Relation to Depression 与抑郁的关系 Closely related to this formulation is Schwartz's view of the paranoid-depressive continuum (1963,1964).A notion basic to the continuum is that of responsibility, the depressive side characterized by self-reference in regard to responsibility, and the paranoid side by object-reference. He suggests that along with the Kleinian view of the introjection of good and bad objects, there is also an introjection of feelings of blame or responsiblity. The child may experience deprivation as related either to himself, to the mother, or to both. Insofar as he assumes the responsibility for his own deprivation, he develops the rudiments of the depressive orientation. If the deprivation is experienced as deriving from an external source over which the child has no control and for which he is not responsible, he develops the basis for a paranoid orientation. Klein's view of depression involves the guilt and remorse over destructive feelings directed to the bad mother insofar as they also injure the good mother. The notion of responsibility is implicit in this formulation, in that guilt and remorse imply it. In the paranoid position, however, there is no concept responsibility, guilt, remorse, or anything except feelings referred to external objects. 与这一提法密切相关的是施瓦茨的“偏执-抑郁连续统”观(1963、1964)。连续体的基本概念是责任，抑郁的一面以自我参照为特征，偏执的一面以客体参照为特征。他认为，除了克莱因学派对好坏客体的内摄性观点外，还有一种责备或责任的感觉的内摄。孩子可能会经历与自己、母亲或两者相关的剥夺。只要他承担起自己被剥夺的责任，他就初步形成了抑郁的倾向。如果这种剥夺来自于孩子无法控制的外部来源，而他又不需要为此负责，那么他就形成了偏执倾向的基础。克莱因对抑郁症的看法涉及到对坏母亲的破坏性情感的内疚和悔恨，因为它们也伤害了好母亲。责任的概念隐含在这一提法中，在其中内疚和悔恨意味着责任。然而，在偏执心位，没有责任、内疚、悔恨或任何概念，除了指外部对象的感觉。 Schwartz substantially follows the point of view laid down by Sullivan, namely, that the paranoid person is faced with his own lack and his own unimportance or insignificance. His delusion is a denial of this intolerable idea and an attempt at compensation. Deprivation is interpreted as meaning that he does not matter to other people. His insignificance is not due to something that he has done or something for which he is responsible, but rather is due to the fact that there is nothing about him which has any value to others. The sense of inferiority and lack of worth is based on a narcissistic fixation which is related to a narcissistic wound suffered in early infancy. Schwartz comments as follows: 施瓦茨基本上遵循了沙利文的观点，即，偏执的人面对自己的不足，自己的不重要或不重要。他的妄想是否认这种不可容忍的想法，并试图进行补偿。剥夺被解释为他对别人不重要。他的渺小不是因为他做了什么或他应该为之负责，而是因为他身上没有任何对他人有价值的东西。自卑感和缺乏价值感是建立在一种自恋固着的基础上的，这种自恋固着与幼年时期所受的自恋创伤有关。施瓦茨评论如下: Generally speaking,the hurt of infancy can be of two kinds:hurts of commission [commission或为笔误，可能应为omission] convey parental displeasure,while hurts of omission convey parental abandonment. The relationship of these hurts to the constructs of "badness" and "insignificance" respectively are evident. Badness is a concept which is introjectible in terms of self-reference; the child can come to think of himself as bad. But meaninglessness and insignificance are not introjectible in self-referential terms, since the self is tautologically meaningful and significant to the self. Thus the internalization of feelings of insignificance must be in terms of object-reference. The denial of such feelings can only come from others. Hence the intense need for importance in the eyes of others, the willingness to settle for persecutory attention, and the preferential use of projection as a defensive technique(1963, pp.352-353). 一般来说，婴儿期的伤害可分为两种:代表父母不满的忽视伤害，代表父母遗弃的忽视伤害。这些伤害与“坏”和“不重要”的建构之间的关系是显而易见的。坏是一个在自我参照方面是内摄性的概念;这孩子会认为自己是坏的。但是无意义和不重要在自我指涉的术语中并不是内摄性的，因为自我对自我来说是同义反复的有意义和重要的。因此，无足轻重的感觉的内化必须以客体参照的方式进行。这种感觉的否定只能来自别人。因此，在他人眼中得到重视的强烈需求，愿意接受被害注意，并优先使用投射作为一种防御手段(1963年，第352-353页)。 The patient thus needs to secure recognition from others, and this need makes him exceedingly hypersensitive to the responses of others, and also extremely vulnerable to them. Because his ability to form relationships to other people in the real community is impaired, the paranoid forms what Cameron(1959) has described as a "paranoid pseudocommunity." The paranoid pseudocommunity has relevance and significance by reason of its relationship to him as the central figure; the pseudocommunity has the specific function of affirming the patient's significance and relevance to other people. Unlike the autistic schizophrenic who denies the meaningful existence of others, the paranoid in fact creates others in a meaningful context in which they have a special relationship to him. As long as the paranoid delusional system is functioning adequately the patient is able to carry on without undue impairment. But as the vulnerability to challenge in the delusional system is increased, the patient becomes more distrusting, suspicious, guarded and even angry. 因此，病人需要得到别人的认可，这种需要使他对别人的反应极度敏感，也使他对别人的反应极度脆弱。因为他与真实社区中其他人建立关系的能力受到了损害，偏执狂形成了Cameron(1959)所说的“偏执伪共同体”。偏执伪共同体与他作为中心人物的关系具有相关性和意义;伪共同体的特殊功能是确认患者的重要性和与其他人的相关性。与自闭症精神分裂症患者否认他人存在的意义不同，偏执狂实际上在一个有意义的情境中创造了他人，他们与他有着特殊的关系。只要偏执妄想系统功能正常，病人就能正常生活而不受损害。但随着妄想症系统对挑战的脆弱性增加，患者变得更加不信任、怀疑、警惕甚至愤怒。 Closely related to this view is Salzman's view of paranoia, in which he sees the denial of low self-esteem as being central to the syndrome(Salzman, 1960). He sees the primary development in the denial of low self-esteem as the grandiosity of the paranoid, which then secondarily produces rebuffs from the environment. The projective transfer of blame through the delusional structure is then organized in a defensive manner to deal with this threat of the primary grandiosity. It is not always clear that grandiosity plays such a primary role in all cases. However, the effort to compensate for the sense of inferiority or the loss of self-esteem seems to be a relatively constant feature. 与这一观点密切相关的是萨尔茨曼的偏执症观点，他认为否认低自尊是该综合症的核心(萨尔茨曼，1960)。他把否认低自尊的主要发展看作是偏执者的夸大，然后再从环境中产生断然拒绝。通过妄想结构的投射性的责备转移，然后被以防御的方式组织起来，以应对这一对基本夸大的威胁。并不总是清楚的是，在所有情况下，夸大都扮演着如此重要的角色。然而，努力弥补自卑感或自尊的丧失似乎是一个相对恒定的特征。 In Modlin's(1963) study of paranoid states in women, he found that in those with adequate life adjustment and satisfactory marital relationships,a specific stress precipitated the patient into a phase of depression which was expressed in the sense of loss and reduction of self-esteem. This was accompanied by significant alterations in the husband-wife relationship, and an actual reduction in the frequency, or complete cessation of, sexual intercourse. Regression followed on the loss of self-esteem and projective delusional mechanisms appeared. Successful treatment of these women focused on the reassertion of the woman's feminine social role, on the regaining of her lost self-esteem, and finally on the reestablishment of the marital relationship. 在Modlin(1963)对女性偏执状态的研究中，他发现在那些有足够的生活适应能力和令人满意的婚姻关系的女性中，一种特定的压力使患者进入抑郁状态，表现为自尊的丧失和降低。与此同时，夫妻关系也发生了显著的变化，性交的频率实际上降低了，或者说完全停止了。随自尊的丧失而来的是退行，投射性妄想机制出现。对这些女性的成功治疗集中在重新确立女性的社会角色，恢复她失去的自尊，最后重建婚姻关系。 The relationship between depression and paranoia has also been stressed by Allen (1967). These two states may substitute for one another, and in the treatment of a paranoid patient one frequently finds an underlying depression. The depression is primary and the paranoia is an attempt to deal with the implicit suicidal impulse. The paranoid patient is extremely sensitive to the suicidal impulse, and can deal with it only by projecting it. When the impulse becomes too strong to be handled by mechanisms of denial and projection,a serious suicide attempt may be made. Thus the paranoid defenses take their place alongside the manic defenses as major strategies to avoid and diminish the pain of depression and lowered self-esteem. The paranoid resorts to mechanisms of denial and projection, while the manic resorts to mechanisms of denial and flight into activity. At their pathological extremes, the paranoid psychosis and the manic-depressive psychosis are often difficult to differentiate. 抑郁症和偏执症之间的关系也被埃伦(1967)强调过。这两种状态可以相互替代，在治疗偏执型病人时，常常会发现潜在的抑郁。抑郁症是主要的，而偏执症是一种试图对付隐性自杀冲动的行为。偏执患者对自杀冲动极其敏感，只能通过将其投射出去来应对。当这种冲动变得过于强烈，无法通过否认和投射的机制来控制时，就可能发生严重的自杀企图。因此，偏执防御取代了躁狂防御成为避免和减少抑郁和降低自尊的痛苦的主要策略。偏执狂求助于否认和投射的机制，而躁狂者求助于否认和投身活动的机制。在极端的病理状态下，偏执型精神病和躁郁型精神病往往难以区分。 In discussing the sources of anxiety in paranoid schizophrenics, Searles(1965) has pointed out that the paranoid sees his world as filled with sinister meanings and with malevolent intentions toward himself. He cannot ignore the persecuting figures because they actually represent the projection of his own unconscious feelings and attitudes, and if he renounces his concern over them, he is in fact renouncing part of himself. Yet he cannot come to terms with them because he cannot accept the abhorrent qualities that he has projected onto them. The alternatives are desperate because the price is cast in terms of loss of identity and disintegration of the self. The psychotic person seeks safety and protection by placing his self outside all experience and activity. It thus becomes an empty vacuum which is constantly threatened with being overwhelmed by the malevolent reality outside. Alongside the dread, however, there is an intense longing for participation in the world. Thus the deepest longing of the self becomes its greatest weakness and the source of its greatest dread, since to participate in reality is to run the risk of obliteration, of what Laing has called "engulfment"(Laing,1965a). 在讨论偏执型精神分裂症患者焦虑的来源时，Searles(1965)指出，偏执型精神分裂症患者认为他的世界充满了险恶的含义，并对自己怀有恶意。他不能忽视这些迫害性的人物，因为他们实际上代表了他自己无意识的情感和态度的投射，如果他放弃对他们的关注，他实际上是放弃了他自身的一部分。然而，他无法与他们达成协议，因为他无法接受他投射到他们身上的可憎的品质。其他的选择是绝望的，因为代价是身份的丧失和自我的瓦解。精神病患者通过将自己置于所有经验和活动之外来寻求安全与保护。因此，它成为一个空虚的真空，不断受到来自外部的恶意现实的威胁。然而，除了恐惧，还有一种强烈的参与世界的渴望。因此，自我最深处的渴望成为它最大的弱点和最大恐惧的根源，因为参与现实就是冒着毁灭的风险，也就是莱恩所说的“吞噬”(莱恩，1965)。 Thus the basic issues of paranoia and depression lie very close together and in fact, we might think, share some of the same genetic roots. On the clinical front, the therapist is constantly faced with the problem of helping the paranoid patient to surrender his delusions, to face and to bear and hopefully to resolve the underlying depression which is threatening and which involves the loss of self and of all personal value. Often the expression of what Laing calls the "false self' is apparently normal—the obedient child, the ideal husband, the industrious worker. But in this compliance the individual does not have a sense of his own autonomy, and thus is unable to experience his separateness on the one hand, or his relatedness on the other, in a normal way. The sense of reality of his own selfhood is bound up in the other, and he is thus placed in a position of ontological dependency on the other. That dependency on the other for one's very existence becomes threatening indeed, so that the slightest indication of hostility or rejection from the other becomes a threat to the very existence of one's self. The alternatives are utter detachment and isolation, and the struggle becomes a struggle for one's lifeblood, for one's very survival. And Laing adds: 因此，偏执狂和抑郁症的基本问题是紧密联系在一起的，事实上，我们可能会认为，它们有着相同的发生根源。在临床方面，治疗师经常面临的问题是帮助偏执的病人放弃他的幻想，去面对和忍受，并希望能解决潜在的抑郁，抑郁一种威胁，它涉及到自我和所有个人价值的丧失。莱因所称的“虚假自体”的表现形式通常很明显是正常的——听话的孩子，理想的丈夫，勤奋的工人。但在这种顺从中，个体没有自己的自主性，因此无法以正常的方式体验他的独立性，或他与他们的关联性。他的自我本体论的现实感是与他者紧密联系在一起的，因此他就处于一种依附于他者的本体论地位。依赖他人来维持自己的存在确实变得具有威胁性，因此来自他人的最轻微的敌意或拒绝就会成为对自我存在的威胁。另一种选择是完全的分离和孤立，而斗争变成了一场为生命而斗争，为生存而斗争。莱恩补充道: Hatred is also necessarily present, for what else is the adequate object of hatred except that which endangers one's self? However, the anxiety to which the self is subject precludes the possiblity of a direct revelation of its hatred, except, as we shall see later, in psychosis. Indeed, what is called psychosis is sometimes simply the sudden removal of the veil of the false self, which had been serving to maintain an outer behavioral normality that may, long ago, have failed to be any reflection of the state of affairs in the secret self. Then the self will pour out accusations of persecution at the hands of that person with whom the false self has been complying for years(1965a, pp.99-100). 仇恨也必然存在，因为除了危及自身的之外，还有什么是足够的仇恨对象呢?然而，自我所受的焦虑排除了直接显露其憎恨的可能性，除非，正如我们将在后面看到的，在精神病中。事实上，所谓的精神错乱有时只是突然揭开虚假自我的面纱，而虚假自我一直在维持一种外在的正常行为，而在很久以前，这种正常行为可能并不能反映出秘密自我的状态。然后，这个自我就会对那个多年来一直遵从虚假自我的人发出迫害的指控(1965a，第99-100页)。