Post date: Dec 26, 2011 3:18:35 AM
by Chao-Ying Wang, Ph.D., Psy.D.
July 20, 2007
The following is a discussion of the case, John—a young Asian male in his early 20s--presented by Dr. Siqing Li.
Brief summary of the reported symptoms and known family dynamics:
Meth and alcohol abuse
Suicide attempt by overdose on Tylenol
Mood swings since age 16
Depression
Violent and self-destructive behaviors following command auditory hallucination
Persecutory delusions
Manic episodes—running 16 miles a day at times, sleeping 2 to 3 hours, “kissing
15 Girls in one night,” picking up fights, made threats to others, compulsive shopping
Eating excessively and weight gain
Anxiety with multiple panic attacks
Current main symptom—anxious for nothing
Medication treatment: for the past two years. Stable until three weeks ago.
Family dynamics:
Parents worked a lot, and he was always home alone.
Parents Indulged him by buying whatever he wanted
“It was hard for my parents to express their love to me,
but I knew they loved me,”
Questions and Case Formulation
To better understand the patient regarding his early history, I would ask these questions: was there any abnormality during his mother’s pregnancy of him? Did his mother give birth naturally? Any problem during delivery? Was he breast-fed? Any early ailment?
What were his earliest memories? Was he taken care by his mother, a nanny, or sent to a nursery? If sent to a nursery, at what age? And how did he react or adjust to that arrangement? How was his relatedness to his mother? His father? How did the parents communicate with him, especially when he misbehaved? How was the relationship between the parents? How was the home atmosphere?
How old was he when he began experiencing sleep disturbance? Does he dream? Does he remember any dream contents? How old was he when he first started substance abuse, and how often did he use them? Was the overdose on Tylenol on October 2003 his first suicide attempt? If not, when and how many times had he attempted? What kind of meds is he on? And, anything happened three weeks ago?
Based on the given information, I infer that John operates on a primitive level, and has some early feelings that were unattended to that now overwhelm him. These emotions of John and his attempts to cope with them manifest themselves in different symptoms.
In his paper, Mourning and Melancholia, Freud (1917) drew a comparison between melancholia and the normal state of mourning. In addition to suffering a loss of an object as in mourning, a melancholic also loses a part of the ego that is identified with the object. Freud states:
“In mourning we found that the inhibition and loss of interest are fully accounted for by work of mourning in which the ego is absorbed. In melancholia, the unknown loss will result in a similar internal work and will therefore be responsible for the melancholic inhibition. The difference is that the inhibition of the melancholic seems puzzling to us because we cannot see what it is that is absorbing him so entirely. The melancholic displays something else besides which is lacking in mourning—an extraordinary diminution in his self-regard, an impoverishment of his ego on a grand scale. In mourning it is the world which has become poor and empty; in melancholia it is the ego itself.” (p. 246)
In the same paper, Freud speaks of how, in certain cases, melancholia readily changes into a state of mania. Manic defense, according to Freud, deals with the same complex as melancholia does, except in melancholia “the ego has succumbed to the complex, whereas in mania, it has mastered it or pushed it aside.” (p. 254).
The paranoid-schizoid position and the depressive position, theorized by Klein, begins in early infancy, and may continue throughout one’s life. The persecutory fears resulted from an infant’s oral- and anal-sadistic impulses give rise to anxiety of being poisoned or annihilated. The defenses used by the early ego include splitting of objects and the selves. If the persecutory fear is very strong, according to Klein, an infant cannot work through the paranoid-schizoid position. These phenomena of paranoid-schizoid position, which are prevalent in the first few months of life, are also found in psychosis. Specifically, Klein states (1946) in Notes on Some Schizoid Mechanisms,
“In early infancy anxieties characteristic of psychosis arise which drive the ego to
develop specific defense mechanisms. In this period the fixation-points for all psychotic disorder are to be found.” (p. 292)
The feelings of sorrow and concern for the loved objects mark the depressive position. In addition to the persecution by the bad objects and the defenses against the persecution, the fear of losing and pining for the good object constitute the depressive position. Klein further speculated that defenses such as obsessional, manic, and paranoid are used to enable an individual to deal with depressive anxiety. The failure to successfully work through the infantile depressive position might result in depressive disorder, mania, or paranoia.
Klein further speaks of manic defensive states in her papers, A Contribution to the Psychogenesis of Manic-Depressive States (1935), and Mourning and its Relation to Manic-Depressive States (1940). She states, in the former of the two papers, “In mania the ego seeks refuge not only from melancholia but also from a paranoiac condition which it is unable to master…” (p. 277). Specifically, Klein points out that within mania there is a sense of omnipotence to control and master objects, the mechanism of denial--denial of psychic and external reality, and the disparagement of the object’s importance and the contempt for it.
Bion (1956) wrote the paper, Development of Schizophrenic Thought, based on his work with schizophrenic patients. He suggested four characteristics of schizophrenic personality: preponderance of destructive impulses, hatred of external and internal reality, dread of annihilation, and a premature but tenacious object relationship. After referring to Klein’s paranoid-schizoid position wherein an infant fantastically attacks on the breast, Bion states,
“Identical attacks are directed against the apparatus of perception from the
beginning of life. This part of his personality is cut up, split into minute
fragments, and then using the projective identification, expelled from the personality…” (p. 345).
The above illustrated theories and postulations seem to address some of the symptoms exhibited by John. It also sounds like John has a limited capacity to modulate his negative emotions such as anger, indicated by his picking fights and making threats to others. His substance abuse, excessive eating, and compulsive shopping could be his ways of soothing himself. The underlying emotions of these symptoms require exploration in the sessions. Further, one of the emotions implied in obsessive thoughts and compulsive behaviors is anxiety. Depression, putting aside the writings of Freud and Klein, in practical daily life, could be experienced as sadness of not being unattended to by one’s parent, not being understood, not being loved, unwanted, loneliness, frustration and anger. In other words, in addition to theoretical understandings of the various symptoms and disorders, the specific and subjective experiences of the patient require to be explored and understood. And as you know, when depression is severe, without perceiving any hope and help, one might intend to end one’s life.
Recommendation
I would recommend intensive psychotherapy or psychoanalysis for this patient.
References
Bion, W. (1956). Development of Schizophrenic Thought. In Second Thoughts, Marshfield Reprints, 1967.
Freud, S. (1917). Mourning and Melancholia. Standard Edition, Vol. XIV, pp. 237– 258.
Klein, M. (1935). A Contribution to the Psychogenesis of Manic-Depressive States.
In Love, Guilt and Reparation, Delta Press: 1977.
Klein, M. (1940). Mourning and its Relation to Manic Defensive States. In Writings of Melanie Klein, Vol. I, London: Hogarth Press, 1984.
Klein, M. (1946). Notes on Some Schizoid Mechanisms. In Writing of Melanie Klein, Vol. III, London: Hogarth Press, 1984.