Depression. Aaron T. Beck, M.D.

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      The patient may show dependency by not wanting to leave the doctor’s office or not wanting the doctor to leave. Terminating the interview often becomes a difficult and painful process.

Vegetative and Physical Manifestations

      The physical and vegetative manifestations are considered by some authors to be evidence for a basic autonomic or hypothalamic disturbance that is responsible for the depressive state.^1,16 These symptoms, contrary to expectation, have a relatively low correlation with each other and with clinical ratings of the depth of depression. The intercorrelation matrix is shown in Table 2-5. The frequency of the symptoms among depressed and nondepressed patients is shown in Table 2-6.

Loss of Appetite

      For many patients, loss of appetite is often the first sign of an incipient depression, and return of appetite may be the first sign that it is beginning to lift. Some degree of appetite loss was reported by 72 percent of the severely depressed patients and only 21 percent of the nondepressed patients.

      Mild: Patients no longer eat meals with the customary degree of relish or enjoyment. There is also some dulling of desire for food.

      Moderate: The desire for food may be mostly gone and patients may miss a meal without realizing it.

      Severe: Patient may have to force themselves—or be forced—to eat. There may even be an aversion to food. After several weeks of severe depression, the amount of weight loss may be considerable.

Sleep Disturbance

      Difficulty in sleeping is one of most notable symptoms of depression, although it occurs in a large proportion of nondepressed patients as well. Difficulty in sleeping was reported by 87 percent of the severely depressed patients and 40 percent of the nondepressed patients.

      There have been a number of careful studies of the sleep of depressed patients (see Chapter 9). The investigators have presented solid evidence, based on direct observation of the patients and EEG recordings during the night, that depressed patients sleep less than do normal controls. In addition, the studies show an excessive degree of restlessness and movement during the night among the depressed patients.

      Mild: Patients report waking a few minutes to half an hour earlier than usual. In many cases, they may state that, although ordinarily they sleep soundly until awakened by the alarm clock, they now awaken several minutes before the alarm goes off. In some cases, the sleep disturbance is in the reverse direction: they find that they sleep more than usual.

      Moderate: Patients awaken one or two hours earlier than usual and frequently report that sleep is not restful. Moreover, they seem to spend a greater proportion of the time in light sleep. They may also awaken after three or four hours of sleep and require a hypnotic to return to sleep. In some cases, patients manifest an excessive sleeping tendency and may sleep up to twelve hours a day.

      Severe: Patients frequently awaken after only four or five hours of sleep and find it impossible to return to sleep. In some cases, they claim that they have not slept at all during the night, that they can remember “thinking” continuously during the night. It is likely, however, as Oswald et al.¹⁷ point out, that the patients are actually in a light sleep for a good part of the time.

Loss of Libido

      Some loss of interest in sex, whether of an autoerotic or directed toward someone else nature, was reported by 61 percent of the depressed patients and 27 percent of the nondepressed patients. Loss of libido correlated most highly with loss of appetite, loss of interest in other people, and depressed mood.

      Mild: There is generally a slight loss of spontaneous sexual desire and responsiveness to sexual stimuli. In some cases, however, sexual desire seems to be heightened when the patient is mildly depressed.

      Moderate: Sexual desire is markedly reduced and is aroused only with considerable stimulation.

      Severe: Any responsiveness to sexual stimuli is lost and the patient may have a pronounced aversion to sex.

Fatigability

      Increased tiredness was reported by 79 percent of the depressed patients and only 33 percent of the nondepressed. Some patients appear to experience this symptom as a purely physical phenomenon: the limbs feel heavy or the body feels as though it is weighted down. Others express fatigability as a loss of pep or energy. The patient complains of feeling “listless,” “worn out,” “too weak to move,” or “run down.”

      It is sometimes difficult to distinguish fatigability from loss of motivation and avoidance wishes. It is interesting to note that fatigability correlates more highly with lack of satisfaction (.36) and with pessimistic outlook (.36) than with other physical or vegetative symptoms such as loss of appetite (.20) and sleep disturbance (.28). The correlation with lack of satisfaction and pessimistic outlook suggests that the mental set may be a major factor in the patient’s feeling of tiredness; the converse, of course, should be considered as a possibility, namely, that tiredness influences the mental set.

      Some authors have conceptualized depression as a “depletion syndrome” because of the prominence of fatigability; they postulate that the patient exhausts available energy during the period prior to the onset of the depression, and the depressed state represents a kind of hibernation, during which the patient gradually builds up a new store of energy. Sometimes the fatigue is attributed to the sleep disturbance. Against this theory is the observation that even when the patients do get more sleep as a result of hypnotics, there is rarely any improvement in the feeling of fatigue. It is interesting to note as well that the correlation between sleep disturbance and fatigability is only .28. If the sleep disturbance were a major factor, a substantially higher correlation would be expected. As will be discussed in Chapter 12, fatigability may be a manifestation of loss of positive motivation.

      There tends to be a diurnal variation in СКАЧАТЬ