The Perplexing Notion of Depression as “Anger Turned Inward”

An attack-self coping response to shame is prominent in depression.

The word “depression” is not sharply defined. When someone claims to be depressed, we may vaguely imagine a level of unhappiness ranging from mild dejection to deep despondency.

A mainstay in the understanding of depression since the Freudian era is the notion that depression represents anger that is directed toward the self or turned inward. This view assumes that the depleted energy of depressed people is due to anger being shifted internally, and, thus, therapists have searched for methods to release the anger of their depressed patients rather than recognize this anger as a response to other emotions (Nathanson, 1994).

In “Mourning and Melancholia,” which some consider Freud’s (1917/1957) classic paper on depression, melancholia (depression) is differentiated from mourning (grief) based on the supposition that in melancholia, anger is directed toward the self in the form of self-reproach and self-attack, in contrast to mourning, where anger is directed toward the lost love object. According to Freud, early childhood loss results in the child’s internalization of ambivalent feelings toward the lost parent that become fused with the child’s ego, later leading to a vulnerability to experience self-directed anger when loss is encountered.

Echoing Freud’s view of depression as involving aggressive impulses turned against the self, Melanie Klein’s (1930) exaggerated notions of depression related it to persecution as a result of the imagined destruction of the love object by the patient’s envy and aggression, and an identification with the imagined damaged object. The syndrome of depression, including symptoms involving self-attack, is considered to be an attempt by one’s ego to spare a love object from harm: for example, by high levels of internal hostility or rivalry, or as an attempt to spare the love object by sympathizing, sharing, and suffering the imagined pain inflicted upon it (Taylor & Richardson, 2007).

The early foundation of Cognitive Behavioral Therapy (CBT) also links depression with anger turned against the self. In his early studies of depression, Aaron Beck (1963, 1964, 1972) found that depressed patients engage in self-blame, self-criticism, and self-dislike to the point of self-disgust and self-hatred. Aligned with Freud’s suppositions about the contribution of emotional memories in depressive disorders, Beck posited that early experiences lead to the development of negatively biased self-referent ideas or schemas (a negative cognitive triad) that may remain latent until activated in adulthood by loss. According to Beck, the thoughts of depressed patients in interpersonal situations are self-derogatory: Others appear to be indifferent; low self-regard is applied to personal attributes, acquisitions, and career performance; and, self-criticisms, self-condemnation, and negative comparisons with others are present.

Although self-derogatory cognitions represent typical shame-related attacks against the self, cognitive behavioral therapists, along with their psychoanalytic colleagues, generally do not recognize shame in the pathology of depressed patients, nor focus on shame in the treatment of depression. Indeed, many symptoms of depression directly involve established coping responses to shame: withdrawal (e.g., hypersomnia, not wanting to be in the presence of others or engage in activities); avoidance (e.g., drug and alcohol abuse); attack-other behaviors (e.g., irritable reactions and rages at others or blaming others for causing the negative mood); and attack-self responses (e.g., self-injurious behaviors and suicide attempts). The attack-self coping response to shame is particularly prominent in depression, and when persistent shame and enduring fear arise in close proximity, the resulting guilt will be experienced as anger that is turned against the self (Nathanson, 1994).

Shame is often central in the experience of depression (Helen Block Lewis, 1987). Why is shame a prominent component in depressive syndromes? One reason is that depression can be the result of the attenuation of positive emotions, whether caused by internal or external factors. Anything which interrupts positive emotions, without completely reducing it, will activate shame (Tomkins, 1962). Some researchers speculate that depressive symptoms are the result of shame experiences in interpersonal contexts that activate maladaptive cognitive-affective spirals (Thompson & Berenbaum, 2006). In shame-based depressions, patients look both sad and defeated, interpreting what they feel as personal inadequacy (Tomkins, 1963).

Many psychologists have long accepted that chronic shame appears as depression (Morrison, 1977; Wurmser, 2015). Nonetheless, the tendency of people to hide shame, in treatment as in their lives, may lead therapists to overlook shame as underlying depressive symptoms (Morrison, 1987). Recent studies have linked depression to central and traumatic memories of shame, indicating that early emotional memories of feeling safe and nurtured within the family can buffer the depressive effects of central shame experiences, but are not as protective in the case of people suffering from traumatic memories of shame (Matos, Pinto-Gouveia, & Duarte, 2013, 2015).

All depressions, whether triggered initially by shame or other causes, can create further shame and distress that interact in a negatively spiraling cycle. As a result, the motivation to accomplish things and have fun becomes increasingly difficult. This misguided cultural perception and the judgments that imply one can simply overcome depression may become an additional source—from both self and others—of shame in anyone suffering from this condition.

The divided self in shame-based depressions that results in self-attacking behavior, alongside introspective or self-soothing behaviors, enables those who suffer to explore an important upside: Depression turns attention inward in ways that can promote resignation and acceptance (Izard, 1977; Lazarus, 1991). Interestingly, the facial expression associated with sadness signals a need for comfort and enables others to become aware of that need (Ekman, 2003). Moreover, the experience of depression provides an opportunity to consider the necessity of revising one’s objectives and strategies for the future, and it may lead us to grapple with the existential question, “Who am I?” (Henretty, Levitt, & Mathews, 2008).

This post is excerpted in part from The Upside of Shame: Therapeutic Interventions Using the Positive Aspects of a "Negative' "Emotion.

Mary C. Lamia, Ph.D., - Website -

References

Beck, A. (1964). Thinking and depression II: Theory and therapy. Achieves of General Psychiatry, 1,561-571. doi:10.1001/archpsyc.1964.01720240015003

Beck, A. T. (1972). Depression: Causes and treatment.Philadelphia, PA: University of Pennsylvania Press.

Ekman, P. (2003). Emotions revealed: Recognizing faces and feelings to improve communication and emotional life. New York, NY, US: Times Books/Henry Holt and Co.

Freud, S. (1957). Mourning and Melancholia. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud, Volume XIV (1914-1916): On the history of the psycho-analytic movement, papers onmetapsychology, and other works (pp. 67-102). London: Hogarth Press. (Original work published 1917)

Henretty, J., Levitt, H., & Mathews, S. (2008). Clients’ experiences of moments of sadness in psychotherapy: A grounded theory analysis. Psychotherapy Research, 18, 243–255.

Izard, C. (1977). Human emotions. New York, NY: Plenum Press.

Klein, M. (1930). The importance of symbol formation in the development of the ego. International Journal of Psychoanalysis, 11, 24-39.

Lazarus, R. (1991). Emotion and adaptation. New York, NY: Oxford University Press.


Lewis, H. B. (1987). Shame and the narcissistic personality. In D. L. Nathanson (Ed.), The many faces of shame (pp. 93-132). New York, NY: Guilford.

Matos, M. Pinto-Gouveia, J., & Duarte, C. (2013). Internalizing early memories of shame and lack of safeness and warmth: The mediating role of shame on depression. Behavioural and Cognitive Psychotherapy, 41, 479-493.

Matos, M. Pinto-Gouveia, J., & Duarte, C. (2015). Constructing a self-protected against shame: The importance of warmth and safeness memories and feelings on the association between shame memories and depression. International Journal of Psychology and Psychological Therapy, 15, 317- 335.

Morrison, A. (1987). The eye turned inward: Shame and the self. In Donald L. Nathanson, (Ed.), The many faces of shame (pp. 271-291). New York, NY: Guilford Press.

Nathanson, D. L. (1992). Shame and pride: Affect, sex, and the birth of the self. New York, NY: W.W. Norton

Nathanson, D. L. (1994). Shame, compassion, and the “borderline” personality. Psychiatric Clinics of North America, 17, 785-810.

Nathanson, D. L. (1994). The case against depression. Bulletin of The Tomkins Institute, 1, 1-5.ISSN 1075-6930.

Taylor, D. & Richardson, P. (2007). The psychoanalytic/psychodynamic approach to depressive disorders. In Glen O. Gabbard, Judith S. Beck, & Jeremy Holmes (Eds.). Oxford textbook of psychotherapy(pp. 127-136). New York, NY: Oxford University Press.

Thompson, R. J. & Berenbaum, H. (2006). Shame reactions to everyday dilemmas are associated with depressive disorder. Cognitive Therapy Research, 30: 415-425.

Tomkins, S. S. (1962). Affect imagery consciousness. Vol I: The positive affects. New York, NY: Springer

Wurmser, L. (2015). Primary shame, mortal wound and tragic circularity: Some new reflections on shame and shame conflicts. International Journal of Psychoanalysis,96,1615-1634.