Chapter 13 – Psychological Approaches to Affective Disorders


The term affective disorders encompasses a range of conditions that affect mood and emotional functioning. It includes unipolar and bipolar disorder as well as anxiety states. This chapter covers the psychodynamic processes involved in depression and anxiety. Key factors that play a role in predisposing, precipitating and perpetuating these conditions are outlined. Along with psychoanalytic theory, the chapter draws on attachment theory and affective neuroscience.

Although psychiatric diagnostic systems classify them separately, there is considerable overlap between anxiety and depression as evidenced in the high levels of concurrent symptoms that are generally seen.

Chapter 13 Psychological Approaches to Affective Disorders

Sue Stuart-Smith


The term affective disorders encompasses a range of conditions that affect mood and emotional functioning. It includes unipolar and bipolar disorder as well as anxiety states. This chapter covers the psychodynamic processes involved in depression and anxiety. Key factors that play a role in predisposing, precipitating and perpetuating these conditions are outlined. Along with psychoanalytic theory, the chapter draws on attachment theory and affective neuroscience.

Although psychiatric diagnostic systems classify them separately, there is considerable overlap between anxiety and depression as evidenced in the high levels of concurrent symptoms that are generally seen. For example up to 60 per cent of patients of patients with generalised anxiety disorder have been found to meet the criteria for major depressive disorder and about 50 per cent of patients with panic disorder experience an episode of major depression [1, 2].

The Subjective Experience of Depression

Depression is characterised by the loss of both motivation and pleasure in life. An underlying flatness of mood is accompanied by persistent feelings of worthlessness which are sustained by negative, ruminatory thoughts. The depressed person suffers from mental pain and finds themselves shut out from aspects of experience they have previously experienced as good, pleasurable or beautiful. This aspect of the condition is vividly portrayed in the following lines from Shakespeare’s Hamlet [3].

I have of late—but wherefore

I know not—lost all my mirth, forgone all custom of

exercises; and indeed it goes so heavily with my

disposition that this goodly frame, the earth, seems to

me a sterile promontory, this most excellent canopy,

the air, look you, this brave o’erhanging firmament,

this majestical roof fretted with golden fire, why,

it appears no other thing to me than a foul and pestilent

congregation of vapours.

When the mind is overtaken by negative affects like this, the sufferer is unable to benefit from relationships or other experiences that might be consoling or replenishing and this state of disconnection in itself helps perpetuate the condition. Sleep and appetite which are also life sustaining are almost invariably disrupted too. In Hamlet’s case, this profound alteration of mental state follows his father’s unexpected death. The context in which it occurs makes it hard for him to mourn his loss and he contemplates both revenge and suicide. As will become clear, an inability to mourn plays a pivotal role in the underlying psychology of depression.

Mourning and Melancholia

The earliest psychoanalytic theories about the origins of depression, or melancholia as it was then called, identified a reaction to loss as a central feature of the condition. Karl Abraham, one of Sigmund Freud’s colleagues, was the first psychoanalyst to write about the association between loss and depression. In 1911, he suggested that early life losses and/or a lack of affection in childhood might predispose to depression in later life [4]. Then in 1917, Freud published a paper entitled Mourning and Melancholia[5]. This work is considered seminal, not only because of its contribution to the understanding of depression, but also because it describes how Freud came to recognise the extent to which the mind is actively engaged in internal relationships and it therefore marks the beginning of ‘object relations’ as a development in psychoanalytic theory. This development involved a shift away from a focus on the instincts and drive theory towards a recognition that early life relationships are represented within the psyche and thereby unconsciously influence psychic functioning. Object relations theory, which emerged in the mid-twentieth century, built on this recognition through the work of Ronald Fairbairn, Melanie Klein and Donald Winnicott [6].

In Mourning and Melancholia, Freud observes that both states involve a loss of interest in the outside world and a high level of internal preoccupation that leaves little energy for other purposes. He refers to mourning as psychological work. Memories of the lost loved one are repeatedly returned to and a range of painful feelings are experienced at different stages, including sadness, anger and guilt. This emotional work gradually leads to an acceptance of the reality of the loss and allows for a recovery of interest and enjoyment in the outside world so that the ego becomes free to form new attachments. Melancholia too can be triggered by bereavement or rejection but in contrast to the ever-present awareness of loss in mourning, the melancholic may withdraw the loss from consciousness, making it less apparent as a cause.

In mourning, Freud writes, it is the world that is rendered ‘poor and empty’ whereas in melancholia, it is the ego itself that is experienced as impoverished or worthless. The low self-worth that typifies melancholia involves a highly active process of self-denigration and self-criticism. Freud observes that it is as if part of the ego has turned on itself in judgement and that in order to do this, it takes itself as an object. He also notes that the melancholic’s self-criticisms are invariably disproportionate and are typically found on closer inspection to resemble complaints against the lost loved one. In this way, he concludes, the self-reproaches of the melancholic may be understood as displaced attacks on the lost love object.

Freud was curious as to how this might come about and he hypothesises that the lost object has been taken in to the ego through a process of unconscious identification. A narcissistic identification like this means there is no separation, so the pain of loss can be mitigated and denied. Furthermore, in directing recriminations towards the self, feelings of guilt towards the lost person are also reduced. Freud writes:

Thus the shadow of the object fell upon the ego, and the latter could henceforth be judged by a special agency, as though it were an object, the forsaken object.

Later on, he named this judgemental agency the superego in order to differentiate it from the ego [7].

Freud outlines how the unconscious processes involved in melancholia are an attempt to deal with internal conflict arising from opposing feelings of love and hate and the accompanying guilt over angry or aggressive impulses. Ambivalence is an element of every love relationship but in depression, the hostile feelings are unconscious, they have been repressed and are redirected towards the ego. The nature of the attacks varies but it often takes on a punitive or sadomasochistic quality. Generally, it can be said that the power of the superego is linked to the severity of the depression and in its most destructive form can lead to self-harm and suicide. Freud points out that the ego can only kill itself if it treats itself as an object and in doing so, splits off aggressive and murderous impulses that are then directed towards the self. A pull towards suicide in the context of loss can also represent a way of seeking continued proximity to the lost object and be an attempt to resolve unbearable pain and fears of disintegration triggered by grief.

Freud identifies a narcissistic aspect to depression because of the extent to which it involves the sufferer turning away from object relating and withdrawing into the self. The negative internal relationship between the ego and superego forms a vicious circle that means that an adjustment to loss is unable to proceed; hence Freud came to regard melancholia as a pathological form of mourning.

A Case of Frozen Grief

Mr R had been suffering from depression for over 12 months when he was referred for psychotherapy. He had originally been treated at home by the crisis team because of persistent suicidal ideation. Antidepressant medication had helped him to some extent but he remained withdrawn from his wife and children and had been unable to return to work.

When he attended for the psychotherapy assessment the therapist was struck by the detached and matter-of-fact account he gave of his father’s death two years previously. His father had been rushed to hospital following a sudden collapse and the last few days of his life had been spent in an intensive care unit. The therapist tried to make a link between this traumatic event and his depression but Mr R was reluctant to consider the possibility, insisting that he had coped with it. However, he then told the therapist that his memory of his father was fixed on those last few days when he was lying in bed unconscious, attached to tubes. He was troubled by this and wished he could recover happier memories of his father.

During the second assessment consultation Mr R became tearful when the therapist commented that with the loss of his good memories of his father, it was as if he had not only lost his father physically but had lost him in his inner world as well. This was the first time since his father’s death that he had shed tears and he then described how as the eldest son he had taken on the role of supporting his mother in her grief. It became clear that Mr R had been unable to mourn himself and that he was living in a state of frozen grief. It also emerged that he had felt unable to live up to his father’s high expectations and doubted his own capacities as a result. As a consequence, along with love and respect for his father, he harboured strong feelings of resentment.

Mr R embarked on a course of weekly therapy in which he was gradually able to acknowledge and express painful feelings. At the same time, he became aware of his own ageing and mortality. These sessions were often exhausting for him and he became anxious that the therapy was making him worse. He started to miss sessions and might well have broken off treatment but was helped to continue with the encouragement of his psychiatrist.

About four months into the therapy he arrived for a session in a more animated state than usual and immediately spoke of a period of his childhood when he and his father used to go fishing together. These trips had been enjoyable for both of them and the recovery of these memories was a relief to him. Following on from this it became possible to explore in more detail the negative aspects of their relationship linked to his father’s tendency to put him down. This had intensified after he started secondary school and for a long period, he barely spoke to his father. It seemed to the therapist that he had been shutting his father out of his mind in a similarly angry way following his death. With the therapist’s help, Mr R began to understand that he had internalised his father’s undermining of him in the form of the relentless self-denigration he suffered from.

As therapy progressed, Mr R came to recognise that while his father could be rigid and domineering, he also had anxious and insecure traits. In turn, Mr R became less harsh on himself and his mood and energy gradually lifted.

The case of Mr R illustrates the link between depression and a difficulty in dealing with ambivalent feelings, particularly aggression. The nature of the relationship with his father had offered little opportunity for his angry feelings to be safely expressed and detoxified. The work of mourning his loss and integrating his hostile feelings took place in the therapy.

The Neurobiology of Attachment

It used to be thought, and sometimes still is, that a ‘reactive’ type of depression which arises in response to life events like Mr R’s can be differentiated from a more biological or ‘endogenous’ form of depression. But human psychology and neurobiology are inextricably linked. The systems that relate to bonding and attachment are particularly important in understanding the origins of affective disorders. The neuroscientist, Jaak Panksepp who pioneered the field of affective neuroscience has hypothesised that depression emerged in the course of evolution as an adaption that promotes survival through conserving the energy of infant mammals when separation distress becomes unduly prolonged [8].

The field of affective neuroscience is focussed on the basic emotional operating systems in the brain which we share in common with other mammals and which have the power to override higher cerebral processes. These are implicated in many of the psychiatric disorders and in depression and anxiety, it is the panic/grief system that is most powerfully implicated. Experiences of loss, separation and rejection all set in motion a cascade of neurobiological changes that involve, among others, the oxytocin, opioid and dopamine systems. Disruptions to these are associated with many of the symptoms seen in affective disorders and may help explain why these disorders are so common [9].

The significance of disrupted attachment is confirmed in research that shows that the experience of a major loss in childhood is associated with an increased risk of depression later in life [10]. Early childhood loss is also associated with bipolar disorder [11] and panic disorder [12].

The long-term vulnerability that arises through adverse childhood experiences arises, at least in part, as a result of neuroendocrine changes involving the hypothalamic–pituitary–adrenal axis. These alter the stress response of the developing brain in a way that predisposes to depression and anxiety in later life. Other effects that have been demonstrated include changes in the hippocampus, amygdala and orbitofrontal cortex [13]. In contrast, the experience of good relationships that lead to secure attachment patterns can confer some protection, which is why John Bowlby regarded attachment as the ‘bedrock’ of human psychology [14].

Childhood experiences of attachment give rise to internal working models of relationships [15]. Interactions with caregivers, in particular the quality of maternal attunement and mirroring, influence the development of neural networks involved in affect regulation. This direct effect on brain structure and functioning has been demonstrated using neuroendocrine markers and fMRI studies [16]. This evidence confirms psychoanalytic theories about the importance of early emotional containment and explains why when containment is lacking there is an impaired ability to recognise and regulate feelings.

A Case Involving Early Life Loss

Mrs H was in her early thirties when she started psychotherapy. Four years previously she discovered that her husband was having an affair with his former girlfriend. She had only been married to him for a few years and was profoundly shocked by the revelation and began to suffer from anxiety and depression. After he left her, her functioning deteriorated rapidly and she was admitted to hospital for a brief period having been found in a distressed and confused state standing by the edge of a motorway bridge near her home.

Once the divorce was finalised, she thought she would be able to move on with her life but this did not happen. Her anxiety levels increased and she became convinced that her friends were fed up with her for being so stuck. These thoughts were feeding her low self-esteem and causing her to isolate herself. She started to experience panic attacks and increasingly found it hard to leave the house. She could not understand why she was unable to move on with her life, particularly as she no longer wished to be reunited with her husband.

The psychotherapy assessment revealed that her early life experience was an important contributing factor in her difficulties. She was the eldest of two children and when she was about three years old, her mother developed post-natal depression following the birth of her brother. It was severe enough for her mother to be hospitalised for a time. It seemed that during this period she received little attention from either her father or the aunt who helped the family out. If she did get attention she was made to feel she was being a nuisance and that her baby brother took precedence. As a result she felt intensely lonely and recalled crying herself to sleep.

Life at home improved when her mother returned but she experienced marked separation distress when she started school. It seemed that yet again she was being a nuisance and her feelings could not be tolerated. The therapist made a link between her recent experience of rejection by her husband and her emotionally traumatic separation from her mother as a child. Mrs H was then able to recognise that she was isolating herself now much as she had felt isolated then and that the anxieties she was experiencing now were in part associated with this much earlier period of her life.

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Jun 6, 2021 | Posted by in PSYCHOLOGY | Comments Off on Chapter 13 – Psychological Approaches to Affective Disorders
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