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DISCUSSION: Dr. Edith Jacobson noted the relationship of this paper to her own work on denial and depersonalization. She raised the question of a possible change in the patient's behavior and defenses in the two analyses due to the new symptoms and to a further ego regression in the second illness. Possibly increased hearing difficulty played a part in this. Dr. Jacobson also wondered about the precise ego state of the patient while she was on the couch, and in what ways it was dreamlike, noting that there appeared to be no tendency to fall asleep or into a state of reverie during the analytic hour. The possible role of her state of consciousness in warding off perverse, especially sado-masochistic fantasies, was discussed, as well as the relationship between trauma, massive denial, and depersonalization.
Dr. Otto Isakower stressed the importance of the early traumatization in this case, especially the consequences of the fact that the auditory sphere was so massively involved. He noted the close relation between auditory impairment and paranoid tendencies. In this patient there was a failure of undisturbed introjection,