Depression viewed as a state of disturbed psychic contact

The nature of disturbed object relations in depression is analyzed. The concept, area of interest, is introduced to describe the disturbed interplay between the depressive subject and the external world. Loss of psychic contact with the environment is considered the central feature in depression. Various psychological symptoms in depression, such as decline in self-esteem, feelings of guilt, self-reproach, hopelessness, and helplessness, are arranged in an understandable sequence beginning with loss of psychic contact. The paper discusses a model of depression, in which the loss of psychic contact with the external world is considered the stimulus for physiological symptoms such as early morning wakening, diurnal variation, and weight loss. The depressive episode may be viewed primarily as a state of disturbed psychic contact rather than as a state of disturbed affect.     

Guilt in obsessive-compulsive disorder

Despite the phenomenological and theoretical importance of guilt in obsessive-compulsive disorder, research in this area has been conducted primarily on normal populations and has produced contradictory results. This study had two aims. First, to compare the guilt of subjects with obsessive-compulsive disorder (n = 30) to the guilt of normal controls (n = 30); second, to examine the relationships among guilt, anxiety, depression, and obsessions in an obsessional and normal population. Obsessional subjects reported significantly more trait guilt, state guilt, and higher moral standards than normal controls. In both populations, trait guilt significantly predicted obsessional compulsive complaints, independent of anxiety and depression. The results are considered in relation to the literature on inflated perceived responsibility for threat; the specific nature of obsessional guilt is discussed.     

Fragmented attachments: the paranoid-schizoid experience of loss and persecution

The author discusses paranoid-schizoid patients who have yet to deal with whole-object depressive fears of harming one's object. Their paranoid-schizoid anxiety is more a combination of dread, paranoia, and fear of destroying one's object with neediness, envy, and other oral desires. In this part-self and part-object world, destruction is absolute. Ego functions and object relational capacities such as guilt and grief are not yet fully consolidated. The part-object is not only destroyed but is also equally capable of magically resurrecting itself to seek revenge. Fear of annihilation of the self and object, as well as desperate attempts at keeping each other alive, are the primary focus of this early anxiety state. These infantile fears are at the root of certain difficult treatment situations. Within the transition from paranoid-schizoid to depressive, the ego struggles with highly exaggerated and distorted fantasies of persecution, loss, and primitive guilt by resorting to crude and often self-destructive mechanisms. These include splitting, projective identification, and idealization. During the course of analytic treatment, three overlapping phases are distinguishable. Acting out is the main theme of early treatment. As this externalization of internal conflict is analyzed and contained, a second phase of intrapsychic struggle emerges. The patient exhibits a paralyzing battle between certain ego-object ties and the striving of a defensive death instinct. If the analytic relationship is able to withstand passage through these difficult phases, the patient begins to work through more core issues of persecutory loss and annihilation. Case material is used for illustration.     

The superego: a revised developmental model

The superego is not, as psychoanalytic theory asserts, primarily heir to the oedipus complex. Freud proposed two theories of identification and superego formation, only one of which is widely known and accepted. The first, which he abandoned, argues for the genesis of conscience as compensation for lost narcissism. The second explains superego formation as a response to object loss and fear of castration. The latter view faces a number of anomalies, including the occurrence of preoedipal and postoedipal identifications unrelated to the castration complex, and the difficulty in providing a cause for female superego development. An alternative theory is proposed that returns to Freud's first theory of identification, arguing that gender-specific explanations are inappropriate for a phenomenon such as conscience, which occurs in both sexes. Prototypical male and female cases are presented alongside a general model of the development of ego processes and object relations. Case material is briefly examined, and the argument is made for conceptualizing psychosexual development as a developmental line rather than as the core of character formation.     

Depression in women. Psychoanalytic concepts

I would now like to summarize the relationship between concepts about depression and formulations of feminine development and personality. What are women's vulnerabilities? 1. The particular vicissitudes of feminine development result in differences, in attachment and anxiety about loss of love and abandonment as part of the normal constellation of feminine personality. These derive, in part, from the difference in the process of separation-individuation and differentiation in women as compared with men. 2. The normal feminine personality includes responsiveness and/or dependency in relation to others and greater anxiety about loss of love. This sensitivity is important in the regulation of and fluctuations of self-esteem. 3. The pathways for development of aggression and its fate includes the powerful effect of social customs that prescribe passivity with consequent likelihood of helplessness and the relatively fewer pathways for activity and active mastery. 4. Problems of self-esteem, including those resulting from the recognition of aggression and also the development of an ego ideal that values sacrifice and service. Devaluation of the female body contributes. 5. Problems of identification with a devalued person as a woman--the mother--who is sometimes also depressed. 6. Sex-role stereotypes and life conditions that support devaluation, subservience, and helplessness and limit opportunities.     

Bargains, treaties, and delusions

Using a case example, I have explored a particular type of difficult patient. This individual has typically suffered poor attachment with his maternal object and through projective identification has developed highly conflicted object ties within the ego. These relations produce cycles of intense persecutory and depressive anxieties, forcing the subject to rely on excessive splitting and other primitive defenses. As part of these protective maneuvers, the ego begins to build internal bargains and treaties with the adversarial objects. These repetitious intrapsychic negotiations lead to delusional thought systems that bring on the very anxiety the ego tried to avoid, creating vicious feedback loops with more severe delusional systems and more rigid bargains to strike. For the price of survival, and the maintenance of an intact object, the ego builds and maintains certain relational configurations. These are attempted solutions for fantasies about destructive forces threatening the ego or the object. Self and object protection are the goals. If these intrapsychic bargains break down, fantasies about self and object destruction, loss, or annihilation enter the forefront. Infusing the concept of compromise formation with the ideas of object relations theory allows a better understanding of this highly defended anxiety state.     

Schizoid anxiety: a reappraisal of the manic defense and the depressive position

The author views the manic defense as a combined attempt to control persecutory objects and to save them from the aggressive forces within the ego. Rather than strictly a manifestation of depressive guilt, it is also a defense against the fear of destroying the object and subsequently the self. Therefore, Melanie Klein's depressive position is a hierarchical outgrowth of more primitive schizoid anxieties about killing off the ideal part object. This is contrasted with the depressive guilt of harming the whole and reliable object. The depressive position is a psychic state of worry about loss of the object's love resulting from temporary harm done to the object that can be fixed. The paranoid-schizoid position is a much more hopeless internal situation involving a complete loss of the object and, by extension, the self. A case study is used for illustration.     

Precocious ego development and obsessive compulsive neurosis

Precocious ego development is frequently mentioned in psychoanalytic theory as an important determinant of obsessive-compulsive neurosis. Writers such as Anna Freud suggest that an imbalance in the development of ego over drive may lead to obsessional neurosis. However, further examination of the psychoanalytic literature reveals that the nature of this supposed link is not clear. Explanations couched in economic language or in terms of an early hypersensitivity to stimulation are open to theoretical criticism or are unsatisfying. The author suggests that we focus on the effect of precocious ego development on developing object relations. It is suggested that precocity may lead to early disappointment in parental objects. The inter-relationships of disappointment with early identifications, premature sense of autonomy and anal problems are discussed. A case of an obsessive-compulsive adolescent girl is presented to illustrate the role of precocious ego development and superior intelligence in the formation of the symptoms.     

Matching services to patients' beliefs about depression in Dublin, Ireland

OBJECTIVES: This study explored tensions between biomedical and psychosocial illness models and between the public health goal of stigma reduction and patients' perceptions of helplessness. Patients' etiological beliefs and use of language are considered as possible pathways to improved care. METHODS: Qualitative and quantitative data were obtained from 18 adults attending a mood disorders support group in Dublin, Ireland. RESULTS: Respondents reported feelings of helplessness concerning the occurrence of depressive episodes. When describing episodes of wellness and depression, respondents used a "light switch" metaphor to indicate this lack of control. For several respondents, acceptance of biomedical causality was linked to helplessness. In contrast, spiritual beliefs offered hope. CONCLUSIONS: Alleviating patients' sense of responsibility may reduce their guilt, but patients' perceptions of illness uncontrollability may diminish their sense of agency, reinforce depressive attributional styles, and undermine overall treatment outcomes. Communication and the patients' involvement in decisions are vital to treatment.     

Brief report: Direct and indirect relations of risk factors with eating behavior problems in late adolescent females

This study explored correlations between risk factors and eating behavior problems in late adolescent, non-clinical females (N = 301). Participants completed questionnaires for assessing eating problems, the closely associated factors of Body Mass Index (BMI) and body dissatisfaction, and a number of other risk variables that are thought to be involved in psychopathology in general, namely insecure attachment, low self-esteem, and negative affect (i.e., social anxiety and depression). Results indicated that high levels of eating problems were associated with high levels of insecure attachment, social anxiety, and depression, and with low levels of self-esteem. Further, regression analyses suggested that depression and self-esteem had a unique, direct relationship with eating problems, whereas insecure attachment and social anxiety only seemed to have indirect relations. The links between these general risk variables and eating behavior problems were independent from the specific eating problem correlates of BMI and body dissatisfaction.     

The orality in phobias

Summary An attempt has been made to focus on the orality in the phobic reaction. The fear of losing control of oral hostility and the fear of oral incorporative guilt are ego-threatening and may be handled by phobic avoidance. Aichmophobia or the dread of sharp objects is presented not as an oedipal or castration anxiety but as fundamentally an oral solution in a decompensating ego.     

Self-esteem in children after traumatic brain injury: an exploratory study

Children with a traumatic brain injury (TBI) often have difficulties in adjusting to their injury and altered abilities, and may be at risk of low self-esteem and loss of confidence. However, few studies have examined self-esteem in this client group. The current study measured the self-esteem of a group of children who were, on average, two years post-TBI and compared this to their performance on other psychometric measures. Participants were 96 children with TBI and 31 peer controls, their parents and teachers. Self-esteem was measured using the Coopersmith Self-esteem Inventory (CSEI). CSEI scores were compared with performance on Wechsler Intelligence Scales (WISC-III), Hospital Anxiety and Depression Scale (HADS); Children's Memory Scale (CMS), Vineland Adaptive Behaviour Scales (VABS) and Parental Stress Index (PSI). Self-esteem was highly correlated with IQ; HADS anxiety and depression; and parental stress (p< 0.001). Children with TBI had significantly lower self-esteem than controls and population norms (p=0.015). Many children with TBI demonstrate low self-esteem and this is closely linked with anxiety and depression. This may hamper academic performance and could lead to further psychosocial problems. It is recommended that self-esteem is routinely assessed after brain injury and rehabilitation strategies implemented to promote a sense of self-worth.     

Impact of perceived racial discrimination and collective self-esteem on psychological distress among Vietnamese-American college students: sense of coherence as mediator

This study examined whether sense of coherence mediated relationships of perceived racial discrimination and of collective self-esteem to psychological distress (depression and anxiety) among 122 Vietnamese American college students. Higher levels of perceived racial discrimination (PRD) were associated with a reduced sense of coherence (SOC) and with higher levels of depression and anxiety. Path analysis found that SOC partially mediated the relationship of PRD to depression as well as to anxiety. Higher collective self-esteem (CSE) was associated with a stronger SOC, which in turn was associated with lower depression and anxiety. SOC mediated the relationship between CSE and depression, and part of the relationship between CSE and anxiety.     

Diagnostic criteria for depression in Parkinson's disease: A study of symptom patterns using latent class analysis

Although major depression is one of the most frequent psychiatric disorders among patients with Parkinson's disease, diagnostic criteria have yet to be validated. The main aim of our study was to validate depressive symptoms using latent class analysis for use as diagnostic criteria for major depression in Parkinson's disease. We examined a consecutive series of 259 patients with Parkinson's disease admitted to 2 movement disorders clinics for regular follow‐ups. All patients were assessed with a comprehensive psychiatric interview that included structured assessments for depression, anxiety, and apathy. The main finding was that all 9 Diagnostic and Statistical Manual (4th edition) diagnostic criteria for major depression (ie, depressed mood, diminished interest or pleasure, weight or appetite changes, sleep changes, psychomotor changes, loss of energy, feelings of worthlessness or inappropriate guilt, poor concentration, and suicidal ideation) identified a patient class (severe depression group) with high statistical significance. Latent class analysis also demonstrated a patient class with minimal depressive symptoms (no‐depression group), and a third patient class with intermediate depressive symptoms (moderate depression). Anxiety and apathy were both significant comorbid conditions of moderate and severe depression. Taken together, our findings support the use of the full Diagnostic and Statistical Manual (4th edition) criteria for major depression for use in clinical practice and research in Parkinson's disease and suggest that anxiety may be included as an additional diagnostic criterion. © 2011 Movement Disorder Society     

A developmental perspective of depression--towards a novel formulation

A novel conceptualization of depression, analyzed in a developmental frame of reference, is based on three major postulates: 1) the distinction between an anaclitic type of depression, triggered by the traumatic loss of a need-satisfying object, and depression of a reflexive (narcissistic) type, caused by the loss of a recognizing/mirroring object; 2) in principle, anaclitic object loss involves reflexive implications and vice versa; 3) very early breaks of object relationships, at the first symbiotic stage of life, are pre-narcissistic by nature. These three assumptions form the basis for a systematic juxtaposition of two developmental lines--one line from first-stage symbiosis to anaclitic object relations, and the second line--from second-stage symbiosis to reflexive object relations. Even though the two lines are closely intertwined, corresponding distinct forms of depressive reactions can be discerned in each line, according to the type of the lost object relationship.     

Can helping others strengthen teens? Character strengths as mediators between prosocial behavior and adolescents’ internalizing symptoms

IntroductionIdentifying protective factors against internalizing behaviors during adolescence is a public health priority, as rates of depression and anxiety are rising. As such, the purpose of this study was to examine whether prosocial engagement toward strangers and family members is protective against depressive and anxiety symptoms, and whether this link is mediated by character strengths (i.e., hope, persistence, gratitude, and self-esteem).MethodThe sample consisted of 500 US adolescents (52% female; 66% European American; 33% from single-parent families). Data across three consecutive yearly waves were utilized in the current study (M_age Time 1 = 13.32).ResultsResults of a longitudinal structural equation model revealed prosocial behavior toward strangers and family members were differentially related to character strengths, and that prosocial behavior toward strangers was indirectly associated with depressive symptoms via self-esteem.ConclusionTaken together, findings extend the Developmental Cascades model and suggest that prosocial behavior and character strengths protect against depressive symptoms during the adolescent period. Findings are discussed in the context of relevant research and theory, and implications for future research and intervention programs are presented.     

Anxiety symptoms and perceived performance in medical students

Medical students represent a highly educated population under significant pressures. During the transition to clinical settings in the third year, they may experience a loss of external control and may counter this with an increase in obsessionality and/or other anxiety symptoms. Our study examines the phenomenology of obsessive-compulsive and other anxiety symptoms in medical students at two U.S. medical schools and relates these symptoms to self-perception of performance. Subjects anonymously completed a battery of questionnaires regarding obsessive-compulsive symptoms, attentional problems, anxiety symptoms, depressive symptoms, and perceived performance in medical school. A factor analysis of obsessional symptoms showed four primary factors: checking/doubts, contamination, long time/detail, and unpleasant thoughts/worries. These four factors were similar to those found among college students and other nonclinical populations. Anxiety, attentional, and depressive symptoms were highest in the third-year medical students. In contrast, obsessional symptoms were highest in the first-year students and lower for subsequent years. Perceived performance was not significantly correlated with obsessionality, although lower perceived performance was associated with higher levels of anxiety and depressive symptoms. Students with lower perceived performance in medical school were significantly more likely to be female, depressed, or older. The progressive decrease in number of obsessional symptoms across years and the lack of correlation with perceived performance suggest that these symptoms may be developmentally appropriate, and perhaps adaptive. In contrast, other anxiety symptoms appear to be maladaptive responses to external stressors.     

Affective Instability Prior to and after Thoughts about Self-Injury in Individuals With and At-Risk of Psychosis: A Mobile Phone Based Study

It has been proposed that affective instability may be associated with thoughts about self-injury. The aim of this study was to test the hypotheses that instability in feelings of depression, but not anxiety, guilt, or hostility, would predict greater concurrent and subsequent thoughts about self-injury. Thirty-six individuals with psychosis completed questions on touch-screen mobile phones at semi-random times each day for one week. The instability of depression predicted greater concurrent and subsequent levels of thoughts about self-injury, even when controlling for depression level. Conversely, self-injurious thoughts predicted more stable depression. The instability of guilt, anxiety, and hostility did not significantly predict levels of thoughts about self-injury. Results indicate that a variable depressive state may trigger the onset of thoughts about self-injury, which increases the risk of its subsequent recurrence. The onset of self-injurious thoughts may, however, have a stabilizing effect on subsequent depression.     

Depressive delusion

In this study of 160 consecutively admitted inpatients who met ICD-9 criteria of endogenous depression, mood-congruent depressive delusions were ascertained in 14.4% (n = 23). The total HRSD score was significantly higher in the delusional than in the nondelusional group. Delusions of guilt were recorded by far the most frequently. There was a correlation between delusions of guilt in the current depressive episode and suicide attempts in the past. In the delusional patients the individual courses of the illness were characterized by marked symptomatological differences from one depressive episode to another. In all but one of the patients, depressive delusions coincided with a thematically identical experience of anxiety. How often anxiety occurs in delusional form depends substantially on the respective theme of anxiety. In accordance with earlier psychopathological literature the findings confirm that depressive delusion is closely linked to the experience of anxiety.