I recently became acquainted with Shiri Ben-Bassat’s remarkable article “War in Times of Love: Prenatal Cell Relations as a Prototype of Autistic Anxieties, Defenses, and Object Relations” (Ben-Bassat, 2021). In this work, the author—formerly an immunologist and now a practicing psychoanalyst—reflects on what happens to the embryo, that is, on the very first forms of psychosomatic experience that arise long before birth and serve as prototypes of autistic anxieties, defensive mechanisms, and early object relations.

In her paper, Ben-Bassat draws upon the latest discoveries in immunology and recent findings in embryological research, as well as on the ideas and clinical observations of psychoanalysts such as Tustin, Bion, Meltzer, Bick, and Durban. In other words, she brings together psychoanalysis and biology—and does so in a way few have managed before her.

The author arrives at the intriguing conclusion that the first psychic experience is not acquired after birth but emerges when the human being still exists as only a handful of cells within the mother’s body. If we approach her text not as a scientific report but as a phenomenological description of the origins of the human psyche, we may say that she attempts to hear the first cry of the unborn—the cry of a cell seeking connection.

What, then, happens on the biological level? We know that the fertilized ovum begins to divide rhythmically and rapidly, and within a few days forms a “cluster”—a mass of cells that at this stage still lacks skin, cohesion, or any form of protection.

This cluster faces two essential tasks: (1) to withstand the aggressive attack of the maternal immune system, which perceives it as a foreign body and attempts to destroy it; and (2) to penetrate the cells of the uterine lining and attach itself there while continuing to multiply. Thus from the very beginning, each human life is both love and “war,” because union and attack occur simultaneously.

This “love-war” has three possible outcomes:

1. The destructive force prevails, and the embryo dies, dissolving in the uterus or resulting in spontaneous abortion.
2. The life force prevails, and embryonic cells begin producing a protein that “pacifies” the mother’s immune cells, which then shift toward supporting its development and implantation.
3. In approximately three out of one hundred cases (CDC, USA, 2023), the embryo implants in the uterus but has almost no regulatory effect on the surrounding maternal immune cells, continuing to develop under constant threat of destruction and disintegration. In such circumstances, the likelihood that the child will later be diagnosed with Autism Spectrum Disorder (ASD) is significantly increased.

What occurs in the uterus literally? Researchers (Ashary, Tiwari, and Modi, 2018) found that the embryo employs various coercive strategies to induce the uterus to accept it and allow implantation. Its cells “adhere” to the endometrium, which then envelops them. This adhesion is the first biological mechanism that protects the embryo from falling away or dissolving.

A decisive role in the implantation process is played by the hormone hCG (human chorionic gonadotropin). This hormone is produced by trophoblast cells (the precursor of the placenta), which themselves form the outer layer of embryonic cells. Rising hCG levels in the mother’s blood indicate pregnancy—that is, that the process of attachment and penetration of embryonic cells into the endometrium is proceeding successfully.

Recent molecular studies (Windham et al., 2016) have found that abnormal hCG levels—either too low or too high—correlate with an increased risk of ASD in the child. In other words, if hCG levels are abnormal, there is a high probability that embryonic development follows the third scenario mentioned above.

At the same time, contrary to idealized notions of prenatal harmony, “in the first trimester of pregnancy, the tissues connecting mother and fetus (placental tissue) consist of immune cells of maternal origin by approximately 40%. Moreover, most of these cells are uNK-cells (uterine Natural Killer cells)” (Ben-Bassat, 2021, p. 7). Scientific work (Mor and Cardenas, 2010) has confirmed that the interaction between fetal cells and the maternal immune system is far more complex than previously assumed.

NK cells are the immune system’s frontier lymphocytes. They are the first to respond to threats, destroying foreign invaders as well as the body’s own infected, malignant, or otherwise “suspicious” cells. Their distinctive feature is that they attack without prior “familiarity” with an antigen. uNK cells are a unique subpopulation of NK cells found exclusively in the uterus.

Researchers (Mandelboim, 2006; Ferreira, 2017) discovered that in a normal pregnancy, the embryo begins to produce a unique protein—HLA-G (Human Leukocyte Antigen, sometimes called the “molecule of peace”). HLA-G not only inhibits maternal uNK cells but also induces their radical transformation.

Under the influence of HLA-G, maternal killers turn into cells that promote life: they begin secreting factors that stimulate embryonic growth and neural development. Thus the amount of HLA-G produced by the embryo indicates the degree to which the life instinct outweighs the death instinct.

And, “in this context, it is not merely a metaphor, but a biological reality” (Ben-Bassat, 2021, p. 8). A literal miracle occurs. The more HLA-G the embryo produces, the weaker the maternal uNK attack becomes, and the more rapidly these cells transform into allies, actively facilitating the embryo’s invasion of the endometrial tissue. Destruction becomes nourishment; attack becomes connection.

But in certain cases—for example, when the mother suffers from depression (Herbert and Cohen, 1993), alcoholism (Crews et al., 2006), or carries specific genetic combinations in her DNA (Mankuta et al., 2016)—this mechanism fails. Maternal uNK cells do not transform; their normal activity is disrupted, and they either kill the embryo or allow it to survive while continuing to attack it.

Even if the embryo survives, from the first days of its existence it encounters a sequence of what Bion called “events,” receiving an experience so contradictory that it becomes bewildering. It becomes overwhelmed by unconscious proto-fantasies of a supernatural, chaotic, and aggressive universe, and of an alien object that simultaneously nourishes and destroys.

The fetus literally experiences unbearable fear—what Bion termed “nameless dread”—or the sensation of disintegration and dissolution (Bick), or the loss of the experience of the body-as-reliable-mother (Durban). These early proto-fantasies force it to rely on primitive defenses: withdrawal, massive detachment, the erection of rigid internal barriers. After birth, these same defensive mechanisms will negatively affect the child’s relations both with objects and with reality.

Later, all interpersonal relations of such a person will be permeated by “memories” stored at the level of cellular memory—traces of the “events” the embryo underwent in the uterus from the moment of conception. These traces become the background of all object relations. Dominating them are anxieties about not being able to hold on, about falling out of the “maternal” womb, and about the potential disintegration of the self following such a fall.

The child will have profound disturbances in the sense of continuity of being. They may experience themselves as if perforated by “black holes.” The traces of that initial struggle manifest as persistent fears of falling, fragmentation, and dissolution, as well as a defensive attachment to autistic objects and forms.

These early cellular experiences become, in essence, the matrix for future psychic mechanisms: autistic defenses, sticky objects, “skins” and “shells,” described by Meltzer, Bick, and Tustin. Maternal uNK cells attacking the embryo thus become the proto-image of “destructive objects”—those earliest internal figures that in psychoanalysis signify the threat of engulfment or annihilation.

The title of the article, “War in Times of Love,” is an oxymoron reflecting the core of the author’s idea: the act of implantation is a war occurring inside an act of love. Implantation is a scene of violence in which the embryo fights for life by “biting into” the endometrium, and the maternal immune system responds with aggression.

Yet it is precisely this clash that becomes the foundation of psychic development: to be born, one must endure contact with the other. Psychoanalytically, this is a proto-drama of object relations, in which the maternal body is the first object that both nourishes and destroys. Psychic life emerges as movement between these poles, from which the innate duality of all human relations arises: love and fear, need and revulsion, fusion and destruction.

In the clinical section of her paper, Ben-Bassat describes the analysis of a four-year-old girl named Yael. She vividly demonstrates that when working with the most severe patients—autistic, psychotic, deeply traumatized—we encounter not symbols or narratives but living traces of cellular memory. Such patients bring into the consulting room not thoughts but sensations: heat, cold, fear of breathing, terror of contact, and so forth.

The central contribution of the article is its opening of a new horizon for psychoanalytic thinking about the origins of the psyche. The author argues that each of us carries within us the memory of that first war—between life and death, union and disintegration. This memory later resurfaces in dreams, in love, in anxiety, and in therapy. Understanding this helps us approach autistic and traumatic phenomena not as “deviations,” but as echoes of real biological events—evidence of a primordial struggle for survival.

PS. The images show the stages of embryo implantation into the endometrium: apposition → adhesion → invasion → complete implantation.

Bibliography:
Ashary, N. Tiwari, A. and Modi, D. (2018). Embryo Implantation: War in Times of Love. Endocrinology, 159(2): 1188–1198.
Ben-Bassat, S. (2021). War in times of love - Prenatal cell relations as a prototype of autistic anxieties, defenses and object relations. Paper that won the 24th Frances Tustin Memorial Prize, 2021. Tel Aviv University, November 5th, 2021.
Crews, F. T. Bechara, R, Brown, L. A. Guidot, D. M. Mandrekar, P. Oak, S. Qin, L. Szabo, G. Wheeler, M. and Zou, J. (2006). Cytokines and alcohol. Alcoholism: Clinical and Experimental Research 30(4): 720-30.
Ferreira, M. R. Meissner, T. B. Tilburgs, T. Strominger, J. L. (2017). HLA-G: At the Interface of Maternal – Fetal Tolerance. Trends in Immunology 38(4): 272-286.
Herbert, T.B. and Cohen, S. (1993). Depression and immunity: a meta-analytic  review. Psychological bulletin 113(3): 472-486.
Mandelboim, O. et al’ (2006). Decidual NK cells regulate key developmental processes at the human Fetal maternal interface. Nature Medicine 12: 1065 – 1074.
Mankuta, D. et. Al. (2016). Paternal HLA-C and Maternal Killer-Cell Immunoglobulin-Like Receptor Genotypes in the Development of Autism. Front. Pediatr., 4: 76.
Mor, G. and Cardenas, I. (2010). The Immune System in Pregnancy: A Unique Complexity. American Journal of Reproduction Immunology. 63(6): 425-433.
Windham, G. C. Lyall, K. Anderson, M. and Kharrazi, M. (2016). Autism Spectrum. Disorder Risk in Relation to Maternal Mid-Pregnancy Serum Hormone and Protein Markers from Prenatal Screening in California. Journal of Autism Developmental Disorders 46(2): 478-88.