Marianne Leuzinger-Bohleber [[Book - Etiopathogenic Theories and Models in Depression]] [[Depression]] # 5.2.1 Depression as a Reaction to Loss, Guilt, and Reparation Page 95 **Depression is seen as a reaction to loss. It could be a real object or an inner object.** - In contemporary psychoanalysis, depression is still seen as the reaction to a loss, that of a real object in the outside reality of the patient or that of an inner object, a loss of an internal relationship. **[[C202005142045 Anger can turn inward to become depression]]** - Karl Abraham had already identified hatred as the cause of depression in 1911, which led to repressed self-accusations and feelings of guilt. In 1924, like Freud, he also recognized identification as a fundamental mechanism. Suppose the person predisposed to depression loses his love object. In that case, he reacts with hatred and contempt, and the frustrating object is ejected and, in the course of regression to the oral-sadistic stage, is immediately introjected back into the self. Through this narcissistic identification with the devalued object, the ego itself becomes worthless and reacts melancholically. ^e814f4 **In Melanie Klein's work, she talks about how children see themselves and others as both good and bad. When children realize they have aggressive feelings towards the good parts, it makes them feel sad and they may become depressed. Klein says that when children try to make up for their aggressive feelings, it helps them feel better. But if their aggressive feelings are too strong, they can't make up for them, and that's when depression can happen**. - In Melanie Klein’s work, the archaic severity of the early superego comes from the splitting of the object and self-representations into an “ideal good object” on the one hand and “phantazised evil one” on the other hand. Through the later integration of these splits in the rep- resentations, the child becomes aware of his own aggression against the idealized primary object and falls into a depression. Melanie Klein introduces the new con- cept of reparation in the so-called depressive position. Depression occurs when the libidinal and aggressive impulses, thoughts, and drives can be integrated and repara- tion associated with it can be achieved. If excessive aggressive impulses are domi- nating the libidinal ones, such an integration and reparation cannot take place: A depression develops.2 **when we cannot achieve what we desire and cannot effectively channel our aggression, it can result in self-blame, self-criticism, and a sense of worthlessness, leading to depressive feelings** - Edith Jacobson describes a basic conflict that can be found in all depressive states. If the ego cannot achieve the satisfaction it desires and cannot use its aggres- sion for achieving this satisfaction, then it turns the aggressive impulses against the self-representation. A narcissistic conflict develops between the desired self-image and the image of the failing devalued self. The self-esteem is lost and a depressive mood develops. # 5.2.2 Narcissistic and Psychotic Depression **Depressive patient's ego are vulnerable and sensitive to disappointment. There is not enough differentiation between self and others.** - Psychoanalytical authors have repeatedly addressed the fact that in depressive patients, the ego is particularly vulnerable and intolerant of frustration and disap- pointment. Also, self-representations and object representations do not yet seem to be sufficiently differentiated from each other. **When people have high expectations of themselves or others, and they are unable to meet those expectations, it leads to feelings of depression.** - It places the basic disorder in the narcissistic regulatory system and describes it as the tension between strongly pronounced narcissistic expectations and ideals on the one hand and the inability to meet these ideals or to receive narcissistic support from the object for them on the other. This then results in the depressive affect. **Depression not only can be due to aggression, it could be from helplessness.** ^a4d7a5 - In 1952, Edward Bibring was the first to elaborate on this explanatory approach and to separate it from the assumption of aggression directed at the self as the main determining factor of depressions. Depression is “an emotional expression of a state of helplessness of the self.” It is a mode of reaction generally available to humans. The ego often finds itself in a state of real or imaginary helplessness in the face of overwhelming difficulties. Others speak of narcissistic depression, given the underlying tensions between ego and ego ideal. ==The dominant feelings here are not feelings of guilt fed by aggression and self-hatred but shame and humiliation and feelings of abandonment and helplessness.== [[Shame and Guilt MOC]] ^748fd8 **Depression arises from loss of sense of well-being, and contentment. When they feel powerless reduce their emotional distress.** - In 1965, Sandler and Joffe describe the loss of narcissistic integrity as the central cause of the depressive affective reaction. It is not so much the loss of a love object that is in the foreground as the loss of the well-being that is inseparably linked to it. It is a feeling of having been deprived of an ideal state of the mind. If the individual feels helpless and resigned in the face of the mental pain experienced and cannot resort to an outwardly directed aggression to remedy it, he or she reacts affectively with a depression. **When there is a mismatch of ideals and reality. This discrepancy leads to lost of the idealised self, and the harsh inner critic takes over robbing the person's self-esteem. This is related to earlier childhood.** - Wolfgang Loch (1967) also assumes an imbalance between the ideals of the individuals and its self-esteem. The perception of this discrepancy produces the depressive affect. In the depressive patient, there is no stable connection between the self and the ideal self, because the process of identifying the self with the ideal object is disturbed by aggressive impulses and attitudes. Thus, the connection between the self and the ideal self is nly guaranteed as long as the real presence of an ideal object is given. In psychotic depression, the ideal self is lost, forcing the cathexis of the superego as a substitute. This archaic persecutory superego has taken the consciousness function of the ego and robbed the depressive of his self-esteem: the real self-assessment gets lost. Because the libidinal cathexis of the ideal object was already disturbed in early childhood, depressive feeling of emptiness and inhibition of vitality develop later in life. # 5.3 Depression and Trauma: Some Interdisciplinary Findings # 5.3.1 Depression and Embodied Memories of Trauma **Helplessness and hopelessness are both a sign pointing to depression and trauma** - The extreme feeling of helplessness and hopelessness is not only, as just outlined, a central basic feeling of depression but also characterizes the traumatic experience. **A Traumatic event overwhelmed the individual, it triggers a sense of helplessness.** - As Bohleber (2010/2012) points out, the traumatic situation can result in an extreme sense of helplessness, linked to the overwhelming anxiety often confronted with the danger of death or annihilation as well as an experience of being completely left alone: **Trauma breaks down trust; between self and others, and within self; own agency.** - The traumatic experience breaks down both the basic trust of the traumatized individual in a helping object (see Erikson, 1958/1993, see also the concept of epistemic trust by Fonagy et al. (2015b) on the one hand and the basic trust in one's own self-agency on the other hand (see, e.g., Emde & Leuzinger-Bohleber, 2014; Leuzinger-Bohleber, 2015). The traumatized person is unconsciously and firmly convinced that nobody but nobody can help him in a situation of extreme, life-threatening danger and dehu- manization, but that he is totally left alone and completely incapable of freeing himself from the unbearable situation. **Psychoanalytical understanding of the long-term effects of trauma is based on survivors of the Holocaust and their descendants.** - The psychoanalytic knowledge of short-term and long-term effects of extreme traumatization is mainly based on clinical psychoanalytical experiences with survivors of the Shoa and their children and grandchildren. The kind of experiences that the victims of the Shoa had gone through exceeds our all imagination. The incomprehensibility of the trauma is described in psychoanalytic-scientific general concepts like extreme traumatization (cf., e.g., Krystal, 1988) or sequential (Keilson, 1991) or cumulative traumatizations (Khan, 1964). The survivors of such extreme traumatizations illustrated that such traumatizations are not to be processed psychically but lead to lifelong disturbances such as nightmares, flashbacks, loneliness and depression, dissociation and derealization, disturbances in the sense of time, and a basic feeling of identity, diffused panic, fear and aggression attacks, and emotional encapsulations, breaking down a basic trust in a helping other and self-agency (see above) as well as basic meanings of life. Some of the psychosomatic symptoms include sleeping disturbances, bodily pain that is not easy to localize, etc. The suffering linked to these deep psychic wounds can be relieved in long psychotherapy, but the wounds can never really be (fully) “healed.” Besides, the experienced trauma is often transmitted to the second and third generation.