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As horrific as the conditions in Bethlehem hospital were, the physicians at the time were nonetheless interested in what caused the maladies of their patients. Table 1.1 lists the hypothesized causes of the illnesses exhibited by patients in 1810 that were recorded by William Black, a physician work...

As horrific as the conditions in Bethlehem hospital were, the physicians at the time were nonetheless interested in what caused the maladies of their patients. Table 1.1 lists the hypothesized causes of the illnesses exhibited by patients in 1810 that were recorded by William Black, a physician working at Bethlehem at the time (Appignannesi, 2008). It is interesting to observe that about half of the presumed causes were biological (e.g., fever, hereditary, venereal) and half were psychological (e.g., grief, love, jealousy). Only around 10 percent of the causes were spiritual. Contemporary developments in biological and psychological approaches to the causes and treatments of mental disorders were heavily influenced by theorists and scientists working in the late nineteenth and early twentieth centuries. We will discuss, compare, and evaluate these approaches more fully in Chapter 2. In this section, we review the historical antecedents of these more contemporary approaches. Recall that in the West, the death of Galen and the decline of Greco-Roman civilization temporarily ended inquiries into the nature of both physical and mental illness. Not until the late Middle Ages did any new facts begin to emerge, thanks to an emerging empirical approach to medical science, which emphasized gathering knowledge by direct observation. Biological Approaches Discovering Biological Origins in General Paresis and Syphilis The anatomy and workings of the nervous system were partially understood by the mid-1800s, but not enough was known to let investigators conclude whether the structural brain abnormalities presumed to cause various mental disorders were present or not. Perhaps the most striking medical success was the elucidation of the nature and origin of syphilis, a venereal disease that had been recognized for several centuries. The story of this discovery provides a good illustration of how an empirical approach, the basis for contemporary science, works. Since the late 1700s it had been known that a number of people with mental illness manifested a syndrome characterized by a steady deterioration of both mental and physical abilities, including symptoms such as delusions of grandeur (i.e., the belief that you hold special and great power or can accomplish more than any other person on the planet) and progressive paralysis; the presumed disease associated with this syndrome was given the name general paresis. Soon after these symptoms were recognized, investigators realized that these people never recovered. By the mid-1800s, it had been established that some patients with general paresis also had syphilis, but a connection between the two conditions had not yet been made. In the 1860s and 1870s, Louis Pasteur established the germ theory of disease, which posited that disease is caused by infection of the body by minute organisms. This theory laid the groundwork for demonstrating the relation between syphilis and general paresis. Finally, in 1905, the specific microorganism that causes syphilis was discovered. For the first time, a causal link had been established between infection, destruction of certain areas of the brain, and a form of psychopathology (general paresis). If one type of psychopathology had a biological cause, so could others. Biological approaches gained credibility, and searches for more biological causes were off and runnin Genetics Francis Galton (1822--1911), often considered the originator of genetic research with twins, because of his study of twins in the late 1800s in England, attributed many behavioral characteristics to heredity. He is credited with coining the terms nature and nurture to talk about differences in genetics (nature) and environment (nurture). In the early twentieth century, investigators became intrigued by the idea that mental illness may run in families, and beginning at that time, a number of studies documented the heritability of mental illnesses such as schizophrenia, bipolar disorder, and depression. These studies would set the stage for later theories about the causes of mental illness. Unfortunately, Galton is also credited with creating the eugenics movement in 1883 (Brooks, 2004). Advocates of this movement sought to eliminate undesirable characteristics from the population by restricting the ability of certain people to have children (e.g., by enforced sterilization). Many of the early efforts in the United States to determine whether mental illness could be inherited were associated with the eugenics movement, and this stalled research progress. Indeed, in a sad page from U.S. history, state laws in the late 1800s and early 1900s prohibited people with mental illness from marrying and forced them to be sterilized in order to prevent them from "passing on" their illness. Such laws were upheld by the U.S. Supreme Court in 1927 (Chase, 1980), and it wasn't until the middle of the twentieth century that these abhorrent practices were halted. Nevertheless, much damage had been done: by 1945, more than 45,000 people with mental illness in the United States had been forcibly sterilized (Whitaker, 2002). Biological Treatments The general warehousing of patients in mental hospitals earlier in the twentieth century, coupled with the shortage of professional staff, created a climate that allowed, perhaps even subtly encouraged, experimentation with radical interventions. In the early 1930s, the practice of inducing a coma with large dosages of insulin was introduced by Sakel (1938), who claimed that up to three-quarters of the people with schizophrenia whom he treated showed significant improvement. Later findings by others were less encouraging, and insulin-coma therapy---which presented serious risks to health, including irreversible coma and death---was gradually abandoned. In the early twentieth century, electroconvulsive therapy (ECT) was originated by two Italian physicians, Ugo Cerletti and Lucino Bini. Cerletti was interested in epilepsy and was seeking a way to induce seizures experimentally. Shortly thereafter he found that by applying electric shocks to the sides of the human head, he could produce full epileptic seizures. Then, in Rome in 1938, he used the technique on a patient with schizophrenia. In the decades that followed, ECT was administered to people with schizophrenia and severe depression, usually in hospital settings. As we will discuss in Chapter 5, it is still used today for people with severe depression. Fortunately, important refinements in the ECT procedures have made it less problematic, and it remains an effective treatment. In 1935, Egas Moniz, a Portuguese psychiatrist, introduced the prefrontal lobotomy, a surgical procedure that destroys the tracts connecting the frontal lobes to other areas of the brain. His initial reports claimed high rates of success (Moniz, 1936), and for 20 years thereafter thousands of people with mental illness underwent variations of this psychosurgery. The procedure was used especially for those whose behavior was violent. Many people did indeed quiet down and could even be discharged from hospitals, largely because their brains were damaged. During the 1950s, this intervention fell into disrepute for several reasons. After surgery, many people became dull and listless and suffered serious losses in their cognitive capacities---for example, becoming unable to carry on a coherent conversation with another person---which is not surprising given the destruction of parts of their brains that support thought and language. Psychological Approaches The search for biological causes dominated the field of psychopathology until well into the twentieth century, no doubt partly because of the exciting discoveries made about the brain and genetics. But beginning in the late eighteenth century, various psychological points of view emerged that attributed mental disorders to psychological malfunctions. These theories were fashionable first in France and Austria, and later in the United States, leading to the development of psychotherapeutic interventions based on the tenets of the individual theories Mesmer and Charcot During the eighteenth century in western Europe, many people were observed to be subject to hysteria, which referred to physical incapacities, such as blindness or paralysis, for which no physical cause could be found. Franz Anton Mesmer (1734--1815), an Austrian physician practicing in Vienna and Paris in the late eighteenth century, believed that hysteria was caused by a particular distribution of a universal magnetic fluid in the body. Moreover, he felt that one person could influence the fluid of another to bring about a change in the other's behavior. Mesmer conducted meetings cloaked in mystery and mysticism, at which afflicted patients sat around a covered wooden tub, with iron rods protruding through the cover from bottles underneath that contained various chemicals. Mesmer would enter the room, take various rods from the tub, and touch afflicted parts of his patients' bodies. The rods were believed to transmit animal magnetism and adjust the distribution of the universal magnetic fluid, thereby removing the hysterical disorder. Later, Mesmer perfected his routines by simply looking at patients rather than using rods. Whatever we may think of this questionable explanation and strange procedure, Mesmer apparently helped many people overcome their hysterical problems. Although Mesmer regarded hysteria as having strictly biological causes, we discuss his work here because he is generally considered one of the earlier practitioners of modern-day hypnosis (the word mesmerism is a synonym for hypnotism; the phenomenon itself was known to the ancients of many cultures, where it was part of the sorcery and magic of conjurers and faith healers). Mesmer came to be regarded as a quack by his contemporaries, which is ironic, since he had earlier contributed to the discrediting of an exorcist, Father Johann Gassner, who was performing similar rituals (Harrington, 2008). Nevertheless, hypnosis gradually became respectable. The great Parisian neurologist Jean Martin Charcot (1825--1893) also studied hysterical states. Although Charcot believed that hysteria was a problem with the nervous system and had a biological cause, he was also persuaded by psychological explanations. One day, some of his enterprising students hypnotized a healthy woman and, by suggestion, induced her to display certain hysterical symptoms. Charcot was deceived into believing that she was an actual patient with hysteria. When the students showed him how readily they could remove the symptoms by waking the woman, Charcot became interested in psychological interpretations of these very puzzling phenomena. Given Charcot's prominence in Parisian society, his support of hypnosis as a worthy treatment for hysteria helped to legitimize this form of treatment among medical professionals of the time (Harrington, 2008; Hustvedt, 2011). Breuer and the Cathartic Method In the nineteenth century, a Viennese physician, Josef Breuer (1842--1925), treated a young woman, whose identity was disguised under the pseudonym Anna O., with a number of hysterical symptoms, including partial paralysis, impairment of sight and hearing, and, often, difficulty speaking. She also sometimes went into a dreamlike state, or "absence," during which she mumbled to herself, seemingly preoccupied with troubling thoughts. Breuer hypnotized her, and while hypnotized, she began talking more freely and, ultimately, with considerable emotion about upsetting events from her past. Frequently, on awakening from a hypnotic session she felt much better. Breuer found that the relief of a particular symptom seemed to last longer if, under hypnosis, she was able to recall the event associated with the first appearance of that symptom and if she was able to express the emotion she had felt at the time. Reliving an earlier emotional trauma and releasing emotional tension by expressing previously forgotten thoughts about the event was called catharsis, and Breuer's method became known as the cathartic method. In 1895, Breuer and a younger colleague, Sigmund Freud (1856--1939), jointly published Studies in Hysteria, partly based on the case of Anna O. The case of Anna O. became one of the best-known clinical cases in the psychoanalytic literature. Ironically, later investigation revealed that Breuer and Freud reported the case incorrectly. Historical study by Henri Ellenberger (1972) indicates that the young woman was helped only temporarily by Breuer's talking cure. This is supported by Carl Jung, a renowned colleague of Freud's, who is quoted as saying that during a conference in 1925, Freud told him that Anna O. had never been cured. Hospital records discovered by Ellenberger confirmed that Anna O. continued to rely on morphine to ease the "hysterical" problems that Breuer is reputed to have cured by catharsis. Freud and Psychoanalysis The apparently powerful role played by factors of which patients seemed unaware led Freud to postulate that much of human behavior is determined by forces that are inaccessible to awareness. The central assumption of Freud's theorizing, often referred to as psychoanalytic theory, is that psychopathology results from unconscious conflicts in the individual. In the next sections, we take a look at Freud's theory. See Focus on Discovery 1.3 for a look at Freud's theory of personality development and Focus on Discovery 1.4 for Freud's ideas about depression. Structure of the Mind Freud divided the mind, or the psyche, into three principal parts: id, ego, and superego. According to Freud, the id is present at birth and is the repository of all of the energy needed to run the psyche, including the basic urges for food, water, elimination, warmth, affection, and sex. Trained as a neurologist, Freud saw the source of the id's energy as biological, and he called this energy libido. The individual cannot consciously perceive this energy---it is unconscious, below the level of awareness. The id seeks immediate gratification of its urges, operating on what Freud called the pleasure principle. When the id is not satisfied, tension is produced, and the id impels a person to eliminate this tension as quickly as possible. For example, a baby feels hunger and is impelled to move about, sucking, in an attempt to reduce the tension arising from the unsatisfied drive. A person may also attempt to obtain gratification by generating images---in essence, fantasies--- of what is desired. For instance, the hungry baby imagines sucking at the mother's breast and thereby obtains some substitute, short-term satisfaction. Of course, fantasizing cannot really satisfy such urges. This is where the ego comes in. According to Freud, the ego begins to develop from the id during the second 6 months of life. Unlike the contents of the id, those of the ego are primarily conscious. The id may resort to fantasy when seeking satisfaction, but the task of the ego is to deal with reality. The ego thus operates on what Freud termed the reality principle as it mediates between the demands of reality and the id's demands for immediate gratification. The superego---the third part of the psyche in Freud's theory---can be roughly conceived of as a person's conscience. Freud believed that the superego develops throughout childhood, arising from the ego much as the ego arises from the id. As children discover that many of their impulses---for example, biting and bed-wetting---are not acceptable to their parents, they begin to incorporate parental values as their own in order to receive the pleasure of parental approval and avoid the pain of disapproval. Defense Mechanisms According to Freud, and as elaborated by his daughter Anna (A. Freud, 1946/1966), herself an influential psychoanalyst, discomforts experienced by the ego as it attempts to resolve conflicts and satisfy the demands of the id and superego can be reduced in several ways. A defense mechanism is a strategy used by the ego to protect itself from anxiety. Examples of defense mechanisms are presented in Table 1.2. Psychoanalytic Therapy Psychotherapy based on Freud's theory is called psychoanalysis or psychoanalytic therapy. It is still practiced today, although not as commonly Josef Breuer, an Austrian physician and physiologist, collaborated with Freud in the early development of psychoanalysis. (Corbis-Bettmann.) Sigmund Freud developed psychoanalytic theory, a theory of the structure and functions of the mind (including explanations of the causes of mental disorders), and psychoanalysis, a new method of therapy based on it. (Corbis-Images. Table 1.2 Selected Defense Mechanisms Defense Mechanism Definition Example Repression Keeping unacceptable impulses or wishes A professor starting a lecture she dreaded giving says, from conscious awareness "In conclusion." Denial Not accepting a painful reality into conscious A victim of childhood abuse does not acknowledge it awareness as an adult. Projection Attributing to someone else one's own unacceptable A man who hates members of a racial group believes thoughts or feelings that it is they who dislike him. Displacement Redirecting emotional responses from their real target A child gets mad at her brother but instead acts to someone else angrily toward her friend. Reaction formation Converting an unacceptable feeling into its opposite A person with sexual feelings toward children leads a campaign against child sexual abuse. Regression Retreating to the behavioral patterns of an earlier An adolescent dealing with unacceptable feelings of stage of development social inadequacy attempts to mask those feelings by seeking oral gratification. Rationalization Offering acceptable reasons for an unacceptable A parent berates a child out of impatience, then action or attitude indicates that she did so to "build character." Sublimation Converting unacceptable aggressive or sexual Someone who has aggressive feelings toward impulses into socially valued behaviors his father becomes a surgeon as it once was. In psychoanalytic and newer psychodynamic treatments, the goal of the therapist is to understand the person's early-childhood experiences, the nature of key relationships, and the patterns in current relationships. The therapist is listening for core emotional and relationship themes that surface again and again (see Table 1.3 for a summary of psychoanalysis techniques). Freud developed a number of techniques in his efforts to help people resolve repressed conflicts. With free association, a patient reclines on a couch, facing away from the analyst, and is encouraged to give free rein to his or her thoughts, verbalizing whatever comes to mind, without censoring anything. Another key component of psychoanalytic therapy is the analysis of transference. Transference refers to the patient's responses to his or her analyst that seem to reflect attitudes and ways of behaving toward important people in the patient's past, rather than reflecting actual aspects of the analyst--patient relationship. For example, a patient might feel that the analyst is generally bored by what he or she is saying and as a result might struggle to be entertaining; this pattern of response might reflect the patient's childhood relationship with a parent rather than what's actually going on between the patient and the analyst. Through careful observation and analysis of these transferred attitudes, Freud believed the analyst could gain insight into the childhood origins of the patient's repressed conflicts. In the example above, the analyst might find that the patient was made to feel boring and unimportant as a child and could only gain parental attention through humor. In the technique of interpretation, the analyst points out to the patient the meanings of certain of the patient's behaviors. Defense mechanisms are a principal focus of interpretation. For instance, a man who appears to have trouble with intimacy may look out the window and change the subject whenever anything touches on closeness during the course of a session FOCUS ON DISCOVERY 1.3 Stages of Psychosexual Development Freud conceived of the personality as developing through a series of four distinct psychosexual stages. He used the term psychosexual because, at each stage, a different part of the body is the most sensitive to sexual excitation and, therefore, the most capable of satisfying the id. According to Freud, too much or too little gratification during one of the psychosexual stages may lead to regression to this stage during stress. (Jennie Woodcock; Reflections Photolibrary/Corbis Images.) In Freud's theory, the first stage of psychosexual development is the oral stage, during which pleasure is obtained from feeding. (Banana Stock/ Superstock.) The oral stage is the first stage. From birth to about 18 months, the demands of an infant's id are satisfied primarily by feeding and the sucking and biting associated with it. The body parts through which the infant receives gratification at this stage are the lips, mouth, gums, and tongue. During the anal stage, from about 18 months to 3 years of age, a child receives pleasure mainly via the anus, by passing and retaining feces. The phallic stage extends from age 3 to age 5 or 6; during this stage, maximum gratification of the id is obtained through genital stimulation. Between the ages of 6 and 12, the child is in a latency period; during these years the id impulses do not play a major role in motivating behavior. The final and adult stage is the genital stage, during which heterosexual interests predominate. During each stage, the developing person must resolve the conflicts between what the id wants and what the environment will provide. How this is accomplished is believed, in Freud's view, to determine basic personality traits that last throughout the person's life. A person who experiences either excessive or deficient amounts of gratification at a particular stage develops a fixation and is likely to regress to that stage The analyst will attempt at some point to interpret the patient's behavior, pointing out its defensive nature in the hope of helping the patient acknowledge that he is in fact avoiding the topic. Neo-Freudian Psychodynamic Perspectives Several of Freud's contemporaries met with him periodically to discuss psychoanalytic theory and therapy. As often happens when a brilliant leader attracts brilliant followers and colleagues, disagreements arose about many general issues, such as the relative importance of id versus ego, of biological versus sociocultural forces on psychological development, of unconscious versus conscious processes, and of childhood versus adult experiences; whether sexual urges drive behaviors that are not obviously sexual; and the role of reflexlike id impulses versus that of purposive behavior governed primarily by conscious ego deliberations. We discuss two influential historical figures here: Carl Jung and Alfred Adler. FOCUS ON DISCOVERY 1.3 Stages of Psychosexual Development Freud conceived of the personality as developing through a series of four distinct psychosexual stages. He used the term psychosexual because, at each stage, a different part of the body is the most sensitive to sexual excitation and, therefore, the most capable of satisfying the id. According to Freud, too much or too little gratification during one of the psychosexual stages may lead to regression to this stage during stress. (Jennie Woodcock; Reflections Photolibrary/Corbis Images.) In Freud's theory, the first stage of psychosexual development is the oral stage, during which pleasure is obtained from feeding. (Banana Stock/ Superstock.) The oral stage is the first stage. From birth to about 18 months, the demands of an infant's id are satisfied primarily by feeding and the sucking and biting associated with it. The body parts through which the infant receives gratification at this stage are the lips, mouth, gums, and tongue. During the anal stage, from about 18 months to 3 years of age, a child receives pleasure mainly via the anus, by passing and retaining feces. The phallic stage extends from age 3 to age 5 or 6; during this stage, maximum gratification of the id is obtained through genital stimulation. Between the ages of 6 and 12, the child is in a latency period; during these years the id impulses do not play a major role in motivating behavior. The final and adult stage is the genital stage, during which heterosexual interests predominate. During each stage, the developing person must resolve the conflicts between what the id wants and what the environment will provide. How this is accomplished is believed, in Freud's view, to determine basic personality traits that last throughout the person's life. A person who experiences either excessive or deficient amounts of gratification at a particular stage develops a fixation and is likely to regress to that stage when stressed. 20 Chapter 1 Introduction and Historical Overview Jung and Analytical Psychology Carl Gustav Jung (1875--1961), a Swiss psychiatrist originally considered Freud's heir apparent, broke with Freud in 1914 on many issues, after a 7-year period of intense correspondence about their disagreements. Jung proposed ideas radically different from Freud's, ultimately establishing analytical psychology. Jung hypothesized that in addition to the personal unconscious postulated by Freud, there is a collective unconscious, the part of the unconscious that is common to all human beings and that consists primarily of what Jung called archetypes, or basic categories that all human beings use in conceptualizing about the world. In addition, Jung asserted that each of us has masculine and feminine traits that are blended and that people's spiritual and religious urges are as basic as their id urges. Jung also catalogued various personality characteristics; perhaps most important among them are extraversion (an orientation toward the external world) versus introversion (an orientation toward the inner, subjective world). This personality dimension continues to be regarded as very important, and we will encounter it again in our discussion of personality disorders in Chapter 15. Adler and Individual Psychology Alfred Adler (1870--1937), also an early adherent of Freud's theories, came to be even less dependent on Freud's views than was Jung, and Freud remained quite bitter toward Adler after their relationship ended. Adler's theory, which came to be known as individual psychology, regarded people as inextricably tied to their society because he believed that fulfillment was found in doing things for the social good. Like Jung, he stressed the importance of working toward goals (Adler, 1930). A central element in Adler's work was his focus on helping individual patients change their illogical and mistaken ideas and expectations; he believed that feeling and behaving better depend on thinking more rationally, an approach that anticipated contemporary developments in cognitive behavior therapy (discussed in Chapter 2). Continuing Influences of Freud and His Followers Freud's original ideas and methods have been heavily criticized over the years. For example, Freud conducted no formal research on the causes and treatments of mental illness. This remains one of the main criticisms today: because they are based on anecdotal evidence gathered during therapy sessions, some psychodynamic theories are not grounded in objectivity and therefore are not scientific. However, other contemporary psychodynamic theories, such as object relations theory (discussed in Chapter 2), have built a limited base of supportive research. Offshoots of object relations theory, such as attachment theory and the idea of the relational self (discussed in Chapter 2), have accumulated a good bit of empirical support, both in children and adults. Though perhaps not as influential as it once was, the work of Freud and his followers continues to have an impact on the field of psychopathology (Westen, 1998). This influence is most evident in the following three commonly held assumptions: 1. Childhood experiences help shape adult personality. Contemporary clinicians and researchers still view childhood experiences and other environmental events as crucial. They seldom focus on the psychosexual stages about which Freud wrote, but some emphasize problematic parent--child relationships in general and how they can influence later adult relationships in negative ways. FOCUS ON DISCOVERY 1.4 Freud's Ideas on Depression The Evolution of Contemporary Thought 21 2. There are unconscious influences on behavior. As we will discuss in Chapter 2, the unconscious is a focus of contemporary research in cognitive neuroscience and psychopathology. This research shows that people can be unaware of the causes of their behavior. However, most current researchers and clinicians do not think of the unconscious as a repository of id instincts. 3. The causes and purposes of human behavior are not always obvious. Freud and his followers sensitized generations of clinicians and researchers to the nonobviousness of the causes and purposes of human behavior. Contemporary psychodynamic theorists continue to caution us against taking everything at face value. A person expressing disdain for another, for example, may actually like the other person very much yet be fearful of admitting positive feelings. This tendency to look under the surface, to find hidden meanings in behavior, is perhaps the best-known legacy of Freud. Quick Summary The nineteenth and twentieth centuries saw a return to biological explanations for mental illness. Developments outside the field of psychopathology, such as the germ theory of disease and the discovery of the cause of syphilis, illustrated how the brain and behavior are linked. Early investigations into the genetics of mental illness led to a tragic emphasis on eugenics and the enforced sterilization of many thousands of people with mental illness. Such biological approaches to treatment as induced insulin coma and lobotomy eventually gave way to drug treatments. Psychological approaches to psychopathology began with Mesmer's manipulation of "magnetism" to treat hysteria (late eighteenth century), proceeded through Breuer's conceptualization of the cathartic method in his treatment of Anna O. (late nineteenth century), and culminated in Freud's psychoanalytic theories and treatment techniques (early twentieth century). Jung and Adler took Freud's basic ideas in a variety of different directions. The theories of Freud and other psychodynamic theorists do not lend themselves to systematic study, which has limited their acceptance by some in the field. Although Freud's early work is often criticized, his theorizing has been influential in the study of psychopathology in that it has made clear the importance of early experiences, the notion that we can do things without conscious awareness, and the insight that the causes of behavior are not always obvious. Check Your Knowledge 1.3 Fill in the blanks. 1. \_\_\_\_\_\_\_\_ was a French neurologist who was influenced by the work of \_\_\_\_\_\_\_\_. 2. \_\_\_\_\_\_\_\_ developed the cathartic method, which \_\_\_\_\_\_\_\_ later built on in the development of psychoanalysis. 3. The \_\_\_\_\_\_\_\_ is driven by the pleasure principle, but the \_\_\_\_\_\_\_\_ is driven by the reality principle. 4. In psychoanalysis, \_\_\_\_\_\_\_\_ refers to interpreting the relationship between therapist and client as indicative of the client's relationship to others. 5. \_\_\_\_\_\_\_\_ developed the concept of the collective unconscious; \_\_\_\_\_\_\_\_ developed the technique of free association; \_\_\_\_\_\_\_\_ is associated with individual psychology. person. According to the theory, the mourner's anger toward the lost one becomes directed inward, developing into ongoing self-blame and depression. In this view, depression can be described as anger turned against oneself. Overly dependent persons are believed to be particularly susceptible to this process, and, as noted above, people fixated in the oral stage are overly dependent on others. Although this theory was interesting at the time, not much research has been carried out to test it, and the little information available does not strongly support it. Contrary to the idea that depression is a result of anger turned inward, people with depression express much more anger than do people without depression (Biglan et al., 1988). Despite this, some of Freud's ideas continue to influence more recent models of depression, as we discuss in Chapter 5. For example, Freud maintained that depression could be triggered by the loss of a loved one. A large body of evidence indicates that episodes of major depressive disorder are precipitated by stressful life events, which often involve losses. Researchers have consistently shown that people who are high in dependency are prone to depressive symptoms after a rejection (Nietzel & Harris, 1990), a finding that is also congruent with Freud's theory. Although some of Freud's ideas still influence theories of depression, researchers have gone far beyond the clinical observations that were