Psychosomatic medicine II: Depression and organic diseases
Since very early in the history of the human being emotions and affects (jealousy, ambition, passion, sorrow, laziness…) have been related with sickness in the body. Emotions are also very related to the capacity of resistance to infectious illness: it has been observed that soldiers from the defeated army were more sensitive to infections than the winner ones.
Depression (melancholy as Freud called it) consists of deep pain mood, lack of interest for the outside world, lack of ability to love, inhibition of all the functions (insomnia, anorexia..) and decrease of self love. This decrease of self love leads to cruel repproachs to himself. Depression presents different clinical forms, sometimes more in the form of body aches such as musculoskeletal pain, cephalia, disorder in the intestinal rhythm… which makes it difficult to be diagnosed.
Depression happens in the case of lost of an object. This lost can be a loved person or an ideal and it has to be unconscious: the depressed patient doesn’t know what he has lost. However, not all the lost of loved objects, lead to depression . Normal consequence of the lost of a loved object is duel. In the case of lost of a loved object, two conditions need to happen to give place to depression: strong attachment to that object and at the same time, weak resistance to the removal of libido put on the object (so that it is possible that the libido can detach from the love object and go back to the ego). This implies that the election of loved object had been narcissistic: the depressed patient love himself in the other one. In depression, first a narcissistic election of love object takes place, and when that object “abandon” the subject, there is a regression from that narcissistic election to the identification: In order not to lose the object, the individual identifies himself with it. However, by doing that, he loses a part of his ego. There is like an injury in his ego, hence the lack of energy in the depressed people. In the case of depression, there is an incapability to substitute the loved object. This shows the rigidity of the libido typical of this disorder.
All in all, these are the three conditions to depression:
Lost of an object.
Ambivalence: it is a loved object but also hated (as he has abandoned me)
Regression of the libido to the ego (through the regression of the object election to the identification).
We have seen that in hysteria, there is an inability to elaborate the psychical stimulus via psyche so they are elaborated via soma and in actual neurosis there is an inability to elaborate the physical stimulus via psyche (so that they are elaborated via soma) what happens in depression is the inability to elaborate stimulus, physical and psychical via soma, so they are all elaborated via psyche.
In depression, superego is extremely cruel. In reality, his reproaches are addressed to the object (however, as the object occupies now part of the ego through identification, is the ego who receives them). In depression, guilt is related to the perception of the hostile desires against the lost object (to who he wants to kill). We can not say that organic illness appears as punishment to calm the guilt. It is more likely that organic illness happens due to economic libidinal causes in a try to mobilise the stagnant libido but once the organic illness is there, it is true that it acts like a punishment which reliefs the guilt and for this reason, it could contribute to keep it (the illness).
If this was the case, the organic illness could be a consequence of depression. We need to clarify that the concept we are using for organic illness is different from the one they use in traditional medicine 1.
When we talk about organic illness, we will refer to an illness which meet these three conditions:
It has somatic implications (corporal).
It has been preceded by depression.
The immune system is involved.
According to that, we consider HIV and cancer to be organic illness whose base is depression with its psychical side: lack of interest for the outside world, insomnia, moral auto denigration lack of appetite and its physical side being: depression of the immune system 2.
We need to take into account that the concept of time used in psychoanalysis is the recurrence (apress - coup) 3. It means that we can not conclude that all the depressed patients will end up producing an organic illness (neither can we conclude that all the anxiety neurotic or neurasthenic patients will end up with a psychosomatic illness) but we can say that very frequently in organic sick patients we can find precedents of depression (and in psychosomatic ones precedents of anxiety neurosis).
We need to be careful at this point: it doesn’t mean that if a patient with anxiety neurosis has repeatedly tachycardia, in the end, the persistence of the functional lesion will end up producing an organic lesion. No, it is not like that. It means that, as far as the individual has anxiety neurosis, he moves within the limits of “normality” (for example, a rise of the blood pressure taking place during an anxiety crisis will never pass the limits to produce and organic lesion). Why does then traditional medicine conclude that all hypertensive without treatment will end up damaging their arteries? That is not necessarily true: the fact that there is organic lesion or not depends on the numbers of blood pressure that the individual can take and its persistence. And those numbers depend on the underlying structure at that time. So… it is not that the persistence of anxiety neurosis produces a psychosomatic illness. Anxiety neurosis precedes the psychosomatic illness but in order to be organic damage, a step further is needed, a change in the underlying structure: from anxiety neurosis to psychosomatic. And this step also depends on the difficulty of the individual to tolerate the immobility of the libido. In fact, it is to defeat the rigidity of the libido that the individual turned to psychosomatic structure (in this case… we could say that “ the remedy is worse than the illness!”).
It is a matter of libidinal economy, the individual can not tolerate the “libidinal kidnapping” that neurosis or depression implies. What happens is that neurosis or depression hoard all the libido and when trying to mobilise that libido, the individual goes from neurosis to psychosomatic structure and from depression to organic illness. That is why, psychoanalysis, whose most immediate effect is to mobilise the libido of the individual, prevents the development of psychosomatic and organic illness.
In order to understand how depression, sometimes gives place to an organic illness, let’s have a look at war neurosis 4. It has been observed that soldiers with an important injury produced at the same time than the trauma didn’t develop neurosis. Why is that? Because the changes in the distribution of the libido caused by the wound, all the libido is concentrated on it - if it is painful or not, if it heals… - there is no libido left to produce and maintain the neurosis.
In the case of depression there is a rigidity of the libido. All the libido is fixed to the fragment of the ego over which the lost object have fallen 5. In a desperate try to move the libido sometimes, depressed individuals “scape” to an organic illness that has a different distribution of the libido. In fact, it has been observed that when a patient is diagnosed with an important organic injury, opposed to what we could expect, depressive symptoms improve 6. We could then conclude that depression predispose towards different organic illness.
So, it is not like we tend to think that because some one has cancer they are depressed but the other way round: pysche determines soma.
This link between depression and organic illness has been highlighted by World Health Organisation (WHO) since 2002. The cases in which the organic illness ends up with the life of the patient, it could be said that the individual has killed himself through the organic illness 7.
Lets now have a look to how depression can influence the immune system. There are many clinical cases which shows how immune depression is one of the physical symptoms of depression 8.
Immune system is a very complex system composed by various structures and cells dispersed across all the organism. When a foreign substance (antigen) penetrates our organism, the immune system is in charge of detecting it and destroy it. All this taking into account, he doesn’t have to go against whatever is his own. A competent immune system is the one which is not only capable to recognise and destry foreign structures but also be able to recognise his own tissues.
Another function the antitumour immune response: under normal circumstances, mutations of the DNA happen, they are tumoural cells. The immune systems is responsible for recognise these cells and destroying them. When the immune system is depressed, this guarding function does not work properly and the development of tumours from mutated cells is more likely.
We could divide the immune system pathologies in two types:
Depression of the function: Cancer and HIV for example.
Exaggerated and disorganised activity of the system: all the autoimmune diseases 9 such as rheumatoid arthritis, multiple sclerosis diabetes mellitus 1…
Lets focus now on the first group. Cancer patients suffer from immune depression: they tend to develop infections by microorganism that rarely cause and infection in individuals with a competent immune system. This is how sometimes cancer is diagnosed: because there is an illness, unusual in patients with competent immune systems but not uncommon in immune depressed patients.
If the immune system is responsible for protecting the organism from the foreign agents, most of them infectious, issues in the immune system would lead not only to an increase on the infectious processes but also germs incapable to hurt individuals with a healthy immune system, will be able to hurt him when the immune system is depressed.
For example, esophageal candidiasis (fungus infection typical in HIV patients).
Lets now see how psychoanalysis brings a new angle to fight these terrible diseases: Traditional medicine try to find out the cause (ethology) of the disease. It would treat the causes of the disease, that would be in the best case scenario. When the cause is unknown, which is the case in the autoimmune disorders, it can only treats the symptoms but not addressed the cause as medicine doesn’t know the causes that led to the individual to react against his own cells. In the case of the immune depressive diseases like cancer and HIV, to a doctor without psychoanalysis knowledge, depression would be the outcome of telling the patient he has cancer.
However, thanks to psychoanalysis, we know that immune depression and psychical depression are two faces of the same process, the psychical and the organic one. An individual who makes his soma and his psyche sick, because psyche and soma are like a Moebius band: apparently it has two faces but in reality it is only one, different but inseparable. In this case, we would have an etiology (depression) of certain organic diseases and a treatment which prevent from its development: psychoanalysis. According to traditional medicine, the etiology is unknown so it can not apply an efficient precautionary treatment, it can only work on the symptoms (which is already something) of an already existing organic disease.
In reality, immune depression is not enough. For example, in the case of cancer there is in the first place, a depressed immune system which doesn’t recognised the mutated cell but also there is a cell who has ignored all the limits to growth. In an HIV patient, there is an immune depression as starting point of the infection. However, not everybody who is in contact with the virus gets infected. There is a issue in the immune system but at the same time, the HIV patient is someone with a lot of parasitic relationships.
An example of an organic disease: AIDS
Look: “ It is like a train going straight to a wall, needles to say that means death ending”. lymphocytes CD4 are the distance left to the wall - the higher the number of CD4, the further will be the distance to the wall and hence to death. Viral load is the speed with which the train moves towards the wall: the higher the viral load, higher the speed: closer is death. “
This could be the explanation to a patient when he is diagnosed with AIDS. Then he is told that the evolution of the disease without medication leads to an increase of the viral load and a decrease of the CD4 number. However, medication has turned a lethal disease into a chronic one.
The patient will also be informed that any breach of medication or the withdrawal of the treatment leads the disease to follow its natural course towards death and any negligence such as forgetting doses or temporary suspending and reinitiating the treatment, give the virus the chance to mutate and become resistant to drugs. This forces to use second best treatments less efficient. This attitude of AIDS patients tends to persist so they have to move to third, fourth options… with the consequent worsening of the response to treatment. You might think this is something exceptional. Who wouldn’t take a medication which turns a lethal disease patient in a “healthy” patient with a chronic treatment? “Healthy” in the sense of asymptomatic and with no restrictions on his day to day life. Shockingly, many wouldn’t.
We have chosen AIDS as example to understand the organic disease because it is very common that AIDS is preceded by depression and the breach of the treatment. Main reason of failure of the antiretroviral treatment is medication adherence 10.
This frequent non adherence to medication, leads us to believe that the same psychic position that led the patient to get sick, leads him to withdraw the treatment. There was a negligence on his own health, not using contraceptives, sexual promiscuity with high risk strangers which is the same negligence he now has with his treatment. This negligence could be seen as ostensibly self- destructive behaviour . This self - destructive behaviour is characteristic of the organic diseases.
Two drives lead our lives: death and life drive. We could then understand the death drive split into three:
Aggressiveness is the death drive, destructiveness addressed to the outside world.
Primary masochism, is the death drive necessary to live (some cells have to die for the survival of the rest of the organism).
Death drive which takes the subject as object: once it has surrounded the object, comes back to the subject —> this is the one which can hurt the subject.
How is it going to help to tell someone who believes he is immortal, that if he does not do this or that, he will die? That exact conviction about his immortality led him to neglect his health and get infected. “ That cant happen to me”, “I cant get infected”.
Lets see a clinical case to understand these statements: AIDS patient who after 8 years with medication is asymptomatic and shows no viral load. In his clinical story, he has been diagnosed several times of depression by his psychiatrist. The patient goes to consultation to inform of his decision of withdrawing the treatment. The doctor is shocked and asked him if there is any side effect that bothers him so much to come up with such a decision. He says: “no, I am just tired of taking pills”.
AIDS infection, as any other human infection is the outcome of being in contact with the virus on the one hand, and the immune system response on the other. In a depressed immune system, the response against the germ will be insufficient and hence it will favor the development of the disease and it will be more severe.
When AIDS appeared on the 80s, according to traditional medicine, every individual who was in touch with the AIDS, got infected and developed the disease sooner or later. However, deeper knowledge about the AIDS infection process, have shown that this is not the case: someone can be in contact with the virus and dont get infected and can be infected and never develop the disease. Clinical experience has proved that there cases in which despite being strongly exposed to the virus, the individuales didn’t get infected. In other cases, the individuals were infected but the immune system was capable to eradicate the infection.
Going back to the clinical case we were analysing, depression can lead to the most severe self injury: suicide. AIDS, exactly as we explained in cancer, it is an undercovered suicide.
Most AIDS patients will follow the same pattern: they will claim to abandon the treatment because of he side effects or the high number of pills. However, there is something in their inside which work against them: their death drive.
Lets have a look at a clinical case: 24 years old male patient, begins psychotherapy right after he is diagnosed with AIDS. When he talks about his disease, he mentioned before he got infected, he was always scared of contracting certain diseases: AIDS, cancer, alzheimer…. Since the moment he gets AIDS, his fear to get sick is interpreted as desire for getting sick. When he goes to consultation, he was partying a lot, doing drugs in the weekends. Then he complains about the terrible hangovers and he says he wants to stop, that he doesn’t want to be addicted to anything. He quits his job and become autonomous. His main concern is how to get loans to open new business. He speaks about his life in couple ideal. After one year in therapy, he began a relationship which lasts until today. During a certain period time, he speaks about his random risky sexual relationships in discos, on the street… he began to call himself “ sexual obsessed”, he talks about his promiscuous experiences in dark rooms, saunas… he said after he felt “like shit” an obsessed exposed to all the contagions and finally he got… AIDS.
During a period of hard times at wok, he felt very sick, was taken to hospital with a pneumonia and diagnosed with AIDS. At the beginning of his therapy (at the same time he began his antiretroviral treatment), he talks about his intolerance to medication, his concerns about lipodsytrofy linked to the treatment. However, two months after along with his physical improvement, these ideas are not that persecutory. He become aware of his situation, the need to live more carefully. Thanks to the psychoanalyst interpretations, the patient transforms the idea of dying young man suffering from cruel medical conditions into a healthy patient with a chronic treatment. This is a key moment in the therapy: when he made the decision to continue alive.
After a year in therapy, there are two important moments: on the one hand, his medical controls show the virus is undetectable. On the other, he bumped into a friend (who had confessed him he had also AIDS) and hadn’t seen in 8 years. The patient realises that thanks to psychoanalysis, he had achieved in one year (virus to become undetectable) what had taken 8 years to his friend (without therapy).
Some comments on this case: we can observe the depressive attitude of the patient prior to getting infected, which is showed in the repetion compulsion of auto injury. Traditional medicine tends to link sexual promiscuity with getting infected with AIDS. However, in reality is not about promiscuity (multiple relationships) but about risk seeking (not using condoms, with potentially infected individuals…) and even in that case, not all the individuals in contact with HIV get infected. There mush also be an immune depression.
Traditional medicine define “organic illness” as a set of symptoms with a common aetiology - for example a germ - or that having an unknown cause, they produce an organic observable lesion. For example, colon cancer: most of the times produce by unknown caused but observable via endoscopy).
Remember that depression has psychical and physical symptoms.
In psychoanalysis, the concept of time used is not the chronological one (in which there is a past, a present and a future), the time used is the pares - coup which means : “ everything will be clarified after the future events take place”. We can only know afterwards.
traumatic neurosis produced during war times
Remember that the depressed individual is not able to replace what he lost - an idea a person he loved…) he identified with it in order not to lose it. The the lost idea or the object became part of themselves consuming their own ego —> there is a wound in the ego. That is why all the libido is fixed on it, on the ego.
However, that should not mislead us: depression hasn’t disappear and in fact, once the organic illness is cured, depression comes back..
This is what we called: the “shy suicide” of the depressed people.
Here we refer to depression as the psychical underlying structure we have explained before.
The immune system attacks their own healthy cells by mistake
Medication adherence refers to whether patients take their medications as prescribed (eg, twice daily), as well as whether they continue to take a prescribed medication. We believe that the same reason that led this individual to get sick, leads him to neglect this treatment