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.