Saturday, August 28, 2010

A quartet of psychosomatic symptoms and their obsessional neurotic roots

In his "Notes on a case of Obsessional Neurosis" Freud remarks how Obsessional Neurosis is a rich and rewarding field of inquiry, and how many closely associated patterns of symptoms exist in this illness that would be worth inquiring into. The most famous constellation of this kind is Freud's delineation of a regular association between parsimony, obstinacy and orderliness, all components of anal eroticism

I have been struck by the following four psychosomatic symptoms that seem to occur together in quite a few of my obsessive patients.

Migraine headaches
Stomach pains and cramps
Panic Attacks with fear of leaving familiar surroundings.

Underlying these symptoms, on careful observation one finds a surfeit of undischarged aggression. The patient who cannot discharge the aggression by normal means does so by taking it out on himself; by creating the suffering in his own body. I will give two such cases where I could make some headway into their psychopathology.

A 26-year-old very attractive girl suffered from horrendous headaches, inability to sleep despite massive doses of benzodiazepines, stomach pains at the thought of leaving the house, throwing up and diarrhea at the slightest bad news, and Panic attacks that would leave her exhausted.
She had highly charged destructive thoughts towards men which she struggled against with all her might. The struggle was reflected in her feeling a constant tension in her head which would quite frequently escalate into frank migraine headaches. She was so ashamed of her evil thoughts towards men, which were connected with the possibility of their being unfaithful, that she had married inter-racially, thinking that a black man would not be unfaithful to her, valuing her highly for being white.

On exploration of her insomnia it was found that she slept in a fetal position in one corner of the bed as if she was anticipating somebody attacking her. She had to go through obsessive rituals like checking and rechecking windows and doorknobs to fall asleep and even then it would take her a long time. The insomnia was connected with her fear of dreaming rather having nightmares. The nightmares were 'anxiety dreams' in which young girls were abducted and tortured and raped and subjected to extreme sexual humiliation. The immediate source of it was watching a cable channel where real life stories of little girls getting abducted by sexual perverts was the staple, but its deeper roots were her unresolved attachment to her father from the oedipal phase. The guilt over her love for her father was handled by regression to anal erotic (obsessional) level marked by fantasies of getting beaten, tortured and killed by a rapist.

The reaction to this desire to abjectly submit herself to men and be beaten and humiliated by them found expression in a great [coexisting] hostility towards them. It was this hostility which caused the panic attacks at the thought of leaving the house. The actual thought of leaving the house and be exposed to strangers whom one may solicit or who may abduct one and then subject one to act out the sexually humiliating fantasies caused churning of the stomach and diarrhea.

The second case is of an adolescent boy who also suffered from migraine headaches, insomnia, stomach cramps and pains, a great urgency to defecate when stressed, but not frank diarrhea, panic attacks and inability to leave the house. Added to this quartet were attention problems, hyperactivity, and motor tics. Motor tics were predominantly around the eyes but also posed difficulty in swallowing that emerged as complex motor movements through the upper torso of his body. He was capable of suppressing these motor manifestations of aggression by actively concentrating upon them, but it would leave him exhausted and give him migraine headaches. The headaches were always there as low lying muscle tension becoming frank migraines if there was parental conflict or if he had to do some trying activity like taking a test. He also had inflammation of the sinuses causing sinus headaches, also probably a manifestation of the same psychosomatic pathology.

The boy was insightful enough to figure out that his attention problems were connected with death wishes towards his parents. In classrooms, instead of listening to his teachers, he would be struggling mightily to prevent the death of his parents by doing some day dreaming or some complex mathematical activity designeded to ward off the evil that was to befall his parents. This animistic thinking also found expression in some compulsive motor movements like having to tap the door or other objects a fixed number of times, generally three, symbolizing his mother, father and himself.

Additional symptoms that confirmed he was struggling against his death wishes towards his father were his castration fears that his hair needed cutting, or his shirt was not trendy enough or marked by defects, or he smelled, or he had body deformities which would subject him to ridicule in public. These are all manifestations of a hypochondriacal and social displacement of castration anxiety. He would take a long time to groom which was displacement/regression of his castration anxiety escalating to an anal-erotic phase.

His great rage towards his father was a reaction to his fear of getting castrated by him for his sexual proclivities towards his mother arising from the oedipal phase, but now buried in the unconscious. He also reacted at the thought of leaving the house with panic and churning of stomach. The panic was at the thought of humiliating himself with strangers by abjectly submitting himself to them. This was a passive dissimulating reaction to hide his desire to murder them, a displacement of the murderous rage towards the father on to strangers.

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