Depression. Aaron T. Beck, M.D.

of a man of means who, dressed in rags, goes begging for alms or food.

      In our study, delusions of poverty were not investigated. Because of the very high proportion of low-income patients in the series, it was difficult to distinguish a delusion of poverty from actual poverty.

      In Rennie’s¹³ study, nearly half of the 99 cases had delusions as part of their psychoses; 49 patients had ideas of persecution or of passivity. (The number of persons with each of these delusions is not given.) Typical depressive delusions were found in 25 patients; these dealt predominantly with self-blame and self-depreciation and with ideas of being dead, of their bodies being changed, or of immorality. Delusions were most common in the oldest age group (72 percent). In patients older than 50 the content revolved predominantly around ideas of poverty, of being destroyed or tortured in some horrible manner, of being poisoned, or of being contaminated by feces.

Hallucinations

      Rennie found that 25 percent of the patients had hallucinations. This was most prominent in the recurrent depressive group. Samples of the types of hallucinations were as follows: “I conversed with God”; “I heard the sentence, ‘Your daughter is dead’ ”; “I heard people talking through my stomach”; “I saw a star on Christmas Day”; “I saw and heard my dead mother”; “Voices told me not to eat”; “Voices told me to walk backward”; “Saw and heard God and angels”; “Saw dead father”; “Animal faces in the food”; “Saw and heard animals”; “Saw dead people”; “Heard brother’s and dead people’s voices”; “Saw husband in his coffin”; “A voice said, ‘Do not stay with your husband” ’; “Saw two men digging a grave.”

      In our study, we found that 13 percent of the severely depressed, psychotic patients acknowledged hearing voices that condemned them. This was the most frequent type of hallucination reported.

      TABLE 2-8. Frequency of Clinical Features of Patients Varying in Depth of depression (%; n = 486)

Clinical Examination

Appearance

      The psychiatrists in our study rated the intensity of certain clinical features in the depressed and nondepressed patients. Many of these features would be considered signs; that is, they are abstracted from observable behaviors rather than from the patients’ self-descriptions. Other features were evaluated on the basis of the patients’ verbal reports as well as on the observation of their behavior. Some of the clinical features overlap those described in the previous section. This particular study provides an opportunity to compare the frequency of symptoms elicited in response to the inventory with the frequency of symptoms derived from a clinical examination.

      The sample consisted of the last 486 patients of the 966 patients described in Table 2-2. The distribution of the clinical features among the nondepressed, mildly depressed, moderately depressed, and severely depressed are found in Table 2-8.

      Most cases of depression can be diagnosed by inspection.¹⁸ The sad, melancholic expression combined with either retardation or agitation is practically pathognomonic of depression. In contrast, many patients conceal their unpleasant feelings behind a cheerful façade (“smiling depression”), and it may require careful interviewing to bring out a pained facial expression.

      The facies show typical characteristics associated with sadness. The corners of the mouth are turned down, the brow is furrowed, the lines and wrinkles are deepened, and the eyes are often red from crying. Among the descriptions used by clinicians are glum, forlorn, gloomy, dejected, unsmiling, solemn, wearily resigned.⁵ Lewis reported that weeping occurred in most of the women but in only one-sixth of the men in his sample.

      In severe cases, the facies may appear to be frozen in a gloomy expression. Most patients, however, show some lability of expression, especially when their attention is diverted from their feelings. Genuine smiles may be elicited at times even in the severe cases, but they are generally transient. Some patients present a forced or social smile, which may be deceiving. The so-called mirthless smile, which indicates a lack of any genuine amusement, is easily recognized. This type of smile may be elicited in response to a humorous remark by the examiner and indicates the patient’s intellectual awareness of the humor but without any emotional response to it.

      A sad facies was observed in 85 percent of the depressed group (including mild, moderate, and severe cases) and in 18 percent of the nondepressed group. In the severely depressed group, 98 percent showed this characteristic.

Retardation

      The most striking sign of a retarded depression is reduction in spontaneous activity. The patient tends to stay in one position longer than usual and to use a minimum of gestures. Movements are slow and deliberate as though the body and limbs are weighted down. He or she walks slowly, frequently hunched over, and with a shuffling gait. These postural characteristics were observed in 87 percent of the severely depressed patients in our sample.

      The speech shows decreased spontaneity and the verbal output is reduced. The patient does not initiate a conversation or volunteer statements and, when questioned, responds in a few words. Sometimes, speaking is decreased only when a painful subject is being discussed. The pitch of the patient’s voice is often lowered and speech tends to be in a monotone. These vocal characteristics were observed in 75 percent of the severely depressed patients.

      The more retarded patients may start sentences but not complete them. They may answer questions with grunts or groans. The most severe cases may be mute. As Lewis points out, it is sometimes difficult to distinguish the scanty talk of a depressive from that of a well-preserved, suspicious paranoid schizophrenic. In both conditions, there may be pauses, hesitations, evasion, breaking off, and brevity. The diagnosis must rest on other observations—of content and behavior.

      In severe depressions patients may manifest signs of a syndrome that has been labeled stupor or semi-stupor.¹⁹ If left alone, they may remain practically motionless whether standing, sitting, or lying in bed. There is rarely, if ever, any waxy flexibility as seen in catatonia or any apparent clouding of consciousness. The patients vary in the degree to which they respond to stimulation. Some respond to sustained efforts by the examiner to establish rapport; others appear oblivious. I questioned several patients in the latter category after they recovered from their depression, and they reported that they had experienced feelings and thoughts during clinical examination but had felt incapable of expressing them in any way.

      In extreme cases, patients do not eat or drink even with urging. Food placed in the mouth may remain there until removed, and under such circumstances tube feeding becomes necessary as a life-preserving measure. Sometimes patients do not move their bowels and digital removal of feces or enemas are necessary. Saliva accumulates and drools out of the mouth. They blink infrequently and may develop corneal ulcers. A more complete description of these extreme cases will be found in the section on Benign Stupors in Chapter 8.

      Bleuler (p. 209)²⁰ described the melancholic triad consisting of depressive affect, inhibition of action, and inhibition of thinking. The first two characteristics are certainly typical of retarded depression. There is, however, a strong question as to whether there is an inhibition of the thought process. Lewis⁵ believes that thinking is active—or even hyperactive—even though speech is inhibited. Refined psychological tests, furthermore, have failed to show significant interference with thought processes (Chapter 10).

Agitation

      The chief characteristic of agitated patients is ceaseless activity. They cannot sit still but move about constantly in the chair. They convey a sense of restlessness and disturbance in wringing the hands or handkerchief, tearing clothing, picking at skin, and clenching