SECTION 16.5 I HOOD DISORDERS: PSYCHODYNAMIC ETIOLOGY
`
`U}?
`
`onset of an episode of depression. The most impressive piece
`of evidence linking loss to subsequent depression is the finding
`that loss of a parent before age 11 places adults at a higher than
`usual risk of depression. Some investigators have postulated
`that early childhood losses or separations actually sensitize neu-
`ronal receptor sites in the brain. thereby producing avulncra-'
`bility to mood disorders in adulthood. Persons who grow up
`with that enhanced vulnerability may be highly sensitive to
`images or ideas linked to depressive states. so that an episode
`of depression may be precipitated without requiring a cata-
`strophic external loss. Chronic stress or deprivation of environ-
`mental origin may produce alterations in the catecholarninerg-ic
`syslaem in response to stimulation from the cor1:i.cotropin-releas-
`ing hormone—adrenooorticotropic hormone (ACTI-I) axis. The
`end result of the changes may be the clinical picture of
`depression.
`- The effects of psychosocial influences on neurophysiological
`,factors have been amply derrronstrated in primate research.
`-'Infant squirrel monkeys who are separated from‘ their mothers
`experience long-lasting and. in some cases. permanent neuro-
`biological changes. The changes include lasting alterations in
`the sensitivity of noradrenergic receptors. changes in hypotha-
`larnir: serotonin mretion, and persistently elevated plasma cor-
`tisol levels. The sensitivity and the number of brain opiate
`receptors are also significantly affected by repeated separations.
`Some of the changes are reversible if the inihnt monkeys are
`reunited with their mothers or siblings; other changes are not.
`Moreover. the separations appear to be more or less damaging
`during certain developmental periods. possibly because of the
`correlation with myelirtization in the nervous system.
`In the ensuing discussion .of psychodynarrric factors in the
`etiology of depression. the reader must keep in mind that psy-
`chological influences work in concert with genetic vulnerability
`and neurophysiological alterations to produce the characteristic
`clinical picture of depression. Those characteristics include psy-
`chomotor retardation. sleep changes, loss oi’ appetite, dimin-
`ished sex drive. anhedonia, loss of energy. inappropriate guilt
`feelings. and suicidal ideation. Similarly. comprehensive treat-
`ment plaruiing must take into account both the psychodynamic
`factors and the'alte.rations of neurotransmitters.‘
`One of. the most sophisticated efforts to define die relative
`conuibutions of psychological vulnerability, genetics. and envi-
`rotunental stressors in major depressive disorder was a predic-
`tion study involving female twins. Multiple assessments of 680
`female-female twin pairs of known zygosity were made over
`time, and the findings allowed the investigators to develop an
`etiological model to__predi'c_t major depressive episodes. One of
`die most influential predictors was the presence of recent stress-
`ful events. Genetic factors were also important in prediction of
`depression. Two other factors. neuroticisrn and interpersonal
`relations". also played a substantial etiological role. Neuroticism
`seemed to contribute in part by reducing the level of social
`support for an individual. Interpersonal dimensions of social
`support.
`recent difficulties. and parental wai-md-r_ all were
`involved in predicting a major depressive episode.
`'
`
`FSYCHODYNAMIC THEOHIES OF DEPRESSION
`
`loss in light of the fact that the fantasied loss may be entirely
`unconscious.
`-
`.
`Freud drew an analogy between serious melancholic states
`and normal grief. Both may be time-limited. but Freud cited
`two principal differences. In cases of grief] there is an actual
`object loss in external reality; in depression the lost object is
`more likely to be errtoriortal than real. The second difference is
`that persons with depression experience profound loss of self-
`esteem. but the self-regard of persons engaged in a mourning
`process is not diminished.
`
`The observational differences between-grief and depression
`were pivotal in Freud's theory. He reasoned that one way of
`dealing with the loss of a beloved person is to become like the
`person. Freud defined that process as irttrojectiorr, a defense
`mechanism central
`to the psychodynamics of depression.
`in
`which the patient irrternalizes the lost object so that it becomes
`an intemal presence. Freud later noted that introjection is the
`only way that the ego can give up a valued and loved object.
`Because depressed persons perceive the departed love object
`as having abandoned them, feelings of hatred and anger are
`intemiingled with feelings of love. Freud suggested that ambiv-
`alence of that nature, involving the coexistence of love and hate,
`is instrumental in the psychodynamics of depression. As a result
`of inltrojecting the lost object, the negative part of the depressed
`patient's arnbivalence—-the hatred and artger—is directed
`inward and results in the pathognornonic picture of self-
`reproach. In that manner a suicidal act may have the uncon-
`scious meaning of murder.
`-
`_
`_
`Karl Abraham. one of Freud's early colleagues. shared
`Freud’s view of depression but also extended and elaborated it
`further. Abraham viewed the process of introjection as a
`defense mechanism that takes two forms. First. he thought that
`the introjection of the original love object is the basis for build-
`ing one‘s ego-ideal. so that the role of the conscience is even-
`tually taken over by the lntrojected object. In that conceptual-
`ization much of pathological self-criticism is seen as emanating
`from the introjected love object. In the.second form of intro-
`jection, more in keeping with Freud's idea. the content of self-
`reproach is merciless criticism directed at the object. In other
`words. Abraham viewed the two processes of introjection as
`instrumental . in the creation of the superego. Abraham also
`linked depression to early fixations at the anal and the oral levels
`of psychosexual development, He viewed oral sadistic tenden-
`cies as the primary source of self-punishment in depressed
`patients. and he inferred that inadequate mothering during the
`oral stage of development was involved.
`The psychodynamic understanding of depression defined by
`Freud and expanded by Abraham is known as the classical view
`of depression. That theory involves four key points: (1) Distur-
`bances in die infant-mother relationship during the oral phase
`(the lirst 12 to 18 months of life) predispose to subsequent vul-
`nerability to depression. (2) Depression can be linked to real or
`imagined object loss. (3) Inn-ojection of the departed object is
`a defense mechanism invoked to deal with the distress con-
`nected with the object
`loss.
`(4) Because the lost object
`is
`regarded with a mixture of love and hate, feelings of anger are
`directed inward at the self.
`
`Anger turned inward A common finding in depressed
`patients is profound self-depreciation. Sigmund Freud, in his
`classic 191? paper “Mourning and Melancholia." attributed
`that self-reproach to anger turned inward, which he related to
`object loss. The object loss may or may not be real. A fantasied
`loss may be suflicient to trigger a severe depression. Moreover.
`the patient may acmally be unaware of any specific feelings of
`
`Depressive position Although Melanie Klein understood
`depression as involving die expression of aggression toward
`loved ones, much as Freud did. the developmental theory on
`which her view was based is quite different from Freudian the-
`ory. During the first year of life. ‘Klein believed. the infar1t-pro-
`greases -from the paranoid-schizoid position to the depressive
`position. In the first few months of life. according to Klein. lhfi
`
`101 of 173
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`Alkermes, Ex. 1060
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`

`
`H18
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`moon olsonosns I
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`cu-mPrEl=r rs-
`
`infanr projects highly destructive fantasies into its mother and
`then becomes terrified of the mother as a sadistic persectrtor.
`That terrifying “bad" mother is kept separate from the loving.
`nurturing "good" mother through the defense mechanism of
`splitting. In that manner the infant's blissful feeding'e.xperience
`remains uncontaminated and undisturbed -by persecutory fears
`of attack by the “bad" mother. In the course of normal devel-
`opment, according to Klein. the positive and the negative
`images of the mother are integrated into a more ambivalent
`view. In other words. the infant recognizes that the "bed"
`mother it fears and hates is the same mother as the "good"
`mother it loves and adores. The recognition that one can hun
`loved ones is the essence of the depressive position.
`Klein connected clinical depression with an inability to suc-
`cessfully negotiate the depressive position of childhood. She
`regarded depressed persons as fixated or stuck at :1 develop-
`mental level in which they are extraordinarily concerned that
`loved good objects have been destroyed by the greed and
`destructiveness they have directed at them. In the absence of
`those good objects. depressed persons feel persecuted by the
`hated bad objects, In short, Klein's view was that depressed
`patients are longing or pining for the lost love objects while
`being persecuted by bad objects. In that theoretical framework
`the feelings of self-depreciation are linked to the fear that one’s
`good parents have been transformed into violent persecutors as
`a result of one‘s own destructive tendencies. Also. the bad inter-
`nal objects are internalized into the superego. which then makes
`sadistic demands on the patient. Hence, in the Klcinian view,
`the self-reproaches experienced by depressed patients are
`directed against the self and internal
`impulses, rather than
`toward an introjected object, as in Freud ’s view.
`
`Tension between ideals and reality Whereas most psy-
`chodynamic theories of depression incorporate the superego as
`a significant part of the conceptual understanding. Edward Bibr-
`ing viewed depression as tension arising from within the ego
`itself. rather than between the ego and the superego. According
`to Bibring, the ego has three highly invested narcissistic aspi-
`rations—to be good and loving, to be superior or strong. and to
`be loved and worthy. Those ideals are held up as standards of
`conduct. Depression sets in when a person becomes aware of
`the discrepancy between those ideals and reality. Helplessness
`and powerlessness result from the feeling that one cannot mea-
`sure up to such high standards. Any blow to the self—esteem or
`any frustration of the strivings toward those aspirations precip-
`itates depression. Bibring‘s theory, unlike Freud’s and Klein's.
`does not regard aggression as playing a primary role in depres-
`sion. The depressed person may ultimately experience anger
`turned inward. resulting from the awareness of helplessness;
`however, such expressions of aggression are secondary. rather
`than primary. The essence of depression, in Bibring’s view, is
`a primary affective state arising within the ego and is based on
`the tension between what one would like to be and what one
`is.
`
`Ego as victim oi supere-go Edith Jacobson compared the
`state of depression to a situation in which the ego is at powerless.
`helpless child, victimized by the superego, which becomes the
`equivalent of a sadistic and powerful mother who takes delight
`in torturing the child. Like Freud, Jacobson assumed that
`depressed persons have identified with arnbivalently regarded
`lost love objects. The self is experienced as identified with the
`negative aspects of the object. and ultimately the sadistic qual-
`ities of the lost love object are transformed into the cruel super-
`ego. Hence. depressed persons feel that they are at the mercy
`
`of a sadistic internal torrnentor that is unrelenting in its victim-
`ization. Jacobson also noted that the boundary between self and
`object may disappear, resulting in a fusion of the bad self with
`the bad object.
`
`Dominant other Silvano Arieti studied the psychodynarnic
`underpinnings of depression in severely ill patients who were
`unresponsive to roost somatic treatments. He observed a com-
`mon psychological theme in those patients that involved living
`for someone else. rather than for themselves. He referred to the
`person for whom depressed patients live as-the dominant other.
`In most cases the dominant other is the spouse or a parent. but
`Arieti also noted that sometimes a principle, an ideal, or an
`organization serves a similar psychodynarnic function. In such
`cases he referred to the entity as the dominant ideology or the
`dominant goal.
`Depression often sets in when patients realize that the person
`for whom they have been living is never going to respond in a
`manner that will meet their expectations. The goal of their lives
`is regarded as unattainable, and a profound feeling of helpless-
`ness sets in. In Ar-ieti‘s conceptualization of depression. he
`stressed a marked rigidity in the tltinlting of depressed persons.
`so that any alternative to living for the dominant other or the
`dominant ideology is viewed as unacceptable and even unthink-
`able. Depresscd patients feel locked into an inflexible perspec-
`tive on how they should live their lives and how gratification
`or fulfillment can be obtained. Even though they are depressed
`because living for someone or something other than themselves
`has been a failure. they nevertheless feel paralyzed and unable
`to shift their approach to life. If the dominant other will not-
`respond to them in the way they have longed for, they feel that
`life is worthless, and thatrigidity is often involved in a decision
`that suicide is the only alternative.
`'
`'
`
`sycbi-
`CASE EXAMPLE A 19-year-old college student consulted a
`airlst after one semester in school. He told the psychiatrist that e was
`depressed and discouraged with collage and with himself. College was
`not what he had expected. and be b
`not
`rformed up to his expec-
`ta.1'.'iol'Is. He was seriously questioning wlie ‘er he should return forrhe
`second semester, and he had a sense of -hopelessness about changing
`his feelings. Suicidal thoughts had occasionally crossed his mind.
`although he was not planning to act on them. His sleep was disturbed
`by awakonin in the middle of the night and ruminating about wharhe
`should do.
`e felt ajsignificant diminution in his energy level. and he
`easure.
`.
`cpmrnented that things he used to find enjoyable no longer gave.
`P The patient attended a prestigious college on the West Coast. but
`indicated that he had actually wanted to get into Harvard. His
`_l1-.'
`cation to Harvard had resulted in his being placed on the waiting 151:
`but he had not been acce ted. The psychiatrist he consulted cornmertted
`that the college he had c osen to attend was certain!
`it highly regardpgl
`one. The patient responded. "It's not Harvard."
`en the sychialrrst
`asked the patient how he had done academicallydurin the rst seine!)-
`rer, the patient appeared embarrassed and re lied, " only got a 3.25
`grade-point average—one A and three Bs.‘ ‘
`epsychiauist asked'h1rn_
`why he mined embarrassed to reveal such a solid acaderrtic'reoOrd:
`The atient ex.
`lained that he had wanted to make the dean‘s list but
`that
`had f
`en short of it. since the list required a 3.5 grade-POIIQE
`avera
`.
`'
`_
`'
`" ‘
`Thgepsychiatrist asked the
`atient if he hoped to be in a different
`situation after one semester 0 college. The paticnt‘s answer revealed
`that be had an extraordinarily high internal expectation of himself. Ht‘-
`had wanted to be "a star." a_stra' ht-A student at Harvard. HF
`explained that his father-had gone to
`arvard, and he hoped tbaI,'bY
`being a standout there. he would finally achieve the raise and ruc0E'
`nition from his father that he had always longed or but had ne)-1'3!
`received. His father seemed disappointed that his sonhad not lfi.-".571.
`accepted to Harvard, and the patient was convinced that his father will?
`r
`ashamed of his son for not making the dean's list.
`-
`
`EXPLANATION The above case example illustrates the psycho-
`dynamic theories of both Arieti and Bibring. The patient was
`living his life for a dominant other—his father. He tried to P3?‘
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`102 of 173
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`Alkermes, Ex. 1060
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`

`
`SECTION 16.5 I MODD DISORDERS: PSYCHDDYNAMIC ETIDLOGY
`
`H19
`
`form beyond his abilities to extract an approving and loving
`response from his father that was never forthcoming. Thar
`longed-for response was rigidly construed as the only thing that
`mattered in life; even though he was succeeding at a highly
`competitive college, his success did not result in his feeling
`good about himself. Moreover. the patient‘s depression can also
`be linked to his awareness of the disparity between his idealized
`expectations of himself and the reality of his situation, as
`described by Bibring. Being a straight-A student at Harvard was
`his own aspiration; the reality was that he was a B+ student at
`a college that did not measure up to Harvard.
`The vignette also reflects two other key elements in the psy-
`chodynamic etiology of depression. First, in accord with the
`psychoanalytic notion of multiple causation, more than one psy-
`chodynarnic theory may be pertinent in understanding an indi-
`vidual patient's depression. Clearly. bodr the dominant other
`and the tension between ideals and realities were significant
`determinants in causing the patient’s depression. Second, the
`precipitating factors that produce depression do not have to be
`catastrophic events involving obvious external disasters. To a
`casual observer the college student had no apparent reason to
`be depressed, since he was performing successfully at a highly
`regarded college. Nonetheless, the inrrnpsychfc meaning of his
`academic performance was such that the patient felt hopeless
`and despairing as a result In assessing the psychodynamic fac-
`tors in depression, clinicians must always attend to idiosyncratic
`personal meanings of events to fully llnderstand the effects they
`have on the patient. Otherwise, clinicians run the risk of
`responding in the same unempathlc manner that often charac-
`terizes the responses of family members. In the absence of
`objective evidence of any disastrous events in the depressed
`person's life, loved ones often react by saying: “You have no
`reason to be depressed. Everything is going so well in your
`life."
`
`Selfnbiecl lailure The ego and the superego do not figure in
`Heinz Kohut‘s conceptualization of depression. Kohur’s theory.
`known as self psychology, rests on die-assumption that the
`developing self has specific needs that must be met by parents
`to give the child a positive sense of self-esteem and self-cohe-
`sion and that similar responses are required from others
`throughout the course of the life cycle. He refened to those
`needs as mirroring. twinship. and idealization. The mirroring
`Eesponses required by the self are equated with the gleam in the
`mother's eye when the child exhibitionistically shows off for
`the rnother. Adrniration. validation, and affirmation are
`responses that are included under the category of mirroring.
`Twinrhip responses refer to the child's need to be like others.
`A small boy who is outside playing with his toy._ lawn mower
`while his father is mowing the lawn is meeting important psy-
`chological needs in asserting his commonality with his father.
`Finally, the need for idenlizarion is an important aspect of the
`'_ development of the self. Children who grow up with parents
`they can respect and idealize develop healthy standards of con-
`' duct and morality.
`--. Kohut referred to those three needs collectively as selfobject
`needs. In other words, the responses demanded from others are
`required by the self, and the needs of the object as a separate
`_ person are not taken into account. The other person serves as
`an object who meets the needs of the self. Selfobject needs
`essentially refer to certain functions that persons ill the envi-
`ronment Ptovide. rather than to those persons themselves.
`E
`' Kohut felt that selfobjecl responses continue to be needed
`5'
`l-ll-toughout life and are as necessary for emotional health as
`- Oxygen is for physical health. Within that conceptual frame-
`
`,
`
`I
`
`work, depression involves the failure of selfobjects in the envi-
`ronment to provide the self of the depressed person with mir-
`roring, twinship, or idcalizing responses necessary for the self
`to feel whole and sustained. The massive loss of self-esteem
`seen in depression is regarded by Kohut and the self psychol-
`ogists as a serious disruption of the self-selfobjcct connection
`or bond.
`
`Depression as affectand compromise formation Among
`contemporary ego psychologists a widely held view is that
`depression is not only a psychiatric disorder or illness. Instead,
`depression is regarded as an affect reflecting conflict and com-
`promise fomiation. Charles Brenner, the principal architect of
`that view. suggested that concern about such childhood calam-
`ities as object loss. loss of love, castration, and punishment are
`associated with two kinds of unpleasure. One form of unplea-
`sure is anxiety, which involves an anticipated calamity or dan-
`ger. The other form of unpleasure, depressive affect, involves
`a calamity that has already happened. That theory of depressive
`affect differs sharply from the classical views of Freud and
`Abraham. Brermct pointed out that depression is not always
`related to object loss or to oral wishes. He also asserted diat
`identification with a lost object is found in some depressed per-
`sons but not in all and that anger turned inward is a result of
`depression, rather than a cause. Depressive affect, in Brenner's
`view, "can be linked to any of the childhood calamities. rather
`than uniquely to object loss. People can experience depressive
`affect because" they feel unloved, because diey feel castrated. or
`because they feel punished in a variety of ways. Depressive
`affect is a normal and universal part of the human condition.
`A critical feature in Brenr1er’s fonnulation is the idea of com-
`promise formation, in which a symptom is viewed as simulta-
`neously expressing an unconscious wish or drive and a defense
`against that wish or drive. A particular compromise formation
`may be more or less successful in eradicating depressive affect
`in the same manner as it may succeed to varying degrees in
`dealing with anxiety. A dog phobia, for example, is a symptom-
`atic compromise formation that succeeds in eliminating anxiety
`as long as dogs are avoided. Similarly, certain forms of com-
`promise formation may eradicate depressive affect while others
`do not.
`
`The central point of Brenner's psychodynamic theory is that
`depressive affect is a universal feature in every pathological
`conflict. whether it is apparent on the surface or buried in the
`depths of the compromise formation. Depressive effect is a uni-
`versal factor in all cases of psychiatric illness. From that stand-
`point, Brenner believed that classifying certain forms of mental
`illness as depression simply because depressive affect is part of
`the conscious symptoms does not make sense. The conscious
`experience of depression provides information about the em-
`cacy and the nature of a patient's defensive maneuvers and
`compromise formations. in Brenner’s view, but it does not
`reveal much about the underlying causes of the patient‘s. illness.
`
`Early cleprlvatlon Several investigators have noted that con-
`sistent, loving. nurturant parental involvement appears to have
`some value in preventing the development of depression. Con-
`versely, separation from parents early in life or the actual loss
`of a parent may predispose one to depression. Edith Zetzel
`observed that adverse experiences in the fonnative years of
`childhood. particularly those involving separation and loss,
`make it difficult for children to tolerate depressive affects with-
`out resorting to primitive defensive operations. If caretakers fail
`to assist children in identifying and tolerating painful feelings
`
`103 of 173
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`Alkermes, Ex. 1060
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`

`
`I120
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`Moon oisonoarls r ' CHAPTER 16
`
`that result from an adverse life experience.'the child will grow
`up with inadequate coping mechanisms. That impaired adap-
`tation may contribute to the subsequent development of
`depression.
`'
`-
`Ernpirica-1 research has provided some corroboration for the
`view that early deprivation is relevant to the cause of depres-
`sion. Rene Spitz demonstrated that infants separated from their
`mothers during the second six months of life have overt signs
`of depression.
`In some cases the infants in Spitz‘s studies
`wasted away and died in response to the separations. Margaret
`Mahler and her colleagues. who studied the interactions
`between normal and abnormal mother-infant pairs. found that
`children's emotional dependence on their parents is instrumen-
`tal in the development of their capacity to grieve and mourn.
`That capacity. in turn. influences children's feelings of self-
`esteem and helplessness. Although the development of depres-
`sion may involve genetic and constitutional factors. as well as
`environmental strcssors. most theorists agree that the early rela-
`tionship between child and parent plays a significant role in
`causing depression.
`I
`
`Prornorbid personality factors A cornpreh_ensiv.e psycho-
`dynamic understanding of depression must include premorbid
`personality factors in] d1e.equation. All persons-may ‘become
`depressed. given sufficient environmental stress, but certain
`personality types or traits appear to dispose one to depression.
`For example, the harsh. perfectionistic superego characteristic
`of persons with ob,sessive-compulsive personality disorder may
`lead them to feel that they are always falling short of their own
`excessive expectations of themselves. As noted earlier.
`that
`intrapsychic constellation may be critical in the development of
`atnajor depressive episode. Similarly. Axis I] -personality dis-
`orders involving dependent yeamings for care—sucl1 as depen-
`dent, histrionic, and borderline personality disorders-—may also
`be more vulnerable to depression. Those personality disorders
`that use projection and other externalizing defense mechanisms,
`such as antisocial and paranoid personality disorders. are less
`likely to decornpensate into depress_ion. No panicolar promot-
`bid personality type has been associated with the development
`of bipolar disorder.
`'
`Evidence is accumulating that an Axis I] diagnosis of aper-
`sonality disorder may complicate
`course and treatment of
`depression. Depressed patients with personality disorders gen-
`erally have ‘poorer outcomes in the area of social functioning
`than those without personality disorders. Furthermore. residual
`depressive symptoms are more likely to present in recovering
`depressed patients who have an Axis H diagnosis. Psychoana-
`lytic clinicians have observed that personality factors frequently
`serve to maintain _a depressed state once, it has occurred. In
`clinical practice the complicating factors of a. comorbid person-
`ality disorder diagnosisare quite common. One study found that
`42 percent of persons with major depressive disorder and 51
`percent of patients with dyslhymic disorder have an accompa-
`nying Axis II diagnosis.
`
`CHAFIACTEHOLOGICAL DEPRESSION Many patients
`encountered in clinical practice report feelings of depression
`even though they lack symptoms of a'well-defined Axis 1 dis-
`order. such as major depressive episode. Many of those patients
`have a primarydiagnosis of a personality disorder on Axis II’
`and experience characterological depression, a feeling of per-
`vasive loneliness or ernptiness associated with the perception
`that others are not meeting one‘s emotional needs. They can be
`distinguished from‘ patients with an Axis I diagnosis of major
`depressive episode by the absence of vegetative symptoms
`
`(such as psychomotor retardation. loss of libido. diminished
`appetite, lack ofenergy._and sleep disturbance) and by the pres-
`ence of certain qualitative features of their complaint of depres-
`sion. Loneliness. emptiness. aod boredom areoften chronic
`complaints in characterological depression but are much less
`common in Axis I illnesses. In addition. a conscious sense of
`rage at not having their needs met may be present. The patients
`often describe childhood experiences in which they ‘felt
`deprived of appropriate emotional nurturance front their par-
`ents. As a result. they continue to seek parental substitutes in
`adult life.
`'
`'
`
`Characterological depression is differentiated from Axis II
`personality disorders by the fact that it is an affective state
`occurring within the context of certain personality disorders.
`rather than a constellation of traits forming an overarching per-
`sonality type.
`-
`
`A 29-yearcld woman came tpdpsychotherapy complaining that she
`was "empty“ inside and "need
`to be filled up" by a positive expe-
`rience with a psychotherapist. She said that, while she was‘ growing
`up. her mother never had time for her and that her mother-loved her
`two sisters more than her. The patient -had had a sericsof romantic
`relationships with men. but she never felt that she was getting the kind
`of attention and love that she needed from any of them. The men often
`ended the relationship because they felt that she wastoo demanding
`and that they could not
`sibly meet all her needs. Her last therapist
`had “given up"_ on her
`ause be, too. felt that he was unable .to be
`of help to her. The patient also indicated that she had called, her "re-
`vious therapist almost every night because she would begin to eel
`lonely and need his reassurance that he still cared. She feared that she
`had turned off her therapist by being too dema.nding..She also described
`several ang
`outbursts dire_cted.at him when he would not talk with
`her for long y periods of time on the phone during the evening. She
`wondered if her outbursts made him hate-her.
`The patient had taken four different antidep1essive_medications with
`no iihfivrovetnent She did not meet the diagnostic criteria for an Axis
`I dys ymic disorder or major de ressive
`isode. However. she did
`have cliaracterislics in keeping wt
`two di erent Axis II diagnoses—
`dependent personality disorder and borderline personality disorder. _
`
`OTHER CIJNICAL ENTITIES In addition to the existence of
`characterological depression in the presence of other Axis-l1
`personality disorders. another clinical entity is described by
`psychoanalysts ‘as depressive personality or depressive charac-
`ter. That disorder may be a form of chronic depression closely
`related to the Axis I diagnosis of dysthymic disorder. Persons
`suffering from the disorder exhibit the following symptoms:
`helplessness; chronic feelings of guilt; relationships ‘character-
`ized by dependency; persistent low self-esteem; an inclination
`to be self-punitive, self-denying, and hypercritica]; and a cone
`viction that things are hopeless and will never change. Patients
`with that character structure do not allow themselves to have
`any fonn of gratification in life because of disturbed relation-
`ships in "childhood with parents or parental substitutes. '
`A related form of charactcrological depression has been
`labeled depressive-masochistic personality -disorder by- Otto
`Kemberg. Patients with the disorder are characterized by an
`extrerrlely demanding superego that results in'humorless.-overly
`conscientious. self-critical tendencies. The patients have exces?
`sive needs for approval. love, and acceptance from others, and
`they unconsciously cause others to feel guilty becauseof their
`inability to meet the patient‘s demands. The consequences of
`that pattem of interaction are further feelings of rejection
`because others do not want to be part of a relationship in which
`' they never meet the expectations-of the patient. People with
`depressive-masochistic ‘personalities are also characterologh
`cally prone to turn anger inward to avoid any expression Of
`aggression and anger toward others.
`-
`Clinicians must remember that depression spans the entire
`spectrum of pathology and health. In addition to being a discrelc
`
`104 of 173
`
`Alkermes, Ex. 1060
`
`

`
`SECTION 16.5 I MOOD DISORDERS: PSYGHODYNAMIC EITOLOGY
`
`1121
`
`psychiatric disorder, depression refers to an emotional state that
`can be present in normal persons at certain times, as well as in
`persons with characterological or psychotic conditions. More-
`over, simply because the patient does not have sufficient symp-
`toms to be given an Axis I diagnosis of a mood disorder does
`not mean that the depression is benign. In one study, employees
`with minor forms of depression that did not meet Axis Icriteria
`had 5] percent more disability days than did persons with a
`diagnosis of major depressive episode.
`
`Karl Abraham Most theories of mania view manic episodes
`as defensive against underlying depression. Karl Abraham, for
`example, believed that manic episodes may reflect an inability
`to tolerate childhood