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Interpersonal and Self-Psychological Treatment of a Case of Psychotic Depression

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Length: 30 minutes

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Joerg Bose, MD

The origin of depression has remained mysterious and mystifying. This presentation  explores a model of dissocation leading to severe psychotic depressive states and postulates that the force that ignites and sustains such dissociation based forms of depression is the force of shame.

The often sudden onset of depression may indicate that dissociative processes are at work, processes that, like an avalanche, may sometimes require only a minor triggering factor, as long as there is a meaningful connection with the memory of a traumatic shame inducing experience.

The blaming or condemning stances of shame can have a massively devastating effect on the illusion of a coherent sense of self, and the resulting essential absence of a sense of self will be experienced by the patient as the excruciating pain of mental meaninglessness, of a self experience that has been emptied out of any significant memory and meaning.

Chefetz (2000 p.295) delineates such a dissociative trajectory to psychotic depression when he writes ”Traumatic experience reaches a crescendo of unbearable affect and melts into a state of numbness associated with a loss of contact with the body and contact with the self”.

A case of a highly depression prone patient will be described who presented with an extreme sensitivity to any kind of rejection experience because of the resultant excessive shelf-shaming reactions created by a fire storm of intense self condemnation that left the bombed and burned out self of psychotic depression in its wake in the form of catatonia like states of  physical and mental paralysis, with severe psychosomatic symptoms.

While these states could last for days and weeks there remained an openness to the therapeutic process when issues of shame and self-condemnation were addressed and the therapist was experienced interpersonally as a coparticipant equal. The sudden lifting of such deeply depressive states under those circumstances was remarkable and challenges the notion of a biological origin of such psychotic depressive states.


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