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Busch and Sandberg present a detailed review of the literature on the aspect of psychopathology that is based on absence of reflective awareness of emotions and related fantasies, and a related therapeutic proposal called panic-focused psychodynamic psychotherapy (PFPP) for working with patients who present with panic and anxiety. Their extensive review of the literature on absence of mental representation is especially valuable for readers not familiar with contemporary developments in this area.
The article has three sources. The first is Freud's (1895) two theories of anxiety he related to two different kinds of neurosis. In actual neurosis, according to Freud, anxiety is the direct consequence of damming up of libido due to lack of sexual gratification, and in the neuroses Freud modeled after hysteria that are the basis for psychoanalysis, anxiety is believed to be a signal of repressed unconscious content. The authors' reading of actual neurosis is that Freud didn't realize that a “representational deficit creates a surplus of the quantitative energy” (p. 180). The second source is the literature the authors review on absence of mental representation. The third and perhaps major source is the work of Fonagy and Target (Fonagy, Gergely, Jurist, & Target, 2002) on the unmentalized state and the treatment they call mentalization.
The work of Target and Fonagy is based on Bowlby's attachment theory as well as Winnicott's concept of mirroring. They studied patients with severe disorders of character and personality from the perspective of disturbed attachment patterns originating in childhood leading to failures to accurately represent affective, somatic, and behavioral states