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Psychoanalysis First Year           DEPRESSION

Teaching Notes - Judith Hamilton M.D.

Seminar 1: History and Basic Concepts 

The following notes are from Myer Mendelson (1974) Psychoanalytic Concepts of Depression. Spectrum Publications, Inc., Flushing, New York.

Prepsychoanalytic Concepts

An on-going debate in the literature on sub-groups of depression:

19th century - idea of morbid taints and heredity

Late 19th century - Manic-Depressive Psychosis versus Dementia Praecox (Kraepelin) - depends on recoverability. Dementia Praecox became known as Schizophrenia (Bleuler).

20th century - included Involutional Melancholia - an agitated depression in post-menopausal women.

Then Neurotic Depression - not psychotic.

Then Endogenous versus Exogenous Depression according to absence or presence of apparent precipitating cause.

And Psychotic versus Neurotic Depression according to presence or absence of delusions.

Then Unipolar (only depressions) and Bipolar (alternating manic and depressive periods) Manic-Depressive Disorder 

Then Primary and Secondary (to physical disease) Affective Disorder

Primary Affective disorder included Manic-Depressive, types 1 and 2 and Recurrent Depression

Psychoanalytic Concepts

 The following notes are from Edith Jacobson – 1971 – Normal and pathological moods: their nature and functions, in Depression: Comparative Studies of Normal, Neurotic and Psychotic Conditions. I.U.P., New York, 66-106.                              Ego Psychology

A. Affect (affective state, feeling, emotions) – early, Freud equated the affects with the energetic forces; later (1915a) he defined affects as a subjective, conscious experience, one part of the drive representation, the other part being the idea. In The Unconscious (1915b) Freud distinguished between affects and feelings, affects referring to the whole set of psychophysiological discharge phenomena, physiological insofar as they express themselves in body changes and psychological insofar as they are perceived as feelings. Examples: love or hate and their derivatives. (American psychology favoured the term “emotions” for the combined physiological and psychological manifestations.)

Jacobson recommends that psychoanalysis use the term “emotion” synonymously with affects to refer to the whole complex set of psychological and physiological manifestations. (including affective motor, behaviour patterns, and affect equivalents). Even in the most “detached” ego states and ego functions we are never without emotions and feelings.

Freud described affects as originating in the ego, but the energic tensions that stimulated them may arise anywhere in the psyche. (e.g. guilt arising from conflict between the ego and the superego). Affects develop from specific though possibly complex tensions, and relate to definite ideational representations; ie. object-directed emotional states. 

B. Mood - examples: sad, hopeless, depressed, angry, irritable, hostile, persecutory, expectant, elated, gay, triumphant. Think about the relation to attitudes.

· definition: temporary fixation of generalized discharge modifications, induced by a significant experience whose discharge pattern lends its quality to all simultaneous discharge patterns. (p. 71)

· represents a cross-section through the entire state of the ego; particular qualities of feelings, thoughts, performances during the whole day, no matter what their object.

· induced by significant emotional experiences expressive of one or more focal discharge processes; such an experience may be stimulated from within, or from without, and need not come to full awareness; it may be significant in terms of current reality, or because it is associated with significant conscious or unconscious memories.

· once established, it affects all patterns of responses to stimuli or objects; have generalized transference phenomena.

· mechanisms involved: to produce a mood, the provocative experience must be of a particular intensity and cause unusually high energetic tensions which cannot be immediately and sufficiently relieved by a focal discharge process only. The memories of the provocative experience will remain strongly hypercathected. The provocation results in temporary, qualitative modifications of the concepts of the self (representations) and of the entire object world. Certain concepts are hypercathected; contradictory inferences derived from past experiences are hypocathected (relatively denied). Since our moods affect our attitudes and behaviour patterns, the responses we get from others as a result of our actions will commonly tend to confirm and promote the notions on which our mood is based, until reality interferes sufficiently [eg. through interpretation, or lived experience] to bring about changes of these concepts and consequently of our mood.

· the economic function of moods; early mood dispositions and their development: If it is characteristic of all moods that they allow a repetitive affective discharge on a great number and variety of objects, such a prolonged discharge in small quantities, combined with reality testing, must liberate psychic energy from fixated positions and reopen the gate to new investments. This process tends to protect the ego from the dangers of too explosive overwhelming discharge; ie. a primitive economic function. The ultimate economic success will, however, depend largely on the extent to which this prolonged discharge process permits true reality testing.

 "Moodiness", inappropriate moods, conspicuous or prolonged swings of mood predominate in persons whose ego operates frequently on a primary process level with high quantities of deneutralized energy which threatens to be discharged suddenly. Their ego lacks the capacity for subtle, “secondary process” modes of economic functioning and affective defense. 

 We can observe individual predispositions to certain prevailing or recurring mood conditions already in earliest childhood. Reveals the child’s predilection for special affectomotor reactions, and/or the influence of repetitive or prolonged exposure to the same type of experiences. 

 Study manic-depressive states, which show a severe pathology of the superego functions - superego formation has a singular influence on the development of affect and mood control and thus of mood predisposition. It has a modulating effect on emotional expression in general; the rises and falls of self-esteem become indicators and regulators of the self- and object-directed cathexes in the total ego, and of the resulting discharge processes. Superego approval or disapproval may no longer relate to special, unacceptable instinctual strivings, but rather refer to opposite notions of the total self in terms of black and white, of “being good, expecting reward” or “being bad, expecting punishment”. Consider also persecutory mood. These characteristics are narcissistic aspects of the self.

The conspicuousness of early infantile affective and mood predispositions shows the extent to which they are determined by such factors as the child’s inherent drive intensity, the depth and intensity of his object cathexes, his inherent tendency to respond to frustration, hurt or deprivation with lesser or greater, rapidly passing or more enduring ambivalence. 

Comparing normal and pathological mood qualities or mood swings: In normal, find a much wider range, more subtle, more intense, as well as tamed, controlled. In pathological, find, narrow range, not well controlled.   

Two Normal Types of Mood Variations; The Nature of sadness and grief, of gaiety and cheerful elation: 

Sadness - an emotional response of the ego to suffering

· suffering may arise from realistic external or from inner, conscious or unconscious, sources.

· suffering may arise from identification with the suffering of others

· The suffering that promotes sadness always seems to be caused by experiences - or fantasies - of loss or deprivation, such as by loss of gratification either previously gained or expected, by loss of love, by separation, or, in the case of mourning, by loss of a love object.

· suffering may also arise as a result of physical sickness, by the concomitant loss of instinctual and emotional gratifications.

· in the case of sadness and grief over loss, have:

MOURNING

· involvement of predominantly libidinal cathexes (unlike depression which involves an aggressive conflict)

· induced by tensions within the ego; hypercathexis of the tragic event of the loss, alternating with

· a preoccupation with the happy experiences of the past, or the expected gratification which could not be attained, combined with painful desires to gain or regain them; alternating between hypercathexis of the happy past and the sad events which induced the grief.

· repetitions of the sad memories lead to innumerable painful but relieving discharge processes (e.g. tears)

· eventually, prolonged reality testing achieves a gradual renunciation of the wishful fantasies and liberates libido for new pursuits.

· the libidinal cathexis of the self in its current situation (of loss and sadness) is reduced, but not in favour of aggression. The libidinal object cathexes are likewise maintained, though they may also be reduced.

· Inasmuch as the stability of his self-esteem and his object relations is essentially unshaken, a grieving person may be able to sustain his normal relationships, interests, and activities. But the gratifications which they may otherwise grant cannot be properly enjoyed, since any pleasure, if permitted to develop at all, is tinged with pain because of what is searched for and missed (eg. listening to music).

· object relations and ego activities acquire a subdued quality. They lack the recurring waves of increasing narcissistic and object cathexes which result from full gratifications and prepare for renewed pleasurable experiences and actions; reduced transference to reality.

· helplessness and hopelessness are also found in sadness and states of grief without depressive features.

· sadness is often mixed with self-pity - hypercathexis of the “poor, deprived self that needs love and sympathy.” 

 Gaiety or normal, cheerful elation

· the pleasurable counterpart of sadness.

· founded on libidinal processes, which lead to pleasurable discharges.

· frequently follow a happy event that follows a state of worry or sadness.

· the gain of pleasure is always a “regaining” which must inevitably conjure up memories of previous loss or deprivation or suffering in general; all the more so, the more intense and the more unexpected the wish fulfillment.

· the factor of unexpected is usually present in joyful and in sad moods. The occurrence of very good or very bad events seems to be forever “unexpected”.   

 Normal, Neurotic and Psychotic Mood Deviations

· moods, with either normal or pathological qualities or motivations are an economic modality of the ego, which partly reinstates a primary process type of mental functioning.

· moods themselves are not pathological, but rather their motivations distinguish normal from pathological. Also, the extent to which they permit of reality testing, and correction of the prevailing self- and object-representations. The overemphasis of one set of representations involves certain degrees of denial of contrary representations.

· in normal moods, denial does not extend to the provocative external event, or to its immediate emotional impact which evokes the mood. This allows easier reality testing. If both are denied, reality testing is interfered with and the psychic situation cannot be mastered and the mood altered.

· duration is not a distinguishing criterion

· as soon as unconscious conflicts participate in the development of the mood, they preclude an ultimate economic success. Infantile fixations prevent a reality testing sufficient to guarantee a true liberation of psychic energy from its original fixated position.

· as well, hypercathexis of the pathogenic, repressed memories survives the mood and tends to turn reality into a constant source of renewed provocations, thus re-establishing the disturbed (anxious or hostile or depressed) affective state. If the mood deviation arises from a pathological narcissistic conflict, reality testing becomes even less effective or, in psychotic mood conditions, impossible.   

 Moods induced by narcissistic conflicts

· permit in general less reality testing than moods evoked by conflicts with the external world.

· the mood disturbance arises from the discrepancy between the self-representations and the ego ideal (superego) or the wishful image of the self. Hence it requires predominantly a testing of inner reality. External reality can be used only as a medium on which the self can assert its value. The self-critical agents, which test our inner reality, are deeply rooted in the unconscious and therefore highly arbitrary. Our self-representations are in general even less realistic than our object-representations. Our chances for correct self evaluation are limited.

· The difficulties of reality testing manifest themselves even in moods evoked by a narcissistic conflict that has a realistic basis.

· In contrast to other origins of moods, in moods caused by narcissistic conflicts, not longings for objects but narcissistic desires are attached to the world or are expected to be satisfied through the medium of the world. The higher and more illusory the narcissistic expectations and the less realistic the object and self representations are to begin with, the more pathological will be the conflict and thus the resulting mood.

· The infantile origin and the power of the superego make moods evoked by unconscious superego conflicts especially resistant to reality testing. This becomes impossible when the superego has replaced the object world and, independent of its standards and judgment, condemns and punishes the self or, the opposite, renounces its critical functions.   

 Denial in moods

· must make a distinction not only between many types, but also between varying degrees of denial and distortion which can be involved in mood development. In general, denial affects both the self and the object world, but it may lead to more conspicuous distortions of one or the other.   

 Pathological moods

· the traditional comparison between grief and depression (Freud, 1917) has been misleading in implying that the former is normal while the latter is pathological. Both depressed and elated states may develop within the range of normal mood conditions.

· the dangers of becoming pathological that are inherent in depressed and hostile mood conditions are because of their involvement with aggression and conflict, and the potential of including unconscious conflict, or, even worse, regressive processes (which preclude reality testing and adequate discharge).

· in depressed moods or states of hostility, of aggressive excitement, the world and the self appear inadequate, faulty, bad, or injurious. They are derogated, criticized with regard to their strength, ability, superiority, or moral perfection, ie. in terms of ego or superego values. Thus the core of the narcissistic disturbance in depression is always an experience of failure, though not necessarily of moral failure. The more the superego contributes to the conflict, the more will the self be conceived of as morally bad, expecting punishment from without or within. Frequently, though, the conscious feelings and ideas of inadequacy fend off hidden guilt conflicts.

· hostile and depressed moods can gain intensity through the calling away of aggression from the self or vice versa. Thus, angry moods may develop from narcissistic conflicts, eg. from guilt conflicts or experiences of failure or faults when the self-directed aggression is secondarily turned toward the object world. Reversely, depressive states may be induced by a shift of aggression from the objects to the self. This prevents a devaluation of the object world, serves as an effective defense against ambivalence conflicts, especially when the latter involve the danger of loss of a significant love object.

· in mood states, the self and the world tend to assume complementary qualities. If there is veering away of aggression to the self in depression accompanied by a libidinal hypercathexis of the world, the self and object world acquire opposite coloring.

· in persons who relate to the object world only by way of narcissistic identifications, all conflicts, even those involving the object world, are narcissistic in nature. Since in this case the boundaries between self and object representations are indistinct, any deflation of the world is cast back upon the self. The self and the world may be felt to have assumed identical qualities.

· However, depressive states do not always develop from attempts to resolve ambivalence conflicts by a turning away of aggression from the love object (the object world) to the self. They may well be directly evoked by a primary, narcissistic conflict. Such states of depression induced by narcissistic conflicts may be intensified or influenced by infantile narcissistic conflicts, but they may also be caused directly by realistic experiences of failure, inadequacy, or moral transgression.  

History and Summary of Freud’s Mourning and Melancholia

The following notes are from Freud, S. (1917) Mourning and melancholia. S.E. 14: 239-258. 

Strachey (1957) - Freud wrote this paper in 1915. He conferred with Abraham who suggested that there was a connection between melancholia and the oral stage of libidinal development.

· an extension of the paper on narcissism, seeing the ‘critical agency’ in operation in melancholia.

· in melancholia, because of regression, an object-cathexis is replaced by an identification.   

Introduction

Freud limits himself to “a small number of cases whose psychogenic nature was indisputable.” Compare and contrast mourning and melancholia - Both follow on similar environmental events, the loss of a loved person or abstraction which takes the place of a person. Both are time-limited. 

Melancholia: profoundly painful dejection

cessation of interest in the outside world

loss of the capacity to love

inhibition of all activity

lowering of the self-regarding feelings to the point of self-reproaches and self-revilings, and culminates in delusional expectation of punishment.

It is a pathological state. 

Mourning: if severe, the same painful frame of mind

same loss of interest in the outside world, insofar as it does not recall the lost object

same loss of capacity to adopt any new object of love

same turning away from activity that is not connected with the lost object

not the lowering of self-regard in mourning.

It is a normal state, not pathological.   

The work of mourning - Reality-testing has shown that the loved object no longer exists, and it proceeds to demand that all libido shall be withdrawn from its attachments to that object.... Each single one of the memories and expectations in which the libido is bound to the object is brought up and hypercathected, and detachment of the libido is accomplished in respect of it.... When the work of mourning is completed, the ego becomes free and uninhibited again.

The psychology of melancholia - Melancholia is also a reaction to the loss of a loved object or an ideal, or of the object’s love. The patient may not know what has been lost. Or if he knows who has been lost he may not know what is lost. This is often unconscious in the patient.

· the unknown loss results in similar internal work as in mourning and will therefore be responsible for the melancholic inhibition. But we cannot see what is absorbing the patient so entirely.

· the lowering of self-regard amounts to an impoverishment of the ego. The patient represents his ego as worthless, incapable of any achievement and morally despicable. He reproaches himself, vilifies himself and expects to be cast out and punished. He extends his self-criticism back over the past, saying he was never any better. This delusion of (mainly moral) inferiority is completed by sleeplessness and refusal to take nourishment, and by an overcoming of the instinct which compels every living thing to cling to life.

· There is no correspondence between the degree of self-abasement and its real justification. Also there is a lackof shame in the melancholic; rather see an opposite trait of insistent communicativeness which finds satisfaction in self-exposure.

. So, he has suffered a loss in regard to an object; what he tells us points to a loss in regard to his ego.   

The structure involved - constitution of the human ego - one part of the ego sets itself over against the other, judges it critically, and as it were, takes it as its object. Distinguish this critical agency from the rest of the ego. The conscience. It can become diseased on its own account. In the melancholic, dissatisfaction with the ego is mostly on moral grounds. 

The dynamics of melancholia - The key to melancholia - the self-reproaches are really against the love object who is lost, but have been shifted from the object to the patient’s own ego.... An object-choice, an attachment of the libido to a particular person, had at one time existed; then, owing to a real slight or disappointment coming from this loved person, (a narcissistic injury) the object-relationship was shattered. The result was not the normal one of a withdrawal of the libido from this object and a displacement of it on to a new one, but something different, for whose coming about various conditions seem to be necessary. The object-cathexis seemed to have little power of resistance and was brought to an end. (Regression to narcissism) Then the free libido was not displaced on to another object; it was withdrawn into the ego. There, it served to establish an identification of the ego with the abandoned object. Thus the shadow of the object fell upon the ego, and the latter could henceforth be judged by a special agency, as though it were an object, the forsaken object. In this way, an object-loss was transformed into an ego-loss and the conflict between the ego and the loved person into a cleavage between the critical activity of the ego and the ego as altered by identification. 

Predisposition to melancholia - A strong fixation to the loved object must have been present - On the other hand, the object-cathexis must have had little power of resistance

· implies that the object-choice has been effected on a narcissistic basis, so that the object-cathexis, when obstacles come its way, can regress to narcissism. The narcissistic identification with the object then becomes a substitute for the erotic cathexis, the result of which is that in spite of the conflict with the loved person the love-relation need not be given up.   

(Identification is the preliminary stage of object-choice. The ego wants to incorporate this object into itself, and, in accordance with the oral or cannibalistic phase of libidinal development in which it is, it wants to do so by devouring it.)

· this object-choice is an ambivalent one. The occasions which give rise to melancholia extend beyond the clear case of a loss by death, and include all those situations of being slighted, neglected or disappointed, which can import opposed feelings of love and hate into the relationship or reinforce an already existing ambivalence. This conflict due to ambivalence, sometimes arises more from real experiences, sometimes more from constitutional factors,...If the love for the object - a love which cannot be given up though the object itself is given up - takes refuge in narcissistic identification, then the hate comes into operation on this substitutive object, abusing it, debasing it, making it suffer and deriving sadistic satisfaction from its suffering....the trends of sadism and hate which relate to an object, and which have been turned round upon the subject’s own self...   

(In both melancholia and obsessional neurosis, the patients usually still succeed in taking revenge on the original object and in tormenting their loved one through their illness, having resorted to it in order to avoid the need to express their hostility to him openly. The object is usually in the immediate environment.) 

Course of the illness - Melancholia passes off after a certain time has elapsed. Shares this feature with mourning. Perhaps analogous work has to be got through. We have no insight into the economics of the course. 

The sleeplessness attests to the rigidity of the condition. The complex of melancholia behaves like an open wound, drawing to itself cathectic energies from all directions, and emptying the ego until it is totally impoverished. 

A somatic factor probably accounts for its amelioration in the evenings. Perhaps a loss in the ego irrespective of the object, a purely narcissistic blow to the ego, may suffice to produce the picture of melancholia, eg. an impoverishment of ego-libido directly due to toxins. 

Tendency to change round into mania - In both melancholia and mania, the content is the same. In the former the ego has succumbed to the complex, whereas in mania it has mastered it or pushed it aside. Joy, exultation or triumph seem to be the normal models for mania; all depend on the same economic conditions. As a result of some influence, a large expenditure of psychical energy, long maintained or habitually occurring, has at last become unnecessary, so that it is available for numerous applications and possibilities of discharge.  

In mania, what the ego has surmounted and triumphed over is hidden from the ego. In mania, the ego must have got over the loss of the object, and thereupon the whole quota of anticathexis which the painful suffering of melancholia had drawn to itself from the ego and ‘bound’ will have become available. The manic person seeks ravenously for new objects. 

This mania may not follow normal mourning because the work of severance from the object is so slow and gradual that by the time it has been finished the expenditure of energy necessary for it is also dissipated. 

Topographic point of view, psychical systems involved in the work of melancholia - In melancholia, the relation to the object is not simple; it is complicated by ambivalence, either constitutional (ie. is an element of every love-relation formed by this particular ego), or else it proceeds precisely from those experiences that involved the threat of losing the object. For this reason, the exciting causes of melancholia have a much wider range than those of mourning. In melancholia, therefore, there are countless separate struggles carried on over the object, in which hate and love contend with each other; the one seeks to detach the libido from the object, the other to maintain this position of the libido against the assault.  

The location of these separate struggles - the Unconscious, the region of the memory-traces of things (as contrasted with word-cathexes). In mourning, too, the efforts to detach the libido are made in this same system; but in it nothing hinders these processes from proceeding along the normal path through the Precconscious to consciousness. This path to consciousness is blocked for the work of melancholia, owing perhaps to a number of causes or a combination of them. Constitutional ambivalence belongs by its nature to the (unconscious) repressed; traumatic experiences in connection with the object may have activated other repressed material. Thus everything to do with these struggles due to ambivalence remains withdrawn from consciousness, until the outcome characteristic of melancholia has set in. This consists in the threatened libidinal cathexis at length abandoning the object, only, however, to draw back to the place in the ego from which it had proceeded. So by taking flight into the ego love escapes extinction.  

After this regression of the libido the process can become conscious, and it is represented to consciousness as a conflict between one part of the ego and the critical agency. What consciousness is aware of in the work of melancholia is thus not the essential part of it, nor is it even the part which we may credit with an influence in bringing the ailment to an end. We see that the ego debases itself and rages against itself. We understand as little as the patient what this can lead to and how it can change. We attribute such a function to the unconscious part of the work. Just as mourning impels the ego to give up the object by declaring the object to be dead and offering the ego the inducement of continuing to live, so does each single struggle of ambivalence loosen the fixation of the libido to the object by disparaging it, denigrating it and even as it were killing it. It is possible for the process in the Unconscious to come to an end, either after the fury has spent itself or after the object has been abandoned as valueless. The ego may enjoy in this the satisfaction of knowing itself as the better of the two, as superior to the object.  

ELEMENTS OF ABRAHAM’S FORMULATION OF MELANCHOLIA

The following notes are from Myer Mendelson, (1974) Psychoanalytic Concepts of Depression.

Spectrum Publications, Inc., Flushing, New York.

Freud (1909) - in the obsessional, hatred and love were always interfering with each other.

Abraham (1911) - neurotic depression is when the person has to give up his sexual aim without having attained gratification. He feels himself unloved and incapable of loving and therefore, he despairs of his life and his future.

Abraham (1911) - in psychotic depression, hatred was paralyzing the person's capacity to love; therefore, depression was associated with ambivalence and the projection of hostility; e.g. "People hate me because of my inborn defects"; "therefore, I am unhappy and depressed." Hostility reveals itself in dreams and symptomatic acts; there is a tendency to annoy other people; have violent desires for revenge. The more violent his unconscious destructive and vengeful fantasies, the more delusions of guilt, as though he thought he'd carried them out. This demonstrates "omnipotence of thought", as in the obsessional. Delusions of poverty spring from a repressed perception of his inability to love. there is hidden pleasure from suffering and from continually thinking about himself.

Freud (1915) wrote "Mourning and Melancholia"; published it in 1917.

Abraham (1916) corroborated clinically the idea of an oral pregenital stage of sexual life. Many patients whose method of achieving sexual pleasure had not achieved independence from the nutritive act, seen in, e.g. resistance to weaning; prefer to eat than have sex; eating relieves depression; medication is useful to depressives because of its oral satisfaction. In patients with psychotic depression, there are often two oral symptoms: refusal to take food, and fear of dying of starvation. Due to the regression to the oral stage the patient has a wish to incorporate his object, and fear that he might.

Abraham (1924) Like the obsessional, the manic-depressives person is ambivalent even between episodes. Both are similar in character structure: cleanliness, parsimony, obstinacy. Both experience sadistic impulses related to anal stage erotism (retention and expulsion) and sadism (destroy and control). In this stage, the object is experienced as being owned or possessed; it can be "done to" like feces.

A neurotic reaction to loss often includes constipation or diarrhea, thus symbolically denying and affirming the loss. The obsessional has a less primitive response: retention and control retains the object; the melancholic has a more primitive response: expulsion and destruction abandons the object. He was able to demonstrate that in the obsessional there was regression to the anal-sadistic stage, whereas in the melancholic, there was regression to the oral-sadistic stage.

Abaraham corroborated Freud's ideas about introjection - by fantasies of incorporation. This had the effect of overwhelming love with hate.

The following notes are from Karl Abraham (1924) A short study of the development of the libido, viewed in the light of mental disorders, in Selected Papers on Psycho-Analysis. 1927. Brunner/Mazel, Inc., New York. 422-433, 453-470.  

Freud - Melancholia involves regression of the libido to the oral stage, and the mechanism of introjection (cannibalistic fantasy of incorporation). 

A. Comparison of Melancholia and Obsessional Neurosis

1. Anality and sadism - In illness-free intervals, patients with cycloid illnesses and obsessional neurosis have the same character ie. anal-sadistic, sublimated. In illness, when threatened with the loss of an object, the melancholic gives up his object while the obsessional does not; ie. They regress to different fixation points.

2. Inference of two substages in the sadistic-anal stage. Anal erotism has two, opposite pleasurable tendencies, and anal sadism has two opposite pleasurable tendencies. At the anal stage, the person experiences his object as something he possesses. Also, at this stage, he is under the strongest influence of ambivalence.

a. Expulsive (early erotic); and retentive (later erotic)

b. Destroy (early sadistic); and control or dominate (later sadistic)         

When loosing an object, or under threat of losing an object, the unconscious experience of the melancholic is that this is done by expulsion of the object with destruction of the object, as the feces are expelled, whereas, the obsessional retains or conserves the object by attempting, compulsively, to control or dominate the object. The difference in these two attitudes towards objects is crucial to one’s relations to the object world.

3. Foreshadowing of the concept of object constancy:

p. 432 - “This differentiation of the anal-sadistic stage into a primitive and a later phase seems to be of radical importance. For at the dividing line between those two phases there takes place a decisive change in the attitude of the individual to the external world. Indeed, we may say that this dividing line is where ‘object-love’ in the narrower sense begins, for it is at this point that the tendency to preserve the object begins to predominate.”

(stable vs. earlier unstable ambivalence)

Once the dividing line has been crossed, the melancholic regresses to still earlier (oral) stages of the libido. (Freud - “The object love has little power of resistance.”) 

    4. Support for Freud’s idea of object loss in melancholia as an active abandonment of the object - find a relationship between object loss, and a tendency to lose (in the unconscious, expel - anal) and destroy (murder) things - followed by the process of introjection(identification) which has the character of a physical incorporation by the mouth (in the unconscious, eat dirt, feces, eating the loved object whom he has killed - oral).   

In normal mourning, introjection occurs, but is set in motion by a real loss (death), which is consciously remembered; its main purpose is to preserve the person’s relations to the dead object. Feelings of affection easily oust the hostile ones in regard to an object he has (in reality) lost. 

In melancholia, introjection is based on a radical disturbance of his libidinal relations to his object. It rests on a severe conflict of ambivalent feelings, from which he can only escape by turning against himself the hostility he originally felt towards his object. In the melancholic, there is so strong a conflict based on libidinal ambivalence that every feeling of love is at once threatened by its opposite emotion. A ‘frustration’, a disappointment from the side of the loved object, may at any time let loose a mighty wave of hatred which will sweep away his all too weakly-rooted feelings of love. Such a removal of the positive libidinal cathexes will have a most profound effect: it will lead to the giving up of the object - a withdrawal of libido from the object, and all other objects and interests, and redirecting it toward the ego. After he has thus “lost” his object, the melancholic attempts a restitution of it, through introjection. 

 B. Introjection in Melancholia - The Oral Phase  

1. Inference of two stages in orality

a. Sucking - loving - earlier In this stage, devouring has the unconscious meaning of sucking in, possessing positively, taking the loved object inside as a result of libidinal desire. The melancholic has a longing to regress to this stage (warm, sucking, milk, soft, love, comfort) This is prior to self-object differentiation, pre-ambivalent.

b. Biting - sadistic - later In the melancholic, frequently see the tendency in cravings to use the mouth in place of the genitals, and vivid cannibalistic fantasies. They also, defensively, or as punishment for their cannibalistic impulses, resist using their teeth “chewing laziness” (eat hamburger meat only). This devouring of the object by biting results in the destruction of the object. In fact, “As soon as the child is attracted by an object, it is liable, indeed bound, to attempt its destruction.” This is the beginning of ambivalence.

The melancholic is fixated at the earlier anal-sadistic stage of expulsion of his object, and at the later oral-sadistic stage of biting, which is the stage where ambivalence begins and is therefore at its most primitive, unmodified. On this level, the individual threatens to destroy his libidinal object by devouring it (the hostile part of the ambivalence). It is only gradually that the ambivalence conflict assumes a milder aspect and that the libido consequently adopts a less violent attitude towards its object. Nevertheless this ambivalent attitude remains inherent in the tendencies of the libido during the subsequent phases of its development. For example, the next phase is also divided into the earlier, phallic phase, and the later, genital phase. Through these there is further modification of the ambivalence until, in the normal person, who is relatively far removed from the infantile forms of sexuality, there is little ambivalence. The libido has reached a post-ambivalent stage. 

On the way to complete object-love: Within the first - the oral- period, the child exchanges its pre-ambivalent libidinal attitude, which is free from conflict, for one which is ambivalent and preponderantly hostile towards its object. Within the second - the anal-sadistic - period, the transition from the earlier to the later stage means that the individual has begun to spare his object from destruction. Finally, within the third - the genital- period, he overcomes his ambivalent attitude and his libido attains to its full capacity both from a sexual and a social point of view. 

 C. The Pathogenesis of Melancholia  

1.The self-directed ambivalence of the melancholic - this is a libidinal conflict and a narcissistic conflict (see Jacobson), self-love vs. self-hatred.   

The melancholic, in his pre-illness, has an unusually high degree of ambivalence in his emotional life - he may suddenly give up any of his intensely pursued interests or objects (as a result of disappointment). When the libidinal cathexis has been withdrawn from the object, it is directed to the ego, while at the same time the object is introjected into the ego. The ego is now mercilessly exposed to the ambivalence of the libido. The melancholic is filled with a tormenting self-contempt and a craving to belittle himself. But also the opposite tendency, a self-aggrandizement, a feeling of superiority, extreme sensitivity to criticism, contempt for other people who apply the standards of reality to his ideas. He feels he is the “greatest sinner of all” and that his anger and feelings of hatred are enormously powerful. So there is an exaggeration of a positive and a negative narcissism.    

2. The precipitating narcissistic injury is an event experienced as a repetition of a childhood trauma It follows a disappointment of love, but the events that usher in the loss of the object are more obscure. The event has a pathogenic effect because the patient is able to regard it in his unconscious as a repetition of an original infantile traumatic experience and to treat it as such - a strong compulsion to repeat in manic-depressive illness (as many episodes). 

3. Etiological factors

a. Constitutionally heightened oral erotism - neuroses of all kinds in the families.

b. Oral fixation - very exacting in their demands to have their special erotogenic zone (and its derivative forms) gratified, and react with great displeasure to every frustration in this connection. For example, very jealous of seeing another child at the breast or of seeing mother love the father.

c. Severe infantile narcissistic injury - very frequently, “The child had felt that he was his mother’s favourite and had been secure of her love. He had then suffered a disappointment at her hands and had with difficulty recovered from its shattering effect. Later on, he had had fresh experiences of the same sort which had made him feel that his loss was an irreparable one, especially as there had been no suitable female person on to whom he could carry over his libido. Furthermore, his attempt to direct it towards his father had failed, either straight away or after some time. Thus as a child he had got the impression of being completely deserted. And it was this feeling that had given rise to his first attacks of depression. The constantly repeated attempts of the melancholic to gain love from a person of the opposite sex are intimately bound up with the early disappointment from both sides.”

d. ...before the Oedipal resolution. The first important disappointment comes before the child’s libido has overcome the narcissistic stage, before the repressive forces have gained control over his Oedipal impulses, just as he is making his first steps towards object-love. Since his oral-sadistic instincts are still in force, a permanent association will be established between his Oedipus complex and the cannibalistic stage of his libido. This will facilitate a subsequent introjection of both his love-objects.

e. Later repetition of the primary disappointment - This is the exciting cause of the onset of a melancholic depression. The whole sum of his anger in later disappointments is ultimately directed towards one single person, the one whom he had been most fond of as a child and who had then ceased to occupy this position in his life. Therefore, in melancholics, it is the mother against whom the original hostile, cannibalistic impulses develop. Although it comes to include the father through the Oedipal stage. Later self-reproaches thus include reproaches against both parents.   

4. Dual introjection into conscience and ego

a. The patient has introjected his original love-object upon which he had built his ego ideal; so that that object has taken over the role of conscience for him, although, it is true, a pathologically formed one. eg. The self-reproaching voice is based on mother’s voice.

b. The content of the self-reproaches is ultimately a merciless criticism of the introjected object. eg. of the one and the other parent who have been introjected into the ego.   

 Starcke’s theory - that the withdrawal of the mother’s breast is a ‘primal castration’. The melancholic wants to revenge himself on his mother for this by castrating her in his turn, either taking away her breasts or her imaginary penis. In his imagination he always chooses biting as the means of doing it. These phantasies are ambivalent, involving, on the one hand, a total or partial incorporation of the mother, that is, an act of positive desire; and, on the other, her castration or death, that is, a negative desire tending to her destruction. 

Review - “When melancholic persons suffer an unbearable disappointment from their love-object, they tend to expel that object as though it were feces and to destroy it. They thereupon accomplish the act of introjecting and devouring it - an act which is a specifically melancholic form of narcissistic identification. Their sadistic thirst for vengeance now finds its satisfaction in tormenting the ego - an activity which is in part pleasurable. This period of self-torment lasts until lapse of time and the gradual appeasement of sadistic desires have removed the love- object from the danger of being destroyed. When this has happened the object can, as it were, come out of its hiding-place in the ego. The melancholic can restore it to its place in the outer world. In his unconscious, the melancholic regards this liberation from his object as once more an act of evacuation. 

 D. Primal Parathymia - the infantile prototype of melancholic depression   

The melancholic depression is derived from disagreeable experiences in the childhood of the patient. Consider the original emotional reactions of the child, discovered through analysis, to traumatic experiences.  

The patient illustrates in his memory “the intense longing of the melancholic for the happy state when he was still at his mother’s breast....Speak of a ‘primal parathymia’ ensuing from the boy’s Oedipus complex. See with impressive clearness how much the child longed to gain his mother as an ally in his struggle against his father, and his disappointment at having his own advances repulsed combined with the violent emotions aroused in him by what he had observed going on in his parents’ bedroom. He nursed terrible plans of revenge in his breast, and yet the ambivalence of his feelings prevented his ever putting them into practice. Unable either to achieve complete love or an unyielding hatred, he succumbed to a feeling of hopelessness. In the years that followed he made repeated attempts to attain a successful object-love; and every failure to do so brought with it a state of mind that as an exact replica of his primal parathymia. It is this state of mind that we call melancholia.

How ready the melancholic is even during his free intervals to be disappointed, betrayed, or abandoned by his love-object....In each symptom of his various depressive periods he faithfully repeated all those feelings of hatred, rage, and resignation, of being abandoned without hope, which had gone to colour the primal parathymia of his early childhood. (p. 470)   

Seminar 2: Depressive Illness 

REVIEW

MOODS

A. Based on Edith Jacobson (1971), "Normal and pathological moods: their nature and function".

B. In contrast to affects, which are always focused on an object, moods are diffused over the whole object world.

C. This allows for the gradual discharge of drive elements that would otherwise be experienced as overwhelming; thus, those predisposed to strong moods are often people with weak affect-tolerance.

D. The theme of any mood is one pole of a contrasting pair: eg. happy/sad, elated/depressed, angry/affectionate. It is part of the psychology of moods that the accentuation of one pole goes along with the denial of the other. This denial is seen, to a greater or lesser degree in all moods, more prominently in the more pathological mood states. "Mostly, in normal moods the denial does not extend to the provocative external event or to its immediate emotional impact which evokes the mood."

E. Moods are complex phenomena, involving every aspect of the ego and, in particular a complementary configuration of the self and object representations, eg. in mania the self is wonderful and the world is adoring.

F. Moods cannot be distinguished from affects or graded as to normality and pathology by their duration alone. Important indicators of pathology are: fixity as opposed to modifiability of the mood, disproportion or inappropriateness to the precipitating event, and inability to test reality. Thus moods are within the normal range and appropriate in quality as long as they are compatible with the momentary external and internal reality and can be recognized as temporary ego states due to conscious reactions to realistic events. They will yield to reality testing and consequently be controllable and of limited duration. The less conscious a person is of the sources from which his moods arise, the less easily can the psychic situation be mastered and the more inappropriate are the mood qualities. (p. 88)   

DEPRESSION AS MOOD STATE FOLLOWING ON NARCISSISTIC INJURY

Edith Jacobson 1971

A. Precipitated by a blow to the self-esteem (a 'narcissistic injury') that interferes with an important source of self-esteem: rejection, criticism, humiliation, illness, failure, etc.

B. The mood state is reversible if the narcissistic injury is reversed.

C. There is no significant regression in the level of object relations and corresponding mode of narcissistic regulation (eg. to object-splitting or decathexis of the object world). It is important to distinguish between withdrawal of interest due to preoccupation with the hurt, and the more ominous decathexis of the entire object world seen in depressive illness.

D. The state of narcissistic injury is always the recurrence of an earlier compensated or defensively warded-off narcissistic injury - usually in childhood. (Abraham 1924)

E. The state may be

1. endured

2. ended by compensatory adjustment to the injury (eg. accepting substitutes, changing ideas of what is valuable)

3. ended by defensive warding off of the injury (eg. denial and reversal, disavowal of the significance, reaction formation)

4. a precursor to a depressive illness

F. The content of the mood state may be extremely varied - helplessness, hurt, self-blame, blame of others, shame, rage, rebellion, etc. Ego functions, especially those reflecting capacity for focused attention, may be affected.   

NEW

EDITH JACOBSON (1953)

Depression (simple, psychotic, endogenous (psychosomatic) features, in cyclothymics) consists of a triad of symptoms: periods of depressed mood, inhibition of thinking, and psychomotor retardation. The central psychological problem in depression - narcissistic breakdown: loss of self-esteem, feelings of impoverishment, helplessness, weakness, and inferiority; or, in the melancholic type, of moral worthlessness and even sinfulness.

Premorbid manic-depressive personality - richness of their sublimations, delightful companions, full genital response, emotional warmth and unusual affectionate clinging to people they like. Remarkable intolerance toward frustration, hurt, and disappointment. Simultaneously thetendency to too strong fixations to their love-object and to a quick withdrawal of object cathexis. The object choice of these persons must have been, to begin with, on a narcissistic basis, which permits them to regress easily to the narcissistic identification with the love-object. They require a constant supply of love and moral support from a highly valued love-object (whom they idealize). The patient's self-representations retain the infantile conception of a helpless self, drawing its strength from a powerful, ideal love-object, which he has to constantly hypercathect with libidinous cathexis.   

EDWARD BIBRING’S MECHANISM OF DEPRESSION (1953)

(An ego state in response to narcissistic injury.)

A. Depression is an ego-psychological phenomenon, a 'state of the ego', an affective state (p. 21) Depression is the emotional expression of a state of helplessness and powerlessness of the ego (e.g. the individuals described either felt helplessly exposed to superior powers, fatal organic disease, or recurrent neurosis, or to the seemingly inescapable fate of being lonely, isolated, or unloved, or unavoidably confronted with the apparent evidence of being weak, inferior, or a failure. (p. 23) In all cases, there is a blow to the person’s self esteem. (p. 24) It results from the tension between highly charged narcissistic aspirations (of the ego ideal) and the ego's awareness of its helplessness and incapacity to live up to these standards.

B. Three sources of self-esteem:

1. The wish to be worthy, to be loved, to be appreciated; that is, to be loved by the ego ideal.

2. The wish to be strong, superior, great, secure; that is, to satisfy remnants of the ideal ego (infantile narcissism).

3. The wish to be good, loving, not aggressive, hateful nor destructive; that is, to love the ego ideal.

Depression sets in when one or more of these conditions fail and the ego feels helpless to resurrect them. It is a state of the ego whose main characteristics are a decrease of self-esteem, a more or less intense state of helplessness, a more or less intensive and extensive inhibition of functions, and a more or less intensely felt particular emotion. It often includes fatigue and anxiety.

C. Narcissistic aspirations of each psychosexual level which can be frustrated and lead to depression:

1. Oral – the need to get affection, to be loved, to be taken care, of to get “supplies,” or by the opposite defensive need: to be independent, self-supporting, self-sufficient.

2. Anal – the wish to have mastery and control over the body, the impulses (drives) and persons (objects). Not to feel guilt or remorse over excessive aggression, nor to experience punishment.

3. Phallic – the wish to be admired, to be centre of attention, to be strong and victorious, not to be defeated. Traumatic narcissistic injuries early in childhood predispose a person to later neurotic and probably also psychotic depression.

But not all depressions occur in “orally-oriented” persons.

Also, aggression against the self is not always present. It is the ego’s awareness of its helplessness, which, in certain cases, forces it to turn the aggression from the object against the self, thus aggravating and complicating the structure of depression.

D. Jacobson's 1971 critique of Bibring, in "On depressive states: nosological and theoretical problems" (p. 175-182):

1. He downplays the role of aggression. In part, he limits himself to the depressions reflecting a tension within the ego (between the ego and the ego ideal, and in which he leaves out the occasion of "hostile deflation of self-image), and he leaves out, or considers it only "complicating", the depressions in which there is tension between the ego and the superego (guilt). Also, in concentrating on the ego and narcissistic feelings of frustration, he downplays the role of ambivalence (the instinctual point of view).

2. In describing depression as a "basic ego state" and limiting this to feelings indicative of the state of narcissistic balance, Bibring ignores the theory that suggests that even "basic ego states" can be understood in terms of the underlying cathectic and discharge processes which involve self- and object-directed, sexual and aggressive or neutralized drives.

3. The issue of 'simple' depression’: he treats it as less severe but she maintains it belongs with the more severe depressions.   

EDITH JACOBSON'S VIEWS ABOUT DEPRESSION (1971)

A.Ego psychology view - feelings of security, depression, and elation are characteristic states of normal or disturbed narcissistic equilibrium. (Agreeing with Mahler), Elated and depressive responses can be found at an early age as a result of experiences of narcissistic gratification or frustration.

B. A clear distinction between neurotic, borderline, psychotic, and between the different types of depressive states.

C. Drives must be included to understand - The basic conflict in all depressed states: "Frustration arouses rage and leads to hostile attempts to gain the desirable gratification. When the ego is unable (for external or internal reasons) to achieve this goal, aggression is turned to the self-image. The ensuing loss of self-esteem is expressive of the narcissistic conflict, ie. a conflict between the wishful self-image and the image of the deflated, failing self. The nature of the mood condition that then develops depends on the intensity of the hostility and the severity and duration of frustration and disappointment." (p. 183)   

To distinguish among the various groups of depression: Freud differentiated the mechanisms operative in the depressive states of compulsive neurotics and melancholias. With respect to psychotic depressions, their special qualities may be determined by the underlying neurophysiological pathology.

A psychoanalytic theory of depression presupposes a "multiple factor" genetic approach, taking into account: the drives involved in the conflict, and in the instinctual constitution; the ego, the super-ego and ego ideal; developmental psychogenetic aspects, including the factors of sequence and timing. 

JOSEPH SANDLER (1967) (from "On disorders of narcissism" in From Safety to Superego, 1989) (Depression as a response to narcissistic injury without using the concept of drives.)   

 The basic form of unpleasure in disturbances of narcissism is an affective experience of mental pain. Mental pain reflects a substantial discrepancy between the mental representation of the actual self of the moment and an ideal shape of the self. Lack of self-esteem, feelings of inferiority and unworthiness, shame and guilt, all represent particular higher-order derivatives of the basic affect of pain. These are determined and influenced by the manifold and complex elements that enter into the formation of the ideal self.

A narcissistic disorder: its central feature is the existence of an overt or latent state of pain that has constantly to be dealt with by the ego; and the defensive and adaptive maneuvers that are responses to it can assume pathological proportions. These include the so-called seeking of narcissistic supplies, overcompensation in fantasy, identification with idealized and omnipotent figures, pathologically exaggerated forms of narcissistic object choice, compulsive pseudosexuality, many aspects of homosexual activity and other perversions. Various forms of self-punishment may be seen, particularly when superego factors predominate in causing pain. Self-damaging and self-denigrating activities may be sexualized and reinforced by masochistic trends.

Depression: If the individual's adaptive and defensive maneuvers fail, and he is left helpless and hopeless in the face of the (conscious or unconscious) state of pain, he may then develop a depressive reaction. This view places the depressions in the wide realm of narcissistic disorders.   

ALAN PARKIN (1976) From "Melancholia: a reconsideration"

(An ego psychological point of view using the metapsychological tradition of separating the ego-ideal and the superego into two equivalent sets of functions – the first being loving and rewarding and the second being critical and punishing.)   

 The basic mechanism of all simple depression - the abandonment by the ego ideal of the ego as a loved object resulting in the fall of self-esteem (Bibring, 1953); a sense of inferiority; loss of the ego ideal's love.

The distinguishing mark of melancholia - the heightening of the criticisms of conscience; increased attacks by the superego on the ego; sense of guilt or moral inferiority; expression of the superego's hatred (Schafer, 1960)

Freud (1923) Melancholia - involves regression from object cathexis to narcissistic cathexis (1917)

Later Freudians (Ego psychology) – conceptualized melancholia as a profound instinctual defusion in which the loosened sadistic-component came to hold "sway in the super-ego; as it were, a pure culture of the death instinct...” The regression was to the preambivalent stage of object relationships.

A. Regression to preambivalence -

(Preambivalence - in which the separated "good" and "bad" objects, with their instinctual cathexes of libido and aggression respectively, are not yet integrated in a state of fusion. This stage, emerging from the preceding one of primary narcissistic fusion of self- and object-representations, is characterized by the attempt to maintain a “purified pleasure” self through the aim "to introject into itself everything that is good and to eject from itself everything that is bad" (Freud, 1925) Thus arise the separated "good" and "bad" objects, the former introjected into the self, initiating the establishment of the differentiating grade of the self-ideal, the "substitute for the lost narcissism of...childhood" (Freud, 1914), and the latter projected into the outer world, the forerunner of denial.

Although the premelancholic has reached the next, ambivalent, anal-sadistic stage in development, under the threat of object loss, he reverts to the previous state of preambivalent object relations. In this reversion, the "bad" (disappointing) object is introjected into the superego.

B. Double introjection

Sandor Rado (1928) formulated the process in melancholia as a doubleintrojection of the lost object. The twin introjects are the "good" and "bad" objects arising out of the instinctual and ego regression to the preambivalent object stage. The "bad" object is introjected into the ego, the "good" into the superego.

Jacobson (1953) confirmed the idea of a double introjection. However, she proposed that the inflated, good or bad, punishing, powerful parents are introjected into the superego, while the deflated, bad, worthless, weak parents are introjected into the ego.   

Parkin (1976) The premelancholic has reached the ambivalent stage of object relations. He seeks in his love object those characteristics of the self's own internal ideal that lie beyond its grasp. The object is loved, that is, for its potential to restore the state in which the self was its own ideal. (the narcissistic object relation). The object is loved as a longed-for extension of the self and is treated in accordance with the desire to bring it into the realm and under the control of the self - that is, to restore the narcissistic fusion.

When the narcissistically loved object disappoints, it loses its function to the patient as the projection of his own ideal and as the haven of the "good" aspect of his ambivalently loved and hated object. Narcissistically, it is a "lost" object. In the ensuing reintrojection of the lost perfection into the patient’s ego-ideal, the patient is thrown back once more upon his own internal self-ideal, which lies outside his attainment. He feels depleted and helpless, and it is in this helpless loss of self-esteem that depression is manifested.

When what is sought in the love object is some form of perfection pertaining to the later preoedipal stages of development, simple depression develops on disappointment and loss. When what is at stake is the recovery of earlier and more archaic forms of grandeur through the establishment of the loved object as the externalization of more primitive forms of the self-ideal, the loss of the loved object may precipitate, not only a fall in self-esteem, but also a re-emergence of the "bad" object as a separate component under the impact of the regression to the preambivalent stage and the accompanying instinctual and object defusion.

The object is not only lost in its "good" aspect, but also must be dealt with in its separation as a "bad" object, one which has hatingly frustrated the wishes of the patient. As such, it not only becomes the target of reactive rage, but is fantasied as a raging, punishing, and depriving aggressive object in itself. As an external inhibitor of wish-fulfillment and prohibitor of need-satisfaction, it is introjected by incorporation within the context of the series of hating introjects that constitute the precursors of the superego. If the object separation is particularly marked and the defused instinct of aggression particularly strong,...severe feelings of guilt and self-reproach become manifest.   

 The clinical picture of melancholia is thus established in a combination of a fall in self-esteem through the loss to the self of the externalized self-ideal (the "good" object), which is reintrojected and assimilated to the unattainable internal self-ideal, and of a heightening of self-criticism through the introjection of the frustrating prohibitor (the "bad" object), which is taken into the superego. To both is added the ingredient of the masochistic helplessness of the self.

RUTH LAX'S CONCEPT OF 'THE NARCISSISTIC DEPRESSION' IN THE ANALYSIS OF CHARACTER NEUROSIS (1989)

(Shift in focus from symptoms to depressive character.)

Pathological character traits develop in a child in response to various extreme parental demands and responses, or following object loss or physical or psychological abuse. The child has a narcissistic investment in the functioning of these traits, in their adaptive, gratifying and reactive capacities. When these traits are analyzed (becoming ego-dystonic), the patient suffers a narcissistic injury to his self-image, which leads to a depression.

"He becomes aware of real and/or imaginary helplessness, and of an incapacity to live up to both conscious and unconscious goals. This is exacerbated further by his recognition of the discrepancy between his goals, aspirations, and the realization of the unacceptable nature of the underlying unconscious motives. Whereas the patient previously may have felt good and righteous, he now feels bad and considers himself unlovable."

He "may experience intense feelings of forlornness, abandonment, and helplessness. His goals may not have changed, but he now sees them as so exalted he no longer hopes ever to attain them. The loss of a sense of mastery evokes feelings of humiliation and shame. Conversely, the goals may now be changed and the patient, when middle-aged, may despair about wasted years and misdirected energy." (p.88)   

Seminar 3: Controversial Issues and the Treatment of Depressed Patients 

REVIEW

Freud’s view of the predisposition to melancholia, precipitant and dynamic processes.

Abraham’s view of the typical disposing sequence.

Bibring’s view of the ego’s response – helplessness and hopelessness (Dorpat 1977)

Mabel Blake Cohen’s group- histories of people with manic-depressive depression as similar to those with depression in narcissistic character.

Jacobson – self- and object-representations; importance of the operation of the aggressive drive.

Parkin's elaboration of the double introject.   

NEW

Charles Brenner (1991) – a good example of the evolution of Freudian theory.

Depression is an affect, not an illness.

Anxiety is the unpleasurable affect that signals the advent of something bad, of calamity; depressive affect – when the calamity has already happened. Either may develop around any of the danger situations – loss of the object, loss of love, castration, and punishment. When either occurs in connection with a wish for gratification of a drive derivative, what ensues is psychic conflict.

Conflict has four components: drive derivatives, unpleasure in the form of anxiety and/or depressive affect, defense, and superego manifestations. These interact, resulting in a compromise formation in such a way as to achieve the greatest pleasure and the least unpleasurable affect. Conflicts that are intense enough to be clinically significant originate in childhood. Libidinal and aggressive (less so) drives are associated with the erogenous zones. Every effort made to reduce unpleasure is part of a defense; in general, defenses oppose the gratification of instinctual wishes that would cause unpleasure.

In every conflict, depressive affect plays its part in initiating defense, just as anxiety does. What varies among patients is the role of depressive affect in the resulting pathological compromise formation.

In Freud’s explanation, the analogy with mourning gives a model for why depression is self-limited in time. Identification occurs in normal mental life, not always associated with object loss; it is a defense against object loss. When identification occurs in a context of intense ambivalence, loss results in depression.

All levels of loss - oral, anal, phallic (p.35) - can result in depression. In some instances, a patient’s symptom of depression is related to object loss and to inadequate mothering, but not in all. Similarly, oral wishes my predominate, but they do not always do so; phallic and anal conflicts are often more important than oral ones. Identification may play a crucial role, but there are many patients in whom that is not so. Finally, aggression turned against oneself is not the cause of depression. It is a consequence of it.

An alternative word for depressive affect would be “misery”. Misery is part of the human condition. Depressive affect is part of every pathological conflict. Similarly, all the calamities of childhood are present in each patient to some degree. However, in many patients, castration conflict has played the major role. Substitute for “castrated” – injured, beaten.                    

Leo Stone (1986) - “narcissistic object” choice indicates an “…original failure of separation… from the mother. (p. 333)

Stone reports from his experience of “the preeminent importance of an archaic characterological core in depressive illness.”

Robert Lupi (1998) Panel at the Fall Meeting of the APA, 1995.

Nersessian – anxiety is always a feature in both mourning and melancholia. Ambivalence is also always a feature of both, and the pain of mourning is more intense and longer in duration when there are more hostile and hateful feelings than affectionate ones in the relationship.

Leon Hoffman – supported Freud’s theorizing against those who criticize it. “Freud’s discovery of transference, as well as his attempts to integrate Adler’s and Jung’s criticisms into a comprehensive theory, led him to consider the theoretical importance of relations between the individual and objects and the mentalization of these relations, and to eventually develop the structural theory.”

Stephen Mitchell – “As one reads this paper (“Mourning and melancholia”) one can almost see the mind fracturing before Freud’s eyes into separate agencies and internalized objects. The boundaries between inside and outside become permeable.”

He described Freud as here describing how internalization happens, but the theory is entirely drive-based. In discussing identification, Freud comes close to articulating the idea that became important to object relations and relational theory,” that identifications have an emotional primacy in their own right and are not simply a compensation for lost objects; instead, primary object relatedness might be a basic motivating factor.”

He quotes Fairbairn’s phrase, it is “when the tie to the object…has been exclusive, adhesive, and addictive that loss is more likely to precipitate and be omnipotently preserved through pathological depression.”.

Otto Kernberg – Proposed that “identification is regarded as the internalization of a significant object relationship, a representation of the object interacting with a representation of the self under the impact of a dominant affective state. The more significant the relationship, the more intense the affect…” He proposed a “genetic disposition to pathological activation of affects that will be integrated into the aggressive drive and, in particular, a tendency to excessive rage, anxiety, and despair under conditions of early frustration and object loss.” These lead to "a “hypertrophic” superego and a predisposition to depressive reactions.” His view of drives are that “they are built up from the underlying affects incorporated into self- and object representations.”

Arnold Rothstein – “...the loss of fantasied aspects of the self are central in narcissistic and masochistic pathology. Similarly, he said, the self-directed rage in melancholia is not simply the displaced object-directed rage now aimed at the internalized identification; it is also a critical, self-punitive response for not being able to omnipotently prevent the calamity.”    

Pierre-Gilles Guéguen (2009) – Depression is “part of an ideology that propagates the ideal of happiness for consumption…its residue which has to respond to the Master’s will by erasing itself through more consumption of the objects ‘medication’.” Lacan suggests that depression “isn’t a state of the soul, it is simply a moral failing…which is ultimately only situated in relation to thought, that is, to the duty of well-saying or to find oneself again in the unconscious, in structure.” It indicates that the subject does not find a voice in which to express its state of being, which includes the body. Treatment involves offering to the patient the opportunity to establish a social bond through speech, supporting the transference, and making maximum use of “the transforming action of speech and the dialectization whereby symptoms change.”  

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