Friday, September 10, 2010

The phenomenal memory of Obsessional Neurotics and Autistic Patients

People who suffer from obsessional neurosis take special pride in their excellent memory. After a therapy session when you try to give them your business card, where you write their next appointment date and time, they are apt to brush it aside with a contemptuous wave of hand, "Ah! I don't need that. I'll remember." And then they give you that smile of superiority which says unmistakably "I am better than you when it comes to remembering things like that and how could you even doubt that I won't remember."

And the remarkable thing is that they do remember. And they are there, on the dot. And you are impressed, and cannot wonder enough at the reliability of their memory, especially because it is not just in keeping their appointments, but in all spheres of life.
Of course this wonderful memory, as the treatment proceeds, takes a fall. The patient who was coming as a clockwork, one day as you go to fetch him from the waiting room, you are surprised to find there is nobody there but empty chairs staring back at you.
And you wonder as to what went wrong with your patient's wonderful memory?
You have a nagging feeling it is something you did in your therapy that has resulted in the loss of his high regard for you, and to the point, that he has forgotten to use his wonderful memory.
And you are right, it is the result of your psychotherapy.
But therapy is suppose to improve a patient's mental faculties not cause them to lose whatever little brains they have left. And their memory is one thing the obsessional neurotics are very proud of. As a counterweight to their involuntary appearing crazy obsessions, compulsions and images of harm coming to their dear ones, they hang on to their phenomenal memory as a badge of pride. It is as if to assure themselves, and others, that whatever else may have gone wrong with them they have at least not lost their mind, and their good memory is a proof of it.
And though we must concede that the lessening of the tautness of their memory is the result of therapy we must not despair that it is because we have done something wrong.
It is part of the course. What has happened is that the patient who was using his excellent memory to show his extreme consideration towards you, now that he is allowed to talk freely in the session, has become bolder in showing his hostility - that was underlying the consideration and was being suppressed by it - and its first victim is, of course, you.
Yes, you, because you were the one who told him to take courage and take cognizance of his ambivalence towards others.

Obsessional neurotics deny the entrance of their hostile unconscious impulses into their consciousness and they do so by putting at the fore exactly opposite thoughts and behaviors; acting as highly concerned, kind and responsible individual; someone who will not hurt a fly. Though the underlying destructive and cruel impulses do, from time to time, break through. In fact, all senseless obsessions and compulsions are manifestations of these aggressive tendencies in a disguised and muted form. They are in essence a compromise between the two trends - the impulse to do harm and its opposite to save you from the destructiveness. Through behaving nicely and showing all kinds of thoughts and impulses to help and save you they tend to "undo" the aggression.
Now the phenomenal memory of the obsessional neurotic is for the most part the opposite of his aggressive tendencies - an expression of the impulse to show oneself to be the most decent and reliable person. When the patient states that he will remember your appointment without fail what he is saying is that you are so important to me that your word is my command and I will make sure that in no way I will insult you by not showing up at the appointed time. It is kind of proclamation of how much they honor you.
But underneath this honoring lies the suppressed opposite impulse. The impulse to defy and insult you. The impulse to say something like: "Oh yeah, come for your appointment, why don't you tell your grandmother to take a piss too." Crazy, absurd counter commands, or ridiculous situations that by their very nature cannot be done. The absurd conditions on whose fulfillment depends honoring your request are a form of defiance. In the above example what the patient is saying is that ask me to come for the appointment after you ask your grandmother to take a piss. An unfulfillable condition. However, as a rule the command or condition does not emerge in the patient's mind in its entirety but as a chopped part of it, and generally entering the consciousness after a reasonable period of time and in a context which makes no sense. He may for instance see his grandmother taking a piss, without any clue as to why that image is recurring and with the only emotion accompanying it is none or annoyance, and it will keep returning as an obsessive image till the rage towards the therapist is exhausted.
Of course, one should not underestimate not showing up for the session and thus causing monetary loss is an excellent way to show negative feelings towards the therapist.
Now what the work of psychotherapy does is to give the patient a voice in the sessions and subsequently courage to take a stand against authorities in his actual conduct. And one of the ways he does so is by indulging in an error of memory; something that he felt so secure about hitherto. The chink in his armor occurs right at the spot where he has the most confidence in his ability to suppress the opposite impulse.

But why? And in the first place why memory is one faculty that becomes so extraordinarily developed in the obsessional neurotics when compared to other mental illnesses?

But does it really? How about other illnesses? Doesn't hysterical people repeat their attacks over and over again, and their attack is nothing but symbolic and muted expression of a traumatic sexual event, whose basic structure was laid down at the earliest period of childhood? That is memory too.

But there is a difference between the memory of a hysteric versus an obsessional neurotic. In hysteria the memory of the trauma is deeply ingrained, but its repetition occurs without the conscious knowledge of the patient. Patient does not recall the trauma, just acts out the traumatic event, or parts of it. It happens under the inexorable law of "Repetition Compulsion." It is not a memory that the patient can use in his day to day behavior or make use of as a feat of memory. It is unconscious memory. So we can't truly call it a faculty of memory. Also in hysterical patients facts and fiction are inextricably mixed, and instead of taking pride in adroitness of their memories, the patients take pride in being "so cutely" forgetful. The forgetfulness becomes a character trait which the hysterical woman - usually a pretty woman, hysterics are as a rule good looking, the proverbial goofy blond - starts taking pride in, and quite often uses it as an excuse for getting special consideration.
In psychosis there is wholesale assault upon memory and a replacement of it with delusional material. Instead of recalling things accurately, the psychotic recalls his fantasies and sees them as real. The memories are remodeled without taking regard for reality.
But there is one condition, a severe form of illness, in fact more severe than ordinary psychosis, where the patient shows even more remarkable memory than the obsessional neurotic.
In many autistic patients the memory is not just phenomenal it is mind-boggling.
An autistic patient of mind, who is now in his early Sixties, remembers thousands upon thousands of streets and their intersections, not only in all the cities he has lived but also some of the streets of the cities where some of the people he has interacted with have lived. He asks you where you live, and then remembers that street forever. But the memory is not just regarding streets, he will ask your birthday, the names of your children, their birthdays, and commits them to his memory. He remembers details about all kinds of musical groups and what song they wrote in which year. Another autistic patient remembers every Led Zeppelin songs and can tell you how long each one lasts to the exact second.
What is the purpose of such a phenomenal memory in these autistic men? One thing is for sure that they have no practical utility. The man who remembers virtually every major street of Metro Detroit, and which one intersects with which one where, is confined to a group home, and not allowed to take a step out of the place on his own. Far from working, he cannot even cook and clean for himself. His day is spent from dawn to dusk complaining about other residents of the home. He cannot tire calling them troublemakers and doing this and that in a wrong and foul fashion. This has no basis in reality. If anything he is the biggest troublemaker in the Group Home. He has the keenest eye for noticing everybody else's errors and he makes no bones lamenting about it all day long. Interestingly he hears them calling him "the stinkie boy."
Is the mystery of the phenomenal memory lies in his phenomenal fault finding ability? And from where did this fault finding tendency emerge in his mental life and became the central feature of his character?
I can only account for this state of affairs in autistic patients, and in obsessional neurotics as well, by assuming that at a very young age, in autistic patients chronologically much earlier than the obsessional neurotics, the child did something aggressive/destructive for which he was severely reprimanded. Or perhaps it was not one major reprimand but a series of them. For in such autistic/obsessional neurotic families there is a culture of not tolerating even the slightest aggressive/deviant behavior. And this culture of intolerance has a cumulative effect in muzzling the child in expressing his emotions. The parents are quick to criticize or mete out harsh punishment or hold off love when the child expresses destructiveness. He is not allowed to mess up things. The house has to be in perfect order. And in autism prone families this non-acceptance of child' nature is practiced with the child as far back as to when he first begins to verbalize to his emotionally deaf parents. Or perhaps in these parents the language is devoid of much emotions. Perhaps the parents themselves grew up in homes where there was great parsimony in showing emotions or even feeling them, where words were used without the richness of emotions suffusing them. Perhaps the child has great difficulty in making emotional connections between what he is verbalizing and what the parents are verbalizing.
To deal with this non-acceptance of his destructiveness - the manifestation of the great destructive instinct - the child develops some characteristic defense mechanisms. These can be broadly put in three categories.
The most disturbing, and which causes the severest damage, and herein lies the secret of autistic disorder, is a profound turning away from the world and the loss of the significance of other people as targets/objects of one's emotional life. The parents become as good as strangers, and subsequently all new people who enter one's life are subjected to the same rejection. There is a fundamental emotional withdrawal from the world, with aggression now directed primarily towards one's own self. The massive increase in brain size of the autistic children perhaps occurs to accommodate this turning of hostility inwards. Outside objects no longer exists and one has to play the role of both subject and the object. The brain increases in size to accommodate this dual role.
A less damaging defense is not to give up others as objects of aggression and turn it against oneself but to indulge in aggressive/destructive behavior but shift the blame for it on others. This is the defense of the autistic patient of mine, who remembers every street. His mental processes go something like this: Granted something nasty is going on, but it not me who is the author of it, it is other residents in the Group Home, folks like me ( my siblings), who are the evil, who wish you ill and want to destroy you. Punish them, not me. This accounts for my patient's constant blaming of others, while in reality he was the biggest trouble maker there. This defense mechanism allows him to discharge some of his aggression with external objects (other people), saving himself from the severest form of autism. He thus preserves his relationship with others - his parents/authorities - through discharging his aggression, but by not owning to it, and blaming (projecting) it upon others, he escapes the fear of impending punishment to some extent. In his unconscious he reasons, whatever punishment will come, it will fall upon others, because they are the trouble makers not him.
The fact that he hears others call him "stinkie boy" which infuriates him, is a pointer that the aggressive and destructive behavior that he attributes to others - in his unconscious his siblings - is arising from him, and he acknowledges to it albeit in a very tangential fashion by first converting it to auditory hallucination.
The choice of Geographical locations, streets, cities etc. in my patient arose from the same "sibling complex". There is a great love for order here. The punishment that is to be meted out for aggressive behavior should be in the exact proportion to each sibling's crime. Also the [meager] love that exists in the parent, when it is meted out should be in exact order and of the exact amount based upon the degree of aggression displayed by the children. That explained his keenest eye for finding faults in all those who could represent his siblings. This fault finding in siblings by displacement and reversal had become finding the minutest details about cities and the roads. There was another causation for the choice of streets and cities to symbolize his siblings. He had four or five of them, and the order in which they were born and the age differences between them was now represented by the geographical sites and their exact relationship with each other.
The patients love of order was also manifested in his great fascination with trains. He could sit all day long at railway lines, watching the orderly progression of one coach after another. It was again an appreciation of the order in which the siblings should be gratified. But at a deeper level it was a manifestation of the most fundamental aspect of autism. His illness arose because of unbridled eruption of his aggressive/destructive tendencies at an age when he was not mature enough to master it and his caregivers were too emotionally cold to help him in dealing with it. His fascination with trains and the orderly appearance of the bogies was a wistful longing for his own emotional life to have unfolded in a similar gentle and orderly fashion. "If only my instinctual life had erupted in proper order and not burst forth pell mell I would not have suffered this ill fate."
The fascination with music and things that went in loop, like fans and gramophone records, appeared to have arisen in him from the same complex. Music is very precise, and beats have to appear in precise order. Which reminds us of the second patient who knew each of Led Zeppelin songs to the precise second. Once again it was demand for justice and an appeal that the punishment that is to be meted out to me must fit the crime. But the fascination with mechanical things that do the same thing over and over again without any chance of deviation was also a projection of wistful longing for a complete control over one's aggression and for a hope to not deviate from the straight and narrow. The total preoccupation with controlling aggression becomes like a loop in the mind of the autistic to the exclusion of every other interest.

It is interesting that even in this defense mechanism of autistic patients, one can easily see the opposite impulse from time to time breaking through. For example my autistic patient who has phenomenal memory for the cities and birthdays invariably makes subtle errors. He does not remember quite correctly that I live in Bloomfield Hills, always recalling it as West Bloomfield, an adjacent city. He remembers the month I was born correctly, but invariably misses out on the correct date by a day. Another autistic patient of mine remembers quite a few dates about me - in my honor of course - but when he recalls it as a way of paying complement, he stutters so miserably that it is more a pain than pleasure and I rather do away his praising of me. Behind the phenomenal memory of facts about you lies the opposite impulse - to distort facts about you.

The least harmful of the three set of defenses in order to deflect aggression away from the parents to avoid the dread of punitive retaliation, and the one which is most characteristic of obsessional neurotics, is covering up of the aggression by "pleasing" behavior. In a little child who is confronted with the spectacle of a newborn sibling and whom he hates as an unwanted rival, he may instead of hitting or pinching show hypocritical professing of tender love. When a four year in throes of Oedipal hatred is tormented with wishes for his father to get lost and never show up again, to counter the hateful impulses he may go and kiss his father's hand and do other little things to please him. It is this doing of just the opposite of destruction that lies behind the phenomenal memory of obsessives no less than it does with autistics. The obsessional neurotic's mind has to be constantly "on alert" to quash the destructive tendencies and replace it with tender ones. Before the thought comes that I should not show up for his appointment "the alert mind" sparks the counter resolve that not only you will come to the appointment you will remember the appointment so well that in no way you will ever forget it. It is this alertness, and a resolve to remember doing the right thing forever, that lies behind the extraordianry memory.
Interestingly even the phenomenal memory which originally arose to show one's love and regard for others in most cases often results in doing just the opposite. An obsessive who knows everything about the road patterns of a city when giving directions may give so many factual information, never coming to the point, that you are left with confusion and are worse off in finding your way with directions than without them.
The question naturally arises as to why some people choose profound withdrawal from the world turning all the aggression inwards, while others indulge in the aggression but project it on to others taking no responsibility for it, and in the process lose that sense of self so characteristic of autism, and yet others cover their aggression by tenderness and thus maintain relationship with others albeit a highly ambivalent one.
Of course the obvious answer is the age at which one's destructiveness is not tenderly mirrored and gently modified but either meets with cold response or is brutally suppressed - the basic psychopathological process in these illnesses. Earlier the age of this subtle rejection, the more likely the child will be unable to displace it upon the siblings or to cover it up with the opposing impulses.
But the role of fear should not be overlooked in these illnesses either. When autistic people are closely examined behind their varied psychopathologies lies a core and profound fear of the world. This fear appears to be the sine qua non of autism, and obsessions, and of so many other mental illnesses. Earlier the age, the greater is the fear of anticipatory punitive retaliation. If the infant feels helpless in discharging his aggression at others at a very young age, he is likely to turn away from the world completely. It is a profound flight from others. A complete shutting out of the world. When he is a little older, and has some sense of his siblings, and has some confidence that he can manipulate or rather influence his caregivers, by his words and by blaming others, he will indulge in the second type of defense. In the third type of defense which is usually seen in obsessives and not so much in autism - though in the latter too there is a tendency to protect others by picking up litter and other out-of-place objects from which harm can possibly come to others - the child has already entered the Oedipal period before the problem arises.
And one more point upon the phenomenal memory of obsessives. The extreme desire for revenge and turning the table upon authorities should not be underestimated. There is an element of hypocrisy in the tenderness/concern/love which is put forward to deflect attention from the underlying hostility. Behind obsessions are desires to get even with the Oedipal father. The fear of castration in hands of the father for one's sexual proclivities provokes the impulses of revenge. And it is these revenge impulses that appear as defiance and destructiveness. Now the original threat of castration is entirely forgotten. And in its place as if by compensation arises a remarkable ability to remember every situation of life, where one is threatened. Every threat and humiliation becomes at bottom a threat of castration and defeat at the hands of the Oedipal father respectively. And the obsessive tries to remember them all with utmost accuracy so he can come back another day and win the fight.

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