Depression: Causes and Treatment

Aaron T. Beck
Brad A. Alford
Copyright Date: 2009
Edition: 2
Pages: 432
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  • Book Info
    Book Description:

    More than forty years ago, Dr. Aaron T. Beck's pioneeringDepression: Causes and Treatmentpresented the first comprehensive account of all aspects of depression and introduced cognitive therapy to health care providers and patients struggling with one of the most common and devastating diseases of the modern age. Since that classic text first appeared, the appreciation of the multifaceted nature of mood disorders has grown, and the phenomenological and biological aspects of psychology are increasingly seen as intertwined. Taking these developments into account, Beck and his colleague Brad A. Alford have written a second edition ofDepressionthat will help patients and caregivers understand depression as a cognitive disorder.The new edition ofDepressionbuilds on the original research and approach of the seminal first edition, including the tests of Freud's theory that led to a new system of psychological theory and therapy, one that addresses the negative schema and automatic thoughts that can trap people in painful emotional states. Beck and Alford examine selected scientific tests and randomized controlled trials that have enhanced the cognitive approach since the time it was first introduced.Incorporating accepted changes in the definitions and categories of the various mood disorders into its discussion,Depressionaddresses the treatment role of revolutionary drugs, such as the selective serotonin reuptake inhibitors (SSRIs), electroconvulsive therapy (ECT), and transcranial magnetic stimulation (TMS) in relation to cognitive approaches. Beck and Alford explore research on neurotrophic and neurogenesis theories of depression. They also report on advances in psychosocial treatment of depression, including the value of cognitive therapy in the prevention of relapse.

    eISBN: 978-0-8122-9088-2
    Subjects: Psychology

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-xvi)
  3. Preface to the Second Edition
    (pp. xvii-xxii)
  4. Part I. Clinical Aspects of Depression
    • Chapter 1 The Definition of Depression
      (pp. 3-11)

      Depression may someday be understood in terms of its paradoxes. There is, for instance, an astonishing contrast between the depressed person’s image of him- or herself and the objective facts. A wealthy woman moans that she doesn’t have the financial resources to feed her children. A widely acclaimed movie star begs for plastic surgery in the belief that he is ugly. An eminent physicist berates herself “for being stupid.”

      Despite the torment experienced as the result of these self-debasing ideas, the patients are not readily swayed by objective evidence or by logical demonstration of the unreasonable nature of these ideas....

    • Chapter 2 Symptomatology of Depression
      (pp. 12-43)

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

    • Chapter 3 Course and Prognosis
      (pp. 44-63)

      In Chapter 2, depression was treated as a psychopathological dimension or syndrome. The clinical features of depression were examined in cross-section, that is, in terms of the cluster of pathological phenomena exhibited at a given point in time. In this chapter, depression is treated as a discrete clinical entity (such as bipolar disorder or dysthymia) that has certain specific characteristics occurring over time in terms of onset, remission, and recurrence. As a clinical entity or reaction type, depression has many salient characteristics that distinguish it from other clinical types such as schizophrenia, even though these other types may have depressive...

    • Chapter 4 Classifying Mood Disorders
      (pp. 64-79)

      Classification of the mood disorders has evolved in the more than 50 years since the American Psychiatric Association’s first diagnostic and statistical manual was published. As research and theory have advanced, they have been reflected in the four editions and two revisions of the manual.

      The current criteria for classifying Major Depressive Episodes and Manic Episodes are listed in Tables 4-1 and 4-2 fromDSM-IV-TR.¹ It might be noted that theDSM-IVcriteria for major depressive episode (as in Table 4-1) include “biological” or physiological symptoms along with cognitive ones. For example, these four symptoms are largely physiological in nature:...

    • Chapter 5 Psychotic Versus Nonpsychotic Depression
      (pp. 80-89)

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

      The dynamic manifestations, the orality, the super-ego structure, etc., are the same in both, and usually the differentiation is made arbitrarily. If the patient has had some previous depressive attacks, he would probably be placed in the psychotic group; if not, he would be placed in the neurotic one. If the patient’s depression is developed as a reaction...

    • Chapter 6 Bipolar Disorders
      (pp. 90-104)

      The contemporary clinical concept of bipolar disorder stems directly from the work of Kraepelin. When he started his ventures into the classification of the mental disorders, he was confronted with a collection of brilliantly described syndromes that were apparently unrelated. He consolidated the various disorders into two major categories: dementia praecox and manic-depressive insanity. He regarded dementia praecox as a progressive disorder leading eventually to a chronic state of intellectual deterioration; manic-depressive insanity was viewed as episodic (i.e., characterized by remissions and recurrences) and nondeteriorating. The new manic-depressive category ultimately was extended to almost all the recognized syndromes that included...

    • Chapter 7 Involutional Depression
      (pp. 105-112)

      In the history of clinical classification of the mood disorders, the concept of a depression that is specific for the involutional period was embodied in the terminvolutional psychotic reactionin the original version of the APA nomenclature.¹ The diagnostic manual specified five criteria, each of which, as will be seen, was subject to question. Theetiologywas definitely indicated by listing this condition under the heading “Disorders due to disturbance of metabolism, growth, nutrition, or endocrine function.” Theage of onsetwas specified as the “involutional period.” Thesymptomatologyconsisted of “worry, intractable insomnia, guilt, anxiety, agitation, and somatic...

    • Chapter 8 Schizoaffective Disorder
      (pp. 113-132)

      The frequent association of prominent schizophrenic and affective symptoms, having engaged the interest of psychiatric nosographers for over a century, led to the inclusion of “schizo-affective reaction” (now schizoaffective disorder) in the first edition of the American Psychiatric Association nomenclature.¹ This category was then listed as a subtype of schizophrenia along with the more traditional subtypes such as hebephrenic (disorganized), catatonic, and paranoid, and its distinguishing characteristic was the occurrence of affective features (either pronounced depression or elation) in a setting of typical schizophrenic thinking and behavior.

      As Clark and Mallet² pointed out in 1963, a large proportion of psychotic...

  5. Part II. Experimental Aspects of Depression
    • Chapter 9 Biological Studies of Depression
      (pp. 135-168)

      The biological aspects of depression have received considerable attention. Thousands of studies have been reported in the literature; tests have been made of almost all the known constituents of the blood, the urine, and the cerebrospinal fluid; and careful pathological studies of the brain and other organs have been conducted. Yet, few “positive” findings have stood the test of time, and there is still very little basic knowledge of the biological substrate of depression.¹

      The concluding words in this chapter as originally written by Beck (p. 153)² were as follows: “With the tightening of the experimental methods it may be...

    • Chapter 10 Psychological Studies: Tests of Psychoanalytic Theory
      (pp. 169-210)

      This chapter provides a summary of selected early psychological studies of depression. The studies include psychological performance comparisons between depressed and nondepressed individuals, and Beck’s original investigations of depression, which led to the cognitive formulations.¹,²,³,⁴ The more recent psychological studies on reactivity, vulnerability (diathesis), and the empirical status of somatic and psychological treatments are covered in subsequent chapters.

      The studies included here are those, included in the first edition, that have conceptual links to Beck’s systematic investigation of depression and led directly to the development of cognitive theory. A comprehensive review of other psychological studies not directly relevant to this...

  6. Part III. Theoretical Aspects of Depression
    • Chapter 11 Theories of Depression
      (pp. 213-223)

      The theories of depression that have been most tested and applied to the psychotherapeutic treatment of the mood disorders include the interpersonal and cognitive behavioral formulations.¹ Other theories include Freud’s psychoanalytic theory, evolutionary theories, existentialism, neurological and neuropsychological perspectives, biochemical theory, and animal models.

      Several behavioral theories of depression have been advanced. Among the early theorists in this area were Ferster,² Seligman,³,⁴ and Lewinsohn.⁵

      Seligman suggested that the phenomenon of “learned helplessness” in animal models might be meaningfully analogous to clinical depression in humans. Briefly, Seligman found that when a normal dog receives escapeavoidance training, it quickly learns to avoid...

    • Chapter 12 Cognition and Psychopathology
      (pp. 224-244)

      Historically, most writers on the psychological aspects of depression used a motivational or adaptational model. Some authors viewed depressive symptomatology in terms of the gratification or discharge of certain needs or drives.¹,² Others emphasized the role of the defenses against these drives.³ Still others emphasized the adaptive aspects of the symptomatology.²,

      Most early attempts to explain the symptoms of depression in psychological terms had introduced troublesome conceptual or empirical problems. First, many writers had a tendency to ascribe some purpose to the symptoms. Rather than looking upon the symptoms simply as a manifestation of the psychological or physiological disorder, these...

    • Chapter 13 Development of Depression
      (pp. 245-264)

      Early in life, individuals develop a wide variety of concepts and attitudes about themselves and their world. Some of these concepts are anchored to reality and form the basis for a healthy personal adjustment. Others deviate from reality and produce vulnerability to possible psychological disorders.

      People’s concepts—realistic as well as unrealistic—are drawn from experiences, from the attitudes and opinions communicated to by others, and from identifications. Among the concepts that are central in the pathogenesis of depression are people’s attitudes toward self, environment, and future. Since the formulation of all three types of concept is similar, that of...

  7. Part IV: Treatment of Depression
    • Chapter 14 Somatic Therapies
      (pp. 267-291)

      This chapter provides an overview of the development and status of the somatic treatments of mood disorders. We delineate conclusions and key questions, rather than providing a comprehensive guide to treatment. This overview may supplement other sources that are designed to provide more direct clinical guidance to the practicing psychiatrist.¹,²,³

      The main topics covered here include (1) history and development of pharmacotherapy, (2) methodological problems and scientific controversies, (3) switching and augmentation strategies for treatment-resistant depression, and (4) early development and contemporary status of electroconvulsive therapy (ECT). We note several of the common pharmacological agents, past to present, such tricyclics...

    • Chapter 15 Psychotherapy
      (pp. 292-324)

      In this chapter, we consider the major psychotherapeutic approaches to the mood disorders, including supportive and psychoanalytic psychotherapy, interpersonal therapy, behavioral treatments, and cognitive therapy. We also consider the psychotherapeutic treatment of bipolar disorder, the prevention of suicide, relapse prevention, and psychotherapy change processes. The greater focus is on the treatments that have been utilized in studies of major depressive disorder and those with comparatively convincing empirical support.¹,² In the concluding chapter, Chapter 16, we provide a specific comparison of pharmacotherapy to psychotherapy and review the relapse prevention studies that have compared the relative effects of drugs and psychotherapy.


    • Chapter 16 Evaluating Depression Treatments: Randomized Controlled Trials
      (pp. 325-344)

      In this chapter we focus on outcome studies comparing psychological to pharmacological treatments. Understanding the relative merits of these respective approaches has obvious clinical implications. We consider studies from more recent to earlier trials, recognizing that (in general) the more recent studies offer more rigorous experimental design and controls.

      Although there have been skeptics,¹ previous meta-analyses²,³ and reviews⁴,⁵ have supported the efficacy of psychological treatments of depression. Bailar⁶ suggested that conventional narrative literature reviews have special advantages, and pointed out that in no case in medicine have metaanalyses alone led to a major change in treatment policy. We have limited...

  8. Afterword
    (pp. 345-348)

    Although the cognitive model of depression and its application in cognitive therapy has rested primarily on clinical observation and psychological theory and experiments in the past, several exciting and recent developments suggest that an integration with findings from neuroscience is now possible. This development promises to broaden the scope of both cognitive theory and therapy. Perhaps of most significance, gene mapping and imaging techniques provide new possibilities for clarifying the cognitive neurobiology of depression. Current studies have been testing cognitive theory by examining physiological structure and function.¹,²,³ This approach elucidates the causes and treatments of depression from the perspective of...

  9. Appendix: Scoring Instructions for Negative Dreams
    (pp. 349-354)
  10. References
    (pp. 355-388)
  11. Name Index
    (pp. 389-394)
  12. Subject Index
    (pp. 395-405)