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In the clinical situation patients tell us about self-blame, self-hatred, and guilt, as well as indignation and anger at the feelings, beliefs, and behavior of others. Certainly ruminative self-blame, sometimes progressing to delusions of self hatred—“I am so rotten do not waste food or water on me; I am responsible for my family's ruin and poverty”—are sometimes present in patients with major depression and are a risk factor for suicide.
We generally conceptualize such clinical data in multiple dimensions, including the consequences of a punitive and rigid superego, and a continuum between self-hatred and rage at others, and between introjection and projection. In patients with depression the old wisdom is that “anger turned against the self” is not only a critical etiological component but a risk factor for suicide as well.
Current neuroanatomical models lump negative emotions together and are unable to explain an individual's bias toward self-blame (guilt) rather than blaming others (indignation). This recent study of normal controls and patients with major depression in remission using fMRI helps us deconstruct negative emotions into more nuanced and distinct experiences. fMRI is a neuroimaging technique that indicates what neural structures are activated or inhibited when a specific stimulus is given to the subject (e.g., looking at a fearful face, listening to a sad story). Activation of certain regions, the subgenual cingulate cortex and adjacent septal regions (SCSR), has been found to reflect feelings of guilt in normal controls. In these subjects activation of the anterior temporal lobe (ATL) is coupled to activation of the SCSR, and this coupling is associated with a complex experience of concurrent guilt and anger. This study investigated whether the normal activation coupling of the SCSR and the ATL is intact in depressed patients. If when a depressed patient is exposed to a specific experimental stimulus the expected coupling were absent, this would illu