Depressives Schulderleben: Symptomatologie und Diagnostik

Abstract

Current psychiatric-psychotherapeutic research no longer tends to focus on feelings of guilt. Although feelings of guilt are frequently dismissed, denied or repressed, we nevertheless consider them clinically relevant. Based on the wide-ranking symptomatology of guilt feelings seen in depression, we propose a distinction between consciousness of guilt (rational component) and feelings of guilt (affective component). A compound term may be guilt-experience. Firstly, we differentiate between three categories of guilt: juridical, a guilt of action or inaction in the sense of making a mistake (Latin: culpa), ontological or existential guilt, a kind of debt (Latin: debitum) similar to owing something to somebody or in not fulfilling one's own potentials in life and, lastly, tragic guilt in the sense of being the cause (Latin: causa) of an evil which was neither consciously nor deliberately intended. This tragic guilt accrues innocently. Phenomenologically and syntactically, several types of guilt feelings can also be distinguished. We define a conscious guilt feeling as a punitive, self-administered emotional state following awareness of transgression of others' limits. An unconscious guilt feeling is not experienced as such by the patient but can nevertheless provoke suffering, e.g. somatoform pain disorders. Previously Schneider and Weitbrecht defined a primary guilt feeling as inexplicable and arising endogenously and a secondary guilt feeling developing in reaction to the primary. Other definitions include real versus pathological guilt feeling - depending on the existence and extent of an underlying correlation, psychotic versus neurotic guilt feeling or self-attributed guilt feeling versus the feeling of guilt which is attributed to others. Additionally, we will explore predispositions and the connections between personality traits (e.g. typus melancholicus, education, piety or extent of clinical depression) and cultural identity. Our findings will be based on the works of Hole, Janzarik, von Orelli and Hafner. Aetiology and pathogenesis of guilt feelings in depression may be studied psychiatrically, postulating a link between biochemical (somatic) alterations and the clinical expression of depression, psychodynamically, suggesting a conflict between ego and super-ego, an alteration of regulation of one's self-esteem and an inhibition of aggression towards parents or superiors and compensation via work and behaviouristically supposing dysfunctional thoughts which can cause a negative view of the self, the world around and the future. These thoughts may be generated automatically and they may reinforce depressive symptoms. In response to the multilayered symptomatology of guilt feelings a multidimensional diagnostic procedure should be applied. Several psychopathological rating scales are named as well as the Structural Analysis of Social Behaviour (SASB), the Operationalised Psychodynamic Diagnostics (OPD) and an analysis of types of attribution (IPC). In clinical practice these tests may not be administered in their entirety, but nevertheless, diagnostic proceedings should be as complex as possible in order to provide an effective patient-orientated treatment.