Meetings of the New York Psychoanalytic Society

February 25, 1964. DEPRESSION: THREE CLINICAL VARIATIONS. Stuart S. Asch, M.D.

Following a classical schematic outline of the depressive constellation, Dr. Asch suggests a re-examination of these formulations in the light of more recent understanding of the contents and structure of the ego. He emphasizes that the term 'depression' includes different clinical states with similar but not identical psychopathology. Variations in these states seem to be a function of the vicissitudes of the introject, depending on the type of incorporation and the ego attitudes toward it. The clinical picture seems to be determined first by the location of the introject, its distance from the 'ego core' (Loewald), or its position in the superego; and second by the expression of the ambivalent conflict over the wish to hold onto and get rid of the psychic representation of this locus.

The author discusses the relationship between body image and narcissism in hypochondriasis. Early defects in external stimulation, or confused internal stimulation, result in a poorly defined body image. A current real or anticipated loss of a narcissistically cathected object may revive the earlier body image, threatened with loss of part of itself. If this loss is regressively experienced, it may result in hypercathexis of the body part involved—one cause of depletion of ego energy that results in the clinical picture of ego restriction with limited abilities in thinking and interests. The affected organ in hypochondriasis is treated as the ambivalently cathected introject seen in depression, but there may be no guilt or depressed mood. The only affect consistently present is anxiety. Since hypochondriasis frequently appears without a depressed mood, it is tempting to consider it a manifestation of 'unconscious depression'. Although frequently seen in medical practice, it is rarely recognized by nonpsychiatrists as a manifestation of depression.

Dr. Asch then discussed depressions involving a s