Beck, Depression

Thinking

and

Depression

/.

_{Idiosyncratic}

Content and

Cognitive

Distortions

AARON T. BECK, MD

PHILADELPHIA

The clinical and _{theoretical papers deal¬}

ing

with the

_{psychological}

correlates of de¬

pression

have

_{predominantly}

utilized a

motivational-affective

model for

_categorizing

and

_interpreting

_{the verbal behavior of the}

patients.

The

_cognitive

_processes as _such

have

received little attention

_except

insofar as

they

were relatedtovariables suchashos¬

tility, orality,

or

guilt.1

The relative lack of

_emphasis

on the

thought

processes in

_depression

_may be a reflectionof—or

_possibly

a

contributing

_fac¬

tor to—the

_widely

heldview that

_depression

isan affective

_disorder,

_pureand

_simple,

_and

that any

impairment

of

_thinking

_{is the} re¬

sult of theaffective disturbance.2 This

_opin¬

ion has been buttressed

_by

the failure to

demonstrate

_{any consistent} evidence of ab¬

normalities in the formal

_thought

_processes

in _{the responses} to the standard

_battery

of

psychological

tests.3

_Furthermore,

_{the few}

experimental

studies of

_thinking

in

_depres¬

sion have revealed no consistent deviations

other than a retardation in the _{responses to}

"speed

tests"* _{anda lowered}

responsiveness

to a Gestalt

Completion

Test.5

In his book on

depression,

Kraines° on

the basis of clinical _{observations indicated} several

_{characteristics}

ofa

thought

disorder

in

_depression.

The

_objective

of the _present

study

has been to

determine

the

_prevalence

of a

thought

disorder among

_depressed

_pa¬

tients in

_{psychotherapy}

and to

delineate

its

characteristics.

An

_{important corollary}

_of this

_objective

has been the

_{specification}

of the

differences

from and the similarities to the

_thinking

of

_{nondepressed psychiatric}

_pa¬

tients. _{This paper will focus}

_particularly

on

the

_following

areas:

₍₁₎

_the

_{idiosyncratic}

thought

content indicative of distorted or

unrealistic

_{conceptualizations; (2)}

_{the proc¬}

esses involved in the

deviations

from

_logical

or _realistic

thinking;

₍₃₎

_{the formal char¬} acteristics of the ideation

_showing

_such

Submitted for publication

_May

6, 1963.

From the _Department of

_Psychiatry,

_University of Pennsylvania School of Medicine.

Thisinvestigation was supported _{in partby Re¬}

searchGrant M3358 from the National Instituteof

deviations;

(4)

the relation between the_cog¬ nitive distortions and the affects characteris¬ tic of

_depression.

Clinical Material

The data for this

_study

were accumulated

from interviews with 50

_{psychiatric patients}

seen

by

the author in

psychotherapy

or formal

_{psychoanalysis.}

Of the

_patients,

four

were

hospitalized

for

varying periods

of

time

_during

the treatment. The rest of the

patients

were seen on an

ambulatory

basis

throughout

their treatment.

The

_frequency

of interviews varied from

one _to six a week with the median number of interviews three a week. The total

length

of time in

_{psychotherapy}

_ranged

_{from six} months to _{six years; the median} was two

years. In no case did a

single episode

of

depression

last

_longer

than a _year. A

large

proportion

of the

_patients

continued in psy¬

chotherapy

for a substantial

period

of time after the remission of their initial

_depressive

episode.

Thirteen

_patients

either had recur¬

rent

_depressions

while in

_{psychotherapy}

or returned to

_{psychotherapy}

because of a re¬ currence.In this recurrent

_depression

_group, six had

_completely

_asymptomatic

_intervals

between the recurrencesand seven _had some

degree

of

_hypomanic

_{elevation. Itwas,}there¬

fore,

possible

to obtain data from these pa¬

tients

_during

each

_phase

of the

_cycle.

Of the 50

_patients

in the

_sample,

16 were

men and 34 were women. The _{age range}

was from 18 to 48 with a median of 34.

An estimate of their

_{intelligence suggested}

that

_they

were all of at least

_bright

average

intelligence.

The socioeconomicstatusof the

patients

was

_judged

_{to be} middle or _upper class. Twelveof the

_patients

were

diagnosed

as

psychotic

depressive

or

manic-depressive

reactions and 38as neurotic

depressive

reac¬

tions.

_(A

_study

based on six of the

patients

in this grouphas

already

been

published.7)

In

_establishing

the

_diagnosis

of

_depres¬

sion the

_following

_diagnostic

indicators were

employed: (a)

objective signs

of de¬

pression

in the

_facies,

_speech,

_posture,

and motor

activity; (b)

a

major complaint

_of

feeling depressed

or sad and _at least 11 of

the

_following

14

_signs

and _symptoms: loss of

_appetite,

_weight

_loss,

_{sleep disturbance,}

loss of

_libido,

_{fatiguability,}

_crying,

_pessi¬

mism,

suicidal

wishes,

_{indecisiveness,}

loss of sense of

_humor,

_{sense of boredom or}

apathy,

overconcern about

health,

excessive

self-criticisms,

and loss of initiative.

Patients

_showing

evidence of

_organic

brain

_damage

or of a

schizophrenic

_process

and cases in which

anxiety

or some other

psychopathological

state was more

promi¬

nent than

_depression

were excluded from

this group.

In additionto _{the group of}

_depressed

_pa¬

tients,

a _group of ₃₁

_{nondepressed patients}

were also seen in

_{psychotherapy.}

_{The com¬}

position

of this group was similar _{to the} de¬

pressed

group in

_respect

to _{age, sex,} and social

_position.

These

_patients

constituted a

"control

_group"

for this

_study.

Procedure

Face-to-face interviews were conducted

during

the

_periods

of time when the

_depres¬

sions were

regarded

as moderate to severe

in

_intensity.

The author wasactive and sup¬

portive

during

these

_periods.

Formal

_analy¬

siswas

employed

for the

long-term

_patients

except

when

_they

_appeared

to be

_seriously

depressed;

the couch was

utilized,

free as¬

sociation was

encouraged,

and the

_psychi¬

atristfollowedthe

_policy

of minimal

_activity.

The recorded data used as the basis for this paper were handwritten notes made

_by

the

author

_during

_the

_{psychotherapeutic}

_inter¬

views. These data included

_{retrospective}

reports

by

the

_patients

of

_feelings

_and

thoughts prior

to the sessions as _{well as}

spontaneous

reports of _their

_feelings

and

thoughts during

the sessions. In

_addition,

several

_{patients regularly kept}

_{notesof their}

feelings

and

_thoughts

between

_{psychothera¬}

peutic

sessions and

_reported

these to the

psychiatrist.

During

the

_period

in which these data

were collected handwritten _{records of the}

verbalizations of the

_{nondepressed patients}

were made. These notes wereused for_pur¬

poses of

_comparison

with _{the verbal reports}

Findings

It was found that each of the

depressed

patients

differed from the

_patients

in the

nondepressed

groups in the

preponderance

of certain

themes,

which will be outlined

below.

Moreover,

each of the other

noso-logical

groups showed an

idiosyncratic

idea-tional content which

_{distinguished}

them

from each other as well as from the de¬

pressed

group. The

typical

ideational content of the

_depressed

_patients

was characterized

by

themes of low

_{self-esteem, self-blame,}

overwhelming responsibilities,

anddesires to

escape; of the

_anxiety

states

by

themes of

personal

danger;

of _the

_hypomanic

_states

_by

themes of

_{self-enhancement;}

and _{of the} hos¬

tile

_paranoid

states

_by

themes of accusations

against

others.

Although

each

_nosological

_{group showed}

particular

types

of

_thought

content

_specific

for that group, the formal characteristics and processes of distortion involved in the

idiosyncratic

ideation were similar for each

of these

_{nosological categories.}

The proc¬ esses _{of distortion and the formal character¬}

istics will be described in _{later sections of}

the paper.

Thematic Content of

_Cognitions

The

_types

of

_cognitions

* _{outlined below}

were

reported by

the

depressed patients

to

occur under two

_general

conditions.

First,

the

_{typical depressive cognitions}

were ob¬ served in response to

_particular

kinds of ex¬

ternal "stimulus situations." These were

situations which contained an

ingredient,

or

combination of

_ingredients,

whose content had some relevance to the content of the

idiosyncratic

response. This

stereotyped

re¬

sponse was

frequently

completely

irrelevant

and

_{inappropriate}

tothe situation as awhole. For

instance,

any

experience

which touched

in any way on _the

subject

_{of the}

patient's

personal

attributes

_{might immediately}

make

him think he was

inadequate.

A _young man _would

_respond

_with

self-derogatory thoughts

to any

interpersonal

situation _{in which another person}

_appeared

indifferent to him. If a

passerby

on the street did not smile at

him,

he was _prone

tothink he wasinferior.

Similarly,

a woman

consistently

had the

_thought

she was a bad mother whenever she saw another woman

with a child.

Secondly,

the

_{typical depressive}

_thoughts

were observed in the

patients'

_ruminations

or "free

associations," ie,

_when

_they

were

not

_reacting

to an immediate external stim¬ ulus and were not

attempting

to direct their

thoughts.

The

_{severely depressed}

_patients

often

_experienced

_long,

_{uninterrupted}

se¬

quences of

depressive

associations,

_complete¬

ly

independently

of the external situation.

Low

_{Self-Regard.—The}

_{low self-evalua¬}

tions formed a _very

_prominent

_{part of} the

depressed patients'

ideation. This

_generally

consisted of an unrealistic

downgrading

of

themselves in areas that were of

particular

importance

to them. A brilliant academician

questioned

his basic

_{intelligence,}

an attrac¬ tive

_society

woman insisted she had become

repulsive-looking,

and a _{successful business¬} man

began

tobelieve he had no real business

acumenandwas headed for

bankruptcy.

The low

_{self-appraisal}

was

applied

_{to per¬}

sonal

_attributes,

such as

ability,

virtue,

at¬

tractiveness,

and

health;

acquisitions

of

tangibles

or

intangibles

(such

as love or

friendship)

; or

_past

performance

in one's career or role as a _spouse or _parent. In

making

these

_{self-appraisals}

the

_depressed

patient

was prone to

_magnify

_{any failures}

or defects and _{to minimize} or

ignore

_any favorable characteristics.

A very common feature of the

self-evaluations was the

comparison

with other

people,

particularly

those in his own social

or

occupational

_{group. Almost}

uniformly,

in

_making

his

_comparisons,

the

_depressed

patient

tended to rate himself as inferior.

He

_regarded

himself as less

intelligent,

_less

productive,

less

attractive,

less

_financially

secure, or less successful as a _spouse or

parent than _those in _his

_comparison

_group.

These types of

_{self-ratings comprise}

the

*_{The termcognition is used in the presenttreat¬}

ment to refer to a specific thought, such as an in¬

terpretation, a self-command, or a self-criticism.

Thetermis also appliedtowishes (such as suicidal

"feeling

of

_{inferiority,"}

which have been noted in the literature on

depressives.

Ideas

_{of Deprivation.—Allied}

to the low

self-appraisals

are the ideas of destitution

that were seen in certain

depressed patients.

These ideas were noted in the

patient's

ver¬

balized

_thoughts

that he was

alone,

un¬

wanted,

and

_unlovable,

often in the face of

overt demonstrations of

_friendship

and af¬ fection from other

_people.

The sense of

deprivation

was also

applied

to _{material pos¬}

sessions,

despite

obvious evidenceto thecon¬

trary.

S

_{elf-Criticisms}

and

_{Self-Blame.—Another}

prominent

theme in the

_reported

_thoughts

of the

_{depressed patients}

was concerned

with self-criticisms and self-condemnations. These themes should be differentiated from

the low self-evaluations described in the pre¬

vious section. While the low self-evaluation refers

_simply

to the

_appraisal

of themselves relative to their

_comparison

group or their

own

standards,

the self-criticisms _represents

the

_reproaches

_they

leveled

_against

them¬ selves for their

_{perceived shortcomings.}

It

should be

_pointed

out,

however,

that not all

patients

with low self-evaluations showed self-criticisms.

It was

noteworthy

that the

self-criticisms,

just

as thelow

self-evaluations,

were

applied

to those

_specific

attributes or behaviors which were

highly

valued

by

the individual. A

_depressed

_woman, for

_example,

con¬ demned herself for not

_having

breakfast

ready

for her husband. On another occa¬

sion, however,

she

_reported

a sexual affair with one of _his

colleagues

without _{any evi¬} dence of

_regret,

self-criticism,

or

guilt:

Competence

as a housewife was one of _her

expectations

of herself whereas marital fi¬

delity

was not.

The

_patients'

_tendency

to blame them¬

selves for their mistakes or

shortcomings

generally

had no

logical

basis. This was

demonstrated

by

a housewife who took her children on a

picnic.

When a thunderstorm

suddenly appeared

she blamed herself for

not

having picked

a better

day.

Overwhelming

Problems and Duties.—

The

_{patients consistently magnified}

the

magnitude

of

_problems

or

responsibilities

that

_they

would consider minor or

insignifi¬

cant when not

_depressed.

A

_depressed

_housewife,

when confronted with the

_necessity

of

_sewing

"name

_tags"

on her children's clothes in

_preparation

for

camp,

perceived

this asa

gigantic

undertak¬

ing

which would take weeks to

_complete.

When she

_finally

did

_get

to work at

it,

she was able tofinish the task in less than a

day.

S

_elf-C

ommands and

Injunctions.—Self-coercive

_cognitions,

while not

_prominently

mentioned in the literature on

depression,

appeared

to form a substantial

proportion

of the verbalized

_thoughts

of the

_patients

inthe

sample.

These

_cognitions

consisted of con¬

stant

"nagging"

or

prodding

to do

_particu¬

lar

_things.

The

_prodding

would

_persist

even

though

it was

impractical,

undesirable,

or

impossible

for the _personto

_implement

these self-instructions.

In a number of _cases, the _{"shoulds" and} "musts" were

applied

to an enormous _range

of

activities,

_{many of which} were

mutually

exclusive. A housewife

_reported

that in a

period

of a few

minutes,

she had

compelling

thoughts

to clean the

house,

lose some

weight,

visit a sick

friend,

be a "Den

Mother,"

get

a full-time

job, plan

_{the week's}

menu, return to

_college

for a

degree,

spend

more time with her

children,

take a _memory

course, to be moreactive in_women's

organi¬

zations,

and start

_putting

_{away her}

_family's

winter clothes.

Escape

and Suicidal

_{Wishes.—Thoughts}

about

_escaping

from the

_problems

of life

were

_frequent

_among all _the

patients.

_Some had

_daydreams

of

_being

a hobo or

going

to

a

tropical

paradise.

Itwas

unusual,

however,

that

_evading

the tasks

_brought

_{any relief.}

Even when a

_temporary

respite

was taken

on the advice of the

_{psychiatrist,}

_{the pa¬}

tients were prone to blame themselves for

"shirking

responsibilities."

The desire to escape seemed to be related to the

_patients'

_viewing

themselves at an im¬

passe. On the one

hand,

they

sawthemselves

as

incapable, incompetent,

and

_helpless.

_On the other hand

_they

saw their _tasks as _pon¬ derous and formidable. Their _response was

a wish to withdraw from the "unsolvable"

problems.

Several

_patients

_spent

consider¬

able time in

bed;

somehid under the covers.

The suicidal

_{preoccupations similarly}

seemed related to the

_{patient's conceptuali¬}

zation of his situation as untenable or

hope¬

less. He believed he could not tolerate a continuation of his

_suffering

and he could

see no solution to the

_problem:

The

_psychi¬

atrist couldnot

_help

_him,

his

_symptoms

could

not be

_alleviated,

and his various

_problems

could not be solved. The suicidal

_patients

generally

stated that

_they

_regarded

suicide

as the

only possible

solution _{for their "des¬}

perate"

or

_"hopeless"

situation.

Typology

of

_Cognitive

Distortions The

_preceding

section

_attempted

to delin¬ eate the

_typical

thematic content of the ver¬

balizations of _the

_depressed

_patients.

A crucial characteristic of _the

_cognitions

with

this content was that

they represented

_vary¬

ing

degrees

of distortion of

_reality.

While

some

degree

of

inaccuracy

_and

inconsistency

would be

_expected

in the

_cognitions

of any

individual,

the

_{distinguishing}

characteristic

of the

_{depressed patients}

was that

they

showeda

systematic

_error;

viz,

a bias

against

themselves.

_Systematic

errors were also noted in the

_{idiosyncratic}

ideation of the other

_nosological

_groups.

The

_{typical depressive cognitions}

can be

categorized

according

to _{the ways in which}

they

deviate from

_logical

or realistic think¬

ing.

The _{processes may} be classified as

paralogical

(arbitrary inference,

selective

abstraction,

and

_{over-generalization), stylis¬}

tic

_{(exaggeration),}

or _semantic

_(inexact

la¬

beling).

These

_cognitive

distortions were

observed at all levels of

_depression,

from

the mild neurotic

_depression

to the severe

psychotic.

While the

_thinking

disorder was

obvious in the

_psychotic

_depressions,

it was

observable in more subtle _{ways among} all

the neurotic

_depressed.

Arbitrary interpretation

is defined as the process of

forming

an

interpretation

of a

situation,

event, or

experience

when there is

no factual evidence to

_support

the conclusion

or when the conclusion is

_contrary

_{to the}

evidence.

A

_patient

_riding

on the _{elevator had the}

thought,

"He

_(the

elevator

_operator)

thinks I'm a

nobody."

The

patient

then felt sad. On

_being

_{questioned by}

the

_{psychiatrist,}

he realized there was no factual basis for his

thought.

Such misconstructions are

particularly

proneto occur_{when the}cues are

ambiguous.

An

_intern,

for

_example,

became

_quite

dis¬

couraged

when he received an announce¬

ment that all

_patients

_"worked-up"

_by

the interns should be examined

_subsequently

_by

the resident

_physicians.

His

_thought

on

reading

the announcement was, "The chief doesn't have faith _{in my} work." In this in¬

stance, he

_personalized

the event

_although

therewas noostensible reasonto suspectthat his

_particular

_performance

had

_anything

to do with the

_policy

decision.

Intrinsic to this

_type

of

_thinking

is the lack of consideration of the alternative ex¬

planations

that are more

plausible

and more

probable.

The

intern,

when

_questioned

about other

_{possible explanations}

for the

policy

decision,

then recalled a

previous

statement

_by

his "chief" to the effect that he wanted the residents to have more con¬

tact with the

_patients,

as

_part

of their train¬

ing.

The idea that this

_explicitly

stated

objective

was the basis for the _new

policy

had not

previously

occurred to him.

Selective abstraction refers to the process

of

_focusing

on a detail taken out of context,

ignoring

other more salient features of the

situation,

and

_{conceptualizing}

the whole ex¬

perience

on thebasis of this element.

A

_patient,

in

_reviewing

her secretarial work with her

_employer,

was

_praised

about

a number of

_aspects

of her work. The em¬

ployer

at one

point

asked her to discontinue

making

extra carbon

_copies

of his letters. Herimmediate

_thought

_was, "He is dissatis¬ fiedwith _mywork." This ideabecame _para¬ mount

_despite

all the

_positive

statements he had made.

Overgeneralization

was manifested

by

the

con-elusion about their

_ability,

_performance,

or worthon thebasis ofa

single

incident.

A

_patient

_reported

the

_following

_sequence

of _events which occurredwithin a

period

of half an hour before he left the house: His

wife was

_upset

because the children were

slow in

_getting

dressed. He

_thought,

"I'm a _poor father because the children are not better

_{disciplined."}

He thennoticeda faucet was

leaky

and

thought

this showed he was

alsoa _poorhusband. While

driving

_to

work,

he

_thought,

"I mustbea_poordriveror other cars would _{not be}

passing

_me." As he ar¬

rived at work he noticed some other _per¬

sonnel had

_already

arrived. He

_thought,

"I

can'tbeverydedicatedor I would have come

earlier." When he noticed folders and pa¬ pers

piled

uponhis

desk,

he

concluded,

"I'm a _poor

organizer

because I have so _much work to do."

Magnification

and minimization refer to

errors in evaluation which are so _gross as

toconstitute distortions. As described in the section on thematic content, these _processes were manifested

by

underestimation of the

individual's

_performance,

achievement or

ability,

and inflation of the

_magnitude

of his

problems

and tasks. Other

_examples

were

the

_exaggeration

of the

_intensity

or

signifi¬

cance of a traumatic event. It was fre¬

quently

observed that the

_patients'

initial reactiontoan

unpleasant

eventwasto

_regard

it as a

catastrophe.

It was

generally

found

on further

inquiry

thatthe

perceived

disaster

was often a

relatively

minor

problem.

A man

reported

that he had been

_upset

because of

_damage

to his house as the result

of a storm. When he first discovered the

damage,

hissequence of

_thoughts

were, "The side of the house is wrecked. ... It will cost

a _fortune to fix it." His immediate reaction was that his

repair

bill would be several thousand dollars. Afterthe initial shock had

dissipated,

he realized that the

_damage

was minor and that the

_repairs

would cost around

_$50.

Often inexact

_labeling

seemsto contribute to this kind of distortion. The affective re¬

action is

_proportional

to the

_descriptive

la-beling

of the event rather than to the actual

intensity

of a traumatic situation.

A man

reported

during

his

therapy

hour

that he was _very

_upset

because he had been

"clobbered"

_by

his

_superior.

On further re¬

flection,

he realized that he had

_magnified

the

incident and that a more

adequate descrip¬

tion was that his

supervisor

"corrected an error" he had made. After

_{re-evaluating}

the

event, he felt better. He also realized that whenever he was correctedor criticized

by

a

person in

authority

he was prone to de¬ scribe this as

being

"clobbered."

Formal Characteristics of

_Depressive

Cognitions

The

_previous

sections have

_attempted

to

categorize

the

_typical

thematic contents of the verbalized

_thoughts

of

_{depressed patients}

and to present observations

_regarding

the processes involved in the

_conceptual

errors

and distortions.

The inaccurate

_{conceptualizations}

withde¬

pressive

content have been labeled

_"depres¬

sive

_cognitions."

This section will

_present

a summary of the

specific

formal characteris¬ tics of the

_{depressive cognitions}

as

_reported

by

the

_patients.

One of the

_striking

features of the

_typical

depressive cognitions

is that

_they

_generally

were

experienced by

the

patients

as

arising

as

though they

were automatic _responses,

ie,

without any

apparent

antecedent reflection

or

reasoning.

A

_patient,

for

_example,

observed that when he was in a situation in which _some¬

body

else was

receiving

_praise,

_{he would}

"automatically"

have the

_thought,

"I'm no¬

body

. . . I'm not

good

enough."

Later,

when he reflected on his _{response, he would}

then

_regard

it as

inappropriate.

_Nonethe¬

less,

his immediate _responses to such situa¬ tions continued to be a self-devaluation.

The

_depressive

_thoughts

not

_only

_ap¬

peared

to be

"automatic,"

in the sense

just

described,

but

_they

seemed, also,

to have an

involuntary quality.

The

_patients

_frequently

reported

that these

_thoughts

would occur

even when

they

had resolved "not to have them" or were

actively trying

to avoid them.

This

_involuntary

characteristic was

_clearly

exemplified by repetitive

thoughts

of suicidal

content but was found in a less dramatic way in other

types

of

_{depressive cognitions.}

Anumberof the

_patients

wereabletoantici¬

pate

the kind of

_{depressive thoughts}

that would occur in certain

specific

situations and would prepare themselves in advance to

make a more realistic

judgment

of the situa¬ tion.

Nevertheless,

despite

the intention to ward off or control these

thoughts, they

would continue to

_pre-empt

a more rational

response.f

Another characteristic of the

_depressive

thoughts

is their

_plausibility

to the

_patient.

At the

_beginning

of

_therapy

the

_patients

tended to

_accept

the

_validity

of the

_cogni¬

tions

_{uncritically.}

It often

_required

con¬

siderable

_experience

in

_observing

these

thoughts

and

_attempting

to

_judge

them ra¬

tionally

for the

_patients

to

recognize

them

as distortions. It was noted that the more

plausible

the

_cognitions

seemed

_(or

the more

uncritically

the

_{patient regarded them),}

the

stronger

the affective reaction. It was also

observed that when the

_patient

was able to

question

the

_validity

of the

_thoughts,

the affective reaction was

generally

reduced.

The converse of this also

appeared

to be true: When the affective reaction to a

thought

was

particularly

_strong,

its

plausi¬

bility

became enhanced and the

_patient

found itmoredifficultto

_appraise

its

_validity.

Fur¬

thermore,

once a

_strong

affect was aroused in response to a distorted

cognition,

_any

subsequent

distortions seemed tohave anin¬

creased

_{plausibility.}

This characteristic ap¬

peared

to be

_present

_irrespective

of whether the affect was

sadness,

_anger,

anxiety,

or

euphoria.

Once the affective response was

dissipated,

however,

the

_patient

could then

appraise

these

_cognitions

_critically

and rec¬

ognize

the distortions.

A final characteristic of the

_depressive

cognitions

was their

perseveration.

Despite

the

_multiplicity

and

_complexity

of life situ¬

ations,

the

_{depressed patient}

was _prone to

interpret

awide _range of his

experiences

in terms of a few

stereotyped

ideas. The same

type

of

_cognition

would be elicited

_{by highly}

heterogeneous experiences.

In

_addition,

these

_{idiosyncratic}

_cognitions

tended to oc¬

cur

repetitively

in the

patients'

ruminations and stream of associations.

Relation of

_{Depressive Thoughts}

to Affects

As _part of the

_{psychotherapy,}

the author

encouraged

the

_patients

toattempt to

specify

as

precisely

as

possible

their

feelings

andthe

thoughts they

had in relation to these feel¬

ings.

A number of

_problems

were

presented

in

the

_attempt

to obtain

_{precise description}

and

labeling

of the

_feelings.

The

_patients

had

no

difficulty

in

designating

their

feelings

as

pleasant

or

unpleasant.

In the

unpleasant

group of affects

they

were

readily

able to

specify

whether

_they

felt

_{depressed (or sad),}

anxious,

angry, and embarrassed. When

they

were asked to discriminate further among the

depressed feelings,

therewascon¬

siderable

_variability

in the group. Most of

the

_patients

were able _to differentiate witha reasonable

_degree

of

_certainty

_among the

following feelings

:

sad,

discouraged,

hurt,

humiliated,

guilty,

empty,

and

_lonely.

In

_attempting

to determine the relation of

_{specific feelings}

to a

specific thought,

the

patients

developed

the routine of

_trying

to focus their attentionon their

thoughts

when¬

ever

they

had an

unpleasant

feeling

or when the

_feeling

became intensified. This often meant

"thinking

back" after

_they

were aware

of the

_unpleasant

_feeling

to recall the con¬

tent of the

_{preceding thought. They}

fre¬

quently

observed that an

unpleasant thought

preceded

the

_unpleasant

affect.

The most

_noteworthy

_finding

was that when the

_thoughts

associated with the

de-tThe foregoing features may suggest that the

depressive thoughts are essentially a type of obses¬ sional thinking. The depressive thoughts, however,

differ from classical obsessional thinking in that their specific content varies according to the par¬ ticular stimulus situation and also in that they are

associated with an affective response. Obsessional

thoughts,on_{the other}hand,tendtoretainessentially the same "wording" with each repetition are _gen¬

erally regarded by the patient as a "strange" or

pressive

affects were identified

they

were

generally

found to contain the _type of con¬

ceptual

distortions or errors

already

de¬

scribed as well as the

typical depressive

thematic content.

_Similarly,

when the af¬

fect was

anxiety,

_anger, or

elation,

the as¬

sociated

_cognitions

had a content

_congruent

with these

_feelings.

An _attempt was made _to

classify

the cog¬ nitions to determine whether there were_any

specific

features that could

_distinguish

among the

types

of

_cognitions

associated re¬

spectively

with

_depression,

_anger, or elation.

Itwas

found,

as

might

be

expected,

that the

typical thoughts

associated with the

_depres¬

sive affect centered around the ideas that the individual was deficient in some sort of

way.

Furthermore,

the

specific

types

of de¬

pressive

affect were

generally

_consistent

with the

_{specific thought}

content.

Thus,

thoughts

of

_being

_{deserted, inferior,}

or derelict in some _way, were associated re¬

spectively

with

_feelings

of

_loneliness,

hu¬

miliation,

or

guilt.

In the

_nondepressed

_{group, the}

_thoughts

associated with the affect of

_anxiety

had the theme of

_anticipation

of some

_unpleasant

event.

Thoughts

associated with anger had an element of blame directed

against

some other person or _agency.

Finally,

feelings

of

euphoria

were associated with

thoughts

that were

self-inflating

in some _way.

Comment

It has been noted that "the

_{schizophrenic}

excels in his

_tendency

to misconstrue the world that is

_presented.

. .

."8 _{While the}

validity

of this statement has been

_supported

by

numerous clinical and

experimental

stud¬

ies,

it has not

_generally

been

_acknowledged

that misconstructions of

_reality

_may also be a characteristic feature of other

psychiatric

disorders. The present

study

indicates

that,

even in mild

phases

of

depression,

_sys¬ tematic deviations from realistic and

_logical

thinking

occur. A crucial feature of these

cognitive

distortions is that

_they

_consistently

appeared only

in the ideational material that

had a

typically depressive

_content; for ex¬

ample,

themes of

_being

deficient in some

way. The other ideational material

reported

by

the

_{depressed patients}

did not _{show any}

systematic

errors.

The

_{thinking-disorder typology}

outlined in this paper is similar to that described in studies of

_{schizophrenia.}

While some of the

most

flagrant schizophrenic

_{signs (such}

as

word-salad,

metaphorical

speech,

neolo¬

gisms,

and

_{condensations)}

were not ob¬

served,

the kinds of

_paralogical

_{processes in} the

_{depressed patients}

resembled those de¬

scribed in

_{schizophrenics.8}

_Moreover,

the same kind of

paralogical thinking

was ob¬

served in the

_{nondepressed patients}

in the

control group.

While each

_nosological

_category

showed a

distinctive

_thought

content, the differences in terms of the

_processes

involved in the deviant

_{thinking appeared}

to be

_quantitative

rather than

_qualitative.

These

_findings

_sug¬

gest

thata

thinking

disorder_maybe common to all

_types

of

_{psychopathology.}

_{By apply¬}

ing

this concept to

psychiatric

classification,

it would be

_possible

to characterize the spe¬

cific

_nosological

_categories

in _terms of the

degree

of

_{cognitive impairment}

and the _par¬ ticular content of the

_{idiosyncratic cogni¬}

tions.

The failure of various

_{psychological}

tests

to reflect a

thinking

disorder in

depres¬

sion3'4·5 _{warrants consideration. It may be}

suggested

that the

_particular

tests

_employed

may not have been

_{adequately designed}

for the purpose of

_detecting

the

_thinking

devia¬ tions in

_depression.

_{Since clinical observa¬}

tion indicates that the

_{typical cognitive}

distortions in

_depression

are limited to

specific

content areas

(such

as _{self-devalua¬}

tions),

the various

_{object-sorting,}

proverb-interpreting,

and

_projective

tests may have missed the essential

_pathology.

_{It may} be noted that even in studies of

schizophrenia,

the demonstration of a

thinking

disorder is

dependent

on the

_type

of test administered and the characteristics of the

_experimental

group. Cohenet

al,5

for

_example,

foundthat

the

_only

instrument

_eliciting

abnormal re¬

sponses in acute

_{schizophrenics}

was the

Rorschach test whereas chronic schizo¬

Completion

testaswellas on the Rorschach.

The clinical

_finding

of a

thinking

disor¬ der at all levels of

_depression

should focus attention onthe

problem

of

defining

the_pre¬ cise

_relationship

of the

_cognitive

distortions to the characteristic affective state in

_depres¬

sion. The

_diagnostic

manual of the Ameri¬ can

Psychiatric

Association

(APA)2

defines

the

_psychotic

affective reactions in terms of

"a

_primary,

severe disorder of mood with

resultant disturbance of

_thought

and behav¬

ior,

in consonance _with the _affect." Al¬

though

this is a

widely accepted

_concept,

the

conversewould appeartobeat leastas

plau¬

sible; viz,

that there is

_primary

disorder of

thought

with resultant disturbance of affect and behavior in consonance with the

cogni¬

tive distortions. This latter thesis is con¬

sistent with the

_conception

that the way an

individual structures an

experience

deter¬

mines his affective response to it.

If,

for

example,

he

_perceives

a situation as dan¬ gerous, he may be

expected

to

respond

with a consonant

_affect,

such as

anxiety.

It is

_proposed,

therefore,

that the

_typical

depressive

affects are evoked

by

the erro¬ neous

conceptualizations:

If the

patient

in¬

correctly perceives

himself as

inadequate,

deserted or

sinful,

he will

experience

cor¬

responding

affects such as

sadness,

loneli¬

ness, or

guilt.

On the other

hand,

the

possibility

that the evoked affect may, in

turn, influence the

_thinking

should be con¬

sidered. It is conceivable that once a de¬

pressive

affect has been

aroused,

it will facilitate the emergence of further

_depres¬

sive-type cognitions.

A continuous interac¬

tion between

_cognition

and affect may,

consequently,

be

_produced

and, thus,

lead to

the

_typical

downward

_spiral

observed in de¬

pression.

Since it seems

likely

that this

interaction would be

_highly

_complex,

appro¬

priately designed

experiments

would bewar¬ ranted to

clarify

the

_{relationships.}

A

_{thorough exposition}

of the theoretical

significance

of the clinical

_findings

is be¬

yond

the scope of this paper. It may be

tentatively

suggested

that in

_depression

there is a

significant

_{rearrangement}

of the

cogni¬

tive

_{organization.}

This modified

organiza-tion channels a

large proportion

of the

thinking

in the direction of

_negative

self-evaluations,

nihilistic

_predictions,

and

_plans

for escape or suicide. It is

postulated

that this

_particular

shift in the

_thought

content results

_specifically

from the activation and

dominance of certain

_{idiosyncratic cognitive}

patterns

(schémas),

which have a content

corresponding

to the

_typical

_depressive

themes in the verbal material. To the ex¬

tent that these

_{idiosyncratic}

schémas su¬

persede

more

appropriate

_{schémas in the}

ordering,

differentiation,

and

_analysis

of ex¬

perience,

the

_resulting

_{conceptualizations}

of

reality

will be distorted. A more

complete

formulation of the

_{cognitive organization}

in

depression

has been

_presented

in another

paper.9

Before this discussion is

_concluded,

a few

methodological

problems

should be men¬

tioned. A

_question

could be

raised,

for ex¬

ample,

regarding

the

_{generalizability}

of the

observations. Since the

_sample

consisted

largely

of

_{psychotherapy patients}

of a rela¬

tively

narrow _range of

intelligence

and social

index,

there may be some

uncertainty

as to whether the

_findings

are

applicable

to the

_general

_population

of

_depressed

_patients.

A

_previous

_{study by}

the author and his

co-investigators

is

_pertinent

to this

_question.

An

_inventory

was derived from the ver¬

balized

_{self-appraisals}

of _the

_depressed

_pa¬

tients included in the present

_study.

A

systematic

study

of the responses to this in¬

strument

_by

a much

larger

and more

heterogeneous

clinic and

_{hospitalized sample}

demonstrated that the

_self-reports

of the

psychotherapy

group were

representative

_of

the much broader

_group.10

In _{view of the obvious}

_{methodological}

problems

associated with

_using

data from

handwritten notes of

_{psychotherapy}

ses¬

sions,

it is

_apparent

that the

_findings

of the

present

study

will have to be

_subjected

to verification

_by

more refined and

_systematic

studies. One

_{promising approach}

has been

developed

by

Gottschalk et aln _{who utilized} verbatim

_recordings

of five-minute

_periods

of free association

_{by depressed patients}

and

subjected

this material to blind

_{scoring by}

trained

_judges.

Such a

procedure

circum¬ vents the hazards of

therapist

bias and sug¬

gestion

associated with verbal material recorded in

_{psychotherapy}

interviews.

Summary

and Conclusions

A group of 50

_depressed

_patients

in

psychotherapy

and a control group of 31

nondepressed patients

were studied to de¬ termine the

_prevalence

and_typesof

_cognitive

abnormalities. Evidence of deviation from

logical

and realistic

_thinking

was found at

everylevel of

depression

from mild neurotic

to severe

psychotic.

The ideation of the

_{depressed patients}

dif¬ fered from that of the

_nondepressed

in the

prominence

of _certain

_typical

_{themes; viz,}

low

self-evaluation,

ideas of

_deprivation,

ex¬

aggeration

of

_problems

and

difficulties,

self-criticisms and

self-commands,

and wishesto

escape or die.

Similarly,

each of the

non-depressed nosological

groups could be dif¬

ferentiatedon the basis of their

idiosyncratic

thought

content.

Abnormalities were detected

consistently

only

in those verbalized

_thoughts

that had

the

_typical

thematic content of the

_depressed

groups. The other kinds of ideation did not show any consistent distortion.

_Among

the deviations in

_thinking,

_the

_following

_proc¬ esses were identified:

arbitrary

inference,

selective

abstraction,

_{over-generalization,}

and

_{magnification}

and minimization.

Since

_paralogical

_processes were also ob¬

served in the

_{idiosyncratic}

ideation of

non-depressed patients,

it was

suggested

that a

thought

disorder_maybe common toall

_types

of

_{psychopathology.}

The thesis was ad¬

vanced that the various

_nosological

_groups could be classified on _{the basis} of the

degree

of

_cognitive

distortion and the characteristic content of their verbalized

_thoughts.

In _{view of the observation that the dis¬}

torted ideas of the

_depressed

_patients

ap¬

peared

immediately

before the arousal or intensification of the

_typical

_depressive

af¬

fects,

it was

suggested

that the affective

dis-turbance may be

secondary

to the

_thinking

disorder. The

_possibility

of a

reciprocal

in¬

teraction between

_cognition

_and affect was

also raised.

The thesiswas advancedthat the

_cognitive

distortions in

_depression

result from the

progressive

dominance of the

_thought

processes

_by

idiosyncratic

schémas.

_By

su¬

perseding

more

_appropriate

_schémas,

the

idiosyncratic

schémas force the

_{conceptuali¬}

zation of

_experience

into certain

_rigid

_pat¬

terns with the _consequent sacrifice of

realisticand

_logical

_qualities.

Aaron T. _{Beck, MD,} 133 S 36th _{St, Philadelphia}

4, Pa.

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_Springfield,

111: Charles C Thomas,

Publisher, 1960.

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Psychological

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1959.

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_Language

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Paper,

1963.

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