Depression. Aaron T. Beck, M.D.

2-1). It is worthy of note that a medical symptom, either localized or generalized, was reported by 33 percent of the manic-depressive patients and 92 percent of the medically sick controls.

Symptoms

      The decision as to which symptoms should be included here was made as a result of several steps. First, several textbooks of psychiatry and monographs on depression were studied to determine what symptoms have been attributed to depression by general consensus. Second, in an intensive study of 50 depressed patients and 30 nondepressed patients in psychotherapy, I attempted to tally which symptoms occurred significantly more often in the depressed than in the nondepressed group. On the basis of this tabulation, an inventory consisting of items relevant to depression was constructed and pretested on approximately 100 patients. Finally, this inventory was revised and presented to 966 psychiatric patients. Distributions of the symptoms reported in response to the inventory are presented in Tables 2-3–2-7.

      One of the symptoms, namely irritability, did not occur significantly more frequently in the depressed than in the nondepressed patients. It, therefore, has been dropped from the list. Incidentally, Cassidy and his coworkers² found that this symptom was more frequent in the anxiety neurotic group than in the manic-depressive group.

      Some of the symptoms often attributed to the manic-depressive syndrome are not included in the symptom descriptions in this chapter. For instance, fear of death was not included because it was not found to be any more common among the depressed patients than among the nondepressed in the preliminary clinical study. Cassidy, Flanagan, and Spellman² found, in fact, that fear of death occurred in 42 percent of patients with anxiety neurosis and only 35 percent of the manic depressives. Similarly, constipation occurred in 60 percent of the manic-depressive patients and 54 percent of the patients with hysteria. Consequently, this particular symptom does not seem to be specific to depression.

      Conventional nosological categories were not used in our analyses of the symptomatology. Instead of being classified according to their primary diagnoses, such as manic-depressive reaction, schizophrenia, anxiety reaction, and so on, the patients were categorized according to the depth of depression they exhibited, independently of their primary diagnoses. There were two major reasons for this. First, in our own studies as well as in previous studies, it was found that the degree of interjudge reliability was relatively low in diagnoses made according to the standard nomenclature. Consequently, any findings based on diagnoses of such low reliability would be of relatively dubious value. The interpsychiatrist ratings of the depth of depression, by contrast, showed a relatively high correlation (.87). Second, we found that the cluster of symptoms generally regarded as constituting the depressive syndrome occurs not only in disorders such as neurotic-depressive reaction and manic-depressive reaction but also in patients whose primary diagnosis is anxiety reaction, schizophrenia, obsessional neurosis, and so on. In fact, we have found that a patient with the primary diagnosis of one of the typical depressive categories may be less depressed than a patient whose primary diagnosis is, for example, schizophrenia or obsessional neurosis. The sample, therefore, was divided into four groups according to the depth of depression: none, mild, moderate, and severe.

      In addition to making the usual qualitative distinctions among the symptoms, I have attempted to provide a guide for assessing their severity. The symptoms are discussed in terms of how they are likely to appear in the mild, moderate, and severe states (or phases) of depression. This may serve as an aid to the clinician or investigator in making a quantitative estimate of the severity of depression. The tables may be used as a guide in diagnosing depression, since they show the relative frequency of the symptoms in patients who were considered to be either nondepressed, mildly depressed, moderately depressed, or severely depressed. The method for collecting the data on which the tables are based is described in greater detail in Chapter 10. The patient sample is described in Table 2-2.

TABLE 2-2. Distribution of Patients According to Race, Sex, and Depth of Depression

      TABLE 2-3. Frequency of Emotional Manifestations Among Depressed and Nondepressed Patients (%)

Emotional Manifestations

      The term emotional manifestations refers to the changes in the patient’s feelings or overt behavior directly attributable to his or her feeling states (Table 2-3). In assessing emotional manifestations, it is important to take into account the individual’s premorbid mood level and behavior, as well as what the examiner might consider the normal range in the patient’s particular age, sex, and social group. The occurrence of frequent crying spells in a patient who rarely or never cried before becoming depressed might indicate a greater level of depression than it would in a patient who habitually cried whether depressed or not.

Dejected Mood

      The characteristic depression in mood is described differently by various clinically depressed patients. Whatever term the patient uses to describe her or his subjective feelings should be further explored by the examiner. If the patient uses the word “depressed,” for instance, the examiner should not take the word at its face value but should try to determine its connotation for the patient. Persons who are in no way clinically depressed may use this adjective to designate transient feelings of loneliness, boredom, or discouragement.

      Sometimes the feeling is expressed predominantly in somatic terms, such as “a lump in my throat,” or “I have an empty feeling in my stomach,” or “I have a sad, heavy feeling in my chest.” On further investigation, these feelings generally are found to be similar to the feelings expressed by other patients in terms of adjectives such as sad, unhappy, lonely, or bored.

      The intensity of the mood deviation must be gauged by the examiner. Some of the rough criteria of the degree of depression are the relative degree or morbidity implied by the adjective chosen, the qualification by adverbs such as “slightly” or “very,” and the degree of tolerance the patient expresses for the feeling (e.g., “I feel so miserable I can’t stand it another minute”).

      Among the adjectives used by depressed patients in answer to the question “How do you feel?” are the following: miserable, hopeless, blue, sad, lonely, unhappy, downhearted, humiliated, ashamed, worried, useless, guilty. Eighty-eight percent of the severely depressed patients reported some degree of sadness or unhappiness, as compared with 23 percent of the nondepressed patients.

      Mild: The patient indicates feeling blue or sad. The unpleasant feeling tends to fluctuate considerably during the day and at times may be absent, and the patient may even feel cheerful. Also the dysphoric feeling can be relieved partially or completely by outside stimuli, such as a compliment, a joke, or a favorable event. With a little effort or ingenuity the examiner can usually evoke a positive response. Patients at this level generally react with genuine amusement to jokes or humorous anecdotes.

      Moderate: The dysphoria tends to be more pronounced and more persistent. The patient’s feeling is less likely to be influenced by other people’s attempts to cheer him or her up, and any relief of this nature is temporary. Also, a diurnal variation is frequently present: The dysphoria is often worse in the morning and tends to be alleviated as the day progresses.

      Severe: In cases of severe depression, patients are apt to state that they feel “hopeless” or “miserable.” Agitated patients frequently state that they are “worried.” In our series, 70 percent of the severely depressed patients indicated that they were sad all the time and “could not snap out of it”; that they were so sad that it was very painful, or that they were so sad they could not stand it.