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    20 views14 pages

    FNBuschMRuddenManualdepressionCh. 2, 3

    Uploaded by

    Stephanie Mokashi

    Copyright:

    © All Rights Reserved
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    of 14
    Emeritus Professor of Pee Psychodynamic Treatment of Depression Fredric N. Busch, M.D. 1 Associnte Professor of Poychiatry ‘Weill Medical College of Cornell University Faculty, Columbia Univesity Genter for Paychoanalytic Training and Research ‘New York, New York Marie Rudden, MLD. al Assistant Professor of Poy Berkshire Psychoanalyt Faculty, New York Poychoanalytic Lust ‘New York, New York Theodore Shapiro, MD. Ws fedical College of C ing and Supervising Analyst, i Tostione Tr New York Peychon NewYork, New York rr Psychodynamic treatment of Wepression ele MB ans Dt, Klein DN: Semana ofthe DSNLIV mood doers eld ‘tan ues over ache Cha North Aa 19-21-28 986, ei MB, MeCaongh Rien DN ea: A companion ofuetaadoae the cop hte beanortanaje sim af paebotberspy and dir combination forunecentment of chen depen Nagi] Med 34214621470, 2000 oct Ken DN (eds) Dingnoteand Trestmeat of Chronic Depron New “Yrk, Gullo, 1985 oyapon MPL js LL, Scheer FA desrigte ano minor depression, ‘nj Pity 187-648, 2002 Sapo DA, Bat M Revs, eal:Efetrftrenmentduraon and ewes al depeion on the eflecnenes of copve emo! heapy 4 po “hathuemicinterperonal pychsberspy J Comat Cha Pret 2522- 1 Spire DA Baytham M, Ress A, eal: ie of reatmentdrason and eve a depeesion am he sitennce of aie fer cgulivebehacrl heapy ‘ppc igerperonal eehotberap.| Corsa Cis Pay ol : ‘s7ase7 1995 stone: conn obersons on te pacogy of depres ines selec “plecr of amiguly or dgrecment J Ar: Pyehoana Aso $4:23-208, “The ME: Refining antidepremant effec iomard longterm ecover | in Phy oop 6):1319, 1989 Chapter 2 Development of a Psychodynamic Model of Depression Ticorists have developed variety of modesto explain why certain inde viduals develop depresive disorders and to ad in the development of « treatment plan for them. Vulneabihy to depresion has bees explained ‘arious it terms of Biochemical, interpersonal, and comnitvebehaviorst todel: Other theorxs have sed a ryehodyainic model explain che Comps et of Felings and behaviors dha make up depressive disorders ‘Tha book focuses oa the pryeodynamiec approach asa comprehosive metus uvderstaningand testing depresioe thats complementary 0 the other models and approsches- tn thin chapter we provide brief sum. inary of paychoonalyc ineotes of depreaion, describe sues of paycho- Toga conthibutions tothe dixorder, and present a psychodynamic fr ‘maiaton tat canbe employed in guiing treatment. Paychoanalys have developed succeatve, overlapping models to ex pain the ecology and peristence of depressive ymdromes These models hha considered the indivcual's iological and temperamental vilner Vales, the quai ofthe persons east tachment relationships, and significant chldnood experiences that may have been accompanied by frastation, shame, loss, elplsinss, loneliness, gut. The impact of suck experiences nd elings doing formative developmental sages on individ’ perceptions of themselves and others is seen a creating amie sucepbes to a range of depressive syudromes tse life Jnckling narelsiie dna, comBlcted ange, excessively high ex pectators of self and other, ad maladaptive defense mechanisms 13 ro bestiussate the various psychodynamic models of depression, we describe tir application ta specifi cae case Bample Ms Gasan nerve yeaolddorced acouncnt who presented Tor reument wa isn af cera er of ety spe nd reat epanter of sperinped sje depression. Dung depreine ‘Sines, er pms nade er ener and moun mpd creeettannnncrened appeste wi wegen 20d mola et ‘it nsoanin Ms Cove here wore apd not deserving of Teron umes pepe tbe sae ne hat he ws for about he (eer Statcntion She was Requerty opel about changing her str tig and wouter have cial oaghtsof pl verde She pa aden nett se arava screwing ings up" Dui Ue oun ofwentmens devel bl is Cece ses of mek {aon wit moderate pact om ber deprive ples Tir seid a tecaror tendency fel rejected others expe siege ies ast aingor purposes Ni Cote cena what ie pees o be unan eient epecil by pe Sine ty Use on whom he depend. These feeings aerate ith le othonelfa obese ie and ata Tbcame apparent during the ail erent Mi Cb be i slit fllowed a prs ae She entered mo relanshis 8 nie snl hang ion, sewing eel ara person oie ave seerught appro! lm a power eang other Over ne owes Meets tec unapplecned ined oroveooked Mi Could reine net and doapgoiatt tat ne other peor wes ot bese Ign scot respon atoning aretater Feng iinshed MEtjecer se woul earring her ppoinunens outa at Ther penn would eect hetero contr her suspicion tat {Benes ened as inadequte and unde inisconee Mo woul cna pone aggresie manne Fort sa ins nuld come ne to metingrat er job or become wie Pau in her aoa Ofer ste nav unnvare othe wy bind SEESRMiuror othe potential impact ersllen stance Tn eponse CEERI eta? te Indiv wi om te nas dsapeined son en wae i ie Coo fe igiea. Se would oe here “Sunjy tem ond ws fr someone to rec hr and igh th or SEE had ocsonet: Over ine, however se woul become ate Iie sere an slr he longer ecreaing of eran (Bipot sceur ler rage woul becone een alee [canny of cored Cc, where she a bea & secy uae members aien taking oa many ofthe del volumes Tie pce aed he chee lade a orig arg men hose pece regard soothe her longatanding Loy selesteem Hone ToC ees fee che leaders ere eponsve fo er prottems wih her hotbnd om whom she was ater doer ‘Ted penance her un vera abuse and cca, Whe the yo of them me ith he ede she fk tat hey were siding wih Fim andgronng her concern She came ary ae ot eve he {Iscomen tote church lenders. However she appeated resend tecame doteltnbe hes Thechurch aces, nes ated sinh her betevion easly encousged Bort feave the paish When Tie Cenaty sees he concen se id to ia seat terete ‘Me Cappeie her cae higher church lender, convince tht he woud years poosnces Whe the dt pt oc she was ete) Uapporeed and plunged ices depeese sate She tegen fo Dame Senelir tes pres and il her vores nd inasegsny were the wee ofher selection by the hare “Aine senso event oeuired st Ne-C50b where she asshoeked soseceneanefane work evi rect her employersdisaustcon (Sats as efance an sullen, otha Alou she nally at ‘Noein resew's noprviy toners iporanee oferta are stern en mie ender shri oe Ma C dened proving up nan soghere of meetin whic she fener press perc ocinreedio Beran abe bso ings Her muther nar pel an aggressive. la otion to interateny {erent Me abou her ful an aperfectons she woul eg [Enpengae inaggrashe rslaton eters te communi, Ths [edo censan.dsrpton fe mother ladon andan tolted ‘Sinenee forthe fay Her ner sph more ind Re wa ee Sy pevced ws unmile sno sthr sorted nor fhe iuhunetde thei the pes deal ih er ota Ms Cn ‘ied ofconttondng bee mothe bere he reported Dat hen she ha Gone one paws hee other woul pt speds toes ey, ing er tekng hep and sey Me sone te tat inpotant te hat she nob ke het mote an she made every effort ott do so This seed be ne mon fr ber yon Belpal behavior on sialy nec incon she weld ew any auemp ac sears it avery ctl Ton asst sc fits er ter aggresive atc 09 ‘rcs Ca el ey guy nen she wage se fared ping ‘they apurtnabe nd wen her mther co. Ulu Ms woul et inc hemet'or being ike he oer wen sbe beeame cnrgedt other, ‘Ser wg se exjeewed er anity para in pave manne, Psychodynamic Models of Depression Ms. depresion can be explained by arin ofpehodymamic models, ‘putforth by ferent pachoanalyc theorists (Table2-1), Below, we apply {Each mode! to the cave oF Ms. We then use chese theories to sil ase ‘St pnyetodyamie factors ental to the wadesstanding and reatment of ‘depression. we sychoaynamee treatment er vepression ale TA Pophodjramie model oF depression ‘rata Freud Pripecing Bers Dyamic rdipoing actors Drone ving redoing fain Dream Jacaboon redoing fore Proanie Proame Sander ano Pretning coe Dream “Taunt ety expres temperment roensiytvard speech becomes Aicsed a odes Ange projected onto oters, ho are then hpetenced at stati contest eof Rewinmdegonte an ober ofsorm and hor eres In of sion fr wom he patient ‘apeiencer ines ambiraers tela Tenicton whe ort oer, anger toward he ‘ter becomes dete ows there ‘Nace vlneabn nee for oten bates veltexees ‘Ga ape ofthe ater internalized in ‘aperego what atace "ad sepecsteoalied ia eyaraton ofa cis dependent esd Discrepancy between the eo ea (hat one woud The tobe} andthe eo the so Atak of parental acepance aod emotional indeeanding abaence tard eters Augrenion toward deppekaing pares becomes teleireced wo protec ibe loved wher Intestine ng parental sts ead 0 pene geno Distance of a eidhood celaonship with lptenne an rseaton with ds selaonsip tects reactive corer send fel severe speres™ erento tia lu of 3 elton aus Tdnging ir tedealized tte feng ove ane an (pene of lrcepleton lading to depresion Table EA. Pychadyramie modes of depression conte) Fredieing factors Heterogeneous factor neu thot mentioned ‘omer eo manic {canton or daempomerment sexpert for egrnie compenie, eal wate a8 ges “Efren sazeion in vxpone 0 Ba becomee scbadoecet Fea etre ‘una wea nse ihey ie forlowscteseen Ponty Pepa iron on aap chet te om Dynan Internal mode of ten as unloable nd Trades ang ote 36 responsive ad pine gtd by oe aera Early Psychoanalytic Models of Depression: Disappointment, Loss, and Anger “The Gist payehoanalytic writezs to develop the concept that depresion rginter om narcisiste valnerabili, developmental traumas, and Coulied anger inched Abrabam (1011, 1924), Freud (1917) and Rado (192), ‘Abrahars (191), 1924) provided an initia) analytic framework fr wx dernanding depression when he Gescribed the syndrome as resulting hom host tonard others tat becomes self directed, Depresed patents tei whom fe wosked demonsratea propensity, based on temperment srethy experiences toward hatred ad ristrat of others (Abraham {oL0,Feeing unable ove the prople with whom hey are connected bt {nghtened an guily about thelr age, uch patents repres thes hos: ty andl peoject it external, They begin to fee ated and thea connect tbetrsene of being disiked wih varios phological or piysica dein ‘des "People hate me because ofthese defees.” Abraham's description oh cent woul be consistent with pects oF Mes inerpemonal dilemmas and beequent depresions. Ms. C was troubled ty penitent anger toward other of wich she was on minis lezen escalated. She wove shen project this anger onto oderv and tee the at hating her Ms. C would then eonelude tat she mest have 8 etet dat woul Hea oer to eat her this way In ation, her pereep- lon afte world asa hateful place wae during and demoralizing "Sopplementng Abraliam’ nial oervaons on the dynais ix peo- ple with depression, Freus (1917) dearbe an additional model or some Bose: On the basis of his observations of simliaries between bereave ‘hent andthe depresed state, Feta hypothesized hatte fos of an i ‘Pont pero i the individual ie, ether in ral or in Faas, can Tigger he onset of depression, As incom mourning, however. ade presion fs smulaed when the person who i ost has been the abject of Ftenely ambivalent feelings om the part of the patent The depresed tua denies with or takes on as part of nel or herselt, one or other ofthe ln person's characterises, to maintain a fecling of con rection wth that person an to misigate aginst the sense of fos ar be envement-flowerer,Becate the last person was vewed with ambivi tence, the anger orignaly directed toward that person now becomes lected toward the new atributes the paint has adopied. Axa est the patent begins to experience intense selec and reproach, which ‘rental lal o depression, Tn accord with Frew’ theory of entiation, when Ms, Cieatifed| reef wih her mother's aggesive and hu behavoss omar’ oben, the became extemely selFeriscal and fle worthless and unlowable. In Ms. Cheats, however, te Tow that consected most immediately wis her urrentdepresion was that of hee rapport wit che prewouly idealized urchins nother ther Thi can bestbe understood by Abrahams ‘Hn to refine Freud's theory and make it consistent with his ear Thodel. Abraham (1924) ee to view an episode of adult melancholia ax Nemning rom a urrent diappoinunent in Ive wich viewed, usually Tinconiioushy as repetition of an eary childhood trumade experience ‘Abraharn (1924) posted that the depremed padent had hada ever i jry to a eaty healthy sense of narcissism (eater) byway of eit ‘hed nppointment in lave, tally tthe hands ofthe mother Such an Ryuy could sem for example, fon losing view of the self as a parent favorite or frm disappointments in gaining an allance wit the mother pana the father (orice wera), Onset ofthe illess in advthood ig. ured bys new disappointment, unleashing strong hostile feelings va hove incivduals, pau and present who have darted the patient’ dese far love. For MG, the church leaders she had rei on emosonall be ‘Sine the objees of considerable hosiisy once they dsappointed her ‘Tis she dcrmonsrated a teadiness to Become enraged at those indivi “hwho lite her mother had diappointed or neglected her Int, com runs by MC linked her anger at de leaders wth her mother. "people ‘ho preach ote thing and behave completely diferent Like Freud, Abraham posite! chat an identification with he rejecting petsne—past or present leads 0 pathologial and merciless attckon the sele. Once Me. G experienced herself an having the same aggresive impulses as her mother Had, she became irsiensely self-critical Rado (1098) cinplifed the theme of injred narisism in depressed patent, He observed that is patients wih depression had an intensely Strong craving for others to utwess heir sefesteem, He noted dat ac Companying iis intense ering fr nzcssisti graifcation wasan inte Ceanceofdhappointmeatin the self or others. Ths, depresed patients acted to rival ofeuses an to fires in expectation not onl with ir [ppotstment and anger but ao tha sigoeane fal ntheir selbester, ‘They seemed wholly reliant om others to feel valued and value iC resembles Rado's patients i this regard Her depresion con- nected not ony tohersacneseand anger about the cris’ presume mor “one unsesponsivenes bat also ro her perception that he effrs within the church (aod a work) were overlooked or underestimated. This com ‘ete 0 the spiral of recsminstions—against the earch leaders and Ther boss an also against here as being itadequate and without value, ‘Thus Ma Cattacked here not only for being angry lke her mother bit hho forsceming wortlew to ors ad being unappreciated by them. “Adding to the themte of ange thar becomes selFdirected, Rado for thr deseribecaplit that ake place nthe perception of selfand otters, iin the depressed patent begins wo sce the seo others a ether all {ood oral bad Inthe proces of development of depression, the good [Galiiesof she loved one ae internalized inthe patients sense of wom ear ahe woul ie tobe (or te ego ideal), whereas the had qualities, tin Freuds formulation, become incorporated into dhe perception of the ego (ore). The self become the whipping by ofthe superego, oF the comacience funeton, which pinahes the patient for flures to ve Upto tie egoideal Thus Ms C internalized the selvighteoures of her rrother i her superego and ego ideal, with the expectation that one ‘hould alaysbehave wi moralrecttade and kindnes, and atacked her selfor being unable to meet these standard Later Models far Depression: Problems With Self-Esteem Regulation and Aggression Biting (1958) followed Rado in hisemphasis on che depresied patient's ‘iteates wit feelings of nares njry but ditfered wih him ana ‘ihe aay in what he saw aster averemphasis on mates of the s- perego and agro, Insead, Bibring viewed depresion aang px unt om dius wih esteem regulation. Lowselfexeem, inthis model, derives fom a significant gap between the patient's slew and nat he orshe woul wish to be ofthe ego ideal deseribed i the previous subsection Tn Bibring’ sew, primal experience of helplessness was most signi icant in contrbuting to the surcepebiay to depression, Hedplessness, which can develop om persistent usration ofachilds dependent nee, Teneo a sense of are and lew selesteem. Rather than anger toward ‘biersand subsequent gui fueling the depression, helplessness tggers fettirected anger A predispossion toward depression is seen by Bib> fing. then, as determined by a constiationa intolerance of rastation, byte sewsity and extent ofstuation o helplessness and by ater dev ‘nee factors that might confirm de paints sense of elElsappoint ‘ment and faire “Seen rom Brings pint afew Me. Cow selfesteem stems fom the iserepaney between her sense of here 3 angry and hurtful ke her nother and her ego ideal of being 2 very mora and caring person. She Iayhave viewed thiinaceqvacy as he cause ofher father’s dsincinaion Colelpherand of her mother’ perceived neglect A seve of heplessnes Shout capturing their recognition stimulated significant anger tard Fersef not only a 2 deflection of her rae and disappointment toad erparenisbut alo onc ofa sense of fruraton and contempt card het selffor her inabiy to capture cir love. “cabo (1954, 1971, 19%) offeredan altematie approach to consid ring selfeteem regulation within the depressed patent, According Jocaaon, alack of parental acceptance and emotional understanding Innes the child's seesteem, Leading to ambivalence, aggresive fe Tras tomard the pores and gui This aggression is turned against the self ha defensive stegy to protect he loved person and to prevent the self ftom enacting hose impulses toward the external worl, Jacobson be eve that further counteract the negative impact of parental sitedes, the deprrned patient develops an excersvelyperfecionistic reactive eg deal snd an encesvely strict superego The patient bases hinselfor her fellfor any ais or behawors that resemble those despised and eared fe the parent Loved ones are deaired s part ofthe sategy of protect. tng them rom aggression and supporting the patent’ agile seiestes, ‘This idealiaion leads the depressed individual to expect ser fo do more than they realisealy ca, leading to recurrent disappoints, “Thus, the dependency on an overated other andthe presence of exces sively high settexpectations lead to. a8 waste and diminished sense of seleescem and o nasi vlnerabily. “Applying Jacobson’ Cormuation to the case of Ms. C further clarifies thetypesot interpersonal relationships chat contribute to er suscepabi- Development ofa Psychodynamic Model of Depression 2 iy eward depresne episodes, Namely, she ideals oxhers to support ber fragile selfesteem and mite fer anger. Tais idealization, howeven Ineitabiy leads to disappointment i those on whom she depends. Her angerin espa to this appointment wigges gui at ceminds he of Der voladle mother, lowering her sefesteem. She fis co ve up to her coverh pefectiicselfexpectaons and er share about this adds 0 ber depressive affens, ‘Stone (1986) highighted particularly the reactive aggression that de ‘elopsin a deeply urating early relationship beeen the person who Inter develop depression and hie or her parent. The aggression becomes texpresed in repeated, fled attempts to cource he paentto respond io Tis or er ces, Asevere superego develops, fale bythe helpless ange. Following Stones model a therapist night explore extensively wit -Ms, Couancesin het historical rlsenship wid ber moder, compasion acl bighighiag her efor to coerce ths seemingly unresponsive pa tent ai then others int secogaizing and addressing her needs, Thsap proach might help the pasent recognize her hostility and its impact on thers aa find alternate anentes for expressing her dsappoiauens ‘Sunler and Joe (1955) researched the extensive case Fes fe Hamp- steal Clinic to look for dyanmie treba thei ld patients sowing ee idence of depressive eromes. These authors found tat the depresive reaction seemed to actu most often when children felt that hey hae lost tomsthing eset other aelesteea and fet helpless io undo defo “ypiealy thie was the lows of an esportant loved on in reality or fama, and especially of tate of well ing mpi nthe relationship with dat [pein This state of welling tends to become idealized: The more itis leotard longed fo, the greater wil be the depresv reaction in he face of isunatainbii, Wocking wih ther model, one might empbasne trih Ms Cte los afer sente of welkbeing that existe when she Felt hpported bythe cleric and pleted wth her sense of accomplishment at ror and focus on her depression ax repressing yearning to ren at ste Rather than focusing om os aa wgge for depresion, Brean (197, 4979) sow many of bie patients a8 imagining themselves to be decisively Auemponered, or symbolically castrate, by otters 8a punishment for ‘competitive, esual, and aggressive wshes Thus, actual or fancasized sc ees could be a tigger of depresion wa the need for punishment, and depression cold be 3 means of diminihing a more elfecve, competi tre stance. Aggression i mobiled aging he person Died for creat ing this dserapoweriiens but becomes self-directed 35 he patent begins tesdopt an ingratiating or propidatory stance tovard the Blamed but feared pry 2 Psychodynamic Treatment of Depression Using Brenner's pespectiv, a therapist would atemp 1 discern for hich bildhood wishes sexual compete, aggresive Ms. Cmay have Felt hat she had been punished, causing her to experience herself an Ihelpiexs powerless indnadual overiooked and noved by al Tn fc. thi patients childhood concerns about compective feelings toward ber Inother forher futher’ attention and her appatent fear of punishment tye mother were seen by her therapist asgafcant inthe evolution of hee guilty inibitons. out (1971) wrote extensively abot pases’ problems with marci icin an was patculry interested in ses of technique in engag Ing and treating such patieats, According to Kohut, depresive affects innarcissisically wlserable individuals ae related to chose feelings ‘emptiness in response to raumnatialy unempathic parenting, When children's alfecve experience are no sensively mirrored by thets pr ‘ary earetakers. they ae lel feeling alone wth del experience and emo- tionally emp and they struggle to 6 themselves by finding others to Ideal and went ith, Techical tention 1 itoring these pies feelings and to iasves of iealzation and devaluation inthe wansference felatonsip wit the therapist are emphasized (Kohut 1971), Ms. C's eaten, described in Chapter § COverview of Pachodymamic Pacho- ‘herapy for Depression") in this wohume, was enhanced by ber therapit’s tention to ths patent’ hunger for recognition and empathy. Attachment Theory [Auachinent theory, a# developed by Bowiby (1968, 1980), dravs heal fon am etholgical and adaptational perspective and has bad igican intuence on piychosnatc models of pychopathology. Bowiy viewed. tachment aya behavioral satem easel for survival, and disruptions attachment. such alos ofa parent, ax crucial in che etiology of ans lous and deprenive disorders Lows riggers series of responses Soy protest anaiety, mourning, and ultimately, detachment. Disrupted atach- fem due to tsecure al uneable relatonships with paren ort heir ejecting and crital behavior, ted to the development of internal od ‘lsat the seifasunlovable and inadequate and of othersas unresponsive Sind punitive The individ! becomes vulnerable to depression inthe set ting ofater experiences oflom or adversity secing such losses as signs of falure and expecting litle seppor fom others “Athough Ms Gi no lea parent eaey ia Lf, her experience of ds rupted stachment from cateal and emotionally unresponsive parents ‘leuy contributed to her view of herself as inadequate and helpes to ‘ange complex and adverse siatone The fos ofthe church incensed Development ofa Psychodynamic Model of Depression 2% fecings offre, helt age, and hopeless aboucher abi to have succes atachiments to ther For eaimpe, Ms Ccheugheit was uses {olookfora ev erch beeaue woul invariably lead to another faire: Defense Mechanisms in Depression Psychoanalytic theorists have considered the posbiity that certain de fem (.e inzmnal or behavioral means of averting painfl feelings or ‘vestening uncosscous fantasies) ether may be specially mobilized ty depres alec or may predispose indinidals othe development of depressive syndromes (Brenner 199; acobyoa 1971). Bloch et.al (1888) Gecenbed tee posses inthis ear 1) defenses may become struc fed in respoote toa chronie mood disturbance; 2} malsdaptve de enses may sctually lead to depression, nd 8) the mood disorder and defenses may each be related fo a thitd ctr, such a underlying low teifeneem, For mots theoreticians, the defenses ip depressed patients te iniallytggered to contend with inolerably angry Eatasis or with analy fow self-esteem bye aca only revulin an exacerbation of de presion, Thus, anger projected outa, accoring to Abraham (1911, Ends up being directed toward he self whereas fforstoidealize che se trorhers to cope wth low seextem eventually lead only o father di ppoistencand demaluation Jacobson 197). Other defenses mentioneé ‘pecially by psychoanalytic thors as mobilized to cope with inoles Hesnger and sadness incade den pase aggresion, reaction forma tion. and idenafcation with the aggressor Toa more astern study by Bloch etal. (1999, the defense mech nismsemployed by patents with dpthymaic disorder were compared with those of patients wath panic disorder, by uring the Defense Meckarsirn Rating Seale (DMS) (Perry 190). The sale whieh contains criteria for operationalized asessent forte presence or absence ofeach defense, Sacored by ue ofa pychodynanie interview Two defenses, denial and ‘epresson, were found i be uted frequendy by both pauents wth panic Alsorder and patients with dpsthymia. Compared with pane disorder pu ‘iets, dose wth dems were found to employ higher levels of eval tin, pase aggression, prnjection, ypackondiiasis acting ot and pro- {ecivesdentifetion. En the formation by Bloch ec al. (188) from die tists depression could occur throws directing anger toward the sel tesprestng anger pasively(pasive aggression), distorting perceptions of ‘elfand other (devaluation, projection). lnvingretaition from others {Geing out, passive aggzesion), or asking foe and thea rejecting help (re lated tothe DMRS formolaton fer hypochondriass) 2 Psychodynamic Treatmenc af Depression In invidlpatents, the clnician shoul he alert othe characterise

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