Depression. Aaron T. Beck, M.D.

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      Chapter 5

      Psychotic Versus Nonpsychotic

      Depression

      Historically, there was considerable controversy among authorities regarding the separation of psychotic and neurotic depressions. Although this cleavage was part of the official nomenclature for many years, authorities such as Paul Hoch¹ questioned the distinction, and it was eventually discarded. Hoch stated:

      The dynamic manifestations, the orality, the super-ego structure, etc., are the same in both, and usually the differentiation is made arbitrarily. If the patient has had some previous depressive attacks, he would probably be placed in the psychotic group; if not, he would be placed in the neurotic one. If the patient’s depression is developed as a reaction to an outside precipitating factor, then he is often judged as having a neurotic depression. If such factors are not demonstrated, he is classified then as an endogenous depression. Actually there is no difference between a so-called psychotic or a so-called neurotic depression. The difference is only a matter of degree.

      Hoch’s statement epitomized the point of view of the gradualists as opposed to the concept of the separatists, who made a dichotomy between neurotic and psychotic depression. The historical precedent for the gradualist concept is found in Kraepelin’s statement:²

      We include in the manic-depressive group certain slight and slightest colorings of mood, some of them periodic, some of them continuously morbid, which on the one hand are to be regarded as the rudiment of more severe disorders; on the other hand, passing over without sharp boundary into the domain of personal predisposition.

      Paskind³ also believed that the psychotic depressions were simply severe forms of the manic-depressive (bipolar) syndrome. They differ from the milder forms in terms of the dramatic symptoms, but not in terms of any fundamental factors. He stated (p. 789): “The situation is somewhat similar, for example, to what descriptions of diabetes would be if only hospital cases were described. Almost every case of diabetes would then show acidosis, coma, gangrene, and massive infection.”

      Separating depression into two distinct disorders would, according to Paskind, be analogous to separating diabetes into two distinct entities on the basis of severity.

      Unlike the current system,⁴ the preponderant opinion in the earlier literature favored the separation of the neurotic and psychotic depressions. Some support for the two-disease concept was provided by the studies of Kiloh and Garside⁵ and Carney, Roth, and Garside.⁶ These authors demonstrated, through the use of factor analysis, a bipolar factor, the poles corresponding to neurotic depression and endogenous depression respectively (see Chapter 4). Sandifer et al.⁷ obtained a bimodal distribution of scores on their rating scale, which they interpreted as representing two types of depression. The bimodal distribution, however, may have depended on the type of instrument employed. Schwab et al.,⁸ for instance, found a bimodal distribution of scores on the Hamilton Rating Scale but not on the Beck Depression Inventory.

“Psychoneurotic” Depressive Reaction

Definition

      In the original American Psychiatric Association diagnostic manual,⁹ this syndrome was characterized as follows:

      The reaction is precipitated by a current situation, frequently by some loss sustained by the patient, and is often associated with a feeling of guilt for past failures or deeds. . . . The term is synonymous with “reactive depression” and is to be differentiated from the corresponding psychotic reaction. In this differentiation, points to be considered are (1) life history of patient, with special reference to mood swings (suggestive of psychotic reaction), to the personality structure (neurotic or cyclothymic), and to precipitating environmental factors, and (2) absence of malignant symptoms (hypochrondriacal preoccupation, agitation, delusions, particularly somatic, hallucinations, severe guilt feelings, intractable insomnia, suicidal ruminations, severe psychomotor retardation, profound retardation of thought, stupor).

      In addition to this statement regarding the manifest characteristics of this condition, the following psychodynamic formulation was included in the manual: “The anxiety in this reaction is allayed, and hence partially relieved, by depression and self-depreciation. . . . The degree of the reaction in such cases is dependent upon the intensity of the patient’s ambivalent feeling towards his loss (love, possession) as well as upon the realistic circumstances of the loss.”

      Although not specified in the manual, the defining characteristics of psychoneurotic depressive reaction may be assumed to be the generally accepted features of depression. The more malignant symptoms indicative of a psychotic depression are mentioned above. It is noteworthy that the authors considered the presence of suicidal ruminations to exclude a diagnosis of neurotic depression. This notion is contradicted by the finding that this symptom was found in 58 percent of patients diagnosed as neurotic depressive reaction (Table 5-1). A patient with a low mood such as dejection, low self-esteem, indecisiveness, and, possibly, some of the physical and vegetative symptoms mentioned in Chapter 2, would have been considered to have a neurotic-depressive reaction.

      In addition to the brief description of the manifest symptoms, the glossary also introduced two etiological concepts. The first, that the depression is precipitated by a current situation, is a derivative of the concept of reactive depression, the development of which will be discussed. The second etiological concept is that the depression is a defense against anxiety (pp. 12, 32), and that the ambivalent feelings toward the presumed lost object determine the intensity of the reaction.

      This specific psychodynamic formulation represented an attempt by the authors of the manual to provide a psychological explanation for this condition. It is not clear whether the psychodynamic formulation was intended to be a defining characteristic of the category. In retrospect, the attempt should have been regarded as experimental, and the validity of the category not dependent upon the validity of the psychodynamic formulation or on whether it is possible to discern this particular configuration in a given case. Reports of investigators trying to apply the psychodynamic formulation questioned its usefulness in making the diagnosis.^10,11 The concept that neurotic depressive reaction is reactive seems to be more integral to the definition of this syndrome and some may have considered that if some external stress could not be demonstrated in a particular case, then the use of this diagnosis was not justified in that case.

      Despite the inclusion of this category in many nomenclatures, it was by no means generally accepted. In fact, a large number of writers on depression continued to accept the gradualist or unitary concept, namely, that the difference between “neurotic” and “psychotic” depression was one of degree, and that there was no more justification for constructing separate categories than for dividing scarlet fever into two groups such as mild and severe. Proponents of this point of view included the authors who wrote most extensively about depression, such as Mapother¹² and Lewis¹³ in England, and Ascher,¹⁰ Cassidy et al.,¹⁴ Campbell,¹⁵ Kraines,¹⁶ Robins et al.,¹⁷ and Winokur and Pitts¹⁸ in the United States.

Evolution of the Concept

      There were a number of radical twists and turns in the gradual evolution and eventual displacement of the concept. In the earlier classifications, the reactive-depressive category was not fused with neurotic depression. Kraepelin recognized a condition similar to the notion of neurotic depression and allocated it to the category of congenital neurasthenia, which he listed under constitutional psychopathic states. He also referred to a group of “psychogenic depressions,” which he considered different from manic-depressive СКАЧАТЬ