Several core dynamics of depression have been identified by these theoreticians (Table 2-2).
Despite their variations in focus, almost all psychoanalysts describing their patients with depression have emphasized narcissistic vulnerability as triggering susceptibility to this syndrome. The basis of this vulnerability varies, however, from disappointments in early relationships to fragile self-esteem based on factors such as childhood experiences of helplessness or reactive fantasies of disempowerment or castration. A sense of narcissistic injury predisposes patients toward the experience of shame and anger, which may become important aspects or triggers of later depressive episodes.
Theorists also focus on conflicted anger as playing a key role in the dynamics of depression, although the origin of the anger and the form it takes may vary. In general the anger is seen as triggered by narcissistic injury, loss, immense frustration, or a sense of helplessness. In many of the models explored earlier in this chapter, aggression triggers conscious or unconscious guilt, which contributes to the self-punishing aspects of the patient's mood, the tendency to self-denigration, and self-defeating behaviors that reinforce the depressive cycle.
In almost every theorist's description, aggression ultimately is directed toward the self, although the basis of this dynamic varies. The possibilities include hatred projected outward and then experienced as directed toward the self, and aggressive feelings and fantasies directed toward aspects of the self identified with an ambivalently experienced other. A severe superego attacks the self for various aggressive, competitive, and sexual feelings, lowering self-esteem.
Several authors have referred to attempts to modulate self-esteem and aggression via idealization and devaluation, leading to increased susceptibility to depression when idealized others prove to be disappointing. Multiple authors also have emphasized an overly perfectionistic ego ideal and superego in their depressed patients. Patients fail to live up to their narcissistic aspirations and moral expectations, leading to a loss of self-esteem.
Finally, characteristic defenses, such as denial, projection, passive aggression, and reaction formation, are described as a means of warding off painful depressive affects but often result in a further lowering of self-esteem.
Table 2-2. Central dynamics of depression
Early experience or perceptions of loss, rejection, inadequacy, possible biochemical vulnerability Sensitivity to perceived or actual losses, rejections Recurrent lowering of self-esteem, triggering depressive affects; rage in response to experience of injury
Response to narcissistic injury; anger at perceived or actual lack of responsiveness of others to the individual's needs and wishes; anger may also arise from a blaming of others for one's sense of vulnerability, or being deeply envious of those who seem less vulnerable Anger at others for injurious, unresponsive behavior, attitudes; blaming others for one's vulnerability; envy of others who are viewed as less vulnerable; anger at others experienced as damaging, threatening, unacceptable Disruptions in interpersonal relationships; anger turned toward the self, triggering depressive affects, lowering of self-esteem
Severe superego, experience of guilt and shame
Cause Anger turned toward the self via harsh self-judgments;
internalization of parental attitudes perceived as harsh and punitive
Content Anger, greed, envy, sexuality, and accompanying wishes seen as wrong or bad
Consequences Negative self-perceptions and self-criticisms trigger lowering of self-esteem, depressive affects
Idealized and devalued expectations of self, others
Efforts to mitigate low self-esteem High self-expectations (ego ideal), others idealized in meeting individual's needs, others devalued to bolster self-esteem
Significant disappointment, anger at self and others, with lowering of self-esteem
Characteristic means of defending against painful affects (defenses)
Intolerable feelings of low self-esteem, anger Denial, projection (seeing anger as coming from others), passive aggression (expressing anger indirectly), reaction formation (denial of anger accompanied by compensatory overly positive feelings) Anger not effectively dealt with; increased depression via anger directed toward the self or via world seen as hostile, menacing, uncaring, or defeating
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