Buddy
The Living Force
For anyone with depression or concerns about depression, this post is offered in the hopes that the cognitive therapy perspective will be of some benefit. :)
Cognitive Therapy and the Emotional Disorders", Aaron T. Beck, M.D., Meridian, 1979
CHAPTER 5 The Paradoxes of Depression
[quote author=Aaron Beck]
A scientist, shortly after assuming the presidency of a prestigious scientific group, gradually became morose and confided to a friend that he had an overwhelming urge to leave his career and become a hobo.
A devoted mother who had always felt strong love for her children started to neglect them and formulated a serious plan to destroy them and then herself.
An epicurean who relished eating beyond all other satisfactions developed an aversion to food and stopped eating.
A woman, upon hearing of the sudden death of a close friend, emitted the first smile in several weeks.
These strange actions, completely inconsistent with the individual's previous behavior and values, are all expressions of the same underlying condition—depression.
By what perversity does depression mock the most hallowed notions of human nature and biology?
The instinct for self-preservation and the maternal instincts appear to vanish. Basic biological drives such as hunger and sexual urge are extinguished. Sleep, the easer of all woes, is thwarted. "Social instincts," such as attraction to other people, love, and affection evaporate. The pleasure principle and reality principle, the goals of maximizing pleasure and minimizing pain, are turned around. Not only is the capacity for enjoyment stifled, but the victims of this odd malady appear driven to behave in ways that enhance their suffering. The depressed person's capacity to respond with mirth to humorous situations or with anger to situations that would ordinarily infuriate him seems lost.
At one time, this strange affliction was ascribed to demons that allegedly took possession of the victim. Theories advanced since that time have not yet provided a durable solution to the problem of depression. We are still encumbered by a psychological disorder that seems to discredit the most firmly entrenched concepts of the nature of man. Paradoxically, the anomalies of depression may provide clues for understanding this mysterious condition.
The complete reversal in the depressed patient's behavior seems, initially, to defy explanation. During his depression, the patient's manifest personality is far more like that of other depressives than his own previous personality. Feelings of pleasure and joy are replaced by sadness and apathy; the broad range of spontaneous desires and involvement in activities are eclipsed by passivity and desires to escape; hunger and sexual drive are replaced by revulsion toward food and sex; interest and involvement in usual activities are converted into avoidance and withdrawal. Finally, the desire to live is switched off and replaced by the wish to die.
As an initial step in understanding depression, we can attempt to arrange the various phenomena into some kind of understandable sequence. Various writers have assigned primacy to one of the following: intense sadness, wishes to "hibernate," self-destructive wishes, or physiological disturbance.
Is the painful emotion the catalytic agent? If depression is a primary affective disorder, it should be possible to account for the other symptoms on the basis of the emotional state. However, the unpleasant subjective state in itself does not appear to be an adequate stimulus for the other depressive symptoms. Other states of suffering such as physical pain, nausea, dizziness, shortness of breath, or anxiety rarely lead to symptoms typical of depression such as renunciation of major objectives in life, obliteration of affectionate feelings, or the wish to die. On the contrary, people suffering physical pain seem to treasure more than ever those aspects of life they have found meaningful. Moreover, the state of sadness does not have qualities we would expect to produce the self-castigations, distortions in thinking, and loss of drive for gratifications characteristic of depression.
Similar problems are raised in assigning primacy to other aspects of depression. Some writers have latched onto the passivity and withdrawal of attachments to other people to advance the notion that depression results from an atavistic wish to hibernate. If the goal of depression is to conserve energy, however, why is the patient driven to castigate himself and engage in continuous, aimless activities when agitated? Why does he seek to destroy himself— the source of energy?
Ascribing the primary role to the physiological symptoms such as disturbances in sleep, appetite, and sexuality also poses problems. It is difficult to understand the sequence by which these physiological disturbances lead to such varied phenomena as self-criticisms, the negative view of the world, and loss of the anger and mirth responses. Certainly, physiological responses such as loss of appetite and sleep resulting from an acute physical illness do not lead to other components of the depressive constellation.
THE CLUE: THE SENSE OF LOSS
The task of sorting the phenomena of depression into an understandable sequence may be simplified by asking the patient what he feels sad about and by encouraging him to express his repetitive ideas. Depressed patients generally provide essential information in spontaneous statements such as: "I'm sad because I'm worthless"; "I have no future"; "I've lost everything"; "My family is gone"; "I have nobody"; "Life has nothing for me." It is relatively easy to detect the dominant theme in the statements of the moderately or severely depressed patient. He regards himself as lacking some element or attribute that he considers essential for his happiness: competence in attaining his goals, attractiveness to other people, closeness to family or friends, tangible possessions, good health, status or position. Such self-appraisals reflect the way the depressed patient perceives his life situation.
In exploring the theme of loss, we find that the psychological disorder revolves around a cognitive problem. The depressed patient shows specific distortions. He has a negative view of his world, a negative concept of himself, and a negative appraisal of his future: the cognitive triad.
The distorted evaluations concern shrinkage of his domain, and lead to sadness (Chapter 3). The depressive's conception of his valued attributes, relationships, and achievements is saturated with the notion of loss—past, present, and future. When he considers his present position, he sees a barren world; he feels pressed to the wall by external demands that cheat him of his meager resources and keep him from attaining what he wants.
The term "loser" captures the flavor of the depressive's appraisal of himself and his experience. He agonizes over the notion that he has experienced significant losses, such as his friends, his health, his prized possessions. He also regards himself as a "loser" in the colloquial sense: He is a misfit—an inferior and an inadequate being who is unable to meet his responsibilities and attain his goals. If he undertakes a project or seeks some gratification, he expects to be defeated or disappointed. He finds no respite during sleep. He has repetitive dreams in which he is a misfit, a failure.
In considering the concept of loss, we should be sensitive to the crucial importance of meanings and connotations. What represents a painful loss for one person may be regarded as trivial by another. It is important to recognize that the depressed patient dwells on hypothetical losses and pseudo losses. When he thinks about a potential loss, he regards the possibility as though it were an accomplished fact. A depressed man, for example, characteristically reacted to his wife's tardiness in meeting him with the thought, "She might have died on the way." He then construed the hypothetical loss as an actual event and became forlorn. Pseudo loss refers to the incorrect labeling of any event as a loss; for example, a change in status that may in actuality be a gain. A depressed patient who sold some shares of stock at a large profit experienced a prolonged sense of deprivation over eliminating the securities from his portfolio; he ruminated over the notion that the sale had impoverished him.
Granted that the perception of loss produces feelings of sadness, how does this sense of loss engender other symptoms of depression: pessimism, self-criticism, escape-avoidance-giving up, suicidal wishes, and physiological disorders?
In order to answer this question, it would be useful to explore the chronology of depression, the onset and full development of symptoms. This sequence is most clearly demonstrated in cases of "reactive depression," that is, depression in which there is a clear-cut precipitating factor. Other cases of depression, in which the onset is more insidious, show similar (although more subtle) patterns.
DEVELOPMENT OF DEPRESSION
In the course of his development, the depression-prone person may become sensitized by certain unfavorable types of life situations, such as the loss of a parent or chronic rejection by his peers. Other unfavorable conditions of a less obvious nature may similarly produce vulnerability to depression. These traumatic experiences predispose the person to overreact to analogous conditions later in life. He has a tendency to make extreme, absolute judgments when such situations occur. A loss is viewed as irrevocable; indifference, as total rejection.
Experiences just prior to the onset of depression are often no more severe than those reported by those who do not become depressed. The depression-prone differ in the way they construe a particular deprivation. They attach overgeneralized or extravagant meanings to the loss.
The manner in which traumatic circumstances involving a loss lead to the constellation of depression may be delineated by an illustrative case: a man whose wife has deserted him unexpectedly. The effect of the desertion on the husband may not be predictable. Obviously, not every person deserted by a spouse becomes depressed. Even though he may experience the desertion as a painful loss, he may have other sources of satisfaction—family members and friends—to help fill the void. If the problem were simply a new hiatus in his life, we would expect that, in the course of time, he would be able to sustain his loss without becoming clinically depressed. Nonetheless, we know that certain vulnerable individuals respond to such a loss with a profound psychological disturbance.
The impact of the loss depends, in part, on the kind and intensity of the meanings attached to the key person. The deserting wife has been the hub of shared experiences, fantasies, and expectations. The deserted husband in our example has built a network of positive ideas around his wife, such as "she is part of me"; "she is everything to me"; "I enjoy life because of her"; "she is my mainstay"; "she comforts me when I am down." These positive associations range from realistic to extremely unrealistic or imaginary. The more extreme and rigid these positive concepts, the greater the impact of the loss on the domain.
If the damage to the domain is great enough, it sets off a chain reaction. The positive assets represented by his wife are totally wiped out. The deprivation of such valued attributes as "the only person who can make me happy" or "the essence of my existence" magnifies the impact of the loss and generates further sadness. Consequently, the deserted husband draws extreme, negative conclusions that parallel the extreme positive associations to his wife. He interprets the consequences of the loss as: "I am nothing without her; I can never be happy again"; "I can't go on without her."
The further reverberations of the desertion lead the husband to question his worth: "If I had been a better person, she wouldn't have left me." Further, he foresees other negative consequences of the break-up of the marriage. "All of our friends will go over to her side"; "The children will want to live with her, not me"; "I will go broke trying to maintain two households."
As the chain reaction progresses to a full-blown depression, his self-doubts and gloomy predictions expand into negative generalizations about himself, his world, and his future. He starts to see himself as permanently impoverished in terms of emotional satisfactions, as well as financially. In addition, he exacerbates his suffering by overly dramatizing the event: "It is too much for a person to bear" or, "This is a terrible disaster." Such ideas undermine his ability and motivation to absorb the shock.
The husband divorces himself from activities and goals that formerly gave him satisfaction. He may withdraw his investment in his career goals ("because they are meaningless without my wife"). He is not motivated to work or even to take care of himself ("because it isn't worth the effort"). His distress is aggravated by the physiological concomitants of depression, such as loss of appetite and sleep disturbances. Finally, he thinks of suicide as an escape ("because life is too painful").
Since the chain reaction is circular, the depression becomes progressively worse. The various symptoms— sadness, decreased physical activity, sleep disturbance— feed back into the psychological system. Hence, as he experiences sadness, his pessimism leads him to conclude, "I shall always be sad." This ideation leads to more sadness, which is further interpreted in a negative way. Similarly, he thinks, "I shall never be able to eat again or to sleep again," and concludes that he is deteriorating physically. As he observes the various manifestations of his disorder (decreased productivity, avoidance of responsibility, withdrawal from other people), he becomes increasingly critical of himself. His self-criticisms lead to further sadness; thus, we see a continuing vicious cycle.
The anecdote of a man deserted by his wife illustrates the impact and reverberations of a loss in a vulnerable individual. We can now depart from the particular case in order to establish generalizations about the development of depression. The depressive chain reaction may be triggered by other kinds of losses such as failure at school or on a job. More chronic deprivations, such as disturbance in key interpersonal relations, may also be triggers.
The concept of the depressive chain reaction can be expanded to provide answers to the following problems: Why does the depressed patient have such low self-esteem? Why is he pervasively pessimistic? Why does he berate himself so viciously? Why does he give up? Why does he believe no one can help him?
LOW SELF-ESTEEM AND SELF-CRITICISMS
As the depressed patient reflects about adverse events (such as a separation, rejection, defeat, not measuring up to his expectations), he ponders over what these experiences tell him about himself. He is likely to assign the cause of the adverse event to an heinous defect in himself. The deserted husband concludes, "I have lost her because I am unlovable." This conclusion, of course, is only one of a number of possible explanations, such as basic incompatibility of their personalities, the wife's own problems, or her desire for an adventure related more to thrill-seeking than to a change in her feelings for her husband.
When the patient attributes the cause of the loss to himself, the rift in his domain becomes a chasm: He suffers not only the loss itself but he "discovers" a deficiency in himself. He tends to view this presumed deficiency in greatly exaggerated terms. A woman reacted to desertion by her lover with the thought, "I'm getting old and ugly ... I must be repulsive-looking." A man who lost his job due to a general decline in the economy thought, "I'm inept... I'm too weak to make a living."
By viewing the desertion in terms of his own deficiency, the patient experiences additional morbid symptoms. His conviction of his presumed defects becomes so imperative that it infiltrates his every thought about himself. In the course of time, his picture of his negative attributes expands to the point that it takes over his self-image. When asked to describe himself, he can think only of his "bad" traits. He has great difficulty in shifting his attention to his abilities and achievements and he glosses over or discounts attributes he may have valued highly in the past.
The patient's preoccupation with his presumed deficiency assumes many forms. He appraises each experience in terms of the deficiency. He interprets ambiguous or slightly negatively toned experiences as evidence of this deficiency. For instance, following an argument with her brother, a mildly depressed woman concluded, "I am incapable of being loved and of giving love," and she became more depressed. In reality, she had a number of intimate friends and a loving husband and children. When a friend was too busy to chat with her on the phone, she thought, "She doesn't want to talk to me any more." If her husband came home late from the office, she decided that he was staying away in order to avoid her. When her children were crabby at dinner, she thought, "I have failed them." In reality, there were more plausible explanations for these events, but the patient had difficulty in even considering explanations that did not reflect badly on her.
The tendency to compare oneself with others further lowers self-esteem. Every encounter with another may be turned into a negative self-evaluation. Thus, when talking to other people, the depressed patient thinks, "I'm not a good conversationalist ... I'm not as interesting as the other people." As he walks down the street, he thinks, "Those people look attractive, but I am unattractive." "I have bad posture and bad breath." He sees a mother with a child and thinks, "She's a much better parent than I am." He observes another patient working industriously in the hospital and thinks, "He's a hard worker; I'm lazy and helpless."
The harshness and inappropriateness of self-reproaches in depression have either been ignored by writers or have stimulated very abstract speculations. Freud postulated that the bereaved patient has a pool of unconscious hostility toward the deceased loved object. Since he cannot allow himself to experience this hostility, the patient directs the anger toward himself and accuses himself of faults that actually are characteristics of the loved object. The concept of inverted rage has remained firmly entrenched in many theories of depression. The convoluted pathway proposed by Freud is so removed from information obtained from patients that it is difficult to test it.
A careful examination of the patient's statements provides a more parsimonious explanation of the self-reproaches. A clue to the genesis of the self-criticisms is found in the observation that many depressed patients are critical of attributes they previously had valued highly. For example, a woman who had enjoyed looking at herself in the mirror berated herself with indignities such as "I'm getting old and ugly." Another acutely depressed woman who had always traded on her conversational ability and had enjoyed the resulting attention castigated herself with the thought, "I've lost my ability to interest people ... I can't even carry on a decent conversation." In both cases, the depression had been precipitated by disruption of a close interpersonal relationship.
In reviewing the histories of depressed patients, we often find that the patient has counted on the attribute that he now debases for balancing the usual stresses of life, mastering new problems, and attaining important objectives. When he reaches the conclusion (often erroneously) that he is unable to master a serious problem, attain a goal, or forestall a loss, he downgrades the asset.
As this attribute appears to fade, he begins to believe that he cannot get satisfaction out of life and that all he can expect is pain and suffering. The depressed patient proceeds from disappointment to self-blame to pessimism.
To illustrate the mechanism of self-blame, we might consider the sequence in which the average person blames and punishes somebody who has offended him. First, he tries to find some bad trait in the offender to account for his noxious behavior—insensitivity, selfishness, etc. He then generalizes this characteristic flaw to encompass his total image of the offender— "He's a selfish person"; "he's bad." After such a moral judgment, he may consider ways to punish the offender. He not only downgrades the other person, but, given the opportunity, he may strike at some sensitive point in order to hurt him. Finally, because the offender has brought him pain, he may want to sever the relationship, to reject the other person totally.
The self-castigating depressed patient reacts similarly to his own presumed deficiency and makes himself the target of attack. He regards himself at fault and deserving of blame. He goes beyond the Biblical injunction, "If thine eye offends thee, pluck it out." His moral condemnation spreads from the particular trait to the totality of his self-concept, and is often accompanied by feelings of self-revulsion. The ultimate of his self-condemnation is total self-rejection—just as though he were discarding another person.
Consider the effects of self-criticism, self-condemnation, and self-rejection. The patient reacts to his own onslaughts as if they were directed at him by another person: he feels hurt, sad, humiliated.
Freud and many more recent writers have attributed the sadness to a transformation of anger turned inwards. By a kind of "alchemy," retroflected anger is supposedly converted into depressed feelings. A simpler explanation is that the sadness is the result of the self-instigated lowering of self-esteem. Suppose I inform a student that his performance is inferior and that he accepts the assessment as fair. Even though I communicate my evaluation without anger and may, in fact, express regret or empathy, he is likely to feel sad. The lowering of his self-esteem suffices to make him sad. Similarly, if the student makes a negative evaluation of himself, he feels sad. The depressed patient is like the self-devaluing student; he feels sad because he lowers his sense of worth by his negative evaluations.
When a depressed patient makes a negative evaluation of himself, he generally does not feel angry with himself; in his frame of reference he is simply making an objective judgment. Similarly, he reacts with sadness when he believes that somebody else is devaluating him.
PESSIMISM
Pessimism sweeps like a tidal wave into the thought content of depressed patients. To some degree, we all tend to "live in the future." We interpret experience not only in terms of what the event means right now, but also in terms of its possible consequences. A young man who had just received a compliment from his girl friend looks forward to receiving more compliments; he might think, "she really likes me," and he foresees a more intimate relationship with her. But, if he is disappointed or rejected, he is likely to anticipate a repetition of this type of unpleasant experience.
Depressed patients have a special penchant for expecting future adversities and experiencing them as though they were happening in the present or had already occurred. For example, a man who suffered a mild business reversal began to think in terms of ultimate bankruptcy. As he dwelt on the theme of bankruptcy, he began to regard himself as already bankrupt. Consequently, he started to feel the same degree of sadness as though he had already suffered bankruptcy.
The predictions of depressed patients tend to be overgeneralized and extreme. Since the patients regard the future as an extension of the present, they expect a deprivation or defeat to continue permanently. If a patient feels miserable now, it means he will always feel miserable. The absolute, global pessimism is expressed in statements such as "things won't ever work out for me"; "life is meaningless ... It's never going to be any different." The depressed patient judges that, since he cannot achieve a major goal now, he never will. He cannot see the possibility of substituting other rewarding goals. Moreover, if a problem appears insoluble now, he assumes he will never be able to find a way of working it out or somehow bypassing it.
Another stream leading to pessimism arises from the patient's negative self-concept. We have noted that the trauma of a loss is especially damaging because it implies to the patient that he is defective in some way. Since he considers the presumed deficiency an integral pan of himself, he is likely to regard it as permanent. Nobody else can help restore a lost talent or attribute. Moreover, his pessimistic view leads him to expect his "flaw" to become progressively worse.
Such pessimism is especially likely to strike a person who generally considers himself instrumental in reaching his major life goals. He characteristically relies on his own ability, personal attractiveness, or vigor to attain his objectives. A depressed writer, for instance, did not receive the degree of praise for one of his works that he had expected. His failure to live up to his expectations led him to two conclusions: first, his writing ability was deteriorating; second, since creative ability is intrinsic, his loss could not be salvaged by anybody else. The loss was, therefore, irreversible.
A similar reaction was reported by a student who was unsuccessful in a competition for an award in mathematics. His reaction was, "I've lost my mathematical ability...I'm never going to do well in a competitive situation." Since not winning was tantamount (for him) to complete failure, this meant that his whole life, past, present, and future was a failure.
An energetic career woman who developed transitory back trouble and had to be confined to bed, became depressed. She concluded that she would always be bedridden. She incorrectly regarded her temporary disability as permanent and irremediable.
As pessimism envelops the patient's total failure orientation, his thinking is dominated by ideas such as, "The game is over.. .1 don't have a second chance. Life has passed me by... It's too late to do anything about it." His losses seem irrevocable; his problems, unsolvable.
Pessimism not only engulfs the distant future, but permeates every wish and every task that the patient undertakes. A housewife, who was listing her domestic duties, automatically predicted before starting each new activity that she would be unable to do it. A depressed physician expected, prior to seeing each new patient, that he would be unable to make a diagnosis.
The negative expectations are so strong that even though the patient may be successful in a specific task (for example, the doctor's making the diagnosis), he expects to fail the very next time. He evidently screens out, or fails to integrate, successful experiences that contradict his negative view of himself.
SNOWBALLING OF SADNESS AND APATHY
Although the onset of depression may be sudden, its full development spreads over a period of days or weeks. The patient experiences a gradual increase hi intensity of sadness and of other symptoms until he "hits bottom." Each repetition of the idea of loss is so strong that it constitutes a fresh experience of loss which is added to the previous inventory of perceived losses. With each successive "loss," further sadness is generated.
As described previously (Chapter 4) any psycho-pathological condition is characterized by sensitivity to particular types of experiences. The depressed person tends to extract elements suggestive of loss and to gloss over other features that are not consonant with, or are contradictory to, this interpretation. As a result of such "selective abstraction," the patient overinterprets daily events in terms of loss and is oblivious to more positive interpretations; he is hypersensitive to stimuli suggestive of loss and is blind to stimuli representing gain. He shows the same type of selectivity in recalling past experiences. He is facile in recalling unpleasant experiences, but may "draw a blank" when questioned about positive experiences. This selectivity in memory has been demonstrated experimentally by Lishman (1972).
As a result of this "tunnel vision," the patient becomes impermeable to stimuli that can arouse pleasant emotions. Although he may be able to acknowledge that certain events are favorable, his attitudes block any happy feelings: "I don't deserve to be happy." "I'm different from other people, and I can't feel happy over the things that make them happy." "How can I be happy when everything else is bad?" Similarly, comical situations do not strike him as funny because of his negative set and his tendency toward self-reference: "There is nothing funny about my life." He has difficulty in experiencing anger because he views himself as responsible for and deserving of any rude or insulting actions of other people.
The tendency to think in absolute terms contributes to the cumulative arousal of sadness. He tends to dwell increasingly on extreme ideas such as "Life is meaningless"; "Nobody loves me"; "I'm totally inadequate"; "I have nothing left."
By downgrading qualities that are closely linked with gratification, the patient takes away gratification from himself. In depreciating his attractiveness, a depressed patient is, in effect, saying, "I no longer can enjoy my physical appearance, or compliments I receive for it, or the friendships that it helped me to form and maintain." The loss of gratification evidently trips a mechanism that reverses the direction of affect arousal—from happiness to sadness. The prevailing tide of pessimism maintains the continual state of sadness.
While the usual consequence of loss is sadness, the passive resignation shown by some depressives may lead to a different emotional state. When the depressed patient regards himself as totally defeated and consequently gives up his goals, he is apt to feel apathetic. Since apathy often is experienced as an absence of feeling, the patient may interpret this state as a sign that he is incapable of emotion, that he is "dead inside."
MOTIVATIONAL CHANGES
The reversals in major objectives are among the most puzzling characteristics of the seriously depressed patient. He not only desires to avoid experiences that formerly gratified him or represented the mainstream of his life, but he is drawn toward a state of inactivity. He even seeks to withdraw from life completely via suicide.
To understand the link between the changes in motivation and the patient's perception of loss, it is valuable to consider the ways in which he has "given up." He no longer feels attracted to the kinds of enterprises he ordinarily would undertake spontaneously. In fact, he finds that he has to force himself to engage in his usual activities. He goes through the motions of attending to his ordinary affairs because he believes he should, or because he knows it is "the right thing to do," because others urge him to do it—but not because he wants to. He finds he has to work against a powerful inner resistance, as though he were trying to drive an automobile with the brakes on or to swim upstream.
In the most extreme cases, the patient experiences "paralysis of the will": He is devoid of spontaneous desire to do anything except to remain in a state of inertia. Nor can he mobilize "will power" to force himself to do what he believes he ought to do.
From this description of the motivational changes, one might surmise that, perhaps, some physically depleting disease has overwhelmed the patient so that he does not have the strength or resources to make even a minimal exertion. An acute or debilitating illness such as pneumonia or advanced cancer would conceivably re* duce a person to such a state of immobility. The physical-depletion notion, however, is contradicted by the patient's own observation that he feels a strong drive to avoid "constructive" or "normal" activities: His inertia is deceptive in that it is derived not only from a desire to be passive, but also from a less obvious desire to shrink from any situation he regards as unpleasant.
He may feel repelled by the thought of performing even elementary functions such as getting out of bed, dressing himself, and attending to personal needs. A retarded, depressed woman would rapidly dive under the bed-covers whenever I entered the room. She would become exceptionally aroused and even energetic in her attempt to escape from an activity that she was pressed to engage in. In contrast, the physically ill person generally wants to be active. It is often necessary to enforce bedrest in order to keep him from taxing himself. The depressed patient's desire to avoid activity and to escape from his current environment are the consequences of his peculiar constructions: the negative view of his future, his environment, and himself.
Everyday experiences—as well as a number of well-designed experiments—demonstrate that when a person believes he cannot succeed at a task, he is likely to give up. He adopts the attitude, "there's no use trying," and does not feel any spontaneous drive to work at it. Moreover, the belief that the task is pointless and that even successful completion is meaningless, minimizes his motivation.
Since the depressed patient expects negative outcomes, he does not experience any internal stimulation to make an effort; he sees no point in trying because he believes the goals are meaningless. People generally try to avoid situations they expect to be painful; because the depressed patient perceives most situations as onerous, boring, or painful, he desires to avoid even the usual amenities of living. These avoidance desires are powerful enough to override any tendencies toward constructive, goal-directed activity.
The setting for the patient's powerful desire to seek a passive state is illustrated by this sequence of thoughts: "I'm too fatigued and sad to do anything. If I am active I shall only feel worse. But if I lie down, I can conserve my strength and my bad feelings will go away." Unfortunately, this attempt to escape from the unpleasant feeling by being passive does not work; if anything, it enhances the dysphoria. The patient finds that far from obtaining any respite from his unpleasant thoughts and feelings, he becomes more preoccupied with them.
SUICIDAL BEHAVIOR
Suicidal wishes and suicide attempts may be regarded as the ultimate expression of the desire to escape. The depressed patient sees his future as filled with suffering. He cannot visualize any way of improving his lot; he does not believe he will get better. On the basis of these premises, suicide seems to be a rational course of action. It not only promises an end to his own misery but presumably will relieve his family of a burden. Once the patient regards death as more desirable than life, he feels attracted to suicide. The more hopeless and painful his life seems, the stronger his desire to end his life.
The wish to find surcease through suicide is illustrated in the lament of a depressed woman who had been rejected by her lover. "There's no sense in living. There's nothing here for me. I need love and I don't have it anymore. I can't be happy without love—only miserable. It will just be the same misery, day in and day out. It's senseless to go on."
The desire to escape from the apparent futility of existence is illustrated by the stream of thought of another depressed patient. "Life means just going through another day. It doesn't make any sense. There's nothing that can give me any satisfaction. The future isn't there—I just don't want life anymore. I want to get out of here.. .It's stupid just to go on living."
Another premise underlying the suicidal wishes is the belief that everybody would be better off if he were dead. Since he regards himself as worthless and as a burden, arguments that his family would be hurt if he died seem hollow to him. How can they be injured by losing a burden? One patient envisioned suicide as doing her parents a favor. She would not only end her own pain, but would relieve them of psychological and financial burdens. "I'm just taking money from my parents. They would use it to better advantage. They wouldn't have to support me. My father wouldn't have to work so hard, and they could travel. I'm unhappy taking their money, and they could be happy with it."
EXPERIMENTAL STUDIES OF DEPRESSION
Although the preceding formulations of depression were derived primarily from clinical observations and reports by depressed patients, it has been possible to subject these hypotheses to a series of correlational and experimental studies. These studies support the model of depression I have presented in this chapter.
DREAMS AND OTHER IDEATIONAL MATERIAL
I observed that depressed patients in psychotherapy showed a higher proportion of dreams with negative outcomes than did a matched group of nondepressed psychiatric patients. A typical dream of a depressed patient showed this content: The dreamer was portrayed as a "loser"; he suffered deprivation of some tangible object, loss of self-esteem, or loss of a person to whom he was attached. Other themes in dreams included the dreamer's being portrayed as inept, repulsive, defective, or thwarted in attempting to reach a goal. This observation was borne out in a systematic study (Beck and Hurvich, 1959).
The theme of deprivation and thwarting are apparent in the following typical dreams of depressed patients: The dreamer desperately wanted to call his wife. He inserted his only coin into a pay telephone. He got the wrong number; since he had wasted his only coin, he was unable to reach his wife and felt sad. Another patient dreamed he was very thirsty. He ordered a glass of beer at a bar. He was served a drink containing a mixture of beer and scotch! He felt disappointed and helpless.
The finding of typical negative themes was validated in a second, more refined study of the most recent dreams of 228 depressed and nondepressed psychiatric patients (Beck and Ward, 1961).
Another approach to the thinking patterns in depression was based on the administration of the Focussed Fantasy Test. The materials consisted of a set of cards; each card contained four frames depicting a continuous sequence of events involving a set of identical twins. The plot was similar to that observed in dreams of depressed patients; namely, one of the twins loses something of value, is rejected, or punished. Depressed patients were much more likely than nondepressed patients to identify with the twin who was the "loser" in each sequence.
In the long-term clinical study previously noted (Beck, 1963), I analyzed the verbatim recorded verbal productions of 81 depressed and nondepressed patients in psychotherapy. I found that depressed patients distorted their experiences in an idiosyncratic way. They misinterpreted events in terms of deprivation, personal failure, or rejection; or they exaggerated the significance of events that seemed to reflect badly on them. They also perser-verated in making indiscriminate, negative predictions. The distorted appraisals of reality showed a .similarity to the content of the dreams.
Our research group has conducted a series of correlational studies to test these clinical findings. We found significant correlations between the depth of depression and the degree of pessimism and negative self-evaluations. After recovery from depression, the patients showed a remarkable improvement in their outlook and self-appraisals (Beck, 1972b). These findings lent strong support to the thesis that depression is associated with a negative view of the self and the future. The high correlation between measures of negative view of the future and negative view of the self supported the concept of the cognitive triad in depression.
The relation between negative view of the future and suicidal wishes has been supported by a number of studies. The most crucial study attempted to determine what psychological factor contributed most strongly to the seriousness of a suicide attempt. We found that hopelessness was the best indicator of how serious the person was about terminating his life (Minkoff, Bergman, Beck, and Beck, 1973; Beck, Kovacs, and Weissman, 1975).
Another way to test the primacy of the negative attitudes in depression is to attempt to modify them and observe the effects. If we ameliorate the depressed patient's unrealistically low concept of his capabilities and of his future, then we would expect the secondary symptoms of depression, such as low mood and loss of constructive motivation, to improve accordingly.
When presented with a simple card-sorting task, depressed patients in the psychiatric clinic were significantly more pessimistic about their chances of success than a matched control group of nondepressed patients. In actuality, the depressed patients performed as well as the nondepressed patients. The depressed patients who succeeded in reaching their stated goals were much more optimistic on a second task. Moreover, their performance on the second task was better than that of the nondepressed group (Loeb, Beck, and Diggory, 1971). We repeated this study with depressed and nondepressed patients who had been hospitalized because of their illness. We found that following a successful experience, the depressed patients showed an increase in self-esteem and optimism that spread to attributes not related to the test. Thus, they were more positive about their personal attractiveness, ability to communicate, and social interests; they also saw their future as brighter and had higher expectations of achieving their major objectives in life.
This change in self-appraisal was paralleled by a lifting of their mood (Beck, 1974).
A similar study of 15 depressed inpatients focused on the depressed patients' difficulty in expressing themselves verbally. They were given a graded series of assignments proceeding in a progression from the simplest step (reading a paragraph aloud) to the most difficult. The final assignment, which all the patients were able to master, consisted of improvising a short talk on a selected subject and trying to convince the experimenter of their point of view. Again we found that the successful completion of these assignments led to significant improvements in their general appraisals of themselves and their future. Their mood also improved.
Our finding that the depressed patient is especially sensitive to tangible evidence of successful performance has important implications for psychotherapy. The meaning of the experimental situation, in which the subject receives positive feedback from the experimenter, obviously has a powerful effect on the depressed patient. This tendency to exaggerate the evaluative aspects of situations and to overgeneralize in a positive direction after "success" provides guidelines for the therapeutic management of depression.
A SYNTHESIS OF DEPRESSION
We have analyzed the development of depression in terms of a chain reaction initiated by experience connoting loss to the patient. We have noted how the sense of loss pervades the person's view of himself, his world, and his future, and leads to the other phenomena of depression.
The typical losses triggering depression may be obvious and dramatic, such as loss of a spouse, or a series of experiences the patient interprets as diminishing him in a significant way. More subtle kinds of deprivations result from the patient's failure to negotiate a reasonable balance between the emotional investments he makes and the return on the investments. The imbalance may stem from a relative deficiency between the gratifications he receives in proportion to what he gives to others, or from a discrepancy between the demands he makes on himself and what he attains. In short, he experiences an upset in his "give-get balance" (Saul, 1947).
After experiencing loss (either as the result of an actual, obvious event or insidious deprivations) the depression-prone person begins to appraise his experiences in a negative way. He overinterprets his experiences in terms of defeat or deprivation. He regards himself as deficient, inadequate, unworthy, and is prone to attribute unpleasant occurrences to a deficiency in himself. As he looks ahead, he anticipates that his present difficulties or suffering will continue indefinitely. He foresees a life of unremitting hardship, frustration, and deprivation. Since he attributes his difficulties to his own defects, he blames himself and becomes increasingly self-critical. The patient's experiences in living thus activate cognitive patterns revolving around the theme of loss. The various emotional, motivational, behavioral, and vegetative phenomena of depression flow from these negative self-evaluations.
The patient's sadness is an inevitable consequence of his sense of deprivation, pessimism, and self-criticism. Apathy results from giving up completely. His loss of spontaneity, his escapist and avoidance wishes, and his suicidal wishes similarly stem from the way he appraises his life. His hopelessness leads to loss of motivation: Because he expects a negative outcome from any course of action, he loses the internal stimulation to engage in any constructive activity. Moreover, this pessimism leads him ultimately to suicidal wishes.
The various behavioral manifestations of depression, such as inertia, fatigability, agitation, are similarly the outcomes of the negative cognitions. Inertia and passivity are expressions of the patient's loss of spontaneous motivation. His easy fatigability results from his continuous expectations of negative outcomes from whatever he undertakes. Similarly, agitation is related to the thought content. Unlike the retarded patient who passively resigns himself to his "fate," the agitated patient fights desperately to find a way out of his predicament. Since he is unable to grasp a solution, he is driven into frantic motor activity, such as pacing the floor or scratching various parts of his body.
The vegetative signs of depression—loss of appetite, loss of libido, sleep disturbance—appear to be the physiological concomitants of the particular psychological disturbance in depression. The physiological signs of depression may be regarded as analogous to the autonomic nervous system manifestations of anxiety. The specific psychological arousal in depression affects, in particular, appetite, sleep, and sexual drive.
The continuous downward course in depression may be explained in terms of the feedback model. As a result of his negative attitudes, the patient interprets his dys-phoria, sense of loss, and physical symptoms in a negative way. His conclusion that he is defective and cannot improve reinforces his negative expectations and negative self-image. Consequently, he feels sadder and more impelled to avoid the "demands" of his environment. Thus, the vicious cycle is perpetrated.
Experimental studies of depression provide leads for therapeutic intervention. By helping the patient to recognize how he consistently distorts his experiences, the therapist may help to alleviate his self-criticalness and pessimism. When these key links in the chain are loosened, the inexorable cycle of depression is interrupted and normal feelings and desires re-emerge. As we shall see in the discussion of other emotional disturbances, the major thrust towards health is achieved by reshaping the patient's erroneous beliefs.[/quote]
Cognitive Therapy and the Emotional Disorders", Aaron T. Beck, M.D., Meridian, 1979
CHAPTER 5 The Paradoxes of Depression
[quote author=Aaron Beck]
A scientist, shortly after assuming the presidency of a prestigious scientific group, gradually became morose and confided to a friend that he had an overwhelming urge to leave his career and become a hobo.
A devoted mother who had always felt strong love for her children started to neglect them and formulated a serious plan to destroy them and then herself.
An epicurean who relished eating beyond all other satisfactions developed an aversion to food and stopped eating.
A woman, upon hearing of the sudden death of a close friend, emitted the first smile in several weeks.
These strange actions, completely inconsistent with the individual's previous behavior and values, are all expressions of the same underlying condition—depression.
By what perversity does depression mock the most hallowed notions of human nature and biology?
The instinct for self-preservation and the maternal instincts appear to vanish. Basic biological drives such as hunger and sexual urge are extinguished. Sleep, the easer of all woes, is thwarted. "Social instincts," such as attraction to other people, love, and affection evaporate. The pleasure principle and reality principle, the goals of maximizing pleasure and minimizing pain, are turned around. Not only is the capacity for enjoyment stifled, but the victims of this odd malady appear driven to behave in ways that enhance their suffering. The depressed person's capacity to respond with mirth to humorous situations or with anger to situations that would ordinarily infuriate him seems lost.
At one time, this strange affliction was ascribed to demons that allegedly took possession of the victim. Theories advanced since that time have not yet provided a durable solution to the problem of depression. We are still encumbered by a psychological disorder that seems to discredit the most firmly entrenched concepts of the nature of man. Paradoxically, the anomalies of depression may provide clues for understanding this mysterious condition.
The complete reversal in the depressed patient's behavior seems, initially, to defy explanation. During his depression, the patient's manifest personality is far more like that of other depressives than his own previous personality. Feelings of pleasure and joy are replaced by sadness and apathy; the broad range of spontaneous desires and involvement in activities are eclipsed by passivity and desires to escape; hunger and sexual drive are replaced by revulsion toward food and sex; interest and involvement in usual activities are converted into avoidance and withdrawal. Finally, the desire to live is switched off and replaced by the wish to die.
As an initial step in understanding depression, we can attempt to arrange the various phenomena into some kind of understandable sequence. Various writers have assigned primacy to one of the following: intense sadness, wishes to "hibernate," self-destructive wishes, or physiological disturbance.
Is the painful emotion the catalytic agent? If depression is a primary affective disorder, it should be possible to account for the other symptoms on the basis of the emotional state. However, the unpleasant subjective state in itself does not appear to be an adequate stimulus for the other depressive symptoms. Other states of suffering such as physical pain, nausea, dizziness, shortness of breath, or anxiety rarely lead to symptoms typical of depression such as renunciation of major objectives in life, obliteration of affectionate feelings, or the wish to die. On the contrary, people suffering physical pain seem to treasure more than ever those aspects of life they have found meaningful. Moreover, the state of sadness does not have qualities we would expect to produce the self-castigations, distortions in thinking, and loss of drive for gratifications characteristic of depression.
Similar problems are raised in assigning primacy to other aspects of depression. Some writers have latched onto the passivity and withdrawal of attachments to other people to advance the notion that depression results from an atavistic wish to hibernate. If the goal of depression is to conserve energy, however, why is the patient driven to castigate himself and engage in continuous, aimless activities when agitated? Why does he seek to destroy himself— the source of energy?
Ascribing the primary role to the physiological symptoms such as disturbances in sleep, appetite, and sexuality also poses problems. It is difficult to understand the sequence by which these physiological disturbances lead to such varied phenomena as self-criticisms, the negative view of the world, and loss of the anger and mirth responses. Certainly, physiological responses such as loss of appetite and sleep resulting from an acute physical illness do not lead to other components of the depressive constellation.
THE CLUE: THE SENSE OF LOSS
The task of sorting the phenomena of depression into an understandable sequence may be simplified by asking the patient what he feels sad about and by encouraging him to express his repetitive ideas. Depressed patients generally provide essential information in spontaneous statements such as: "I'm sad because I'm worthless"; "I have no future"; "I've lost everything"; "My family is gone"; "I have nobody"; "Life has nothing for me." It is relatively easy to detect the dominant theme in the statements of the moderately or severely depressed patient. He regards himself as lacking some element or attribute that he considers essential for his happiness: competence in attaining his goals, attractiveness to other people, closeness to family or friends, tangible possessions, good health, status or position. Such self-appraisals reflect the way the depressed patient perceives his life situation.
In exploring the theme of loss, we find that the psychological disorder revolves around a cognitive problem. The depressed patient shows specific distortions. He has a negative view of his world, a negative concept of himself, and a negative appraisal of his future: the cognitive triad.
The distorted evaluations concern shrinkage of his domain, and lead to sadness (Chapter 3). The depressive's conception of his valued attributes, relationships, and achievements is saturated with the notion of loss—past, present, and future. When he considers his present position, he sees a barren world; he feels pressed to the wall by external demands that cheat him of his meager resources and keep him from attaining what he wants.
The term "loser" captures the flavor of the depressive's appraisal of himself and his experience. He agonizes over the notion that he has experienced significant losses, such as his friends, his health, his prized possessions. He also regards himself as a "loser" in the colloquial sense: He is a misfit—an inferior and an inadequate being who is unable to meet his responsibilities and attain his goals. If he undertakes a project or seeks some gratification, he expects to be defeated or disappointed. He finds no respite during sleep. He has repetitive dreams in which he is a misfit, a failure.
In considering the concept of loss, we should be sensitive to the crucial importance of meanings and connotations. What represents a painful loss for one person may be regarded as trivial by another. It is important to recognize that the depressed patient dwells on hypothetical losses and pseudo losses. When he thinks about a potential loss, he regards the possibility as though it were an accomplished fact. A depressed man, for example, characteristically reacted to his wife's tardiness in meeting him with the thought, "She might have died on the way." He then construed the hypothetical loss as an actual event and became forlorn. Pseudo loss refers to the incorrect labeling of any event as a loss; for example, a change in status that may in actuality be a gain. A depressed patient who sold some shares of stock at a large profit experienced a prolonged sense of deprivation over eliminating the securities from his portfolio; he ruminated over the notion that the sale had impoverished him.
Granted that the perception of loss produces feelings of sadness, how does this sense of loss engender other symptoms of depression: pessimism, self-criticism, escape-avoidance-giving up, suicidal wishes, and physiological disorders?
In order to answer this question, it would be useful to explore the chronology of depression, the onset and full development of symptoms. This sequence is most clearly demonstrated in cases of "reactive depression," that is, depression in which there is a clear-cut precipitating factor. Other cases of depression, in which the onset is more insidious, show similar (although more subtle) patterns.
DEVELOPMENT OF DEPRESSION
In the course of his development, the depression-prone person may become sensitized by certain unfavorable types of life situations, such as the loss of a parent or chronic rejection by his peers. Other unfavorable conditions of a less obvious nature may similarly produce vulnerability to depression. These traumatic experiences predispose the person to overreact to analogous conditions later in life. He has a tendency to make extreme, absolute judgments when such situations occur. A loss is viewed as irrevocable; indifference, as total rejection.
Experiences just prior to the onset of depression are often no more severe than those reported by those who do not become depressed. The depression-prone differ in the way they construe a particular deprivation. They attach overgeneralized or extravagant meanings to the loss.
The manner in which traumatic circumstances involving a loss lead to the constellation of depression may be delineated by an illustrative case: a man whose wife has deserted him unexpectedly. The effect of the desertion on the husband may not be predictable. Obviously, not every person deserted by a spouse becomes depressed. Even though he may experience the desertion as a painful loss, he may have other sources of satisfaction—family members and friends—to help fill the void. If the problem were simply a new hiatus in his life, we would expect that, in the course of time, he would be able to sustain his loss without becoming clinically depressed. Nonetheless, we know that certain vulnerable individuals respond to such a loss with a profound psychological disturbance.
The impact of the loss depends, in part, on the kind and intensity of the meanings attached to the key person. The deserting wife has been the hub of shared experiences, fantasies, and expectations. The deserted husband in our example has built a network of positive ideas around his wife, such as "she is part of me"; "she is everything to me"; "I enjoy life because of her"; "she is my mainstay"; "she comforts me when I am down." These positive associations range from realistic to extremely unrealistic or imaginary. The more extreme and rigid these positive concepts, the greater the impact of the loss on the domain.
If the damage to the domain is great enough, it sets off a chain reaction. The positive assets represented by his wife are totally wiped out. The deprivation of such valued attributes as "the only person who can make me happy" or "the essence of my existence" magnifies the impact of the loss and generates further sadness. Consequently, the deserted husband draws extreme, negative conclusions that parallel the extreme positive associations to his wife. He interprets the consequences of the loss as: "I am nothing without her; I can never be happy again"; "I can't go on without her."
The further reverberations of the desertion lead the husband to question his worth: "If I had been a better person, she wouldn't have left me." Further, he foresees other negative consequences of the break-up of the marriage. "All of our friends will go over to her side"; "The children will want to live with her, not me"; "I will go broke trying to maintain two households."
As the chain reaction progresses to a full-blown depression, his self-doubts and gloomy predictions expand into negative generalizations about himself, his world, and his future. He starts to see himself as permanently impoverished in terms of emotional satisfactions, as well as financially. In addition, he exacerbates his suffering by overly dramatizing the event: "It is too much for a person to bear" or, "This is a terrible disaster." Such ideas undermine his ability and motivation to absorb the shock.
The husband divorces himself from activities and goals that formerly gave him satisfaction. He may withdraw his investment in his career goals ("because they are meaningless without my wife"). He is not motivated to work or even to take care of himself ("because it isn't worth the effort"). His distress is aggravated by the physiological concomitants of depression, such as loss of appetite and sleep disturbances. Finally, he thinks of suicide as an escape ("because life is too painful").
Since the chain reaction is circular, the depression becomes progressively worse. The various symptoms— sadness, decreased physical activity, sleep disturbance— feed back into the psychological system. Hence, as he experiences sadness, his pessimism leads him to conclude, "I shall always be sad." This ideation leads to more sadness, which is further interpreted in a negative way. Similarly, he thinks, "I shall never be able to eat again or to sleep again," and concludes that he is deteriorating physically. As he observes the various manifestations of his disorder (decreased productivity, avoidance of responsibility, withdrawal from other people), he becomes increasingly critical of himself. His self-criticisms lead to further sadness; thus, we see a continuing vicious cycle.
The anecdote of a man deserted by his wife illustrates the impact and reverberations of a loss in a vulnerable individual. We can now depart from the particular case in order to establish generalizations about the development of depression. The depressive chain reaction may be triggered by other kinds of losses such as failure at school or on a job. More chronic deprivations, such as disturbance in key interpersonal relations, may also be triggers.
The concept of the depressive chain reaction can be expanded to provide answers to the following problems: Why does the depressed patient have such low self-esteem? Why is he pervasively pessimistic? Why does he berate himself so viciously? Why does he give up? Why does he believe no one can help him?
LOW SELF-ESTEEM AND SELF-CRITICISMS
As the depressed patient reflects about adverse events (such as a separation, rejection, defeat, not measuring up to his expectations), he ponders over what these experiences tell him about himself. He is likely to assign the cause of the adverse event to an heinous defect in himself. The deserted husband concludes, "I have lost her because I am unlovable." This conclusion, of course, is only one of a number of possible explanations, such as basic incompatibility of their personalities, the wife's own problems, or her desire for an adventure related more to thrill-seeking than to a change in her feelings for her husband.
When the patient attributes the cause of the loss to himself, the rift in his domain becomes a chasm: He suffers not only the loss itself but he "discovers" a deficiency in himself. He tends to view this presumed deficiency in greatly exaggerated terms. A woman reacted to desertion by her lover with the thought, "I'm getting old and ugly ... I must be repulsive-looking." A man who lost his job due to a general decline in the economy thought, "I'm inept... I'm too weak to make a living."
By viewing the desertion in terms of his own deficiency, the patient experiences additional morbid symptoms. His conviction of his presumed defects becomes so imperative that it infiltrates his every thought about himself. In the course of time, his picture of his negative attributes expands to the point that it takes over his self-image. When asked to describe himself, he can think only of his "bad" traits. He has great difficulty in shifting his attention to his abilities and achievements and he glosses over or discounts attributes he may have valued highly in the past.
The patient's preoccupation with his presumed deficiency assumes many forms. He appraises each experience in terms of the deficiency. He interprets ambiguous or slightly negatively toned experiences as evidence of this deficiency. For instance, following an argument with her brother, a mildly depressed woman concluded, "I am incapable of being loved and of giving love," and she became more depressed. In reality, she had a number of intimate friends and a loving husband and children. When a friend was too busy to chat with her on the phone, she thought, "She doesn't want to talk to me any more." If her husband came home late from the office, she decided that he was staying away in order to avoid her. When her children were crabby at dinner, she thought, "I have failed them." In reality, there were more plausible explanations for these events, but the patient had difficulty in even considering explanations that did not reflect badly on her.
The tendency to compare oneself with others further lowers self-esteem. Every encounter with another may be turned into a negative self-evaluation. Thus, when talking to other people, the depressed patient thinks, "I'm not a good conversationalist ... I'm not as interesting as the other people." As he walks down the street, he thinks, "Those people look attractive, but I am unattractive." "I have bad posture and bad breath." He sees a mother with a child and thinks, "She's a much better parent than I am." He observes another patient working industriously in the hospital and thinks, "He's a hard worker; I'm lazy and helpless."
The harshness and inappropriateness of self-reproaches in depression have either been ignored by writers or have stimulated very abstract speculations. Freud postulated that the bereaved patient has a pool of unconscious hostility toward the deceased loved object. Since he cannot allow himself to experience this hostility, the patient directs the anger toward himself and accuses himself of faults that actually are characteristics of the loved object. The concept of inverted rage has remained firmly entrenched in many theories of depression. The convoluted pathway proposed by Freud is so removed from information obtained from patients that it is difficult to test it.
A careful examination of the patient's statements provides a more parsimonious explanation of the self-reproaches. A clue to the genesis of the self-criticisms is found in the observation that many depressed patients are critical of attributes they previously had valued highly. For example, a woman who had enjoyed looking at herself in the mirror berated herself with indignities such as "I'm getting old and ugly." Another acutely depressed woman who had always traded on her conversational ability and had enjoyed the resulting attention castigated herself with the thought, "I've lost my ability to interest people ... I can't even carry on a decent conversation." In both cases, the depression had been precipitated by disruption of a close interpersonal relationship.
In reviewing the histories of depressed patients, we often find that the patient has counted on the attribute that he now debases for balancing the usual stresses of life, mastering new problems, and attaining important objectives. When he reaches the conclusion (often erroneously) that he is unable to master a serious problem, attain a goal, or forestall a loss, he downgrades the asset.
As this attribute appears to fade, he begins to believe that he cannot get satisfaction out of life and that all he can expect is pain and suffering. The depressed patient proceeds from disappointment to self-blame to pessimism.
To illustrate the mechanism of self-blame, we might consider the sequence in which the average person blames and punishes somebody who has offended him. First, he tries to find some bad trait in the offender to account for his noxious behavior—insensitivity, selfishness, etc. He then generalizes this characteristic flaw to encompass his total image of the offender— "He's a selfish person"; "he's bad." After such a moral judgment, he may consider ways to punish the offender. He not only downgrades the other person, but, given the opportunity, he may strike at some sensitive point in order to hurt him. Finally, because the offender has brought him pain, he may want to sever the relationship, to reject the other person totally.
The self-castigating depressed patient reacts similarly to his own presumed deficiency and makes himself the target of attack. He regards himself at fault and deserving of blame. He goes beyond the Biblical injunction, "If thine eye offends thee, pluck it out." His moral condemnation spreads from the particular trait to the totality of his self-concept, and is often accompanied by feelings of self-revulsion. The ultimate of his self-condemnation is total self-rejection—just as though he were discarding another person.
Consider the effects of self-criticism, self-condemnation, and self-rejection. The patient reacts to his own onslaughts as if they were directed at him by another person: he feels hurt, sad, humiliated.
Freud and many more recent writers have attributed the sadness to a transformation of anger turned inwards. By a kind of "alchemy," retroflected anger is supposedly converted into depressed feelings. A simpler explanation is that the sadness is the result of the self-instigated lowering of self-esteem. Suppose I inform a student that his performance is inferior and that he accepts the assessment as fair. Even though I communicate my evaluation without anger and may, in fact, express regret or empathy, he is likely to feel sad. The lowering of his self-esteem suffices to make him sad. Similarly, if the student makes a negative evaluation of himself, he feels sad. The depressed patient is like the self-devaluing student; he feels sad because he lowers his sense of worth by his negative evaluations.
When a depressed patient makes a negative evaluation of himself, he generally does not feel angry with himself; in his frame of reference he is simply making an objective judgment. Similarly, he reacts with sadness when he believes that somebody else is devaluating him.
PESSIMISM
Pessimism sweeps like a tidal wave into the thought content of depressed patients. To some degree, we all tend to "live in the future." We interpret experience not only in terms of what the event means right now, but also in terms of its possible consequences. A young man who had just received a compliment from his girl friend looks forward to receiving more compliments; he might think, "she really likes me," and he foresees a more intimate relationship with her. But, if he is disappointed or rejected, he is likely to anticipate a repetition of this type of unpleasant experience.
Depressed patients have a special penchant for expecting future adversities and experiencing them as though they were happening in the present or had already occurred. For example, a man who suffered a mild business reversal began to think in terms of ultimate bankruptcy. As he dwelt on the theme of bankruptcy, he began to regard himself as already bankrupt. Consequently, he started to feel the same degree of sadness as though he had already suffered bankruptcy.
The predictions of depressed patients tend to be overgeneralized and extreme. Since the patients regard the future as an extension of the present, they expect a deprivation or defeat to continue permanently. If a patient feels miserable now, it means he will always feel miserable. The absolute, global pessimism is expressed in statements such as "things won't ever work out for me"; "life is meaningless ... It's never going to be any different." The depressed patient judges that, since he cannot achieve a major goal now, he never will. He cannot see the possibility of substituting other rewarding goals. Moreover, if a problem appears insoluble now, he assumes he will never be able to find a way of working it out or somehow bypassing it.
Another stream leading to pessimism arises from the patient's negative self-concept. We have noted that the trauma of a loss is especially damaging because it implies to the patient that he is defective in some way. Since he considers the presumed deficiency an integral pan of himself, he is likely to regard it as permanent. Nobody else can help restore a lost talent or attribute. Moreover, his pessimistic view leads him to expect his "flaw" to become progressively worse.
Such pessimism is especially likely to strike a person who generally considers himself instrumental in reaching his major life goals. He characteristically relies on his own ability, personal attractiveness, or vigor to attain his objectives. A depressed writer, for instance, did not receive the degree of praise for one of his works that he had expected. His failure to live up to his expectations led him to two conclusions: first, his writing ability was deteriorating; second, since creative ability is intrinsic, his loss could not be salvaged by anybody else. The loss was, therefore, irreversible.
A similar reaction was reported by a student who was unsuccessful in a competition for an award in mathematics. His reaction was, "I've lost my mathematical ability...I'm never going to do well in a competitive situation." Since not winning was tantamount (for him) to complete failure, this meant that his whole life, past, present, and future was a failure.
An energetic career woman who developed transitory back trouble and had to be confined to bed, became depressed. She concluded that she would always be bedridden. She incorrectly regarded her temporary disability as permanent and irremediable.
As pessimism envelops the patient's total failure orientation, his thinking is dominated by ideas such as, "The game is over.. .1 don't have a second chance. Life has passed me by... It's too late to do anything about it." His losses seem irrevocable; his problems, unsolvable.
Pessimism not only engulfs the distant future, but permeates every wish and every task that the patient undertakes. A housewife, who was listing her domestic duties, automatically predicted before starting each new activity that she would be unable to do it. A depressed physician expected, prior to seeing each new patient, that he would be unable to make a diagnosis.
The negative expectations are so strong that even though the patient may be successful in a specific task (for example, the doctor's making the diagnosis), he expects to fail the very next time. He evidently screens out, or fails to integrate, successful experiences that contradict his negative view of himself.
SNOWBALLING OF SADNESS AND APATHY
Although the onset of depression may be sudden, its full development spreads over a period of days or weeks. The patient experiences a gradual increase hi intensity of sadness and of other symptoms until he "hits bottom." Each repetition of the idea of loss is so strong that it constitutes a fresh experience of loss which is added to the previous inventory of perceived losses. With each successive "loss," further sadness is generated.
As described previously (Chapter 4) any psycho-pathological condition is characterized by sensitivity to particular types of experiences. The depressed person tends to extract elements suggestive of loss and to gloss over other features that are not consonant with, or are contradictory to, this interpretation. As a result of such "selective abstraction," the patient overinterprets daily events in terms of loss and is oblivious to more positive interpretations; he is hypersensitive to stimuli suggestive of loss and is blind to stimuli representing gain. He shows the same type of selectivity in recalling past experiences. He is facile in recalling unpleasant experiences, but may "draw a blank" when questioned about positive experiences. This selectivity in memory has been demonstrated experimentally by Lishman (1972).
As a result of this "tunnel vision," the patient becomes impermeable to stimuli that can arouse pleasant emotions. Although he may be able to acknowledge that certain events are favorable, his attitudes block any happy feelings: "I don't deserve to be happy." "I'm different from other people, and I can't feel happy over the things that make them happy." "How can I be happy when everything else is bad?" Similarly, comical situations do not strike him as funny because of his negative set and his tendency toward self-reference: "There is nothing funny about my life." He has difficulty in experiencing anger because he views himself as responsible for and deserving of any rude or insulting actions of other people.
The tendency to think in absolute terms contributes to the cumulative arousal of sadness. He tends to dwell increasingly on extreme ideas such as "Life is meaningless"; "Nobody loves me"; "I'm totally inadequate"; "I have nothing left."
By downgrading qualities that are closely linked with gratification, the patient takes away gratification from himself. In depreciating his attractiveness, a depressed patient is, in effect, saying, "I no longer can enjoy my physical appearance, or compliments I receive for it, or the friendships that it helped me to form and maintain." The loss of gratification evidently trips a mechanism that reverses the direction of affect arousal—from happiness to sadness. The prevailing tide of pessimism maintains the continual state of sadness.
While the usual consequence of loss is sadness, the passive resignation shown by some depressives may lead to a different emotional state. When the depressed patient regards himself as totally defeated and consequently gives up his goals, he is apt to feel apathetic. Since apathy often is experienced as an absence of feeling, the patient may interpret this state as a sign that he is incapable of emotion, that he is "dead inside."
MOTIVATIONAL CHANGES
The reversals in major objectives are among the most puzzling characteristics of the seriously depressed patient. He not only desires to avoid experiences that formerly gratified him or represented the mainstream of his life, but he is drawn toward a state of inactivity. He even seeks to withdraw from life completely via suicide.
To understand the link between the changes in motivation and the patient's perception of loss, it is valuable to consider the ways in which he has "given up." He no longer feels attracted to the kinds of enterprises he ordinarily would undertake spontaneously. In fact, he finds that he has to force himself to engage in his usual activities. He goes through the motions of attending to his ordinary affairs because he believes he should, or because he knows it is "the right thing to do," because others urge him to do it—but not because he wants to. He finds he has to work against a powerful inner resistance, as though he were trying to drive an automobile with the brakes on or to swim upstream.
In the most extreme cases, the patient experiences "paralysis of the will": He is devoid of spontaneous desire to do anything except to remain in a state of inertia. Nor can he mobilize "will power" to force himself to do what he believes he ought to do.
From this description of the motivational changes, one might surmise that, perhaps, some physically depleting disease has overwhelmed the patient so that he does not have the strength or resources to make even a minimal exertion. An acute or debilitating illness such as pneumonia or advanced cancer would conceivably re* duce a person to such a state of immobility. The physical-depletion notion, however, is contradicted by the patient's own observation that he feels a strong drive to avoid "constructive" or "normal" activities: His inertia is deceptive in that it is derived not only from a desire to be passive, but also from a less obvious desire to shrink from any situation he regards as unpleasant.
He may feel repelled by the thought of performing even elementary functions such as getting out of bed, dressing himself, and attending to personal needs. A retarded, depressed woman would rapidly dive under the bed-covers whenever I entered the room. She would become exceptionally aroused and even energetic in her attempt to escape from an activity that she was pressed to engage in. In contrast, the physically ill person generally wants to be active. It is often necessary to enforce bedrest in order to keep him from taxing himself. The depressed patient's desire to avoid activity and to escape from his current environment are the consequences of his peculiar constructions: the negative view of his future, his environment, and himself.
Everyday experiences—as well as a number of well-designed experiments—demonstrate that when a person believes he cannot succeed at a task, he is likely to give up. He adopts the attitude, "there's no use trying," and does not feel any spontaneous drive to work at it. Moreover, the belief that the task is pointless and that even successful completion is meaningless, minimizes his motivation.
Since the depressed patient expects negative outcomes, he does not experience any internal stimulation to make an effort; he sees no point in trying because he believes the goals are meaningless. People generally try to avoid situations they expect to be painful; because the depressed patient perceives most situations as onerous, boring, or painful, he desires to avoid even the usual amenities of living. These avoidance desires are powerful enough to override any tendencies toward constructive, goal-directed activity.
The setting for the patient's powerful desire to seek a passive state is illustrated by this sequence of thoughts: "I'm too fatigued and sad to do anything. If I am active I shall only feel worse. But if I lie down, I can conserve my strength and my bad feelings will go away." Unfortunately, this attempt to escape from the unpleasant feeling by being passive does not work; if anything, it enhances the dysphoria. The patient finds that far from obtaining any respite from his unpleasant thoughts and feelings, he becomes more preoccupied with them.
SUICIDAL BEHAVIOR
Suicidal wishes and suicide attempts may be regarded as the ultimate expression of the desire to escape. The depressed patient sees his future as filled with suffering. He cannot visualize any way of improving his lot; he does not believe he will get better. On the basis of these premises, suicide seems to be a rational course of action. It not only promises an end to his own misery but presumably will relieve his family of a burden. Once the patient regards death as more desirable than life, he feels attracted to suicide. The more hopeless and painful his life seems, the stronger his desire to end his life.
The wish to find surcease through suicide is illustrated in the lament of a depressed woman who had been rejected by her lover. "There's no sense in living. There's nothing here for me. I need love and I don't have it anymore. I can't be happy without love—only miserable. It will just be the same misery, day in and day out. It's senseless to go on."
The desire to escape from the apparent futility of existence is illustrated by the stream of thought of another depressed patient. "Life means just going through another day. It doesn't make any sense. There's nothing that can give me any satisfaction. The future isn't there—I just don't want life anymore. I want to get out of here.. .It's stupid just to go on living."
Another premise underlying the suicidal wishes is the belief that everybody would be better off if he were dead. Since he regards himself as worthless and as a burden, arguments that his family would be hurt if he died seem hollow to him. How can they be injured by losing a burden? One patient envisioned suicide as doing her parents a favor. She would not only end her own pain, but would relieve them of psychological and financial burdens. "I'm just taking money from my parents. They would use it to better advantage. They wouldn't have to support me. My father wouldn't have to work so hard, and they could travel. I'm unhappy taking their money, and they could be happy with it."
EXPERIMENTAL STUDIES OF DEPRESSION
Although the preceding formulations of depression were derived primarily from clinical observations and reports by depressed patients, it has been possible to subject these hypotheses to a series of correlational and experimental studies. These studies support the model of depression I have presented in this chapter.
DREAMS AND OTHER IDEATIONAL MATERIAL
I observed that depressed patients in psychotherapy showed a higher proportion of dreams with negative outcomes than did a matched group of nondepressed psychiatric patients. A typical dream of a depressed patient showed this content: The dreamer was portrayed as a "loser"; he suffered deprivation of some tangible object, loss of self-esteem, or loss of a person to whom he was attached. Other themes in dreams included the dreamer's being portrayed as inept, repulsive, defective, or thwarted in attempting to reach a goal. This observation was borne out in a systematic study (Beck and Hurvich, 1959).
The theme of deprivation and thwarting are apparent in the following typical dreams of depressed patients: The dreamer desperately wanted to call his wife. He inserted his only coin into a pay telephone. He got the wrong number; since he had wasted his only coin, he was unable to reach his wife and felt sad. Another patient dreamed he was very thirsty. He ordered a glass of beer at a bar. He was served a drink containing a mixture of beer and scotch! He felt disappointed and helpless.
The finding of typical negative themes was validated in a second, more refined study of the most recent dreams of 228 depressed and nondepressed psychiatric patients (Beck and Ward, 1961).
Another approach to the thinking patterns in depression was based on the administration of the Focussed Fantasy Test. The materials consisted of a set of cards; each card contained four frames depicting a continuous sequence of events involving a set of identical twins. The plot was similar to that observed in dreams of depressed patients; namely, one of the twins loses something of value, is rejected, or punished. Depressed patients were much more likely than nondepressed patients to identify with the twin who was the "loser" in each sequence.
In the long-term clinical study previously noted (Beck, 1963), I analyzed the verbatim recorded verbal productions of 81 depressed and nondepressed patients in psychotherapy. I found that depressed patients distorted their experiences in an idiosyncratic way. They misinterpreted events in terms of deprivation, personal failure, or rejection; or they exaggerated the significance of events that seemed to reflect badly on them. They also perser-verated in making indiscriminate, negative predictions. The distorted appraisals of reality showed a .similarity to the content of the dreams.
Our research group has conducted a series of correlational studies to test these clinical findings. We found significant correlations between the depth of depression and the degree of pessimism and negative self-evaluations. After recovery from depression, the patients showed a remarkable improvement in their outlook and self-appraisals (Beck, 1972b). These findings lent strong support to the thesis that depression is associated with a negative view of the self and the future. The high correlation between measures of negative view of the future and negative view of the self supported the concept of the cognitive triad in depression.
The relation between negative view of the future and suicidal wishes has been supported by a number of studies. The most crucial study attempted to determine what psychological factor contributed most strongly to the seriousness of a suicide attempt. We found that hopelessness was the best indicator of how serious the person was about terminating his life (Minkoff, Bergman, Beck, and Beck, 1973; Beck, Kovacs, and Weissman, 1975).
Another way to test the primacy of the negative attitudes in depression is to attempt to modify them and observe the effects. If we ameliorate the depressed patient's unrealistically low concept of his capabilities and of his future, then we would expect the secondary symptoms of depression, such as low mood and loss of constructive motivation, to improve accordingly.
When presented with a simple card-sorting task, depressed patients in the psychiatric clinic were significantly more pessimistic about their chances of success than a matched control group of nondepressed patients. In actuality, the depressed patients performed as well as the nondepressed patients. The depressed patients who succeeded in reaching their stated goals were much more optimistic on a second task. Moreover, their performance on the second task was better than that of the nondepressed group (Loeb, Beck, and Diggory, 1971). We repeated this study with depressed and nondepressed patients who had been hospitalized because of their illness. We found that following a successful experience, the depressed patients showed an increase in self-esteem and optimism that spread to attributes not related to the test. Thus, they were more positive about their personal attractiveness, ability to communicate, and social interests; they also saw their future as brighter and had higher expectations of achieving their major objectives in life.
This change in self-appraisal was paralleled by a lifting of their mood (Beck, 1974).
A similar study of 15 depressed inpatients focused on the depressed patients' difficulty in expressing themselves verbally. They were given a graded series of assignments proceeding in a progression from the simplest step (reading a paragraph aloud) to the most difficult. The final assignment, which all the patients were able to master, consisted of improvising a short talk on a selected subject and trying to convince the experimenter of their point of view. Again we found that the successful completion of these assignments led to significant improvements in their general appraisals of themselves and their future. Their mood also improved.
Our finding that the depressed patient is especially sensitive to tangible evidence of successful performance has important implications for psychotherapy. The meaning of the experimental situation, in which the subject receives positive feedback from the experimenter, obviously has a powerful effect on the depressed patient. This tendency to exaggerate the evaluative aspects of situations and to overgeneralize in a positive direction after "success" provides guidelines for the therapeutic management of depression.
A SYNTHESIS OF DEPRESSION
We have analyzed the development of depression in terms of a chain reaction initiated by experience connoting loss to the patient. We have noted how the sense of loss pervades the person's view of himself, his world, and his future, and leads to the other phenomena of depression.
The typical losses triggering depression may be obvious and dramatic, such as loss of a spouse, or a series of experiences the patient interprets as diminishing him in a significant way. More subtle kinds of deprivations result from the patient's failure to negotiate a reasonable balance between the emotional investments he makes and the return on the investments. The imbalance may stem from a relative deficiency between the gratifications he receives in proportion to what he gives to others, or from a discrepancy between the demands he makes on himself and what he attains. In short, he experiences an upset in his "give-get balance" (Saul, 1947).
After experiencing loss (either as the result of an actual, obvious event or insidious deprivations) the depression-prone person begins to appraise his experiences in a negative way. He overinterprets his experiences in terms of defeat or deprivation. He regards himself as deficient, inadequate, unworthy, and is prone to attribute unpleasant occurrences to a deficiency in himself. As he looks ahead, he anticipates that his present difficulties or suffering will continue indefinitely. He foresees a life of unremitting hardship, frustration, and deprivation. Since he attributes his difficulties to his own defects, he blames himself and becomes increasingly self-critical. The patient's experiences in living thus activate cognitive patterns revolving around the theme of loss. The various emotional, motivational, behavioral, and vegetative phenomena of depression flow from these negative self-evaluations.
The patient's sadness is an inevitable consequence of his sense of deprivation, pessimism, and self-criticism. Apathy results from giving up completely. His loss of spontaneity, his escapist and avoidance wishes, and his suicidal wishes similarly stem from the way he appraises his life. His hopelessness leads to loss of motivation: Because he expects a negative outcome from any course of action, he loses the internal stimulation to engage in any constructive activity. Moreover, this pessimism leads him ultimately to suicidal wishes.
The various behavioral manifestations of depression, such as inertia, fatigability, agitation, are similarly the outcomes of the negative cognitions. Inertia and passivity are expressions of the patient's loss of spontaneous motivation. His easy fatigability results from his continuous expectations of negative outcomes from whatever he undertakes. Similarly, agitation is related to the thought content. Unlike the retarded patient who passively resigns himself to his "fate," the agitated patient fights desperately to find a way out of his predicament. Since he is unable to grasp a solution, he is driven into frantic motor activity, such as pacing the floor or scratching various parts of his body.
The vegetative signs of depression—loss of appetite, loss of libido, sleep disturbance—appear to be the physiological concomitants of the particular psychological disturbance in depression. The physiological signs of depression may be regarded as analogous to the autonomic nervous system manifestations of anxiety. The specific psychological arousal in depression affects, in particular, appetite, sleep, and sexual drive.
The continuous downward course in depression may be explained in terms of the feedback model. As a result of his negative attitudes, the patient interprets his dys-phoria, sense of loss, and physical symptoms in a negative way. His conclusion that he is defective and cannot improve reinforces his negative expectations and negative self-image. Consequently, he feels sadder and more impelled to avoid the "demands" of his environment. Thus, the vicious cycle is perpetrated.
Experimental studies of depression provide leads for therapeutic intervention. By helping the patient to recognize how he consistently distorts his experiences, the therapist may help to alleviate his self-criticalness and pessimism. When these key links in the chain are loosened, the inexorable cycle of depression is interrupted and normal feelings and desires re-emerge. As we shall see in the discussion of other emotional disturbances, the major thrust towards health is achieved by reshaping the patient's erroneous beliefs.[/quote]
