- 1 For beauty is nothing but the beginning of terror, that we are still able to bear, and we revere i (...)
Denn das Schöne ist nichts als des Schrecklichen Anfang, den wir noch grade ertragen, und wir bewundern es so, weil es gelassen verschmäht, uns zu zerstören.1
(Reiner Maria Rilke, Duino Elegies, Capitol 1)
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An die Melancholie
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To melancholy
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Zum Wein, zu Freunden bin ich dir entflohn,
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Because I felt horror at the sight of your dark eyes,
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Da mir vor deinem dunklen Auge graute,
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I fled to wine, to friends, in order o escape you,
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In Liebesarmen und beim Klang der Laute
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In the arms of love and by the sound of the lute
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Vergaß ich dich, dein ungetreuer Sohn.
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I, your unfaithful son, forgot you.
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Du aber gingest mir verschwiegen nach
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But you followed me silently,
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Und warst im Wein, den ich verzweifelt zechte,
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And you were in the wine that I quaffed desperately,
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Warst in der Schwüle meiner Liebesnächte
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You were in the fervor of my nights of love
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Und warest noch im Hohn, den ich dir sprach.
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And were even inn the derision that I directed at you.
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Nun kühlst du die erschöpften Glieder mir
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Now you cool my exhausted limbs
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Und hast mein Haupt in deinen Schoß genommen,
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And have taken my head into your lap,
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Da ich von meinen Fahrten heimgekommen:
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When I have come home from all my journeying:
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Denn all mein Irren war ein weg zu dir.
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For all my straying was a path to you.
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(Hermann Hesse)
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1Depression is a commonly occurring mental disorder and a major cause of morbidity worldwide (Kessler and Bromet, 2013). According to the World Health Organization (WHO, 2001), with growing number of patients predicted in the next years, depression is one of the most common diseases in the world, contributing heavily on the global morbidity. Classified as Major Depressive Disorder in the Diagnostic and Statistical manual of Mental Disorders 5 (APA, DSM 5), depression is typically characterized by disturbances of mood and affect, diminished ability to concentrate, anxiety, fatigue, recurrent thoughts of death, decreased appetite, weight loss and insomnia. Treatment of depression involves pharmacological interventions, among which serotonin selective reuptake inhibitors (SSRIs) are the most prescribed medications, and non-pharmacological interventions like chronobiologic strategies (light therapy and sleep deprivation), somatic treatments (transcranial magnetic stimulation, TMS; electroconvulsive therapy, ECT) and psychotherapy. As Herpertz and Fuchs (2014) recently wrote: “The DSM-IV and DSM 5 as well as the ICD-10 are mainly conceived for purposes of reliability and, therefore, characterized by rather simple psychopathological concepts compatible with easily applicable data collection techniques. Consciousness and subjectivity, however, are virtually excluded on the theoretical level and undervalued on the pragmatic level” (p. 1). Despite the impressive progresses of neuroscience and psychopharmacology of the last decades, the causes of psychiatric disorders remain unknown. Modern cognitive neurosciences have mainly studied the mind, as discrete and replicable functions and processes, without considering the first-person experiential dimension. On the contrary, phenomenological psychopathology is a method to assess the patient’s abnormal experiences from their own perspective, whose theoretical origin goes back to the Karl Jaspers’ masterpiece “General Psychopathology” published in 1913. The fundamental objective of the phenomenological approach is the understanding of the way-of-being-in-the-world of the patient. What the patient feels in his own words, the way the patient experiences the dimensions of time and space, how the patient experiences the body and in which terms the inter-personal dialogue with the others is interrupted become the funding questions of the psychopathology. Among others, the most important philosophers who exerted a great influence on many phenomenological psychopathologists are Edmund Husserl and Martin Heidegger.
2Phenomenology (from the ancient Greek word φαινόμενον (phainómenon), “thing appearing to view”) is a philosophical movement founded in the early years of the 20th century by Edmund Husserl. As conveyed with the famous husserlian sentence “to the things themselves” (zu den Sachen selbst), letting the things appear as they are, is the fundamental Husserl’s message. According to Husserl, the phenomena studied by phenomenology, must be the psychic experiences (psychische Erlebnisse). To begin, the philosopher should deflect the attention from the external material objects and direct her to the subjective experience of the objects themselves, the phenomena. This phenomenological reduction (phänomenologishce Reduktion), which is the first reduction of the Husserl’s phenomenological method, requires the suspension of judgements (Urteilsenthaltung) or epoché (ἐποχή: suspension), in order to identify the phenomena. After the phenomenological reduction, when the phenomena appear, we need to proceed with the eidetic (from the Greek word εἶδος, eidos, “shape”) reduction (eidetische Reduktion), in order to describe the phenomena. Aim of the eidetic reduction is to describe the fundamental structures (Grundstrukturen), the essences, of the phenomena. Through the description, the phenomenology makes these structures visible. According to Husserl, the most important structure of the psychic experiences (psychische Erlebnisse) is the intentionality (Intentionalität). The phenomena are always intentional experiences (intentionale Erlebnisse) and the act of experiencing (Erleben) is always experiencing of something (Erleben von Etwas). With the transcendental reduction (tranzendentale Reduktion), the objectivity is referred to the subjectivity, being the world always there within the framework of the conscience (Bewusstsein). Husserl, as mathematician, understood that psychic experiences must be the object of interest of philosophy, in order to understand the world. In other words, in the attempt to give consistency of truth to the objective world, Husserl went back to the human conscience. This thesis, pervading the whole Husserl’s philosophy, deeply influenced many psychopathologists of the time, who remained fascinated by the importance of conscience and subjective experience postulated by Husserl, in the context of mental disorders.
3Martin Heidegger starts from the Husserl’s conceptions to create his hermeneutic phenomenology; in particular, Heidegger recognizes the intentionality as the substantial structure of the Dasein. Usually translated in English with “experience”, in his masterpiece Sein und Zeit, Heidegger uses the term Dasein to refer to the human being. Coming from the Latin words in-tendere, intentionality literally means “to be addressed to”, underlining the eccentric position in the world of the Dasein, always addressed to something. The existence (Exsistenz), from the Latin words ex-sistere, literally “being outside one-self”, according to Heidegger, is the fundamental characteristic of the Dasein. The phenomenologically oriented psychopathologists took this message from Heidegger’s philosophy and interpreted it in the context of mentally disordered patients. If the human being is an intentional being, always addressed to something, a projected project, if the human lives in this eccentric position, always dialoguing between himself and the world, how this can change in psychiatric disorders? How is the intentionality of a depressed patient? How the delicate encounter with another person modified in schizophrenia? To fundamental questions like these, phenomenological psychopathology tried to give answers. With important repercussions for the phenomenological psychopathology is also the Heidegger’s concept of “readiness-to-hand” (Zuhandenheit); the Dasein, in fact, exists in-the-world, among the things, towards which it is constantly addressed. With the terms “environment” (Umwelt) and in later works “world” (Welt), Heidegger conceives everything that has an importance, a meaning, with respect to the Dasein, the human being. The thing, the equipment (Zeug) acquires a meaning, based on the practical personal experience. The Zuhandenheit is the way of being of the things that have a significance. In patients affected by mental disorders, the world, all the things that have an importance, can appear as tremendous, fighting, laden with sinister messages, the things lose their significance and the hands are useless. Heidegger stresses the point that his phenomenology is a hermeneutic phenomenology, in light of the original meaning of hermeneutic, which was the art of understanding texts. Therefore, Heidegger’s whole philosophy could be seen as an attempt to understand (verstehen) the Dasein. In his masterpiece “Being and Time” (Sein und Zeit), Heidegger poses himself the question of Being, achieving the main thesis that Being is based on time.
- 2 “The concrete elaboration of the question about the meaning of “Being” is the aim of the following (...)
Die konkrete Ausarbeitung der Frage nach dem Sinn von “Sein” ist die Absicht der folgenden Abhandlung. Die Interpretation der Zeit als des möglichen Horizontes eines jeden Seinsverständniss überhaupt ist ihr vorläufiges Ziel2. (Sein und Zeit, Vorsatzblatt)
4Heidegger thinks that the link between being and time has always been present in the western philosophy. In fact, time was already in the construct of the Aristoteles’s οὐσία (ousia), translated in Latin as substantia or essentia, being the word ousia derived from the participle of the verb εἰμί (eimí). Many authors linked to the phenomenological psychopathology have analyzed this importance of time in psychiatric disorders, having every form of psychopathological alteration a particular rhythm of the time experience. In the case of depression, for example, the Swiss psychiatrist Ludwig Binswanger and the French psychiatrist Eugéne Minkowski have evidenced a stagnation of the lived time with a general tendency of the prevailing of the past, over the present and future.
- 3 This paragraph was inspired by the lecture held by Gilberto Di Petta in Figline on 20th October 20 (...)
5“How do you feel?” and “what do you feel?” are the opening questions of many psychiatric interviews and they exactly represent the attempt to begin the phenomenological reduction, the effort to have access to the subjective experience of the patient, the phenomenon, the thing itself (die Sache selbst). Phenomenology is a discipline focused on the experience of the conscience, a series of methods that aims at describe and understand the lived experiences. To grasp, realize and describe the structure of the patients’ subjective first person lived experiences represent the basis of Karl Jaspers’ “General Psychopathology”. The etymology of the word experience is complex, letting foresee the kaleidoscopic spectrum of meanings and nuances contained by the word. The topic “experience” has been thoroughly analyzed by Andrea Tagliapietra, whose book “Esperienza” has been held as main source of the following etymological considerations (2017, pp. 74-79). The word experience, like the French expérience, the Spanish experiencia, the Italian esperienza, comes from the Latin experientia. Interestingly, the Latin verb experiri belongs to the deponent verb class, detaining an active meaning with a passive form. This Janus double-faceted aspect of the verb is structural in the actual experience, where there is no centrifugal experience without a centripetal movement; there is no making feel something without feeling or being felt. Both the Latin experientia and the Greek ἐμπειρία (empeiria) comprehend the fundamental Indo-European root –per, associated with the significances of danger (the Latin periculum, the Italian pericolo, the German Gefhar and the English fear) and crossing (the Latin particle “per” indicated a passage through something, the German fahren, the English fare and ferry). The root -per- is also present in the Italian word for experience, esperienza, often used as synonym of adventure. We often use the expression “going through something” in our colloquial language to mean an emotionally relevant and in some way dangerous experience. In the ancient Greek language the verbs peiráo (πειράω) and peráo (περάω) respectively meant “I feel” and “I go through”. Péras (πέρας) meant “limit” and “bond”. “Here, from the etymological memory of the word, the dual consideration of the péras linked to the overcoming of a border emerges, his crossing, but also to the ascertainment of the limit as what determines, in se, the living being, located in his environment and in his corporeity, in the singularity and in the belong to his own death” (Tagliapietra, 2017, p. 76). Péira (πεῖρα) comes from the verb peíro (πείρω) which meant, “I pass from side to side”, “I insert”, “I tuck”. “The peírata are the ropes, the hawsers, those boundaries that, in the Homeric episode of the mermaids, force Ulysses at the mainmast (Tagliapietra, 2017, p. 77). Moreover, the Latin ex-perire includes the verb per-ire, dying, which meant the passage through the limit par excellence. “The experience seems to be linked with a constellation of meanings that imply the idea of travel, that of test (of oneself, of others, of something), exposing to a danger (even to the extreme danger of death) and, therefore, bringing to mind the notion itself of adventure.” (Tagliapietra, 2017 p. 75). In German, there are two words for the English word experience: Erfahrung and Erlebniss, conveying a broad spectrum of meanings. The word Erfahrung possess the shades of significances associated with the Indo-European particle –per. The other German word for experience is what the phenomenologists have in mind when they stress the importance of the experience. The word Erlebniss in fact is linked to the German words Leben, to live or the life, Leib, the lived body, the body that I am and Liebe, the love. The word Erlebniss is loaded with strong emotional content; in phenomenology, the experience is pathic, full of pathos (πάθος, emotion or sufferance). To the phenomenological psychopathologists not the conventional, every day, emotionally indifferent experiences are important, but the emotionally relevant ones, the experiences full of pathos. Heidegger disclosed the importance of affectivity in phenomenology in his headwork “Sein und Zeit” (Heidegger, 1923).
- 4 “One cannot enter into the truth without love.”
Non intratur in veritatem nisi per caritatem4 (St. Augustine)
6Originating from the ancient proto-indoerupean root –ka, meaning “to like, desire”, the word caritas in Latin was the common translation of the Greek word agape (ἀγάπη) which was one of the possible ways the Greeks had to express the love. Agape was the endless, unconditioned and transcendent love. In addition, Kama in Sanskrit meant love. “The truth is accessible through love”; the Saint Augustine’s sentence stresses the role of the emotions for having access to the truth. Heidegger, who carefully read the texts of Saint Augustine, confirmed this role of affectivity as fundament of human existence. In particular, Heidegger conceived the attunement (Befindlichkeit) as one of the main “existentials” (Exsistenziale) of the Dasein. What Heidegger exactly meant with the word Befindlichkeit is far from being clear, but the German significance of the word could help, transmitting a wide range of colors. Sich befinden literally means “Being located” letting see the closeness between the affective disposition of the individual and the existence. Only in the affection, the Dasein exists. What matters to Heidegger is apparently not the fleeting emotions, but the affective attunement preceding them. The Augustine’s love is not short-lived and transient; it is pre-theoretical (Ur-etwas). In Heidegger’s “Grundbegriffe der aristotelischen Philosophie”, the Author sees a precursor of his Befindlichkeit in the Aristoteles’s Pathos.
- 5 “These πάθη, affects, are not conditions of the psychic, it is about an attunement of the living i (...)
Diese πάθη, »Affekte«, sind nicht Zustände des Seelischen, es handelt sich um eine Befindlichkeit des Lebenden in seiner Welt, in der Weise, wie er gestellt ist zu etwas, wie er eine Sache sich angehen läßt. Die Affekte spielen eine fundamentale Rolle bei der Bestimmung des Seins-in-der-Welt, des Seins-mit-und-zu-anderen5. (p. 122)
7The importance of affectivity as basic requirement of the Dasein is further clarified in the same text:
- 6 We will see from the understanding of which is meant with εξις the analysis of the πάθη understand (...)
Wir werden aus dem genaueren Verständnis dessen, was mit εξις gemeint ist, die Analyse der πάθη verstehen, sehen, wie das mit πάθος Bezeichnete das Sein-in-der-Welt in einem fundamentalen Sinne bestimmt und wie es als solche Grund-bestimmung des Seins-in-der-Welt in Frage kommt bei der Aus-bildung der κρίσις, des »Stellungnehmens«, des »Entscheidens« einer entscheidenden Frage. Mit dem Aufweis dieser fundamentalen Rolle der πάθη im κρίνειν selbst bekommen wir zugleich die Möglichkeit, den Boden des λόγος selbst konkreter zu sehen.6 (p. 169).
8In “Was ist Metaphysik”, we find more clarifications concerning the affectivity in Heidegger’s philosophical speculation.
- 7 Being attuned and attunement are the basic way of comprehending and disclosing the world.
Das Gestimmtsein und die Stimmung ist die Grundart der Erfassung und Er(s)chliessung der Welt7. (p. 738)
9Tellenbach gave credit to the Heidegger’s “Befindlichkeit” concept as highlighted in these sentences taken from his masterpiece Melancholy (1980):
Only in the mood, in the attunement, all Dasein’s knowledge, understanding, experience, every meaning and appearing of the world, the global connection of their meanings is made accessible… […]. It is the “condition”(Befindlichkeit) the mean with which the world influences the existence. (p. 52)
10Depression takes origin from the sensitivity, the attunement, in German “die Befindlinchkeit”; this concept is linked with the Kurt Schneider (1949)’s ideas of subsoil (“der Untergrund”) and subsoil-depressions (“die Untergrundsdepressionen”). Schneider (1949) himself admits the incomprehensibility of the “Untergrund”:
- 8 What the subsoil actually is surpasses the experience and is a philosophical question. Unfortunate (...)
Was der Untergrund selbst ist überschreitet die Erfahrung und ist eine philosophische Frage. Er ist für uns leidglich ein Grenzbegriff. Wir erfassen mit ihm also eine Grenze, hinter die keine Erfahrung reichen kann, etwas, worüber es keine Aussagen gibt, was also nicht einfach als somatisch postuliert, aber auch nicht psychologisiert werden kann.8
11For the Author, the Untergrund, translatable with “base color”, “subsoil” or “foundation” is what is altered, without a recognizable cause, in some forms of depression (“die Untergrundsdepressionen”). On the other hand, Schneider identifies subtypes of depression, secondary to a cause, different form the previous ones: the “Hintergrundsdepressionen”. While the “Hintergrundsdepressionen” are in some way comprehensible, the Untergrundsdepressionen are hardly achievable, regarding the “Untergrund”, which is a limit concept, in the balance between somatology and psychology, more a “philosophical question”, something “that surpasses the experience”. This distinction recalls the clinical classification of exogenous and endogenous depressions, applied every day in the clinical practice. The exogenous depressions have a recognizable cause, an external stressor, linked with the ongoing episode. The endogenous depressions, on the contrary, do not have an environmental cause, they do not have a recognizable explanation. The distinction between the two forms plays a key role in clinical psychiatry, being the treatment of the first mainly psychological and the treatment for the second ones mainly pharmacological. According to Tellenbach (1980), the “Endon”, like the Schneider’s Untergrund, “is not to be mistaken neither with the somatogenic nor with the psychologic […] therefore is neither psychologically comprehensible nor somatically explainable” (Tatossian, 1979, p. 126). The complex definition of the “endon” is conveyed by the following Tellenbach’s words:
And so we define as endogenous what arises as fundamental character’s unit in everything that occurs in the life. The endon unfolds since the very beginning of the phenomena of the endogenous and in the physis that impregnates them; where with physis we do not mean the physical in contrast to the psychic, but rather that nature as appears to us for example in Goethe’s morphological works; the Aristotelian φύσις that means “heaven and earth, plants and animals and in some way the man… (Heidegger, 1950, p. 299). As a consequence of that, we mean the endon neither as the apersonal of the biological nor as the personal in the sense of the existence, of his vivifying a mental reality. The endon stands before these things because it, first of all, makes them possible and imprints them; it stands after them because it can be influenced, permeated, formed by them… (Tellebach, 1980, p. 44)
12With the word depression, we mean the endogenous depression, and we use the word melancholy as a synonym of endogenous depression. It is hard to define and describe the sufferance experienced by the depressed. “The melancholic sufferance is actually inexpressible and inexplicable; a sort of sense of emptiness and petrification” (Tatossian, 1962, p74). Tatossian (1981) distinguished between sadness and depression, defining the first as a feeling and the latter as a mood, i.e. a global mode of being. The German translation of mood, Stimmung, evokes its fundamental feature: the resonance, the agreement, with what surrounds the subject. While sadness has always an object, somebody or something to be sad of, depression has no object, no external or internal reference, and no clear and direct causal explanation. Using Tatossian (1981)’s own words, “sadness, as a feeling, has a temporal course, whereas depression, as long as it is present, seems to have neither beginning nor end”; moreover, sadness is often intermittent and occasional, while depression is permanent and pervasive. Finally, if sadness is merely psychic, depression is a disturbance of the lived body, being bodily as well as psychic. In addition to that, while sadness, as feeling, has a movement, a dynamicity, depression implicates a general hypo-mobility, a loss of kinesis. The distinction between sadness (the feeling) and depression (the mood) has a key operational impact in the psychiatric clinical practice, because the standard antidepressant medications are efficacious for depression. Quoting again Tatossian (1981)’s own words, “the medications called antidepressants are not efficacious on sadness where, frankly speaking, the doctor doesn’t do anything better than a true friend”. To support the distinction between sadness and depression, many depressed patients are not capable of feeling sad at all: Schulte (1961) already indicated the incapacity of being sad (Nicht-traurig-sein-können) as a core phenomenon in depression. For this reason, during the treatment of a depressed person, the reappearing of emotions, weeping and feelings of sadness normally indicate initial recovery. Tellenbach (1980) describes this key phenomenon in melancholy with the following words: “In melancholy the ego stands beside his sadness. If sadness is a movement that comes into the world, grows and passes, the melancholic sadness does not show any kind of movement. It stands there permanently, without extending. […] The melancholic can suffer only the obsession of a sadness that does not belong to him. This suffer is an endogenously transformed, extraneous, monstrous, deformed suffer, even perverted, a pathic apathy, so to speak” (p. 28). The essence of the melancholic experience is conveyed by Tellenbach’s extract of his patient MBK’s own description.
All connections are lost. One feels or is like a little stone, lost in the endless grey of a fading landscape. The sensation of smallness, insecurity and loss can become so strong, that one almost has a feeling of a dream world in which even being oneself is anything more than an abandoned point, like a dried leaf moved here and there in a lifeless autumnal world. […] The solitude of the depressed is different form every other solitude and from every other state of abandonment. One is not alone in a house, in a city or country. For the house is like lost, it does not mean protection anymore; the city is not a familiar city, the country is not homeland anymore, the starry sky burnt by the ice… However, now one is not humans in the flesh, with heart, strengths and spirit to bear solitude – one is a stone. A stone that suffers and thinks; something like that exists. So to speak, one is retro-evolved in stone. Sometime I have thought, “Now I know what is like to be a stone”. It is even too clear that this little stone in the cold universe, this enigmatically afraid and doubting man strives to grab himself, with ineffable, fervid effort, and find a hold in everything on which he can in some way grab himself (human, animals, things)… […] What is left of the human, when he is deprived of the rational capacity, the intuitive force, the capacity of transmitting and receiving love? A little intellect is left…it is nothing but the bed of a dried stream, a binary on which nothing travels anymore. It is in himself a poor dried leaf. […] It does not matter which fuel you put into the furnace of suffering and for which reason the fire develops. In a sense it is a good that objects are found, even though this sharpens the suffering; because the true and horrible essence of anguish, in the depression, is its lack of an object. (Tellenbach, 1980, pp. 250-252)
13In reference to the patient MBK, Ludwig Binswanger (1960, p. 50) writes: “The patient compares the melancholic, deprived of the capacity of communicating, intuiting and loving, to the “bed of a dried river”, to a “rail on which nothing passes”. In both the comparisons, the “emptying of the melancholic conscience” the absence of a Worauf (“link”) and of a Worüber (“object”).
14In the melancholic experience, loss seems to be a basic phenomenon (Grundthema), the eidos (shape) itself of depression; the “style of loss” (Binswanger, 1960, p. 48) (Verluststil) of the depressed is different from our normal conception of loss, because it is irreparable and inexorable. Loss may concern physical, moral or economical integrity, thus leading respectively to the melancholic themes of hypochondriasis, guilt and poverty. Typically the depressed feels guilty towards the relatives, parents, wife or husband, daughter or son. Gilberto Di Petta (2003) described the theme of guilt in depression as “guilt towards oneself, other people, life, one’s own wishes, one’s own body, for existing.” Melancholic patients typically feel guilty about ancient facts, often irrelevant, experienced as sources of continuous ruminations. Quoting Tellenbach’s own words:
…in many cases guilts dated long time ago are often recalled to memory, and their burden cannot be attenuated by any repentance, confession, penitence or grace. There are things they can never forget, things that always come back to oppress (pp. 102-103).
The patient only lived in the past that forced her continuously to interrogate herselfabout the right and the wrong of every action. (p. 104)
15The dominance of themes of guilt in the melancholic patients’ thoughts are so radical that it rather seems that “the theme of guilt “finds” melancholy, so to speak” (Tellenabch, 1980, p. 108).
From a genetic point of view, the melancholic does not derive his conscience of guilt form the given opportunities; he rather feels guilt in a primary way, and simply chooses opportunities for his “being-guilty”. (Tellenbach, 1980, p. 199)
16In severe forms of melancholy, guilt can acquire psychotic depth, representing a frequent theme of depressive delusions. Professor Hans D described by Tellebach seems to have suffered from a delusional depression where he felt guilty about having destroyed the world. We report here a fragment of the clinical vignette described by Tellenbach:
He pronounced just brief sentences like: ‘All is over, all is nothing, and all is deceit’. He still lived, although he must have been dead long time ago. Therefore, he had overstepped the laws of life and hence the world was lost, and had attributed to himself a monstrous guilt to bear. (p. 169)
17The guilt experience in melancholy is always primary, pre-thematic, always part of the depressive core, even if patients tend to indicate external causes, often personal facts occurred long time ago, in reference to which they feel guilty.
This is indeed the genuineness of such guilt, which is proof of the transformation in psychosis – that is endogenously deformed guilt, culpabilité endogène, as appropriately says Hesnard (1949). (Tellenbach, 1980, p. 198)
18Ideas of financial ruin are common in depressed patients, especially in self-employed workers, although real data do not support the patients’ convictions. Finally, melancholic patients frequently report physical complaints, in a general perception of the body as degraded, spoiled and transformed. According to Maldiney (1976), the melancholic loss has no object (a loss tout court) because it is located at a pre-objective level, before the formation of the objective world. Ludwig Binswanger, quoting the Swiss writer Reto Ross, defines melancholy as “the loss of a hold”, of an anchor, of a vital contact with the things (Binswanger, 1960), and from Hubertus Tellenbach’s patient MBK., that it is the lack itself of an object.
It does not matter which fuel you put into the furnace of suffering and for which reason the fire develops. In a sense it is a good that objects are found, even though this sharpens the suffering; because the true and horrible essence of anguish, in the depression, is its lack of an object. (Tellenbach, 1980, p. 253)
The pure present is an ungraspable advance of the past devouring the future. In truth, all sensation is already memory. (Bergson, Matter and memory, 1986)
19The depression experience is enlighten by phenomenology as a global way of being with one self, with the world and with the others. In depression, various authors have described a typical alteration of the experience of lived time. The lived time is not the time of the external world, measured by the clocks, but a human time. Straus (1928) named these two times “Ich-Zeit” and “Welt-Zeit” respectively and identified a contrast between these two modalities in endogenous depression. Eugène Minkowski (1933) identified the lived time alteration as the phenomenological essence (le trouble générateur) of melancholy, having the depressed lost the “élan vital” (propulsive energy). The melancholic alteration of the lived time is slowing down and stagnation of the intimate time.
The melancholic do not experience time as «propulsive energy», but feel it as a flow of temporal current. Thus, for these patients, the future is perceived as blocked; their attention is directed to the past and the present feels stagnant. (Cardinalli, 2012, 30)
20Minkowski says (1933, p. 279):
Here (in endogenous depression) the lived time seems to singularly slow down, even stop, and the modification of the temporal structure stands between the underlying biological disorder, on one side, and the current clinical symptoms on the other.
21Ludwig Binswanger (1960) is one of the most prominent contributors to phenomenological psychopathology and confirmed, in his depressed patients Cécile Münch and David Bürge, an alteration of the time experience. Using the husserlian terms of retentio, presentatio and protentio, with referral to the past, present and future, Binswanger claimed that in the healthy individual there is a natural interweaving of these elements. Binswanger used the speaker metaphor taken by Szilasi, according to which a speaker must have a natural fluency of what’s already been said (retetntio) and what it’s going to be said (protentio), in order to keep talking in the present (presentatio) and perform an intelligible speech. In depression, the delicate and dynamic balance between the three time dimensions is altered, because present and future are infiltrated by the past: retentio expands and infiltrates presentatio and protentio.
22Kimura Bin (2005) coined the term post-festum (literally after the celebration) to describe the temporality of depression, a fundamental phenomenological process in which the past is lived by the patient as irremediable, irrecoverable and ineluctable. The human Dasein in melancholy is always late with respect to itself, having always already missed the “celebration”. As a confirmation of the analysis of the lived time in melancholy performed by the psychopathologists, neuropsychological experiments have shown that depressed patients exhibit a slowed experience of time and that they tend to overestimate time spans, as highlighted by Gallagher (2012) and Vogel (2018).
23In addition to the time experience, phenomenological psychopathology has also described a typical alteration of the lived space in depression.
Space tend to be experienced as desperately empty, dull, flat and without perspective, reaching a critical level. The depressed loses existential proximity with things. Distancing is experienced as loss of spatial depth and things become «dull and flat as in everything is out of reach, living as static objects; not integrated into a landscape, occupying places and not regions. (Tatossian, 1979, p. 87)
24The melancholic loses the existential proximity with things and so their utilizability (Zuhandenheit). The presence of physical complaints has always been object of interest in classical psychopathology (Wernicke, 1909), reporting depressed patients often abdominal pains, headaches, fatigue, dyspepsia, loss of appetite and insomnia. Phenomenological psychopathology considers the alterations of the lived body as core symptoms of the depressive state. Tatossian (1982) distinguishes between the “body that I am” (corps que je suis) and the “body that I have” (corps que j’ai). While the first is the body-subject, the second is the body-object, respectively Leib and Körper, in German. The Leib is the lived-body, representing the lived experience of the body itself. The Körper is the body as res extensa, the measurable body, it is the interface with the world, it enables inter-subjectivity, concreteness as a body that can see and be seen, perceive and been perceived. In a healthy person, there is balance between body-subject and body-object. In depression, the body-object disappears, this making the depressed person experiencing exclusively the body subject. In depression, without body-object, the person loses the connection to the world. Simple acts become difficult; the body is perceived as extremely heavy, stuck and incapable of projection. The absence of the body-object makes the person loose the accessibility to the world, which becomes far, out of accessibility. Fuchs (2005) considers depression as a corporealization of the self; citing Fuchs’s own words “in melancholia, the body loses the lightness, fluidity, and mobility of a medium and turns into a heavy, solid body that puts up resistance to the subject’s intentions and impulses. Its materiality, density, and weight, otherwise suspended and unnoticed in everyday performance, now come to the fore and are felt painfully. Thus, melancholia may be described as a reification or corporealization of the lived body”. Moreover, “Corporealization thus means that the body does not give access to the world, but stands in the way as an obstacle, separated from its surroundings: The phenomenal space is not embodied anymore”. “Melancholia may be regarded as a “stasis”, a freezing or rigidity of the lived-body” (Fuchs, 2003, p. 237). Otto Doerr-Zegers (2017) proposes characteristic disturbances of embodiment as fundamental phenomena of depression. The first phenomenon is the alteration of the embodied self, which is the alteration of the subject’s relationship with his own body. This phenomenon implicates the “reification” of the bodily experience, also called chrematization (Doerr-Zegers, 1980), literally feeling like a thing. The reduction of the body vitality may have different degrees in depressed patients and can culminate in Cotard’s syndrome, characterized by nihilistic delusions and the painful conviction about the impossibility to die. These patients usually report that their body is made of glass, in support of the phenomenological description of the body reification in depression. The second phenomenon involves the body intentionality and corresponds to the alteration of the relationship of the subject with the world. Ludwig Binswanger (1960) described this inability as a core phenomenon in depression and referred to it as the “not-being-able-to” (das Nicht-Können), while Bleuler (1975) talked about “alteration of the centrifugal functions” (Alterationen der zentrifugalen Funktionen). The third phenomenon is the alteration of the embodied time, corresponding to the disturbances of the biological rhythms. Several evidences (Wehr et al, 1983; Germain and Kupfer, 2009) have pointed out the circadian rhythms alterations in depressed patients, this letting the scientists hypothesize an etiological role of the biological clock for depression. In particular, symptoms tend to be worse in the morning and ameliorate in the evening, oscillating during the day; moreover, in depression, a disruption of the sleep-wake cycle occurs, with a progressive anticipation of the sleep time and a typical late-night insomnia. Depressed patients also present alteration of the body temperature (Souetre, 1989), cortisol (Koeningsberg, 2004; Bhagwagar, 2005) and melatonin (Nair, 1984; Karodottir, 2001) secretion, all physiological parameters regulated by the biological clock. The time stagnation in melancholy takes on a great importance in the clinical practice, representing the fluctuations a relevant moment in the treatment response of the depressed patients. Typically, the time experience of the depressed modifies at the beginning of the treatment response, but this modification is not stable, but rather oscillating in the days and within the single day. This course starts in the body and reveals itself with objective modifications, in terms of distensions of the facial expression, ameliorations of the psycho-motor retardation and improvement of the motor activity. This transition moment, where the time restarts in the body, is particularly delicate, because the mind, the subjective experience of sorrow, is still blocked and frozen. Many suicides linked to depression occur in this transition phase where the body is less blocked and with some energy gifted again, but the mind is still surrounded by the sufferance and the cognition is still distorted. In addition to the lived time, space and body, the inter-subjectivity is typically altered in depression.
25“All those looks that devour me…Ha, you are not but two? I thought that there were many more of you. Then, that is hell. I would have never believed that… You remember that: the sulphur, the pyre, the grill… Ah! What a joke: hell is other people”. (Sartre JP, 1943. Huis Clos).
26Tatossian (1979) understands that the depressed experiences a blockage of vital communication with the world, which would be the “background of all the depression” and Borgna (1992) states that “the depressive psychosis, the patient not only gets away from the world but he loses the world itself in an implacable cancellation of any inter-subjectivity”. The encounter with another person lacks the normal pre-reflective resonance and agreement, defined in Japanese as Ki by Kimura Bin (1966). The word “Ki” means initially “origin of the universe”, “pneuma”, “breath”, “air” and at the same time “soul” (Kimura Bin, 1966, 1971). “In the Ki the single takes part to the atmospheric pneuma, to the origin of cosmos” (Tellenbach, 1980, p. 31). Interestingly, the significances nuances of the Ki are similar of those of the Greek particle –ψυ, linked with the images of the vital fresh air, the breath, at the basis of the word ψυχή (psyche), soul.
27The idea that a particular personality might be associated with an increased risk of, in other words might predispose to, specific psychic sufferance was present in the Corpus Hippocraticum. Hippocrates named melancholic (μελαγχολικός) those people prone to develop melancholy. Hubertus Tellenbach (Tellenbach, 1980) in a famous study in a sample of hospitalized patients affected my monopolar depression called typus melancholicus the premorbid personality structure of depression. The most important feature of this kind of personality is the orderliness, the need for meticulous organization of one’s own life-world and the fixation on harmony in interpersonal relationships. In the relationships typically, the typus melancholicus cannot stand any controversy, as highlighted in the following extract taken from Tellenbach (1980): “When a dispute occurs “this does not give me peace. I try to accommodate everything for the best”. If that is not accepted, “then it does not get out of my mind anymore”. Often “a controversial point can fill all of my conscience so that I do not think about anything else and I have no peace until that is smoothed out again”. “Peace at any price” is the motto” (F. J. Ayd, 1961, p. 5).” Other features are conscientiousness (the commitment to prevent guilt-attributions and guilt-feelings), hyper/heteronomia (an exaggerated norm adaptation and external norm receptiveness) and intolerance of ambiguity (emotional and cognitive incapacity to perceive opposite characteristics concerning the same object or person). The life of the typus melnacholicus is submitted to the duty and to the supremacy of the job, his adhesion to the Lebenswelt is very stable, rigid and firm. He must accomplish what he has set himself as a goal, with certain parameters, with no delegations and no delays. The typus melancholics normally lacks in sense of humor, avoids risks and feels easily guilty (hyper-sensibility to guilt). Tellenbach finds similarities in his typus with the Shuchaku-Seikaku by Shimoda (Shimoda, 1932), where Schuchaku means, “persistently sink oneself in thoughts” and Seikaku means character. According to the Japanese, a particular personality constitution was a prerequisite to develop depression and this was marked by “an inclination to stay anchored to the thoughts or feelings… For this reason a person with such a character cannot feel lighten before having meticulously completed what they had begun… These people are always particularly valued as exemplars, for the trustiness and honesty” (Tellenbach, 1980, p. 74). Central in this constitution, according to Tellenbach, is its “psychic retentiveness, the tendency to stay anchored at the thoughts and the difficulty of simply letting them go. Tellenbach examines in depth the pre-melancholic situation, that phase in which a melancholic type experiences the very beginning of a depressive episode. According to him, a key role in this situation is held by two constellations, these are includence and remanence. Ambrosini (2011, p. 39) says: “The constellation of includence indicates a self-contradiction that sees the typus melnacholicus parallelly in the extreme attempt to maintain their order and in the need to overcome it, exceeding their own limits. This is the moment in which the undesired is manifested and imposes in the existence to thus destabilize the typical meticulous and orderly form of being of the TM (typus melancholicus)”. Citing again the words of Ambrosini (2011, p. 39), “the other constellation is that of remanence. This is characterized by the danger of remaining behind regarding the subject’s own expectations and the emergency of the duty. The melancholic type is characterized by the paradoxical tendency of cancelling possible debts early. When they are up against the unexpected and chance and the unforeseen breaks the schemes, this may precipitate the melancholic episode”. Finally, despair (Verzweiflung) is the link that bridges the patient from the pre-melancholic situation to melancholy. The term used originally by Tellenbach is hardly translatable, because the Author did not want to express the feelings of helplessness and hopelessness typically experienced in depression, but he rather wanted to convey the “remaining captured in doubt” meaning (Tellenbach, 1980, p. 187). The word despair in German, Verzweiflung, contains the word Zweifel, meaning doubt, which in turn, includes the word zwei (two), suggesting the doubling aspect held in the conditions of doubt. Depressed patient, often at the beginning of the episode, complaint of pathological doubts that severely interfere with their every-day life. The occurrence of pathological doubts and obsessive ruminations in depressed patients is also present in a very commonly employed evaluation scale for depression in clinical settings, the Hamilton Depression Rating Scale (HAMD), as a confirm of the role played by this phenomenological dimension in depressed patients (Rohan et al, 2016).
28Monopolar depression is a commonly occurring mental disorder, classified in DSM 5 as Major Depressive Disorder, and a major cause of morbidity worldwide. The phenomenological psychopathologists have analyzed the lived experience of the melancholic patients, this allowing a fine description of the structure of melancholy and permitting a closer look at the specific alterations of the fundamental dimensions of time, space, body and others. Among other authors, in this paper we have focused our attention mainly on Eugène Minkowski, Ludwig Binswanger, Arthur Tatossian, Kimura Bin and Hubertus Tellenbach. The eidos of melancholy seems to be the loss, a pre-thematic irreparable loss, in the absence of an object. In the MBK patient’s words, “the true and horrible essence of anguish, in the depression, is its lack of an object” (Tellenbach, 1980, p. 253). Declined in the loss of moral, physical and economical integrity, loss often gives origin to the typical themes of the melancholic experience: guilt, poverty and hypochondriasis. Time seems to be a lowest common denominator in the authors’ descriptions of melancholy, being depression characterized by a slowed lived time. The time alteration, elucidated by Binswanger as a dominance of the past over present and future, has been considered by Minkowski as the generative disorder (trouble génératuer) of depression. Modern neurobiological studies have repeatedly confirmed the circadian rhythms alterations in depression, letting hypothesize a dysregulation of the biological clock as fundamental mark of affective disorders, in support of the clinical intuitions of the phenomenological psychopathologists. We could reinterpret the expression “maladie du temps” (disease of time) by Fabrice Gzil (2014) and accost it to depression, where time stagnates, days are devoured by the past and the élan vital (propulsive energy) is lost, making the prospective of the future impossible. Although melancholic sufferance is “actually inexpressible and inexplicable” (Tatossian, 1962, p. 74), depression is something that concerns the mood, the Stimmung, the accordance, the resonance. The choir where the depressed intones his chant is empty, dull, out of tune; the world, the others, are out of reach, a stage of stuffed men. Far from being a merely psychic phenomenon, melancholy is also present in the body, it shouts in the body. The body object (Körper) disappears, making lose the interface with the world and letting the body subject (Leib), the lived body, expand and undisputedly dominate the balance between the two. The premorbid personality characteristics of melancholy are those of the melancholic type described by Hubertus Tellenbach, whose most important feature is orderliness. The melancholic type “strives not to lag behind himself… His entire life can be interpreted as an effort to pay his debts before he contracts them” (Ambrosini, 2014). In melancholy, the dialogue with the other is interrupted, the other is far, out of reach. What strikes the most during an interview with a melancholic person is the silence, felt in the impalpable pre-reflective texture of the relation, not as calm and peaceful, but rather as tense, dull, heavy and sinister. The silence of Dante’s Inferno, with the damned frozen in the Cocito, incapable of crying.
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Quand’io m’ebbi dintorno alquanto visto,
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When round about me somewhat I had looked,
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volsimi a’ piedi, e vidi due sì stretti,
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I downward turned me, and saw two so close,
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che ’l pel del capo avieno insieme misto.
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The hair upon their heads together mingled.
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“Ditemi, voi che sì strignete i petti”,
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“Ye who so strain your breasts together, tell me,”
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diss’io, “chi siete?”. E quei piegaro i colli;
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I said “who are you”; and they bent their necks,
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e poi ch’ebber li visi a me eretti,
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And when to me their faces they had lifted,
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li occhi lor, ch’eran pria pur dentro molli,
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Their eyes, which first were only most within,
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gocciar su per le labbra, e ’l gelo strinse
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Gushed o’er the eyelids, and the frost congealed
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le lagrime tra essi e riserrolli.
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The tears between, and locked them up again.
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(Dante Alighieri, Inferno, Divina Commedia, Canto XXXII, 40-48)
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