Friday, December 10, 2010

Stuttering and destructive impulses in an Autistic patient

A man in his late forties, who lives in a supervised setting because he carries the label of Developmentally Disabled, suffers from crippling stuttering. He rarely completes a sentence of any length without such severe stuttering that the listener quickly loses interest in relating with him.
In a therapy session, after the Thanksgiving holiday, noticing that he was stuttering more than usual, I paid closer attention to his chopped speech. And what I heard took me by surprise. He was hurling violent abuses against his mother, to whose house he had gone for the big dinner.
They ran - with stuttering obscuring one's ability to understand them clearly - something like this: "I will blow my mother with a pistol. I will knock her to the ground....bash her teeth."
Curious - for they were Tourettian in their intensity and explosiveness - I inquired what his mother did that has him so enraged. All he could say was that she was a bitch throughout the dinner. Then he went into a tirade about how she was cruel to him when he was growing up, would not let him speak his mind, and would hit him with the back of her hand right on his mouth for the slightest mistake, when he was so little.
"I want to tell her suck my you-know-what," and this piece was delivered without any stutter. And then, as if horrified at his own boldness, he immediately retreated into an apologetic mode. "It will hurt her feelings. So I cannot say that to her, you know that Dr. Kelwala. You know that Dr. Kelwala. I should get a pistol and blow myself."
After expressing remorse in which he thought the most deserving punishment for expressing defiance towards his mother would be to blow his head off or be jailed for life, he returned to the previous hostile mood, as if the aggressive impulse had to go back and forth against his mother and himself.
"I want to call her, "You fat broad. You bitch. And other bad names. But it will hurt her feelings, you know that Dr. Kelwala. You know that. So I cannot do that."
Then returning to the remorse mode he said that he should be punished because he is not thankful for all he got in his life. "There are people who are homeless. There are people who have nothing to eat. They are much worse than me."
Now I constructed in my mind that his stuttering has to do with sadistic sexual impulses and [premature and excessively strong] counter measures that got displaced on to his speech centers.
What was the ground for such a construction?
The fact that he made the statement:
"I want to tell her suck my you-know-what," followed by immediate guilt and wishing to be locked up in jail and blowing off his brain with a pistol. So here was a sadistic incestuous thought and guilt and countermeasures and punishment for it. Theoretically, the sadistic sexual impulse must have arose in the Oedipal period and the fear associated with such an incestuous thought had brought on the inhibition. Then the struggle over that impulse had got displaced on to expressing such a thought through speech and countermeasures to prevent the expression had resulted in stuttering.
But in the normal Oedipal Complex the anger would have targeted the father more than the mother. So I asked him did he have any such angry thoughts towards his father.
To my astonishment he said, "Yes, I always wanted to hit my father on the jaw. Or give him a bloody nose. Get a gun and shoot him in the stomach."
And he claimed that his father was as mean as his mother, and worse, for though he did not hit him directly, he never intervened and stopped his mother from hitting.
So the aggression from the Oedipal period had found outlet towards father as well. However, because of the fear of retaliation he had redirected it mostly upon his own self. The sexual current had regressed from the genital phase to sado-masochistic phase perhaps because the mother was too hostile for him to approach her without contemplating first knocking her down to the ground, bashing her teeth or outright shooting her, so she would not castrate him for his attempt.
His sexuality had mostly withdrawn on to himself and only a very small portion of it flowed to others, and here too through the center of speech with the impediment of stuttering blocking its passage.
Now could we place all of the blame for his stuttering on his paretn's cruelty towards him.
Well, something prevents us from doing so. And this something was confirmed in that very session.
I got a phone call from my son to which I had to attend to for a few minutes.
My autistic patient threw a fit at my focus shifting from him to the phone. Within 30 seconds he started ranting, "You are ignoring me. I am being ignored." He started sighing and muttered "shit" and threw up his hands in despair.
So behind the stuttering, more than his mother's hitting him on the mouth, was his inability to postpone gratification. The man wanted attention, right now and could share the person from whom he wanted attention with nobody. In fact his acute discomfort was so excessive and motor movements accompanying it so wild, almost bordering on violent, and the speech associated with the protest so aggressive that one had to wonder whether the primary pathology lay in this inborn aggression and the parents were provoked to mete out harsher punishments to contain the explosive behavior.
One also had to consider whether his autism itself was not a withdrawal from the world to prevent acting out upon others such an inordinate response to frustration.

Wednesday, December 8, 2010

Body odors: A psychosomatic method of discharging aggression?

An Indian man in his mid-fifties reported that when stressed he gets allergic reaction that manifests as excessive mucous secretions from his sinuses and tracheo-bronchial passage. His face turns red, he has to repeatedly blow his nose, he can hardly talk because the constant dabbing of nose and mouth with facial tissues interferes with it, and he is unable to focus or listen to others.

A little exploration revealed that the last such attack occurred when his boss was being mean to him. The boss had exaggerated the significance of the mistake he had made, and this had triggered a strong reaction in him to resign, or to tell the boss some home truths about him too. But he could do neither.

So his "allergic reaction" had set in. But to me it appeared like an extension of crying. Now that he was a grown up man, the secretory response had shifted from mucosa of the eye to those of surrounding regions. It was crying in displacement.  It was discharge of tension and rage, caused by the insult, through a secretory response.

But there was something else to this displaced crying. Along with the paranasal sinus discharge and post-nasal drip, when stressed he also emits a strong odor. Which also, he attributes to allergic reaction. But why should an allergic reaction give rise to foul smell?

Is it possible that his odor was a form of aggression designed to tell others to get lost when he could not do it by words or physical action?

He claimed that his foul smell has nothing to do with anger because he does not believe in getting angry. Responding with negative emotions never resolves a conflict per his philosophy.

Now this gentleman, a sterling fellow, who I know well, is very religious, devotee of a Hindu Goddess, whose bhajjans (hymns) he listens to as he drives his car, and he genuinely strives to be saintly. Every insult hurled at him is handled with turning the other cheek and equanimity.

He countered my theory of undischarged rage by claiming that the odor is due to secretion of nitric oxide. And there is nothing more to it.

But can we accept his explanation? Or is it just a rationalization to hide from himself that he does get angry? A rationalization so strong that he does not feel the affect of anger which seeks expression through halitosis aimed to tell others to get off from his space.

Over the years I have observed that anger/destructive urges often find expression through foul odors. When something disturbs one, there is an immediate motor response to destroy the source of the disturbance. However, this is not always possible. The source of disturbance is often stronger than one's self or out of one's reach. In such cases I have found the motor response may occur through involuntary muscles. I have found that if I am driving and someone cuts in front of me, or honks at me, or even if someone else makes a traffic violation which has nothing to do with me, I react with a tinge of fear and then immediately get unpleasant sensations in my chest, and sometimes, a few minutes later,  get a gut reaction. The gut reaction is sensing of slight tension or pressure in the abdomen, an awareness of increased motility in the intestines, and sometimes discharge of the tension through flatulence.

Is the mechanism of Irritable Bowel Syndrome and various other colitis similar to this pathophysiological process that I see in myself?

Many of my patients who show a tendency to act out their conflicts through their intestines have reported to me that when something disturbs them, or if they hear their parents fighting, or a sibling makes them angry, they get "the gut reaction" and have to run to the toilet. The greater the stress the more thunderous is the reaction of the bowel.

They also report that greater the stress more foul is the smell that accompanies the gas and feces. Now in the man whose breath becomes foul under stress, he insists that it is due to allergic reaction.

Now allergic reaction itself is a method to expel and destroy foreign objects. There appears to be a cascading relationship between rage, motor response [mediated by cholinergic neurotransmission], generation of nitric oxide, histamine over-activity, allergic reaction, GI tract excessive secretions and foul odor.

Are all these different methods of getting rid of something alien or unwanted?

Wednesday, December 1, 2010

Psychology of feeling depressed in winter and gloomy weather in a young man

A 26 year old man reported that with approaching winter his mood is going down. Till Spring comes, he wants to just stay inside the house. He finds it difficult to tolerate the dark and gloomy weather. Outside feels cold. The overcast skies and lack of sun makes him feel listless. He claimed without the sun he has a bad attitude. He attributed his problems to suffering from "the winter blues" and wondered if he should get "serotonin light therapy". He claimed that there are lamps which emit light that raises your serotonin, the lack of which is behind depression. He also wondered if he should take 5HTP pills, along with St. John's wort. He talked about going to the chiropractor to boost up his morale. He wanted my opinion if high doses of Vitamin D would be a possible antidote to his "SAD" - Seasonal Affective Disorder.
He also attributed his addiction to narcotics -Vicodin - which goes out of control during winter as an attempt to create warmth inside him. When I go out in winter I can feel the chill penetrating right into my marrow. The Vicodins wipe out that feeling. I feel warm and confident and ready to face the world.

The patient suffers from remarkable inhibitions in all areas of life despite having superior intelligence. He attributes it to heredity and declares that his father and his aunts have the same problems. "We are all shy and inhibited. We lack confidence."
He claimed he is so inhibited that he cannot even go to the toilet freely if he is in uncomfortable surroundings, including his parents home, where he still lives and never feels at home. When I conjectured that he is uncomfortable there because he has disturbed relationship with his father, he outright rejected that construction, claiming that he has great relationship with his father, only to proceed on to indirectly confirm the accuracy of my construction by saying that he does have disturbed relationship with his siblings, one of whom broke his nose. The ambivalence towards his father had long ago gotten displaced to his brothers.
He stated that he has to take laxatives to goad his inhibited bowels. But remarkably the lax bowels resume their normal tone when he is staying at his girlfriend's house. So, he declared, there is something psychological rather than physical that keeps his bowels inhibited.
When the construction was made that his lack of confidence was because he feels he lacks the psychological support of his father - symbolized by the sun - and he feels completely not up to par to face the world without his father/sun with him, he was stunned. He said that he had always felt that, and had arrived by his own independent thinking that his feeling of inadequacy in cold and gloomy weather has to do with not feeling man enough, but he had never expressed it to anybody because of the fear of appearing crazy. It was easier to rationalize his problems as "Seasonal Affective Disorder."
The patient agreed that his searching for Vitamin D, 5-HTP, chiropractitioners, different therapists, and other esoteric objects also was an attempt to get "phallic potency", which he felt he had not received enough from his father. Bright shining sun nullified best this feeling of inadequacy, hence he felt good in summers.
That his inhibitions had to do with excessive sensitivity to pain, which had made him shy in interacting with other men to avoid getting hurt, and this lack of robust relationship with men in general, was behind his feelings of phallic inadequacy, and when he took Vicodin the fear of pain disappeared, enabling him to face the world and other men, was conjectured but not explored with the patient.

Saturday, November 27, 2010

An agoraphobic's dream

A patient who suffers from severe agoraphobia and cannot step out of her apartment, without being accompanied by someone familiar, brought the following dream to the session:

My husband is taking me out to dinner. It is not a fancy place. May be a drive-thru fast food restaurant. I look through the menu to decide what to eat. But I can barely see the items. Then I find that my husband is not interested in the menu. He has not even come there to eat but to meet someone. I get angry, and throw the menu across. The scene shifts to inside of the restaurant. It is really dark and uncanny.
It is a stark white building. I notice there is nothing inside; no people at all. There is just one dim light. There is a whole stack of plastic menus. My husband responds to my anger, and my sending the menu sailing through the air, with even greater anger. So I start running. He begins to throw rocks at me. They hurt. I get pelted by big and small rocks as I run down the street to my house. But I can barely get past the rock throwing. Even when I reach the house I cannot get inside as I cannot get the key in to the lock because so many dirt clods and rocks are falling on me.

he patient is divorced from her husband, but they still live together for financial reasons. First thing she expressed about the dream was her surprise that her husband is throwing stones. It is so unlike him. He is not a violent person at all. It makes no sense. Also it makes no sense that she has gone to eat at a restaurant because her agoraphobia precludes that. She cannot eat in public. So the dream, according to the patient, was senseless.
She brought scanty associations to the other elements of the dream which - following the technical rules of dream interpretation - allowed me to proceed with the analysis primarily on the basis of typical symbols and typical scenarios that dreamwork utilizes to couch our ordinary thoughts in the language of dreams.
Now the patient did associate here and there to the constructions I made, and which served as guideposts that the analysis was proceeding in the right direction.
First construction which was made was that in the dream she is free of her illness and eating at the restaurant, something she can only dream about in real life. Further construction was made that eating in public in her case could mean meeting strangers on the street and having liaison with them. For underneath the agoraphobic's fear of streets lies the fear of getting too bold in demanding sexual satisfaction and becoming a brazen hussy who does not hesitate to solicit sex from total strangers - prostitution fantasy.
The patient responded with "That is so weird. So strange. I would have never thought of that."All the typical phrases which patients use - as if they have jointly conspired - to confirm the correctness of an interpretation. Then she went on to say that she had read somewhere that behind agoraphobia lies the fear of soliciting sex on the street. But she always thought that that explanation applied to low life agoraphobics not her.

I look through the menu to decide what to eat. But I can barely see the items.

This expressed two contrary impulses. Finding a dish on the meny was finding something satisfactory to eat - sexual satisfaction - while the inability to read expressed the emergence of repression and blocking of the wish which was unacceptable to her conscience.

Then I find that my husband is not interested in the menu. He has not even come there to eat but to meet someone.

This was a projection of her impulse to meet someone upon her husband out of moral sense. She is avoiding the guilt of having the impulse to solicit sex with a stranger by projecting the tendency, and hence the blame, from herself to her husband. There is of course the element of wish fulfillment, vicariously, through her husband. The unconscious hypocritical reasoning which the dreamwork uses must have gone something like this: "I have come here just to eat food and I am looking so innocently at the menu, and it is my husband who is interested in getting illicit sex, and has come here to meet someone."

I get angry and throw the menu across

his anger is actually the superego anger directed towards her unacceptable conduct - wanting sex with a stranger. Her father was very strict disciplinarian, quick to anger and take up the belt to punish children for the slightest infraction. Her superego [conscience] had become the representative of her father, and she was identifying with her father to give expression to the condemnation, with her husband taking on the role of her lascivious self and becoming the object of the fury. The throwing away of the menu gave expression to her rejection of the impulse to take interest in women - the flat menu and the food items in it represented women. In the sexual encounter that she was hoping that would happen to her, in the dream she was identifying with the male role.

Then the scene shifts to inside the restaurant. It is really dark and uncanny.

Lack of success in finding the fulfillment of the wish - inability to read the menu, and its getting thrown away - leads to the complex getting reenacted on a different venue. And the wish tries to find an outlet at a much deeper [regressed] level. Being inside a structure like a restaurant or a house or a Mall, especially which is dark and uncanny, is fulfillment of the wish to return to the womb. So it is the familiar 'womb fantasy'. The patient frightened of soliciting sex on the street, shown here as looking for food at a drive-thru restaurant, and hoping to see its fulfillment through her husband, to whom she is attempting to present the women [the menu items] while simultaneously opposing it, out of jealousy - throwing the menu across - now shifts the stage for the acting out of the two contrary impulses on to her mother's womb.

It is a stark white building.

his is an allusion to death. Fantasy of returning to womb - the fantasy of rebirth - is regularly accompanied by fear of death. Birth of our children, heralds our own death. White is often used as an allusion to death. So she wants to die and reemerge as a new avatar.
Now we know from countless other dreams that the womb fantasy is always undertaken to fulfill the wish of the dreamer to go back to the womb and reemerge as a better fortified avatar. And this fortification is invariably connected with the deepest wish of women - to be born again, and this time with a penis, so as to do a better job of her life in her masculine reincarnation.

I notice as to how no one is in the restaurant. No people at all.

The association to this was how Kroger -the supermarket - is so full of people and how even the thought of facing them triggers a panic attack. So the fear/panic of crowded places - the core of her agoraphobia - is a defense strategy the mind of the agoraphobic uses to suppress the impulse to have illicit liaisons with strangers. In the dream, however, she has managed to conquer this fear. And she has done this making all the people who would stare and disapprove of her disappear. With no disapproving people around, she can indulge in her fantasy.

There is just one dim light. There is a whole stack of plastic menus.

The whole stack of menus alludes to a row or pile of women. The patient's relationship with men had been severely disturbed in childhood primarily because of her father's harshness and ruthlessness. She felt more comfortable with women, and in the unconscious her sexuality sought satisfaction from women. In the dream the desired women were being portrayed by flat menus. The dim light was allusion to clitoris, and the inferiority of female organ, and thus an allusion to her rejection of finding sexual satisfaction with women. Patient's taking special pains to mention that the menus were of plastic was expression that I may desire women, but real intercourse with them would be artificial and non-satisfactory.

My husband responds to my anger, and my sending the menu sailing through the air, with even greater anger.

Wish fulfilment had blocked the restraining influence of public by showing no people at all in the restaurant. But the moral sense was making a comeback finding expression through showing her husband getting angry [at her brazenness]. Sailing of the menu through the air was an allusion to sexual satisfaction as well. In fact this was the core of the dream. It was the most vivid element of the dream. And she did emphasize as to how dramatic was her sending of the menu across the room. The dream was woven around this wish. It alluded to her going back to the womb, stealing the penis from there from the father, while parental intercourse was taking place, and then flying away with it. The familiar feeling of being at the top of the world after satisfactory sexual act. It is best captured by the song "Oh what a feeling, dancing on the ceiling."The fear that it will arouse the ire of her father - who in the dream was being represented by her husband - whose penis she was stealing, brought an end to that section of the dream.

So I start running. He begins to throw rocks at me. They hurt. I get pelted by big and small rocks as I run down the street to my house.

ow the wish is on the retreat and the punishment for it takes the upper hand. She could make the public and the public opinion disappear for a moment at the restaurant, but the moral sense was returning with a vengeance. The association to the rock throwing at her was to the Biblical woman who was about to be stoned by the crowd for adultery. She is running back to the house - womb - away from the trysts of life which will invite dirt and rocks to be thrown at her.

Even when I reach the house I cannot get inside as I cannot get the key in to the lock because so many dirt clods and rocks are falling on me.

his was the last to replay the two opposing impulses. Entering the house by opening the lock with the key would have been symbolic depiction of intercourse. But the hail of abuse, represented by the rocks and mud clods, and the fact that she does not know how to use the key -penis - holds her back.

he dream ended with her waking up in fright.

Wednesday, November 17, 2010

Aggressive impulse at the root of easy distractability and multi-tasking

A 29 year old girl who came for Suboxone treatment reported that the reason she was addicted to Vicodin, and now kind of addicted to Suboxone, is because they attenuate her distractability. She claimed she can rarely keep her focus on a task long enough to complete it unless she is taking Vicodin or Suboxone. Every task undertaken, after sometime, is interfered by a creeping anxiety and premonition of disaster happening somewhere else, and her mind begins to search for some other project that she was supposed to do, and forgot, and which, if not immediately attended to, will cause problems and she abandons whatever she is doing to take up the new task. The cycle repeats itself with the new project, leading her to pick up yet another project, till there are so many open projects that she feels overwhelmed and gives up on all of them.
If she can't find something to do that has the potential to distract her in the outside world than she searches for pimples on her face and bursts them lest they grow too big and offensive and make her object of ridicule. When asked as to why others would they find the pimples offensive she said because they are ugly and it will invite them to attack her.
Now we know that Attention Deficit Disorder and Obsessional Neurosis are two sides of the same coin. The aggressive/destructive impulse, which these people are plagued with more than others, has to be suppressed and an impulse opposite in its intent [constructive in nature] has to be put in its place to keep the hostile impulse from getting hold of the motor apparatus. The hyperactivity of the ADHD child is a compromise formation between these two motor trends, to wit, destructive and constructive.
The easy distractability of ADHD patients is also a play between these two opposing impulses. The person is beseeched with an impulse to cause harm. This he suppresses with doing something constructive that will not only occupy his motor apparatus so the harmful impulse cannot take hold of motor movements, but also because by doing something constructive he hopes to please the person/s towards towards whom the destructive impulse was aimed at.
In this girl, the destructive impulses were directed towards her mother. In her conscious mind, she was completely unaware that she harbored extensive rage towards her mother.
Her mother was abused as a child, and had numerous mental problems herself, and she was mean towards her children. However, mother had also been in therapy all her life, and had taken the kids to her therapist to undo the damage her erratic and mean behavior was possibly doing to them. In these therapy sessions, the children had learnt not to hate their mother for her meanness on the rationalization that she was mentally ill. So the girl had learnt to not consciously feel angry towards her mother and also to believe that she harbored no resentment because she understood the roots of her mother's behavior. Nevertheless in her unconscious the desire to give tit for tat for her mother's meanness had persisted.
It was these revenge impulses, laced with furious rage, that sought motor actions and had to be kept at bay by doing some constructive project [that would please her mother].
Now in mild cases of obsessional neurosis, or where obsessional neurosis is sublimated towards useful goal, and this includes majority of mankind, for our world's do-gooders are no more than those who have harnessed their destructiveness to fuel the opposite impulse of constructiveness in such a fashion that the latter almost always manages to triumph over the former, the pathology is only apparent in that the person obsessively wants to do good - herein lies the psychology of hyperfocusing in ADHD.
But where the destructiveness is too powerful, as was the case in this girl, the constructive activity fails to keep the former in check for too long. The person gets a premonition that her good intention is going to be trumped by the evil one, which will result in some disaster happening [anticipation of punishment for the evil designs], and the conscious mind perceives it as a rising anxiety. And to take care of this anxiety she looks around for some project that was supposed to be done but which has not been done and which she deems as a potential candidate for causing trouble and she leaves whatever she was doing to take care of this new project. Herein lies the psychology of distractability. The destructive and constructive impulses are equally matched and the projects undertaken get interminably procrastinated.
The phenomena of multi-tasking arises from the same complex as well. Here projects are not abandoned but pursued simultaneously. When the anxiety arises about destructive impulse messing up the task at hand, the person, instead of putting additional energy in the constructive efforts, or abandoning the project and moving on to something else as the ADHD distractable person does, does not abandon the first project but takes on another, and then yet another, and juggles between all of them, and if he does it successfully then he is looked upon with admiration and if he messes it up he is viewed as a bumbling fool.
Now to her preoccupation with pimples. They symbolized siblings. She was trying to hurt her mother by identifying herself with her mother and destroying the mother's potential children. As if the desire to harm her mother had been displaced on to harming her mother's children. The penance for such fratricidal behavior was also expressed from the same act. The pimples stood for her children too, which she was destroying as a retribution for doing the same to her mother's children. It is interesting that despite her being at the peak of her femininity she had no interest in settling down and having children. As if all her interest in life had been consumed in managing this interplay between aggression and love impulses which strove to fight with each other in every aspect of her life.

Wednesday, October 27, 2010

Childhood sexual abuse, Kleptomania and Castration Complex

There is little doubt that nothing causes greater disturbance of mental stability than prepubertal sexual abuse. Earlier the age of abuse, greater is the disturbance. With genital sexual apparatus not yet ready for sexual activity/sexual arousal, and thus incapable of discharging genital sexual stimulation, the reaction is abnormal, excessive, pre-genital, and condemns the child to perverted and inordinate sexual preoccupations for the rest of her life. Fibromyalgia - which use to be called Beard's Disease and then neurasthenia at Freud's time - is almost always present in these individuals and there is never-ending restlessness that does not leave the patient in peace even when she is asleep.
The memory traces of the abuse obsessively emerge during daytime, and the thoughts and affects associated with these memories return in disguise in dreams. Since the affects are exceedingly strong, and more negative than positive, the dreams are usually nightmares. The dreams quite often are a faithful reproduction of the abuse, but over time the usual wish-fulfilling dream mechanisms are utilized to lessen the pain/dysphoria associated with the humiliation and the perpetrator/s may appear in the guise of strangers or wild animals who are chasing the dreamer. The sexual act itself is portrayed as getting knifed, gored or killed. The sexuality becomes predominantly sadomasochistic with the affect of fear masking all other emotions. The daytime reveries and nighttime dreams are accompanied by revenge fantasies. And this preoccupation with the childhood sexual abuse pervades the person's life so extensively that one marvels as to how childhood sexual trauma, sometimes limited to just one incident, can disturb someone to such a remarkable extent.
For sometime I have been noticing an interesting pathological behavior in these victims of childhood sexual abuse. They show kleptomania. Since the unconscious complexes that underlie this kleptomania is of theoretical interest, I will discuss a case in detail and then discuss its psychology.

The patient was 39 years old when I interviewed her. She had been sentenced to jail for a year for incorrigible kleptomania. She stated that she "stole for the rush of it". It was small items that she stole, and emphasized that the thefts were undertaken not because there was no money in her purse, but because the excitement of getting something for free was too overpowering. She placed the blame for this irresistible impulse to childhood sexual abuse. "When I was sexually abused I got nothing, in fact it was more humiliating and painful than pleasurable, so now I am entitled to all these [alluring] objects in the store without paying for them. I am so "mad" all the time. I need something to calm me down. I want somebody to love me. I have never been loved. No one ever showed love to me. They just wanted to fuck me. I never got love from my mother or father. So I feel a right for these things which others got but I did not."
At the age of 5, she was repeatedly subjected to anal intercourse by an uncle. It came to an end when her sister, who was 16 years older than her, discovered the abuse and threatened to cut the uncle's penis with a butcher knife if she ever caught him doing this to her sister. That put a stop to the abuse but not without leaving her permanently addicted to victimization.
Now it is well known that once a victim always a victim- as if to undo the trauma the person keeps seeking identical situations. She faced another round of abuse at the age of 12 by a cousin. And when she was incarcerated for habitual shoplifting, in the prison too, she was raped by a female prisoner. She had been married twice and both her husbands had abused her. Her second husband called her crazy and stupid.
Now as if abuse and victimization by real people was not enough she also developed pain in her lower back, hips, and legs, which she labelled as arthritis but which were more hysterical conversion of the memory of the rape than physical diseases. The hysteria was overlaid upon underlying real physical problems. Victimization persisted in the dreams as well, where she would relive the trauma, and see herself getting raped by the uncle and cousin.
There were strong reactions to this passivity/victimization at the same time. She would go in to spells of anorexia - rejection of oral sexuality- and would hardly eat. In fact, when she came to see me, she had lost 100 pounds. She normally was overweight, but in her current episode of anorexia she had made herself pathologically thin. She was consumed with the fantasy of taking a knife, finding her uncle and cutting his penis off. She would hear voices telling her to do so or at least to go and stab him. And while walking on the streets she often looked back over her shoulder to make sure that the police were not following her to arrest her for stabbing strangers on the road - strangers on the streets had become, in her unconscious - substitutes for her uncle. She had attempted suicide at least couple of times as a punishment for her promiscuity. She had become hypercritical of herself and people around her. But the biggest reaction formation was her pathological obsession with the Bible. She was constantly drawn towards older men, and she resisted the impulse to try to seduce them by keeping the Bible with her all the time and reading uplifting passages from it.
But it is not these symptoms of victimization that are the main objective of this post. It is the analysis of her impulse to steal. And that the analysis showed to be a demand for compensation. "If I was subjected to such horrible pain and humiliation at such an early age, and way ahead of all other children, then I am very special and I am entitled to all those shiny stuff in these stores and without paying anything, because I have already paid a huge price."
This attitude of entitlement at bottom was nothing more than pathological exaggeration of the central complex of women - a demand for penis. The logic behind it ran something like this: "I have been unnaturally subjected to these sexual activities at such an early age, certainly before other children, so I am way ahead of them all, boys included, and I am entitled to a penis. Especially with this experience under my belt I am no less than any boy that I know." It is the same impulse that in normal development, without hobbled by seduction or other disturbances from the environment like excessive parental fighting - would have metamorphosed from a wish for a penis into the wish for a baby. Wish for a penis is an earlier version of the wish for a child. In victims of childhood sexual abuse a fixation occurs at the stage of crude wish for a penis. The victimized child is unable to get past this stage. Or more correctly the later versions of this developmental line are feeble in comparison to this earlier wish.
And the disturbances from such an arrested development are protean. There is a great overvaluation of the role of sexuality in human affairs. The girl starts seeing her primary role in society as a sex object. The main purpose of life for her becomes being sexually attractive and pleasing to men, especially men she can put in class of fathers. The main game of her life becomes "to act seductive" and get victimized by men. There is of course reaction formation to this role of being just a sex kitten, and the girl occasionally lurches towards taking the responsible role of the mother which will cure her of this obsession with being an innocent/unsuspecting sex victim - for mothers are responsible beings, so engrossed with taking care of their children that they have no time for sex. But unfortunately this often results in teenage pregnancies.
And now to the kleptomania which is the subject of this discussion.
Why does this happen? Because when the child is sexually stimulated at that early age there is less sexual excitement in her than in the man who is abusing her. In her the predominant affect is that of anxiety and fear. Also the furtive behavior of the man, who is looking over the shoulder lest someone shows up, who is constantly threatening her that if she tells this to anybody he will kill her and her family, or extracting promises from her that this is our own little secret that should never be told to anyone else, all the while groping areas which are generally thought to be unclean, they all feel to her as something connected with excretory activity fun than genital. But the child can still rightly deduce that while in her the activity is more in pregenital zones, in man the nexus of the pleasure is in his penis and he is getting far more excitement and discharge of tensions through his penis than she is getting from the stimulation of her anal and oral zones. The penis then becomes the coveted organ.
And there are further pathological consequences. With the vaginal passage still not mature to become subject of excitement, the pregenital oral and anal passages become disproportionately more erotogenic. And this has serious consequences for the future fate of sexuality. After puberty the sexual discharge instead of maturing into the genital zone, remains fixated in oral and anal zone. The struggle against excessive pressure of oral sexuality often manifests as alternating bulimia and anorexia and in anally disposed person as Irritable Bowel Syndrome and other types of colitis. Also, sexual stimulation of genital area when it is not yet ready for reproductive activity, since it does not bring discharge and relief from tension, leads to an endless sexual preoccupation. This explains why the victims of prepubertal sexual abuse act seductive, but refuse genital sex when approached and get blamed for being a "tease". Their loud, histrionic and ostentatious display of hypersexuality are a facade and underneath lies sexual frigidity. And even when they give into genital sex, since it gives them little relief, they keep repeating the behavior and garner the epithet of "nymphomaniac."
The solution to all their problems they see in having their own penis. There are number of converging reasons for it. The child sees that because the man has a penis he can subjugate her to abuse. If only she had a penis she would not be subjected to this passivity. The penis also inflicts upon her pain and humiliation. The child also feels that since she has been subjected to this pain now she should be compensated with the reward of having her own penis which she can use upon others to get even. Also as the abuse causes a permanent irritation in her without possibility of complete discharge she is all the time seeking the repetition of the abuse. But the repetition implies repetition of the same pain and humiliation, which she detests. [In fact as the victimized girl gets older she often gives up all sexual activities with men, despite constant sexual tension]. To escape this dilemma she often turns to homosexuality along with wishing for a penis of her own that she could use at will without subjection to humiliation in hands of men. There is also, of course, another powerful motive added to all the above complexes - the revenge fantasy of castrating the man and it is done in displacement.
The whole process of castrating a man is now transferred to symbolic stealing - kleptomania. The fine objects in the store are symbols of the male genitals that are coveted and stolen.
But is kleptomania always a result of childhood abuse?
Of course not. But let us examine a few cases where there was no sexual abuse and see what they have to teach us.
An extremely pretty Caucasian girl of 26, who had married an African-American man way below her socially and academically, suffered from kleptomania. She had all the symptoms generally associated with childhood sexual abuse like fibromyalgia, migraine headaches, hysterical vomiting, colitis and victimization in hands of men. Yet, she had no history of sexual abuse as a child.
But careful history revealed that while she had no personal history of sexual abuse, her motheras a child was abused by her step-grandfather, her sister had been raped, and she strongly identified with both of them. Her mother had all the stigmata of childhood sexual abuse and she had identified herself with her mother. She herself had great passivity of character and vulnerability in her demeanor and been many times had had near-rape intimidation by men, and one time had been subjected to a prolonged stalking by an Arab-American ex-boyfriend. Her nightmares were full of extreme anxiety. They were based upon a TV show she regularly watched which showed in graphic details the sexual victimization of young children by sexual predators and serial killers. In her nightmares she would identify with these children and see herself subjected to similar sexual abuse.
Another lady, a doctor, turned to kleptomania after she found her husband was cheating on her. This was the reason she gave for acting kleptomaniac. But analysis showed that the act had greater connection with the death of her father which had occured when she was around 12, leaving her feeling cheated and an attitude of revenge towards society, and when marriage did not compensate her enough for the unfair loss of her father she turned to kleptomania.
Another woman an Arab-American was severely bullied by her classmates for her darker complexion, being overweight and her Arab features, and she always harbored revenge fantasies against the world, and compensated herself through kleptomania. There was an additional factor. She was the only child and spoilt rotten by her father to whom she was very tenderly attached and when he died she compensated for his disappearance from her life through stealing.
A master kleptomaniac, who boasted of having amassed a fortune through stealing costly vintage wine bottles and who was expert in forging checks and embezzling, and who had come to me not for cure from his illness but just because he was court ordered, gave the history of having been subjected to a brutal beating as a child by his father for a single incident of stealing, and in the teenage years had turned into a thief to get even with his father with whom, to begin with, he had intense feelings of rivalry from the Oedipal period.

Sunday, October 24, 2010

Forgetting as an expression of Death Wish

In Psychopathology of Everyday life Freud discusses how ordinary forgetting, mislaying of objects, slips of tongue, errors in execution of goal directed motor movements, for example making a wrong turn while driving or accidentally pressing upon the accelerator instead of the brakes, they all indicate hidden [repressed] motives. They cannot be dismissed as purely chance errors. They indicate the existence of some repressed complex which, when opportunity had presented itself, had seized upon the consciously directed behavior - to which it was connected in some way - and had interfered with it. The links between the repressed complex and the goal-directed conscious behavior occur in the unconscious and through Primary Process logic. In conscious mind we just perceive the silly error and cannot account as to why it happened or more likely give false explanations like it happened due to fatigue or distraction.
Freud's book goes into details of how forgetting of a name often indicates some negative association with that name, and in order to not allow the unpleasant affect attached to the negative memory to emerge in the consciousness, the person, along with the affect, blocks out [forgets] the name as well.
I once had devil of a time trying to recall the name of a teacher of mine from my medical school, of whom I had pleasant memories. So why would I block the name of a person whose memory did not provoke any unpleasant affect? For he was a nice man and kind to me, and his physiognomy and complexion, and the way he carried himself, reminded me of of an uncle of mine. He was a teacher in the department of Pathology. It made no sense. You do not block the name of a person of whom you are fond of. Unless of course something else is attached to the memory of that name which is unpleasant or which you rather not deal with. The analysis of the forgetting of his name affirmed this general rule.
Let us see why I forgot his name.
One morning, during a time when I was under lot of stress trying to get a Residency Training Program going that I had nurtured from scratch, and also was having devil of a time with insomnia due to my inability to get my personal and professional life in a trajectory which would be commensurate with what I believed I deserved, I woke up and found myself thinking of this teacher. His face popped up in my mind's eye as clear as day, but for the world I could not recall his name. I racked my brain for weeks. And weeks turned to months. Then my mind must have put the issue on a backburner for I ceased trying to think of dozens of other names in order to arrive at the right one. Though every now and then I would get preoccupied with the puzzle and would wonder as to why the name had become a closed book to me. Only when I went back to the medical college for a Class Reunion, where his name was mentioned by someone did I recall it perfectly and could not be more amazed as to why such an easy and familiar name had disappeared from my consciousness. The name was Anand Daate.
And I at once knew too as to why I had forgotten his name. He had always reminded me of one of my uncles, whose name too was Anand. And I had blocked out the name common to both, because they had many other features in common besides the name.
But why was I trying to block the memory of my uncle?
It was only one particular aspect of my uncle that I was trying to banish from my memory. My uncle was a child prodigy, who had won numerous prizes in school and colleges and every one was expecting him to be a trailblazer on reaching maturity. Yet once his education was over, he could find no other job in his speciality of Chemistry, but the job of a school teacher. In a few years of trying to exhort his students to do extraordinary things, which landed one of them to try to swim across a lake and drowning in the attempt, his job became a dead end for his extraordinary abilities. He became increasingly mentally disturbed over this cruel turn of fate, withdrew from the world, resigned as a teacher and turned into a monk. So his life trajectory had not turned out to be commensurate with what he deserved. Now that was exactly what I was dreading was happening to my career and life trajectory. As a Veterans Hospital psychiatrist I was doing not much in way of treating patients other than medicating them. Yes, I was doing a large scale study on lithium's usefulness in schizophrenia, and had over half a million dollar grant for it, but I knew at heart that the study was worthless. The residency program was somewhat satisfying, but I did not think I was cut out for that kind of bureaucratic career.
So what I was trying to block out from fully realizing and submitting to the fact that I was becoming more and more like my loser uncle. And along with blocking out the realization of this commonness between my uncle and myself, I was also blocking out his name.
But that does not explain as to why suddenly waking up one morning, completely out of the blue, I would recall the face but not the name of the teacher who had been nice to me. If anything I should have neither recalled his face nor his name. That would be more in keeping with how our mind works - block out all associations that would provoke the unwanted emotions.
Now the reason why his face emerged without any rhyme or reason was to counterbalance the dreaded possibility that I was turning into my uncle. The pathology professor looked, carried himself, and even had the name common with my uncle, but he did not look unhappy with his life as a teacher unlike my uncle. So it was his [hopeful] face that my mind had conjured up as a counterbalance to the depressing memory of my uncle. And so the mind did two activities that were diametrically opposite to each other. It blocked out the memory of the fate of my uncle and its residue the [common] name from my consciousness, while it brought out the memory of my pathology teacher [with the same name] with extra emphasis.
And why did I not recall his last name Daate?
One was because if I had recalled his last name I would have recalled the first name as well. They always called him with both his name. But there was another unpleasant memory associated with the last name. There was a military officer Captain Datta, who I had befriended in a military regiment in Kashmir, when I was 16. I had gone in summer vacation to another uncle of mine - brother of the uncle who turned into a monk - who was a medical officer there, and Captain Datta was stationed at the same regiment. He boasted himself as the youngest captain in whole of India. And he was just 21 years old. I identified with him, and had looked up to him, till in a social get together he had tried appearing funny at my expense, which left a bitter taste of him in my memory. Since he was also in the category of Uncles in my mind, I had put him and Anand Daate together and by using the phonetic similarity had used the unpleasantness associated with the captain in blocking out the last name of the pathology professor.
And now to the title of the essay which is that we forget and distort names as an attempt to show our distaste for the other person or something distasteful connected with the other person, and which often implies wishing them to disappear/die . I don't recall Freud specifically going into any discussion into how forgetting of name has very often at its root a wish for the person to be dead, at least for immediate expediency and not as a permanent solution, and hence the justification for writing this.
We often forget the name of a person who we wish was not there at that particular moment. This wishing for the other person not to be there is in some sense equivalent [in the unconscious] to that person being dead .
In obsessional neurotics who are constantly plagued with death wishes, this impulse to have the other person dead takes an interesting twist. Instead of not remembering the other person's name and other facts about him, the obsessive hyper-remembers not just the name but trivial facts about the other person. It is as if he is overcompensating for his thought/desire for death by making sure that he remembers every single thing and holds the person in such high regard that he takes pain not to wipe out [cause death] even insignificant facts about him.
In one obsessive lady this wish for death of others emerged in wanting to forget their birthdays. By not remembering the birthday of the other person she was declaring in a very roundabout fashion that you are as good as not ever being born as far as I am concerned. This wish for death of hated people had primarily arisen from death wishes towards her younger brother - 2 years her junior and her hated rival in childhood in getting their father's attention - but had now generalized to great number of people. He favorite abuse towards others was saying in contempt,"I don't know from where people like you get born."
Curiously she had a phenomenal memory for remembering the birthdays of all her relatives, and not just siblings and immediate family members, but up to most of her second cousins. She did not fail to call and wish them happy birthday. It was a Reaction Formation to her wish - which was quite strong when she was a child - for them to disappear and for her to be all alone with her father. Now she remembered everyone's birthday religiously as if to tell them that far from harboring any wish for them to have never been born, she values their birth so much that she can never forget such a precious day.

Saturday, October 16, 2010

Obsessive visualization of violence as a protection against self cutting

A woman in her mid-twenties complained bitterly about her "madness" of seeing, in embarrassing details, her daughter being subjected to all kinds of violence.
When asked to give an example, she said like her running across the street and getting run over by a truck that smashes her skull into so many pieces. That she could imagine the violence in such minute details caused her intense shame and horror.
An interpretation was made that obsessive ruminations of violence happening to one's loved ones is a displacement of violence happening to one's own self. The original fear is of violence happening to oneself. However, the mind, in order to lessen the fear, reasons, unconsciously, as follows: there is someone there who you love so much that if this happens to him or her, you will suffer even more. So instead of now worrying about harm coming to yourself you start worrying about harm coming to someone very close to you. And as a rule, this fear of harm coming to oneself - and in displacement harm happening to the loved one - is a fear of retaliation for wishing harm to somebody else.
The patient protested that she wishes evil to nobody.
When it was explained that such irrationalthoughts of violence towards oneself could not arise de novo for nobody wishes harm to oneself for no reason. They make sense once one makes the presumption that they are punishment fantasy for having violent impulses towards others.
She wanted to know why would one want to punish oneself for wishing evil to others.
It is not you but your conscience/superego that wants to do that. It remains in the background, completely unconscious. Even the thought of harming others remains under repression and unconscious. What comes to the conscious mind is the affect of guilt, and images of retaliatory violence happening to oneself and those who are close to oneself.
She was not convinced but added that she has to concede that her constant sense of guilt makes no sense. She always feels guilty, which she should not, because she is a very conscientious person and strives to hurt nobody.
When it was explained that there is no such thing as irrational guilt and if there is guilt which one cannot account for that means in the unconscious mind there are evil intentions/thoughts, she added that she does see visual images of harm coming to herself.
"Like what?" I asked her.
"Like a I am combing my hair with an iron brush and the bloody layers of my scalp are peeling off. It is horrifying image."
"Any other images?"
"I see my head getting cut off or I am getting cut into two or I am hanging myself."
When interpretation was made that beheading is a symbol of castration and perhaps she sees it as a punishment for castrating someone else, she said she had never thought of cutting her husband's penis so I am wrong on that one.
But such a spontaneous association without any suggestion on my part that the impulse was directed against her husband, left me no choice but to assume that the person she wants to castrate is her husband.
When I said that perhaps the impulse is directed towards her husband, she said, "I cannot see that but I do admit that I am a cutter. When in great anxiety I cut myself. In my teenage years I was a great self-cutter."
Is cutting a self-punishment for the impulse to castrate others, I wondered silently.
But loudly I asked her if the imagery of her being cut in to two has to do with her parents getting divorced when she was four. The guilt of separating the parents in to two being avenged by her getting cut in to two.
She drew a blank on that construction. But added that number 6, or any multiple of number 3 is bad for her.
When asked to explain that she said that after her parents' divorce she had to live either with her father and her step-mother or her mother and grandmother. There was always three people, and she was always the odd one out, and she blames it upon her parents divorce.
At this point the patient started dreading that if she talks more about such thoughts, she will start cutting herself again which she has not done in years. She also admitted that she always fears that one of these days she will give into the thoughts of beheading or hanging herself.
It was explained that bringing such thoughts to consciousness protects one from acting upon them rather than other way round. Such impulses are more likely to get hold of the motor system without any hint to the conscious mind, if they are allowed to fester for too long in the unconscious, without any outlet.
Patient agreed and said," Yes you are right on that one. In my teenage years I just would have these irresistible urges to cut myself to get relief from guilt and anxiety and impending sense of doom. But since these obsessive images of harm coming to my children and myself have started coming to my mind I have stopped cutting myself. These images make me very uncomfortable and I feel horrible about thinking of such things happening to my children, but still it is better to deal with unpleasant thoughts than to deal with a cut arm, and having to explain it to the ER doctors."

Tuesday, October 5, 2010

Obsessional neurosis underlying ADHD - two typical cases

While it is generally believed that ADHD is some kind of neurological disorder where the faculty of attention mysteriously disappears in otherwise normal - or more often than not, above average - boy, I usually find that behind lack of attention lies psychological problems. And so far in all cases I have come across where I have made headway into their psyche, the problems have shown to be a preoccupation with controlling obsessive fantasies. It is trying to (unsuccessfully) deal with these obsessive/aggressive impulses which robs the child his ability to pay attention to what is happening in the present.

In majority of cases I have found these obsessive impulses to be reminiscences of traumatic events, generally domestic violence, or death wishes against family members and mental counter measures to undo such wishes. Recently I came across two cases where this phenomena was so transparent that I feel it is worth reporting.

Case I
A 14-year-old girl came to my office with her mother for Attention Deficit problems. She had received in past Concerta - slow release Ritalin - which improved her attention and her grades at school, but she had stopped the medicine because it made her like a zombie. And she felt terribly sad on it.
On further probing, and after some initial psychological inhibitions and resistances were overcome, she volunteered that she cannot pay attention because she daydreams foolish things like her 10 year old sister is getting kidnapped at the bus stop or she is falling off the edge of the sports field at school.
When asked how can her sister fall off the sports field, the girl said yes, it is ridiculous, but since the field does not have fence around it, I worry that she will fall off the field.
Another telling obsession was her mother meeting some horrible death. For example while driving home from work meeting a terrible accident.
In addition to visualizing her mother's and sister's death her mind would also be preoccupied with all kinds of weird thoughts and other motor activities to prevent their imagined death becoming a reality. And it was this preoccupation with preventing death that was exhausting all her mental energies, leaving none for paying attention to what what was being taught in the class.
She had some other obsessive problems as well. It took her many hours to fall asleep, and though she slept hard, she woke up unrefreshed. When asked why she would not get rest from sleep she said because she had "repetitious dream". When asked what are these repetitious dream, she said for example once all night long she dreamt a single scene of a dog chasing his tail. When asked what could be the meaning of it, she said the dream was "an obsessive loop", no different than her worrying endlessly about her sister getting kidnapped at the bus stop.
Her mother described her as excessively kind to animals, and a most considerate person to everybody but herself. This excessive kindness was easily confirmed as a reaction formation to the contrary unconscious impulses to do harm.

She reported having a lizard, a dog, and three cats as pets. She obsessively worried about her lizard getting eaten by the cat, and though she would know perfectly well that she had locked the cage, she had to check and recheck whether the door had not been left open by mistake while she was not paying attention.
She confessed to another strange obsessive symptom. In class she would pay more attention to somebody sneezing, or making some other noise or doing some other unusual or inappropriate activity than to what was being taught. She had to do mental exercises to prevent these kids from doing such behaviors or to undo the impact of it on the class. She claimed that this preoccupation with classmates activities and trying to mentally prevent it or to block her mind from noticing it spilled into blocking her ability to pay attention altogether. It was a case of overkill.
Little analysis showed that this focusing upon the disruptive behavior of classmates was a shifting of attention away from her own impulses to be disruptive. It was a projection of her disruptive tendencies upon others and trying to control them in others in lieu of controlling it in oneself.
Her feelings of sadness on face made no sense. They were there all the time but excessively strong on Ritalin/Concerta. Addition of Prozac to combat the sadness had not done any good. The people over whom she felt sad was even more senseless. She would feel sad over the death of her great-grandmother, who had died when she was just 4. When asked how come she was worried about somebody whom she could have barely known, she said she feels similar sadness over the death of her maternal aunt from cancer which took place when the patient was just one and a half and about whom she had absolutely no memory. But she had heard from family members about her tragic untimely death and had made visual pictures of the circumstances of the death and could grieve over it. She could also feel sadness over an Uncle of hers being in jail for drug charges.
When she was told that she feels sad because she takes responsibility for the death and other misfortunes of her relatives she agreed to it indirectly saying that she knows a cousin of hers who blames herself for death of virtual strangers. But this is not true about herself for she never ever thought of her great grandmother and her aunt's death as her fault. This appeared to be a classical disclaimer of an obsessional neurotic that yes what you say rings a bell but it really does not apply in my case. I can only confess of what you say as being present in me by acknowledging of its presence in somebody else who is like me.
Then she went on to say that an year ago her paternal grandmother died. She did not feel guilty about it. So you cannot be right that I feel guilty about visualizing all these people's death. Maybe I did have some guilt over my grandmother's death but because I failed to call the hospital and find out as to how she was doing before she died. I never went to see her or call her. Then her voice became tearful.
On psychoanalytically exploring why she became so fearful of her relatives meeting the fate of violent death, it became clear that the fear arose partly from her own innate anal-sadistic disposition of which she was very uncomfortable and hence used all maneuvers to undo it but there was also a strong identification with her mother who suffered from similar chronic worries of harm coming to her daughters. The mother had obsessive/aggressive disposition as well, and in her unconscious would imagine the death of other people, which in the conscious mind emerged as revenge/retaliation on part of these people but not towards her, but towards her daughter, including their abducting her daughters. The mother would react to these fears of harm coming to her and her daughters by having become externally quite "tough" and in her behavior demanding and expecting immediate compliance to whatever she asked from her daughter. Her demandingness and constant control of daughter had bred a fear of interacting with the world in the latter, and also a fear of expressing her aggressive impulses in normal social situations. The undischarged aggression had found an outlet in the death wishes towards her mother and sister, and had led to the chain of mental activities described above that robbed her of her ability to focus in class.

Case II

A boy of 14 reported that in class instead of paying attention to what was being taught he would be doing complicated mental mathematics to save his parents from dying. When asked how he saved his parents from death he said like if the teacher asked to do a math problem say multiply 9 by 7, first he would come with the correct answer of 63, then obsessive doubts will emerge that perhaps the correct is 62, or may be 64, and if he does not change his answer to 61 or 64, his mother or his father or both will die. He would keep struggling whether to answer the question as 63 or 62 or 64 endlessly - he called it his obsessive loop - paying no attention to what was going on in the class. On a good day he would ultimately be able to put the right answer and feel triumphant that he did not give into his superstition. On a bad day, however, he will deliberately make mistake and suffer the consequences in order to save his parents from dying.
On Ritalin, the problem would go away. He would be able to answer the questions correctly. However, when the effects of Ritalin will wear off, he will feel tremendous sadness, and suicidal thoughts, as if he should die for killing his parents.
The only medication that gave him true relief from his "obsessive loop" were Vicodins or Codeine, a prospect that I explained to him will lead to dangerous obsession.
The etiology of the obsession to make mistake could be solved on further inquiry from mother. At age of 4, at the height of Oedipal period, he had developed extraordinary skills as a "numbers child', doing some extraordinary feats of mathematics like ability to recite multiplication tables and instant adding of complicated numbers, along with other abilities, for example ability to speed read. Along with these extraordinary cognitive development arose a tremendous phobia of everything. He was afraid of elevators, dinosaurs, cars, parks. He also developed very mild eye tics and a fear of his parents dying. The only thing that consoled him were Christmas carols, which assured him that Santa Claus will make everything alright. The mother recognized that these psychological symptoms were connected to his fear at his tremendous potential and had treated the problem by making a joke of his mathematical abilities. For example they would play the game of his adding 2+2 as 3 or 2+2 as 5. This was the basis of his making mistakes in his obsessive loop.
With dumbing of his cognitive abilities, slowly the phobias, fears and dysphoria disappeared as well. But in its place was left the Attention Deficit Disorder and a keen eye for others making mistakes.

Tuesday, September 28, 2010

Hysterical fear of sexual intercouse occurring as a recurrent dream

A girl of 21 brought in the following dream, which she had regularly dreamt when she was about 4 or 5. Then after a hiatus of 15 years, while in a process of separation from her father, while she was on vacation, she dreamt it again.
She gave the following preamble to the dream:
There was a building on the street where I grew up which always fascinated me, perhaps becasue I never ever saw anybody inside it. Generally the parking lot was empty as well. The building had three large windows facing the street and they always had shades reaching right to the bottom, keeping everything inside hidden, which gave me the creeps. There was something uncanny about the building. It was a doctor's office.

The dream:

I am inside that building. Everything appears familiar, though in reality I have never been inside. There are masked men after us and in fact they have taken us as hostages. There are three or four of them. They are wearing ski masks. We are trying to escape from them underneath two desks that face each other. Under one desk is my mother, my sister J, and myself. My mother is trying to comfort and reassure me. Under the other desk are my mother's relatives. I look intensely at the carpet to forget about the masked men who are after us. The carpet has red, blue and black designs that I have seen somewhere. Since I am the youngest, my mother tells me to make my escape by going down the basement where there should be an escape door. But when I go down into the basement I find it completely dark with no way to escape. I notice pipes all over the place, perhaps connected to a boiler. I wait in fear of the masked men, and hear one of them coming down the stairs. He takes me upstairs. When I reach upstairs I find that he is my father. I feel safe and he puts me back under the table with my mother.

The above was the recurrent dream when she was 4 or 5. The dream that she recently dreamt
was almost identical except for one detail. The man who comes down the stairs, whose approach she awaits in great fear and anticipation, this time does not turn out to be her father but one of the masked men. One of the masked men who comes down and puts a gun against her head and pulls the trigger. She does not see herself dying, but wakes up in fright her heart beating fast.

"Why did you find that building creepy, and why does it come in the dream?
The girl could give no associations. But based upon our theoretical knowledge of typical dreams, we know that uncanny buildings, mansions, churches, temples, museums, statuesque structures, eerie ruins are typical dream symbols of the mother, and quite often taking refuge in them symbolizes the fantasy of returning/escaping back to the womb. Once the most familiar, or rather the only object we knew for nine months, the process of repression, changes it to something uncanny, strange and eerie. No different than how on returning to our old school or college or house or city, after hiatus of decades, we find everything oddly strange, as if we cannot believe that once it was the place whose every nook and cranny we explored. Even the feeling of strangeness and slight eeriness that women's genital areas and articles of clothing intimately connected to it give us, owes to the fact that it was once our home. The strangeness acts as a block/defence against the wish to go back there. The feeling of dread and eeriness which caskets, and other enclosed spaces, including the phobia of getting buried alive by mistake, arises from the same complex - the temptation and horror of returning to the womb.
So the dream is taking her inside her mother's womb (medical building) and we are left with no choice but to assume that she is frightened of something and is seeking her mother for protection. Now the dream portray the objec to fear as the masked men and so we have to analyze as to what danger is represented by the masked men, and what wish underlies behind for the fullfillment of which she is willing to court that danger.
At first she could bring up no memories to tell us as to where the masked men were taken from, but on some encouragement she remembered that when she was very young - and she confirmed that the dream started immediately after this event - one evening, while returning to her 'subdivision' with her family, some police cars rushed past them with their sirens blaring and lights blazing. Her father joked that for sure they are headed to our house. And to their surprise on arriving at their house they did find those police cars on their driveway.
Her half-sister T, about 13 years older than the patient, had broken up with her boyfriend, and he had come to their house in a ski mask and had kicked open their door, busted their windows, smashed a glass grille, and poured their alcohol in the swimming pool.
She went on to tell that the boy was weird and though her half-sister T had gone back with him, when he showed up at her graduation party, her father had gone after him to teach him a lesson. The graduation party had all her mother's relatives present.
"Now the memory accounts for just one masked man, why there are 3 or 4 in the dream?"
"Because if there was one masked man, my father would have overpowered him. But if there were three men than they would overpower him." So whatever the wish that needed fulfillment required that the father be overpowered, and she herself should be overpowered by the men. So here was the hysterical phantasy of giving into sex only when overpowered and having no choice over the matter.
"Any other associations to 3 or 4 men?"
"Yes, in my life about 3 or if you include my fiancee 4 men who have had romantic interest in me."
"Why these men are coming after you in a doctor's office?"
To this she produced the association that the fear of the masked men was similar to the fear of needle she felt when getting vaccine shots, and these shots were given in a a doctor's office.
So she was equating getting penetrated by the hypodermic needle with getting sexually penetrated by the masked men. So here was the [dreaded] central wish of the dream around which rest of the dream was festooned. The motive force was the desire for sexual satisfaction with the men who were taking interest in her, with special interest in the fourth one, her fiancee, and the dread was the reflection of fright over it.
"Any other association to the doctor's office?"
When they gave shots I tried to block out the fear by just look intensely at the red, blue and black design of the carpet.
The colors of the carpet also symbolized the pleasure that awaited her if she gets over her fright of getting [sexually] poked by men. This of course is my construction.

We are trying to escape from them underneath two desks that face each other. Under one desk is my mother, my sister J, and myself. My mother is trying to comfort and reassure me. Under the other desk are my mother's relatives.
There were two desks in our bedroom. My sister and I use to play underneath it using a computer keyboard pretending to be supermarket cashiers or doctor's office girls.
So here was the promise of becoming grown up, enjoying all the pleasures of adulthood, if one gives into getting sexually penetrated by men and from which she was running away and hiding under the desk, seeking the protection of her mother. Mother's presence next to her, and desk itself as symbol of mother attests to it.
Mother's relatives under the other desk appear in the dream because of her father going after the ski-masked kid at Sister T's graduation party. In the party all the mother's relatives were there. They come into the dream as an attempt to shift, at least partially, the danger of men from herself to them.

Since I am the youngest, my mother tells me to make my escape by going down the basement where there should be an escape door. But when I go down into the basement I find it completely dark with no way to escape.
Further elaboration - duplication - of the fantasy of returning to the womb. But what looks like escape turns into a no-escape situation for return to womb is one-way street to death/darkness. So the mother's encouragement/pull to return to her, instead of giving into having sex with men, is no solution either, and the dream shows it as absence of any escape.

I notice that it has pipes all over, perhaps connected to a boiler.

The association to it was A Nightmare on Elm Street horror movie and its main character the serial killer Freddy Krueger. Apparently in the movie Freddy Krueger gets burnt in a basement which has similar pipes and boiler. He also emerges disfigured and half-charred, evil and revengeful. Also the patient's association led to her recalling the detail that Freddie Krueger does the killing in people's dreams, and if they don't wake up in time, they die in real life as well. Recall here, how in her recent dream she wakes up before the masked man shoots her.
Now the lure of horror movies psychologically is based upon the lure of incest and dread and castration associated with it. So Freddie Krueger's coming after innocent children is nothing but fulfillment of incest fantasies with father where the guilt over it regresses the satisfaction in to sadomasochistic forms - getting shot or knifed. The fear generally completely blocks out the pleasure of the underlying sexual satisfaction.
The girl confirmed that as a child she was addicted to horror movies. A reflection of her strong attachment to her parents which was now making it difficult for her to make transition to strange men.
The pipes and boilers were allusions to male genitals rather an exaggeration of it - the eerie feeling, the horror of it - while the disfigurement and half-charring of the body were symbolizing castration.
The impulse to castrate was directed against her father [Freddie Krueger] whom she would encounter in her mother's womb as a competitor and find it as a danger. In her real life too, she had extremely ambivalent relationship with her father, whom she had once loved very dearly but now could not criticize enough.
So her fright was as much of getting sexually penetrated by men as of the fear of her own desire for revenge which would not hesitate to castrate, disfigure and char them who would dare to poke her.

I wait in fear of the masked men, and hear one of them coming down the stairs. He takes me upstairs. When I reach upstairs I find that he is my father. I feel safe and he puts me back under the table with my mother.

Here the father is being represented as her savior. "Instead of having sex with these strange men, who will penetrate me, and cause damage just like my sister T's boyfriend did to the window and the glass grille of my house, I rather run back to my father who will protect me and save me. In dream she climbs back with her father who puts her back under the desk with the mother [incestual fantasy with the father while in the womb].

In the contemporary dream, which was sparked by separation from her father, he is being replaced by one of the masked man.

It is one of the masked men who comes down and puts a gun against her head and pulls the trigger. She does not see herself dying, but wakes up in fright her heart beating fast.

In the recent dream, unlike the ones she dreamt as a child, she is making progress for she chooses one of the masked man as the person making love to her instead of running back to her father and mother.
To understand this we have to interpret that the sexual activity is depicted as getting shot with a gun and having sex is equated with dying.
The pounding heart is reflection of the anxiety that accompanies sexual excitement.

Sunday, September 26, 2010

Sexual perpetrators returning as animals and the Devil in reminesnces

A 48 year old woman who suffers from severe fibromyalgia symptoms, along with a number of painful physical illnesses, that arose in her primarily as a response to sexual abuse from age of 9 onwards and which had lasted well in to her late twenties, reported some bizarre psychotic symptoms.

She reported seeing animals, half-man half-animal figures, and the devil himself. They would also mock and scare her.It is interesting that she kept the experience of these hallucinations well hidden from the world and did not allow them to affect her daily conduct.

Besides her stepfather, with whom she had relationship till in her twenties, she had been abused by other men in her prepubertal period. However, these abuses were limited to just inappropriate touching. At the age of 16 she was raped on a blind date. She claimed these animals were the men who had abused her and the Devil was the step-father himself.

Now the consequences of these abuses, and premature sexual arousal, was a life long pattern of victimization. Not only she placed herself in social situations that led to her being humiliated, exploited or taken advantage of, but her self abuse extended into the physical sphere as well. She tended to fall and hurt herself, that had for example destroyed her knee joints. She also had developed many self-destructive psychosomatic illnesses as hypertension, chronic back pain and asthma.

She suffered from physical pain all the time and felt her muscles throb all night long.

In contrast to hallucinations in dreams, her molesters returned, but interestingly not as animals or the devil, but as themselves. This is the opposite of what usually dreamwork does. Generally people return in disguise, not as themselves.

In dreams she would threaten these men with telling on them to her mother. Which she never did during childhood, because she was afraid the blame will fall on her and not on the perpetrators. She was trying to do now what she should have done then, with the advantage of having the experience of 40 years. She was now rectifying the errors of omission. She would also tell the evil men in her dreams to leave her alone, not to touch her, and preach to them as to why they should not have sex.

She also reported that while watching TV, she would suddenly see a black pastor in one corner of the screen preaching verses from Bible. This icon like little black minister would also pop up in movie theaters.

Now what was the purpose of these hallucinations and the relentless pain and suffering?

They were the repetitions of her unwanted sexual stimulation. She had been sexually stimulated when her body was not mature enough to discharge out the physical pain and sexual arousal that was thrust upon her by her stepfather and other men.

Her whole life had become an exercise in getting out of her system the trauma of that premature stimulation. It was undoing of the traumas.

Conversion of those men into animals was lessening of their significance as human beings. Turning stepfather into devil, was to make him the bad guy, whose destruction she could now hope to achieve by the forces of good. The preacher at the corner of the TV and movie screen quoting Bible versus were intended as a counter-weapon to the evil powers of her stepfather. In the dreams she was taking the role of the preacher herself, admonishing those molesters.

One should notice that the desire was not just for undoing the whole thing and getting rid of the molesters. The molestation had left such a strong impression that it had become the core of her being. Her whole life, day as well as night, was about nothing but reliving the sexual abuse. Without such a hypothesis it is impossible to explain as to why the molesters in form of animals, ghosts and other stalkers followed her all the time

Wednesday, September 22, 2010

Obsession with lucky numbers as a magical manuver to avert disaster/death

A lady who suffers from severe anxiety and quite a few obsessions brought up her fixation on number 5 in the session. "When it comes to numbers I have to do everything in multiples of five to avoid disaster."
The ostensible reason that she gave was that by bringing in the number 5 she converts bad luck to good luck.
An example she gave was her going to a horse competition - she is an avid horsewoman - where her horse was given a tag with the number 164. She immediately began worrying that it had no 5 in it, and that meant ill omen. But then she found an ingenious solution. She reasoned that if she subtracts the first number (1) from the second (6) it becomes 5. And as far as the last number is concerned if she adds second number (6) to the third (4) it becomes 10, which is a multiple of 5. And with this calculation she knew she was in good hands. And with this confidence under her belt she could singlemindedly devote herself to lead her horse to victory.
What lied behind this obsessive mathematical exercise?
Now she has two brothers, and if we count them, herself and her parents, the total comes to 5. Was the obsessive invoking of the number 5 a ritualistic way to protect her family? She did not affirm or deny this psychoanalytic construction, but indirectly confirmed its correctness by immediately adding that just like number 5 is good, the number 3 is unlucky for her. She hates 3 and its multiple 6, 9 etc. and has to replace them with 5 to turn bad into good.
The associations to number 3 brought her parents divorce when she was just 4. She made sure to immediately claim that the parents divorce made no impression on her. She was too young to understand it or be bothered by it.
This pricked up my ears, because we know from Freud that obsessional neurotics often reveal their deepest secrets almost as a non sequitur with hardly any emotions. They will say something like "Oh by the way this thing happened, but I never paid much attention to it." What they are saying is that what I just revealed is the core of my problems, but to protect myself from it I have drained it off of all its emotional energies, and so now it is remains in my psyche as a colorless memory towards which I behave as if it has no significance.
So I deduced that the divorce did matter to her, but she sequestered it and stopped giving thoughts to it.
"So did anything bother your about your parent's divorce?"
"What bothered me was my father immediately marrying my step-mother. Hardly a few months after the divorce she was there in our lives. I hated her as an intruder [third person] in our lives.
She then proceeded to tell as to how she never hated her mother. A psychoanalyst has to ignore the disclaimer and take the statement at face value, ignoring the negative prefix, and saying to oneself, "She does hate her mother."
She confirmed this by quickly going on to tell me went on to tell that she may not have hated her mother but she absolutely hated having to move into her grandmother's house, where she had to share the same bedroom with her mother, and had to sleep with her in the same bed up to the age of 16.
"Who else you hated?"
"I hated my grandmother. We had to live in her house. She was mean. She tried to suck the life out of me. She could not stand my taking interest in anybody. Even putting on the lipstick was treated as something horrible."
So the three women, all who could be put in the category of mother, she hated, and it was this hatred which was hidden behind her detestation of number 3 and its multiples. The appearance of my mother, step-mother, grandmother spells disaster for me was the unconscious reasoning.
"Does the number 5 protect you or your loved ones from evil and death?"
"I don't know that," the patient replied, "But whenever I hit a bump from one side of the car I have to find a bump to hit from the other side of the car to even it out, otherwise I fear somebody close to me will die."
But if the people she hated were her mother, step mother and grandmother why would she wish her brothers and her father dead , if we assume that the use of number 5 was to protect them from her death wishes?
Here we recall that she has the obsession to bump the car by the other side if one side hits a pothole. This was easily confirmed as a reparation for the death of one parent by balancing it out with the death of the other. Her death wishes towards her mother was balanced by equally strong death wishes towards her father.
Her brothers who were many years older than her were loved and resented at the same time, for they reminded her of not being the only child.
So this obsessive young woman was plagued by death wishes towards both her siblings, and her parents, and as a punishment for these evil impulses, death wishes towards her own self. And with the aid of number 5 she could save them from her feared destructive impulses.