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Four patients, none of them out of touch with reality, are described by the author as suffering from psychotic depressions. All had intense oral and anal impulses and primitive defenses. They were strongly sado-masochistic and had too close a pregenital attachment to their seductive and masochistic mothers; their castration anxiety was overwhelming. The patients used much denial, they suffered narcissistic injury by identification with the mother as a devalued love object, and their identification with the father failed. Their sublimation was poor, their penis envy so intense that the whole body represented a phallus. Identification with the castrated mother resulted in hopelessness and depression. The patients strove to replace the mother as object by a man. Disengagement from the mother leaves the ego with a feeling of loss and narcissistic injury, compensated for by the fantasy of having the biggest penis, and by oral acquisitive sadistic wishes. Violent sadistic fantasies of superseding the father are accompanied by excitement, triumph, and elation, and identification is made with the fantasied aggressive masculine father. There is no sublimated, desexualized, affectionate identification with the father. Depression begins with great anxiety and guilt. Identification with the phallus-father is relinquished and identification with the devalued mother re-established. The transition between depression and elation occurs within the narcissistic organization of the ego.
The 'circular disorder' germinates in the pregenital period; its specific characteristics are established during the phallic phase, lie dormant during latency, and are revived in adolescence. A fixed complex of conflicts centers about the process of identification, from which the labile narcissistic system of defenses is derived.