Sunday, August 10, 2014

Depression as a deferred response to narcissistic injury

Recently  I came across a case where betrayal of trust, that had caused the patient great mental pain, anger and desire for revenge, had eventually found discharge in depression when the winter months came.

The patient a robust lad in his late twenties, half-Japanese, half-American, who is helpful to a fault, partially because he seeks acceptance, a reflection of his not being an all American kid and thus not quite the in-crowd, and partially because of his inborn obliging nature, had co-signed for two of his friends to get them motorbikes.

He was warned by others to not be a fool, but he did not know how to say no. The motorbike dealership worked out a plan where his friends would have to pay just 99 dollars a month for six months, and if that was done on time, a new financing would take place and the patient would no longer be a co-signer.

Both the motorbikes were repossessed. One friend never made any payment after he totaled the motorbike within 48 hours of getting it. The other made just one payment, and his bike was taken away 45 days later.

The sucker was filled with rage, and developed extensive fantasies of revenge. None of which he could put in action. The friends were no where to be found and secondly he was in trouble with the law for possession of a controlled substance in his car which was not in the prescription bottle - a victim of American law enforcement's love for bullying its youth and criminalizing everybody so they can have a lucrative supply of money through their probation departments- which precluded a fight which could have violated his probation. And so he just sucked it up, as the saying goes.

This debacle happened in Summer.  By Fall he thought he had put the whole unpleasant experience behind. But when winter came he noticed he was feeling melancholic. Analysis revealed this melancholic feelings towards the world to be the anger towards his treacherous friends getting discharged upon his own self. As if he identified with those two scumbags and was trying to beat them up through playing the dual role of the beater and the beaten. The misery that he was experiencing through the depression was the suffering he so badly wanted to cause the two former friends and to restore his sense of himself as not their victim but superior to them. His narcissistic pride had been injured and now it needed to be mended by causing damage to those who had succeeded in doing so.

Now why didn't the man get depressed right away but wait for the winter?

The patient stated that he has always been a summer person. When it is sunny and the days are longer, he feels good. Winter with its cloudy and dark skies has always meant gloom and doom for him. On dreary days he always felt more fearful and pessimistic. 

So through the summer while the sun was out there longer he could cling on to his optimism that there is still time to put the revenge - the aggressive motor plans and thoughts that were constantly getting generated in him - in to action. But once the days shrank the possibility of getting even shrank too, and he became depressed. It is interesting that the patient when he was prescribed buproprion, an anti-depressant, did not find it useful for his depression, but nevertheless insisted upon taking it, because he felt "by simply taking those pills I am somehow destroying those two bastards." As if he was poisoning those two hated people by poisoning himself with that pill.

He confirmed this conjecture by stating that even in winter as long as the sun is shining brightly and it is day he feels no depression. He feels like the sun is on his side [now we know how sun is symbol of the father]. So as long as he had his father at his side  - the sun shining over him - he could hope to get even with his enemies.  As if sun - the father - had his back and so he felt upbeat and ready to face the world, confident of his ability to triumph over the competition.

It may sound far fetched and it does not quite fit in with rest of the composition but it may be of some value to insert the following here.

I once got an insight into an old lady's love for sun bathing. She too would be depressed when it was cloudy and dismal outside, and felt buoyant when she could lie down on her balcony soaking up the sun. The unmistakable bliss that was present on her face as she let the sun rays penetrate the pores of her skin reminded one of the bliss that suffuses the face of the woman when she is truly enjoying  sexual intercourse. The fascination of mankind with sunbathing may have its origin in the primal fantasy of mankind of making love to the father while witnessing parental intercourse during the intrauterine phase of one's existence. See my previous posts on this wish to return to the womb fantasy. The way people line up on the decks of vacation cruises and on the beaches, their eyes closed, as if they are soaking up the ultimate pleasure perhaps arises from this equating of the sun with the father.

It is of some clinical interest that this deferment of depression is not limited just from Summer to Winter but it sometimes happens diurnally as well.  In our patient he told me that in the evenings his anxieties build up real high, and he has to take a little Suboxone to keep the depression at bay.

This phenomena of shifting one's conflicts from day to the evening and nights was brought home to me by the care taker of a developmentally disabled patient that I once treated. This patient would be completely passive during the day, often asleep, but agitated and wide awake during the night. The care taker summed up his problem by declaring that he does not deal with his problems during the waking hours but postpones it for the night, to do it in his sleep and dreams, and that is what keeps him awake at night. His days and nights have got reversed and I should give him a medicine that would readjust that.

Perhaps much of the insomnia in humans owes to this phenomena of not facing up to the challenges of life during the day because of actual inadequacy in dealing with them or because of other mental illnesses or because of adverse life circumstances that precludes one from doing what is required, and then keeping awake at night trying to solve them or even when managing to fall asleep entering only in partial sleep with the mind failing to shut off adequately.

A highly anxious patient of mine claimed that by taking Xanax (alprzolam) and suboxone (buprenorphine) during the day he can keep his anxiety at bay and his spirits buoyant. "But then I keep awake worrying all night. The medicines just postpone [defer] my fears." He added that when he went to hospital and they suddenly cut him off from all Xanax he was hearing voices. He could hear people plotting against him outside his room, on the corridor of the ward. When asked what exactly were they plotting he replied all the different methods by which they would kill him. "And why would they want to kill you", I asked him. And he said well they were falsely accusing him of being an asshole and other good things, and were trying to make up their mind as to what would be the best method to kill him. This case along with confirming the reality of postponement of affects from day to night as the main cause of insomnia in humans also tells us as to how behind anxiety lies paranoid thoughts. 

I had another instructive case of deferred depression. An Italian immigrant, who came to the US in his twenties, worked very hard in produce business, raised his children and grandchildren, saw all of them doing good, developed cancer in his Sixties. He was an indefatigable worker, who could not ever even catch cold and cough lest his work suffers, so when he came down with such a drastic disease he felt very betrayed by what fate had done to him. He had led an ideal and virtuous life. He reflected with envy upon  all those who were lazy and careless and had not been struck by such a dreadful disease. But quickly suppressed all these useless thoughts and applied himself diligently to the cure of the cancer. Once his whole attention was directed upon conquering his disease he felt no bad emotions.

Till the winter came. And then he slipped into a profound melancholic depression, the chief feature of which was constant worrying about the fate of others. He felt as if the end of the world was nigh. He felt everybody's future was bleak. He especially pitied those factory workers, and other lower middle class folks, who were getting laid off. He worried about the bag ladies, and urchins who were living in Shelters, and about the homeless sleeping under the viaducts in the devastatingly cold weather.

It was not hard to analyze the underlying logic. It was abreaction of the thought that how come these low class worthless people are not getting cancer and dying while I the virtuous one is. And a constant concern for them was to hide, even to his own self, the evil wishes towards them. His slipping into depression (exhaustion) was secondary to the paralyzing effect these two contrary impulses were doing to his psyche.

It is interesting in his case too, the depression did not occur as long as it was warm and the sun was shining brightly when he could engage himself in doing something productive. Only when the gloom and doom of winter set in, did he get depressed.

The much discussed Post Christmas Depression that is so common in Western societies may have its root in this phenomena of deferment. Christmas is time for families to get together and compare how one is faring in relationship to others, mainly one's siblings, our most hated rivals. And since grass always looks greener on the other side of the fence, one always returns from these gatherings with lingering bitterness and anger, which one abreacts with winter blues in the subsequent month or two. 

No comments:

Post a Comment