H. KEITH FISCHER, M.D.

Faces and masks of depression:

The psychodynamic side
ABSTRACT: Advancement of understanding and improvement of Varying manifestations
therapy require a consideration of the variety of personality traits Depression will have different
and patterns, symptoms, syndromes, and mechanisms that are manifestations in each individual,
the precursors of, components of, and defenses against manifest depending on the earliest life expe-
depression. The childhood depressive constellation, core depres- riences, the core and developing
sive traits, and defenses against depression are examined, and personality traits and patterns, the
therapeutic suggestions are made for achieving contact with the patient's age, and his current envi-
ronment or life situation.
patient and relieving the helplessness and hopelessness that are The depressive elements may be
often present. completely masked, not only from
other observers, but from the indi-
vidual himself. In the latter in-
Estimates suggest there are be- sent only the tip of the iceberg. stance, a variety of syndromes in-
tween 8 and 15 million cases of Research has produced tremen- volving recognizable behavior
depression in the United States. dous and exciting progress in phar- patterns and reactions (as well as
About 1.5 million of these people macodynamic therapy for the de- panic, anxieties, and a whole host
receive adequate treatment. I pressions and manias. Progress in of psychosomatic changes in the
These figures, however, refer these areas has, for the moment, body with and without organic pa-
only to the obvious and sordid exceeded understanding of the thology) may be the only present-
manifestations recognizable in the clinical aspects; but it is evident ing symptoms. Unless these symp-
several clinical depressive, manic, that the psychotherapeutic and dy- toms are recognized and
and suicidal syndromes. But de- namic approaches are striving to considered, treatment will be lim-
pression also lends itself to being catch up, giving us a broader un- ited to only the most obvious and
hidden and masked, so that from derstanding of the nature of de- extreme manifestations and will
the clinical and morbidity point of pression. It is on these approaches frequently fail.
view, the above figures must repre- that this paper will focus. In addition, when we include
such elements as grief, mourning,
From the Third Weiss-English Symposium, Philadelphia, October 29, 1977. Dr. reactive depressions following
Fischer is clinical professor ofpsychiatry at the Temple University Health Sciences acute loss or stressful life-situation
Center and past president of the Academy of Psychosomatic Medicine. Reprint change, anniversaries and emo-
requests to Dr. Fischer, 5450 Wissahickon A venue, A -ll0, Philadelphia, PA 19144. tionally invested deadlines, as well

PSYCHOSOMATICS
as the unipolar and bipolar depres-
sive clinical syndromes, it is clear
that in speaking of depression, we
are talking about not one thing, but
many.2
Fortunately, we are beginning to
recognize this complexity and to
expand our understanding and
therapy not only to reach those
whose illness has already become
manifest, but to make the primary
and secondary preventive efforts
that are the ultimate goals of our
therapeutic endeavors.
Psychodynamic factors
The core psychodynamic factors
that have been related to the de-
pressive phase are ambivalence,
guilt, loss ofan object or something
of value-which result in psychic
hurt and mourning-and loss of
self-esteem. In the course of dealing
with the personality, emotional and
behavioral symptoms, the individ-
ual will use many mechanisms that
influence presenting symptoms.
These include denial, regression,
withdrawal, rage, and varying ef-
forts at restitution and recovery.
In the manic phase, the individ-
ual is narcissistically hungry. He
expresses impulses and acts free of
restricting or inhibiting factors. In
this situation there is a major denial
of dependencies, with or without
paranoid tendencies.
Psychiatrists have also focused
on certain consciously or uncon-
sciously held attitudes and emo-
tionally invested states related to
depression: helplessness, which has
its origin in pathology dating back
to the first year of life; hopelessness,
which finds its dynamic origins in
certain situations in the ages of
three to six; and finally, the situa-
tion in which a hurting and over-
whelmed, functionally paralyzed,
helpless and hopeless individual
APRIL 1979 VOL 20 NO 4
may be in the process of "giving up"
or in the state of having "given up. ''3
With all of these variables within
the individual and outside the indi-
vidual, with various personality
traits and attitudes, his intellectual
opinions and resources-in addi-
tion to environmental and psycho-
social experiences that are in-
fluencing the problem, depending
on the varying ages and states of
the patient's life cycle-is it any
wonder that at different times the
manifestations of the illness and
the vicissitudes in the onset, the
acute phase, the remissions, or re-
currences can be so protean?
When these concepts are consid-
ered, it is quite easy to see that no
individual psychotherapy, no three
or four separate psychopharmaco-
logic regimens alone, no matter
how effective at certain times, can
in themselves provide sufficient
treatment. It is in accepting this
broader view of depression that we
see that psychodynamic psycho-
therapy and pharmacotherapy
must be fitted together appropri-
ately and varyingly to achieve op-
timum treatment.
Emotional core
For too long, interest in the prob-
lem of the depressions has focused
on the idea of a grievous loss or hurt
and the reaction of grief, sadness,
and melancholy. The focus on this
dynamic is often too restrictive, too
simplified, and does not begin to
explain the larger, deeper, and
more complicated mechanisms. A
more dynamic and humanistic
focus would be upon the core of an
individual's discovery, emotionally,
of his innate helplessness. The in-
fant, indeed all humans, wishes to
be omnipotent and omniscient. To
find oneself hurt and failing, to find
oneself threatened and frightened
is part of living. Adding the idea of
helplessness to this central aware-
ness brings us closer to the central
dynamic issue.
In the dynamic understanding of
the hysterias, Freud focused on the
core fear of castration as the central
emotional issue. However, we are
now focusing much more on the
earlier frightening awareness of
man's helplessness and his inability
to cope with threats to his own
existence as a more basic issue. In
this regard, we would not be deny-
ing the former importance, but we
are emphasizing more a pre-
oedipal, pregenital, and existential
issue.
Even in the individual who has a
hysterical and oedipal problem,
there can frequently be an earlier
psychopathologic problem hidden
by the character neurosis. The
means of opening this up and mak-
ing conscious and available the va-
riety of disturbed emotions and
conflict cathexes lies in the under-
standing of the depressive traits
and personality issues. Therapeu-
tically, the key that opens this up is
a focus on the depressive elements
that distinguish man as a sexual
machine from man as a sensitive,
humanistic, passionately emo-
tional, and now hurting and fright-
ened individual.
Precursors
Psychoanalytic research and clini-
cal studies into the psychogenetic,
experiential, and developmental
precursors of depression early in
life frequently reveal traits that de-
termine whether the individual will
tend to steer away from depressive
reactions, or to become sick. The
findings are fascinating.
Depressive constellation: Bene-
deJc4.5 has described a dynamic ex-
perience that she calls the "depres-

sive constellation." This is a primi-
tive psychic construct evolving
from memory traces of the infant's
hunger, discomfort, and pain, and
its varying satiations. When hunger
and discomfort are not gratified
appropriately, there is a sensory
perception of frustration; this may
occur with or without energy
changes that result in a psychic
precipitate that evolves in the un-
differentiated neonatal state. If the
total time of the experience of grat-
ification, satiation, and pleasure is
predominant over the negative-
hunger, discomfort, agony and,
even in the extreme instance, actual
pain-the child is soon pro-
grammed in healthy adjustment
patterning. If the weight is on the
negative side, the depressive con-
stellation develops. In the healthy
situation, the trait of confidence
begins to be developed, and along
with it an appropriate patience and
learning to wait. In the depressive
constellation, an ambivalence of
experience due to a mix of frustra-
tion and gratification becomes
fixed in personality traits and per-
sonality structure. These traits are
specifically psychogenetically, de-
velopmentally, and clinically re-
lated to the presence or absence ofa
variety of symptoms of the depres-
sive states. Other traits that mayor
may not evolve are tolerance, se-
renity, sincerity, optimism, humor,
wisdom, and conscience and
conscientiousness.
Anaclitic depression: Spitz and
Wolfti and, more recently, Bowlby7
have talked about "anaclitic de-
pression," which results from
grievous psychic, social, physical,
and emotional traumas related to
early separation. In this regard, the
psychic and biologic "directions" of
death may be clearly involved on
an emotional level long before the
APRIL 1979 VOL 20 NO 4
infant is old enough to intellec-
tually and consciously have any
will or choice in the matter.8
Klein9 and Mahler lO have con-
tributed the terms "depressive posi-
tion" and "basic depressive mood"
which refer to mood changes and,
in Mahler's formulation, also a
"normal depression" related to sep-
aration/individuation in the devel-
opmental phase in the second 18
months of the infant's life. In addi-
tion, Zetzel ll has talked about the
"capacity for depression." All of
these formulations indicate that
situations and experiences, both
normal and pathologic, occurring
in the earliest months of life at the
Depressive elements may be
maskedfrom other observers
and the individual himself.
so-called phase of "orality" are rel-
evant to the presence or absence of
depression.
Traits relating to self-image, self-
regard, and self-esteem are also de-
termining sides of the personality,
healthy or unhealthy, as the indi-
vidual develops. The traits and
drives resulting in exhibitionism,
grandiosity, omnipotence, healthy
pride, and enjoyment of one's ef-
forts and performance in life also
start to be determined early in life.
In their absence, hypochondriacal
symptoms and/or the loss of wish
to make an effort, the idea of un-
bearable "emptiness," shame, and
helplessness and hopelessness re-
sult in giving up and literal or sym-
bolic death experiences.
Other depressive traits
Helplessness: Several traits and at-
titudes related to choice factors
have been proposed by Schmale
Depression: Faces and masks
and Engel.) The first has to do with
the idea of helplessness. Feelings of
helplessness evolve in a situation in
which the infant later experiences
himself as being treated badly and
neglected, and unable to do any-
thing to relieve it.
Certain socio-political and racial
difficulties in overcoming obstacles
and achieving desired goals are
sometimes described as being the
result of past neglect or past injus-
tices. These unfortunately may be
used to justify helplessness. The sit-
uation is dominated by the idea of
overwhelming exogenous difficul-
ties, and the "victim" in this for-
mulation sees himself as helpless.
He is only passively involved. In
this there is no guilt or shame.
These same dynamics may char-
acterize depressive individuals.
Their stance often becomes fixed,
not only as a reaction to problems
but also as a general personality
outlook that makes no effort and
expects no favorable change. Fear
and anger are not far away. Social
groups may, unfortunately, also see
themselves this way.
Hopelessness: A second and re-
lated factor has to do with hope-
lessness. It generally finds its ori-
gins around the ages of three to six.
There is a focus on the idea of
self-neglect, and the depressions
that go with it tend to be precipi-
tated mostly by endogenous fac-
tors. They furthermore tend to be
bipolar and can express themselves
in either depressive or in manic
manifestations. Conflicts about
presence or absence of strengths,
power, and shame are often in-
volved. Naturally, any of these
traits can manifest itself directly in
the therapeutic relationship and in
the transactions that are so crucial
between doctor and patient.
Giving up-given up syndrome:
259

Next, there is a "giving up-given
up" syndrome. While we do have
some say in terms of willful choices
to make efforts or withdraw from
them, these decisions are too often
determined inwardly by the emo-
tional state or mood of the individ-
ual, rather than by the realities of
what is available and what can
evolve in terms of realistic change.
The point here is that all of these
traits, attitudes, and dynamic in-
volvements can occur in anyone to
some degree or other. However, in
more severe form, they also can be
formed into the more or less rigid
details of the character neurosis
known as "depressive personality."
These traits must be considered,
recognized, and discussed in the
psychotherapy of the depressive
person whenever they become
manifest, either prior to the acute
episode or during it.
Other manifestations
Withdrawal: Certain other condi-
tions need to be mentioned as com-
mon and frequent in depressive
syndromes. The first has to do with
the tendency to withdraw. We go
on vacations to "get away from it
all." This is acceptable. We "shift
gears" with a cocktail, a movie, or a
pleasant evening. We take a nap.
These are considered appropriate
and socially acceptable means of
coping with the stresses and strains
of living. The depressive individ-
ual, on the other hand, may with-
draw to a greater degree, and his
withdrawal may really be a flight
from the stressful situations within
himself. This can be either a
healthy, strategic flight from a real-
ity situation, or a pathologic with-
drawal from social and interper-
sonal transactions in which the
individual largely views himself as
fighting. The pathologic with-
APRIL 1979 VOL 20 NO 4
drawal brings no help and no rest.
Its extreme may be represented by
the catatonic state.
Pseudonormal calm: In another
clinical area, we need to pay atten-
tion to what Fischer and Dlin 12
have called the "calm before the
storm state. " This is related to pri-
mal anxiety. In this condition, the
individual, sometimes a patient in
the hospital, is thought to be nor-
mal. He is not complaining; he is
taking his medicine and is quietly
cooperative; he answers questions
and is seemingly in contact; but he
is not active and he is not broadly
involved. He is pseudonormal and
really seething inside. Frequently,
this is the individual who jumps out
the window, or has an acute psy-
chosomatic or psychotic episode.
Everyone is surprised, because
their emotional denial had led
them to accept the superficial pic-
ture of this quiet individual as
healthy and normal. If they had
tuned in to his true psychic state,
they would have realized the
mounting turmoil and made pre-
ventive efforts. When pseudonor-
mality is unrecognized, the patient
often feels that no one is sensitive
and aware enough to help him. As
long as this functiona/~y paralyzed
state is not recognized, it cannot be
prevented or treated. The physician
who can "feel" this state in a suf-
fering individual, as well as intel-
lectually recognizing its signs and
symptoms, can do a great deal to
relieve it. 12
Related to this is a state men-
tioned by Engel in his first Edward
Weiss Memorial Lecture several
years ago. 13 This is a state that he
calls "conservation-withdrawal. "He
relates it to a biologic state of al-
most playing dead or sham death.
Under overwhelming inner and
outer threats, the human animal
Depression: Faces and masks
will adopt this last-ditch survival
method rather than die. In this sit-
uation, as well as in the prior state
of pseudonormal calm before the
storm, there are certain elements of
emotional functional paralysis, but
the individual is not in pain and not
irrational in the usual sense.
A nhedonia: Another clinical
symptom that should be considered
is anhedonia. Anhedonia is a per-
vasive sadness or boredom that can
begin very early in life. It involves
feelings of emptiness, loneliness,
aloneness, lack oflove, and absence
of pleasure. Achievements and suc-
cesses fail to neutralize this sadness.
There is deficient power and ability
to have pleasure. While this symp-
tom is seen in severe character neu-
rosis and schizophrenia, it is also
the zenith of depression. 14
A number of other behavioral
and clinical manifestations often
precede or accompany depression
and can also serve as defenses
against deeper and more severe
clinical consequences. Acts of re-
bellion and other forms of neurotic
acting out, for example, often pre-
cede depression.
It must be remembered that loss
of love, frustration, defeat, or es-
teem injury are not specific for de-
pression. However, these "triggers"
frequently disturb intrapsychic
equilibrium, leading to a variety of
depressive symptoms and/or de-
pressive illness itself.
Defense against depression
Several behavior patterns, or dy-
namic situations, may be consid-
ered primal defenses against
depression. II
Paradoxical motivation: The first
of these, which might be called
"paradoxical motivation," may in-
volve an increase in activity (per-
haps in sex), incurring danger, ex-

cessive work, provoking and con-
fronting authority, social activism,
or drug abuse. All of these help to
defend against and deny the core
fear that goes with a threat to losing
libidinal energy. Whether mania
follows depression or the opposite
can be argued; the more recent
votes tend to the idea that mania
may precede depression.
Clinging: When the focus is on
the fears that go with being alone
and being helpless, the defense
may often be seen in clinging. In
this behavior, the individual may
manifest demands for physical
proximity, excessive displays of af-
fection, demands for sexual gratifi-
cation, and for gifts, money, adora-
tion, increased appetite, and an
aggressive component. Weeping in
this situation signals a wish for rec-
onciliation with someone who has
been alienated or lost. Occasion-
ally, anticipatory guilt and punish-
ment may be involved. Other pa-
tients have what Ostowl 5 calls
"negative training," and display
the opposite of the expected be-
havior in an effort to hide, conceal,
and deny clinging impulses. Cling-
ing also can be used to mask a
variety of phobias and counter-
phobias. In this situation, some ele-
ments of aggressive behavior can
be noted.
Angry withdrawal: Another de-
fensive state is that of angry with-
drawal. In the usual withdrawal,
the depressive state suggests being
overwhelmed, and acknowledging
and accepting defeat with a giving-
up strategy. In angry withdrawal,
the patient pretends his withdrawal
is by choice.
Narcissistic tranquility: In this
defense, the individual who is suf-
fering depression acts as if he is not
really depressed at all; he appears
calm and "above it all" in the face
APRIL 1979 VOL 20 NO 4
of the vicissitudes of daily life. His
behavior implies that he has no
stresses. Ostowl 5 says that this can
occur in patients on psychic ener-
gizers and can occur as the converse
of Selye's general adaptation syn-
drome. It also has been seen in
schizophrenic patients on antipsy-
chotic drugs.
Physical illness: The final cam-
ouflage for depression is in func-
tional and body illness. These psy-
chosomatic symptoms represent
the emotionally stressful over-
Dy1Ultnic psychotherapy and
phannacotherapy must be
fitted together to achieve
optimum treatment.
whelming of the individual who is
not maintaining enough ego stabil-
ity to be able to defend against and
master the emotional stresses, but is
still capable of pushing the stresses
into the soma while maintaining
unconflicted intel1ectual activity,
work, and social adjustment. This
individual shows no obvious man-
ifestations of stressful or psychiatric
illness. In the true American tradi-
tion, he is "going down with his
boots on." His illness is often not
recognized for what it is, and peo-
ple laud his courage for "going on"
as the inner psychic stresses and the
outer organic manifestations take
their toll.
As Selye l6 has pointed out. the
most frequent source of stress is
that produced by emotional and
psychiatric conflicts. When stress is
concealed behind an ulcer, heart
attack, al1ergy, or skin disorder,
treatment initial1y must focus on
correcting the disturbed pathology
in its physiologic, biochemical, and
neural manifestations. However.
Depression: Faces and masks
the real prevention and the real
cure involve handling the masked
psychodynamic aspects.
I do not maintain that the core of
psychosomatic illness is depressive,
but depressive syndromes are
always a part of the cause, along
with disturbances of affect. which
include pent-up anxieties and sex-
ual, aggressive, and other prob-
lems. A basic and core fear often
underlies it all.
Beginning psychodynamic
psychotherapy
The patient with hidden depres-
sion, as well as the patient with
manifest depression, is varyingly
overwhelmed, fighting or fleeing.
helpless and/or hopeless. Perhaps
he is close to giving up. With all
depression there is some fear; and
with all fear there is some
depression.
The determining factors in
achieving or failing to achieve a
working contact between dynamic
psychotherapist and patient are
twofold: the capacity of the thera-
pist to understand the multiple
variables and complexities of the
clinical illness he is dealing with,
and the crucial ego achievement of
some personal mastery, first by the
therapist, of the primal emotions
involved.
This contact, in turn, is the foun-
dation of successful psychotherapy.
When the personal doctor-patient
contact is achieved, the patient is
no longer alone. When therapeutic
insight progresses. the situation is
no longer either helpless or hope-
less. Both the depression and the
primal fears often resolve and
change favorably.
Pharmacodynamic therapy is
often crucial in this effort at certain
times, and a collaborative therapy
offers the wisest help; but one can-
U,7
Depression: Faces and masks

not be a substitute for the other.

This summary, while admittedly
oversimplified, reflects the author's
encouragement of the therapeutic The Academy of
work outlined here and his opti-
mism about the ultimate outcome
of that work. 0
Psychosomatic Medicine
REFERENCES
Now celebrating it 25th Anniversary, the Academy continues to
1. Fawcett J: Depression-Suicide (interview). work for the goal et forth by it founders:
West Point, Pa, Merck, Sharp & Dohme, The integration of medical treatment for illness-organic and
1977.
2. Mathis Jl: Depression: The symptoms and p ychologic-with the practice of p ychiatry to en ure the best
the illness. Lecture summary. Department of comprehen ive care for all patient in need of therapy-emo-
Psychiatry, East Carolina University School of
Medicine, Greenville, NC, 1977. tional or physical.
3. Schmale AH, Engel GL: The role of conserva-
tion withdrawal in depressive reactions, in
Anthony EJ, Benedek T (eds): Depression The Academy's philosophy stresses the growth of its members-
and Human Existence, New York, Little, through clinical practice, study, and research-as advocate of the
Brown & Co, 1975, pp 183-198.
4. Benedek T: Toward the biology of the de- psychosomatic approach to the prevention, diagno i and treat-
pressive constellation. J Am Psychoanal ment of illness.
Assoc 4:389, 1956.
5. Benedek T: Ambivalence and the depressive Membership
constellation in the sell, in Anthony EJ, Ben-
edek T (eds): Depression and Human Exis- .. provide OpportuOltle to meet and exchange information
tence, New York, Little, Brown & Co, 1975, while earning AMA and AAFP Continuing Medical Education
pp 143-167.
6. Spitz R, Woll K: Anaclitic depression: An credit through work hop, seminars, lectures, symposia. and
inquiry into the genesis of psychiatric condi- demonstration at the prestigious annual meeting and other
tions in early childhood. Psychoanal Sludy
Child 2:313, 1946. meetings held throughout the year.
7. Bowlby J: Grief and mourning in infancy and .. enables you to participate after three years in the Distin-
early childhood. Psychoanal Study Child
15:9, 1960. guished Fellowship Program, culminating in certification as a
8. Fischer HK: Symptoms, repressions, anniver- Fellow of the Academy of Psycho omatic Medicine.
saries and the death instinct. Read before the
Philadelphia Psychoanalytic Society, Phila- .. entitles you to receive Psychosomatics throughout the year.
delphia, Sept 17, 1975. .. is open to individuals with professional degrees who work as
9. Klein M: The Psycho-Analysis ot Children.
London, Hogarth Press, 1932. health care providers. Many members represent the fields of
10. Mahler MS: Notes Oil the development of psychiatry, neurology, p ychology, pharmacology, family medi-
basic moods: The depressive affect in psy-
choanalysis, in Loewenstein RM, et al (eds): cine, dentistry, and biochemistry, but profes ionals in other
Psychoanalysis: A General Psychology, New areas are also invited to apply.
York, International Universities Press, 1966.
11. Zetzel E: Depression and the incapacity to
bear it, in Schur M (f:ld): Drives, Affects, For further information about the Academy, clip and end the
Behavior. New York, International Universi- coupon below.
ties Press, 1965, p 243.
12. Fischer HK, Dlin BM: Primal anxiety and psy-
chiatric emergencies. Postgrad Moo 30:200-
217,1961. Mr. Tom Nelson, Executive Director
13. Engel Gl: Vasopressor syncope and sudden Academy of Psychosomatic Medicine
death: A biopsychosocial perspective. Read 70 West Hubbard Street. Suite 202. Chicago, IL 60610
before the First Weiss-English Symposium,
Philadelphia, Oct 11, 1975.
14. Grinker RR, Sr: Anhedonia and depression, in Please send me your information kit.
Anthony EJ, Benedek T (eds): Depression Name _
and Human Existence. New York, Little
Brown, 1975, pp 413-424.
15. Ostow M: Psychological defense against de-
Address _
pression, in Anthony EJ, Benedek T (eds):
Depression and Human Existence. New York, City State _ _ Zlp _ _
Little, Brown & Co, 1975, pp 394-411.
16. Selye H: The Stress of Life. New York,
McGraw-Hili, 1956.

268 PSYCHOSOMATICS