CLAUSTROPHOBIA
AND DEPRESSION :
STUART
S. ASCH,M.D.
I
to present several familiar clinical entities which I think
require further explanation and understanding. These include two major phenomenological groups of depression-the
agitated and the contrasting apathetic depression. There is no
satisfactory dynamic formulation in the literature to explain the
marked dichotomy in clinical appearance of these two depressive
states. Quite to the contrary, there is a tendency to group these
two together. In attempting to formulate differences in depressive
manifestations, certain theoretical considerations led me to another clinical problem that impressed me as being dynamically
related-claustrophobia, especially those malignant forms of the
phobia that prove so resistant to analysis. I now suggest that these
disparate clinical phenomena-claustrophobia,
agitated depression, and apathetic depression-all have important similarities in
their dynamic structure and in their underlying conflict. I n certain
circumstances they may even be variants of the same defensive
maneuver.
INTEND
T h e Claustrophobic Fantasy and Its Drive Derivatives
T h e claustrophobe is characterized by his fear of entering enclosed spaces. Lewin defines it as "a fear of being caught or crushed
by a gradual closing in of the space around one" (10). T h e passive
wish to be enveloped by the mother has been projected, with the
Associate Attending Psychiatrist, Department of Pqchiatry, Institute of Psychiatry, AI. R. Raufrnan, M.D., Director, The Mount Sinai Hospital of New York.
71 1
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
712
STUART S. ASCH
conflict then displaced from mother onto a new object which becomes the terrifying claustrum. I n Lewin’s classic article, he distinguishes between two separate fears in the claustrophobe: (i) a
fear of entering an enclosed space; (ii) a fear of something dreadful occurring while within the enclosed space.
T h e fears of entering an enclosed space are derived from a
phallic level of instinctual and ego development. As has been discussed by both Lewin and Fenichel (5), it is the phallic orientation
that associates the entrance to the claustrum with the vagina dentata. T h e whole self representation having been conceptualized as
a phallus, the danger is now of castration by the object, which is
the claustrum. T h e claustrum object has become the threatening
castrator, “Mme. GuilIotine.” However, it is really the danger
once inside that is customarily thought of as the true claustro. is the fear of
phobia. “The central claustrophobic fantasy
being expelled from the mother’s body by the crushing, Rushing,
or other activity of the father” (10).
Lewin sees this as an identification with the fetus inside
mother, with the fear of being disturbed by father’s penis during
intercourse. Such a fantasy includes the intrauterine observation
of coitus. I t is also the fear of father’s castrating penis from which
one cannot escape when one is within the restricting confines of
the womb. T h e basic fear of the claustrophobe has always been
considered to be castration anxiety. However, the phenomenon of
claustrophobia is not necessarily symptomatic of a phallic conflict.
I shall offer some theoretical formulations to emphasize preoedipal
elements contained in the phobic fantasy. I n some cases, regression
has made these the predominant elements, with the preoedipal
mother replacing the oedipal object. Those claustrophobias that
remain especially resistant despite analysis of the oedipal conflict
may, for the foregoing reasons, require the working through of
specific pregenital material. I shall illustrate this with examples
from literature and two patients.
It is with the group of claustrophobes who experience anxiety
when inside the claustrum that I intend to delineate and describe
two other fears that are more primitive than the usual castration
anxiety. I t is my belief that identification with the fetus inside the
mother is associated with two fantasies of dread: (i) the danger of
..
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
CLAUSTROPHOBIA AND DEPRESSION
713
being squeezed out passively: abandoned and flushed away like a
bad, smelly stool; this involves a fantasy of birth as an anal process
of separation from the mother; it is pregenital and does not involve the father; (ii) the danger of being passively chewed up, dissolved, and digested; to be fused with the mother on the most
primitive level, with a terrifying loss of identity.
These are two distinct anxieties with mainly anal and oral
drive derivatives. One is a fear of separation from mother, while
the other is its opposite, a fear of complete fusion. One involves
abandonment by the object, while the latter consists of loss of the
self representation. Both involve prephallic conflicts with regression to levels of object relationships that precede those with the
father. We are dealing in this group of patients with vicissitudes
of the primitive mother relationship and the father is not involved.
If avoidance of the claustrum itself is not possible, anxiety
may still be relieved through the reassurance that there is an exit
available or that movement is possible. Without these reassurances the experiencing part of the ego acts as if the self is realIy
enclosed. There is an actual feeling of suffocation with labored
gasping, breathing, etc. Confining clothes must be loosened and
even torn off if the anxiety is great enough. It is as if even the
clothes themselves are the claustrum (viz., the similarity in certain
states of mourning where the clothes can take on the significance
of the ambivalently cathected lost object [3]).
Gehl (8) feels that the claustrophobic anxiety is due to this
specific inability to move or feel movement. H e claims that movement is the specific and important antidote. “The greater the stillness, quiet, lack of movement, darkness, heat, etc., the greater the
fear of loss of the cathexis of their body and ego boundaries.” This
seems similar to the panic that often occurs with sensory deprivation experiments. T h e reverse is seen in the analytic situation,
where the couch with its restriction of motility is used with the
aim of ego regression.
Does the individual inside the claustrum see himself as a
whole object, encapsulated like Jonah in the whale? QJ is his
regressive urge so strong and his self representation so fragile that
he anticipates that he will fragment and dissolve into the clausDownloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
714
STUART S. ASCH
trum, merge with it, losing his own identity (with perhaps the
residue passed out as feces)?
T h e classical claustrophobe tries to deal with his phallic conflict by displacing his phallus onto his whole body. He then becomes afraid that his whole body (or phallus) will be damaged,
although the representation of its outlines remains essentially
distinct and intact. However, when the self representation is unstable, there is a tendency toward regressive fusion with the representation of the early mother and disintegration of the self. This
is the distinction between an intact Jonah in the whale’s stomach
as a foreign body, and a digested Jonah, no longer distinguishable
from the rest of the host’s body.
Case 1
A twenty-two-year-old borderline patient had a conscious conviction since at least the age of five that she would be abandoned by
her parents. At the age of four to six, she was in terror of the
basement in her home. Some unnamed dreaded danger existed
there. If she had to go down the cellar stairs, she would reassure
herself by passing a side door on the way. It was a reminder that
she could always dash through it to safety if necessary, an escape
from the unnamed danger (see “Pit and the Pendulum” below)
in the deeper basement. This danger gradually emerged as a dim
fantasy of a witch living in the cellar. This was associated with
Hansel and Gretel. T h e fear of the cellar could then be understood as a fear of the devouring, oral-cannibalistic mother. I n this
situation the “side door” served as an escape from the phobic
situation.
Several years later a different fear of the basement appeared.
She was now afraid that as she passed this side door on her way
down to the basement, mother would push her out the door and
leave her in the cold to die. Since the idea of being abandoned
and helpless was intolerable, she imagined she would just lie there
until she froze and died. T h e fantasy included the idea that her
father would find her there in the morning; but, unlike the General in Poe’s “Pit and the Pendulum,” he would be too late to
rescue her. Her bitterness and resentment toward the man who
failed to rescue her from mother were evident in all her dealings
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
CLAUSTROPHOBIA AND DEPRESSION
715
with men. This basic fantasy persisted to the present with some
variations.
Just before her twenty-first birthday both fantasies reappeared
in a combined form. Following an unhappy love affair, ending
with an abortion, her Weltschmerz became unbearable. Hopeless
and depressed, she felt life meant only a prolonged suffering. This
suffering was conceptualized in several dreams. In one she was
being packed tightly into a box with other victims. Some kind of
wadding is pressed into the spaces between the bodies. She will
slowly suffocate. T h e only reassurance was to think of a “side door”
out, suicide. (It was through the investigation of the “side door”
figure of speech and the current fantasy that the earlier material
and its connections with the present were uncovered.)
After several unsuccessful suicide attempts and a growing belief that she could not even succeed in suicide now, she began to
feel that her “side door” was no longer available. She felt there
was no way out of her oppressive, smothering, suffocating life
situation, and anxiety and severe agitation appeared. At these
times, the clinical picture was of an agitated depression, and two
brief hospitalizations were required as suicide precautions.
Much of this girl’s energies in later life were spent in obsessional attitudes about her appearance. She presented a faqade of a
beautiful, sophisticated young girl, always immaculately dressed,
flawlessly groomed, and well styled. She was compulsively clean
and tidy. No great emotion was ever displayed and no great desire.
Control, or in the current idiom, “cool,” was the main aim. For
example, she could eat only dainty little mouthfuls and had to
leave most of the dinner on the plate. All this was the fasade
necessary to disguise her “real” self representation of a disgusting,
evil, dirty, impulse-ridden character. Any pimple or other evidence of her “inner badness” bursting through would stimulate
real anxiety with the deeper fantasy that now all could be seen.
Unlike the picture of Dorian Grey, her sins of the flesh were not
projected and displaced. They appeared visibly on herself for all
to see. I n treatment she was preoccupied with a need to reassure
herself that I would treat her in “special” ways, and that I would
continue to keep her as my patient. She felt that it was “inevitable” that I would discard her, and she kept trying to anticipate
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
716
STUART S. ASCH
this. In addition, however, any breakthrough of a skin blemish,
etc., would convince her that this would provoke my displeasure
and that I would then throw her out for this reason. At these times
she felt convinced that I was finding her disgusting and worthless.
It was clear that this anxiety was associated with an image of herself as a bad stool to be gotten rid of (or, as emerged in a later
context, as the fetus that mother had aborted when the patient
was three).
Her object choices were narcissistically selected. They were all
good-looking boys, who dressed well, with a veneer of good manners and social poise, but who warded off any real emotional
involvement. As a result she constantly felt rejected and left out.
However, when on occasion she unintentionally became involved
with a man who mistook her overtures for the real thing and
responded emotionally, she would panic. Her initial reaction would
be to feel as if something was swelling up inside, rising up, bursting out (up and out of her mouth). Sometimes this would be replaced by a welling u p of nausea. Sometimes there would be a
feeling of being stifled, of smothering, and she would have to r u n
out of the relationship, the situation, or out of the room.
Case 2
This was a thirty-five-year-old man who had built up a large and
successful business enterprise. Nevertheless he was in constant fear
that people would find out he was really inadequate, stupid, and
that he indulged in shameful acts. If the people he needed and
admired recognized him to be the “shit” he felt he was, they would
abandon him.
Among his symptoms was a classic subway and elevator phobia. An unusual refinement, however, was an additional terror of
swimming under water. H e was afraid he would look up and find
that the round bottoms of boats were above him. This terror included thoughts of finding debris floating in the water. I t gradually
became clear that this fear of swimming under water involved an
identification with his mother’s expelled feces, and the associated
fear of being abandoned in the toilet bowl and flushed away by
her as worthless.
From infancy on, the patient was able to use several figures
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
CLAUSTROPHOBIA AND DEPRESSION
717
in place of both father and mother. His was a wealthy family dominated by a matriarchal grandmother. His ambivalence was split
between a beloved nursemaid and the hated grandmother. These
were the two main maternal figures presented in the analysis, with
his real mother pictured as a secondary and indifferent figure.
TVhen toilet functions were subjected to analysis, the importance
of his mother in the development of his anal-oriented object relations emerged.
From a very early age, he was required to have a bowel movement each evening after dinner. He would be forced to sit on the
toilet until he produced and his mother would then be called to
approve of the size and amount of his production. If his bowel
movements were “inadequate,” there was an immediate enema.
This toilet game was the main basis of his relationship with
mother, and from then on colored his relationship with all objects. H e developed a great interest in people’s “backsides,” which
persisted to the time of treatment, while he evaluated people
almost exclusively on the basis of how much money they earned.
There were only two categories: he “looked down” on those with
limited earning capacities and held them in contempt, while there
were those “far above” with vast, inexhaustible amounts of money
whom he admired and envied.
This patient could recall an unusual Isakower phenomenon
from childhood. Before falling asleep, he would sometimes have
the sudden frightening sensation that a tremendous piece of feces
was bearing down on him to crush him. Two dreams during the
course of the analysis might be mentioned here. I n the first, he saw
someone on the couch with the biggest ass in the world exposed
and looming over him. I n the second, he is in a little boat on the
Hudson River. Suddenly the biggest wave in the world starts bearing down on him. He knows it is the end.
A specific genetic determinant of the underwater fantasy was
his exposure to the Alorro Castle ship fire when he was seven. This
was a cruise ship that caught fire just off the Jersey coast and
burned for several days. During this period, dead and charred
bodies were found floating on the water and washed u p on the
beach. T h e overturned hull of the great ship itself was clearly
visible from the beach with its blackened, scarred bottom. His
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
718
STUART S. ASCH
parents rented one of the many small pleasure crafts that brought
sightseers out through the debris to see the spectacle. I t was not
established whether the patient went along, but his view from the
beach was certainly unimpaired. This long-forgotten memory had
not been connected by him with his underwater fear. (It is significant that he volunteered for the Navy during TVorld War 11,
aIthough he never did get to sea.)
Literature
I n his short story “Pit and the Pendulum” Edgar Allan Poe encompasses almost all the libidinal levels of the claustrophobic fantasy with varying intensity, Poe’s story is a perceptive, but chilling
description of the ego’s regressive flight from the dangers of phallic
confrontation with father. Safety lies in relinquishing any phallic
competition with father. But mother is not given up as an object.
Instead she is held on to through the fantasy of the whoIe body
returning to mother and entering the womb.
I n Poe’s story the hero is a victim of the Inquisition. Accused
of a never stated crime, it can be inferred that he is to be punished
for forbidden thoughts or acts against the Mother Church. A confrontation with the judging hooded monks causes him to faint. H e
wakes to find himselE tied up in a little room deep under ground,
away from his Inquisitors, and unable to move. Soon, however,
the phallic danger reappears i n the little room in the form of the
slowly descending scythelike pendulum of Father Time. Its razor
edge is inexorably inching downward to cut his heart in two.
(hlarie Bonaparte [4] has called attention to Edgar Allan Poe’s
frequent displacement of the phallus to the heart.) T h e regressive
flight to a form of claustrophilia has now created a new danger and
anxiety reappears. Once again he escapes the phallic danger
through the device of being eaten, this time by rats that eat away
his leather bonds. Again there is suddenly a new threat. T h e walls
of the room become red-hot and begin to compress, to squeeze
and push him out of thi! room into a pit. At the penultimate moment, just as he is about to be squeezed into the pit, he faints
again. This time he is revived by his rescuer, the General.
Poe suffered from severe recurrent depressions throughout
most of his life. An alcoholic, he finally died in a drunken stupor
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
CLAUSTROPHOBIA AND DEPRESSION
719
at the age of forty. hlarie Bonaparte’s classic study of Poe tends to
emphasize the phallic and oedipal conflicts in Poe’s writing. However, just about all of his writings are actually literary variations
of necrophiliac fantasies, or claustrophiliac or claustrophobic adventures. I n the “Pit and the Pendulum” Poe presented us with a
nightmare, in poetic form, of his obsessively recurrent theme of
being buried alive. Here he used entombing as a regressive device,
to ward off the disturbing, frightening confrontation with the
threatening phallic father (the hooded monks). But this regressive
defense results in a new and even more terrible (more primitive)
danger. There is now the danger of the claustrum of the preoedipal orally devouring fiery furnace of the primitive Earth
Mother (1).
T h e hero is unable to describe the terrors of the pit that he
can glimpse. It is too overwhelming a sight, and the reader is
cleverly left to fill in the blank with his own personal dreadful
fantasy. (This was also done i n Orwell’s 1984 in which the hero’s
worst fear was being eaten by rats.) This is then the threat of
either being separated Erom mother by being extruded from her
body as unwanted feces and flushed away, or the dangers of an
even more complete incorporation by mother leading to being
devoured by her with a complete and frightening loss of identity.
At the last moment, as he is about to be pushed into the pit, he is
rescued by his friend, the General, and “awakened.” This is
Lewin’s (11) classic awakener, the father who now becomes the
rescuer from the oral-cannibalistic mother. Poe is repeating his
theme here, that safety lies only in submission to father, in being
passively loved by him and giving u p mother as an object.
I am suggesting that the “Pit” represents the two prephallic
anxieties that confront the claustrophobe. One is the danger of
being passively squeezed out of mother’s body (abandoned and
flushed away like an unwanted stool), while the other is the danger
of a more primitive incorporation, a fusion with mother through
being crushed and eaten, with a terrifying loss of identity.
Depression and Claustrophobia: T h e Ego Aspects
When one examines the form of the object relations in claustrophobia, one is impressed with the many similarities to those usuDownloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
720
STUART S. ASCH
ally associated with depression. I n functional terms, the depressive
is involved in an ambivalent, narcissistic object relationship. H e
has, as an aim, the regressive fusion of object and self representations. I am suggesting that the aim in depression, claustrophilia
(a term introduced by H. Schlossman), and the phobia which
wards it off, is an attempt to recover or to hold on to a lost object,
through this kind of regressive fusion.
T h e depressive uses the fantasy of incorporating the object,
which he often experiences as if his self representation enclosed
or contained an ambivalently cathected object. This is a part that
is experienced as something “inside” that is no good, either as a
“foreign object” or even as the whole self representation (for
exceptions see Asch [3]).
T h e depressive affect relates to a special attitude of the ego
and superego toward this part of the self representation. Claustrophobia is similarly a special attitude toward something “inside,”
but the identical content has been projected and displaced as is
characteristic of the phobic. Now i t is the enclosing object itself
that is the “foreign object,” with the whole self representation
being inside this claustrum. It is then experienced as if one is
being incorporated by mother. She in turn has been displaced onto
the enclosing space, the claustrum. What has‘happened is that the
“inside and outside” have changed places, and the room is now
experienced as though it were actively enclosing the self, “the oral
cavity, in which the interoceptive and exteroceptive perceptive
systems are united. . in which inside and outside are interchangeable” (13). This may well be the genesis of the symbol of the
“cave,” the first receptacle and first object. This is mother, the first
woman. T h e primal cavity is originally experienced as part of the
self, but through its association with the mother it becomes identified as mother, the “cave.”
Both depression and claustrophobia imply an initial readiness
of the body ego to regress to a primitive, narcissistic cathexis of
the whole body. This seems to be a necessary preliminary step for
such primitive object relationships. Lewin has clarified this with
his concept of the “body as a phallus.” This is only one level of
body-image regression, however, since there are also certainly
.
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
CLAUSTROPHOBIA AND DEPRESSION
721
images of the body as feces, as in case 2, or as part of the mother’s
body, etc.
Both depression and claustrophilia can be characterized in
terms of Lewin’s three basic wishes: to eat (to take the object inside): to be eaten (to be inside the object); and to sleep (to fuse
completely with the object, with a loss of identity). When these
aims become conflicted (perhaps when too much unneutralized
aggression is involved) anxiety appears. T h e oral triad, to eat, to
be eaten, and to sleep, must now be warded off, and is replaced by
anorexia, claustrophobia, and insomnia. This is now the clinical
picture of an agitated depression. Clinically, however, the ego does
not always react with anxiety to being “enveloped,” for claustrophilia is in fact much more common, although less obvious clinically than the phobia.
T h e apathetic depressive, like the claustrophiliac, is not anxious. H e wants to sleep, wants to “dissolve itself into a dew,” to be
overtaken by death. It is the kind of depression one sees that is
characterized by a hopeless submissiveness with a passive wish for
death, and with little interest in real objects. For these reasons,
passive depression is a better descriptive category than apathetic
depression.
T h e mental representation of enclosing an internalized object
can shift to an identification with that same object. This involves
the transition in fantasy from eating to being eaten. I t is a transition that seems to be set off by a further regression of both the
body ego and the drives. It is experienced as “I give up,” a hopelessness. T h e yearning and the seeking, which previously recognized an outside object, are now anticipated with inevitable
failure. There is a feeling of emptiness, apathy, stupor, and sleep.
It is as though the self is willing to be eaten. For purposes of
exposition, such an aim could be expressed in the following form:
“Let me be eaten. If I can’t be cleansed a n d purified of the ‘bad’
part of me i n order to be loved and in this way recover the object
as an object-r
even more primitively as a part of me in me, then
I am willing to regress even further. My whole self representation
now becomes involved, and I am completely the bad ‘introject.’
Let my object engulf me, eat me up. I willingly give up my
identity because I will then be one with my object.”
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
722
STUART S. ASCH
This may explain the phenomenon of sleep hunger, so often
seen clinically in the passive depression. This is a special “sleep,”
and one that is symbolically closer to suicide. This involves a more
primitive wish than that of being an appendage of the loved
object, e.g., its phallus. I n that situation some of the ego’s integrity
remains intact. But this kind of sleep has the aim of complete
dissolution of the ego into the object. Jonah is no longer a fantasied introject, a bezoar in the whale’s stomach; he has now been
digested. This may also be one meaning of the passive suicide of
the alcoholic.
This fantasy of fusion derives from archaic memories and
fantasies of the symbiotic mother-child phase. A young girl (case
I), who had made several serious suicide attempts, would at times
become too passive for such an active role and would instead wait
longingly for death. She would then view it as her only hope in a
disappointing and hopeless world. At these times of quiet depression, withdrawal, and submissiveness, she longed for a fatal disease
or an automobile accident, i.e., for death to overtake her. There
was little urge to initiate the regressive action at these times, and
the real world was related to benignly and indifferently.
Ernest Hemingway often seemed to be preoccupied with a
similar conflict and he peopled many of his stories with such characters who were waiting to die. I n “The Killers” the Swede submissively turns his back to his killers and resignedly stares at the
blank wall; Pablo, in the early part of For Whom the BeZZ Tolls,
repeatedly intones “I do not provoke,” when his accusers try to
arouse him to attack, and he passively waits to be executed.
These people are immobilized from direct action. Their
drives are directed instead toward a passive engulfment by the
object. They have given up any other interests in real objects.
T h e ego’s attitude toward the claustrum (or in the case of
depression toward the self representation) depends upon which
aspect of the ambivalence is dominant, love or hate. T h e appearance of anxiety depends on which drive or derivative is being
projected. Does the “swallowing” object use predominantly (projected) libidinal or aggressive energies? That is, how much defusion of the instinctual drives, with their projection, is there?
Claustrophilia (and its counterpart of increased self esteem) reflects
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
CLAUSTROPIIOBIA AND DEPRESSION
723
a heightened libidinal cathexis between the eater and what is
eaten, while it is aggression that determines the unpleasure in
claustrophobia and depression. IYhen the passive wish to be swallowed involves a wish for fusion that contains an excess of free
aggression over libidinal energy (S), the ego responds with anxiety.
I t is this anxiety which, in my opinion, has a very close relationship to claustrophobic anxiety.
Clinical psychiatry has the old rule of thumb that the depressed patient who exhibits psychomotor retardation is not a
suicidal risk until he begins to be more active. T h e usefulness of
this has been proven many times. However, the unconscious fantasies associated with these ego states have not been delineated and
contrasted.
T h e contrast between the agitated depression and the passive
depression with psychomotor retardation is similar to the contrast
between the claustrophobe and the claustrophiliac. T h e relationship with the ambivalent internalized object is felt to be so destructive to the self that the individual is desperate to dissolve the
fusion and to separate from the terrible object. Clinically the
agitated depressive behaves as though he is desperately pleading
for a new good object to clutch, to help it to destroy and get rid of
the bad part of the self. T h e suicide aim of the agitated depression
has just such a basis. T h e claustrophobe is similarly desperate to
get rid of the terrible object by extricating himself from it. T h e
agitated depressive cannot tolerate being enveloped by the arms
of Morpheus in sleep, while the claustrophobe must run from the
confines of the elevator or subway train.
Agitation makes its appearance in the depressed passive patient or in the claustrophile (who then becomes phobic) when the
ego’s attitude changes, when the loss of identity into the claustrum
-primal cavity, mother-is anticipated with anxiety rather than
with pleasurable reunion. I t is the change of the ego’s attitude
from pleasure to anxiety, from the wish to be enveloped and
merged into the primal cavity to the fear of damage or the fear
of dissolution of the self representation. Clinically, we see the wish.
to sleep being replaced by insomnia. T h e pleasurable sleep, and.
especially the “sleep addiction” of the passive depression, changes.
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
724
STUART S. ASCH
to agitated wakefulness. In addition, the previously disregarded
external objects are now recathected and clutched.
T h e appearance of agitation in depression may even be considered as a restitutive attempt, since, as with the phobic, there is
now more involvement with objects. T h e agitated depressive feels
a need for action, and usually calls on people, pleadingly, clutchingly, for help directly. This seems more reality-oriented than the
passive wish for death.
T h e young girl (case 1) would exhibit this kind of shift from
a passive to an agitated depression that was clinically quite similar
to claustrophobia. On one occasion she had been hospitalized because of an increase in suicidal impulses. Once hospitalized she felt
greatly relieved and even comforted by the safe surroundings.
During one session she reacted unexpectedly and violently to a
comment describing her withdrawal and lack of involvement in
her surroundings and in treatment. She experienced a sudden,
overwhelming flood of anxiety. She felt she was choking, that something was welling up in her throat, and a desperate need to get out
of the hospital immediately. I t seemed to be closing in on her, she
felt hemmed in. T h e previous indifference to me changed to a
frantic imploring to help her, begging me to let her out. Up to
this point, she had felt protected and cared for in the hospital.
TVhen this reaction could be examined with the patient at a later
time, she recognized that at the moment of my comment she had
interpreted it as a criticism of her behavior. It meant that I was
displeased with her and would therefore leave and abandon her,
as happened in all her fantasies. T h e immediate reaction was the
feeling of an acute awareness of the oppressive hospital around
her with a frantic need to escape. T h e anticipated loss of the object
had led her to project and displace her conflict about me onto the
hospital, while the rage provoked by my “abandonment” of her
made it a danger. Here the agitated depression and an acute claustrophobic anxiety were almost identical.
T h e agitated depression and the claustrophobe stuck in the
claustrum do have many clinical similarities. Gehl speaks of the
depressive as feeling “stuck within himself.” T h e claustrophobe
must be in movement, must feel he can get out of the claustrumthat he is not fused with it, crushed or squeezed out, or cut off by
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
CLAUSTROPHOBIA AND DEPRESSION
725
it. Movement reassures him of his ability to escape. T h e sensations
of movement also recathect body images and outlines, reassuring
the classic phobic of his phallic integrity and the more primitive
phobic against fears of disintegration, fears of the self representation dissolving into the object. Constant motion is also characteristic of the agitated depression, probably also to ward off
dissolution.
Something similar occurs in the individual who wards off hypnosis. Here the struggle to stay awake is again to avoid being taken
over (i.e., swallowed up) by the hypnotist. T h e drowsy person
fighting sleep tries to keep at least part of his body moving (to
keep his body image cathected) in his attempt to keep it from
being engulfed and dissolved by sleep. When the person “gives
up” and surrenders his executive ego function to the hypnotist’s
ego, he behaves as if he has become an introject of the hypnotist,
as if he were a part of the hypnotist’s ego. TVhether this is as a
phallic appendage or total dissolution depends on the stability of
the cathexis of the body ego.
Such a passive aim is experienced as a danger when there is
too much unneutralized aggression. T h e anxiety then intervenes
and the ego struggles against the threat to its integrity in anticipation of the defenses being overwhelmed. T h e need to be actively
moving may be motivated by this need to maintain the self image
through physical stimulation and is also an attempt to return to
the active role of the engulfer.
T h e individual may see himself in the role of either the
claustrum or the introject. Such a labile shifting of identities is
derived from an inadequately developed distinction between object and self representations (also in certain “normal” ego regression phenomena as occur in pregnancy, febrile illness, etc.). These
identities are often interchangeable or confused, especially in the
infantile ego, where self and object representations are not very
discrete. Anna Freud and Burlingham (7) observed how little children under the age of two would feed the doll or mother, as
though it were as satisfying as feeding themselves. Anna Freud
(6) similarly observed that “the child . . adopts the mother’s role
thus playing mother and child with his own body.”
Spitz (13) has very carefully delineated the stage of develop-
...
.
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
726
STUART S. ASCH
ment in which both these identifications, self and object, internalized object and claustrum, are experienced simultaneously: “the
early intra-oral experience consists of taking into oneself the breast,
while being enveloped by mother’s arms and breasts. T h e grownu p conceives of this as two separate experiences. But for the child
they are one experience, single and inseparable, with differences
between the constituting parts, and each constituting part being
able to stand for the whole of the experience. This is essentially
the paradigma of Lewin’s formulation: ‘to eat and to be eaten.”’
Such an alternation or confusion is similarly anticipated by
Jacobson (9) who emphasizes the memory traces that “cluster
around this primitive, first, visual mother (breast-primal cavity)
image.” This is also related to the fusion fantasies and symbiotic
mother-child relationships of Mahler (12).
Confirming phenomena can be found in the psychic experiences frequently found in pregnancy. One is the common fear of
the pregnant woman that she will crush or otherwise kill the being
inside her. T h e other is the less well-known but nevertheless common, and perhaps universal, appearance of phobias at some time
during pregnancy. Phobias during pregnancy are much more frequent than reported (Z), and tend to disappear after delivery. This
can be understood as an identification with the fetus inside, and
sometimes is even accompanied by an urgent need to get the baby
out as soon as possible. This confusion of identities, with a labile
shifting between self and object representations, between the
mother and the baby, is perhaps most dramatically seen in the
postpartum psychotic depressions, where suicide and infanticide
seem to be alternative aspects of the same aggressive-destructive
fantasy.
This same alternation of roles is even more apparent in pseudocyesis when the pregnancy itself is a fantasy of an introject rather
than an actual fetus. T h e young girl of case 1 at times also presented an anorexia nervosa picture. Since childhood, her fear of
abandonment was tempered by the hope that at some time in
the future she would be pregnant or have a baby, and then everything would be safe and blissful. This was clearly with the aim of
re-establishing the mother-child unit by herself through reversing
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
CLAUSTROPHOBIA AND DEPRESSION
727
the roles. However, eating became regressively sexualized in later
life and anorexia appeared. When she would eat, her abdomen
would feel unbearably distended and she would have to make herself vomit and get out what was inside. This “inside” position ivas
of course the position in which she pictured herself at other times.
I would like to just touch on still another clinical variation
of these phenomena that occurs when the claustrophobic anxiety
and the reassuring ability to escape the claustrum are libidinized.
T h e tension becomes an aim in itself. I t is quite likely that the
science of spelunking (cave exploring) and skin diving are given
much of their drive incentive through this libidinized anxiety, i n
addition to counterphobic aims, infantile curiosity, etc. It would
be interesting to know the kind of problems that arise with the
crews of long submerged nuclear submarines; or what will be the
emotional problems of a spacecraft crew, who will be isolated,
cramped, and almost immobile in tight living quarters for long
periods of time.
At this point I can only speculate on the choice of depression
vs. phobia (pregenital), since reunion with mother is the aim of
both. There is a difference i n the function of object relations in
these two types. I t may be that those individuals who externalize
more, either as an ego characteristic or just‘ under certain as yet
unclear circumstances, tend to exhibit claustrophobia as the manifestation of their primitive object relations. I n contrast, the depressive tends to look for the lost object in himself, rather than
displacing onto new objects outside. Wangh (14) emphasizes easy
object displaceability and avoidance as factors most commonly
found in phobias.
I t is true that case 1, where depression predominated, had a
close ambivalent tie to mother and could not shift to new objects
easily. Case 2, who presented himself as a phobic, had been raised
by several different people, with the maternal role shared by nursemaid, mother, and grandmother. I n this respect he was very much
like Wangh’s patient who had several mother substitutes available,
which served to encourage the use of displacement. However,
these considerations will have to remain speculative until wider
clinical material is available.
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
728
STUART S. ASCH
Summary
1. Re-examination of the classic formulation of claustrophobia indicates the importance of anal and oral elements in
addition to castration anxiety. Fears of being squeezed out of
mother as feces or of being fused with mother are prominent in
those phobias resistant to analysis of the oedipal conflict.
2. Claustrophobia is shown to have several areas of similarity
to depression. Both are presented as specific reactions to the threatened loss of an object. T h e concept of an ambivalent introject
inside the self, in contrast to the concept of the self inside a threatening claustrum, are variants of a related fantasy. Such a substitution of object for self representations is shown to be derived from
early “primal cavity” memory traces, and may be due to a developmental failure of the ego to maintain a stable cathexis of an intact
self representation in the face of threatened object loss.
3. Clinical and dynamic distinctions have been demonstrated
between passive and agitated depressions. These distinctions are
shown to be similar to those existing between claustrophilia and
claustrophobia.
4. It may be that the clinical picture of claustrophobia appears in place of depression, when there is threatened object loss
in an ego that has developed a propensity for displacement and
avoidance.
BIBLIOGRAPHY
1. Alrnansi, R. Psychoanalytic interpretation of the Menorah. J . Hillside Hosp.,
3:3-18, 1934.
2. Asch, S. Mental and emotional problems in pregnancy. In: Medical, Surgical
and Gynecological Complications of Pregnancy, ed. A. F. Guttmacher & J. J.
Rovinsky. Baltimore: Williams & TVilkins. 1960, pp. 375-383.
3. Asch, S. Depression: three clinical variations. T h e Psychoanalytic Study of the
Child, 21. New York: ‘International Universities Press, 1966 (in press).
4. Bonaparte. Af. T h e Life and Works of Edgar Allan Poe. London: Imago, 19-19.
5. Fenichel. 0. T h e Psychoanalytic Theory of Neurosis. New York: Norton, 1945.
6. Freud, A. T h e role of bodily illness in thc mental life of children. T h e Psychoanalytic Study of the Cliifd, 7:69-81. New York: International Universities
Press, 1952.
7. Freud, A. & Burlingham, D. Infants Without Families (194). New York: International Universities Press. 1947.
8. Gehl, R. Depression and claustrophobia. Znt. J . Psychoanal., 45:312-323, 1964.
9. Jacobson, E. T h e Self and the Object World. New York: International Universities Press, 1964.
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016
CLAUSTROPHOBIA AND DEPRESSION
729
10. Lewin. B. D. Claustrophobia. Psychoanul. Quart., 43227-233, 1935.
11. Lewin, B. D. Phobic symptoms and dream interpretation. Psychoanal. Quart.,
21:295-322, 1952.
12. Afahler. AI. S. & Gosliner, B. J. On symbiotic child psychosis: genetic, dpamic
and restitutional aspects. The Psychoanalytic Study of the Child, 103193-212.
New York: International Universities Press, 1955.
13. Spitz, R. A. The primal cavity. T h e Psychoanalytic Study of the Child, 10:215210. New York: International Universities Press, 1955.
14. Wangh, AI. Structural determinants of phobia. This Journal, 73675-695, 1959.
Submitted October 10,1965
1172 Purk Avenue
New York, N.Y. 10028
Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on February 21, 2016