CONCEPT OF AMMON - THE HOLED EGO

Prof. Dr. Luiz Miller de Paiva
Adjunto Prof. of Behavior Science Escola Paulista de Medicina, member of the National and International Societies: Int. Psychoanal. Ass., Psychosomatic Med., Psychosom. College, Japanese Psychosom. Med., Dynam. Psychiat. and Group Analyst Psychotherapy.

Ammon (1,a,b) believes that certain psychoses and psychosomatic diseases are the result of early disturbances in the development of the ego based on severe narcissistic injury - narcissistic deficiency of holed ego - in the symbiotic relationship of the infant with its mother in the primary (familiar) group; he does not deny the importance of the genetic somatic factors in the etiology of the holed ego; however, he emphasizes motherliness and the “social energy” (engendered by interindividual and group dynamic relationships) in the origin of this disease. Ammon (1,b,c,d) denominates as the archaic ego disease, the psychotic reactions of schizophrenics, the cyclic manic-depressive forms of the borderline syndromes, sexual perversions and certain psychosomatic diseases.

The characteristics of these diseases are shown by the arrest or mutilation in the development of the identity and of the ego, in framing the pre-Oedipian mother-child symbiosis which lead to the lack of support to the child in building the frontiers of its ego and of its ego development, mainly in its constructive aggressivity due to previous traumatic anxieties (separation and destruction), which kept it from elaborating a coherent and flexible structure of its ego.

The symptoms of archaic ego diseases differ basically from the symptom of Oedipal neurosis. In this neurosis, we can understand the symptom as an expression of intrapsychic conflicts between developed psychic instances which remained unconscious, owing to regression (suppresion) and whose dynamics of evolution in the unconscious leads to the ego, which was initially coherent and functional, becoming partially disturbed and hampered both in its living-out and
behavior.

Ammon says (1,a): "it is not possible, through the symptomatology of the archaic ego diseases, to show a differentiation and delimitation of psychic and structural instances. The symptom does not show, therefore, disturbance of the ego, in the sense of any alteration in its functionality, but rather, serves as compensation for a structural lesion, in the sense of a "deficit" of narcissism and as a defense from the anxieties of separation and destruction invariably related to a "hole in the ego". From this double characteristic of the symptom, which in one case appears as a disturbance in the structural and functionally developed un it, and in another case should serve as a substitute for a structure that is not developed, specific differences are derived also in the psychoanalytic treatment of the archaic ego diseases. The child whose ego-functions in development was impeded by an inexperienced or, also, openly hostile mother, or by a mother and an aggressively primary group, as dependent an the mother as the respective people.
Essential functions of the ego of times are not developed or are negatively deformed by the effort of the child to come up to the needs and to have fear of the mother, a dynamics, that shows up, particularly, in the genesis of disease of the ego with psychosomatic reactions. After separation from the primary group, we see the patients in search of substitute objects, that may assume the functions of the primary group and to which the patient may delegate the functions of the delimiting ego of control, integration, defense, etc.

This strong ambivalence that regularly determines the forced unconscious repetition of the symbiotic relationship, leads more and more to difficulties and, finally, to the greater or lesser destruction of the pathological relationship. The patient experiences sudden abandonment by the objects to which he delegated the functions of the ego, and, consequently, engenders an eruption of the symptomatic behavior that acts as a defense of the unconscious fears of abandonment and destruction. The child interiorizes the group of his earliest infancy. Using an adequate expression, Stierlin (18) talked about the "gyroscopic function" of the interior objects, based on the gyroscope, a nautical instrument which stabilizes the ship on the correct raute, against the forces such as winds and current. In patients with a sick ego, this function would, essentially, be upset. The patient who, in early infancy, suffered extreme abandonment by the mother (primary group), a true scaffolding for the young maturing ego, and who, for this reason, was unable to delimit the identity of his own ego, and to separate himself as a personality with its own right, without feeling of guilt toward the mother and primary group, is forever in search of objects to assume the role of good internal objects and that will offer him protection from the destructive dynamics of the interiorized group; on the other hand, he, also, will always require situations that represent the situation that first generated the infirmity of the primary group".

Mannoni (13), among other observations, mentions the fact that at times a young ego is not allowed space to grow, through the undue invasion of unconscious elements which are forthcoming from the parental group.

Thus, in these patients, who would always meet up with setbacks in constructive aggresion, mutilation of identity, loss of the limits of the ego and a constant fear of abandonment and defenselessness, this could lead them to a desperate search for new symbiotic bonds, to compensate for what was lacking in the past. Such bonds, however, would end up by updating the pathology of the former conflict-generating bonds.

Ammon (1,e) justly observes how the psychosomatic symptom is invariably preceded by anaclitic depression, through a deficiency of narcissism, through a lack of healthy symbiotic bonds at a time when they were essential to psychic survival. The symptom would be taking the place of a "hole"; therefore, to remove it would only increase this void, favoring a break of the remaining ego functions.

We also always valorize the first molding periods (the first (14,a) emotional and intellectual mother-child relationships) at a time that is specially narcissistic and symbiotic for the baby, and that, according to the vicissitudes of this phase, will lead to psychic health or to a pathological state.

A holed ego is similar to Balint's (4) basic lack, to the first site of the Jungians' critical distress, and to the nucleus of critical distress described by Gomes (9). "Such flaws or holes or sites would have been structured at the very beginning of the baby's emotional development, owing to repeated and constant traumatic experiences and, where there should have been a first outline of a psychic" object and is attributes and a consequent primary identification, there would be these gaps or holes or flaws.

The affective expression of these "flaws" would be of a depressive nature, painful and unstructuring, affording mental states of depersonalization, due to the constant threat of panic, death and sensations of inner emptiness, without the slightest hope of protection.

As a defense against the force of attraction exerted by these primitive traumatic experiences, the most powerful and creative defenses are elected by the human mind, including delirium, hallucinations and autistic states.

To relive these experiences in analytic transference would become less remote by the fact that in the analyst-analysand two-some, a state of mind can be schieved that is able to tolerate the pain and share it together, rather than by the capacity to provide a well-elaborated interpretation, for the nomination of these affective states for such analysands would always be threatened by their first failures which occurred in relations ot the world, as a first delimiting receptacle".

"In work with analysands who present this structural peculiarity that is so faulty, in the experience of analysis, to broach Oedipean aspects of fantasies relating to more evolved levels of the mind, would be similar to making a full-length film, where they would see images parading before their eyes, spoken in a foreign language and inaccessible to them and to their personal living experience. They may, of course, learn the language of the analyst, mimic it, be enthralled, adhere to certain aspects of the analysis, which would gravitate around their empty nucleus of pain, hidden, inaccessible, an expression of the traumatic flaws in the ego, defended by psychotic defenses".

The analyst, who should represent a primary object who must know everything, is quickly transformed into an object of hate, for the reflector and containing object is something so indispensable that to lose it would mean losing themselves (14,c,d).

The difficulty of introjection and symbolization, occurring concomitantly with a yearning for fusion, cause these analysands to establish extremely regressive levels of contact, within the analytic experience, where the living-out of separation from the analyst is equivalent to death.

Excessive primary envy described by the Kleinians would be the driving spring of the violent fragmentation of the good object and of the impossibility of introjecting it, as also intolerance to frustration that, associated to excessive greed, demands more and more from the object, in an insatiable yearning, rendering it difficult to perceive the existence of gratifying moments. The "scattering" of senses seems to bring, as result, an in capacity for the stable introjection of the object, producing, in that case, the dismantling of the mental structure and of the state of "dementalization". This autistic retreat from the world, says Meltzer, would be to avoid psychic pain, persecutory anguish and despair (12).

According to Meltzer (12), the difficulty to contain objects withing the mind would, therefore, be related to a lack of internal psychic space, owing to the nonintrojection of the first primary containing psychic object and a consequent primary non-identification. As a defense, the mind would cling to another type of identification that he named adhesive identification, producing an extraordinary dependence on the external object, not only to its care but also to its mental functions.

Rosenfeld (16) believes that in cases of severe parasitism, the hate on perceiving life outside it would dominate the analytic situation and prevent the patient from receiving the analyst's help.

Sapienza (17) proposes mental activity opposed to everything that is a living bond with some object, aiming at an illusory self-sufficiency. For this purpose. This type of patients use a violent attack on everything that will bind, both the self and the internal and external objects, generating a state of interior emptiness in the subject, that is filled by depressive paranoid coloring.

To obviate such suffering, the subject would attack the consciousness of himself and of his emotions, seeking a state similar to Nirvana in Buddhist terminology or to beatitude. We believe that the alterations in the erogeneity in the libidinal interior within the ego for the anguish of death, represents the anguish of castration, because it attacks our feeling of omnipotence, in other words, if we are not what we imagined we were, we are nothing, we are a vacuum (14,e).

Andreucci (2) investigates archaic situations experienced in the analytic process, in which prevail a lack of organization, a lack of rhythm - anguish in face of the prospect of "not being". The patient would use immobility as a defense in face os such a state of total abandonment to preserve something that is basically fragile, continuously threatened by the dynamic relationship with the analyst. And according to Bion (6) certain patients then use reversion of perspective that he refers to as static splitting.
Andreucci (2) conjectures that it would be static due to the fact that these patients feel immobility as a guarantee and movement as something that is a threat to the existential situation. A patient can make use of massive projective identification, that is, he can project himself into the object, resulting in a feeling of disappearing into the other, the living-out of non-existence.

Based on these principles, I explained, a long while ago (14,a,b), the psychosomatic mechanism of asthenia, myasthenia and of catatonia. Also, his concepts would explain the immobility of Narcissus in face of his image in the lake, as we have said, for through immobility in space and in time he would never grow old, the fear of losing his beautiful body and reveal what he has in his mind - homicidal fantasies (14,c)(against the bad mother).

In the archaic ego diseases, Ammon (1,a) believes that the interpretative technique should be preceded by support therapy of "stabilizing urgency" in which the therapist will function as auxiliary ego". In this period of preanalysis, it will be verified if the patient has the prior conditions for analytic therapy within a classic situation: if he understand his symptomatic pathological behavior, and if his
motivation is sufficiently strong to think and to alter his living experiences and behavior. Only when these conditions have been met will therapy commence, to interpret the patient's intrapsychic conflicts".

To Ammon (1,a) in the archaic ego illnesses, the symptom is the substitute for an absent psychic structure (which, as I have already said, is not the expression of conflicts between developed psychic instances, as in neurosis). The "specific objective of support therapy consists in these cases, before the analytic-interpretative work, in dealing with the patient's extreme fears of being abandoned", originating in the pre-Oedipal phase, in these cases there will be a deficit of narcissism, a detaining of the development of the identity and of the ego, in the framework of the mothe-child symbiosis that led to a support that was not adequate in constructing the limits of the ego, in developing primary functions, in constructive aggression and in delimiting identity itself".

"The archaic-symbiotic dependence of the objects of the primary group, undifferentiated and dangerous, would express itself in the symptom that would be a defense against the fears of separation and of destruction, invariably related to a "hole in the ego" (similar to Winnicott's concept of a "deprived" child) (19). "For this reason, this type of patient is not really analyzable and support therapy must gradually provide conditions for his analyzalibity, substituting immediately what the patient lacks, that is, a last external structure (the "scaffolding") that he has tried to replace with his pathological group behavior. "The therapist must immediately help him to organize his situation in life and at work, must talk to him about the real problems related to this, and give direct instructions". "Before anything else, the client requires a symbiotic union with on auxiliary ego. This must be recognized by the therapist who must say that the existential fears, are the answer to a real deficiency (real abandonment)".

"The therapist must not, beforehand, restrict himself to being a mirror and a projecting screen to show that he is willing to help the client in delimiting his identity". "Only when the therapist makes if clear that he is willing to fill the ego left by real abandonment in early infancy and to compensate, as an auxiliary ego, for the deficiency of narcissism, will the patient's ego accept the analytic situation".

We are in complete agreement with Ammon (1,a,f,g) that the therapist cannot restrict himself to being a "mirror and projecting screen", but that he must often act as an "auxiliary ego" (and at times, even as an "auxiliary super-ego"). However, we have observed that such aspects are also found in insight therapy. Withing as analysis, by our posture, tone of voice, constant presence and by our interpretations that show respect and understanding for the patient's problems, we can show that we are interested, affectively, in them.

As for observing together with the patient, his possible real difficulties in life and at work, we do not find any contradiction with therapy that, such as the analytic has among its objectives to and the patient to attain a judgment of reality and the better use of his external and internal resources (14,b).

Maggi (11), Mario Pacheco (15) and we (14,b) ourselves believe that possibly, because the definition of psychoanalysis provided by Ammon (1,a,b) is more circunscript than our own, this would explain his need to complete it with prior support therapy. In fact, Kernberg says that "should the analyst perceive an impasse, he may modify the treatment to a support approach (10).

To us (14,b), Maggi (11) and Mario Pacheco (15), "to work on the client's extreme fears of abandonment", as advocated by Ammon, "is already to work on his anguish analytically; we can dispense with the resources of another therapy described as support therapy; also it is within analysis that we feels it is possible to deal with the patients desire for symbiosis, not only interpreting, but we become, according to Piera Aulagnier's (3) advice, the "prosthesis ego of the other's ego", while he requires such support.

Maggi (11) believes that "many of our interventions offer support" to the client, interpreting his wishes and the reality of what is occurring at the meeting, without leaving "insight" therapy, that deals with transferential and counter transferential data.

Transference, in Bleger's fine definition is the "up-dating of living experiences" (7), in that it can convey in the "here" and "now" of the session, both Oedipal anguishes and those of the pre-Oedipal period; it will be in this that we will be able to feel the client's "holes in the ego" that will be gradually "filled in" and, if the client finds a "good containe" in us, he can place his preoccupations, dysfunctions, aggressions, receiving something in return that has been largely elaborated by our feeling and by our thought.

At the actual moment of encounter then, "the introjection of the good object" and a firm point of support will occur, so essential for the development of the ego that he felt was missing in the first interpersonal relationship in his past. We would also see no obstacle, within analysis, in leading the client to overcome the delimitations of his identity, overcoming even confusional states, where the ego connot be distinguished from the non-ego, good from bad, "within" from "without", "real" from "fantastic". Or yet, in dealing with his deficit of narcissism. As to updating the mother-baby dyad within the setting and the possibility of dealing with archaic material coming from the original symbiosis, we also feel here the proposal and the objective of the aalyst's work; since he is always dealing with the first object relationships, that are for earlier than Oedipus. We believe that therapy that offers only support, would run the risk of being somewhat superficial in the elaboration of these previous emotional situations. Where as analysis is an eminently reconstructive and integrative therapy, it would, in our opinion, allow us to better fill the "holes in the ego", favoring the development of its functions. Obviously this will depend on the good use of a technique that "interprets" what is occurring in the interpersonal dynamic field of the pain in which, as shown by the Barangeres (17), many other structures continuously overlap with the real structure, which is the encounter of an analysand with his analyst. And when we use the word "interpret", we include not only the use of the word but also postures, acts, attitudes, and affective guidance that will allow the client to grasp that he was understood, in his needs, and we act as good, interpreters and receptacles of the same" (14,f).

"Good understanding, for example, of Bion's outlook would certainly help us to understand how the function of the client can change itself into an alpha functions, causing his psychic apparatus (formerly similar to an intestine that only "evacuates" to become an apparatus for "thinking thoughts" (6).

In the technique recommended by Ammon (1,a), we found some important aspects as never loss of “fleating attention” that might create difficulties. The first of these, by the prior and directive choice of two different therapies that would, necessarily, follow each other, there might be the risk of an inevitable loss of "floating attention". Besides, to focus too much on the client in terms of diagnosis, makes it difficult to see him in his unique specificity. This is why modern trends in psychoanalysis advise us not to base ourselves on prior diagnoses while we are working with the client.

Ammon (1,a) proposes to interpret the real loss of the dyad on the part of the client, from the every start - that is, the lack of support that he really felt, including in this feeling both the possibility of real abandonment on the part of the mother, and a subjective interpretation of the client, which however, does not correspond to the true history of his past.

In his work, Maggi (11) makes an interesting observation we will to confirm the importance of the concepts of Ammon (1) by a example the same time, to reaffirm his position of his criticism of him.
A girl, single, a socialogist, went to him for treatment because of a depressive state and attempt at suicide. She had a stomach operation for a duodenal ulcer, which obliged her to eat at short intervals. At the age of 3, she had last her mother who gave her little affection (and who was always ill in bed). She was brought up by a Hungrian nursemaid for which reason she only spoke Hungarian and only learned to speak Portuguese when her stepmather dismissed her nursemaid. She had no affection for her father who brought home several stepmothers. During her analysis she revealed, by association of ideas, that she felt mutilated in an internal organ, similar to her dead mother. She had sexual fantasies about her brother, however, they were not genital fantasies but pregenital and unconsciously, she would allude once more to the first lost symbiotic band with her mother and to constant dissatisfaction, her depression alternating with attitudes she described as "madly irresponsible", that is, in which she was able to do everything with great inconstancy and promisculty, and playing varied roles. As analysis proceded, she was able to feel the analyst as a good object; however, she was in constant anguish of one day being abandoned by the analyst (that diminished only after the elaboration that she was punishing herself because she felt guilty for her mother's death - a distortion that was recognized by the patient herself).

Our point of view concerning the holed ego is similar to that of Mario Pacheco (15) and Maggi (11). We should like to emphasize, however, that we regard Ammon's concept as being of great use, for the more holed the ego, the more fragile it will be and the more difficult the therapy will be. In his concept, we can valorize, even more, the genetic importance in the origin of the psychoses. An ego that is born fragile and meets with the kind of mother described by Ammon (1,b), will evidently aggravate the baby's envy and his homicidal fantasies that are the cause of so many feelings of guilt. The more aggressive the child, the more it will throw this aggressivity on its parents and on the family and will eventually receive it back, thus further worsening its conflicts.

It is under these conditions that projective identification is of capital importance, for through it, the boomerang system is formed, that is who ever shows aggressivity, will eventually receive it back - these are the Bionian bizarre objects or the Lacanian corps morcelés. We had cases of psychotics (paranoid schizophrenia and one borderline case) supervised by Bion and Rosenfeld, they said that, at a given moment, the patients were needing not an interpretation of content, but only that they should feel they were being understood by the analyst. This situation reminds me of all the discussion we had at the International Forum of Psychosomatic Medicine, held in São Paulo in 1981, with prof. Ammon, on analytic technique of psychotic and narcissistic patients. Interpretations must be cautious. We may even run, away from interpreting very deep contents (I am not saying we should never provide a deep interpretation) but must let the patient know, that we do understand him, as well as the causes of his anguish and despair; it is not exactly a support psychotherapy; it is, however, support provided by means of analytic knowledge based on projective identification.

Prof. Ammon acted correctly intuitively, having in mind his case of alcoholism and homosexuality, in which he explained that the internal void and the loneliness of this patient were the main motives for his analysis and, not the normal causes, however, there was lack of use of an analytic technique that was more refined, which is the Kleinian, Bionian or Lacanian manner of acting.

By means of this discussion, we may conclude with the fallowing concepts:

1. A patient with a holed ego has a disturbed "gyroscope".

2. A patient with a holed ego lacks affection (Winnicott's deprivé) (19).

3. With a patient with a holed ego, we must interpret not only the real loss of the parents, as also, the loss owing to fantasies.

4. A patient with a holed ego lacks an external structure (scaffolding).

5. A patient with a holed ego may be "used" by the family as a "scapegoat" for, without it, the family would be disaggregated.

6. The patient with a holed ego, requires that the analyst be the "prosthesis ego of the ego of the Other" (8).

7. A patient with a holed ego must be understand, owing to his excessive fear of being abandoned; proceed with a "stabilizing urgency" before interpreting the contents.

8. A patient with a holed ego needs to count an the support and "reverie" of the analyst, by means of his constant presence, attention and full of therapeutic Eros. It is after these facts, that there would be greater and better understanding of the causes of his conflicts in the transferential "here and now".

9. If the patient with a holed ego finds the analyst a good receptacle, the latter will fill the holes (the patient's preoccupations, anguish, aggression, distress, love, hate, negative throughts, will be thrown onto the analyst - all to be metabolized and to return to their own holes). The attitude, posture, affection, "reverie" of the analyst will allow the patient to feel that he is being understood and may, then, transform his mental beta functions into alpha functions, in the words of Bion.

10. A patient with a holed ego exerts an omnipotent control over the analyst, so that the latter is transformed into something he is not. The good breast (good analyst) mitigates this attitude of the baby (the patient); on the contrary, fear of the breast (fear of the analyst's interpretation) leads so the use of evacuation (he will not accept the interpretation) as in the case cited by Mario Pacheco (15) in which the patient had suspected typhus or cancer. This is a schizoparanoid episode expressed by an attack on the body (diarrhea and colic). The analyst must gather up the pieces (corps morcelés) for therapeutic efficiency, for the anguish of abandonment causes the threat of disintegration.

11. In a patient with a holed ego, there is on object without coupling with the subject, for which reason no mental concept is formed.

12. A patient with a holed ego may be in a defensive position that must be evacuated from the mind because it contains much death instinct. In both cases, these conditions must be transformed into verbal elements for later progress (14,a).

BIBLIOGRAPHY

1. AMMON, G. a) The genesis os schizophrenic reactions caused by Ego-Structural, Socio Energetic and Groupdynamic Factors and a Corresponding Method. Special Conference in Forum Internacional de Medicina Psicossomática. São Paulo (Brasil), 6-11, April, 1981. b) Das narzisstische Défizit als Problem der psychoanalytischen Behandlung technik - Ein Beitrag zur Theorie und Praxis der nacholendem Ich-Entwicklung. Dynam. Psychiat. 27: 201-214, 1974. c) Die Psychodynamik der Psychosen der Symbiosekomplex und das Spektrum der archaischen Ich-Krankhetten. Dynam. Psychiat. 6: 255-372, 1973. d) Psychosomatic Illness as the Result of a Déficit in Ego Structurs under Consideration of the Genetic Dynamic Structural and Group Dynamic Point of View. Dynam. Psychiat. 50: 179-189,1977. e) Die psychosomatische Erkrankung als Ergebnis lines Ich-Strukturellen Defizits. Dynam. Psychiat. (Berlin) 51:287-299, 1978. f) Das Ich-Struktkrellan und gruppendynamische Prinzip bei Depression und psychosomatischer Erkrankung. Dynam. Psychiat. (Berlin) 59: 445-471, 1979. g) Entwurfeines Dynamisch-Psychiatrischen Ich-Struktur-Konzepts-Zur Integration von funktional-struktureller Ich-Psychologie, analytischer Gruppendynamik und Narzissmus-Theorie. In: Ammon, Günter (Hrsg.) Handbuch der Dynamischen Psychiatrie. Bd. 1, (München: Ernst Reinhardt Verlag), 1979.

2. ANDREUCCI, J. C. Contribuições para o estudo de situações arcaicas vivencia- das na situação analítica. Rev. Brasil. Psicanal. 3: 312-340, 1969.

3. AULAGNIER, A. "A violência da interpretação". Trans. M.C. Pellegrine. Ed. Imago. Rio, 1979.

4. BALINT, M. The basic fault: therapeutic aspects of repression. Edit. Tavistock. London, 1968.

5. BARANGER, W.M. Problemas del campo psicoanalitico. Edit. Kargueman. B. Aires, 1969.

6. BION, W. a) Aprendiendo de la experiencia. Trans. H. Fernandes. Edit. Paidós, B. Aires, 1966. b) Second thoughts. Edit. W. Heinegan. London, 1970.

7. BLEGER, J. Simbiosis y ambiguidad. Edit. Hormé. Buenos Aires, 1972.

8. BRENMAN, E. O narcisismo do analista, seu efeito na prática clínica. Lecture at the Soc. Psic. S.Paulo,1982.

9. GOMES, M.C.A. O núcleo da mágina crítica. Lecture at the Soc. Psicanal. S.Paulo, 26-VI-1985.

10. KERNBERG, O. Borderline conditions and pathological narcissism. Edit. J. Aronson, N.Y. 1975.

11. MAGGI, A. A commentary on Dr. Gunter Ammon's contributions regarding depression and psychosomatic medicine. Forum International of Psychosomatic Med. São Paulo, 1981.

12. MELTZER, D. The human expansion of Freud's metapsychology. Int. J. Psychoanal. 62: 177-185, 1981.

13. MANONI, M. A criança, sua doença e os outros. Edit. Zahar, rio, 1976.

14. MILLER DE PAIVA, L. a) Medicina Psicossomática, psicopatologia e terapêutica. Edit. Artes Médicas. S. Paulo, 1993, 1000 pgs. b) Psychosomatic Psychiatry. Edit. Garatuja, São Paulo, 1990, vol. II. c) Witch message in group therapy. Group Analysis. (London). 7: 84-86, 1975. d) Phases of psychosexual evolution in a group. Attempt to dismantle the combined figure. Dynam. Psychiat. (Berlin) 46: 387-405, 1977. e) Tanatismo vol. I - Crime. Psicanálise e Psicossomática. 1981. vol II - Depressão e Suicídio. Psicossomática e Psicanálise. 1982. Edit. Imago, Rio. f) Técnica de Psicanálise - filigranas e bricolage. Edit. Imago, Rio, 1987.

15. PACHECO DE ALMEIDA PRADO, M. a) Brief psychoanalytical approach to psychosomatic manifestations. International Forum of Psychosom. Med. S. Paulo, 1981. b) Identificação projetiva com elementos básicos de percepção. Algumas considerações sobre o aspecto técnico do tratamento psicanalítico da depressão. Rev. Brasil. Psicoanal. 4: 5-27, 1970. c) Narcisismo e Estado de entranhamento. in collab. with BARROS, J.C.; JUCA, G.P.; HONGSTEIN, H. & SAUBERMAN, P.R. Edit. Fonfon. Rio, 1978.

16. ROSENFELD, H. Os estados psicóticos. Trans. J. Salomão & P.D. Correa. Edit. Zahar. Rio, 1968.

17. SAPIENZA, A. Contribuição ao estudo psicanalítico da depressão psicótica. Lecture Soc. Brasil. Psicanal. S. Paulo, 1977.

18. STIERLIN. A. a) Aus der Sicht des Distanzierten Beobachters. Psychê. 13: 742, 1959. b) apud Ammon opus cit pg. 212.

19. WINNICOTT, D.W. a) A criança e o seu mundo. Trans. A. Cabral. Edit. Zahar. Rio, 1972. b) Therapeutic consultation in child psychiatry. Edit. Hogarth Press. London, 1972.