtly expressed anxiety, fewer feelings of guilt and fewer self-accusations. The reason for masking a depression behind somatic symptoms may be based on several factors, viz, cultural, sociological, psychological and somatic. It is still socially more acceptable to have a somatic disease, since you recover from a broken leg, but in people's opinion you never recover from a mental disease. One is socially tainted even in our so-called educated world. In the psychological field there are many reasons, but one is that the masked depressions seem to be more ego-alien. You are not besetted by the depression, your ego is not totally occupied by it, making it egosyntonic, as expressed by the melancholic patient: "I am the biggest sinner in the world". In the somatic field knowledge is still sparse, but there is probably also an important somatic factor in depressions giving validity to the patients seeing a somatic doctor. Engel (1961) in his excellent paper "Is grief a disease?" has asked for more research. Marder et al. (1967) with their point of departure in separation anxiety, stated the possibility of psychosomatic diseases as a masked depression, because of the great similarity in many respects between patients with psychosomatic diseases and those with depressions. The psychotic quality is present also in masked depressions as in other types of melancholia. Example: A man, aged 59, who in his own opinion suffered from leg and knee trouble, with absence of somatic pathology, expressed his opinion about his future-he would have to sell his house, move into a cheap apartment far out in the country where living expenses were low. He thought he was unable to work any more. The break with reality lies in the fact that even when put on a disablement pension he would still be in the upper 2 % income bracket in Norway. The Involutional Aspect. In their study, Schwab et al. (1973) pointed out a higher prevalence in the age group 50-59 and not as expected between 40-49 years of age. They do not differentiate between males and females. It might be more correct to use 40-55 years of age for females and Volume XV
INVOLUTIONAL MELANCHOLIA-ASKEVOLD
45-59 for males as the period where involution may take place. The question of a special involutional melancholia has been the subject of different opinions. Langfeldt (1951) described it in his textbook as an entity both for males and females and he specially mentions a male climacterium. In the revised edition, 1965, he abandons it, referring to increased clinical experience without referring to any publications or research. He refutes the concept of a male climacterium on the basis of testosterone studies. Henderson and Gillespie (1957) have a clear description of involutional melancholia. Ewalt et at. (1957) state: "In this age in life man must recognize that his future now has become his present and that he has probably realized the top status in life which he can hope to achieve. Also the odds are great against showing much more progress in his professional or business career and his employability is less." Kringlen (1972) is negative to the concept but Dlett and Goodrich (1969) point to the marked changes in the family and work roles at this age, lowering of mental and physical strength and endurance and loss of orgastic potential. These give a specific psychological coloring to the melancholias appearing in this age group. Hormonal studies have not given evidence for changes in males paraIlel to the female menopause Nicola-Baumann (1971). Lay observations, however, state clearly that at about 50 years of age something happens. The turgor of the skin and subcutaneous tissue slackens, muscular elasticity is diminished and physical speed is reduced, even in those who keep up their physical training. The graying of hair is all too weIl known and there is usuaIly also a reduction in sexual potency. The inability to find hormonal changes must be due to the inadequacy of the present methods which cannot disclose what everybody can see. I would like to quote a Norwegian author, A. Sandemose in "Felicias Wedding", Oslo 1961: "He got a stronger vaccination against his fright of age, more than the majority of men, when he lived through his period of horror of two to three years duration from 1941, the so-caIled male climacterium, a misleading term" (p. 55) and later: "... it was just youth which had dissolved itself in a desert storm which they call the male climacterium and now it has past" (p. 113), and he describes how after this he again felt strength and vigor returning to him. It is also difficult to put one single episode occuring at this age into a cyclic concept as many try to do. There is also a difference in premorbid personality in cyclic and involutional melancholia.
Henderson and Gillespie (1957) give a lucid description: "Record of hard work, sensitive, meticulous, busy, active people who take a pride in their October/November /December, 1974
work and have a high sense of duty towards others and with little or no relationship to the manic-depressive constitution". In investigating this we have to rule out all who have had any previous attack of depression or other mental break-downs.
Our own material: In our department I have personally investigated 150 males during 1972 and up to May 1973. The diagnosis of masked depression was given to 19, all between 45 and 59 years of age-average 49.3 years. No cases fell outside this age group. (The hospital is purely somatic with a psychosomatic liaison service attached-but no psychiatric department). In order to have a baseline we compared this group (DEP) with another male group, aged 45-55 with an average mean of 50.2 years. They were all admitted to the hospital for serious somatic diseases, but in a psychiatric interview were found to be weIl-integrated, normal persons without depressive traits. Askevold (1973). This is caIled our reference group (REF). We find the first prominent difference between the groups in the social background (table I). The depressed come from a higer social stratum than the reference group, which in turn is closer to the general population as it was 40-50 years ago. There was a distinct upward social movement in both groups, but much more marked in the depressed (tables 2 and 3), thus fitting weIl with the personality description given by Henderson. These traits are of the kind that provide success in vocational life. As both groups are from the same hospital population, selection procedures are unlikely to play a part in the social differences. Educational level (table 4) is partly a reflection TABLE I SOCIAL CONDITIONS IN CHILDHOOD
Class
Dep.
1+11
3
I
III
6
3
10
18
IV
+
V
Ref.
TABLE 2 ACTUAL SOCIAL STATUS
Class
Dep.
Ref.
5 l! 6
I 5 16
I + II III IV + V
TABLE 3 SOCIAL MOBILITY
Class I + 11 III IV
+
V
Parents soc. status
Dep. Actual soc. status
3 6 10
8 6
5
Ref. Parents Actual soc. status soc.status I 3 18
I 5 16
171
PSYCHOSOMATICS
of the parents' social status and partly one of intelligence. Marriage status (table 6) is the same in both groups and there is a slightly higher percentage of married males than in the general population. This contradicts to some extent the rule of loneliness as pathogenic in depressive mental suffering. There is no difference in family size nor in position in the sibling hierarchy (table 5). There is no difference in urbanity versus rurality in childhood, nor in migration or in broken homes. Neither is there a difference in upbringing in incomplete homes (table 8). There is a great difference in the subjective experience of the emotional conditions in childhood, reflecting the contact and object relations. The majority of the reference group experienced their homes in childhood as harmonious with openness and trust. Six out of 22 had a feeling of slight distance and emotional deprivation. Of the depressives only 3 of 19 had experienced the feeling of harmony and even in those the interviewer felt this assertion was made more out of loyalty to the parents than to the truth. The feeling of disharmony is not influenced by the depressive mood in the interview situation. The major feelings were distance, deprivation, lack of intimacy, lack of hasic contact and trust. They felt claims from their parents on conventional behaviour with gratification only on adaptation to the parents' values and norms-"be quiet and obedient children". The personalities of the patients are in agreement with Henderson's description. Ambition is a word they often use about themselves, with a great investment and pride in their work performances-unrelated to social class. They are proud of their career and material achievements. They are socially hyperadapted with inhibition of aggression, but not of self-assertiveness. In contact relations they are often bound with ambivalent feelings to the close family. Outside the family they have few friends, but many acquaintances and a great engagement in superficial social contacts. It looks as if they have to a great extent the tendency to create an outer form of security or safety based on materialistic values. Many of the patients were ardent body worshippers. Most of these traits point to a character neurosis with a rather narcissistic colour. Nemiah (1973) underlines the narcissistic basis of all depressions and he mentions incorporation of lost objects as the origin of somatic complaints. In my patients, loss of objects in relation to the onset of depression was not present in one single case, nor was there a threat of loss. Previous psychosomatic diseases were common: 4 peptic ulcers, one with hypertension, one with polyarthritis, one with irritable colon, one with asthma and one had a myocardial infarction. This last patient died later, but had found relief for his depression. This seems to corroborate the statements of Marder et al. 172
TABLE 4 EDUCATION Dep. 7 yrs. school 8 9 yrs. school I 12 yrs. school 10 University grad. 4 TABLE 5 FAMILY CONSTELLATION Dep. Large (over 4 children) 10 Small (3 or less) 9 Single child 3 Oldest child 4 Youngest child 6 Middle child 6 TABLE 6 MARRIAGE STATUS Dep. Married 16 Mamed twke I Single: Widowed 1 Divorced o 1 Unmarried
Ref. 18 3 I I
Ref. 16 6 I 6 3 12
Ref. 18 1
TABLE 7 EMOTIONAL ENVIRONMENT IN CHILDHOOD Dep. Ref. 3 16 Harmonious 16 6 Disharmonious 4 1 Restricted 10 4 Remote 2 1 Demanding TABLE 8 MISCELLANEOUS DATAS Ref. Dep. 5 (17) 9 (10) Urban childhood 8 (14) 7 (12) Migration 5 (17) 3 (16) Broken Home
(1967) on a theoretical kinship between depression and psychosomatic diseases, where the common basis is the narcissistic traits in the personality. This is compensated by other and stronger personality traits and the use of conventionalism as the major defense. This is the reason why they don't decompensate earlier under the stresses of life, only in certain life phases. One of the reasons for the masking of the depression might be these previous somatic ailments. The diffuse somatic complaints' of the depression is suggestively concentrated by the memory of the previous disease. An example: A 49-year old man had symptoms of peptic ulcer from his early twenties and was treated for this on several occasions, sometimes the X-ray evidence was positive. At age 45 he was admitted to the hospital after being out of work for six months. In addition to the ordinary treatment for his dyspepVolume XV
INVOLUTIONAL MELANCHOUA-ASKEVOLD
sia, (this time without demonstrable ulcer), he underwent a course of psychotherapy aimed at achieving insight in behaviour patterns and relationship with his superiors. He stayed well for four years. When his symptoms reappeared they looked very much the same, but superficially only when viewed in retrospect. Ventricular surgery was suggested, but X-rays were negative and the surgeon refused to operate. He then got pneumonia, was adequately treated, but showed an unusually slow recovery. When questioned at this phase, he could confirm the presence of disturbed sleep with early morning awakening, loss of potency, loss of lust for life and the only future he saw was a disablement pension. After three weeks on an antidepressive drug he showed the first signs of optimism, and in the course of a further two weeks he was completely changed. He smiled, was eager to resume work and he even took on a leading position which he had never ventured to do before. Tn my last contact with him a year later he was still working with great success. It must be mentioned that there are no manic qualities in his behaviour. TREATMENT
To confirm a diagnosis by treatment results is tempting. hut not considered scientific in the positive meaning of this word. All patients here were treated with Doxepin (Sinequan) in the usual way. We adhere to a maintenance course of treatment of one year. One half of the patients are still on this dosage. In the other half there have been two relapses, probably because at that time the maintenance administration of the drug did not last so long. (Serry and Serry (1969) ) Tn all patients there has been good response within three to four weeks; in 10 excellent. They are all back at work except one who has suffered a grave head injury in a traffic accident which was not his fault. They are as socially well-adapted as before and they have resumed sex life. Some of them show a more realistic acceptance of their age-induced lowered physical capacity. CONCLUSION
This type of depression proves to be a melancholia under the mask of somatic complaints. This occurs as a distinct disturbance in a special life phase. Lay opinion confirms the term "male climacterium". On this basis there are ample reasons to uphold the old
October/November/December, 1974
concept of 'involutional melancholia also applied to males. REFERENCES 1. Alsen, V.: Behandlung des depressiven Friiherwachens und Friihtiefs mit Saroten retard. Med. Klinik. (1971) 66, 1086-1088. 2. Anchersen, P.: A-typical Endogenous Depressions. Acta. Psych. Scand. (1961), suppl. 162, 232-239. 3. Askevold, F.: De skjulte depresjoner. T. norske laegefor. (1969) 89, 1905-1908. 4. Askevold, F.: The Search for Parameters. Psychother. Psychosom. (1973), 22, 112-120. 5. Bigelow, N.: The involutional psychoses. in Arieti S. (Ed.) American Handbook of Psychiatry, Vol. I. New York 1959. 6. Engel, G.L.: Is Grief a Disease. PsycllOsom. MI'lJ. (1961), 23, 18-22. 7. Ewalt, J.F., Strecker, E.A., Ebaugh, T.G.: Involutional psychotic reactions. p. 172 in Practical Clinical Psychiatry New York 1957. 8. Geissler, L.: Masked depressions. 1973 cit Medical Tribu:le 30.7. from Ciba/Geigy Symp. SI. Moritz, June. 9. Hawkins, D.R. & Mendels, J.: Sleep Disturbance in Depressive Symptomes. Am. J. Psychiatry (1966), 123, 682690. 10. Henderson, D., Gillespie. R.D.: Involutional Melancholy. in Textbook in Psychiatry, London 1957. 11. Jacobowsky, B.: Psychosomatic Equivalense of Endogenous Depression. Acta Psych. Scand. (1961) suppl. 162, 253-260. 12. Kringlen, E.: Psykiatri. Universitetsforlaget. Oslo 1972. 13. Langfeldt. G.: Laerebok i klinisk psykiatri. Oslo 1951. 14. Langfeldt, G.: Laerebok i klinisk psykiatri. Oslo 1965. 15. Lindner, M.: Organsymptom in der Psychiatrie. Die ver· kannte Depression. Hippokrates (1960) 37, 860-863. 16. Marder, L.; Horgerbrek, J.D.: Psychosomatic disease as a masked Depression. Psychosomatics (1967) III, 263-27\. 17. Melgard, 8.J.: Latta endogena depressioner som differensialdiagnostisk problem. Liikartidn. (1968) 65, 25032513. 18. Nemiah, J.C.: Symptomene og det ubevisste. Gyldendal (1973). 19. Nicola-Baumann, L.: Endocrinological studies on subjects with involutional melancholia. Acta. Psych. SCf/nd. ( 1971 ), Suppl. 226. 20. Schwab, J.J., Holler, C.E., Warnett, G.J.: Depressive Symptomatology and Age. Psychosomatics (1973), 14, 135-141. 21. Serry, D. and Serry, M.: Masked Depression and the Use of Anti-depressants in General Practice. Med. J. Austral. (1969), 1,334-338. 22. Ulelt, G.A. and Goodrich, D.W.: A Synopsis of Contemporary Psychiatry. St. Louis 1969. (Mosby) 23, Wahl, C.W.: Physical Symptoms as a Mask of Psychiatric Disorders in the Hospital. Hospital Medicine. (1964), 28-29.
173
The purpose of this paper is twofold, firstly it will underline the importance of the concept "Masked depression", secondly it will show, on the basis of clinical material, the possibility of an involutional melancholia being present in males parallel to that of females. By masked depression we understand the condition of a patient whose personal sufferings are expressed in somatic terms, while the basis of his complaints is a depressive emotional state not recognized as such by the person himself. Anchersen (1961), Askevold (1969), Geissler (1973). The patient communicates his depression in a somatic symptom language. Lindner (1960), Melgard (1968), Jacobowsky (1961). Consequently it is of great importance both for the general practitioner and for the somatic specialist to interpret this communication correctly. The importance is increased by the fact that these depressions lend themselves very well to treatment with antidepressant drugs, especially when combined with supportive psychotherapy. There has been much controversy regarding the concept of depression. For practical clinical purposes we chose the description by Schwab et al (1973). They list depression as a syndrome consisting of five major dimensions: 1) an affective disturbance with symptoms related to lowered mood, 2) some physical distress with a variety of somatic symptoms, 3) altered type of psychobiological activities such as sleep and appetite, 4) a negative self-evaluation involving lowered selfesteem, self-blame, suicidal ideation and a sense of guilt, 5) an existential dimension typified by pessimism, despair and a gloomy outlook for the future. This multidimensional concept of depression was derived from the works of Freud, Abraham, Rado, Fenichel, Bibring and others. With only slight alteration and translation of the words used, we can describe the same states of mind just as well in the terms of Kraepelin, Bleuler and Kretschmer. I would like to add a few items to point 3, the patterns of psychobiological activity. The sleep pattern in melancholy is the early morning awakening which is almost pathognomonic. (Hawkins et al. (1966), Alsen (1971). Impotency with loss of interest and morning erection and also frigidity in women are important alterations. In the patients' terms it is expressed as "loss of interest" as compared to a previously wellfunctioning sex life. The last item is constipation which Dr. Askevold is from the Psychosomatic Department, Oslo University Hospital, (Rikshospitalet). 170
exceeds the effect of lowered food intake due to anorexia. The masked depressions presenting themselves to the general practitioner may differ somewhat from the classical descriptions of patients in psychiatric institutions. They have less marked psychomotor inhibition, more overtly expressed anxiety, fewer feelings of guilt and fewer self-accusations. The reason for masking a depression behind somatic symptoms may be based on several factors, viz, cultural, sociological, psychological and somatic. It is still socially more acceptable to have a somatic disease, since you recover from a broken leg, but in people's opinion you never recover from a mental disease. One is socially tainted even in our so-called educated world. In the psychological field there are many reasons, but one is that the masked depressions seem to be more ego-alien. You are not besetted by the depression, your ego is not totally occupied by it, making it egosyntonic, as expressed by the melancholic patient: "I am the biggest sinner in the world". In the somatic field knowledge is still sparse, but there is probably also an important somatic factor in depressions giving validity to the patients seeing a somatic doctor. Engel (1961) in his excellent paper "Is grief a disease?" has asked for more research. Marder et al. (1967) with their point of departure in separation anxiety, stated the possibility of psychosomatic diseases as a masked depression, because of the great similarity in many respects between patients with psychosomatic diseases and those with depressions. The psychotic quality is present also in masked depressions as in other types of melancholia. Example: A man, aged 59, who in his own opinion suffered from leg and knee trouble, with absence of somatic pathology, expressed his opinion about his future-he would have to sell his house, move into a cheap apartment far out in the country where living expenses were low. He thought he was unable to work any more. The break with reality lies in the fact that even when put on a disablement pension he would still be in the upper 2 % income bracket in Norway. The Involutional Aspect. In their study, Schwab et al. (1973) pointed out a higher prevalence in the age group 50-59 and not as expected between 40-49 years of age. They do not differentiate between males and females. It might be more correct to use 40-55 years of age for females and Volume XV
INVOLUTIONAL MELANCHOLIA-ASKEVOLD
45-59 for males as the period where involution may take place. The question of a special involutional melancholia has been the subject of different opinions. Langfeldt (1951) described it in his textbook as an entity both for males and females and he specially mentions a male climacterium. In the revised edition, 1965, he abandons it, referring to increased clinical experience without referring to any publications or research. He refutes the concept of a male climacterium on the basis of testosterone studies. Henderson and Gillespie (1957) have a clear description of involutional melancholia. Ewalt et at. (1957) state: "In this age in life man must recognize that his future now has become his present and that he has probably realized the top status in life which he can hope to achieve. Also the odds are great against showing much more progress in his professional or business career and his employability is less." Kringlen (1972) is negative to the concept but Dlett and Goodrich (1969) point to the marked changes in the family and work roles at this age, lowering of mental and physical strength and endurance and loss of orgastic potential. These give a specific psychological coloring to the melancholias appearing in this age group. Hormonal studies have not given evidence for changes in males paraIlel to the female menopause Nicola-Baumann (1971). Lay observations, however, state clearly that at about 50 years of age something happens. The turgor of the skin and subcutaneous tissue slackens, muscular elasticity is diminished and physical speed is reduced, even in those who keep up their physical training. The graying of hair is all too weIl known and there is usuaIly also a reduction in sexual potency. The inability to find hormonal changes must be due to the inadequacy of the present methods which cannot disclose what everybody can see. I would like to quote a Norwegian author, A. Sandemose in "Felicias Wedding", Oslo 1961: "He got a stronger vaccination against his fright of age, more than the majority of men, when he lived through his period of horror of two to three years duration from 1941, the so-caIled male climacterium, a misleading term" (p. 55) and later: "... it was just youth which had dissolved itself in a desert storm which they call the male climacterium and now it has past" (p. 113), and he describes how after this he again felt strength and vigor returning to him. It is also difficult to put one single episode occuring at this age into a cyclic concept as many try to do. There is also a difference in premorbid personality in cyclic and involutional melancholia.
Henderson and Gillespie (1957) give a lucid description: "Record of hard work, sensitive, meticulous, busy, active people who take a pride in their October/November /December, 1974
work and have a high sense of duty towards others and with little or no relationship to the manic-depressive constitution". In investigating this we have to rule out all who have had any previous attack of depression or other mental break-downs.
Our own material: In our department I have personally investigated 150 males during 1972 and up to May 1973. The diagnosis of masked depression was given to 19, all between 45 and 59 years of age-average 49.3 years. No cases fell outside this age group. (The hospital is purely somatic with a psychosomatic liaison service attached-but no psychiatric department). In order to have a baseline we compared this group (DEP) with another male group, aged 45-55 with an average mean of 50.2 years. They were all admitted to the hospital for serious somatic diseases, but in a psychiatric interview were found to be weIl-integrated, normal persons without depressive traits. Askevold (1973). This is caIled our reference group (REF). We find the first prominent difference between the groups in the social background (table I). The depressed come from a higer social stratum than the reference group, which in turn is closer to the general population as it was 40-50 years ago. There was a distinct upward social movement in both groups, but much more marked in the depressed (tables 2 and 3), thus fitting weIl with the personality description given by Henderson. These traits are of the kind that provide success in vocational life. As both groups are from the same hospital population, selection procedures are unlikely to play a part in the social differences. Educational level (table 4) is partly a reflection TABLE I SOCIAL CONDITIONS IN CHILDHOOD
Class
Dep.
1+11
3
I
III
6
3
10
18
IV
+
V
Ref.
TABLE 2 ACTUAL SOCIAL STATUS
Class
Dep.
Ref.
5 l! 6
I 5 16
I + II III IV + V
TABLE 3 SOCIAL MOBILITY
Class I + 11 III IV
+
V
Parents soc. status
Dep. Actual soc. status
3 6 10
8 6
5
Ref. Parents Actual soc. status soc.status I 3 18
I 5 16
171
PSYCHOSOMATICS
of the parents' social status and partly one of intelligence. Marriage status (table 6) is the same in both groups and there is a slightly higher percentage of married males than in the general population. This contradicts to some extent the rule of loneliness as pathogenic in depressive mental suffering. There is no difference in family size nor in position in the sibling hierarchy (table 5). There is no difference in urbanity versus rurality in childhood, nor in migration or in broken homes. Neither is there a difference in upbringing in incomplete homes (table 8). There is a great difference in the subjective experience of the emotional conditions in childhood, reflecting the contact and object relations. The majority of the reference group experienced their homes in childhood as harmonious with openness and trust. Six out of 22 had a feeling of slight distance and emotional deprivation. Of the depressives only 3 of 19 had experienced the feeling of harmony and even in those the interviewer felt this assertion was made more out of loyalty to the parents than to the truth. The feeling of disharmony is not influenced by the depressive mood in the interview situation. The major feelings were distance, deprivation, lack of intimacy, lack of hasic contact and trust. They felt claims from their parents on conventional behaviour with gratification only on adaptation to the parents' values and norms-"be quiet and obedient children". The personalities of the patients are in agreement with Henderson's description. Ambition is a word they often use about themselves, with a great investment and pride in their work performances-unrelated to social class. They are proud of their career and material achievements. They are socially hyperadapted with inhibition of aggression, but not of self-assertiveness. In contact relations they are often bound with ambivalent feelings to the close family. Outside the family they have few friends, but many acquaintances and a great engagement in superficial social contacts. It looks as if they have to a great extent the tendency to create an outer form of security or safety based on materialistic values. Many of the patients were ardent body worshippers. Most of these traits point to a character neurosis with a rather narcissistic colour. Nemiah (1973) underlines the narcissistic basis of all depressions and he mentions incorporation of lost objects as the origin of somatic complaints. In my patients, loss of objects in relation to the onset of depression was not present in one single case, nor was there a threat of loss. Previous psychosomatic diseases were common: 4 peptic ulcers, one with hypertension, one with polyarthritis, one with irritable colon, one with asthma and one had a myocardial infarction. This last patient died later, but had found relief for his depression. This seems to corroborate the statements of Marder et al. 172
TABLE 4 EDUCATION Dep. 7 yrs. school 8 9 yrs. school I 12 yrs. school 10 University grad. 4 TABLE 5 FAMILY CONSTELLATION Dep. Large (over 4 children) 10 Small (3 or less) 9 Single child 3 Oldest child 4 Youngest child 6 Middle child 6 TABLE 6 MARRIAGE STATUS Dep. Married 16 Mamed twke I Single: Widowed 1 Divorced o 1 Unmarried
Ref. 18 3 I I
Ref. 16 6 I 6 3 12
Ref. 18 1
TABLE 7 EMOTIONAL ENVIRONMENT IN CHILDHOOD Dep. Ref. 3 16 Harmonious 16 6 Disharmonious 4 1 Restricted 10 4 Remote 2 1 Demanding TABLE 8 MISCELLANEOUS DATAS Ref. Dep. 5 (17) 9 (10) Urban childhood 8 (14) 7 (12) Migration 5 (17) 3 (16) Broken Home
(1967) on a theoretical kinship between depression and psychosomatic diseases, where the common basis is the narcissistic traits in the personality. This is compensated by other and stronger personality traits and the use of conventionalism as the major defense. This is the reason why they don't decompensate earlier under the stresses of life, only in certain life phases. One of the reasons for the masking of the depression might be these previous somatic ailments. The diffuse somatic complaints' of the depression is suggestively concentrated by the memory of the previous disease. An example: A 49-year old man had symptoms of peptic ulcer from his early twenties and was treated for this on several occasions, sometimes the X-ray evidence was positive. At age 45 he was admitted to the hospital after being out of work for six months. In addition to the ordinary treatment for his dyspepVolume XV
INVOLUTIONAL MELANCHOUA-ASKEVOLD
sia, (this time without demonstrable ulcer), he underwent a course of psychotherapy aimed at achieving insight in behaviour patterns and relationship with his superiors. He stayed well for four years. When his symptoms reappeared they looked very much the same, but superficially only when viewed in retrospect. Ventricular surgery was suggested, but X-rays were negative and the surgeon refused to operate. He then got pneumonia, was adequately treated, but showed an unusually slow recovery. When questioned at this phase, he could confirm the presence of disturbed sleep with early morning awakening, loss of potency, loss of lust for life and the only future he saw was a disablement pension. After three weeks on an antidepressive drug he showed the first signs of optimism, and in the course of a further two weeks he was completely changed. He smiled, was eager to resume work and he even took on a leading position which he had never ventured to do before. Tn my last contact with him a year later he was still working with great success. It must be mentioned that there are no manic qualities in his behaviour. TREATMENT
To confirm a diagnosis by treatment results is tempting. hut not considered scientific in the positive meaning of this word. All patients here were treated with Doxepin (Sinequan) in the usual way. We adhere to a maintenance course of treatment of one year. One half of the patients are still on this dosage. In the other half there have been two relapses, probably because at that time the maintenance administration of the drug did not last so long. (Serry and Serry (1969) ) Tn all patients there has been good response within three to four weeks; in 10 excellent. They are all back at work except one who has suffered a grave head injury in a traffic accident which was not his fault. They are as socially well-adapted as before and they have resumed sex life. Some of them show a more realistic acceptance of their age-induced lowered physical capacity. CONCLUSION
This type of depression proves to be a melancholia under the mask of somatic complaints. This occurs as a distinct disturbance in a special life phase. Lay opinion confirms the term "male climacterium". On this basis there are ample reasons to uphold the old
October/November/December, 1974
concept of 'involutional melancholia also applied to males. REFERENCES 1. Alsen, V.: Behandlung des depressiven Friiherwachens und Friihtiefs mit Saroten retard. Med. Klinik. (1971) 66, 1086-1088. 2. Anchersen, P.: A-typical Endogenous Depressions. Acta. Psych. Scand. (1961), suppl. 162, 232-239. 3. Askevold, F.: De skjulte depresjoner. T. norske laegefor. (1969) 89, 1905-1908. 4. Askevold, F.: The Search for Parameters. Psychother. Psychosom. (1973), 22, 112-120. 5. Bigelow, N.: The involutional psychoses. in Arieti S. (Ed.) American Handbook of Psychiatry, Vol. I. New York 1959. 6. Engel, G.L.: Is Grief a Disease. PsycllOsom. MI'lJ. (1961), 23, 18-22. 7. Ewalt, J.F., Strecker, E.A., Ebaugh, T.G.: Involutional psychotic reactions. p. 172 in Practical Clinical Psychiatry New York 1957. 8. Geissler, L.: Masked depressions. 1973 cit Medical Tribu:le 30.7. from Ciba/Geigy Symp. SI. Moritz, June. 9. Hawkins, D.R. & Mendels, J.: Sleep Disturbance in Depressive Symptomes. Am. J. Psychiatry (1966), 123, 682690. 10. Henderson, D., Gillespie. R.D.: Involutional Melancholy. in Textbook in Psychiatry, London 1957. 11. Jacobowsky, B.: Psychosomatic Equivalense of Endogenous Depression. Acta Psych. Scand. (1961) suppl. 162, 253-260. 12. Kringlen, E.: Psykiatri. Universitetsforlaget. Oslo 1972. 13. Langfeldt. G.: Laerebok i klinisk psykiatri. Oslo 1951. 14. Langfeldt, G.: Laerebok i klinisk psykiatri. Oslo 1965. 15. Lindner, M.: Organsymptom in der Psychiatrie. Die ver· kannte Depression. Hippokrates (1960) 37, 860-863. 16. Marder, L.; Horgerbrek, J.D.: Psychosomatic disease as a masked Depression. Psychosomatics (1967) III, 263-27\. 17. Melgard, 8.J.: Latta endogena depressioner som differensialdiagnostisk problem. Liikartidn. (1968) 65, 25032513. 18. Nemiah, J.C.: Symptomene og det ubevisste. Gyldendal (1973). 19. Nicola-Baumann, L.: Endocrinological studies on subjects with involutional melancholia. Acta. Psych. SCf/nd. ( 1971 ), Suppl. 226. 20. Schwab, J.J., Holler, C.E., Warnett, G.J.: Depressive Symptomatology and Age. Psychosomatics (1973), 14, 135-141. 21. Serry, D. and Serry, M.: Masked Depression and the Use of Anti-depressants in General Practice. Med. J. Austral. (1969), 1,334-338. 22. Ulelt, G.A. and Goodrich, D.W.: A Synopsis of Contemporary Psychiatry. St. Louis 1969. (Mosby) 23, Wahl, C.W.: Physical Symptoms as a Mask of Psychiatric Disorders in the Hospital. Hospital Medicine. (1964), 28-29.
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