Depression. Aaron T. Beck, M.D.

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      Chapter 2

      Symptomatology of Depression

Previous Systematic Studies

      As stated in Chapter 1, there has been remarkable consistency in the descriptions of depression since ancient times. While there has been unanimity among the writers on many of the characteristics, however, there has been lack of agreement on many others. The core signs and symptoms such as low mood, pessimism, self-criticism, and retardation or agitation seem to have been universally accepted. Other signs and symptoms that have been regarded as intrinsic to the depressive syndrome include autonomic symptoms, constipation, difficulty in concentrating, slow thinking, and anxiety. In 1953, Campbell¹ listed 29 medical manifestations of autonomic disturbance, among which the most common in manic depressives were hot flashes, tachycardia, dyspnea, weakness, head pains, coldness and numbness of the extremities, frontal headaches, and dizziness.

      Very few systematic studies have been designed to delineate the characteristic signs and symptoms of depression. Cassidy et al.² compared the symptomatology of 100 patients diagnosed as manic depressive with a control group of 50 patients with diagnoses of recognized medical diseases. The frequency of the specific symptoms was determined by having the patient complete a questionnaire of 199 items. Among the symptoms that were endorsed significantly more often by those in the psychiatric group were anorexia, sleep disturbance, low mood, suicidal thoughts, crying, irritability, fear of losing the mind, poor concentration, and delusions.

      It is interesting to note that Cassidy and his coworkers found that only 25 percent of the manic-depressive group thought that they would get well as compared with 61 percent of those who were medically ill. This is indicative of the pessimism characteristic of manic depressives: almost all could be expected to recover completely from their illness, in contrast to the number of incurably ill among the medical patients. Certain symptoms sometimes attributed to manic depressives, such as constipation, were found in similar proportions in the two groups.

      Campbell reported a high frequency of medical symptoms, generally attributed to autonomic imbalance, among manic depressives. Cassidy’s study, however, found that most of these medical symptoms occurred at least as frequently among the medically ill patients as among the manic-depressive patients. Moreover, many of these symptoms were found in a group of healthy control patients. Headaches, for instance, were reported by 49 percent of the manic-depressive patients, 36 percent of the medically sick controls, and 25 percent of the healthy controls. When the symptoms of manic depressives, anxiety neurotics, and hysteria patients were compared, it was found that autonomic symptoms occurred at least as frequently in the latter two groups as they did in the manic-depressive group. Palpitation, for instance, was reported by 56 percent of the manic depressives, 94 percent of the anxiety neurotics, and 76 percent of the hysterics. It therefore seems clear that autonomic symptoms are not specifically characteristic of manic-depressive disorders.

      In the early 1960s, two systematic investigations of the symptomatology of depressive disorders were conducted to delineate the typical clinical picture, as well as to suggest typical subgroupings of depression.^3,4 But because the case material consisted primarily of depressed patients and did not include a control group of nondepressed psychiatric patients for comparison, it was not possible to determine which symptom clusters might be characteristic of depression or its various subgroupings and which might occur in any psychiatric patient or even in normals.

      The following material is reprinted in its entirety from the first edition, with some minor updating of the language. The chapter ends with a brief section on variations in symptoms by age and culture as they are understood in the twenty-first century.

      Following a review of the chief complaints, the symptoms of depression are described under four major headings: emotional, cognitive, motivational, and physical and vegetative. This is followed by a section on delusions and hallucinations. Some of these divisions may appear arbitrary, and it is undoubtedly true that some of the symptoms described separately may simply be different facets of the same phenomenon. Nonetheless, I think it is desirable at this stage to present the symptomatology as broadly as possible, despite the inevitable overlap. A section on behavioral observation follows the categorization of symptoms. The descriptions in this latter section were obtained by direct observation of the patients’ nonverbal as well as their verbal behavior.

Chief Complaint

      The chief complaint presented by depressed patients often points immediately to the diagnosis of depression; although it sometimes suggests a physical disturbance. Skillful questioning can generally determine whether the basic depressive symptomatology is present.

      The chief complaint may take a variety of forms: (1) an unpleasant emotional state; (2) a changed attitude toward life; (3) somatic symptoms of a specifically depressive nature; or (4) somatic symptoms not typical of depression.

      Among the most common subjective complaints⁵ are “I feel miserable.” “I just feel hopeless.” “I’m desperate.” “I’m worried about everything.” Although depression is generally considered an affective disorder, it should be emphasized that a subjective change in mood is not reported by all depressed patients. As in many other disorders, the absence of a significant clinical feature does not rule out the diagnosis of that disorder. In our series, for instance, only 53 percent of the mildly depressed patients acknowledged feeling sad or unhappy.

      Sometimes the chief complaint is in the form of a change of one’s actions, reactions, or attitudes toward life. For example, a patient may say, “I don’t have any goals any more.” “I don’t care anymore what happens to me.” “I don’t see any point to living.” Sometimes the major complaint is a sense of futility about life.

      Often the chief complaint of the depressed patient centers around some physical symptom that is characteristic of depression. The patient may complain of fatigue, lack of pep, or loss of appetite. Sometimes patients complain of some alteration in appearance or bodily functions, or that they are beginning to look old or are getting ugly. Others complain of some dramatic physical symptom such as, “My bowels are blocked up.”

      Depressed patients attending medical clinics or consulting either internists or general practitioners frequently present some symptom suggestive of a physical disease.⁶ In many cases, the physical examination fails to reveal any physical abnormality. СКАЧАТЬ