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.