Depression. Aaron T. Beck, M.D.

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      Bleuler¹⁹ evidently allocated the milder depressions to the manic-depressive category, as indicated by his statement that “probably everything designated as periodic neurasthenia, recurrent dyspepsia, and neurasthenic melancholias belong entirely to manic-depressive insanity.” He also conceded the existence of psychogenic depressions: “Simple psychogenic depressions, occurring in psychopaths not of the manic-depressive group and reaching the intensity of a mental disease, are rare.”

      The most definite precursor of the concept of neurotic-depressive reaction was that of reactive depression. In 1926, Lange listed psychogenic and reactive depression separately in his classification of depression. He differentiated psychogenic depressions from the endogenous variety on the basis of greater aggressiveness, egocentricity, stubbornness, and overt hostility. In addition, he stated that there were no discernible variations in mood in the psychogenic depressions. Changes in the milieu influenced this condition, and it became better when the personality conflict was solved. Wexberg²⁰ described seven different groups of “mild depressive states.” He included a “reactive group,” but made no distinction between neurotic and psychotic in his classification.

      Paskind²¹ described 663 cases of mild manic-depressive disorder seen in outpatient practice. Harrowes²² defined six groups of depression which included separate categories for the reactive and psychoneurotic types. Patients classified as psychoneurotic depressives showed “psychopathy, neuropathy, anxiety attacks, feelings of failure in life, sex trauma, unreality feelings and a greater subjectively than objectively depressed mood.” This condition occurred in the third decade of life and, while mild, tended toward chronicity.

      Aubrey Lewis,¹³ in his classic paper on depression, stated that a careful analysis of 61 cases indicated that the neurotic symptoms appeared with equal frequency among the reactive and the endogenous forms of depression. He stressed that no sharp line could be drawn between psychotic and neurotic depressions.

      It is apparent that despite the objections of authorities such as Lewis, there was a dominant tendency among nosographers to separate reactive and neurotic depressions from other types of depressions. The concepts of reactive and neurotic depressions gradually converged. The fusion of these categories occurred officially in 1934. At that time, the American Psychiatric Association approved a new classification in which reactive depression was subsumed under the psychoneuroses. This concept did not attain wide currency in the decade that followed, however, as indicated by the failure of most American textbooks and reference books on psychiatry to include a category of depression among the psychoneuroses.

      The category reactive depression was defined in Cheney’s Outlines for Psychiatric Examinations²³ as follows:

      Here are to be classified those cases which show depression in reaction to obvious external causes which might naturally produce sadness, such as bereavement, sickness, and financial and other worries. The reaction of a more marked degree and of longer duration than normal sadness, may be looked upon as pathological. The deep depressions with motor and mental retardation are not present, but these reactions may be more closely related in fact to the manic-depressive reactions than to the psychoneuroses. (emphasis added)

      At this stage in its development, the concept of neurotic depression was still closely allied to the all-embracing category of manic-depressive disorder.

      The next step in the evolution of the current concept was a major thrust in the direction of the current etiological concept. In the United States War Department classification, adopted in 1945, the term neurotic depressive reaction was used. The term reaction represented a clearcut deviation from the Kraepelinian notion of a defined disease entity, and it incorporated Adolph Meyer’s psychobiological concept of an interaction of a particular type of personality with the environment. Since the presence of a specific external stress was more salient in an army at war than in civilian practice, the emphasis on reaction to stress seemed to gain increased plausibility.

      The other significant departure in the definition in the army nomenclature was the introduction of two psychoanalytic hypotheses: that depression represents an attempt to allay anxiety through the mechanism of introjection, and that depression is related to repressed aggression. It states:

      The anxiety in this reaction is allayed, and, hence, partially relieved by self-depreciation through the mental mechanism of introjection. It is often associated with guilt for past failure or deeds. . . . This reaction is a nonpsychotic response precipitated by a current situation—frequently some loss sustained by the patient—although dynamically the depression is usually related to a repressed (unconscious) aggression.

      The War Department classification received an extensive trial in the armed forces and was subsequently adopted in a slightly revised form by the Veterans Administration. The opinion of psychiatrists using the nomenclature, both in the army and at Veterans Administration clinics and hospitals, was evidently favorable, because this classification was subsequently used as the basis for the 1952 diagnostic manual of the American Psychiatric Association. The new categories of neurotic-depressive reaction and psychotic-depressive reaction had then become firmly established.

Severe Depression with Psychotic Features (Psychotic Depressive Reaction)

      The term psychotic depressive reaction does not appear in any of the official American or European classifications prior to the end of World War II, but in 1951 the standard Veterans Administration classification included this term. In 1952, it was included in the official classification of the American Psychiatric Association. In the glossary accompanying this nomenclature, psychotic depressive reaction was characterized as including patients who were severely depressed and who gave evidence of gross misinterpretation of reality, including at times delusions and hallucinations.

      The nomenclature distinguished this reaction from the manic-depressive reaction, depressed type, on the basis of the following features: absence of a history of repeated depressions or of marked psychothymic mood swings and presence of environmental precipitating factors. This category evidently was considered to be the analogue of the neurotic-depressive reaction and an updating of the reactive psychotic depressions described in the German literature in the 1920s.

      Several features relevant to this diagnostic category troubled some authorities in the field, many of whom did not accept the distinction between neurotic-depressive reaction and psychotic-depressive reaction. As they saw it, the first depressive episode of a typical manic-depressive disorder might very well appear in reaction to some environmental stress.² On the basis of symptomatology, there were no criteria to distinguish the psychotic-depressive reaction from the depressed phase of the manic-depressive reaction.

      The characteristics of psychotic-depressive reaction are illustrated in the following cases from Beck and Valin,²⁴ selected from a group of soldiers who experienced psychotic-depressive reaction after accidentally killing their buddies during the Korean War. The cases had the following common features relevant to the concept of psychotic-depressive reaction: (1) The psychosis followed a specific event that was highly disturbing to the patient; (2) there were clear-cut psychotic symptoms such as delusions and hallucinations; (3) the content of the patients’ preoccupations, delusions, and hallucinations revolved around the dead buddy; (4) the typical symptoms of depression were present—depressed mood, hopelessness, suicidal wishes, and self-recriminations; (5) the patients recovered completely after a course of ECT or psychotherapy; and (6) there was no previous history of depression or mood swings.

Case 1

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