Relation of Paranoia and Depression to Aggression 偏执和抑郁与攻击性的关系 Both depression and paranoia involve a partial regression and dedifferentiation. The depressed patient and the paranoid are both dealing with the management of aggressive impulses. The depressed patient wards off aggressive impulses toward the loved object and translates them into an intensification of superego aggression. It is as if the ego protects itself from expressing aggression and destroying the loved object by projecting the aggression onto an internal persecutor—a sort of intrapsychic projection or externalization(Meissner,1971b). The paranoid projection places the aggression in an external object instead of an internal object(introject). The depressive position represents a higher level of functioning, since it implies greater mastery of, and tolerance for, the aggression. But the regressive stance does not allow the ego to master the internalized conflict. The inner-directed hostility remains destructive, however, and the ego runs the risk of further regression toward an undifferentiated state. The aggressive conflict which was decathected externally is recathected internally in the conflict between superego and ego. Thus the depressive position internalizes the aggressive conflict which the paranoid position deals with by externalization (Katan,1969). 抑郁和偏执都涉及部分退行和去分化。抑郁症患者和偏执者都在处理攻击性冲动的管理。抑郁患者会抑制对所爱客体的攻击冲动，并将其转化为超我攻击的强化。这就好像自我通过把攻击投射到一个内在的迫害者身上，来避免自己表达攻击和摧毁所爱客体——这是一种精神内部投射或外化(Meissner,1971b)。偏执投射将攻击放置在外部客体而不是内部客体(内摄物)身上。抑郁心位代表着更高层次的功能，因为它意味着对攻击的更强的控制力和对容忍力。但是退行的姿态不允许自我掌握内化的冲突。然而，内指向的敌意仍然是破坏性的，而自我则有进一步退行到无分化状态的风险。被外部撤离的攻击冲突，在超我与自我的冲突中得到内部重新连接。因此，抑郁心位将偏执心位通过外化处理的攻击性冲突内化了(Katan,1969)。 There have been a number of attempts in the literature to deal with the relationship between paranoid and depressive states. Salzman's(1960) treatment of paranoia is of interest in this regard in that it deals with it primarily as a response to an underlying depression. He sees it as a delusional attempt to secure certain and universal acceptance. The primary step in the paranoid process is the development of a grandiose, if not messianic, self-concept, which is a direct attempt to deny and compensate for the underlying impoverishment of self and the depressive diminution of self-esteem. The primary grandiosity and its attendant narcissism produce rebuffs from the environment. The consequent threat to self-esteem is dealt with by secondary defensive externalizations, projections, and transfer of blame to external agents. Paranoia appears in this light as an alternate solution to the manic defense. 在文献中已经有许多处理偏执和抑郁状态之间关系的尝试。萨尔茨曼(1960)对偏执的治疗在这方面很有趣，因为它主要是把它作为对潜在抑郁的一种反应来处理。他认为这是一种妄想尝试，试图获得一定和普遍的接受。偏执过程中的首要步骤是发展一种夸大的，如果不是救世主式的，自我概念，这是一种直接的尝试，来否认和弥补潜在自我贫乏和自尊的抑郁的减少。最初的夸大和随之而来的自恋会遭到周围环境的拒绝。随之而来的对自尊的威胁通过次级防御外化、投射，并将责任转移到外部因素来处理。在这种看法中，偏执作为躁狂防御的替代解决方案出现。 In this formulation the grandiosity is the primary paranoid response and other defensive maneuvers are secondary. It is not always so clear, however, that paranoid grandiosity is so primary that the other manifestations of the syndrome must be regarded as consequent on it. It seems overly simple to regard the patient's projective defenses as serving only to protect his grandiosity. Moreover, while grandiosity is part of the classic paranoid profile, it frequently enough plays a minimal, if not negligible, part in the patient's clinical picture. However, even if one qualifies the central role of paranoid grandiosity, the role of self-devaluation and low self-esteem in the development of paranoia must be taken into account. Even where the patient does not resort to the restitutive resource of paranoid grandiosity, his defensive stance may be seen as an attempt to salvage self-esteem. The essential technique is that of blaming, by which the patient absolves himself of responsibility for his deficiencies. 在这种理解中，夸大是主要的偏执反应，其他的防御策略是次要的。偏执夸大是如此基本，以致于必须将该综合症的其他表现视为它的结果，然而，这一点并不总是很清楚。把病人的投射性防御仅仅看作是为了保护他的夸大，似乎过于简单了。此外，虽然夸大是典型的偏执特征的一部分，但它在病人的临床表现中往往只占很小的一部分(如果不是微不足道的话)。然而，即使有资格成为偏执的中心角色，在偏执发展过程中，自我贬低和低自尊的角色也必须被考虑在内。即使在病人没有求助于偏执夸大的恢复性资源时，他的防御姿态也可能被视为试图挽救自尊。最基本的技巧是责备，藉此病人为自己的缺陷开脱责任。 It has commonly been observed that paranoid and depressive states substitute for each other, and that they are found in different phases of the course of the same patient. Allen(1967) has pointed out that paranoia and depression, moreover, are two sides of the same coin. He sees depression as primary and the paranoid position as a defense. He feels that every depression involves a suicidal impulse, however repressed or latent. Paranoia, then, is an attempt to deal with the suicidal impulse by projecting it onto the environment and dealing with it as an external threat. He feels that paranoids are extremely sensitive to the suicidal aspect of depression, and that when the impulse becomes too strong for mechanisms of denial and projection to handle, then a suicide attempt may be made. The degree of intensity of the underlying suicidal impulse can be gauged frequently by the degree of elaboration and systematization in the paranoid destruction. Schreber's elaborate systematizations and fantasies of world destruction are a case in point. Without feeling it necessary to think of depression always at a level of suicidal intensity, paranoia can be seen as an attempt to deal with self-destructive aggression. There is no reason to doubt that, where the restorative process reaches psychotic proportions, the underlying self-destructive impulses are suicidal in intensity. Paranoid mechanisms may, however, also come into play at less intense levels of self-preservation, where the issues are more in terms of preserving self-esteem. Suicidal issues are more psychotic than neurotic issues, as Frosch(1967) has suggested. We must also keep in mind that paranoid mechanisms and paranoid defenses can be operative in relatively normal, adaptive, or developmental contexts in which suicidal issues are negligible. 人们通常观察到，偏执和抑郁状态相互替代，而且它们出现在同一病人病程的不同阶段。Allen(1967)指出偏执和抑郁是同一枚硬币的两面。他认为抑郁是首要的，偏执是一种防御。他觉得每一次抑郁都包含着一种自杀的冲动，无论这种冲动是被压抑的还是潜伏的的。因此，偏执是一种试图通过将自杀冲动投射到环境中并将其作为外部威胁来处理的行为。他觉得偏执对抑郁症的自杀倾向非常敏感，当这种冲动变得太强烈，否认和投射机制无法控制时，就可能会发生自杀企图。潜在的自杀冲动的强度可以通过对偏执破坏的详细描述和系统化程度来衡量。史瑞伯[弗洛伊德分析过的著名偏执患者]对世界毁灭的精心系统化和幻想就是一个恰当的例子。没有必要认为抑郁总是处于自杀强度的水平，偏执可以被看作是一种对付自我毁灭性攻击的尝试。没有理由怀疑，当恢复过程达到精神病的程度时，潜在的自我毁灭的冲动是强烈的自杀倾向。然而，偏执机制也可能在较低程度的自我保护中发挥作用，在这种情况下，问题更多的是保护自尊。正如Frosch(1967)所说，自杀问题比神经质问题更具有精神病性。我们还必须记住，偏执机制和偏执防御可以在相对正常、适应性或发展性的环境中起作用，在这些环境中，自杀问题可以忽略不计。 In his reconsideration of the paranoid concept, Schwartz(1963,1964) focuses on what he calls the "paranoid-depressive existential continuum." The central notion to the continuum is that of responsibility. The depressive pole of the continuum is that in which the subject refers the responsibility for his discomfort to himself; the paranoid pole is that in which the subject refers his discomfort to an object. The paranoid position in this conception is akin to Klein's formulation in which the internal experience, whether pleasurable or unpleasurable, is referred to objects. Internal pleasure is referred to a good object and internal lack of pleasure to a bad one. The paranoid position, therefore, recognizes no concept of responsibility, or guilt, or remorse, but only feelings referred to the good or bad qualities of external objects or part objects. 在对偏执概念的重新思考中，施瓦茨(1963, 1964)着重于他所说的“偏执-抑郁存在连续统”。连续统的中心概念是责任。连续体的抑郁极是主体将自己的不适归咎于自己;偏执极是主体将他的不适归咎于客体。在这一概念中的偏执心位类似于克莱因的说法，在其中内部经验，无论是愉快的或不愉快的，都归于客体。内部愉悦被归于好客体，内部缺乏愉悦被归于坏客体。因此，偏执心位，不承认责任，内疚，悔恨，而只是把感受归于外部客体或部分客体的好的或坏的品质。 The paranoid is faced with his own inferiority and lack. He denies the intolerable idea of his own insignificance and shifts the responsibility for this elsewhere. He sees his deprivation as meaning that he does not matter to others because there is nothing in him that has any value to them. In this view, then, there is an underlying sense of inferiority and lack of worth—a form of narcissistic fixation and trauma—which the paranoid cannot internalize in self-referential terms, but only in terms of others. The denial of his significance comes from others. Thus, the essential aspects of the paranoid attitude include the underlying sense of worthlessness and insignificance, the inability to accept responsibility for these feelings, the incapacity to tolerate ambivalence and a consequent need to think in terms of absolutes. The paranoid maintains a constant need to find acceptance and recognition from others and is unable to accept himself as insignificant to them. 偏执者被迫面对自己的劣等和不足。他否认自己很渺小这种难以忍受的想法，并将责任转移到别处。他认为他的匮乏意味着他对别人不重要，因为他身上没有任何对别人有价值的东西。在这种观点中，有一种潜在的劣等和价值缺乏感——一种自恋的固着和创伤的形式——偏执者无法根据自己，只能根据他人内化。别人否认他的重要性。因此，偏执态度的基本方面包括潜在的无价值感和不重要感，无法为这些感觉承担责任，无法容忍矛盾心理，以及因此需要从绝对的角度思考。偏执者总是想要得到别人的接纳和认可，他们无法接受自己对他们来说是无足轻重的。 In her paper on manic-depressive states, Helene Deutsch (1965) reported on a lengthy analytic treatment of a woman who showed recurrent episodes of angry rebellion during the treatment. These passed directly into manic states without any noticeable depression. The patient's rebellious episodes were distinctly paranoid in character and the analyst was regarded as hostile, unloving, and persecuting. Deutsch remarks that this sort of paranoid element is present in all cases in which aggression appears as a constituent of the manic-depressive picture. The patient can fend off the guilt feelings associated with aggression by projecting the blame for this hatred onto the outside world. Thus the patient's own anger and hate can be considered as merely a response to ill treatment from others. The paranoia serves as a defense against the superego and the underlying depression. If the superego proved stronger than the defense, the patient would become depressed. 在她关于躁狂-抑郁状态的论文中，Helene Deutsch(1965)报告了对一个妇女漫长的分析治疗，该妇女在治疗期间表现出反复发作的愤怒反抗。这些都直接进入躁狂状态，没有任何明显的抑郁。病人的叛逆期在性格上明显是偏执的，而精神分析师被认为是敌对的、没有爱心的和迫害的。Deutsch指出，这种偏执因素存在于所有的案例中，在这些案例中，攻击性表现为躁狂-抑郁的一个组成部分。患者可以通过将这种憎恨的责任投射到外部世界，来抵御与攻击性相关的内疚感。因此，病人自己的愤怒和憎恨可以被看作是对他人虐待的反应。偏执是对超我和潜在抑郁的一种防御。如果超我被证明比防御更强大，病人就会变得抑郁。 Another of Deutsch's patients became severely depressed following the death of her husband but then developed the delusional idea that her husband was not dead. Her delusional system developed around the idea that her husband was not dead, but that he had become a cruel persecutor trying to terrify her and do her harm. The patient was able to detoxify the malignant introject, which led her into a severe depression, by the projection of aggressive impulses onto the object. The transformation of the depressive position into a paranoid position served a defensive purpose in that it preserved the ego from the annihilative force of the fatal introject. Deutsch的另一个病人在她丈夫死后变得严重抑郁，但随后产生了她丈夫没有死的妄想。她的妄想系统围绕着这样的想法发展:她的丈夫没有死，但他已经成为一个残酷的迫害者，试图恐吓她，伤害她。病人能够通过在客体上投射攻击冲动来排出有害的内摄，这内摄导致了她严重的抑郁。从抑郁心位到偏执心位的转变起到了防御的作用，因为它保护了自我，使其不受致命的内摄的毁灭性力量的影响。