Depression. Aaron T. Beck, M.D.

is only one way out—to kill myself”; “I must weep myself to death. I can’t live and you won’t let me die”; “I can’t bear to live through another day. Please put me out of my misery.”

Increased Dependency

      The term dependency is used here to designate the desire to receive help, guidance, or direction rather than the actual process of relying on someone else. The accentuated wishes for dependency have only occasionally been included in clinical descriptions of depression; they have, however, been recognized and assigned a major etiological role in several psychodynamic explanations of depression.^14,15 The accentuated orality attributed to depressed patients by those authors includes the kinds of wishes that are generally regarded as “dependent.”

      Since increased dependency has been attributed to other conditions as well as to depression, the question could be raised whether dependency can be justifiably listed as a specific manifestation of depression. Increased dependency wishes are seen in an overt form in people who have an acute or chronic physical illness; moreover, covert or repressed dependency has been regarded by many theoreticians as the central factor in certain psychosomatic conditions such as peptic ulcer, as well as in alcoholism and other addictions. However, it is my contention that frank, undisguised, and intensified desires for help, support, and encouragement are very prominent elements in the advanced stages of depression and belong in any clinical description of this syndrome. In other conditions, intensified dependency may be a variable and transient characteristic.

      The desire for help seems to transcend the realistic need for help; that is, the patient can often reach his or her objective without assistance. Receiving help, however, appears to carry special emotional meaning for the patient beyond its practical importance and is often satisfying—at least temporarily.

      Mild: The patient who is ordinarily very self-sufficient and independent begins to express a desire to be helped, guided, or supported. A patient who had always insisted on driving when he was in the car with his wife asked her to drive. He felt that he was capable of driving, but the idea of her driving was more appealing to him at this time.

      As the dependency wishes become stronger, they tend to supersede habitual independent drives. Patients now find that they prefer to have somebody do things with them than to do them alone. The dependent desire does not seem to be simply a by-product of the feelings of helplessness and inadequacy or fatigue. Patients feel a craving for help even though they recognize that they do not need it, and when the help is received they generally experience some gratification and lessening of depression.

      Moderate: The patient’s desire to have things done for him or her, to receive instruction and reassurance, is stronger. The patient who experiences a wish for help in the mild phase now experiences this as a need. Receiving help no longer is an optional luxury but is conceived of as a necessity. A depressed woman, who was legally separated from her husband, begged him to come back to her. “I need you desperately,” she said. It was not clear to her exactly what she needed him for, except that she wanted to have a strong person near her.

      When confronted with a task or problem, moderately depressed patients feel impelled to seek help before attempting to undertake it themselves. They not infrequently state that they want to be told what to do. Some patients shop around for opinions about a certain course of action and seem to be more involved in the idea of getting advice than in using it. One woman would ask numerous questions about trivial problems but did not seem to pay much attention to the content of the answer—just so an answer was forthcoming.

      Severe: The intensity of the desire to be helped is increased, and the content of the wish has a predominantly passive cast. It is couched almost exclusively in terms of wanting someone to do everything for the patient, including caretaking. Patients are no longer concerned about getting direction or advice, or in sharing problems. They want the other person to do the job and solve the problem for them. A patient clung to the physician and pleaded, “Doctor, you must help me.” Her desire was for the psychiatrist to do everything for her without her doing anything. She even wanted the psychiatrist to adopt her children.

TABLE 2-5. Intercorrelation of Physical and Vegetative Symptoms (n = 606)

      *Pearson product-moment correlation coefficients.

TABLE 2-6. Frequency of Vegetative and Physical Manifestations Among Depressed and Nondepressed Patients (%)

      The patient may show dependency by not wanting to leave the doctor’s office or not wanting the doctor to leave. Terminating the interview often becomes a difficult and painful process.

Vegetative and Physical Manifestations

      The physical and vegetative manifestations are considered by some authors to be evidence for a basic autonomic or hypothalamic disturbance that is responsible for the depressive state.^1,16 These symptoms, contrary to expectation, have a relatively low correlation with each other and with clinical ratings of the depth of depression. The intercorrelation matrix is shown in Table 2-5. The frequency of the symptoms among depressed and nondepressed patients is shown in Table 2-6.

Loss of Appetite

      For many patients, loss of appetite is often the first sign of an incipient depression, and return of appetite may be the first sign that it is beginning to lift. Some degree of appetite loss was reported by 72 percent of the severely depressed patients and only 21 percent of the nondepressed patients.

      Mild: Patients no longer eat meals with the customary degree of relish or enjoyment. There is also some dulling of desire for food.

      Moderate: The desire for food may be mostly gone and patients may miss a meal without realizing it.

      Severe: Patient may have to force themselves—or be forced—to eat. There may even be an aversion to food. After several weeks of severe depression, the amount of weight loss may be considerable.

Sleep Disturbance

      Difficulty in sleeping is one of most notable symptoms of depression, although it occurs in a large proportion of nondepressed patients as well. Difficulty in sleeping was reported by 87 percent of the severely depressed patients and 40 percent of the nondepressed patients.

      There have been a number of careful studies of the sleep of depressed patients (see Chapter 9). The investigators have presented solid evidence, based on direct observation of the patients and EEG recordings during the night, that depressed patients sleep less than do normal controls. In addition, the studies show an excessive degree of restlessness and movement during the night among the depressed patients.

      Mild: Patients report waking a few minutes to half an hour earlier than usual. In many cases, they may state that, although ordinarily they sleep soundly until awakened by the alarm clock, they now awaken several minutes before the alarm goes off. In some cases, the sleep disturbance is in the reverse direction: they find that they sleep more than usual.

      Moderate: Patients awaken one or two hours earlier than usual and frequently report that sleep is not restful. Moreover, they seem to spend a greater proportion of the time in light sleep. They may also awaken after three or four hours of sleep and require a hypnotic to return to sleep. In some cases, patients manifest an excessive sleeping tendency and may sleep up to twelve hours a day.

      Severe: Patients frequently awaken after only four or five hours of sleep and find it impossible to return to sleep. In some cases, they claim that they have not slept at all during the night, that they can remember “thinking” continuously during the night. It is likely, however,