Autistic defenses in agoraphobic syndrome: "flat" objects and the retardation of projective identification

The function of autistic defenses in the generation of agoraphobic symptoms is explored in the case of a patient treated in psychoanalytic psychotherapy. The therapist's growing awareness of autistic modes of relating in the case facilitated various changes in the transference relationship. Although oedipal concerns are seen as important, a formulation is presented whereby autistic modes of generating experience are viewed as fundamental to an understanding of agoraphobic experience. Clinical findings in the transference-countertransference relationship led to the additional observation that the retardation of defensive forms of projective identification further contributed to the patient's agoraphobic difficulties. This formulation is tied theoretically to the idea that agoraphobic experience occurs when the dialectic between paranoid-schizoid and autistic-contiguous modes of generating experience collapses. The treatment implications of these observations are briefly explored.