Depression. Aaron T. Beck, M.D.

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СКАЧАТЬ age, sex, and social group. The occurrence of frequent crying spells in a patient who rarely or never cried before becoming depressed might indicate a greater level of depression than it would in a patient who habitually cried whether depressed or not.

Dejected Mood

      The characteristic depression in mood is described differently by various clinically depressed patients. Whatever term the patient uses to describe her or his subjective feelings should be further explored by the examiner. If the patient uses the word “depressed,” for instance, the examiner should not take the word at its face value but should try to determine its connotation for the patient. Persons who are in no way clinically depressed may use this adjective to designate transient feelings of loneliness, boredom, or discouragement.

      Sometimes the feeling is expressed predominantly in somatic terms, such as “a lump in my throat,” or “I have an empty feeling in my stomach,” or “I have a sad, heavy feeling in my chest.” On further investigation, these feelings generally are found to be similar to the feelings expressed by other patients in terms of adjectives such as sad, unhappy, lonely, or bored.

      The intensity of the mood deviation must be gauged by the examiner. Some of the rough criteria of the degree of depression are the relative degree or morbidity implied by the adjective chosen, the qualification by adverbs such as “slightly” or “very,” and the degree of tolerance the patient expresses for the feeling (e.g., “I feel so miserable I can’t stand it another minute”).

      Among the adjectives used by depressed patients in answer to the question “How do you feel?” are the following: miserable, hopeless, blue, sad, lonely, unhappy, downhearted, humiliated, ashamed, worried, useless, guilty. Eighty-eight percent of the severely depressed patients reported some degree of sadness or unhappiness, as compared with 23 percent of the nondepressed patients.

      Mild: The patient indicates feeling blue or sad. The unpleasant feeling tends to fluctuate considerably during the day and at times may be absent, and the patient may even feel cheerful. Also the dysphoric feeling can be relieved partially or completely by outside stimuli, such as a compliment, a joke, or a favorable event. With a little effort or ingenuity the examiner can usually evoke a positive response. Patients at this level generally react with genuine amusement to jokes or humorous anecdotes.

      Moderate: The dysphoria tends to be more pronounced and more persistent. The patient’s feeling is less likely to be influenced by other people’s attempts to cheer him or her up, and any relief of this nature is temporary. Also, a diurnal variation is frequently present: The dysphoria is often worse in the morning and tends to be alleviated as the day progresses.

      Severe: In cases of severe depression, patients are apt to state that they feel “hopeless” or “miserable.” Agitated patients frequently state that they are “worried.” In our series, 70 percent of the severely depressed patients indicated that they were sad all the time and “could not snap out of it”; that they were so sad that it was very painful, or that they were so sad they could not stand it.

Negative Feelings Toward Self

      Depressed patients often express negative feelings about themselves. These feelings may be related to the general dysphoric feelings just described, but they are different in that they are specifically directed toward the self. The patients appear to distinguish feelings of dislike for themselves from negative attitudes about themselves such as “I am worthless.” The frequency of self-dislike ranged from 37 percent in the nondepressed group to 86 percent among the severely depressed.

      Mild: Patients state that they feel disappointed in themselves. This feeling is accompanied by ideas such as “I’ve let everybody down . . . If I had tried harder, I could have made the grade.”

      Moderate: The feeling of self-dislike is stronger and may progress to a feeling of disgust with oneself. This is generally accompanied by ideas such as “I’m a weakling . . . I don’t do anything right . . . I’m no good.”

      Severe: The feeling may progress to the point where patients hate themselves. This stage may be identified by statements such as: “I’m a terrible person . . . I don’t deserve to live . . . I’m despicable . . . I loathe myself.”

Reduction in Gratification

      The loss of gratification is such a pervasive process among depressives that many patients regard it as the central feature of their illness. In our series, 92 percent of the severely depressed patients reported at least partial loss of satisfaction. This was the most common symptom among the depressed group as a whole.

      Loss of gratification appears to start with a few activities and, as the depression progresses, spreads to practically everything the patient does. Even activities that are generally associated with biological needs or drives, such as eating or sexual experiences, are not spared. Experiences that are primarily psychosocial such as achieving fame, receiving expressions of love or friendship, or even engaging in conversations are similarly stripped of their pleasurable properties.

      The emphasis placed by some patients on loss of satisfaction gives the impression that they are especially oriented in their lives toward obtaining gratification. Whether or not this applies to the premorbid state cannot be stated with certainty, but it is true that the feverish pursuit of gratification is a cardinal feature of their manic states.

      The initial loss of satisfaction from activities involving responsibility or obligation, such as those involved in the role of worker, stay-at-home spouse, or student, is often compensated for by increasing satisfaction from recreational activities. This observation has prompted Saul¹⁰ and others to suggest that, in depression, the “give-get” balance is upset; the patient, depleted psychologically over a period of time by activities predominantly giving in nature, experiences an accentuation of passive needs, which are gratified by activities involving less of a sense of duty or responsibility (giving) and more of a tangible and easily obtained satisfaction. In the more advanced stages of the illness, however, even passive, regressive activities fail to bring any satisfaction.

      Mild: The patient complains that some of the joy has gone out of life. He or she no longer gets a “kick” or pleasure from family, friends, or job. Characteristically, activities involving responsibility, obligation, or effort become less satisfying. Often, patients find greater satisfaction in passive activities involving recreation, relaxation, or rest. They may seek unusual types of activities in order to get some of their former thrill. One patient reported that he could always pull himself out of a mild depression by watching a performance of deviant sexual practices.

      Moderate: Patients feel bored much of the time. They may try to enjoy some former favorite activities but these seem “flat” now. Business or professional activities that formerly excited them now fail to move them. They may obtain temporary relief from a change, such as a vacation, but the boredom returns upon resumption of usual activities.

      Severe: They experience no enjoyment from activities that were formerly pleasurable, and may even feel an aversion for activities they once enjoyed. Popular acclaim or expressions of love or friendship no longer bring any degree of satisfaction. The patients almost uniformly complain that nothing gives them any degree of satisfaction.

Loss of Emotional Attachments

      Loss of emotional involvement in other people or activities usually accompanies loss of satisfaction. This is manifested by a decline in interest in particular activities or in affection or concern for other persons. Loss of affection for family members is often a cause for concern to the patient and occasionally is a major factor in seeking medical attention. Sixty-four percent of the severely depressed patients СКАЧАТЬ