Depression. Aaron T. Beck, M.D.

a good part of the time.

Loss of Libido

      Some loss of interest in sex, whether of an autoerotic or directed toward someone else nature, was reported by 61 percent of the depressed patients and 27 percent of the nondepressed patients. Loss of libido correlated most highly with loss of appetite, loss of interest in other people, and depressed mood.

      Mild: There is generally a slight loss of spontaneous sexual desire and responsiveness to sexual stimuli. In some cases, however, sexual desire seems to be heightened when the patient is mildly depressed.

      Moderate: Sexual desire is markedly reduced and is aroused only with considerable stimulation.

      Severe: Any responsiveness to sexual stimuli is lost and the patient may have a pronounced aversion to sex.

Fatigability

      Increased tiredness was reported by 79 percent of the depressed patients and only 33 percent of the nondepressed. Some patients appear to experience this symptom as a purely physical phenomenon: the limbs feel heavy or the body feels as though it is weighted down. Others express fatigability as a loss of pep or energy. The patient complains of feeling “listless,” “worn out,” “too weak to move,” or “run down.”

      It is sometimes difficult to distinguish fatigability from loss of motivation and avoidance wishes. It is interesting to note that fatigability correlates more highly with lack of satisfaction (.36) and with pessimistic outlook (.36) than with other physical or vegetative symptoms such as loss of appetite (.20) and sleep disturbance (.28). The correlation with lack of satisfaction and pessimistic outlook suggests that the mental set may be a major factor in the patient’s feeling of tiredness; the converse, of course, should be considered as a possibility, namely, that tiredness influences the mental set.

      Some authors have conceptualized depression as a “depletion syndrome” because of the prominence of fatigability; they postulate that the patient exhausts available energy during the period prior to the onset of the depression, and the depressed state represents a kind of hibernation, during which the patient gradually builds up a new store of energy. Sometimes the fatigue is attributed to the sleep disturbance. Against this theory is the observation that even when the patients do get more sleep as a result of hypnotics, there is rarely any improvement in the feeling of fatigue. It is interesting to note as well that the correlation between sleep disturbance and fatigability is only .28. If the sleep disturbance were a major factor, a substantially higher correlation would be expected. As will be discussed in Chapter 12, fatigability may be a manifestation of loss of positive motivation.

      There tends to be a diurnal variation in fatigability parallel to low mood and negative expectations. The patient tends to feel more tired upon awakening but somewhat less tired as the day progresses.

      Mild: Patients find that they tire more easily than usual. If they have had a hypomanic period just prior to the depression, the contrast is marked: whereas previously they could be very active for many hours without any feeling of tiredness, they now feel fatigued after a relatively short period of work. Not infrequently a diversion or a short nap may restore a feeling of vitality, but the improvement is transient.

      Moderate: Patients are generally tired when they awaken in the morning. Almost any activity seems to accentuate the tiredness. Rest, relaxation, and recreation do not appear to alleviate this feeling and may, in fact, aggravate it. A patient who customarily walked great distances when well would feel exhausted after short walks when depressed. Not only physical activity but focused mental activity such as reading often increases the sense of tiredness.

      Severe: Patients complain that they are too tired to do anything. Under external pressure they are sometimes able to perform tasks requiring a large expenditure of energy. Without such stimulation, however, they do not seem to be able to mobilize the energy to perform even simple tasks such as getting dressed. They may complain, for instance, that they do not have enough strength even to lift an arm.

Delusions

      Delusions in depression may be grouped into several categories: delusions of worthlessness; delusions of the “unpardonable” sin and of being punished or expecting punishment; nihilistic delusions; somatic delusions; and delusions of poverty. Any of the cognitive distortions described above may progress in intensity and achieve sufficient rigidity to warrant its being considered a delusion. A person with low self-esteem, for instance, may progress in thinking to believing that he is the devil. A person with a tendency to blame herself may eventually begin to ascribe to herself crimes such as the assassination of the president.

      To determine the frequency of the various delusions among psychotically depressed patients, a series of 280 psychotic patients were interviewed. The results are shown in Table 2-7.

Worthlessness

      Delusions of worthlessness occurred in 48 percent of the severely depressed psychotics. This delusion was expressed in the following way by one patient: “I must weep myself to death. I cannot live. I cannot die. I have failed so. It would be better if I had not been born. My life has always been a burden . . . I am the most inferior person in the world . . . I am subhuman.” Another patient said, “I am totally useless. I can’t do anything. I have never done anything worthwhile.”

TABLE 2-7. Frequency of Delusions with Depressive Content Among Psychotic Patients Varying in Depth of Depression (%; n = 280)

Crime and Punishment

      Some patients believe they have committed a terrible crime for which they deserve or expect to be punished. Of the severely depressed, psychotic patients, 46 percent reported the delusion of being very bad sinners. In many cases, patients feel that severe punishment such as torture or hanging is imminent; 42 percent of the severely depressed patients expected punishment of some type. Many other patients believed that they were being punished and that the hospital was a kind of penal institution. The patient wails, “Will God never give up?” “Why must I be singled out for punishment?” “My heart is gone. Can’t He see this? Can’t He let me alone?” In some cases patients may believe that they are the devil; 14 percent of the severely depressed psychotics had this delusion.

Nihilistic Delusions

      Nihilistic delusions have traditionally been associated with depression. A typical nihilistic delusion is reflected in the following statement: “It’s no use. All is lost. The world is empty. Everybody died last night.” Sometimes patients believes that they themselves are dead; this occurred in 10 percent of the severely depressed patients.

      Organ preoccupation is particularly common in nihilistic delusions. The patients complain that an organ is missing or that all their viscera have been removed. This was expressed in statements such as “My heart, my liver, my intestines are gone. I’m nothing but an empty shell.”

Somatic Delusions

      Sometimes patients believe that their bodies are deteriorating, or that they have some incurable disease. Of the severely depressed patients, 24 percent believed that their bodies were decaying and 20 percent that they had fatal illnesses. Somatic delusions are expressed in statements such as the following: “I can’t eat. The taste in my mouth is terrible. My guts are diseased. They can’t digest the food“; “I can’t think. My brain is all blocked up”; “My intestines are blocked. The food can’t get through.” Allied to the idea of having a severe abnormality is a patient’s statement, “I haven’t slept at all in six months.”

Poverty

      Delusions of poverty seem to be an outgrowth of the overconcern with finances manifested by depressed patients. A wealthy patient may complain bitterly, “All my money is