Melancholia

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In the traditional language of psychiatry, melancholia denotes a type of depressive state characterized by its intensity and its responsiveness to biological antidepressant agents. The experience of the melancholic individual, often called "mental suffering," is characterized by profound sadness and lack of interest in the outside world. Melancholia brings about a form of pessimism that sees the future as blocked and unchangeable. Such pessimism is accompanied by ideas of guilt and unworthiness, which find expression through self-accusation and can even give rise to delusion. Hypochondriacal ideas are also frequent. In addition, the subject complains of emotional numbness and the painful sentiment of being unable to love. Mental suffering engenders a continual desire for death. Hence, the subject runs the risk of suicide. Melancholia is accompanied by a marked slowdown in psychomotor activity, sometimes leading to stupor. Classic signs of the illness are anorexia and weight loss, insomnia and disturbed sleep patterns, and an improvement in clinical symptoms in the evening.

An episode of melancholic depression can be unique or recurrent, in which case it becomes part of the framework of a manic-depressive illness that is unipolar (recurring melancholic episodes) or bipolar (recurring melancholic and manic episodes). The bipolar situation reveals a fundamental characteristic of melancholia: it can reverse itself spontaneously or under the effect of drug treatments, into a state of manic excitation.

Karl Abraham (1927b) noted the relationship between mourning and depression, and he distinguished melancholia from neurotic depression, which results from the failure to satisfy drives because of repressed unconscious factors. For Abraham, the structure of melancholia is closer to that of obsessive neurosis on account of the intense hostility toward the outside world. In both illnesses, hostility considerably reduces the ability to love, and this reduction is responsible for the onset of the illness. But in melancholia, the projection of hostile drives is combined with their repression. Abraham proposed a psychopathological model of psychotic depression, based on the Freudian model of paranoia, in which libidinal hatred, projected onto the outside world, reverts back onto the subject in the form of depressed feelings of being detested and of guilt (the source of masochistic pleasure).

In "Mourning and Melancholia" (1916-1917g [1915]), Freud based his thinking on how melancholia and mourning converge. They are both triggered by the same phenomenon, namely loss. They differ in that although mourning occurs after the death of a loved one, in melancholia the lost object is an object of love and therefore is not truly dead. Melancholic individuals may, in some cases, know that they have lost something, but they never know what they have lost, for the loss is inaccessible to consciousness. The clinical signs of melancholia and mourning are identical, except that melancholia is accompanied by a loss of self-esteem. Unlike people in mourning, melancholic individuals suffer from a loss involving the ego, which they describe as poor and without value. They reproach themselves but do not experience shame, for their reproaches are really directed not at themselves but at lost objects. Their egos are split: one part, the critical faculty, takes as its object another part, which is identified as the lost object by means of a narcissistic mechanism. This process implies that the object choice is narcissistic and characterized by a strong fixation on the object but a weak cathexis of it, with cathectic energy always readily withdrawn into the ego.

For melancholia to occur, the object relationship must be ambivalent: hate and love must be in contention. Once love for the object has taken refuge in narcissistic identification, hatred can function against the part of the ego identified with that object. There it obtains sadistic satisfaction, as reflected in the melancholic individual's suicidal desires. Such desires result in hatred of the object being redirected back upon the self. The ambivalence, constitutional or associated with the circumstance of loss, leads to love and hate doing battle against one another in various parts of the unconscious psyche until love escapes into the ego to preserve itself and melancholia finds expression in the typical form we are familiar with. This confrontation always ends in exhaustion, whether the unrelenting struggle with the lost object stops on its own or the object is abandoned because it is without value.

In "Melancholia and Obsessional Neurosis" (1927a) Abraham investigated the relation between manic-depressive states and the pregenital stages of libidinal organization. After clarifying the connection between sadism and anal eroticism, he divided the anal-sadistic phase into two periods. In the earliest period, the drives obtain satisfaction by rejecting and destroying the object. During this first period the libido of the melancholic individual begins to regress. The libidinal regression does not end with the first period, however, but continues through the oral-cannibalistic stage by introjecting the lost object. This is accompanied by a refusal to eat, a key indicator of melancholic depression. Abraham concluded by listing five factors whose "interaction causes the specific clinical manifestations of melancholia." These are the constitutional reinforcement of oral eroticism in melancholics, the fixation of the libido on the oral phase of its development, the injury to infantile narcissism caused by disappointment in love from the maternal object, the overcoming of this injury prior to the control of oedipal desires, and the repetition of this primary disappointment later in the life of the subject.

References

  1. Abraham, Karl. (1927a). Melancholia and obsessional neurosis. In Selected papers of Karl Abraham, M.D. (Douglas Bryan and Alix Strachey, Trans.; pp. 422-432). London: Hogarth. (Original work published 1924)
  2. Abraham, Karl. (1927b). Notes on the psychoanalytical investigation and treatment of manic-depressive insanity and allied conditions. In Selected papers of Karl Abraham, M.D. (Douglas Bryan and Alix Strachey, Trans.; pp. 137-56). London: Hogarth. (Original work published 1911)
  3. Freud, Sigmund. (1916-1917g [1915]). Mourning and melancholia. SE, 14: 237-258.
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