Depression. Aaron T. Beck, M.D.

diagnosed as manic depressive with a control group of 50 patients with diagnoses of recognized medical diseases. The frequency of the specific symptoms was determined by having the patient complete a questionnaire of 199 items. Among the symptoms that were endorsed significantly more often by those in the psychiatric group were anorexia, sleep disturbance, low mood, suicidal thoughts, crying, irritability, fear of losing the mind, poor concentration, and delusions.

      It is interesting to note that Cassidy and his coworkers found that only 25 percent of the manic-depressive group thought that they would get well as compared with 61 percent of those who were medically ill. This is indicative of the pessimism characteristic of manic depressives: almost all could be expected to recover completely from their illness, in contrast to the number of incurably ill among the medical patients. Certain symptoms sometimes attributed to manic depressives, such as constipation, were found in similar proportions in the two groups.

      Campbell reported a high frequency of medical symptoms, generally attributed to autonomic imbalance, among manic depressives. Cassidy’s study, however, found that most of these medical symptoms occurred at least as frequently among the medically ill patients as among the manic-depressive patients. Moreover, many of these symptoms were found in a group of healthy control patients. Headaches, for instance, were reported by 49 percent of the manic-depressive patients, 36 percent of the medically sick controls, and 25 percent of the healthy controls. When the symptoms of manic depressives, anxiety neurotics, and hysteria patients were compared, it was found that autonomic symptoms occurred at least as frequently in the latter two groups as they did in the manic-depressive group. Palpitation, for instance, was reported by 56 percent of the manic depressives, 94 percent of the anxiety neurotics, and 76 percent of the hysterics. It therefore seems clear that autonomic symptoms are not specifically characteristic of manic-depressive disorders.

      In the early 1960s, two systematic investigations of the symptomatology of depressive disorders were conducted to delineate the typical clinical picture, as well as to suggest typical subgroupings of depression.^3,4 But because the case material consisted primarily of depressed patients and did not include a control group of nondepressed psychiatric patients for comparison, it was not possible to determine which symptom clusters might be characteristic of depression or its various subgroupings and which might occur in any psychiatric patient or even in normals.

      The following material is reprinted in its entirety from the first edition, with some minor updating of the language. The chapter ends with a brief section on variations in symptoms by age and culture as they are understood in the twenty-first century.

      Following a review of the chief complaints, the symptoms of depression are described under four major headings: emotional, cognitive, motivational, and physical and vegetative. This is followed by a section on delusions and hallucinations. Some of these divisions may appear arbitrary, and it is undoubtedly true that some of the symptoms described separately may simply be different facets of the same phenomenon. Nonetheless, I think it is desirable at this stage to present the symptomatology as broadly as possible, despite the inevitable overlap. A section on behavioral observation follows the categorization of symptoms. The descriptions in this latter section were obtained by direct observation of the patients’ nonverbal as well as their verbal behavior.

Chief Complaint

      The chief complaint presented by depressed patients often points immediately to the diagnosis of depression; although it sometimes suggests a physical disturbance. Skillful questioning can generally determine whether the basic depressive symptomatology is present.

      The chief complaint may take a variety of forms: (1) an unpleasant emotional state; (2) a changed attitude toward life; (3) somatic symptoms of a specifically depressive nature; or (4) somatic symptoms not typical of depression.

      Among the most common subjective complaints⁵ are “I feel miserable.” “I just feel hopeless.” “I’m desperate.” “I’m worried about everything.” Although depression is generally considered an affective disorder, it should be emphasized that a subjective change in mood is not reported by all depressed patients. As in many other disorders, the absence of a significant clinical feature does not rule out the diagnosis of that disorder. In our series, for instance, only 53 percent of the mildly depressed patients acknowledged feeling sad or unhappy.

      Sometimes the chief complaint is in the form of a change of one’s actions, reactions, or attitudes toward life. For example, a patient may say, “I don’t have any goals any more.” “I don’t care anymore what happens to me.” “I don’t see any point to living.” Sometimes the major complaint is a sense of futility about life.

      Often the chief complaint of the depressed patient centers around some physical symptom that is characteristic of depression. The patient may complain of fatigue, lack of pep, or loss of appetite. Sometimes patients complain of some alteration in appearance or bodily functions, or that they are beginning to look old or are getting ugly. Others complain of some dramatic physical symptom such as, “My bowels are blocked up.”

      Depressed patients attending medical clinics or consulting either internists or general practitioners frequently present some symptom suggestive of a physical disease.⁶ In many cases, the physical examination fails to reveal any physical abnormality. In other cases, some minor abnormality may be found but it is of insufficient severity to account for the magnitude of the patient’s discomfort. On further examination, the patient may acknowledge a change in mood but is likely to attribute this to the somatic symptoms.

      Severe localized or generalized pain may often be the chief focus of a patient’s complaint. Bradley⁷ reported 35 cases of depression in which the main complaint was severe localized pain. In each case, feelings of depression were either spontaneously reported by the patient or elicited on interview. In the cases in which the pain was integrally connected with the depression, the pain cleared up as the depression cleared up. Kennedy⁸ and Von Hagen⁹ reported that pain associated with depression responded to electroconvulsive therapy (ECT).

      Cassidy et al.² analyzed the chief complaints of the manic-depressive patients. These complaints were divided into several categories which included (1) psychological; (2) localized medical; (3) generalized medical; (4) mixed medical and psychological; (5) medical, general and local; and (6) no clear information. Some of the typical complaints in each category are listed below:

TABLE 2-1. Chief Complaints of 100 Patients with Manic-Depressive Diagnosis and 50 Patients with Medical Diagnosis (%)

      Adapted from Cassidy et al. 1957.

      (1) Psychological (58 percent): “depressed”; “I have nothing to look forward to”; “afraid to be alone”; “no interest”; “can’t remember anything”; “get discouraged and hurt”; “black moods and blind rages”; “I’m doing such stupid things”; “I’m all mixed up”; “very unhappy at times”; “brooded around the house.”

      (2) Localized medical (18 percent): “head is heavy”; “pressure in my throat”; “headaches”; “urinating frequently”; “pain in head like a balloon that burst”; “upset stomach.”

      (3) Generalized medical (11 percent): “tired”; “I’m exhausted”; “I feel all in”; “tire easy”; “jumpy most at night”; “I can’t do my work, I don’t feel strong”; “I tremble like a leaf.”

      (4) Medical and psychological (2 percent): “I get scared to death and can’t breath”; “stiff neck and crying spells.”

      (5) Medical, general and local (2 percent): “breathing difficulty . . . pain all over”; “I have no power. My arms are weak”; “I can’t work.”

      (6) No information (9 percent).

      The authors tabulated the percentages of the various symptom types that were named by manic-depressive patients and by medically sick controls (