Depression. Aaron T. Beck, M.D.

Чтение книги онлайн.

СКАЧАТЬ may now be defined in terms of the following attributes:

      1. A specific alteration in mood: sadness, loneliness, apathy.

      2. A negative self-concept associated with self-reproaches and self-blame.

      3. Regressive and self-punitive wishes: desires to escape, hide, or die.

      4. Vegetative changes: anorexia, insomnia, loss of libido.

      5. Change in activity level: retardation or agitation.

Semantics of Depression

      One of the difficulties in conceptualizing depression is essentially semantic, namely, that the term has been variously applied to designate a particular type of feeling or symptom; a symptom-complex (or syndrome); and a well-defined disease entity.

      Not infrequently, normal people say they are depressed when they observe any lowering of their mood below their baseline level. A person experiencing a transient sadness or loneliness may state that he or she is depressed. Whether this normal mood is synonymous with, or even related to, the feeling experienced in the abnormal condition of depression is open to question. In any event, when a person complains of feeling inordinately dejected, hopeless, or unhappy, the term depressed is often used to label this subjective state.

      The term depression is often used to designate a complex pattern of deviations in feelings, cognition, and behavior (described in the previous section) that is not represented as a discrete psychiatric disorder. In such instances it is regarded as a syndrome, or symptom-complex. The cluster of signs and symptoms is sometimes conceptualized as a psychopathological dimension ranging in intensity (or in degree of abnormality) from mild to severe. The syndrome of depression may at times appear as a concomitant of a definite psychiatric disorder such as schizophrenic reaction; in such a case, the diagnosis would be “schizophrenic reaction with depression.” At times, the syndrome may be secondary to, or a manifestation of, organic disease of the brain such as general paresis or cerebral artereosclerosis.

      Finally, the term depression has been used to designate a discrete nosological entity. The term has generally been qualified by some adjective to indicate a particular type or form, as for example: reactive depression, agitated depression, or psychotic-depressive reaction. When conceptualized as a specific clinical entity, depression is assumed to have certain consistent attributes in addition to the characteristic signs and symptoms; these attributes include a specifiable type of onset, course, duration, and outcome.

      One such classification system, the diagnostic manual of the American Psychiatric Association (APA),⁵ illustrates some of these aspects. The APA categorizes the mood disorders into (1) depressive disorders (unipolar depression) and (2) bipolar disorders. In the former, there is no history of a manic or hypomanic episode, and in the latter there is such a history.

      The depressive disorders include major depressive disorder and dysthymic disorder. Major depressive disorder is defined by one or more major depressive episodes. Such episodes include 2 weeks of depressed mood or loss of interest, along with a minimum of four additional depression symptoms. Dysthymic disorder is defined in part by at least 2 years of low-level depressed mood, where the person is depressed for more days than not. The bipolar disorders are usually accompanied by major depressive episodes, and are divided into two types, Bipolar I and Bipolar II disorder.⁵ The classification of the mood disorders will be considered in more detail in Chapter 4.

      In medicine, a clinical entity or disease is assumed to be responsive to specific forms of treatment (not necessarily discovered as yet) and to have a specific etiology. There is a considerable body of evidence indicating that the clinical entity depression responds to certain drugs and/or electroconvulsive therapy (ECT), but there is no consensus as yet regarding its etiology. This issue will be further considered in Part II, “Experimental Aspects of Depression.”

Depression and Normal Moods

      There is little agreement among authorities regarding the relationship of depression to the changes in mood experienced by normal individuals. The term mood is generally applied to a spectrum of feelings extending from elation and happiness at one extreme, to sadness and unhappiness at the other. The particular feelings encompassed by this term, consequently, are directly related to either happiness or sadness. Subjective states, such as anxiety or anger, that do not fit into the happiness-sadness categories are not generally included. Some authors¹⁴ believe that all individuals have mood swings and that normal individuals may have “blue” hours or “blue” days. This belief has been supported by systematic studies of oscillations in mood in normal subjects.¹⁵

      The episodes of low mood or of feeling blue experienced by normal individuals are similar in a number of ways to the clinical states of depression. First, there is a similarity between the descriptions of the subjective experience of normal low mood and of depression. The words used to describe normal low mood tend to be the same used by depressives to describe their feelings— blue, sad, unhappy, empty, low, lonely. It is possible, however, that this resemblance may be due to depressed patients’ drawing on familiar vocabulary to describe a pathological state for which they have no available words. Some patients, in fact, state that their feelings during their depressions are quite distinct from any feelings they have ever experienced when not in a clinical depression.

      Second, the behavior of the depressed patient resembles that of a person who is sad or unhappy, particularly in the mournful facial expression and the lowered voice. Third, some of the vegetative and physical manifestations characteristic of depression are occasionally seen in individuals who are feeling sad but who would not be considered clinically depressed. A person who has failed an examination, lost a job, or been jilted may not only feel discouraged and forlorn, but also experience anorexia, insomnia, and fatigability. Finally, many individuals experience blue states that seem to oscillate in a consistent or rhythmic fashion, independently of external stimuli, suggestive of the rhythmic variations in the intensity of depression.¹⁵

      The resemblance between depression and the low mood of normals has led to the concept that the pathological is simply an exaggeration of the normal. On the surface, this view seems plausible. As will be discussed in Chapter 2, each symptom of depression may be graded in intensity along a dimension, and the more mild intensities are certainly similar to the phenomena observed in normal individuals who are feeling blue.

      In support of the continuity perspective, Hankin et al.¹⁶ used Meehl’s¹⁷ taxometric procedures to examine the structure of depression in a sample of children and adolescents. Taking into account the skewness of depressive symptoms, the authors reported youth depression to be a dimensional, not categorical, construct. In discussing the implications of their findings, Hankin et al.¹⁶ point out that by using continuously distributed scores, the statistical power of the research is enhanced, thus aiding the ability of researchers to ascertain correctly the true causes and consequences of depression.

      Similar to the findings of Hankin et al.,¹⁷ Haslam and Beck¹⁸ used taxometric procedures to test for discreteness (discontinuity) of 5 hypothesized subtypes of major depression, including endogenous, sociotropic, autonomous, self-critical, and hopelessness forms. The study used self-reported symptom and personality profiles of 531 consecutively admitted outpatients diagnosed with major depression. The features of the respective subtypes were not found to covary as predicted, except for the endogenous subtype.¹⁸

      It could be contended that many pathological states that seem to be on a continuum with the normal state are different in their essential character from the normal state. To illustrate СКАЧАТЬ