Depression. Aaron T. Beck, M.D.
Чтение книги онлайн.

Читать онлайн книгу Depression - Aaron T. Beck, M.D. страница 20

Название: Depression

Автор: Aaron T. Beck, M.D.

Издательство: Ingram

Жанр: Общая психология

Серия:

isbn: 9780812290882

isbn:

СКАЧАТЬ

      Mild: Patients find that they tire more easily than usual. If they have had a hypomanic period just prior to the depression, the contrast is marked: whereas previously they could be very active for many hours without any feeling of tiredness, they now feel fatigued after a relatively short period of work. Not infrequently a diversion or a short nap may restore a feeling of vitality, but the improvement is transient.

      Moderate: Patients are generally tired when they awaken in the morning. Almost any activity seems to accentuate the tiredness. Rest, relaxation, and recreation do not appear to alleviate this feeling and may, in fact, aggravate it. A patient who customarily walked great distances when well would feel exhausted after short walks when depressed. Not only physical activity but focused mental activity such as reading often increases the sense of tiredness.

      Severe: Patients complain that they are too tired to do anything. Under external pressure they are sometimes able to perform tasks requiring a large expenditure of energy. Without such stimulation, however, they do not seem to be able to mobilize the energy to perform even simple tasks such as getting dressed. They may complain, for instance, that they do not have enough strength even to lift an arm.

      Delusions in depression may be grouped into several categories: delusions of worthlessness; delusions of the “unpardonable” sin and of being punished or expecting punishment; nihilistic delusions; somatic delusions; and delusions of poverty. Any of the cognitive distortions described above may progress in intensity and achieve sufficient rigidity to warrant its being considered a delusion. A person with low self-esteem, for instance, may progress in thinking to believing that he is the devil. A person with a tendency to blame herself may eventually begin to ascribe to herself crimes such as the assassination of the president.

      To determine the frequency of the various delusions among psychotically depressed patients, a series of 280 psychotic patients were interviewed. The results are shown in Table 2-7.

      Delusions of worthlessness occurred in 48 percent of the severely depressed psychotics. This delusion was expressed in the following way by one patient: “I must weep myself to death. I cannot live. I cannot die. I have failed so. It would be better if I had not been born. My life has always been a burden . . . I am the most inferior person in the world . . . I am subhuman.” Another patient said, “I am totally useless. I can’t do anything. I have never done anything worthwhile.”

image

      Some patients believe they have committed a terrible crime for which they deserve or expect to be punished. Of the severely depressed, psychotic patients, 46 percent reported the delusion of being very bad sinners. In many cases, patients feel that severe punishment such as torture or hanging is imminent; 42 percent of the severely depressed patients expected punishment of some type. Many other patients believed that they were being punished and that the hospital was a kind of penal institution. The patient wails, “Will God never give up?” “Why must I be singled out for punishment?” “My heart is gone. Can’t He see this? Can’t He let me alone?” In some cases patients may believe that they are the devil; 14 percent of the severely depressed psychotics had this delusion.

      Nihilistic delusions have traditionally been associated with depression. A typical nihilistic delusion is reflected in the following statement: “It’s no use. All is lost. The world is empty. Everybody died last night.” Sometimes patients believes that they themselves are dead; this occurred in 10 percent of the severely depressed patients.

      Organ preoccupation is particularly common in nihilistic delusions. The patients complain that an organ is missing or that all their viscera have been removed. This was expressed in statements such as “My heart, my liver, my intestines are gone. I’m nothing but an empty shell.”

      Sometimes patients believe that their bodies are deteriorating, or that they have some incurable disease. Of the severely depressed patients, 24 percent believed that their bodies were decaying and 20 percent that they had fatal illnesses. Somatic delusions are expressed in statements such as the following: “I can’t eat. The taste in my mouth is terrible. My guts are diseased. They can’t digest the food“; “I can’t think. My brain is all blocked up”; “My intestines are blocked. The food can’t get through.” Allied to the idea of having a severe abnormality is a patient’s statement, “I haven’t slept at all in six months.”

      Delusions of poverty seem to be an outgrowth of the overconcern with finances manifested by depressed patients. A wealthy patient may complain bitterly, “All my money is gone. What will I live on? Who will buy food for my children?” Many authors have described the incongruity of a man of means who, dressed in rags, goes begging for alms or food.

      In our study, delusions of poverty were not investigated. Because of the very high proportion of low-income patients in the series, it was difficult to distinguish a delusion of poverty from actual poverty.

      In Rennie’s13 study, nearly half of the 99 cases had delusions as part of their psychoses; 49 patients had ideas of persecution or of passivity. (The number of persons with each of these delusions is not given.) Typical depressive delusions were found in 25 patients; these dealt predominantly with self-blame and self-depreciation and with ideas of being dead, of their bodies being changed, or of immorality. Delusions were most common in the oldest age group (72 percent). In patients older than 50 the content revolved predominantly around ideas of poverty, of being destroyed or tortured in some horrible manner, of being poisoned, or of being contaminated by feces.

      Rennie found that 25 percent of the patients had hallucinations. This was most prominent in the recurrent depressive group. Samples of the types of hallucinations were as follows: “I conversed with God”; “I heard the sentence, ‘Your daughter is dead’ ”; “I heard people talking through my stomach”; “I saw a star on Christmas Day”; “I saw and heard my dead mother”; “Voices told me not to eat”; “Voices told me to walk backward”; “Saw and heard God and angels”; “Saw dead father”; “Animal faces in the food”; “Saw and heard animals”; “Saw dead people”; “Heard brother’s and dead people’s voices”; “Saw husband in his coffin”; “A voice said, ‘Do not stay with your husband” ’; “Saw two men digging a grave.”

      In our study, we found that 13 percent of the severely depressed, psychotic patients acknowledged hearing voices that condemned them. This was the most frequent type of hallucination reported.

      TABLE 2-8. Frequency of Clinical Features of Patients Varying in Depth of depression (%; n = 486)

image

      The psychiatrists in our study rated the intensity of certain clinical features in the depressed and nondepressed patients. Many of these features would be considered signs; that is, they are abstracted from observable behaviors rather than from СКАЧАТЬ