Depression. Aaron T. Beck, M.D.

      Depressed patients often express negative feelings about themselves. These feelings may be related to the general dysphoric feelings just described, but they are different in that they are specifically directed toward the self. The patients appear to distinguish feelings of dislike for themselves from negative attitudes about themselves such as “I am worthless.” The frequency of self-dislike ranged from 37 percent in the nondepressed group to 86 percent among the severely depressed.

      Mild: Patients state that they feel disappointed in themselves. This feeling is accompanied by ideas such as “I’ve let everybody down . . . If I had tried harder, I could have made the grade.”

      Moderate: The feeling of self-dislike is stronger and may progress to a feeling of disgust with oneself. This is generally accompanied by ideas such as “I’m a weakling . . . I don’t do anything right . . . I’m no good.”

      Severe: The feeling may progress to the point where patients hate themselves. This stage may be identified by statements such as: “I’m a terrible person . . . I don’t deserve to live . . . I’m despicable . . . I loathe myself.”

Reduction in Gratification

      The loss of gratification is such a pervasive process among depressives that many patients regard it as the central feature of their illness. In our series, 92 percent of the severely depressed patients reported at least partial loss of satisfaction. This was the most common symptom among the depressed group as a whole.

      Loss of gratification appears to start with a few activities and, as the depression progresses, spreads to practically everything the patient does. Even activities that are generally associated with biological needs or drives, such as eating or sexual experiences, are not spared. Experiences that are primarily psychosocial such as achieving fame, receiving expressions of love or friendship, or even engaging in conversations are similarly stripped of their pleasurable properties.

      The emphasis placed by some patients on loss of satisfaction gives the impression that they are especially oriented in their lives toward obtaining gratification. Whether or not this applies to the premorbid state cannot be stated with certainty, but it is true that the feverish pursuit of gratification is a cardinal feature of their manic states.

      The initial loss of satisfaction from activities involving responsibility or obligation, such as those involved in the role of worker, stay-at-home spouse, or student, is often compensated for by increasing satisfaction from recreational activities. This observation has prompted Saul¹⁰ and others to suggest that, in depression, the “give-get” balance is upset; the patient, depleted psychologically over a period of time by activities predominantly giving in nature, experiences an accentuation of passive needs, which are gratified by activities involving less of a sense of duty or responsibility (giving) and more of a tangible and easily obtained satisfaction. In the more advanced stages of the illness, however, even passive, regressive activities fail to bring any satisfaction.

      Mild: The patient complains that some of the joy has gone out of life. He or she no longer gets a “kick” or pleasure from family, friends, or job. Characteristically, activities involving responsibility, obligation, or effort become less satisfying. Often, patients find greater satisfaction in passive activities involving recreation, relaxation, or rest. They may seek unusual types of activities in order to get some of their former thrill. One patient reported that he could always pull himself out of a mild depression by watching a performance of deviant sexual practices.

      Moderate: Patients feel bored much of the time. They may try to enjoy some former favorite activities but these seem “flat” now. Business or professional activities that formerly excited them now fail to move them. They may obtain temporary relief from a change, such as a vacation, but the boredom returns upon resumption of usual activities.

      Severe: They experience no enjoyment from activities that were formerly pleasurable, and may even feel an aversion for activities they once enjoyed. Popular acclaim or expressions of love or friendship no longer bring any degree of satisfaction. The patients almost uniformly complain that nothing gives them any degree of satisfaction.

Loss of Emotional Attachments

      Loss of emotional involvement in other people or activities usually accompanies loss of satisfaction. This is manifested by a decline in interest in particular activities or in affection or concern for other persons. Loss of affection for family members is often a cause for concern to the patient and occasionally is a major factor in seeking medical attention. Sixty-four percent of the severely depressed patients reported loss of feeling for or interest in other people, whereas only 16 percent of the nondepressed patients reported this symptom.

      Mild: In mild cases, there is some decline in the degree of enthusiasm for, or absorption in, an activity. The patient sometimes reports no longer experiencing the same intensity of love or affection for spouse, children, or friends, but at the same time may feel more dependent on them.

      Moderate: The loss of interest or of positive feeling may progress to indifference. A number of patients described this as a “wall” between themselves and other people. Sometimes a husband may complain that he no longer loves his wife, or a mother may be concerned that she does not seem to care about her children or what happens to them. A previously devoted employee may report no longer being concerned about his or her job. Both men and women may no longer care about their appearance.

      Severe: The loss of attachment to external objects may progress to apathy. The patient may not only lose any positive feeling for family members but may be surprised to find that her or his only reaction is a negative one. In some cases, the patient experiences only a kind of cold hate, which may be masked by dependency. A typical patient’s report is, “I’ve been told I have love and can give love. But now I don’t feel anything toward my family. I don’t give a damn about them. I know this is terrible, but sometimes I hate them.”

Crying Spells

      Increased periods of crying are frequent among depressed patients. This is particularly true of the depressed women in our series. Of the severely depressed patients, 83 percent reported that they cried more frequently than they did before becoming depressed, or that they felt like crying even though the tears did not come.

      Some patients who rarely cried when not depressed were able to diagnose the onset of depression by observing a strong desire to weep. One woman remarked, “I don’t know whether I feel sad or not but I do feel like crying, so I guess I am depressed.” Further questioning elicited the rest of the cardinal symptoms of depression.

      Mild: There is an increased tendency to weep or cry. Stimuli or situations that would ordinarily not affect the patient may now elicit tears. A mother, for example, might burst out crying during an argument with her children or if she feels her husband is not attentive. Although increased crying is frequent among mildly depressed women, it is unusual for a mildly depressed man to cry.⁵

      Moderate: The patient may cry during the psychiatric interview, and references to his or her problems may elicit tears. Men who have not cried since childhood may cry while discussing their problems. Women may cry for no apparent reason: “It just comes over me like a wave and I can’t help crying.” Sometimes patients feel relieved after crying but more often they feel more depressed.

      Severe: By the time they have reached the severe stage, patients who were easily moved to tears in the earlier phase may find that they no longer can cry even when they want to. They may weep but have no tears (“dry depression”); 29 percent reported that although they had previously been capable of crying when feeling sad, they no longer could cry—even though they wanted to do so.

Loss of Mirth Response

      Depressed patients frequently volunteer the information that they have lost their sense of humor. The problem does not seem to be loss of the ability to perceive the point of the joke or even, when instructed, to construct a joke. The difficulty rather seems to be that patients do not respond to humor in the usual