Depression. Aaron T. Beck, M.D.

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СКАЧАТЬ Mood disorder due to a general medical condition A prominent and persistent disturbance in mood that is judged to be a direct physiological consequence of a general medical condition Substance-induced mood disorder A prominent and persistent disturbance in mood that is judged to be a direct physiological consequence of a drug of abuse, a medication, another somatic treatment for depression, or toxin exposure Mood Disorder Not Otherwise Specified Included for coding disorders with mood symptoms that do not meet the criteria for any specific Mood Disorder and in which it is difficult to choose between Depressive Disorder Not Otherwise Specified and Bipolar Disorder Not Otherwise Specified (e.g., acute agitation)

      Adapted from DSM-IV-TR.

Reliability and Validity of Classification

      Early studies in the United States and the United Kingdom cast doubt on the reliability of the official nomenclatures. Some investigators, however, suggested at the time that the essential problem may be in the application of the nomenclature, rather than in its construction.^11,12,13 Substantial discrepancies were found among diagnosticians concurrently interviewing the same patients. Diagnostic agreement improved considerably by formulating operational definitions of the categories in the official nomenclature.

      The validity of a nomenclature refers to the accuracy with which the diagnostic terms designate veridical entities. Unfortunately, in the case of the so-called functional psychiatric disorders, there has been no known pathology or physiological abnormality to provide guidelines in the construction of the nomenclature. The basic definition of the nosological categories has rested largely on clinical criteria.

      In assessing the validity of a medical or psychiatric classification, it is appropriate to ask whether the specific groups or syndromes isolated from each other are different in ways that are of medical or psychiatric significance, that is, in terms of symptoms, duration, outcome, tendency to recur, and response to treatment. In general, the studies seem to justify the isolation of the group of depressive disorders from other psychiatric disorders; in addition, there is some support for the separation within the affective (now mood disorders) group of the endogenous depressions from the reactive (now adjustment disorder¹) depressions.

      In the early 1960s, Clark and Mallet¹⁴ conducted a follow-up study of cases of depression and schizophrenia in young adults, in which 74 cases diagnosed as manic-depressive psychosis or reactive depression and 76 initially diagnosed with schizophrenia were followed for three years. During the follow-up period, 70 percent of those with schizophrenia were readmitted, as were 20 percent of the depressives. Thirteen (17 percent) of those with schizophrenia became chronic, compared with only one (1.3 percent) of the depressives. Of the 15 depressed patients requiring readmission to the hospital, four were considered to have schizophrenia at that time. Of the 76 patients initially diagnosed with schizophrenia, none were considered to have a depressive disorder on readmission.

      Several inferences may be drawn from the clinical studies. Two major categories are distinguishable (as Kraepelin suggested) when rate of recovery and chronicity are examined as parts of the clinical picture. These are (1) depressive disorders having a relatively high rate of recovery, a moderate rate of relapse within three years of the initial diagnosis, and a moderate rate of chronicity; and (2) schizophrenia having a high rate of relapse and a high rate of chronicity. Some cases that initially evince the clinical picture of depression ultimately develop symptoms of schizophrenia. But it is rare for a patient who has symptoms of schizophrenia to develop bipolar disorder symptoms later. Lewis and Piotrowski¹⁵ suggested that many cases are diagnosed incorrectly as bipolar disorder because of insufficient recognition of certain signs of schizophrenia.

Dichotomies and Dualisms: Past and Present

      Aubrey Lewis¹⁶ and Paul Hoch¹⁷ regarded depression as essentially a single entity, while others sliced the syndrome along various planes to produce several dichotomies. This controversy reflected fundamental differences between the unitary and the separatist schools.¹⁸ The unitary school (gradualists) maintained that depression is a single clinical disorder that can express itself in a variety of forms; the separatists stated that there are several distinguishable types.

Endogenous Versus Exogenous

      This division attempted to establish the basic etiology of depression. Cases of depression were divided into those caused essentially by internal factors (endogenous) and those caused by external factors (exogenous). Although originally the exogenous group included such environmental agents as toxins and bacteria, writers have equated exogenous with psychogenic factors. This dichotomy will be discussed at greater length below.

Autonomous Versus Reactive

      Some writers have distinguished between types of depression on the basis of degree of reactivity to external events. Gillespie¹⁹ described several groups of depressed patients that differed in their responsiveness to external influences. He labeled those cases that followed a relentless course irrespective of any favorable environmental influences as “autonomous.” Those that responded favorably to encouragement and understanding were labeled “reactive.”

Agitated Versus Retarded

      Depression has often been characterized in terms of the predominant activity level. Many authors considered agitation as characteristic of depressions of the so-called involutional period and retardation of activity as characteristic of earlier depressions. Several studies (see Chapter 7) have discounted this hypothesis.

Psychotic Versus Neurotic

      Most authors have drawn a sharp line between psychotic and non-psychotic depressions. The gradualists, however,^16,17 believed that this distinction is artificial and that the differences are primarily quantitative. They asserted that the reported distinctions are based entirely on differences in the severity of the illness.

Endogenous and Exogenous Depressions

      The focus of the controversy between the separatists and the gradualists was primarily on the etiological concepts of depression. The separatists favored two distinct entities. One category consisted of cases that were thought to be endogenous, that is, caused primarily by some biological derangement in the human organism. The second category, reactive depressions, consisted of cases caused primarily by some external stress (bereavement, financial reverses, loss of employment). The unitary school considered these distinctions artificial and did not recognize the validity of labeling some cases endogenous and others reactive.

      The concept of two etiologically different types of depression was not new. In 1586 Timothy Bright, a physician, wrote a monograph, Melancholy and the Conscience of Sinne, in which he distinguished two different types of depression. He described one type “where the peril is not of the body” and requires “cure of the minde” (psychotherapy). In the second type, “the melancholy humour, deluding the organical actions, abuseth the minde”; this type requires physical treatment.

Origin of Endogenous-Exogenous Model

      The words “endogen” and “exogen” were coined by the Swiss botanist Augustin de Candolle.²⁰ The concept was introduced into psychiatry toward the end of the nineteenth century by the German neuropsychiatrist P. J. Moebius (for a more complete discussion of the evolution of the concept, see Heron²²). Moebius attached the label of “endogenous” to the group of mental disorders considered at that time to be due to degeneration or hereditary factors (internal causes). He further distinguished СКАЧАТЬ