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Chapter 2

Symptomatology of Depression

Previous Systematic Studies

As stated in Chapter 1, there has been remarkable consistency in the descriptions of depression since ancient times. While there has been unanimity among the writers on many of the characteristics, however, there has been lack of agreement on many others. The core signs and symptoms such as low mood, pessimism, self-criticism, and retardation or agitation seem to have been universally accepted. Other signs and symptoms that have been regarded as intrinsic to the depressive syndrome include autonomic symptoms, constipation, difficulty in concentrating, slow thinking, and anxiety. In 1953, Campbell¹ listed 29 medical manifestations of autonomic disturbance, among which the most common in manic depressives were hot flashes, tachycardia, dyspnea, weakness, head pains, coldness and numbness of the extremities, frontal headaches, and dizziness.

Very few systematic studies have been designed to delineate the characteristic signs and symptoms of depression. Cassidy et al.² compared the symptomatology of 100 patients diagnosed as manic depressive with a control group of 50 patients with diagnoses of recognized medical diseases. The frequency of the specific symptoms was determined by having the patient complete a questionnaire of 199 items. Among the symptoms that were endorsed significantly more often by those in the psychiatric group were anorexia, sleep disturbance, low mood, suicidal thoughts, crying, irritability, fear of losing the mind, poor concentration, and delusions.

It is interesting to note that Cassidy and his coworkers found that only 25 percent of the manic-depressive group thought that they would get well as compared with 61 percent of those who were medically ill. This is indicative of the pessimism characteristic of manic depressives: almost all could be expected to recover completely from their illness, in contrast to the number of incurably ill among the medical patients. Certain symptoms sometimes attributed to manic depressives, such as constipation, were found in similar proportions in the two groups.

Campbell reported a high frequency of medical symptoms, generally attributed to autonomic imbalance, among manic depressives. Cassidy’s study, however, found that most of these medical symptoms occurred at least as frequently among the medically ill patients as among the manic-depressive patients. Moreover, many of these symptoms were found in a group of healthy control patients. Headaches, for instance, were reported by 49 percent of the manic-depressive patients, 36 percent of the medically sick controls, and 25 percent of the healthy controls. When the symptoms of manic depressives, anxiety neurotics, and hysteria patients were compared, it was found that autonomic symptoms occurred at least as frequently in the latter two groups as they did in the manic-depressive group. Palpitation, for instance, was reported by 56 percent of the manic depressives, 94 percent of the anxiety neurotics, and 76 percent of the hysterics. It therefore seems clear that autonomic symptoms are not specifically characteristic of manic-depressive disorders.

In the early 1960s, two systematic investigations of the symptomatology of depressive disorders were conducted to delineate the typical clinical picture, as well as to suggest typical subgroupings of depression.^3,4 But because the case material consisted primarily of depressed patients and did not include a control group of nondepressed psychiatric patients for comparison, it was not possible to determine which symptom clusters might be characteristic of depression or its various subgroupings and which might occur in any psychiatric patient or even in normals.

The following material is reprinted in its entirety from the first edition, with some minor updating of the language. The chapter ends with a brief section on variations in symptoms by age and culture as they are understood in the twenty-first century.

Following a review of the chief complaints, the symptoms of depression are described under four major headings: emotional, cognitive, motivational, and physical and vegetative. This is followed by a section on delusions and hallucinations. Some of these divisions may appear arbitrary, and it is undoubtedly true that some of the symptoms described separately may simply be different facets of the same phenomenon. Nonetheless, I think it is desirable at this stage to present the symptomatology as broadly as possible, despite the inevitable overlap. A section on behavioral observation follows the categorization of symptoms. The descriptions in this latter section were obtained by direct observation of the patients’ nonverbal as well as their verbal behavior.

Chief Complaint

The chief complaint presented by depressed patients often points immediately to the diagnosis of depression; although it sometimes suggests a physical disturbance. Skillful questioning can generally determine whether the basic depressive symptomatology is present.

The chief complaint may take a variety of forms: (1) an unpleasant emotional state; (2) a changed attitude toward life; (3) somatic symptoms of a specifically depressive nature; or (4) somatic symptoms not typical of depression.

Among the most common subjective complaints⁵ are “I feel miserable.” “I just feel hopeless.” “I’m desperate.” “I’m worried about everything.” Although depression is generally considered an affective disorder, it should be emphasized that a subjective change in mood is not reported by all depressed patients. As in many other disorders, the absence of a significant clinical feature does not rule out the diagnosis of that disorder. In our series, for instance, only 53 percent of the mildly depressed patients acknowledged feeling sad or unhappy.

Sometimes the chief complaint is in the form of a change of one’s actions, reactions, or attitudes toward life. For example, a patient may say, “I don’t have any goals any more.” “I don’t care anymore what happens to me.” “I don’t see any point to living.” Sometimes the major complaint is a sense of futility about life.

Often the chief complaint of the depressed patient centers around some physical symptom that is characteristic of depression. The patient may complain of fatigue, lack of pep, or loss of appetite. Sometimes patients complain of some alteration in appearance or bodily functions, or that they are beginning to look old or are getting ugly. Others complain of some dramatic physical symptom such as, “My bowels are blocked up.”

Depressed patients attending medical clinics or consulting either internists or general practitioners frequently present some symptom suggestive of a physical disease.⁶ In many cases, the physical examination fails to reveal any physical abnormality. In other cases, some minor abnormality may be found but it is of insufficient severity to account for the magnitude of the patient’s discomfort. On further examination, the patient may acknowledge a change in mood but is likely to attribute this to the somatic symptoms.

Severe localized or generalized pain may often be the chief focus of a patient’s complaint. Bradley⁷ reported 35 cases of depression in which the main complaint was severe localized pain. In each case, feelings of depression were either spontaneously reported by the patient or elicited on interview. In the cases in which the pain was integrally connected with the depression, the pain cleared up as the depression cleared up. Kennedy⁸ and Von Hagen⁹ reported that pain associated with depression responded to electroconvulsive therapy (ECT).

Cassidy et al.² analyzed the chief complaints of the manic-depressive patients. These complaints were divided into several categories which included (1) psychological; (2) localized medical; (3) generalized medical; (4) mixed medical and psychological; (5) medical, general and local; and (6) no clear information. Some of the typical complaints in each category are listed below:

TABLE 2-1. Chief Complaints of 100 Patients with Manic-Depressive Diagnosis and 50 Patients with Medical Diagnosis (%)

Adapted from Cassidy et al. 1957.

(1) Psychological (58 percent): “depressed”; “I have nothing to look forward to”; “afraid to be alone”; “no interest”; “can’t remember anything”; “get discouraged and hurt”; “black moods and blind rages”; “I’m doing such stupid things”; “I’m all mixed up”; “very unhappy at times”; “brooded around the house.”

(2) Localized medical (18 percent): “head is heavy”; “pressure in my throat”; “headaches”; “urinating frequently”; “pain in head like a balloon that burst”; “upset stomach.”

(3) Generalized medical (11 percent): “tired”; “I’m exhausted”; “I feel all in”; “tire easy”; “jumpy most at night”; “I can’t do my work, I don’t feel strong”; “I tremble like a leaf.”

(4) Medical and psychological (2 percent): “I get scared to death and can’t breath”; “stiff neck and crying spells.”

(5) Medical, general and local (2 percent): “breathing difficulty . . . pain all over”; “I have no power. My arms are weak”; “I can’t work.”

(6) No information (9 percent).

The authors tabulated the percentages of the various symptom types that were named by manic-depressive patients and by medically sick controls (Table 2-1). It is worthy of note that a medical symptom, either localized or generalized, was reported by 33 percent of the manic-depressive patients and 92 percent of the medically sick controls.

Symptoms

The decision as to which symptoms should be included here was made as a result of several steps. First, several textbooks of psychiatry and monographs on depression were studied to determine what symptoms have been attributed to depression by general consensus. Second, in an intensive study of 50 depressed patients and 30 nondepressed patients in psychotherapy, I attempted to tally which symptoms occurred significantly more often in the depressed than in the nondepressed group. On the basis of this tabulation, an inventory consisting of items relevant to depression was constructed and pretested on approximately 100 patients. Finally, this inventory was revised and presented to 966 psychiatric patients. Distributions of the symptoms reported in response to the inventory are presented in Tables 2-3–2-7.

One of the symptoms, namely irritability, did not occur significantly more frequently in the depressed than in the nondepressed patients. It, therefore, has been dropped from the list. Incidentally, Cassidy and his coworkers² found that this symptom was more frequent in the anxiety neurotic group than in the manic-depressive group.

Some of the symptoms often attributed to the manic-depressive syndrome are not included in the symptom descriptions in this chapter. For instance, fear of death was not included because it was not found to be any more common among the depressed patients than among the nondepressed in the preliminary clinical study. Cassidy, Flanagan, and Spellman² found, in fact, that fear of death occurred in 42 percent of patients with anxiety neurosis and only 35 percent of the manic depressives. Similarly, constipation occurred in 60 percent of the manic-depressive patients and 54 percent of the patients with hysteria. Consequently, this particular symptom does not seem to be specific to depression.

Conventional nosological categories were not used in our analyses of the symptomatology. Instead of being classified according to their primary diagnoses, such as manic-depressive reaction, schizophrenia, anxiety reaction, and so on, the patients were categorized according to the depth of depression they exhibited, independently of their primary diagnoses. There were two major reasons for this. First, in our own studies as well as in previous studies, it was found that the degree of interjudge reliability was relatively low in diagnoses made according to the standard nomenclature. Consequently, any findings based on diagnoses of such low reliability would be of relatively dubious value. The interpsychiatrist ratings of the depth of depression, by contrast, showed a relatively high correlation (.87). Second, we found that the cluster of symptoms generally regarded as constituting the depressive syndrome occurs not only in disorders such as neurotic-depressive reaction and manic-depressive reaction but also in patients whose primary diagnosis is anxiety reaction, schizophrenia, obsessional neurosis, and so on. In fact, we have found that a patient with the primary diagnosis of one of the typical depressive categories may be less depressed than a patient whose primary diagnosis is, for example, schizophrenia or obsessional neurosis. The sample, therefore, was divided into four groups according to the depth of depression: none, mild, moderate, and severe.

In addition to making the usual qualitative distinctions among the symptoms, I have attempted to provide a guide for assessing their severity. The symptoms are discussed in terms of how they are likely to appear in the mild, moderate, and severe states (or phases) of depression. This may serve as an aid to the clinician or investigator in making a quantitative estimate of the severity of depression. The tables may be used as a guide in diagnosing depression, since they show the relative frequency of the symptoms in patients who were considered to be either nondepressed, mildly depressed, moderately depressed, or severely depressed. The method for collecting the data on which the tables are based is described in greater detail in Chapter 10. The patient sample is described in Table 2-2.

TABLE 2-2. Distribution of Patients According to Race, Sex, and Depth of Depression

TABLE 2-3. Frequency of Emotional Manifestations Among Depressed and Nondepressed Patients (%)

Emotional Manifestations

The term emotional manifestations refers to the changes in the patient’s feelings or overt behavior directly attributable to his or her feeling states (Table 2-3). In assessing emotional manifestations, it is important to take into account the individual’s premorbid mood level and behavior, as well as what the examiner might consider the normal range in the patient’s particular age, sex, and social group. The occurrence of frequent crying spells in a patient who rarely or never cried before becoming depressed might indicate a greater level of depression than it would in a patient who habitually cried whether depressed or not.

Dejected Mood

The characteristic depression in mood is described differently by various clinically depressed patients. Whatever term the patient uses to describe her or his subjective feelings should be further explored by the examiner. If the patient uses the word “depressed,” for instance, the examiner should not take the word at its face value but should try to determine its connotation for the patient. Persons who are in no way clinically depressed may use this adjective to designate transient feelings of loneliness, boredom, or discouragement.

Sometimes the feeling is expressed predominantly in somatic terms, such as “a lump in my throat,” or “I have an empty feeling in my stomach,” or “I have a sad, heavy feeling in my chest.” On further investigation, these feelings generally are found to be similar to the feelings expressed by other patients in terms of adjectives such as sad, unhappy, lonely, or bored.

The intensity of the mood deviation must be gauged by the examiner. Some of the rough criteria of the degree of depression are the relative degree or morbidity implied by the adjective chosen, the qualification by adverbs such as “slightly” or “very,” and the degree of tolerance the patient expresses for the feeling (e.g., “I feel so miserable I can’t stand it another minute”).

Among the adjectives used by depressed patients in answer to the question “How do you feel?” are the following: miserable, hopeless, blue, sad, lonely, unhappy, downhearted, humiliated, ashamed, worried, useless, guilty. Eighty-eight percent of the severely depressed patients reported some degree of sadness or unhappiness, as compared with 23 percent of the nondepressed patients.

Mild: The patient indicates feeling blue or sad. The unpleasant feeling tends to fluctuate considerably during the day and at times may be absent, and the patient may even feel cheerful. Also the dysphoric feeling can be relieved partially or completely by outside stimuli, such as a compliment, a joke, or a favorable event. With a little effort or ingenuity the examiner can usually evoke a positive response. Patients at this level generally react with genuine amusement to jokes or humorous anecdotes.

Moderate: The dysphoria tends to be more pronounced and more persistent. The patient’s feeling is less likely to be influenced by other people’s attempts to cheer him or her up, and any relief of this nature is temporary. Also, a diurnal variation is frequently present: The dysphoria is often worse in the morning and tends to be alleviated as the day progresses.

Severe: In cases of severe depression, patients are apt to state that they feel “hopeless” or “miserable.” Agitated patients frequently state that they are “worried.” In our series, 70 percent of the severely depressed patients indicated that they were sad all the time and “could not snap out of it”; that they were so sad that it was very painful, or that they were so sad they could not stand it.

Negative Feelings Toward Self

Depressed patients often express negative feelings about themselves. These feelings may be related to the general dysphoric feelings just described, but they are different in that they are specifically directed toward the self. The patients appear to distinguish feelings of dislike for themselves from negative attitudes about themselves such as “I am worthless.” The frequency of self-dislike ranged from 37 percent in the nondepressed group to 86 percent among the severely depressed.

Mild: Patients state that they feel disappointed in themselves. This feeling is accompanied by ideas such as “I’ve let everybody down . . . If I had tried harder, I could have made the grade.”

Moderate: The feeling of self-dislike is stronger and may progress to a feeling of disgust with oneself. This is generally accompanied by ideas such as “I’m a weakling . . . I don’t do anything right . . . I’m no good.”

Severe: The feeling may progress to the point where patients hate themselves. This stage may be identified by statements such as: “I’m a terrible person . . . I don’t deserve to live . . . I’m despicable . . . I loathe myself.”

Reduction in Gratification

The loss of gratification is such a pervasive process among depressives that many patients regard it as the central feature of their illness. In our series, 92 percent of the severely depressed patients reported at least partial loss of satisfaction. This was the most common symptom among the depressed group as a whole.

Loss of gratification appears to start with a few activities and, as the depression progresses, spreads to practically everything the patient does. Even activities that are generally associated with biological needs or drives, such as eating or sexual experiences, are not spared. Experiences that are primarily psychosocial such as achieving fame, receiving expressions of love or friendship, or even engaging in conversations are similarly stripped of their pleasurable properties.

The emphasis placed by some patients on loss of satisfaction gives the impression that they are especially oriented in their lives toward obtaining gratification. Whether or not this applies to the premorbid state cannot be stated with certainty, but it is true that the feverish pursuit of gratification is a cardinal feature of their manic states.

The initial loss of satisfaction from activities involving responsibility or obligation, such as those involved in the role of worker, stay-at-home spouse, or student, is often compensated for by increasing satisfaction from recreational activities. This observation has prompted Saul¹⁰ and others to suggest that, in depression, the “give-get” balance is upset; the patient, depleted psychologically over a period of time by activities predominantly giving in nature, experiences an accentuation of passive needs, which are gratified by activities involving less of a sense of duty or responsibility (giving) and more of a tangible and easily obtained satisfaction. In the more advanced stages of the illness, however, even passive, regressive activities fail to bring any satisfaction.

Mild: The patient complains that some of the joy has gone out of life. He or she no longer gets a “kick” or pleasure from family, friends, or job. Characteristically, activities involving responsibility, obligation, or effort become less satisfying. Often, patients find greater satisfaction in passive activities involving recreation, relaxation, or rest. They may seek unusual types of activities in order to get some of their former thrill. One patient reported that he could always pull himself out of a mild depression by watching a performance of deviant sexual practices.

Moderate: Patients feel bored much of the time. They may try to enjoy some former favorite activities but these seem “flat” now. Business or professional activities that formerly excited them now fail to move them. They may obtain temporary relief from a change, such as a vacation, but the boredom returns upon resumption of usual activities.

Severe: They experience no enjoyment from activities that were formerly pleasurable, and may even feel an aversion for activities they once enjoyed. Popular acclaim or expressions of love or friendship no longer bring any degree of satisfaction. The patients almost uniformly complain that nothing gives them any degree of satisfaction.

Loss of Emotional Attachments

Loss of emotional involvement in other people or activities usually accompanies loss of satisfaction. This is manifested by a decline in interest in particular activities or in affection or concern for other persons. Loss of affection for family members is often a cause for concern to the patient and occasionally is a major factor in seeking medical attention. Sixty-four percent of the severely depressed patients reported loss of feeling for or interest in other people, whereas only 16 percent of the nondepressed patients reported this symptom.

Mild: In mild cases, there is some decline in the degree of enthusiasm for, or absorption in, an activity. The patient sometimes reports no longer experiencing the same intensity of love or affection for spouse, children, or friends, but at the same time may feel more dependent on them.

Moderate: The loss of interest or of positive feeling may progress to indifference. A number of patients described this as a “wall” between themselves and other people. Sometimes a husband may complain that he no longer loves his wife, or a mother may be concerned that she does not seem to care about her children or what happens to them. A previously devoted employee may report no longer being concerned about his or her job. Both men and women may no longer care about their appearance.

Severe: The loss of attachment to external objects may progress to apathy. The patient may not only lose any positive feeling for family members but may be surprised to find that her or his only reaction is a negative one. In some cases, the patient experiences only a kind of cold hate, which may be masked by dependency. A typical patient’s report is, “I’ve been told I have love and can give love. But now I don’t feel anything toward my family. I don’t give a damn about them. I know this is terrible, but sometimes I hate them.”

Crying Spells

Increased periods of crying are frequent among depressed patients. This is particularly true of the depressed women in our series. Of the severely depressed patients, 83 percent reported that they cried more frequently than they did before becoming depressed, or that they felt like crying even though the tears did not come.

Some patients who rarely cried when not depressed were able to diagnose the onset of depression by observing a strong desire to weep. One woman remarked, “I don’t know whether I feel sad or not but I do feel like crying, so I guess I am depressed.” Further questioning elicited the rest of the cardinal symptoms of depression.

Mild: There is an increased tendency to weep or cry. Stimuli or situations that would ordinarily not affect the patient may now elicit tears. A mother, for example, might burst out crying during an argument with her children or if she feels her husband is not attentive. Although increased crying is frequent among mildly depressed women, it is unusual for a mildly depressed man to cry.⁵

Moderate: The patient may cry during the psychiatric interview, and references to his or her problems may elicit tears. Men who have not cried since childhood may cry while discussing their problems. Women may cry for no apparent reason: “It just comes over me like a wave and I can’t help crying.” Sometimes patients feel relieved after crying but more often they feel more depressed.

Severe: By the time they have reached the severe stage, patients who were easily moved to tears in the earlier phase may find that they no longer can cry even when they want to. They may weep but have no tears (“dry depression”); 29 percent reported that although they had previously been capable of crying when feeling sad, they no longer could cry—even though they wanted to do so.

Loss of Mirth Response

Depressed patients frequently volunteer the information that they have lost their sense of humor. The problem does not seem to be loss of the ability to perceive the point of the joke or even, when instructed, to construct a joke. The difficulty rather seems to be that patients do not respond to humor in the usual way. They are not amused, do not feel like laughing, and do not get any feeling of satisfaction from a jesting remark, joke, or cartoon.

In our series, 52 percent of the severely depressed patients indicated that they had lost their sense of humor, as contrasted with 8 percent of the nondepressed patients.

Nussbaum and Michaux¹¹ studied the response to humor (in the form of riddles and jokes) in 18 women patients with severe neurotic and psychotic depressions. They found that improvements in response to humorous stimuli correlated well with clinical ratings of improvement of the depression.

Mild: Patients who frequently enjoy listening to jokes and telling jokes find that this is no longer such a ready source of gratification. They remark that jokes no longer seem funny to them. Furthermore, they do not handle kidding or joshing by their friends as well as previously.

Moderate: Patients may see the point of a joke and can even force a smile, but are usually not amused. They cannot see the light side of events and tend to take everything seriously.

Severe: Patients do not respond at all to humorous sallies by other people. Where others may respond to the humorous element in a joke, they are more likely to respond to the aggressive or hostile content and feel hurt or disgusted.

Cognitive Manifestations

The cognitive manifestations of depression include a number of diverse phenomena (Table 2-4). One group is composed of the patient’s distorted attitudes toward self, personal experience, and the future. This group includes low self-evaluations, distortions of the body image, and negative expectations. Another symptom, self-blame, expresses patients’ notion of causality: they are prone to hold themselves responsible for any difficulties or problems they encounter. A third kind of symptom involves the area of decision-making: The patient typically vacillates and is indecisive.

Low Self-Evaluation

Low self-esteem is a characteristic feature of depression. Self-devaluation is apparently part of depressed patients’ pattern of viewing themselves as deficient in those attributes that are specifically important to them: ability, performance, intelligence, health, strength, personal attractiveness, popularity, or financial resources. Often the sense of deficiency is expressed in terms such as “I am inferior” or “I am inadequate.” This symptom was reported by 81 percent of the severely depressed patients and by 38 percent of the nondepressed patients.

TABLE 2-4. Frequency of Cognitive and Motivational Manifestations Among Depressed and Nondepressed Patients (%)

The sense of deficiency may also be reflected in complaints of deprivation of love or material possessions. This reaction is most apparent in patients who have had, respectively, an unhappy love affair or a financial reversal just prior to the depression.

Mild: Patients show an excessive reaction to their errors or difficulties and are prone to regard them as a reflection of inadequacy or a defect. They compare themselves with others and, more often than not, conclude they are inferior. It is possible, however, to correct these inaccurate self-evaluations, at least temporarily, by confronting patients with appropriate evidence or by reasoning with them.

Moderate: Most of the patients’ thought content revolves about the sense of deficiency, and they are prone to interpret neutral situations as indicative of this deficiency. They exaggerate the degree and significance of any errors. When they look at their present and past life, they see their failures as outstanding and their successes as faint by comparison. They complain that they have lost confidence in themselves, and their sense of inadequacy is such that when confronted with tasks they have easily handled in the past, their initial reaction is: “I can’t do it.”

Religious or moralistic patients tend to dwell on their sins or moral shortcomings. Patients who placed a premium on personal attractiveness, intelligence, or business success tend to believe they have slipped in these areas. Attempts to modify distorted self-evaluations by reassuring the patients or by presenting contradictory evidence generally meet with considerable resistance; any increase in realistic thinking about themselves is transient.

Severe: Patients’ self-evaluations are at the lowest point. They drastically downgrade themselves in terms of personal attributes and their role as parent, spouse, employer, and so on. They regard themselves as worthless, completely inept, and total failures. They claim they are a burden to family members, who would be better off without them. The severely depressed patient may be preoccupied with ideas of being the world’s worst sinner, completely impoverished, or totally inadequate. Attempts to correct the erroneous ideas are generally fruitless.

Negative Expectations

A gloomy outlook and pessimism are closely related to the feelings of hopelessness mentioned previously. More than 78 percent of the depressed patients reported a negative outlook, as compared with 22 percent of the nondepressed group. This symptom showed the highest correlation with the clinical rating of depression.

Depressed patients’ pattern of expecting the worst and rejecting the possibility of any improvement poses formidable obstacles in attempts to engage them in a therapeutic program. Their negative outlook is often a source of frustration to friends, family, and physician when they try to be of help. Not infrequently, for example, patients may discard their antidepressant pills because they believe a priori that they “cannot do any good.”

Unlike anxious patients, who temper negative anticipations with the realization that the unpleasant events may be avoided or will pass in time, depressed patients thinks in terms of a future in which the present deficient condition (financial, social, physical) will continue or even get worse. This sense of permanence and irreversibility of one’s status or problems seems to form the basis for consideration of suicide as a logical course of action. The relationship of hopelessness to suicide is indicated by the finding that, of all the symptoms that were correlated with suicide, the correlation coefficient of hopelessness:suicide was the highest.

Mild: Patients tend to expect a negative outcome in ambiguous or equivocal situations. When associates and friends feel justified in anticipating favorable results, their expectations lean toward the negative or pessimistic. Whether the subject of concern is health, personal problems, or economic problems, they doubt whether any improvement will take place.

Moderate: They regard the future as unpromising and state they have nothing to which to look forward. It is difficult to get them to do anything because their initial response is “I won’t like it” or “it won’t do any good.”

Severe: They view the future as black and hopeless. They state they will never get over their troubles and that things cannot get better. They believe none of their problems can be solved. They make statements such as “This is the end of the road. From now on I will look older and uglier”; “There is nothing here for me any more. I have no place. There is no future”; “I know I can’t get better . . . it’s all over for me.”

Self-Blame and Self-Criticism

Depressives’ perseverating self-blame and self-criticism appear to be related to their egocentric notions of causality and penchant for criticizing themselves for their alleged deficiencies. They are particularly prone to ascribe adverse occurrences to some deficiency in themselves and then rebuke themselves for this alleged defect. In the more severe cases, patients may blame themselves for happenings that are in no way connected with them and abuse themselves in a savage manner. Eighty percent of the severely depressed patients reported this symptom.

Mild: In mild cases, patients are prone to blame and criticize themselves when they fall short of their rigid, perfectionist standards. If people seem less responsive to them, or they are slow at solving a problem, they are likely to berate themselves for being dull or stupid. They seem to be intolerant of any shortcomings in themselves and cannot accept the idea that it is human to err.

Moderate: Patients are likely to criticize themselves harshly for any aspects of personality or behavior they judge to be substandard. They are likely to blame themselves for mishaps that are obviously not their fault. Their self-criticisms become more extreme.

Severe: In the severe state, patients are even more extreme in self-blame or self-criticism. They make statements such as “I’m responsible for the violence and suffering in the world. There’s no way in which I can be punished enough for my sins. I wish you would take me out and hang me.” They view themselves as social lepers or criminals and interpret various extraneous stimuli as signs of public disapproval.

Indecisiveness

Difficulty in making decisions, vacillating between alternatives, and changing decisions are depressive characteristics that are usually quite vexing to the patient’s family and friends as well as to the patient. The frequency of indecisiveness ranged from 48 percent in the mildly depressed patients to 76 percent in the severely depressed group.

There appear to be at least two facets to this indecisiveness. The first is primarily in the cognitive sphere. Depressed patients anticipate making the wrong decision: whenever they consider one of various possibilities they tend to regard it as wrong and think they will regret making that choice. The second facet is primarily motivational and is related to “paralysis of the will,” avoidance tendencies, and increased dependency. Patients have a lack of motivation to go through the mental operations required to arrive at a conclusion. Also, the idea of making a decision represents a burden; they desire to evade or at least to get help with any situation they perceive will be burdensome. Furthermore, they realize that making a decision often commits them to a course of action and, since they desire to avoid action, they are prone to procrastinate.

Routine decisions that must be made in carrying out their occupational or household roles become major problems for the depressed patients. A professor cannot decide what material to include in a lecture; a householder cannot decide what to cook for an evening meal; a student cannot decide whether to spend the spring recess studying at college or go home; an executive cannot decide whether to hire a new assistant.

Mild: Patients who can ordinarily make rapid-fire decisions find that solutions do not seem to occur so readily. Whereas in their normal state they reach a decision “without even thinking about it,” they now find themselves impelled to mull over the problem, review the possible consequences of the decision, and consider a variety of often irrelevant alternatives. The fear of making the wrong decision is reflected in a general sense of uncertainty. Frequently, they seek confirmation from another person.

Moderate: Difficulty in making decisions spreads to almost every activity and involves such minor problems as what clothes to wear, what route to take to the office, and whether to have a haircut. Often it is of little practical importance which alternative is selected, but the vacillation and failure to arrive at some decision can have unfavorable consequences. A woman, for example, spent several weeks trying to choose between two shades of paint for her house. The two shades under consideration were hardly distinguishable, but her failure to reach a decision created a turmoil in the house, the painter having left his buckets of paint and scaffolding until a decision could be made.

Severe: Severely depressed patients generally believe they are incapable of making a decision and consequently do not even try. A woman prodded to make a shopping list or a list of clothes for her children to take to camp insisted she could not decide what to put down. Patients frequently have doubts about everything they do and say. One woman seriously doubted that she had given her correct name to the psychiatrist, or that she had enunciated it properly.

Distortion of Body Image

Patients’ distorted picture of their physical appearance is often quite marked in depression. This occurs somewhat more frequently among women than among men. In our series, 66 percent of the severely depressed patients believed that they had become unattractive, as compared with 12 percent of the nondepressed patients.

Mild: Patients begin to be excessively concerned with physical appearance. A woman finds herself frowning at her reflection whenever she passes a mirror. She examines her face minutely for signs of blemishes and becomes preoccupied with the thought that she looks plain or is getting fat. A man worries incessantly about the beginnings of hair loss, convinced that women find him unattractive.

Moderate: The concern about physical appearance is greater. A man believes that there has been a change in his looks since the onset of the depression even though there is no objective evidence to support this idea. When he sees an ugly person, he thinks, “I look like that.” As he becomes worried about his appearance, his brow becomes furrowed. When he observes his furrowed brow in the mirror, he thinks, “my whole face is wrinkled and the wrinkles will never disappear.” Some patients seek plastic surgery to remedy the fancied or exaggerated facial changes.

Sometimes a woman may believe she has grown fat even though there is no objective evidence to support this. In fact, some patients have this notion even though they are losing weight.

Severe: The idea of personal unattractiveness becomes more fixed. Patients believe they are ugly and repulsive looking. They expect other people to turn away in revulsion: one woman wore a veil and another turned her head whenever anybody approached her.

Motivational Manifestations

Motivational manifestations include consciously experienced strivings, desires, and impulses that are prominent in depressions. These motivational patterns can often be inferred from observing the patient’s behavior; however, direct questioning generally elicits a fairly precise and comprehensive description of motivations (see Table 2-4).

A striking feature of the characteristic motivations of the depressed patient is their regressive nature. The term regressive is applicable in that the patient seems drawn to activities that are the least demanding in the degree of responsibility or initiative or the amount of energy required. They turn away from activities that are specifically associated with the adult role and seek activities more characteristic of the child’s role. When confronted with a choice, they prefer passivity to activity and dependence to independence (autonomy); they avoid responsibility and escape from their problems rather than trying to solve them; they seek immediate but transient gratifications instead of delayed but prolonged satisfactions. The ultimate manifestation of the escapist trend is expressed in the desire to withdraw from life via suicide.

An important aspect of these motivations is that their fulfillment is generally incompatible with the individual’s major premorbid goals and values. In essence, yielding to passive impulses and desires to retreat or commit suicide leads to abandonment of family, friends, and vocation. Similarly, the patient defaults on the chance to obtain personal satisfaction through accomplishment or interpersonal relations. By avoiding even the simplest problems, moreover, the patient finds that they accumulate until they seem overwhelming.

The specific motivational patterns to be described are presented as distinct phenomena, although they are obviously interrelated and may, in fact, represent different facets of the same fundamental pattern. It is possible that certain phenomena are primary and the others are secondary or tertiary; for instance, it could be postulated that paralysis of the will is the result of escapist or passive wishes, a sense of futility, loss of external investments, or the sense of fatigue. Since these suggestions are purely speculative, it seems preferable at present to treat these phenomena separately, rather than prematurely to assign primacy to certain patterns.

Paralysis of the Will

The loss of positive motivation is often a striking feature of depression. Patients may have a major problem in mobilizing themselves to perform even the most elemental and vital tasks such as eating, elimination, or taking medication to relieve their distress. The essence of the problem appears to be that, although they can define for themselves what they should do, they do not experience any internal stimulus to do it. Even when urged, cajoled, or threatened, they do not seem able to arouse any desire to do these things. Loss of positive motivation ranged from 65 percent of the mild cases to 86 percent of the severe cases.

Occasionally an actual or impending shift in a patient’s life situation may serve to mobilize constructive motivations. One notably retarded and apathetic patient was suddenly aroused when her husband became ill and she experienced a strong desire to help him. Another patient experienced a return of positive motivation when informed she was going to be hospitalized, a prospect she viewed as extremely distasteful.

Mild: Patients find they no longer spontaneously desire to do certain specific things, especially those that do not bring any immediate gratification. An advertising executive observes a loss of drive and initiative in planning a special sales promotion; a college professor finds himself devoid of any desire to prepare his lectures; a medical student loses her desire to study. A retiree who formerly felt driven to engage in a variety of domestic and community projects, described her loss of motivation in the following terms: “I have no desire to do anything. I just do things mechanically without any feeling for what I’m doing. I just go through the motions like a robot and when I run down I just stop.”

Moderate: In moderate cases the loss of spontaneous desire spreads to almost all of the patient’s usual activities. A woman complained, “There are certain things I know I have to do like eat, brush my teeth, and go to the bathroom, but I have no desire to do them.” In contrast to severely depressed patients, moderately depressed patients find they can “force” themselves to do things. Also, they are responsive to pressure from other people or to potentially embarrassing situations. A woman, for instance, waited in front of an elevator for about 15 minutes because she could not mobilize any desire to press the button. When others approached the elevator, however, she rapidly pressed the button lest they think she was peculiar.

Severe: In severe cases, there often is complete paralysis of the will. Patients have no desire to do anything, even things that are essential to life. Consequently, they may be relatively immobile unless prodded or pushed into activity by others. It is sometimes necessary to pull patients out of bed, wash, dress, and feed them. In extreme cases, even communication may be blocked by the patient’s inertia. One woman, who was unable to respond to questions during the worst part of her depression, remarked later that even though she “wanted” to answer she could not summon the “will power” to do so.

Avoidance, Escapist, and Withdrawal Wishes

The wish to break out of the usual pattern or routine of life is a common manifestation of depression. The office assistant wants to get away from paper work, the student daydreams of faraway places, and the stay-at-home spouse yearns to leave domestic tasks. Depressed individuals regard their duties as dull, meaningless, or burdensome and want to escape to an activity that offers relaxation or refuge.

These escapist wishes resemble the attitudes described as paralysis of the will. A useful distinction is that the escapist wishes are experienced as definite motivations with specific goals, whereas paralysis of the will refers to the loss or absence of motivation.

Mild: Mildly depressed patients experience a strong inclination to avoid or postpone doing certain things they regard as uninteresting or taxing. They tend to shy away from attending to details they consider unimportant. They are likely to procrastinate or avoid entirely an activity that does not promise immediate gratification or involves effort. Just as they are repelled by activities that involve effort or responsibility, they are attracted to more passive and less complex activities.

A depressed student expressed this as follows: “It’s much easier to daydream in lectures than pay attention. It’s easier to stay home and drink than call a girl for a date. . . . It’s easier to mumble and not be heard than to talk clearly and distinctly. It’s much easier to write sloppily than to make the effort to write legibly. It’s much easier to lead a self-centered, passive life than to make the effort to change it.”

Moderate: In moderate cases, avoidance wishes are stronger and spread to a much wider range of usual activities. A depressed college professor described this as follows: “Escape seems to be my strongest desire. I feel as though I would feel better in almost any other occupation or profession. As I ride the bus to the university, I wish I were the bus driver instead of a teacher.”

Patients think continually of ways of diversion or escape. They would like to indulge in passive recreation such as going to the movies, watching television, or getting drunk. They may daydream of going to a desert island or becoming a hobo. At this stage, they may withdraw from most social contacts since interpersonal relations seem to be too demanding. At the same time, because of their loneliness and increased dependency, they may want to be with other people.

Severe: In severe cases, the wish to avoid or escape is manifested in marked seclusiveness. Not infrequently the patient stays in bed, and when people approach, may hide under the covers. A patient said, “I just feel like getting away from everybody and everything. I don’t want to see anybody or do anything. All I want to do is sleep.” One form of escape that generally occurs to severely depressed patients is suicide. They feel a strong desire to end their life as a way of escaping from a situation they regard as intolerable.

Suicidal Wishes

Suicidal wishes have historically been associated with a depressed state. While suicidal wishes may occur in nondepressed individuals, they occur substantially more frequently in depressed patients. In our series this was the symptom reported least frequently (12 percent) by the nondepressed patients, but it was reported frequently (74 percent) by the severely depressed patients. This difference indicates the diagnostic value of this particular symptom in the identification of severe depression. The intensity with which this symptom was expressed also showed one of the highest correlations with the intensity of depression.

The patient’s interest in suicide may take a variety of forms. It may be experienced as a passive wish (“I wish I were dead”); an activity wish (“I want to kill myself”); as a repetitive, obsessive thought without any volitional quality; as a daydream; or as a meticulously conceived plan. In some patients, the suicidal wishes occur constantly throughout the illness, and the patient may have to battle continually to ward them off. In other cases, the wish is sporadic and is characterized by a gradual build-up, then a slackening of intensity until it disappears temporarily. Patients often report, once the wish has been dissipated, that they are glad they did not succumb to it. It should be noted that the impulsive suicidal attempt may be just as dangerous as the deliberately planned attempt.

The importance of suicidal symptoms is obvious, since nowadays it is practically the only feature of depression that poses a reasonably high probability of fatal consequences. The incidence of suicide among manic depressives ranged from 2.8 percent in one study with a 10-year follow-up¹² to 5 percent in a 25-year period of observation.¹³

Mild: Wishes to die were reported by about 31 percent of the mildly depressed patients. Often these take the passive form such as “I would be better off dead.” Patients may state that they would not do anything to hasten death, but find the idea of dying attractive. One patient looked forward to an airplane trip because of the possibility the plane might crash.

Sometimes the patient expresses an indifference toward living (“I don’t care whether I live or die”). Other patients may show ambivalence (“I would like to die but at the same time I’m afraid of dying”).

Moderate: In these cases, suicidal wishes are more direct, frequent, and compelling; there is a definite risk of either impulsive or premeditated suicidal attempts. The patient may express this desire in the passive form: “I hope I won’t wake up in the morning” or “If I died, my family would be better off.” The active expression of the wish may vary from an ambivalent statement, “I’d like to kill myself but I don’t have the guts,” to the bald assertion, “If I could do it and not botch it up, I would go ahead and kill myself.” The suicidal wish may be manifested by the patient’s taking unnecessary risks. A number of patients drove their cars at excessive rates of speed in the hope that something might happen.

Severe: In severe cases, suicidal wishes tend to be intense, although the patient may be too retarded to complete a suicidal attempt. Among typical statements are the following: “I feel so hopeless. Why won’t you let me die?”; “It’s no use. All is lost. There is only one way out—to kill myself”; “I must weep myself to death. I can’t live and you won’t let me die”; “I can’t bear to live through another day. Please put me out of my misery.”

Increased Dependency

The term dependency is used here to designate the desire to receive help, guidance, or direction rather than the actual process of relying on someone else. The accentuated wishes for dependency have only occasionally been included in clinical descriptions of depression; they have, however, been recognized and assigned a major etiological role in several psychodynamic explanations of depression.^14,15 The accentuated orality attributed to depressed patients by those authors includes the kinds of wishes that are generally regarded as “dependent.”

Since increased dependency has been attributed to other conditions as well as to depression, the question could be raised whether dependency can be justifiably listed as a specific manifestation of depression. Increased dependency wishes are seen in an overt form in people who have an acute or chronic physical illness; moreover, covert or repressed dependency has been regarded by many theoreticians as the central factor in certain psychosomatic conditions such as peptic ulcer, as well as in alcoholism and other addictions. However, it is my contention that frank, undisguised, and intensified desires for help, support, and encouragement are very prominent elements in the advanced stages of depression and belong in any clinical description of this syndrome. In other conditions, intensified dependency may be a variable and transient characteristic.

The desire for help seems to transcend the realistic need for help; that is, the patient can often reach his or her objective without assistance. Receiving help, however, appears to carry special emotional meaning for the patient beyond its practical importance and is often satisfying—at least temporarily.

Mild: The patient who is ordinarily very self-sufficient and independent begins to express a desire to be helped, guided, or supported. A patient who had always insisted on driving when he was in the car with his wife asked her to drive. He felt that he was capable of driving, but the idea of her driving was more appealing to him at this time.

As the dependency wishes become stronger, they tend to supersede habitual independent drives. Patients now find that they prefer to have somebody do things with them than to do them alone. The dependent desire does not seem to be simply a by-product of the feelings of helplessness and inadequacy or fatigue. Patients feel a craving for help even though they recognize that they do not need it, and when the help is received they generally experience some gratification and lessening of depression.

Moderate: The patient’s desire to have things done for him or her, to receive instruction and reassurance, is stronger. The patient who experiences a wish for help in the mild phase now experiences this as a need. Receiving help no longer is an optional luxury but is conceived of as a necessity. A depressed woman, who was legally separated from her husband, begged him to come back to her. “I need you desperately,” she said. It was not clear to her exactly what she needed him for, except that she wanted to have a strong person near her.

When confronted with a task or problem, moderately depressed patients feel impelled to seek help before attempting to undertake it themselves. They not infrequently state that they want to be told what to do. Some patients shop around for opinions about a certain course of action and seem to be more involved in the idea of getting advice than in using it. One woman would ask numerous questions about trivial problems but did not seem to pay much attention to the content of the answer—just so an answer was forthcoming.

Severe: The intensity of the desire to be helped is increased, and the content of the wish has a predominantly passive cast. It is couched almost exclusively in terms of wanting someone to do everything for the patient, including caretaking. Patients are no longer concerned about getting direction or advice, or in sharing problems. They want the other person to do the job and solve the problem for them. A patient clung to the physician and pleaded, “Doctor, you must help me.” Her desire was for the psychiatrist to do everything for her without her doing anything. She even wanted the psychiatrist to adopt her children.

TABLE 2-5. Intercorrelation of Physical and Vegetative Symptoms (n = 606)

*Pearson product-moment correlation coefficients.

TABLE 2-6. Frequency of Vegetative and Physical Manifestations Among Depressed and Nondepressed Patients (%)

The patient may show dependency by not wanting to leave the doctor’s office or not wanting the doctor to leave. Terminating the interview often becomes a difficult and painful process.

Vegetative and Physical Manifestations

The physical and vegetative manifestations are considered by some authors to be evidence for a basic autonomic or hypothalamic disturbance that is responsible for the depressive state.^1,16 These symptoms, contrary to expectation, have a relatively low correlation with each other and with clinical ratings of the depth of depression. The intercorrelation matrix is shown in Table 2-5. The frequency of the symptoms among depressed and nondepressed patients is shown in Table 2-6.

Loss of Appetite

For many patients, loss of appetite is often the first sign of an incipient depression, and return of appetite may be the first sign that it is beginning to lift. Some degree of appetite loss was reported by 72 percent of the severely depressed patients and only 21 percent of the nondepressed patients.

Mild: Patients no longer eat meals with the customary degree of relish or enjoyment. There is also some dulling of desire for food.

Moderate: The desire for food may be mostly gone and patients may miss a meal without realizing it.

Severe: Patient may have to force themselves—or be forced—to eat. There may even be an aversion to food. After several weeks of severe depression, the amount of weight loss may be considerable.

Sleep Disturbance

Difficulty in sleeping is one of most notable symptoms of depression, although it occurs in a large proportion of nondepressed patients as well. Difficulty in sleeping was reported by 87 percent of the severely depressed patients and 40 percent of the nondepressed patients.

There have been a number of careful studies of the sleep of depressed patients (see Chapter 9). The investigators have presented solid evidence, based on direct observation of the patients and EEG recordings during the night, that depressed patients sleep less than do normal controls. In addition, the studies show an excessive degree of restlessness and movement during the night among the depressed patients.

Mild: Patients report waking a few minutes to half an hour earlier than usual. In many cases, they may state that, although ordinarily they sleep soundly until awakened by the alarm clock, they now awaken several minutes before the alarm goes off. In some cases, the sleep disturbance is in the reverse direction: they find that they sleep more than usual.

Moderate: Patients awaken one or two hours earlier than usual and frequently report that sleep is not restful. Moreover, they seem to spend a greater proportion of the time in light sleep. They may also awaken after three or four hours of sleep and require a hypnotic to return to sleep. In some cases, patients manifest an excessive sleeping tendency and may sleep up to twelve hours a day.

Severe: Patients frequently awaken after only four or five hours of sleep and find it impossible to return to sleep. In some cases, they claim that they have not slept at all during the night, that they can remember “thinking” continuously during the night. It is likely, however, as Oswald et al.¹⁷ point out, that the patients are actually in a light sleep for a good part of the time.

Loss of Libido

Some loss of interest in sex, whether of an autoerotic or directed toward someone else nature, was reported by 61 percent of the depressed patients and 27 percent of the nondepressed patients. Loss of libido correlated most highly with loss of appetite, loss of interest in other people, and depressed mood.

Mild: There is generally a slight loss of spontaneous sexual desire and responsiveness to sexual stimuli. In some cases, however, sexual desire seems to be heightened when the patient is mildly depressed.

Moderate: Sexual desire is markedly reduced and is aroused only with considerable stimulation.

Severe: Any responsiveness to sexual stimuli is lost and the patient may have a pronounced aversion to sex.

Fatigability

Increased tiredness was reported by 79 percent of the depressed patients and only 33 percent of the nondepressed. Some patients appear to experience this symptom as a purely physical phenomenon: the limbs feel heavy or the body feels as though it is weighted down. Others express fatigability as a loss of pep or energy. The patient complains of feeling “listless,” “worn out,” “too weak to move,” or “run down.”

It is sometimes difficult to distinguish fatigability from loss of motivation and avoidance wishes. It is interesting to note that fatigability correlates more highly with lack of satisfaction (.36) and with pessimistic outlook (.36) than with other physical or vegetative symptoms such as loss of appetite (.20) and sleep disturbance (.28). The correlation with lack of satisfaction and pessimistic outlook suggests that the mental set may be a major factor in the patient’s feeling of tiredness; the converse, of course, should be considered as a possibility, namely, that tiredness influences the mental set.

Some authors have conceptualized depression as a “depletion syndrome” because of the prominence of fatigability; they postulate that the patient exhausts available energy during the period prior to the onset of the depression, and the depressed state represents a kind of hibernation, during which the patient gradually builds up a new store of energy. Sometimes the fatigue is attributed to the sleep disturbance. Against this theory is the observation that even when the patients do get more sleep as a result of hypnotics, there is rarely any improvement in the feeling of fatigue. It is interesting to note as well that the correlation between sleep disturbance and fatigability is only .28. If the sleep disturbance were a major factor, a substantially higher correlation would be expected. As will be discussed in Chapter 12, fatigability may be a manifestation of loss of positive motivation.

There tends to be a diurnal variation in fatigability parallel to low mood and negative expectations. The patient tends to feel more tired upon awakening but somewhat less tired as the day progresses.

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

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.

Worthlessness

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.”

TABLE 2-7. Frequency of Delusions with Depressive Content Among Psychotic Patients Varying in Depth of Depression (%; n = 280)

Crime and Punishment

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

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.”

Somatic Delusions

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.”

Poverty

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.

Hallucinations

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)

Clinical Examination

Appearance

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 the patients’ self-descriptions. Other features were evaluated on the basis of the patients’ verbal reports as well as on the observation of their behavior. Some of the clinical features overlap those described in the previous section. This particular study provides an opportunity to compare the frequency of symptoms elicited in response to the inventory with the frequency of symptoms derived from a clinical examination.

The sample consisted of the last 486 patients of the 966 patients described in Table 2-2. The distribution of the clinical features among the nondepressed, mildly depressed, moderately depressed, and severely depressed are found in Table 2-8.

Most cases of depression can be diagnosed by inspection.¹⁸ The sad, melancholic expression combined with either retardation or agitation is practically pathognomonic of depression. In contrast, many patients conceal their unpleasant feelings behind a cheerful façade (“smiling depression”), and it may require careful interviewing to bring out a pained facial expression.

The facies show typical characteristics associated with sadness. The corners of the mouth are turned down, the brow is furrowed, the lines and wrinkles are deepened, and the eyes are often red from crying. Among the descriptions used by clinicians are glum, forlorn, gloomy, dejected, unsmiling, solemn, wearily resigned.⁵ Lewis reported that weeping occurred in most of the women but in only one-sixth of the men in his sample.

In severe cases, the facies may appear to be frozen in a gloomy expression. Most patients, however, show some lability of expression, especially when their attention is diverted from their feelings. Genuine smiles may be elicited at times even in the severe cases, but they are generally transient. Some patients present a forced or social smile, which may be deceiving. The so-called mirthless smile, which indicates a lack of any genuine amusement, is easily recognized. This type of smile may be elicited in response to a humorous remark by the examiner and indicates the patient’s intellectual awareness of the humor but without any emotional response to it.

A sad facies was observed in 85 percent of the depressed group (including mild, moderate, and severe cases) and in 18 percent of the nondepressed group. In the severely depressed group, 98 percent showed this characteristic.

Retardation

The most striking sign of a retarded depression is reduction in spontaneous activity. The patient tends to stay in one position longer than usual and to use a minimum of gestures. Movements are slow and deliberate as though the body and limbs are weighted down. He or she walks slowly, frequently hunched over, and with a shuffling gait. These postural characteristics were observed in 87 percent of the severely depressed patients in our sample.

The speech shows decreased spontaneity and the verbal output is reduced. The patient does not initiate a conversation or volunteer statements and, when questioned, responds in a few words. Sometimes, speaking is decreased only when a painful subject is being discussed. The pitch of the patient’s voice is often lowered and speech tends to be in a monotone. These vocal characteristics were observed in 75 percent of the severely depressed patients.

The more retarded patients may start sentences but not complete them. They may answer questions with grunts or groans. The most severe cases may be mute. As Lewis points out, it is sometimes difficult to distinguish the scanty talk of a depressive from that of a well-preserved, suspicious paranoid schizophrenic. In both conditions, there may be pauses, hesitations, evasion, breaking off, and brevity. The diagnosis must rest on other observations—of content and behavior.

In severe depressions patients may manifest signs of a syndrome that has been labeled stupor or semi-stupor.¹⁹ If left alone, they may remain practically motionless whether standing, sitting, or lying in bed. There is rarely, if ever, any waxy flexibility as seen in catatonia or any apparent clouding of consciousness. The patients vary in the degree to which they respond to stimulation. Some respond to sustained efforts by the examiner to establish rapport; others appear oblivious. I questioned several patients in the latter category after they recovered from their depression, and they reported that they had experienced feelings and thoughts during clinical examination but had felt incapable of expressing them in any way.

In extreme cases, patients do not eat or drink even with urging. Food placed in the mouth may remain there until removed, and under such circumstances tube feeding becomes necessary as a life-preserving measure. Sometimes patients do not move their bowels and digital removal of feces or enemas are necessary. Saliva accumulates and drools out of the mouth. They blink infrequently and may develop corneal ulcers. A more complete description of these extreme cases will be found in the section on Benign Stupors in Chapter 8.

Bleuler (p. 209)²⁰ described the melancholic triad consisting of depressive affect, inhibition of action, and inhibition of thinking. The first two characteristics are certainly typical of retarded depression. There is, however, a strong question as to whether there is an inhibition of the thought process. Lewis⁵ believes that thinking is active—or even hyperactive—even though speech is inhibited. Refined psychological tests, furthermore, have failed to show significant interference with thought processes (Chapter 10).

Agitation

The chief characteristic of agitated patients is ceaseless activity. They cannot sit still but move about constantly in the chair. They convey a sense of restlessness and disturbance in wringing the hands or handkerchief, tearing clothing, picking at skin, and clenching and unclenching fingers. They may rub their scalp or other parts of the body until the skin is worn away.

They may get out of the chair many times in the course of an interview and pace the floor. At night, they may get out of bed frequently and walk incessantly back and forth. It is just as difficult for them to engage in constructive activity as it is to stay still. Their agitation is also manifested by frequent moans and groans. They approach doctors, nurses, and other patients and besiege them with requests or pleas for reassurance.

The emotions of frenzy and anguish are congruent with their thought content. They wail, “Why did I do it? Oh, God, what is to become of me? Please have mercy on me.” They believe they are about to be butchered or buried alive. They moan, “My bowels are gone. It’s intolerable.” They scream, “I can’t stand the pain. Please put me out of my misery.” They groan, “My home is gone. My family is gone. I just want to die. Please let me die.”

The thought content of the retarded patient appears to revolve around passive resignation to his or her fate. The agitated patient, on the other hand, cannot accept or tolerate the torture envisioned. The agitated behavior appears to represent desperate attempts to fight off impending doom.

Variations in Symptoms

Children and Adolescents

Weiss and Garber²¹ reviewed the empirical findings on whether children and adolescents experience and express depression in the same way as do adults. Although it is commonly accepted that depression occurs in this age group, and that developmental level has relatively little influence on the phenomenology of the depression, the developmental perspective predicts the possibility of unique manifestations and experiences of such. Thus, it is possible that a person’s level of physiological, social, and cognitive development must be taken into account in defining depression.

Considering over a dozen studies relevant to the question, Weiss and Garber²¹ concluded that the matter remains unresolved: It is not known how depression in childhood and adolescence may differ from that in adults. However, they did articulate the issues. In so doing, they distinguished between continuity within the individual and continuity of the form or nature of depression across developmental levels. Among other examples they provided was anhedonia (lack of pleasure), present at all developmental levels, but expressed differently in each. Young children may express anhedonia by lack of interest in toy play; adolescents may appear bored; adults may lose interest in sex.

It is important to note that the review and metaanalysis of the empirical literature²¹ did not imply that there are no differences between children and adults in the experience and expression of depression; rather the current state of research is such that unequivocal outcomes have not yet emerged. If differences are found following properly controlled studies, the most essential research question is whether the differences result from the causes or consequences of depression. Before getting to that, however, “the fundamental question of whether there are developmental differences in the symptoms that comprise the syndrome of depression remains to be answered” (p. 427).

The official diagnostic manual of the American Psychiatric Association (APA)²² is not as circumspect as the reviewers above, asserting instead that the “core symptoms” of a major depressive episode are the same for children and adolescents. However, it is stated that the prominence of characteristic symptoms may change with age: “Certain symptoms such as somatic complaints, irritability, and social withdrawal are particularly common in children, whereas psychomotor retardation, hypersomnia, and delusions are less common in prepuberty than in adolescence and adulthood” (p. 354).

Cultural Variations

Cultural context must be better understood in order to avoid underdiagnosis or misdiagnosis due to variation in the experience and communication of depressive symptoms.²² The following may serve as concrete examples: “Complaints of ‘nerves’ and headaches (in Latino and Mediterranean cultures), of weakness, tiredness, or ‘imbalance’ (in Chinese and Asian cultures), of problems of the ‘heart’ (in Middle Eastern cultures), or of being ‘heartbroken’ (among Hopi) may [all] express the depressive experience” (p. 353).’ Research is needed to more fully understand the symptoms of depression as expressed in different cultures around the world.