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In his 1914 paper on narcissism, Freud suggested that, as with other elusive phenomena, much can be understood about the normal sense of self by exploring the abnormal (1). He specifically recommended patients with organic disease as promising subjects for this type of investigation into narcissistic disturbance. Considerable psychoanalytic work has been done since Freud's time on the impact of chronic physical illness and loss of bodily parts and function on the sense of self. There has been virtually no systematic psychodynamic exploration of this phenomenon in patients with a biological psychiatric disorder.
If any significant dysfunction would alter a patient's sense of self, the damage must be especially profound when the illness is in the mind. Kohut wrote about the problems of brain-damaged patients:
Our own body can be seen and since perception is primarily directed toward the outside world, it is easier to think of our body in objective terms. The unseeable thought processes, however, are considered by us as inseparable from or coinciding with our very self. The loss of a limb can, therefore, be mourned, like the loss of a love object; a defect in the realm of our mental functions, however, is experienced as a loss of self. (2)
This compelling analysis of the impact of neurological impairment could apply to biological psychiatric disorders as well. I would like to suggest ways in which patients with an endogenous psychiatric illness, a major affective disorder, experience this loss of self. It is my impression, based on