Depression. Aaron T. Beck, M.D.

any feeling of satisfaction from a jesting remark, joke, or cartoon.

      In our series, 52 percent of the severely depressed patients indicated that they had lost their sense of humor, as contrasted with 8 percent of the nondepressed patients.

      Nussbaum and Michaux¹¹ studied the response to humor (in the form of riddles and jokes) in 18 women patients with severe neurotic and psychotic depressions. They found that improvements in response to humorous stimuli correlated well with clinical ratings of improvement of the depression.

      Mild: Patients who frequently enjoy listening to jokes and telling jokes find that this is no longer such a ready source of gratification. They remark that jokes no longer seem funny to them. Furthermore, they do not handle kidding or joshing by their friends as well as previously.

      Moderate: Patients may see the point of a joke and can even force a smile, but are usually not amused. They cannot see the light side of events and tend to take everything seriously.

      Severe: Patients do not respond at all to humorous sallies by other people. Where others may respond to the humorous element in a joke, they are more likely to respond to the aggressive or hostile content and feel hurt or disgusted.

Cognitive Manifestations

      The cognitive manifestations of depression include a number of diverse phenomena (Table 2-4). One group is composed of the patient’s distorted attitudes toward self, personal experience, and the future. This group includes low self-evaluations, distortions of the body image, and negative expectations. Another symptom, self-blame, expresses patients’ notion of causality: they are prone to hold themselves responsible for any difficulties or problems they encounter. A third kind of symptom involves the area of decision-making: The patient typically vacillates and is indecisive.

Low Self-Evaluation

      Low self-esteem is a characteristic feature of depression. Self-devaluation is apparently part of depressed patients’ pattern of viewing themselves as deficient in those attributes that are specifically important to them: ability, performance, intelligence, health, strength, personal attractiveness, popularity, or financial resources. Often the sense of deficiency is expressed in terms such as “I am inferior” or “I am inadequate.” This symptom was reported by 81 percent of the severely depressed patients and by 38 percent of the nondepressed patients.

TABLE 2-4. Frequency of Cognitive and Motivational Manifestations Among Depressed and Nondepressed Patients (%)

      The sense of deficiency may also be reflected in complaints of deprivation of love or material possessions. This reaction is most apparent in patients who have had, respectively, an unhappy love affair or a financial reversal just prior to the depression.

      Mild: Patients show an excessive reaction to their errors or difficulties and are prone to regard them as a reflection of inadequacy or a defect. They compare themselves with others and, more often than not, conclude they are inferior. It is possible, however, to correct these inaccurate self-evaluations, at least temporarily, by confronting patients with appropriate evidence or by reasoning with them.

      Moderate: Most of the patients’ thought content revolves about the sense of deficiency, and they are prone to interpret neutral situations as indicative of this deficiency. They exaggerate the degree and significance of any errors. When they look at their present and past life, they see their failures as outstanding and their successes as faint by comparison. They complain that they have lost confidence in themselves, and their sense of inadequacy is such that when confronted with tasks they have easily handled in the past, their initial reaction is: “I can’t do it.”

      Religious or moralistic patients tend to dwell on their sins or moral shortcomings. Patients who placed a premium on personal attractiveness, intelligence, or business success tend to believe they have slipped in these areas. Attempts to modify distorted self-evaluations by reassuring the patients or by presenting contradictory evidence generally meet with considerable resistance; any increase in realistic thinking about themselves is transient.

      Severe: Patients’ self-evaluations are at the lowest point. They drastically downgrade themselves in terms of personal attributes and their role as parent, spouse, employer, and so on. They regard themselves as worthless, completely inept, and total failures. They claim they are a burden to family members, who would be better off without them. The severely depressed patient may be preoccupied with ideas of being the world’s worst sinner, completely impoverished, or totally inadequate. Attempts to correct the erroneous ideas are generally fruitless.

Negative Expectations

      A gloomy outlook and pessimism are closely related to the feelings of hopelessness mentioned previously. More than 78 percent of the depressed patients reported a negative outlook, as compared with 22 percent of the nondepressed group. This symptom showed the highest correlation with the clinical rating of depression.

      Depressed patients’ pattern of expecting the worst and rejecting the possibility of any improvement poses formidable obstacles in attempts to engage them in a therapeutic program. Their negative outlook is often a source of frustration to friends, family, and physician when they try to be of help. Not infrequently, for example, patients may discard their antidepressant pills because they believe a priori that they “cannot do any good.”

      Unlike anxious patients, who temper negative anticipations with the realization that the unpleasant events may be avoided or will pass in time, depressed patients thinks in terms of a future in which the present deficient condition (financial, social, physical) will continue or even get worse. This sense of permanence and irreversibility of one’s status or problems seems to form the basis for consideration of suicide as a logical course of action. The relationship of hopelessness to suicide is indicated by the finding that, of all the symptoms that were correlated with suicide, the correlation coefficient of hopelessness:suicide was the highest.

      Mild: Patients tend to expect a negative outcome in ambiguous or equivocal situations. When associates and friends feel justified in anticipating favorable results, their expectations lean toward the negative or pessimistic. Whether the subject of concern is health, personal problems, or economic problems, they doubt whether any improvement will take place.

      Moderate: They regard the future as unpromising and state they have nothing to which to look forward. It is difficult to get them to do anything because their initial response is “I won’t like it” or “it won’t do any good.”

      Severe: They view the future as black and hopeless. They state they will never get over their troubles and that things cannot get better. They believe none of their problems can be solved. They make statements such as “This is the end of the road. From now on I will look older and uglier”; “There is nothing here for me any more. I have no place. There is no future”; “I know I can’t get better . . . it’s all over for me.”

Self-Blame and Self-Criticism

      Depressives’ perseverating self-blame and self-criticism appear to be related to their egocentric notions of causality and penchant for criticizing themselves for their alleged deficiencies. They are particularly prone to ascribe adverse occurrences to some deficiency in themselves and then rebuke themselves for this alleged defect. In the more severe cases, patients may blame themselves for happenings that are in no way connected with them and abuse themselves in a savage manner. Eighty percent of the severely depressed patients reported this symptom.

      Mild: In mild cases, patients are prone to blame and criticize themselves when they fall short of their rigid, perfectionist standards. If people seem less responsive to them, or they are slow at solving a problem, they are likely to berate themselves for being dull or stupid. They seem to be intolerant of any shortcomings in themselves and cannot accept the idea that it is human to err.

      Moderate: Patients