Here’s what I’ve been working with, the idea that people with serious depression are also “crazy.”

Crazy has a technical meaning in psychiatry. If you hear that Mr Jones is “still crazy,” it doesn’t mean he’s a wild and crazy guy. It means that he still thinks there are cameras in the ceiling observing him. Crazy is synonymous with “psychotic,” and means loss of contact with reality in the form of delusions and hallucinations. So crazy is a slang term for psychosis.

But we don’t think of mood disorders as typically involving psychosis. People are sad, or demoralized, without having systematic delusions of persecution or oral hallucinations in which voices comment on their conduct. This is a convention in psychiatry: that mood disorders are disorders of “affect” (how one feels) rather than disorders of intellect (deranged thoughts).

This convention goes back to 1899, when German psychiatrist Emil Kraepelin definitively separated “manic depressive illness” from “dementia praecox” (schizophrenia). And the convention is so intact today that when you, as a depressed patient, have an episode of psychosis, “depression” may be scratched out and “schizophrenia” written in.

Hey, now you’re schizophrenic! Great news.

There is, of course, the diagnosis “psychotic depression” that bridges the two (on the mood side), and the diagnosis “schizoaffective disorder” (on the psychosis side). (Swartz & Shorter, 2007) But deep down, your clinicians are trying to figure out what you “really” have: problems with mood or problems with thought.

Today’s clinicians know in their heart of hearts something that I know from history books: that the intermingling of depression and psychosis is just as common as grass. It is very common for patients with serious depression to ruminate about being watched on the streetcar or have some other delusive thought that falls below the DSM-5 criteria for full-blast “delusional disorder”: Do you have “some great (but unrecognized) talent or insight”? DSM-5 asks. Or do you have the (erroneous) belief that someone else is madly in love with you? These are heavy-caliber delusional systems: You might end up killing the person you believe is in love with you if your love is not reciprocated.

But beneath these full-bore delusional systems, all kinds of thoughts may qualify as delusional, as long as they’re fixed and false. And these are common in melancholic depression: to take the obvious, that you have no hope of recovery. This is delusional. Melancholic illness is something people recover from spontaneously, sooner or later.

What am I getting at with all this rabbiting on about delusions? I’m getting at the idea that there’s more to serious depression that mood changes. That mood changes and fixed false ideas might be the same illness, rather than “comorbid.” This is kind of interesting, isn’t it? It means that what we call “depression” may involve the entire brain rather than just the mood parts of it (We’re talking neurochemistry here rather than neuroanatomy).

Is this my bright idea? No, it’s not. German psychiatrist (and philosopher) Karl Jaspers, the founder of the modern study of “psychopathology,” said in 1942 that there was such as thing as “primary delusional experience” (primäres Wahnerlebnis): the perception that “something is different,” without as yet being integrated into a system (Jaspers, 1942). And this is very common in depression.

1942! Did anybody pick this up? Fat chance. The world was in the middle of a terrible war. German was going out of style as an academic language at flank speed. And Freud’s psychoanalysis was overwhelming everything else: the head psychiatrist of the US Army, William Menninger, was a psychoanalyst. No, Jaspers’ idea died stillborn.

But now, that we’re strangling in the vise of the “Kraepelinian dichotomy” – the separation of mood and psychosis -- we need all the help we can get.

And, oh, these Germans! Too cute for words, aren’t they? Next week we’re going to talk about another one of the ways in which you might be crazy if you’re depressed.

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