Angry (Guilt-Ridden) vs. Empty (Shame-Filled) Depressions

by Martha Stark, MD / Faculty, Harvard Medical School

 

I make a critically important distinction between angry (guilt-ridden) and empty (shame-filled) depressions.

 

Patients who are depressed are NOT always angry; nor are their depressions always a story about “anger turned inward.”

 

I conceptualize the difference between angry depressions and empty depressions as follows:

 

In order to understand angry depressions, I think in terms of the aggressive drive and the introjective pair “victimizer/victim.”  The victimizer introject resides in the superego; the victim introject resides in the ego.

 

The ego experiences guilt in relation to the critical and punitive superego; the superego experiences anger in relation to the bad and morally reprehensible ego.

 

Angry depressions are the province of classical psychoanalysis.  They are the result of excess aggression and are accompanied by excess guilt arising from conflict between superego and ego, conflict between victimizer and victim pathogenic introjects.

 

In order to understand empty depressions, I think in terms of the narcissistic need for perfection and the introjective pair “superior/inferior.”  The superior introject resides in the ego ideal; the inferior introject resides in the ego.

 

The ego experiences shame in relation to the demanding and perfectionistic ego ideal; the ego ideal experiences contempt in relation to the defective, inadequate, and flawed ego.

 

Empty depressions are the province of self psychology.  They are the result of an excess need for perfection and are accompanied by intense shame arising from conflict between ego ideal and ego, conflict between superior and inferior pathogenic introjects.

 

In this connection, I think about the Nobel Prize complex, an expression that Dr. Helen Tartakoff (1966) coined about a patient of hers who suffered from this syndrome – Dr. Harvey Shein, an extraordinarily gifted psychiatrist (and mentor of mine) who was the director of residency training at McLean Hospital (in Belmont, Massachusetts) in the 1970s.  In this syndrome, the goals are unrealizable and patients suffer terribly from their sense of themselves as a failure.  Ultimately and tragically, Harvey Shein suicided – perhaps because of his inability to realize his dreams…

 

This spotlighting of the discrepancy between ego ideal and ego is very similar to Edward Bibring's (1953) conceptualization of depression as the result of tension between narcissistic aspirations and the ego's awareness of its failure to live up to such aspirations.

 

The greater the discrepancy between the ego ideal and the ego, the greater the sense of shame.  The patient’s experience will be one of narcissistic mortification and humiliation because of her failure to fulfill her potential.

 

Bibring has been faulted by some for not taking into consideration the role of aggression in depression.  In truth, I think that Bibring was talking about empty depressions, depressions that do not involve excess aggression and guilt but an excess need for perfection and intense shame.

 

Let me hasten to add that patients can of course suffer from both angry (guilt-ridden) depression and empty (shame-filled) depression.

 

In any event, whereas the patient with an angry depression experiences herself as “doing bad things,” the patient with an empty depression experiences herself as “not being good enough.”

 

In the developmental history of the depressive, we often hear that the parent responded to the child’s needs – whether “age-appropriate” or “excessive” – in guilt‑provoking and shame‑inducing ways.

 

With respect to the child's (age-appropriate) aggressive drives, the parent was often judgmental and moralistic, arbitrarily authoritarian, harshly punitive, and scathingly critical.

 

The parent was not able to recognize and respond to the child's anger in appropriate, helpful ways.

 

The parent did not provide gentle but firm limits, that is, benevolent containment.  Instead, the child was sharply reprimanded and made to feel that she was bad for being angry.

 

With respect to the child’s (age-appropriate) narcissistic needs, the parent often responded in ways that induced shame in the child.

 

For example, the child's wish to show herself off proudly to her parent for the parent’s approval and admiration – that is, the child's developmentally appropriate exhibitionism – might have been met with scorn.

 

The child was made to feel shame, made to feel like a failure, inadequate, defective, worthless, and never quite good enough.

 

The parent was relentlessly demanding – and never satisfied.

 

The child was given the very clear message that she did not measure up to the parental standards of excellence and was therefore inferior.

 

In sum, patients who, as adults, are suffering from depression often have a history of having had their “infantile strivings” traumatically frustrated by guilt-provoking and/or shame-inducing parents who made the child feel bad about herself.

 

Conclusion

 

On the one hand, angry depressions speak to the presence of excess aggression and unconscious intrapsychic conflict between victimizer introject (in the superego) and victim introject (in the ego).  Such depressions are characterized by anger, guilt, and a sense of the self as bad and morally reprehensible.

 

Interestingly, angrily depressed patients often have a wish to confess, to expose themselves as bad, and to be punished (as if in order to assuage the guilt they feel because of their badness).

 

On the other hand, empty depressions speak to the presence of a desire for perfection and unconscious intrapsychic conflict between superior introject (in the ego ideal) and inferior introject (in the ego).  Such depressions are characterized by emptiness, despair, shame, and a sense of the self as defective, inferior, and worthless.

 

Patients with empty depressions often have a wish to conceal and to keep hidden; they have an intense need to avoid exposing themselves and being found out.

References

Bibring, E. (1953).  The mechanism of depression.  In P. Greenacre (Ed.), Affective disorders.  New York, NY:  International Universities Press.

Tartakoff, H. (1966).  The normal personality in our culture and the Nobel Prize complex.  In R. M. Lowenstein, L. M. Newman, M. Schur, et al. (Eds.), Psychoanalysis: A general psychology, essays in honor

of Heinz Hartmann.  New York, NY:  International Universities Press.

© 2020  Martha Stark, MD ~ Founder / CEO, SynergyMed for MindBodyHealth ~ 617.244.7188 ~ MarthaStarkMD@HMS.Harvard.edu


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