Le site des recherches fondées sur les pratiques psychothérapiques

Edith Jacobson M.D.

METAPSYCHOLOGY OF CYCLOTHYMIC DEPRESSION
Phyllis Greenacre, M.D. New York, International University Press, INC.

… Or else, the partner of the manic-depressive may be an oral type of a different variety.
As a point of departure for the metapsychological study of this personality structure and of the development of the depressive conflict and defense and restitution mechanisms, I have chosen a short dream of patient B., a physician who was at the beginning of a depression. It had been precipitated by the alarming news than his mother had a cancer of the uterus, which required immediate operation. During the last years B. had developed depressive states with a paranoid tinge, with feelings of tiredness and exhaustion, and with a series of psychosomatic and hypochondriacal symptoms and fears. They had begun at the time he detected that his wife had to undergo a gynecological operation which might affect her fertility.

B. dreamed that he had lost two of his "excellent" teeth. As they fell out, a fine thin silver cord that held them together went to pieces.

B.'s immediate interpretation was that the two teeth represented himself and his mother and that the connecting structure was the umbilical cord by which he was still attached to her. If his mother should die, he would feel as though he had lost his own self. The silver cord also represented his weak personality, which, in the case of her death, would break down.
When this patient was not depressed, he would manifest a rather conspicuous self-inflation. He would express his feelings of being very good-looking, bright and smart, as "excellent" in his field as his teeth were. In these states he would also talk incessantly of his worship for his mother, of her unending kindness and generosity, her great intelligence, her physical and mental strength. He had married his wife because she seemed to resemble his mother. Neither woman in any way corresponded to this ideal picture. They were neurotic, overanxious, clinging women, and, as mentioned above, both suffered from a chronic gynecological condition. The patient had managed for years to deny their weaknesses, including their physical handicaps. He himself had gone through several serious illnesses to which he had regularly responded with a depressive state along with hypochondriacal complaints and fears. At other times, the patient would exhibit an uncommon pride in his body.

His dream of the loss of his teeth referred to an experience in his adolescence when the patient had lost a tooth because his mother had neglected the adequate dental care of her children, in the same way as she had neglected her own present illness until it was almost too late for help. At the time of his tooth trouble, the boy had to take the matter into his own hands. He had found a dentist who extracted the tooth, supposedly because it could not be saved. I may interject here that B. went into medicine because the mother's only brother as well as his own older brother, a father substitute, were physicians. Both men he had greatly admired.
Hence, medicine, his vocation, represented an ideal derived from both parental love-objects. His mother had told him repeatedly how she had nursed and cured him during his early childhood diseases. But an outstanding early childhood trauma had been the death of his maternal grandmother whom neither uncle nor mother had been able to cure. And both, uncle and brother, had been very gifted and promising young men who failed completely in their careers.

During the dream session the patient began to express his deep resentment of his mother's and his wife's inability to take proper care of their own health and that of their children. He would blame his mother for his severe childhood diseases, which had probably been neglected as much as his teeth.
As the session proceeded, the patient started derogating the whole medical profession for its utter impotence. He talked of prominent but incompetent doctors who drew a fortune from their patients' ignorance. And, finally, he indulged in severe self-reproaches : he blamed himself for being an incompetent, neglectful physician, uninterested in his patients and unable to cure them. He ended the session with an expression of deep guilt feelings toward his mother, whose sickness he had ignored and neglected and diagnosed too late to save her. He left in a very depressed state.
The dream and dream material and the corresponding emotional reactions during this one session show in a nutshell the prerequisites for and the development of the depressive conflict.
The superficial symbolic interpretation by the patient informs us already about the pathogenic core of the manic-depressive personality. The thin, fragile silver cord in the dream indicates the weakness of his ego, resting on the intimate bond between himself and his mother. The two teeth are the symbol of his love-object- and his self-representations. The one tooth, representing his mother, is his own. The two teeth are connected. In other words, we see what I regard as characteristic of these patients : the insufficient separation between the love-object and self-representations, the lack of distinct boundaries between them, which accounts for the patient's too strong fixation to the parental love-objects. The self-representations extend, so to speak, to the object-representations ; both show insufficient maturation and stability. The patient gauges his love-objects and himself by infantile value measures, predominantly by their omnipotent physical power and invulnerability.

These standards are embedded in his high-flung ideal of a competent, in fact omnipotent, physician, who devotes his whole life to the rescue of his patients. In the patient's associations, we observe also the personification of his ego ideal, its insufficient distinction from the ideal parental image. He talks indiscriminately of the value or worthlessness of the whole medical science and profession and of the individual physicians who represent parental images.
His example shows, furthermore, how in manic-depressives all ambitions and pursuits revolve only about representations of the overvalued parental love-objects, which extend, as it were, to the whole world. This is why all their ego functions fail when the love-object is depreciated. Frequently we observe that manic-depressives live on their ideals or their idealized partners rather than on their own real self. They exhibit an unusual pride in their idealizations as though their own idealism would per se turn them into valuable human beings. We may add that the "idealism" of the manic-depressive differs greatly, in type, from that of the schizophrenic. The latter is abstract, removed from personal objects, the former is concrete and, as in the above-described case, mostly attached to a personal representative object. This accounts for the seeming, "realism" of the manic-depressive, which clinical psychiatrists, such as Lange, have described.

We shall now investigate how the depressed state developed in our patient. This time it was precipitated by his mother's sickness, but at other times it had developed when he himself became sick or met with failure in his work, with financial difficulties, or with disappointments in his love life. In other words, his depressive states would be precipitated by a failing of his love-object or of himself. But the analysis showed that, in either case, the patient felt hurt and blamed the love-object for it. In fact this patient expressed with unusual clarity his feeling that all his achievements or failures were due to the effectiveness or failure of his "Intuition" - in German, Eingebung ; that is, all achievements or failures were the result of what had been given to him. He regarded his ego functions not as his own productions but as reproductions of what he had received. We understand that in disregard of his potential abilities, his self-representations retained the infantile conception of a helpless self, drawing, its strength from a powerful, ideal love-object. He tried to keep the image of this love-object hypercathected, by constantly depriving the self-image of its libidinous cathexis and pouring it on the object-image. He then had to bolster his self again by a reflux of libido from the love-object image. These continuous cathectic fluctuations found expression in corresponding emotional vacillations. In his actual attitudes he would show a mixture of conceited and humble, sadomasochistic and protective behavior to the love-object and simultaneously demand continuous evidence of the latter's value, power and devotion. This is the basis of the “symbiotic“ type of relationship to which I pointed above.

This position is inevitably unstable and facilitates easy, rapid, and drastic cathectic changes on the slightest provocation. Against this danger the manic-depressive has to protect himself by strong pathological safeguards, essentially by the denial mechanisms so beautifully described by Lewin (1950). He can maintain a lasting libidinous overcathexis of the love-object image only by constant efforts at denial of his own intrinsic value and of the weaknesses of the real love-object, i.e., by a continuous, illusory overestimation of the love-object and an equally illusory under- or overestimation of himself. If he meets with disappointment or failure, the denial mechanisms will either break down or have to be so fortified that the patient may go into a manic state, which in contradiction to schizophrenic feelings of grandeur - represents, I believe, a state of lasting participation of the self in the imagined omnipotence of the love-object. The manic can afford to discharge his aggression fully and diffusely. Since, by his denial of the existence of unpleasure and destruction, the whole world will become a valley of unending and undestructible pleasure, his aggression can do no damage⁷.

In case the denial mecanisms fail, the patient's first reaction will be to master the narcissistic injury and build up his self by disparaging the love-object in a way as illusory as he had previously glorified it. He will try to repair the hurt by switching the whole aggressive cathexis to the object image and the libidinous cathexis to the self-image. In adolescence this mechanism was still effectual in our patient. He asserted himself by derogating his neglectful mother and by reactive identification with her ideal image. Thus he went ahead and took care of his tooth, instead of and in spite of his mother. But he indicated in his dream that unconsciously he regarded his success - for good reasons - as a failure : he actually lost his tooth, which in the dream was equated with his own self and his mother. In fact, manic-depressives may react to success in love or work in the same way as to failure : with either a hypomanic or manic state or with a depression.

Their reaction depends on what the success will mean : an aggressive self-assertion by derogation and destruction of the love-object, or a present from the powerful love-object. Their inability to accept success is not always or not only an expression of their moral masochism and of their guilt conflict. One of my depressive patients regularly responds to achievements by a struggle between feelings of tremendous pride and of rising anxiety and emptiness. He feels as though the most precious thing in life were gone ; life will be empty forever. He loses his interest in his precious endeavors and may end by feeling that his whole work has been worthless anyhow. This response is only more intense and pathological than the well-known attitude of narcissistic people who value an object as long as they cannot get it and depreciate it as soon as they have got it. But the manic-depressive cannot bear a self-assertion through denegation of his love-object. He tries to avoid such a situation by keeping the valued love-object at a distance, as it were, which protects it from deflation. The simultaneous libidinous hypercathexis of the object clearly distinguishes this attitude from the schizoid remoteness. Since the love-object has to stay unattainable, he may avoid success by delaying a final achievement or the real consummation of a love relationship, for which he has deseperately struggled.

Evidently, he is so afraid of a lasting self-inflation at the expense of the love-object, because it might lead to a complete libidinous withdrawal and a letting loose of all his severe hostility on this one objet. His fear of a “loss of the object" is fear of a destructive absorption of the ''good, powerful" object-image by the self-image. Here is a situation that induces an immediate and intense need to retrieve his old position. He will be overperceptive of any flaw in his achievements and use it to confirm his own weakness and to reinstate the strengh and value of the object. This is why success afflicts the manic-depressive in the same way as failure. Either may arouse an initial hostile derogation of the love-object, which cannot be tolerated and which yields to a rapid reversal, undoing, and denial of the previous situation.
There will be an immediate, increased reflux of aggression from the love-object to the self-image ; but by this time the pathological process may have proceeded so far that the patient will be too depleted of libido to sufficiently recathect the object. All he can achieve may be an aggressive devaluation of both : of himself and of his love-object. He will return to his position of participation, but in the worthlessness instead of the value of the love-object. Many patients, especially those with chronic simple depression, and many depressive children, may prescrit this picture. They manifest a general pessimism, disillusionment, and lack of interest in life and in themselves. Everything has become worthless, unpleasurable, or empty. They maintain a continuous denial of the world's and their own value.

I postulated in a previous paper (1947) that I regard this as the primary depressive disturbance, which may be distinguished from the secondary attempts at defense and restitution. Some patients give evidence indeed of very intense efforts to recathect and build up the love-object image again and to regain their original unstable equibibrium.

We will now investigate the defenses that the patient uses for this purpose. Since his libidinous resources are fading, his first line of defense will be to turn to the real object world for support. He will try to resolve his inner conflict by help from without. He wants to use the love of an outside person to whom he has attached his ideal object-image as a stimulant for his failing ability to love. This is the stage when the patient, in his frantic endeavor to stop the depressive process, will develop a persistent and increasing clinging to the person he has chosen for this purpose. He will gather all his available libido and pour it on this one person in a desperate appeal to give such convincing evidence of unending love and indestructible power and value as to evoke a libidinous response in himself and, in this way, enable him to re-establish an ideal object-image that cannot be deflated and destroyed. It is a phase of acting out that we can well observe in the treatment of depressives in the transference situation. The patient will exhaust himself in efforts to concentrate on the analyst whatever love is still at his disposal. He will believe in an extremely submissive, masochistic and, at the same time, sadistic way, give himself up to, the analyst but expect the impossible in return. He will desire his constant presence and try to blackmail him into a continuous show of omnipotent love, value, and power.

Much depends at this stage, on the analyst's handling, of the transference situation. But, as the depressive episode develops, things may get out of hand. The analyst may no longer be able to live up to the patient's expectations. Analyst and patient will be in a trap. The patient will be less and less able to tolerate the analyst's warmth and sympathy, which, failing to elicit an adequate libidinous response, will only increase the disappointment and the hostile claim for a more powerful love. In his fear of a complete breakdown of the object-image, the patient will regress a step further. I emphasized in the first part of the paper that the deserted child prefers an aggressive, strong love-object to its loss. Correspondingly, the patient may now attempt to hold on at least to the reanimated image of an omnipotent, not loving, but punitive, sadistic object. This will manifest itself in the patient's increasing masochistic provocations of the analyst's anger, to a show of aggression, which may bring temporary relief but will actually promote the pathological process.
If the outside world has failed to help the patient in the solution of this conflict, he may turn to his last line of defense : retreat from the object world. The conflict may become fully internalized and a melancholic blatantly psychotic syndrome may develop.
Before we turn to the problem of melancholia, I should like to interpolate that, for reasons of simplification, I have so far deliberately neglected the superego aspects of the depressive conflict.

The melancholic introjection mechanisms seem to represent the last failing attempt at a recovery of the lost original position. What they achieve is at least to restore the powerful object-image by making it a part of the self. What happens is shortly this :
The final escape of the patient from the real object world will, first of all, facilitate a withdrawal of cathexis from the realistic part of the object-representations. Consequently, the object-images will be split up. During the last phase of the conflict the archaic image of a powerful, but punitive, love-object had been built up as against the image of a weak, bad love-object. This reanimated, inflated image will now be dissolved as a representation in the system ego and will be absorbed by the superego, whereas the deflated worthless object-image merges with the self-representations. Within the self a dangerous schism will develop, which still reflects the patient's effort to rescue the valued object by keeping it protected from his destructive impulses at an unattainable distance from the self. The aggressive forces will accumulate in the superego and cathect the self-image, while the ego gathers the reduced libidinous forces and surrenders to the assault. Thus the patient will succeed in rescuing the powerful love-object but only by a complete deflation or even destruction of the self. The incessant complaints and self-accusations of the melancholic, his exhibition of his helplessness and his moral worthlessness, are both a denial and a confession of guilt : of the crime of having destroyed the valuable love-object. Both indeed tell the truth : the powerful image bas collapsed as an object-representation in the ego but it has been reconstituted in the superego.

I may point out once more the difference between these introjection processes and normal or neurotic ego and superego identifications. In normal and in neurotic superego identifications, the object-representations in the ego system are maintained, whereas the melancholic introjection of the "ideal" object-image into the superego goes along with a giving up of the “good“ object-representations in the ego and leads to their merging with and a personification of the superego. This is facilitated by the insufficient initial separation between object-image and ego ideal, of which I have talked above. The introjection mechanism in the ego, on the other hand, does not lead to an identification of the ego with the love-object but to a merging of the "worthless" object-image with the image of the self. The ego does not assume any characteristics of the love-object ; the self is perceived and is treated by the superego as though it were the deflated love-object.⁸

This metapsychological description and discussion of the problem of depression had of necessity to be one-sided and schematic. I deliberately left out of consideration the corresponding instinctual processes. In the frame of this paper it has seemed to me to be of lesser importance that the melancholic divulges cannibalistic incorporation and anal-sadistic ejection fantasies. All psychotics, schizophrenic or manic-depressive, manifest such deeply regressive id material, which corresponds to the processes that I discussed : the threatening destruction of the object and self-representations and their restitution by their partial merging. The questions I have tried to explore in this paper are : where, in psychotic depression, these fusions, i.e., introjections, take place from the structural point of view and what they mean with regard to the disintegration of the ego and superego systems. This is why I wished to concentrate on the following issues : the concept of self-representations, and its importance for an understanding of the depressive type of identification ; the cathectic fluctuations and shifts from self- to object-representations and the reverse, and the fusions with each other ; the struggle of the manic-depressive to maintain and recover his position of participation in the power of his love-object ; the defense function of the patient's clinging to the real, outside love-object during the depressed period ; and, finally, the melancholic symptom formation as an expression of his last failing attempts at restitution of a powerful love-object in the superego.

Naturally, the phases in the development of the depressive conflict and its pathological solution are interwoven and cannot be distinguished so clearly as they are in this description. Even during the free intervals we usually find that the manic-depressive will show more or less continuous vacillations in his mood and efficiency and will try to recover his narcissistic equilibrium once by a clinging to his real love objects and by claims for support from without and then again by temporary retreats into a pseudo self-sufficiency and attempts to resort to his own superego standards only. This is why I consider it not quite correct to say that during his free intervals he shows compulsive attitudes. lt even seems to me that the main difference between the manic-depressive and the compulsive personality is the former's simultaneous or alternate leaning on an idealized love-object and on his own superego, a mixture of pseudo independence and dependency, which true compulsives do not show.

(7) A patient in a hypomanic state, which terminated a nine-month period of depression, told me that she felt so voracious : she would like to eat up everything - food, books, pictures, persons, the whole world. when I jokingly and with deliberate provocation remarked that this seemed to be quite bad and dangerous, what would she do if everything were eaten up, she said, highly amused : "Oh no, the world is so rich, there is no end to it. Things are never finished. I cannot hurt anybody, or anything."

(8) Abraham (1911) neglects these differences when he equates the identification with the lost love-object in mourning with the melancholic identification. In his example, the turning gray of his hair after the death of his father, a realistic identification has been achieved.

Texte intégral in: Affective Disorders. Psychoanalytic contribution to their study.
Edited by Phyllis Greenacre, M.D. New York, International University Press, INC.
Pages 49 à 84.

Dernière mise à jour : 30 March, 2008
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