Depression. Aaron T. Beck, M.D.

harshly for any aspects of personality or behavior they judge to be substandard. They are likely to blame themselves for mishaps that are obviously not their fault. Their self-criticisms become more extreme.

      Severe: In the severe state, patients are even more extreme in self-blame or self-criticism. They make statements such as “I’m responsible for the violence and suffering in the world. There’s no way in which I can be punished enough for my sins. I wish you would take me out and hang me.” They view themselves as social lepers or criminals and interpret various extraneous stimuli as signs of public disapproval.

Indecisiveness

      Difficulty in making decisions, vacillating between alternatives, and changing decisions are depressive characteristics that are usually quite vexing to the patient’s family and friends as well as to the patient. The frequency of indecisiveness ranged from 48 percent in the mildly depressed patients to 76 percent in the severely depressed group.

      There appear to be at least two facets to this indecisiveness. The first is primarily in the cognitive sphere. Depressed patients anticipate making the wrong decision: whenever they consider one of various possibilities they tend to regard it as wrong and think they will regret making that choice. The second facet is primarily motivational and is related to “paralysis of the will,” avoidance tendencies, and increased dependency. Patients have a lack of motivation to go through the mental operations required to arrive at a conclusion. Also, the idea of making a decision represents a burden; they desire to evade or at least to get help with any situation they perceive will be burdensome. Furthermore, they realize that making a decision often commits them to a course of action and, since they desire to avoid action, they are prone to procrastinate.

      Routine decisions that must be made in carrying out their occupational or household roles become major problems for the depressed patients. A professor cannot decide what material to include in a lecture; a householder cannot decide what to cook for an evening meal; a student cannot decide whether to spend the spring recess studying at college or go home; an executive cannot decide whether to hire a new assistant.

      Mild: Patients who can ordinarily make rapid-fire decisions find that solutions do not seem to occur so readily. Whereas in their normal state they reach a decision “without even thinking about it,” they now find themselves impelled to mull over the problem, review the possible consequences of the decision, and consider a variety of often irrelevant alternatives. The fear of making the wrong decision is reflected in a general sense of uncertainty. Frequently, they seek confirmation from another person.

      Moderate: Difficulty in making decisions spreads to almost every activity and involves such minor problems as what clothes to wear, what route to take to the office, and whether to have a haircut. Often it is of little practical importance which alternative is selected, but the vacillation and failure to arrive at some decision can have unfavorable consequences. A woman, for example, spent several weeks trying to choose between two shades of paint for her house. The two shades under consideration were hardly distinguishable, but her failure to reach a decision created a turmoil in the house, the painter having left his buckets of paint and scaffolding until a decision could be made.

      Severe: Severely depressed patients generally believe they are incapable of making a decision and consequently do not even try. A woman prodded to make a shopping list or a list of clothes for her children to take to camp insisted she could not decide what to put down. Patients frequently have doubts about everything they do and say. One woman seriously doubted that she had given her correct name to the psychiatrist, or that she had enunciated it properly.

Distortion of Body Image

      Patients’ distorted picture of their physical appearance is often quite marked in depression. This occurs somewhat more frequently among women than among men. In our series, 66 percent of the severely depressed patients believed that they had become unattractive, as compared with 12 percent of the nondepressed patients.

      Mild: Patients begin to be excessively concerned with physical appearance. A woman finds herself frowning at her reflection whenever she passes a mirror. She examines her face minutely for signs of blemishes and becomes preoccupied with the thought that she looks plain or is getting fat. A man worries incessantly about the beginnings of hair loss, convinced that women find him unattractive.

      Moderate: The concern about physical appearance is greater. A man believes that there has been a change in his looks since the onset of the depression even though there is no objective evidence to support this idea. When he sees an ugly person, he thinks, “I look like that.” As he becomes worried about his appearance, his brow becomes furrowed. When he observes his furrowed brow in the mirror, he thinks, “my whole face is wrinkled and the wrinkles will never disappear.” Some patients seek plastic surgery to remedy the fancied or exaggerated facial changes.

      Sometimes a woman may believe she has grown fat even though there is no objective evidence to support this. In fact, some patients have this notion even though they are losing weight.

      Severe: The idea of personal unattractiveness becomes more fixed. Patients believe they are ugly and repulsive looking. They expect other people to turn away in revulsion: one woman wore a veil and another turned her head whenever anybody approached her.

Motivational Manifestations

      Motivational manifestations include consciously experienced strivings, desires, and impulses that are prominent in depressions. These motivational patterns can often be inferred from observing the patient’s behavior; however, direct questioning generally elicits a fairly precise and comprehensive description of motivations (see Table 2-4).

      A striking feature of the characteristic motivations of the depressed patient is their regressive nature. The term regressive is applicable in that the patient seems drawn to activities that are the least demanding in the degree of responsibility or initiative or the amount of energy required. They turn away from activities that are specifically associated with the adult role and seek activities more characteristic of the child’s role. When confronted with a choice, they prefer passivity to activity and dependence to independence (autonomy); they avoid responsibility and escape from their problems rather than trying to solve them; they seek immediate but transient gratifications instead of delayed but prolonged satisfactions. The ultimate manifestation of the escapist trend is expressed in the desire to withdraw from life via suicide.

      An important aspect of these motivations is that their fulfillment is generally incompatible with the individual’s major premorbid goals and values. In essence, yielding to passive impulses and desires to retreat or commit suicide leads to abandonment of family, friends, and vocation. Similarly, the patient defaults on the chance to obtain personal satisfaction through accomplishment or interpersonal relations. By avoiding even the simplest problems, moreover, the patient finds that they accumulate until they seem overwhelming.

      The specific motivational patterns to be described are presented as distinct phenomena, although they are obviously interrelated and may, in fact, represent different facets of the same fundamental pattern. It is possible that certain phenomena are primary and the others are secondary or tertiary; for instance, it could be postulated that paralysis of the will is the result of escapist or passive wishes, a sense of futility, loss of external investments, or the sense of fatigue. Since these suggestions are purely speculative, it seems preferable at present to treat these phenomena separately, rather than prematurely to assign primacy to certain patterns.

Paralysis of the Will

      The loss of positive motivation is often a striking feature of depression. Patients may have a major problem in mobilizing themselves to perform even the most elemental and vital tasks such as eating, elimination, or taking medication to relieve their distress. The essence of the problem appears to be that, although they can define for themselves what they should do, they do not experience any internal stimulus to do it. Even when urged, cajoled, or threatened, they do not seem able to arouse any desire to do these things. Loss of positive motivation ranged from 65 percent of the mild cases