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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 psychosis. Patients with psychogenic depressions showed a high degree of reactivity to external situations and their depression tended to improve when the external situation improved. The manic-depressive attack, in contrast, was not then understood to result in part from external stress situations.

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