Defenses against Melancholia

Defenses against Melancholia

The two patients – Mr. D and Mr. E (Kaplan-Solms & Solms, 2000, pp.187-197) – were anything but unconcerned and indifferent about their deficits: they were absolutely obsessed by them. They also displayed such symptoms – misoplegia (hatred of the paretic limb). One of these patients (Mr.D) had only a mild paresis of the left hand, and he would have been able to use it if he had tried. However, he refused to use the hand, and he actually demanded that the surgeon cut it off because he loathed it so much. Mr. D once became so enraged at his hand that he smashed it against a radiator, claiming that he was going to break it to pieces and post the bits of flesh in an envelope to the neurosurgeon who had operated on him. This conveys vividly the emotional state of such patients.

It is interesting that the same lesion site can produce such opposite emotional reactions: unawareness of a limb and denial of its deficits, versus obsessive hatred of a limb and its imperfections. This state of affairs almost demands a psychodynamic explanation. The psychoanalyst who treated these two patients came to the conclusion that their underlying psychodynamics were very similar to those of Mrs. A: they, too, attacked their internal awareness of their loss, but rather than attempt to kill themselves (like Mrs.A), they reacted by trying literally to detach the hated (damaged) image of themselves – or parts of themselves – from the rest of themselves, in order to preserve their intact selves.

No doubt, other permutations are possible (Moss and Turnball described in 1996 a 10-year-old child, with the classic right-hemisphere syndrome, who alternated between a state of denial (anognosia) and hatred (misoplegia) in relation to his left hand. During the period when he hated it, he said that he wanted to have that arm surgically removed and replaced with the left arm of his mother).

What all of these cases have in common is a failure of the process of mourning. Underlying the range of clinical presentations was this commun dynamic mechanism : these patients could not tolerate the difficult feelings associated with coming to terms with loss. The superficial differences between the patients are attributable to to fact that they defended themselves against this intolerable situation in various ways.

Psychoanalytic hypotheses are no less prone to error than cognitive ones. Photo by Elena.

The reason mourning fails in these patients

We are in position to integrate these findings.   The right perisylvian convexity is specialized for spatial cognition. Damage to this area therefore undermines the patients' ability to represent the relationship between self and objects accurately. This in turn undermines object relationships in the psychoanalytic sense: object love (based on a realistic conception of the separateness between self and object) collapses, and the patients' object relationships regress to the level of narcissism. This results in narcissistic defenses against object loss, rendering these patients incapable of normal mourning. They deny their loss and all the feelings (and even external perceptions) associated with it, using a variety of defenses to shore up their denial whenever the intolerable reality threatens to break through.

Left-hemisphere patients, by contrast, retain the capacity for object love, for the reason that the requisite “spatial” concepts remain intact. Accordingly, these patients, whose objective loss is at least equivalent to that of right-hemisphere patients, are able to negotiate the difficult process of mourning. The “depression” and so-called catastrophic reactions of left-hemisphere patients are, in fact, healthy and appropriate responses to devastating loss. Right-hemisphere patients, however, stuck in their narcissism, cannot test their fantastic misconceptions against the perceived reality (as Mrs. K did), and they cannot undertake the normal work of mourning that Mr. J didn.

Psychoanalytic investigation of the inner life of neurological patients clearly has much to offer us. In this instance, it was able to throw important light on a syndrome that was inadequately accounted for by a variety of neurocognitive theories, each of which failed to accommodate the psychological complexities of human emotional life.

Psychoanalytic theories therefore need to be subjected to the same rigorous empirical tests. Photo by Elena.