The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria
Abstract
The tower of Babel never yielded such confusion of tongues, as the chaos of melancholy doth variety of symptoms.—Robert Burton, Anatomy of Melancholia, 6th edition, 1651 (1, p. 456)
Method
Results
Textbooks’ Descriptions of Symptoms and Signs
Author, Year (Reference) | Mood | Interest | Cognitive Content | Cognitive Function | Volition/Motivation | Decision Making | Anhedonia | Psychomotor Changes | Energy | Speech | Sleep | Anxiety | Appetite | Weight | Other Physical Symptoms | Suicidal Behavior | Circadian Effects | Depersonalization/Derealization |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Kraepelin, 1899 (8) | Gloomy, utterly miserable | Nothing can arouse interest, indifferent | Hopeless, future gloomy, without purpose | Thinking difficult, psychic inhibition* | Lack of initiative,* work very difficult | Very difficult | Nothing gives pleasure | Psychomotor inhibition | Tired, worn out | Quiet and hesitant | Greatly impaired | Obsessional ideas common | Much reduced | Usually drops significantly | Palpitations, heaviness; limp facial expression and posture | Does not want to live | Deeply perplexed | |
De Fursac, 1905 (9) | Painful,* sad, gloomy | Indifferent to everything* | Pessimistic | Psychic inhibition* | Abulia* | Constant indecision | Experiencing no affection | Slow | Indistinct, few words | Diminished, unrefreshing, disturbed | Spells | Anorexia | Loss of weight | Headache, vague pains, constipation | Everything appears strange | |||
Paton, 1905 (10) | Emotional depression | Self-insufficiency and unworthiness | Retardation in thought, difficulty thinking | Inability to think or act | Slow, with difficulty | Slow or unable to speak | Apprehension to marked anxiety | |||||||||||
Dana, 1907 (11) | Mental depression* | Apathy, loss of interest | Hopeless | Slowness, difficulty in thinking* and attention | Weakness of will, attempts at work are futile | Hopeless indecision | Psychomotor retardation,* but agitation also seen | Insomnia | Often anxiety | Loss of appetite | Emaciation | Dyspeptic troubles; precordial distress, constipation; menstrual irregularities; loss of libido | Suicidal ideas and impulses | Stupefied by gloom | ||||
Craig, 1912 (12) | Feeling of depression* | Loss of interest | Self-accusation | Slowing of thought and action* | Inability to work | Slow | Vague fears | “Potential suicides” | Depression more acute in morning | |||||||||
White, 1913 (13) | Emotional depression* | Self-accusatory, hypochondriacal | Difficulty thinking* | Incapable of effort | Psychomotor retardation* | Speaks slowly, monosyllabic | Limp posture and facial expression | Disaggregation of the personality | ||||||||||
Cole, 1913 (14) | Mental pain, abject misery, wretchedness | Lack of interest in family or others, apathetic | Future impossible, feeling of impending evil, pervaded by painful emotions | Difficulty in association | Gait is slow but can pace, be restless | Only snatches of sleep, nights are wretched and sleepless | Morbid apprehensions | Loses all appetite | Loses weight | Dyspepsia, constipation, lost sexual drive, scanty menstruation, dry skin, specific facial expressions | Suicidal intention frequently expressed | |||||||
Buckley, 1920 (15) | Depression of emotional tone,* sadness | No interest in anything | Hopelessness, personal inadequacy | Retardation of thought,* sluggishness, poor attention | Reduced; efforts made with difficulty | Lost all feeling of affection | Retardation,* all action slowed | Fatigue, exhaustion | Commonly absent | Not infrequent state of fear | Weakness | Unlike themselves/surroundings have changed | ||||||
Jelliffe, 1923 (16) | Emotional depression* | Self-accusatory, inadequacy, hypochondriacal | Difficulty thinking* | Incapable of effort, interference when trying to exert will | Psychomotor retardation* | Unable to make any effort, lack of energy | Monosyllabic, sometimes inaudible | Disturbed | Anxiety attacks, apprehension, nameless dread | Poor | Loss of weight | Constipation, cold extremities, flexion of body | ||||||
Bleuler, 1924 (17) | Depressive mood,* painful | All experiences colored painfully; focus on imagined misfortune | Retardation of mental stream* | Reduced resolution of acting* | Retardation of motility,* movements slow and weak, but can be restless, wailing | Quiet, slow | Often, compulsive fears | Specific facial expression, weakness, headache | Suicidal impulses | Loss of emotion, everything strange, colorless; depersonalization | ||||||||
Yellowlees, 1932 (18) | Unhappiness, emotional dullness | No interest in anything, general indifference | Focus on their moral failings, ideas of unworthiness | From lack of initiative to grave impairment in volition | Complete emotional unresponsiveness* | Lowering of activity,* general slowness, but sometimes pacing restlessly | Slow, low-pitched, dull | Often insomnia | Refusal of food | Gastrointestinal disturbance | Suicidal tendency | |||||||
Sadler, 1936 (19) | Emotional depression,* painful, gloomy | Lost all interest | Unworthiness, guilt, hopeless, self-accusatory, discouraged | Difficulty thinking,* slowed down | Devoid of ability to initiate action | Psychomotor retardation,* all acting slowed down | Fatigue, exhaustion | Low tone, monosyllabic | Disturbed, un- refreshing | Irritability | Headaches, indigestion, constipation; careworn expression | Danger of suicide | At worst in morning | Complain of unreality of the environment | ||||
Noyes, 1936 (20) | Despondency, “blue” | Hopelessness, unworthiness, gloomy | Difficulty thinking | Unable to carry out activities | Indecision | Movements slow, inhibited | Fatigue | Slow and in low tone | Insomnia | Headache, hypochondriacal complaints; typical posture, stooped | ||||||||
Gordon, 1936 (21) | Depression* | Lose all usual interests | Hopelessness,* unworthiness* | Difficulty concentrating | Everything a burden | Lacks the natural enjoyment of life | Slowness of thought and action, but sometimes agitation, weeping, hand wringing | Delay in responses | Insomnia | Worry over trifles | Intestinal upset, constipation, face is very aged | Common | Often worst in early morning | In a fog | ||||
Muncie, 1939 (22) | Depressed, blue, sad, lonesome, worried, homesick* | Ideas of self-derogation, unworthiness, guilt, sin* | Thinking difficulty | Inhibition, lack of initiative | General slowing of motility* | Fatigue | Slowed | Principally early morning awakening* | Poor* | Weight loss* | Menstrual irregularity, reduction in erections, reduced libido; stooped posture, constipation* | Suicidal preoccupations* | Early morning worst* | Depersonalization, puzzle, perplexity* | ||||
Henderson, 1944 (23) | Depression* | Unable to take interest | A failure, hopeless, a disgrace | Difficulty in thinking* and concentrating | Loss of feeling | Psychomotor retardation* but can be agitated | Fatigue, exhaustion | Typically, reduced speech, but can be increased | Frequently disturbed, always unrefreshing | Not infrequently present | Reduced | Headache, dyspepsia, constipation, careworn expression | Danger of suicide | Worst in morning | Environment seems unreal | |||
Curran, 1945 (24) | Sadness,* listlessness | Apathetic | Guilt, self-reproach | Retarded thinking* | Indecision | Motor retardation* | Insomnia, especially early awakening | Frequent | Loss | Loss of sexual desire,* constipation, amenorrhea, sallow complexion* | Suicidal ideas* | Worse in morning | Depersonalization, feels changed, lifeless, derealization | |||||
Mayer-Gross, 1954 (25) | Depression, indifference, misery | Loss of interest | Feeling of insufficiency, future dark and gloomy, hopeless | Diminished quickness of thought | Loss of willpower, incapable of initiating actions | Inability to reach decisions | Loss of enjoyment | Retardation | Fatigue, heaviness of limbs | Retardation | Sleeplessness, unrefreshing sleep | Exaggerated fears and anxieties, anxiety attacks | Loss of appetite | Loss of weight | Constipation, reduced sexual desire, amenorrhea; distinct posture, facial expression | Common | Worse in morning | Depersonalization; world through a mist |
Ulett, 1956 (26) | Emotional depression,* melancholy | Guilt, self-accusation, self-deprecation | Slowness and difficulty in thinking* | Painful uncertainty | Psychomotor retardation* | Slowly and in low tone | Insomnia, early rising | Failure to eat | Weight loss | Libido is lost, constipation, menstrual disorder, depressed countenance | Suicidal ruminations | |||||||
Number of times noted | 19 | 12 | 19 | 18 | 15 | 7 | 7 | 18 | 8 | 17 | 14 | 14 | 10 | 9 | 17 | 13 | 7 | 12 |
Number of times prominent (of 15) | 13 | 0 | 2 | 12 | 3 | 0 | 1 | 11 | 0 | 0 | 1 | 0 | 1 | 1 | 2 | 2 | 1 | 1 |
Prominent Symptoms and Signs
Criteria for Depression Proposed by Muncie
Criterion | Name | Description |
---|---|---|
1 | Mood | Depressed, melancholy, blue, sad, lonesome, worried, homesick, and noted in the facial expression |
1.a | Mood equivalent | Depersonalization, feelings of unrealityb |
1.b | Mood equivalent | Puzzle and perplexity |
2 | Cognitive content: appropriate to mood | Self-derogatory, self-depreciatory ideas, ideas of unworthiness, guilt, sin, the source of trouble for others |
3 | Suicidal preoccupations | Natural consequence of mood and content |
4 | General slowing of motility | Of musculature, speech, thinking, including feelings of inhibition, lack of initiative, fatigue |
5 | Diurnal variation | Early morning after waking worst, the evening better |
6 | Physiological alterations | |
6.a | Insomnia | Principally early morning awakening |
6.b | Poor appetite | |
6.c | Weight loss | |
6.d | Reduction in sexual functions | In women, menstrual irregularity. In men, reduction in frequency of erections. In both sexes, reduction or loss of sexual desire. |
6.e | Reduction in muscular tone | Stooped posture |
6.f | Slowed motility | Constipation, lowered blood pressure, pulse |
6.g | Reduction in basal metabolism |
Lewis’s Monograph
Symptom Area | Description |
---|---|
Mood | Depressed, miserable, dreadful, brokenhearted, worried, frightened, low, unhappy, despondent, awful, in agony, desperate, and reflects “the complex quality of experienced totality” |
Interest | Little or no interest in their surroundings |
Cognitive content | Hopeless, nothing to live for, useless, inadequate, degradation, attribution to self of evil motives, self-reproach and self-accusation. These are “among the most striking of melancholic symptoms” |
Cognitive function | Difficulties with concentration and focus. Muddled. But in some patients, due to a constant press of thoughts. “Difficulty in thinking, not slowness of thought, is the essential feature.” Feelings of inadequacy more important than performance. |
Volition/motivation | No will power |
Decision making | |
Anhedonia | Rarely noted compared with loss of interest. One patient stated, “I can’t enjoy anything.” |
Psychomotor changes | General slowing of action. But agitation seen in one-quarter of patients. Wringing of hands, picking. Also descriptions of “inner restlessness” |
Energy | Tired, worn out, exhausted |
Speech | Around a third of patients “talked a great deal” and another third said “little” |
Sleep | |
Anxiety | “The relation of anxiety to depression is intimate.” Apprehension very common, fear of something unpleasant happening. Seen both “in attacks or as a lasting state.” Thirteen patients demonstrated compulsive symptoms. Obscene thoughts, repeating picking (“I feel I must do that; I know it’s wrong”), washing, “I can’t keep my thoughts off my private parts. It’s dreadful.” |
Appetite | “Refusal of food is one of the prominent features of any depressive state.” |
Weight | Loss is common |
Other physical symptoms | Headaches, other “aches and pains” common. Drooping slack posture, facial expression “more easily recognized than described” |
Suicidal behavior | 26 patients attempted suicide; 12 others often spoke of suicide |
Circadian effects | Infrequently seen in this sample |
Depersonalization/derealization | Feel dazed, queer, different, no feeling at all, don’t feel myself; 19 cases with depersonalization—“I have no feeling at all in me,” “I feel all dead”; 21 cases with derealization—“everything changed and unreal,” “a veil or mist interposed between them” and reality |
Quantitative Analysis
Symptom Area | Degree of Coverage by DSM Criteria |
---|---|
Mood | Partly covered, criterion A1 |
Interest | Well covered, criterion A2 |
Cognitive content | Partly covered, criterion A7 |
Cognitive function | Well covered, criterion A8 |
Volition/motivation | Not covered |
Decision making | Well covered, criterion A8 |
Anhedonia | Well covered, criterion A2 |
Psychomotor changes | Well covered, criterion A5 |
Energy | Well covered, criterion A6 |
Speech | Not covered |
Sleep | Well covered, criterion A4 |
Anxiety | Not covered |
Appetite | Well covered, criterion A3 |
Weight | Well covered, criterion A3 |
Other physical symptoms | Not covered |
Suicidal behavior | Well covered, criterion A9 |
Circadian effects | Well covered, criterion B2 for melancholia |
Depersonalization/derealization | Not covered |
Discussion
Empirical Conclusions
This point is well captured by a recent first-person report:The typical affect is that of sadness, but has been described as being qualitatively … different to that normally experienced … the typical depressed mood thus shades into depersonalization in which the patient feels changes—strange, lifeless, detached, automatic. Sometimes, instead of feeling that they themselves have changed, the patients lay emphasis on a change in the outer world which seems dead or macabre (24, p. 157).
It was as if the whatness of each thing … the essence of each thing in the sense of the tableness of the table or the chairness of the chair … was gone. There was a mute and indifferent object in that place. Its availability to human living … in the world was drained out of it. Its identity as a familiar object that we live with each day was gone … the world had lost its welcoming quality (31, pp. 212–213).
Conceptual Issues With Our Current Approach to DSM Criteria
Illustrations of the Problems Associated With Our Category Mistake
Consequences of Our Category Mistake
Potential Limitations
While this argument has force, it falls short in three major ways. First, it fails to recognize the degree to which many mental health clinicians have conflated clinical evaluation and assessment of DSM criteria in our clinical work, research, and teaching. We often see a clinical evaluation as simply the evaluation of DSM diagnostic criteria. Second, it does not explain the diminution in psychopathological expertise and interest since the advent of DSM-III (4). Third and most importantly, the critique does not address the underlying conceptual problems of diagnostic literalism and reification that arise directly from our category mistake of confusing our fallible diagnostic criteria with the categories they are designed to assess.All you have done is pointed out the difference between diagnostic criteria and clinical evaluation. Since DSM-III, DSM has contained an “associated features” section that describes common symptoms and signs of the disorder not included as diagnostic criteria. We use diagnostic criteria for referral or treatment decisions but then put them aside and do our complete clinical evaluation.
Conclusions
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