Depression. Aaron T. Beck, M.D.

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СКАЧАТЬ write sloppily than to make the effort to write legibly. It’s much easier to lead a self-centered, passive life than to make the effort to change it.”

      Moderate: In moderate cases, avoidance wishes are stronger and spread to a much wider range of usual activities. A depressed college professor described this as follows: “Escape seems to be my strongest desire. I feel as though I would feel better in almost any other occupation or profession. As I ride the bus to the university, I wish I were the bus driver instead of a teacher.”

      Patients think continually of ways of diversion or escape. They would like to indulge in passive recreation such as going to the movies, watching television, or getting drunk. They may daydream of going to a desert island or becoming a hobo. At this stage, they may withdraw from most social contacts since interpersonal relations seem to be too demanding. At the same time, because of their loneliness and increased dependency, they may want to be with other people.

      Severe: In severe cases, the wish to avoid or escape is manifested in marked seclusiveness. Not infrequently the patient stays in bed, and when people approach, may hide under the covers. A patient said, “I just feel like getting away from everybody and everything. I don’t want to see anybody or do anything. All I want to do is sleep.” One form of escape that generally occurs to severely depressed patients is suicide. They feel a strong desire to end their life as a way of escaping from a situation they regard as intolerable.

Suicidal Wishes

      Suicidal wishes have historically been associated with a depressed state. While suicidal wishes may occur in nondepressed individuals, they occur substantially more frequently in depressed patients. In our series this was the symptom reported least frequently (12 percent) by the nondepressed patients, but it was reported frequently (74 percent) by the severely depressed patients. This difference indicates the diagnostic value of this particular symptom in the identification of severe depression. The intensity with which this symptom was expressed also showed one of the highest correlations with the intensity of depression.

      The patient’s interest in suicide may take a variety of forms. It may be experienced as a passive wish (“I wish I were dead”); an activity wish (“I want to kill myself”); as a repetitive, obsessive thought without any volitional quality; as a daydream; or as a meticulously conceived plan. In some patients, the suicidal wishes occur constantly throughout the illness, and the patient may have to battle continually to ward them off. In other cases, the wish is sporadic and is characterized by a gradual build-up, then a slackening of intensity until it disappears temporarily. Patients often report, once the wish has been dissipated, that they are glad they did not succumb to it. It should be noted that the impulsive suicidal attempt may be just as dangerous as the deliberately planned attempt.

      The importance of suicidal symptoms is obvious, since nowadays it is practically the only feature of depression that poses a reasonably high probability of fatal consequences. The incidence of suicide among manic depressives ranged from 2.8 percent in one study with a 10-year follow-up¹² to 5 percent in a 25-year period of observation.¹³

      Mild: Wishes to die were reported by about 31 percent of the mildly depressed patients. Often these take the passive form such as “I would be better off dead.” Patients may state that they would not do anything to hasten death, but find the idea of dying attractive. One patient looked forward to an airplane trip because of the possibility the plane might crash.

      Sometimes the patient expresses an indifference toward living (“I don’t care whether I live or die”). Other patients may show ambivalence (“I would like to die but at the same time I’m afraid of dying”).

      Moderate: In these cases, suicidal wishes are more direct, frequent, and compelling; there is a definite risk of either impulsive or premeditated suicidal attempts. The patient may express this desire in the passive form: “I hope I won’t wake up in the morning” or “If I died, my family would be better off.” The active expression of the wish may vary from an ambivalent statement, “I’d like to kill myself but I don’t have the guts,” to the bald assertion, “If I could do it and not botch it up, I would go ahead and kill myself.” The suicidal wish may be manifested by the patient’s taking unnecessary risks. A number of patients drove their cars at excessive rates of speed in the hope that something might happen.

      Severe: In severe cases, suicidal wishes tend to be intense, although the patient may be too retarded to complete a suicidal attempt. Among typical statements are the following: “I feel so hopeless. Why won’t you let me die?”; “It’s no use. All is lost. There is only one way out—to kill myself”; “I must weep myself to death. I can’t live and you won’t let me die”; “I can’t bear to live through another day. Please put me out of my misery.”

Increased Dependency

      The term dependency is used here to designate the desire to receive help, guidance, or direction rather than the actual process of relying on someone else. The accentuated wishes for dependency have only occasionally been included in clinical descriptions of depression; they have, however, been recognized and assigned a major etiological role in several psychodynamic explanations of depression.^14,15 The accentuated orality attributed to depressed patients by those authors includes the kinds of wishes that are generally regarded as “dependent.”

      Since increased dependency has been attributed to other conditions as well as to depression, the question could be raised whether dependency can be justifiably listed as a specific manifestation of depression. Increased dependency wishes are seen in an overt form in people who have an acute or chronic physical illness; moreover, covert or repressed dependency has been regarded by many theoreticians as the central factor in certain psychosomatic conditions such as peptic ulcer, as well as in alcoholism and other addictions. However, it is my contention that frank, undisguised, and intensified desires for help, support, and encouragement are very prominent elements in the advanced stages of depression and belong in any clinical description of this syndrome. In other conditions, intensified dependency may be a variable and transient characteristic.

      The desire for help seems to transcend the realistic need for help; that is, the patient can often reach his or her objective without assistance. Receiving help, however, appears to carry special emotional meaning for the patient beyond its practical importance and is often satisfying—at least temporarily.

      Mild: The patient who is ordinarily very self-sufficient and independent begins to express a desire to be helped, guided, or supported. A patient who had always insisted on driving when he was in the car with his wife asked her to drive. He felt that he was capable of driving, but the idea of her driving was more appealing to him at this time.

      As the dependency wishes become stronger, they tend to supersede habitual independent drives. Patients now find that they prefer to have somebody do things with them than to do them alone. The dependent desire does not seem to be simply a by-product of the feelings of helplessness and inadequacy or fatigue. Patients feel a craving for help even though they recognize that they do not need it, and when the help is received they generally experience some gratification and lessening of depression.

      Moderate: The patient’s desire to have things done for him or her, to receive instruction and reassurance, is stronger. The patient who experiences a wish for help in the mild phase now experiences this as a need. Receiving help no longer is an optional luxury but is conceived of as a necessity. A depressed woman, who was legally separated from her husband, begged him to come back to her. “I need you desperately,” she said. It was not clear to her exactly what she needed him for, except that she wanted to have a strong person near her.

      When confronted with a task or problem, moderately depressed patients feel impelled to seek help before attempting to undertake it СКАЧАТЬ