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.


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