Tsuda Hitoshi
Nagoya University: Center for Student Counseling, Department of Psychopathology and Psychotherapy, Graduate School, Faculty of Medicine.
Seishin Shinkeigaku Zasshi. 2005;107(12):1268-85.
In the current research concerning the relation between depression and personality a phenomenological, anthropological method and an empirical, statistical method coexist. Each of these methods has its own limitations. The latter is abandoning the classical endogenous-neurotic dichotomy without full considerations. It also tries to treat the personality as an objectively defined entity and it lacks insight into the fact that the "pre"-morbid personality is sometimes revealed "after" onset of the illness. Although the former has succeeded in establishing the concept of "Typus melancholicus," which is still of a clinical significance today, it is not sufficiently well developed to deal with patients having endogenous symptoms who show other types of personality. It also lacks the profound description on the domain of neurotic depression or depression with personality disorder. Typus melancholicus personality includes two components, not only as found in its original phenomenological arguments but also as suggested by the recent empirical research. The first component consists of the tendency to seek for a symbiotic relation with others and the intolerance of ambiguity. The excessive narcissistic cathexis to the "private self," rather than the "official self" (Matussek), can also be included here. The second component consists of the "orderliness" and the "hypernomic" identification with role identities. Typus melancholicus is brought about only when these two components are integrated into one personal structure and the contradiction between them remains not overt. In contrast, it can be considered that in such marginal types as the dependent anaclytic type, avoidant type and soft bipolar type, this contradiction is already overt. Although these marginal types show neurotic or personality disorder-like manifestations, it can be considered that the authentic domain of neurotic depression and the depression of personality disorder spreads outside of these marginal types. In this domain the depression in which the problems of object relations play a dominant role is important. It is worth taking into consideration the contrast between endogenous depression and depression associated with the problems of object relations when we decide therapeutic strategies. This contrast can be pointed out from the following three perspectives; the relation between subject and society, ambivalence, and the status of somatic symptoms. In the former, social elements play a limited role, constituting only the background conditions of patients, while in the latter patients' personal conflicts are closely intermingled with social elements. In the former the patients are almost unable to maintain ambivalent feelings so as to deal with reality and they rather adjust themselves to reality utilizing their syntonic personalities. The latter patients, on the other hand, have intense ambivalent feelings and are impacted when the negative side of the ambivalence predominates. In the former, pathological phenomena are located where somatic and psychological spheres are not yet divided, while in the latter metaphorical interpretations of somatic symptoms from the psychological contents are sometimes possible to a certain degree.
在当前关于抑郁症与人格关系的研究中,现象学、人类学方法与实证、统计学方法并存。这些方法各自都有其局限性。后者在没有充分考虑的情况下摒弃了经典的内源性 - 神经症二分法。它还试图将人格视为一个客观定义的实体,并且没有洞察到“病前”人格有时在疾病发作“后”才显现这一事实。尽管前者成功地确立了“抑郁型人格”的概念,这一概念至今仍具有临床意义,但它在处理具有内源性症状且表现出其他类型人格的患者时,发展还不够完善。它也缺乏对神经症性抑郁症或伴有人格障碍的抑郁症领域的深入描述。抑郁型人格包括两个成分,这不仅在其最初的现象学论证中有所发现,近期的实证研究也有所提示。第一个成分包括寻求与他人建立共生关系的倾向以及对模糊性的不容忍。对“私人自我”而非“官方自我”(马图塞克)的过度自恋投注也可包含在此处。第二个成分包括“有序性”以及对角色身份的“超规范”认同。只有当这两个成分整合到一个个人结构中且它们之间的矛盾不明显时,抑郁型人格才会形成。相比之下,可以认为在诸如依赖型退行型、回避型和软双相型等边缘类型中,这种矛盾已经很明显。尽管这些边缘类型表现出神经症或人格障碍样的表现,但可以认为神经症性抑郁症和人格障碍抑郁症的真正领域超出了这些边缘类型。在这个领域中,客体关系问题起主导作用的抑郁症很重要。在决定治疗策略时,考虑内源性抑郁症与与客体关系问题相关的抑郁症之间的对比是值得的。这种对比可以从以下三个角度指出:主体与社会的关系、矛盾情感以及躯体症状的状况。在前者中,社会因素起的作用有限,仅构成患者的背景条件,而在后者中,患者的个人冲突与社会因素紧密交织。在前者中,患者几乎无法维持矛盾情感以应对现实,而是利用其顺应性人格来适应现实。另一方面,后者患者有强烈的矛盾情感,当矛盾情感的负面占主导时会受到影响。在前者中,病理现象位于躯体和心理领域尚未分化之处,而在后者中,从心理内容对躯体症状进行一定程度的隐喻性解释有时是可能的。