Wednesday, March 30, 2011

Hallucinations in non-psychotic people

In the Seventies when I was doing my residency patients would get diagnosed as schizophrenic at the drop of a hat. Added to this was the evidence-based science of that era which proclaimed that "Once a schizophrenic always a schizophrenic."

Schizophrenics never recovered was the dictum. And they really believed in this self-serving medical fact.  To complete this demonic vision of the illness, the psychiatrists in those days took awful pride in being the kind of guy who did not flinch at prescribing gargantuan dosages of antipsychotics. It is not surprising the hospitals overflowed with patients who did nothing but drool and do the Thorazine shuffle, lending further evidence to the "evidence-based" scientific thinking of those days that schizophrenia was a life long malady.

And a single confession of hearing voices could garner the diagnosis.

Over the years I have done Disability Determination evaluation for Social Security in poor sections of Detroit, examining hundreds of African-American patients and have been struck by as to how often they report presence of hallucinations. And it hardly seems to be confined to those suffering from psychosis.  Hallucinations in general is more prevalent in African American patients than whites even when they are suffering from identical psychotic illness.  But it was an eye opener as to how many non-psychotic African-American patients also report hallucinations.

I came across two such patients today reporting of which may have some scientific value.

Case I

A 59 year old African-American woman who is severely depressed and does not leave her room since her 18 year old son was shot dead emerging from a grocery store, reported that she sees her son every day.

When asked where does she see him, she replied, "Standing at the door of my bedroom." And for how long, she replied, "Ten minutes. And he is clear as can be, and looks straight at me." When asked does he talk she replied, "He tells me he is alright. Sometimes he tells me I am still with you."

This assurance was easily analyzed as her extreme desire to know that he is happy wherever he is for she cannot forgive herself for not protecting him from death. He was her favorite child. "He was Momma's boy, who hung around me more than any of my other children."

She was in the vicinity of the grocery store where he was killed, and had actually heard the gunshots that had bled him to death, and though came quickly to where the shooting occurred, he was already unresponsive.  When she heard the gunshots, something told her that it was him getting shot and so she feels guilty that somehow she had a role in his death. Furthermore she feels that it was a failure on her part that the killers could not be brought to justice, though nobody found the assailant/s, or even discovered the motive of the crime.
So hearing the dead boy telling her in the vision that he is alright acts as a balm to her sense of guilt.

This motive to create hallucination to feel less guilty I saw in another girl, whose sister died in a car accident, and the reality of whose death she constantly forgets, often living in the make-belief that her sister is still alive. This 17 year old girl, one night woke up to find her sister lying next to her in bed. The sister said, "Sister it is not as bad here as you think," and then disappeared.

In both cases the hallucinations were produced to assuage the guilt over the death and a need for the reassurance that the dead person is not suffering but is happy.

Case II

An 18 year old African American boy reported that his father, while in the hospital for collapsed lung and pneumonia, on brink of death, had an extraordinary out-of-body experience. He died for 20 seconds, which was, per patient, confirmed by his brother and sister. When asked how did they know he was dead, the boy stated that his father rolled up his eyes, which is a sure sign of dying.

The boy then narrated to me what his father experienced while he was dead. It was like a blackout in which he came out of his body and saw himself lying dead on the hospital bed. While hovering he cried out that his time is not due yet. He then heard a voice, "Yes, his time is not due yet."

The voice caused his soul to immediately return to his body. The father swears by the reality of the voice and the brothers and sister insist that he was definitely dead for 20 seconds.

Now here is a shared magical thinking. To call it shared psychosis would not be correct.

But there is no doubt this was a hallucinatory experience.

Why did it happen?

Perhaps the man had two contradictory wishes towards death. One was to get it over with it and embrace eternal peace and the other was that he still has unfinished business in this life. His youngest child is just 18, and very much vulnerable to harshness of this exploitative world, about which the father worries. And anyway the desire to cling to life is perhaps the strongest drive in all organisms, and is given up only when there is complete hopelessness. So he cried that his time is not due yet, and heard the projection of his own father's voice, telling him that his time is not due yet.

Do white people have hallucinations without psychosis? Yes, they do, but not that often.

Here is one case.

A 47 year old man, in midlife crisis, in throes of severe agitated depression, that was precipitated by the closing down of the machine shop in which he had worked for 20 years, and with his particular skill no longer in demand was faced with the prospect of working for minimum wages, which his pride would not let him, for he was used to making over 25 dollars an hour, and his finances dwindling to the point of having literally no food in the house to feed his wife and children, went into severe panic attacks, insomnia and nasty mood towards everybody.

He had the following two hallucinations.

My mother, who is now dead for over 15 years, is sitting across the room looking her usual no-nonsense West Virginian self. She makes an admonishing sign at me with her index finger. As usual a smoking cigarette is on her mouth.

The hallucination was easy to interpret and actually done by the patient himself. "I was seriously contemplating suicide or just walking out on my family for they would be better off without me. My mother who did everything by the book once told me that departed souls are allowed one visit from the beyond was using that one-time privilege to save me. And the motion of her finger was admonishment to not give up on living and that walking out on my children was not an option."

It is interesting that this patient's father had walked out on the family when he was a child. And his mother had brought him up. Taking advantage of life's adversities, he was trying to do to his kids what his father had done to him.

The second hallucination which took place a few weeks later was about his best friend.

I see this friend of mine sitting next to me. He was as real as you. He inquired after Mom and Dad and then asked, "How have you been. I have missed you." I told him, "I am going fucking nuts." Then I went to the kitchen to get coke and when I came back he was gone.

The person who appeared was his best friend and someone he grew up with and whose opinion he valued. One day he visited his friend, who was just 29 then, and while he went to get some coke in the kitchen, he heard a thud, and rushed back to his friend, who was lying on the floor his eyes showing no life. He had been struck dead by a ruptured brain aneurysm. The patient attributed the hallucinatory return of his friend from the dead to tell him as to how fragile and valuable life is and even if he is going nuts it is better to be nuts than be amongst the dead.

 He added that his mother and his friend were the two most important people in his life. It was not difficult to analyze that when life became unbearable it was natural that he thought of joining them. But in the hallucination his good sense made them reject this desire of his and tell him that he should return to his family and that being alive however miserable is better than being dead.

In all the above hallucinations a common thread is of death and of departed people. It appears that dead people are made to return as hallucinations to help the person in dealing with life's difficulties. So many of the African-American patients I have evaluated and who report hallucinations on further questioning report that the people who they see or feel the presence of are those who had been kind and helpful to them when they were alive. A beloved grandmother, or a favorite aunt, or some other parental substitute becomes one's constant companion and takes on hallucinatory proportions when under extreme stress. Not too different than how a child who feels helpless creates an imaginary friend whom he always carries around with him.
However, it is not always that hallucinatory figures are there to be a helpful companion. Sometimes one may bring a dead person back to life to help him or her from a difficult situation where one could not help when it was actually occurring.

A 19 year old girl reported hallucinations of seeing her mother screaming and yelling for help. The mother had died when the girl was barely 12. In those 12 years she had frequently and helplessly witnessed her mother being subjected to brutal beatings by her stepfather. Now when she was grown up enough to fight back with her stepfather and protect her mother, her mother was already dead. The vow to protect her mother could now be filled only in her hallucinations.

In an even more moving account of a hallucination I heard from an African-American woman, whose 18 year old son was shot right in front of their house. In fact he was shot 8 times, and as he bled from all over his body, he turned to his mother and beseeched her with his last breath,"Don't let me die on the street mother. I want to die in my bed."

"He did no harm to nobody. Why did they shoot my baby?" the mother cried once again in the interview.

His last words, "Don't let me die on the street mother. I want to die in my bed," keep echoing in her head and sometimes turn in to hallucinations.

The motive behind the hallucination, besides to see her son alive again, was the praise for her son's indomitable spirit, which even seconds before dying expressed his desire to be triumphant, having a say on the manner of his death, opting for his own bed and its security over the contemptuous, dirty, dangerous street.

Dreams of teeth falling out as punishment for incestuous thoughts

A young girl wanted to know the meaning of teeth crumbling and falling out in dreams. When asked to tell the whole dream, she confessed that it was her boyfriend's dream, which he often has and she is just curious
as to its meaning.

On being told that psychoanalytic literature considers losing of teeth as a typical dream - which means it is a universal dream, with at least one meaning always the same across all cultures and individuals - and it represents castration as a punishment for masturbation, she found it highly amusing and added that it certainly could not apply to her because she too dreams of her teeth falling out, and the question of castration does not arise in her case, and perhaps we psychoanalysts may consider an alternative explanation that since her teeth are truly rotten and full of cavities they are simply falling out in dreams before they do so in real life.

We laughed and proceeded on with the exploration of her boyfriend's dream. She could not remember any more details then what she told me and asked as to why somebody would be castrated for masturbation?

I replied that it has more to do with fantasies associated with masturbation for which the dreamer's dream censor [conscience] thinks that the right punishment should be castration.

With this feedback there was lifting of some repression and the patient now could recall his dream clearly:

The dream begins with there being a woman at a lake who as soon as she sees him begins to leave. He cannot see her face. Her leaving is followed by his finding himself drowning and then he shuts his mouth and the teeth crumble and fall.

On the basis of symbols alone, I interpreted,"The woman is his mother. His teeth are falling as a punishment for incestuous thoughts towards her."

"That is interesting," the patient was impressed, "For though he sees no face, he has no doubt she is his mother." And added, "Why cannot he see her face? What could be the meaning of that?"

"Vague or indistinct facial features which obscure the identity of a person usually symbolize someone who is very familiar, but the context requires the identity be hidden. Incestuous thoughts are highly anxiety producing and most deeply repressed. But absence of details on the face could also be displacement of
absence of something else from another part of the body - a hysterical transfer from bottom to the top. The discovery of the absence of penis in females during the infantile masturbatory phase - Oedipal phase -
provokes a violent denial of what one is seeing and also a massive fear in the little boy of the real possibility of his own castration for indulging in masturbation and masturbatory fantasies."

Patient then brought in following details about the boyfriend. His mother left him when he was 8. Father was neglectful as well, and he grew up in foster homes from age of 13. He has lot of rage towards his mother.
Patient then wanted to know why would he want to make love to his mother when he hated her so much for abandoning him.

"The hatred did not cancel out the earlier love for her. Just drove it in to the unconscious. They both exist in him. In fact as a child he may have exaggerated his love for her to override his hatred. Drowning in the dream is symbolizing his wish to have a child with her and to give the product - a new version of himself - to her as a present. This wish which is present in all humans to give a baby to the mother for giving birth to oneself got markedly strengthened in his case as an attempt to keep her from leaving him."

"That is interesting," the patient added, "For my boyfriend thinks the lady in the dream is his mother because one moment she is there the next moment she is gone. Just like she did in real life."

"And he wants to give her a present of himself, through making a baby of himself, before she leaves, as a parting gift."

Restless Leg Syndrome - an impulse to run away from conflicts and pain?

Restless Leg syndrome [RLS] is an interesting disorder which is rarely mentioned by patients unless one specifically asks for its presence. And then one is surprised to find how prevalent it is. Then one searches on the Internet as to what is the current wisdom on RLS and is slightly taken aback when only physical illnesses, like iron deficiency and uremia, are given as its causes.

Stress is mentioned, but as an afterthought. To me it is primarily a psychological disorder: an impulse to run away from one's problems. During the day, an individual may stoically face his worries, stand his ground to all the slings and arrows that are thrown in one's way by the harsh and selfish world, but at night, when the ego [the protective shield of our mind, the rationally organized part of our psyche] must go to sleep  and drop its guards to refresh itself to face another day, one's worries may take on an insurmountable demeanor, and running away from them may look like the best option. And since our muscles are mostly paralyzed in sleep, the impulse to run finds expression in a muted, condensed and uncoordinated form, and results in the restlessness of legs.

Today I came across two cases of restless legs: one complained of it interestingly just during the day, the other at night.

The first one was a 26 year old woman, who had been medically discharged from the army for the problem of  pains and motor restlessness in her legs.

Her restlessness had been given the medical label of "Compartment Syndrome". However, she never had injury of her legs, which I think is held as the principal etiological factor behind "Compartment Syndrome." Whether such an illness in reality exists or not is another matter.

The pain and restlessness were uniformly distributed in both legs, and the surgeries, done bilaterally, had brought no relief. She complained that she could neither sit nor stand for any length of time. She suffered from hemorrhoids - which so often is a result of stress - and freely admitted that she was depressed and anxious. However, she did not agree with the suggestion that the restlessness of her legs was psychogenic.

But I wondered if her so labelled Compartment Syndrome was not actually Restless Leg Syndrome and an attempt to run away from her problems. She did run away from the army, and since then has not been able to hold on to any job because of her constant need to be on the move.

The second case was of a young mother, 26 year old as well, who had typical restless leg syndrome. In her case it did not happen during the day but at night. But whenever she took Vicodins or Percocets, the restlessness disappeared, only to come back with vengeance when she stopped the medications. ,along with goose bumps and other funny feelings, which she described as getting the chicken skin. She freely admitted that the Restlessness of the legs was due to psychological pressures and it increased when the stress worsened.
Why narcotics took away the restless legs in this patient?
Now we know the reason addicts take narcotics is because it sets them free to indulge in activities they would not in sober state. As a rule we ignore and suppress the existence of ever present subtle sensations of pain in our system, and show little appreciation of the fact that how much of our behavior and interests in life are restricted by the affect of low degree barely conscious ever present pain. It appears as if growing up means a gradual suppression of activities and interests which once gave us pleasure but then got associated with affect of pain. And to avoid the emergence of this pain we ceased indulging in those once-pleasurable activities.
What are these erstwhile pleasurable activities and why do growing up results in their suppression?
Maturation means giving up of juvenile pleasures. And this occurs because such activities were met with pain in our evolutionary past as well as the fact that our care takers meted out real punishment, threats and humiliation in our actual past. Activities which are pleasurable in certain age bracket cease to be so when we grow out of that development stage. For example the pleasure young children take in defecation and messiness become disgusting, and forbidden, once we are out of the anal phase of our development. Uninhibited indulgence in such activities in the latency period, and beyond, causes pain more than pleasure. As if we are biologically programmed to generate pain if we indulge in age inappropriate forms of pleasure.
Now there is one activity which was indulged with greatest pleasure during childhood, and was accompanied with far ranging fantasies. That activity was masturbation during the Oedipal phase. In fact it remains the primary addiction of mankind.
And this masturbatory activity, and the extensive fantasies associated with, directed towards the parents, come to an end, with the end of Oedipal phase, for we are programmed for this to happen. And this happens not only because our care givers punish us for playing with ourselves, or for doing substitutive activities like bed-wetting [enuresis] at that age, but phylogenetically there is threat of castration [and pain] associated with it, and anticipation of which is perhaps the greatest evolutionary source of fear and pain in mankind.
So the greatest pain, and suppression of pleasurable activities, is associated with giving up our parents as love objects. But humans never give up Oedipal strivings. Whenever life becomes
stressful, and there is little pleasure to be derived from one's current love objects, we hark back to Oedipal fantasies and the pleasures associated with it. And it is primarily done in our sleep and
dreams, where we can once again indulge in loving the parental figures, although in displacement and disguise.
However, the fear and pain that is associated with these fantasies, which brought Oedipus Complex to an end, does not stay inactive, but follows close behind to counter these fantasies. And it is this fear, and anticipation of pain, that makes the person want to run, which reflects in the restlessness of his legs.
Now narcotics by taking away the fear of pain, and actual pain itself, allow one to indulge in regressive forms of pleasure without feeling the fear. Narcotics by blocking pain, take away the stress from everyday worries, and worries that arise from indulging in forbidden sexual fantasies in dreams. Then one can sleep without feeling stressed. As stress lessens, so does the impulse to run away from the world and the restlessness of legs.
Narcotics not only free us from dreaming of forbidden incestuous and other regressive pleasures in sleep, but they also free us to do routine things in life which have got blocked by excessive presence of psychological pain in the psyche. Narcotic addicts will tell you that they have withdrawn from life. They feel irritable, cranky, and can do nothing. Everything is in "a freeze". They cannot finish any task without some painful thought emerging half way while on it that distracts them and makes them want to return to their bedroom and go to sleep. Only on taking Oxycontin or Vicodin or Suboxone can they reverse this withdrawal from life. The pain blockers brings back their interest in life. And from where does this excessive psychological pain comes in to the psyche which saps the person's energy and every task becomes like climbing a mountain? It arises from indulging in forbidden regressive fantasies. While the person is on drugs he can indulge in forbidden activities. When the drug effect is gone, the punishment that was kept at bay returns, and with a vengeance, and now not only blocks the forbidden activity even more forcefully, but extends its net over every day activities. As if the sins for indulging in forbidden pleasures are paid later by the paralysis of will of every kind. What is the role of dopamine in all this? For we do know that dopaminergic agents like Requip decrease RLS while anti-dopaminergic drugs like Haldol cause worsening of it to the point of flagrant Akathisia [an intense restlessness, as if bugs are crawling under the skin].
What happens is something like this: Narcotics by blocking pain allow one to indulge in forbidden activities that bring satisfaction. And whenever there is satisfaction there is release of dopamine to reinforce the behavior that brought the satisfaction. Dopamine is a neurotransmitter that reinforces behavior which brings pleasure/satisfaction. Dopamine is a chemical that induces
repetition/stereotypy of pleasure-giving behaviors. Current science views dopamine is a neurochemical which is secreted to give pleasure as a reward. The real state of affairs is slightly more complex. Dopamine does not bring pleasure. What it does is to further facilitate behavior
that brought the pleasure - release of tensions.
Now when dopaminergic drugs are given they make the brain falsely believe that release of tension is occurring, for release of tension, which is same thing as getting pleasure, causes natural secretion of dopamine. So giving of dopamine drugs gives an illusion that something satisfying is happening. This makes the mind think that it is experiencing pleasure and happiness not stress. And when the feeling tone is that there is no stress but pleasure from interacting with the world the person does not feel the need to run away from it. In short the creation of pleasure in one part of the brain can block out the tension/stress occurring in another.
A discussion on RLS cannot be ended without mentioning [1] its relationship with muscle fasciculations of anxiety [2] the toe curl that occurs in highly satisfying orgasm
People in high state of anxiety may show muscle fasciculations and tics. There appear to be akin to the restlessness of legs during the night. These are also attempts at flight which is aborted by the muscle activity occurring in uncoordinated fashion. The tics around the mouth appear as an attempt to "tell" a displaced portion of oneself to make a run.
The toe curl accompanying orgasm appears to be the normal counterpart of RLS. Humans cannot have sex, without an associated feeling of doing something forbidden and wrong, and with that comes the thought of running away from it. Sex cannot be indulged in without a element of danger attached to it. And once the orgasm is reached without any danger befalling one, the person relaxes, and the tension that was built up to prepare for running is allowed release through the toes, doubling the orgasmic pleasure. As if the purely libidial element is discharged through the penis and clitoris while the aggressive element is discharged through the toes.

Sunday, March 27, 2011

Self abusive and aggressive behavior in mentally retarded as manifestation of autoeroticism

Since I do not "screen" patients before seeing them, and have no problem accepting any patient in to my practice as long as they can pay my fees, over the years I have accumulated quite a few mentally retarded individuals in my service.
The most common complaint, not by such patients - for they are mostly non-verbal, or in possession of limited vocabulary - but by their caregivers, is their destructiveness. And the usual solution suggested by them is for me to prescribe more medications. And sometimes it does help to raise their medications though they are quite often already on the maximum dosages of anti-psychotics, sometimes two or three of them, in addition to couple of mood stabilizers like depakote or lamictal along with an anti-anxiety agent or two and an antidepressant.
So what do I do?
Besides lowering the dosages of their psychotropic in good many cases, over the years I have been struck by something about these patients which is worth mentioning in the blog. I find their destructiveness, more often directed against themselves than against others, is often due to undischarged sexual tensions. Their scratching of their skin, sometimes to the point of digging deep in to the flesh, tearing off their clothes, sometimes to the point of outright stripping buck naked in public, repetitively playing with their hair, sometimes to the point
of pulling them out, scratching and clawing themselves and their caregivers, defecating or urinating in bed or in common areas of the Group Homes, despite having mental capacity to go to the toilet, digging into rectum or other private parts, banging their head against the wall, eating rubbish, licking the floor, singing or humming to
themselves relentlessly, doing other repetitive activities like brushing their hair or asking others to do it for them, staring longingly at some caretaker, trying to touch or rub against others, gripping hands and not letting it go, they all appear to be means to discharge sexual tensions.
Now such bizarre and aggressive behavior could have origins in other pathologies as well, but quite often they are conduits to get rid of sexual cravings.
Mental retardation does not necessarily mean retardation of sex drives as well. Granted some retarded patients with genetic or chromosomal defects may have across the board stunted growth, including stunted
sexual drives. But most don't. Specially those who develop mental retardation due to cerebral palsy, viral infections in infancy, or closed head injuries in first years of life. In mental retardation sexual tensions often become pathologically reinforced because there are limited areas of satisfaction for these individuals from other activities of life. Social pleasures are hardly present and therefore deriving of satisfaction from sexual discharge become preeminent. In those whose retardation occurs due to environmental insults, they often have good genetic endowment but not enough brains to keep pace with their physical and sexual development.
These individuals are most troubled by their high sex drive. As a rule, high sex drive is sine qua non of
good genetic endowment. And generally the high sex drive also brings with it good brains to keep the drives and the rational part of the individual (ego) which controls it in good balance, channelizing most of sexual strivings into sublimated socially acceptable higher goals than direct sexual behaviors. In fact intelligence may be nothing more than complex displacement of sex seeking behavior. The high energy that comes with strong sex drive leads one to relentlessly search for suitable partners to mix one's sexual substances with. And this means constant scouring of the environment and finding the right pathways to such partners. Mentally retarded individuals do not have enough brains to make pathways to suitable partners to mix their sexual substances
with and discharge their sexual tensions.
But sexual drive is a constant thing. The human organisms are relentlessly pressured, albeit the pressure builds up so slowly, by secretion of chemicals that power the sexual drives. And when these drives become super saturated with the chemicals, they push the person to do something about it. And when another suitable person cannot be found because of the handicapp, the person starts treating his or her own body as a sexual object. And slowly the masturbatory activities or even more regressed forms of auto-eroticism take over the person's mind. When restrain is put upon it, they fight and get aggressive. Occasionally no external restraints are needed and the activation of internal restraints, for we seem to have genes to do that too, create a
fight within the individual, and after masturbation, or sometimes even before indulging in it, the person starts a fight. Sometimes these patients will slap themselves for indulging in the forbidden sexual behaviors, and in an occasional patient one can see masturbation and hitting oneself going on simultaneously.
In this context it may be worth mentioning that rocking and repetitively banging the head against the wall seem to be a most preferred method of releasing sexual tensions. Hitting against the wall seems to be like a symbolic action of finding a break (crack) in the world where one can release one's sexual tensions.
Anyway, do I have any practical tips for dealing with this sex driven destructiveness, besides high psychoanalysis, which of course one has fat chance of applying with these patients who hardly know themselves from the their rocking movement?
I have found that naltraxene (Revia) which blocks the opiate receptors sometimes reduces this sex driven destructiveness. Not always, but it does show some efficacy in quite a few such patients. The success is
partial and over time it does fade some, but blocking the naturally occurring opiate activity in the brains of people does lessen the urge to satisfy oneself auto-eroticially.
Why does it do that?
I think the infliction of pain on others and oneself releases opiate like neurochemicals in the brain. And these opiates facilitate sexual behavior. They lessen the anticipation of pain and thus lessen the fear of indulging in auto-eroticism. By giving naltraxene the effect of the natural opiates is blocked. The patient decreases hurting himself or others because with naltraxene blocking the opiate activity there is no point in being destructive and generating the opiate like neurochemicals.
One may mention in passing that giving of SSRI such as Paxil and Prozac also help in some of these patients. Increase in serotonin reuptake is a known damper of sex drive. Less pressured by sex drive the patients have less urges to be destructive.

Chronic fatigue syndrome, Sleep attacks, ADHD and Daydreams as counter measures against anger

A patient in his late forties complained of severe attacks of fatigue and wondered if it was Chronic Fatigue Syndrome.

However, his history pointed to another explanation. As a child he was often beaten mercilessly by his step-father. These memories, after a long period of latency, and after being forced to early retirement from his job at an auto plant, had begun to reemerge, and at the slightest provocation.

An emotional show on the TV, an emotionally charged random word even if overheard and uttered by a perfect stranger, somebody tailgating his vehicle, would trigger the memories, and after a brief period of unpleasant mood and listlessness he would nod off.

He claimed if he had been able to hold on to his job these fatigue attacks would not have emerged or at least not so badly. For as long as he was busy as a bee he had no time to ruminate on his unpleasant past. But now with nothing to do all day long, the past wounds were trying to throw off their scabs in hopes of getting a better healing this time around.

Associated with the memories of being a victim in hands of his step-father were memories of his fights as a teenager with Black kids. He had grown up in a rough neighborhood of Detroit, which was overwhelmingly African-American and he had been made the whipping boy for the Whites. He had quickly learnt to fight back and though mostly got his snort beaten he had nevertheless enjoyed these fights. They had become an outlet for the pain and humiliation he had been subjected to at home and over which he had no control. With the school kids he could at least fight back and discharge some of the rage he felt towards his stepfather.

Now, thirty years later, he had this symptoms of wanting to keep moving his hands and legs when in company of men. This motor restlessness appeared to me to be a muted form of running away or fighting back.  He was not consciously aware that his fidgeting was to avoid direct confrontation with others. He just got  hyperactive in presence of men who he unconsciously feared and hated. He had to take early retirement from job because he could not take being talked down by his bosses, and when they would tell him to do something he would start fidgeting and daydreaming instead of paying attention to them. The alternate was to make some sarcastic remark like, "Oh you want me to make how many pieces today, why don't you go and screw your aunt instead." To avoid coming up with such sarcastic nonsensical repartee he would bite his tongue and get hyperactive.

If he could not fidget or move, his mind would go "on blank". He declared this mental blank as his  attention deficit disorder.  "Growing up for me meant learning to avoid fights. And this meant learning to think before lashing out with my fist or my tongue. But before I could learn to think my way out of a sticky situation was to go in to a blank. Next came the stage of daydreams. Instead of fighting I would go into blank which would be followed by daydreams. As a child unpleasant situations were dealt by going in to daydreams.  Now I go straight into the sleep mode, where, surely, I must be dreaming of revenge.

He added that it is strange that I married a woman who already had kids. For these step-kids piss me off just like I pissed off my step-father. They are lazy as hell, and I want to attack them the way my step-father attacked me. But I don't. When they make me angry instead of confronting them, and smacking their butts, I get my attack of fatigue and I fall asleep.

And I wondered if sleep attacks, ADHD, chronic fatigue syndrome, Tourette's, oppositional defiance and daydreams are not all related to each other and are but different ways to control anger from turning into frank aggression and fight.

Wednesday, March 23, 2011

Guilt over parents divorce holding back a person from living her life and finding happiness

A woman in her early thirties, who lives with the father of her second child, but has ambivalence towards making him her life partner, had the following dream:

I meet my old boyfriend who I have not thought about in ages in a restaurant. And we rush and hug each other.

"Now why would I dream of him when I am living with someone else? I have not seen this guy in 10 years. Nothing happened recently that would have made me think of him. In the end the relationship turned abusive, and I went to the court to get Personal Protection Order against him. So there could be no reason for me to dream of him."

"Tell me the whole dream," I asked her.

The dream begins with my calling my mom to go shopping with me. We are in a Mall. We are buying high heel shoes for my mother, which is ridiculous because nothing could be further from our style. I am a tennis-shoe kind of girl, tomboyish, never caring for girlie things. I do not enjoy shopping. I am in and out of stores in 20 minutes, and certainly not the one who goes to Mall, spends the whole afternoon there, eats chocolate and looks for frilly things. But in the dream my mother and I not just go to the shoe shop, but look for other fancy clothes, even fur coats. Also my mom looks younger and healthier in my dream, without the heart problems that makes her look old now.
Then my mother is no longer in the dream and I am working in a restaurant in the Mall. There is is an old couple. I have to bring them ice tea. But every time I try to do it something happens to prevent it. I cannot find the glasses, or the ice, or something else is not ready yet to be able to serve them. I go to other restaurants in the Mall to get the glasses for the ice tea. They are kind of connected to the restaurant where I work, as if they are separate yet part of one, for each restaurant has a different theme. Finally when I get everything together, the couple have already left.
Then I spot my ex-boyfriend. He is eating or having drinks in the restaurant. I approach him nervous and fearfully. [For once, in real life, I thought I had seen him but on rushing up to the person, I found that that was not him.] But he is real amicable and friendly, so my nervousness was unjustified. We hug each other. My two children are with me. Then the dream goes on and on, in which I keep running into him, over and over again.

Based upon her preliminary associations the following construction was made:

Mall is like a meeting place, a fair, where your dream takes you to find a suitable person. You take your Mom with you to the mall so as to escape the accusation that you are abandoning her for the sake of a man. [A woman often cannot give up her attachment to her mother and refuses to make the transition from mother to a strange man. Its roots lie in guilt over wishing ill/death for the mother to escape her influence and indulge in sexual pleasures with men. This psychology is behind many a women choosing not to marry]. So you are buying shoes for her to placate her. The high heel shoes could symbolize a male baby. So your are are going to meet a man in the Mall but for her [mother's] sake. To get a present[baby] out of him to give to your mother.
The patient agreed that the Mall could be a meeting place, but added that she has no interest in sex or meeting men period. She feels no sexual urges anymore.
I pointed out that when people get demoralized or disheartened about finding love in real life, they stop thinking about love and sex in their waking hours, but then these urges return even more forcefully in dreams and sometimes pathologically in neurotic symptoms. If one is finding love in real life there is no need for one to dream about it.
The clarification had an immediate effect. The patient started describing her relationship with the ex-boyfriend who came in her dream. She had liked him very much in the beginning. Unlike the boyfriend before him, her first one, with whom she went out for 5 years, the new one was great in bed, and instinctively knew what to do to give her pleasure. They had wonderful sex for a year.
Patient then admitted that I was right, she still has urges to find somebody to love and the dream was sparked because she had found some old film rolls that needed development, and those rolls must have reminded her of the good old days, when she was with the ex-boyfriend.
Patient then went into a description of how her childhood was ruined by her parents never getting along with each other. Her father was the jealous type and would not let her mother do anything so the mother was dissatisfied with her marriage.
But they stuck together for the sake of the children. When she [the patient] was 14, they felt the children had grown up enough, and got divorced. It must have affected her very badly, for she started using drugs and staying out late till 2 or 3 am, which infuriated her father to no end.
"Was buying the high heel shoes [in the dream] an attempt to satisfy your dissatisfied mother - playing the role of the father, taking her out to shopping and doing things for her which your father had not done?"
Patient confirmed, the correctness of the interpretation in her characteristic way, and added "My rebellious acting out and staying late at night was to get even with my father for being so mean to my mother and not letting her do anything. I did everything with all those boys, which he prevented her from doing. That is the reason he was so furious with me then."
"Were the old couple your parents too, and and bringing the ice tea to them another attempt to satisfy them, and this time both of them?"
Patient confirmed that the old couple were her parents.
Then she wanted to know if getting ice tea for them was to please them, why was she having so much difficulties in finding the glasses and ice for them.
This was interpreted as her ambivalence towards them. She wanted to please them yet she was angry at them for getting divorced and abandoning her. So every attempt to please them was being nullified by the counter-impulse to not do so.
Patient first disagreed with the interpretation, and said she has no anger towards her parents and only feels love for them, but took back this rosy assessment of her filial piety on being pointed out that staying out till 2 and 3 in the morning when she was 14 could only be explained as expression of anger and revenge.
The patient added that going to different restaurants in the Mall in search for glasses for her parents points to the return of her teenage promiscuity in the dream. After the parents' divorce she had become very promiscuous. It was trying to find love which was no longer present at home, but also it was revenge against her parents.
Another interpretation of this promiscuous behavior, which was symbolized by going to different restaurants with different themes, could have been her desperate search for finding in outside relationships something that was different that she could present to her parents to make their marriage work.
Why was she buying high heel shoes and other frilly girlie things for her mother and herself?
This was not confirmed by the patient, but knowing her history and her other behaviors, I knew that she had significantly cutoff herself from her feminine nature out of deference for her mother.
She was tenderly attached to her father as a child, which was further strengthened by the conflict between her parents, leading to her wanting to take the place of her mother. This aroused counter feelings of guilt and remorse and command to do everything possible not to replace her mother. So the patient abandoned all interests in making herself attractive in a feminine manner, eschewing all frilly things, including high heel shoes, preferring tennis shoes and rough and tumble ways. Going to the mall, eating chocolate and looking for high heel shoes, frilly things and wrapping herself in fur coats was way too much acting the role of the mother, which her guilt forbid. Now that she wanted to go back to the man she once loved she felt the need to rethink about neglecting her feminine side, and was returning to her mother in the dreams to relearn being a frilly furry kind of a woman.
Her nervousness and fear in approaching her dream-man is part of her tomboyish nature. The girl is somewhat of a gun-toting Mae West type in her demeanor and mannerisms. The fear that if the man would not immediately respond to her overture it may end up in her flying off the handle and slugging him, was reflected in her nervousness. In fact their relationship had ended when she had put a key from her key-chain between her fingers and hit him on the forehead with a closed fist, and had left him bleeding like a pig on the ground, leading her to believe that she had killed him. They had broken up despite her having so much feelings for him, because she had a violent streak in her.
Meeting him in a restaurant which is connected to other restaurants was wish for being married to him. Marriage is often symbolized in the dream as a house with multiple rooms. Multiple rooms standing for different women and promiscuity, and by reversal - reversal of infidelity - dream makes it in to a symbol of marriage. So in our dreamer marriage instead of being symbolized by her going from one room to the next - a typical symbol of marriage - was shown as going from one restaurant to the next.
Her two children are with her.
his was allusion to her wish, or rather demand, that if I go to him and leave my current partner, he better accept me with my two children.
I keep running into him over and over again.
This is multiplication of the wish to meet him. Though she protested she has no interest left for men. The dream belies that. She wished so much to find love that she kept finding it over and over again. It also perhaps symbolized multiple sexual encounters with her dream-man. But alas just in dreams.
However, there was another reason behind the endless repetition of meeting the man of her dreams. There was an obstacle to it. Her guilt over her parents' divorce. She had to make up to them, and restore their marriage, before she could find marriage and happiness for herself. But there was ambivalence there as well. It was reflected in her trying to serve ice-tea to them, which they could drink together in a restaurant like a married couple. But hard as she tried she could not get the ice-tea ready, and by the time she did, they had already left.

Tuesday, March 22, 2011

The Psychology of Lucid Dreaming and a few comments on Borderline Personality Disorder

In psychiatric conferences there are two topics that cause no end of excitement, and it is hard to find standing room when a lecture on any one of them is going on.

One is Borderline Personality Disorder. Why it fires the imagination of the mental health professionals is too complex an issue to take up here in any detail. Suffice it to say the main reason lies in the fact that the concept has no true existence at all. It is the failure to identify the actual problems of the patient, out of one's ignorance of how mental issues should be analyzed and understood, which has caused the profession to artificially create the concept of Borderline Personality Disorder. And since humans love to wage the most passionate polemics on trivialities, it should not surprise us that the concept of Borderline Personality Disorder invites a limitless scope to get profound.

And boy do they get profound on this topic. Every lecture that I have attended on Borderline Personality Disorder starting from the great Otto Kernberg himself, to his wife   - isn't it strange that both husband and wife are experts on the same illness - to other lesser specialists, I have invariably found it to be so erudite that after the first five minutes every member of the audience appears to be grasping for straws if not outright baffled as to what is going on. And therein lies the second reason for its appeal. If nobody can make out head or tail of what the speaker is talking about then each member of the audience can feel equal to everybody else  - obfuscation is a great leveler. The last, and for that reason not any less important, reason is the belief, or rather a fear, which an astonishing number of mental health professionals are plagued with, that they themselves have a touch of Borderline Personality Disorder. In other words the irrational aspect of themselves which they don't understand they think it must be the borderline behavior present in them.

And what lies behind the irrational, erratic, and very cleverly annoying behaviors of the so called Borderline patients that mental health professionals cannot scream enough as "splitting" - a concept that was introduced by Freud and never with any intention for it to be used as an pejorative epithet against the patients- which gets their goat? It is a negative transference towards authorities stemming from their rage at their parents for not doing enough for them. Making staff members on the hospital ward fight with each other - the so called splitting - is at bottom nothing but making the parents fight with each other. And their self-destructiveness is also often a way to punish themselves but at the same time a means to annoy and frustrate authorities (parents).

The lure of Lucid Dreaming is little hard to figure out. But there is no doubt that any lecture on the topic will cause the folks to jam pack the lecture room to the point of overflowing into the corridor. And the psychology of its appeal appears to lie in the hope of finding some great pearl of wisdom there which will enable one to start dreaming lucidly oneself. And behind this desire lies another desire: the hope of curing ones problems by lucidly dreaming and directing them to resolution. It is therefore driven by a desire for self-therapy. And this brings me to the unpleasant task of bursting the bubble of enthusiasm surrounding lucid dreaming. There is not much to its metapsychology.  Lucid dreamers are people who are more awake while dreaming than others.

Dreaming is a state of semi-wakefulness to begin with - the failure of our ego to go to sleep completely (complete withdrawal of cathexis)  - and not some special third state of consciousness which neither belongs to wakefulness nor sleep as that completely idiotic Activation-Synthesis hypothesis used to claim. While dreaming we are only partially sleeping. Part of our brain gets activated and awake. This is why, if one fully wakes up a person out of intense dreaming, he can quickly get oriented to the real world. The neuronal networks responsible for wakefulness are already partially in gear.

Now individuals differ greatly in the ratio of their wakefulness and sleepiness while dreaming. Some tolerate high degree of partial wakefulness while dreaming, others do not, and get out of dreams/sleep altogether at quite low thresholds. Lucid dreamers appear to be individuals who can continue to dream while the centers responsible for wakefulness are quite active. They are individuals who can more easily ride the two horses of partial wakefulness and dreaming at the same time. They can divide their consciousness into taking cognizance of the dream world and the real one at the same time.

The psychological mechanism behind this appears to be similar to how hysterics can tolerate co-existence of multiple personalities. People who are highly suggestible and enter into hypnosis easily - traits of hysterical disposition - appear to have greater ability to dream lucidly. While dreaming their mind splits into two states of consciousness, one aligned to the real world and the other to the dream world. The first state can even influence the course of what is happening in the second state. And this is felt by them to be a special gift akin to some magical ability. It is the wish to acquire this magical ability which underlies the fascination with this phenomena. The lure of Lucid Dreaming is at bottom a lure of magic and a desire to become a magician with one's dreams and one's problems.

Sunday, March 20, 2011

Dreams of using in recovering addicts and its psychology

Recovering alcoholics and drug addicts often report dreams of using their drug of choice, and express surprise at it emergence in their sleep. They express their annoyance at its happening and try to convince us that they have no wish to go back to drugs despite what the dream shows.
Narcotic and Alcoholics Anonymous (NA and AA) spokesperson view their assurance with some suspicion, and consider the dreams part of "stinking thinking", and a warning sign of possible relapse.
What lies behind these "dreams of using?
The patient is at a loss. During the day and in his conscious mind he does not want to "use', and feels a little nonplussed at the dream's creeping into his sleep. He will ask the therapist the reason for such stupidity on part of his dreams. In the beginning I was at a loss too, for these dreams appear to contradict the psychoanalytic theory of dreams. Dreams are wish fulfillment and the dreamer wishes just the opposite: freedom from addiction not going back to drugs.

Or does he? While he may in his conscious mind he may be full of resolve to give up using the drug, the cravings for doing it may still be active in the unconscious, and when he falls asleep and the conscious mind goes to rest the unconscious wish to do the drug may come to the fore and attract consciousness, resulting in the formation of dream.

While the explanation is true there is a twist to it. The wish is not so much to do drugs as the wish to do those forbidden things that he can only do while under the influence of drugs. Perhaps people do drugs to make it possible to indulge in forbidden wishes; wishes that the addict's conscience will object to if he is in sober state.
And here we come across the empirical observation that an increase in stress and other adversities in life makes a person seek illicit and forbidden pleasures, partly as defiance because of life's unfairness, and partly because the pleasure obtained from fulfillment of base wishes counters the pain of stress. Drugs silence the conscience and allow one to indulge in low-life pleasures that can make one forget the pain and stress in one's life. 

So NA and AA people are right. Dreams of using are "stinking thinking" and indicate that the person wants to start fulfilling those wishes which his conscience will object to if one was not intoxicated.
The following dream from a heroin addict who is currently on Suboxone and doing her best to kick the habit shows an interesting relationship between stress and dreams of using.
The patient dreamt the following:

I am in downtown Detroit, in real bad section. The road is desolate and dark. I am looking for Josh, who I have not seen in 6 years. Then I am with him. I see a house. It looks familiar. It is a drug house. Party is going on. I am asking for cocaine and ecstasy. Which is weird because they are not my drug of choice. I went to those places only for heroin. Then I see my 3 year old son. A woman comes and smacks him. I attack her and pummel her till she is knocked unconscious. I notice her hair and her pasty face. Also her stringy hair as if she just came out of shower. She looks dead. Lips blue, face white. Then some other things happen that I cannot recall now. Then I see the woman who had attacked my son back again. This time I throw her down the balcony. She falls with the loudest thud. The blood from the injury comes up in huge quantity and spatters my and my son's face. We run. A man from the party chases us. I go to another house and drop my son off. I explain I have killed somebody and I have to leave. You have to take care of my son. The man who
is chasing me catches up. I am hiding behind trees. He catches up and shoots me in the face. Then everything turns white and I wake out of the nightmare, my heart pounding with fright

The patient produced following associations:

To the desolate road she associated that when she was abusing drugs once she went to a crackhouse in a real bad neighborhood and while returning, ran out of gas, and had to walk a mile through the most dangerous and desolate section of the city. The whole ordeal was as good as nightmare, since all the while she walked she feared she will get attacked and raped.

So here was the wish to do drugs again, but along with it came the danger of going to the crackhouse and it sordid surroundings.

Other associations led us to conclude that Josh comes in to the picture because he was her drug buddy in her days of heavy addiction. Her marriage - at the time of the dream - was on the rocks and in the dream she was trying to deal with it by going back to rehash her relationship with her parents. Her parents were drug addicts themselves and were mean and abusive to the children. So she was returning to her parent's house to get even with her mother for making her life trajectory miserable and holding the mother primarily responsible for the breakup of her marriage.

However, the dream shows her returning to the drug house instead of her parent's house. The dream had superimposed [condensed] the two houses. Her house of origin was as chaotic as the drug house. Breakup of her marriage meant return to the lifestyle of her parents and the continuous parties and drug abuse that characterized their house. In her teenage years she had sought the same pleasures and now that her marriage was breaking up she was being tempted to return to it - the stinking thinking.
Why cocaine and ecstasy instead of heroin, her drug of choice?
Her conscience was objecting to slipping back into drug habits even in dreams. Conscience [superego] which becomes less watchful in sleep, thus allowing the primary process thinking that enables the formation of dream images - which themselves are compromise formations between primary and secondary process thinking - nevertheless still keeps tabs upon the ego. In her case it was still objecting to going back to heroin. So a compromise was reached and instead of heroin she was using less dangerous drugs like cocaine and

The woman with whom she had a fight and whom she killed because of her attack upon the son, was her mother. On her own she would not attack her mother out of filial piety. But if the mother attacked her son then she could justify turning her revenge feelings towards her mother into deadly action.

The last part of the dream is punishment in hands of a strange man - substitute for father - who would punish her for killing her mother, but also underneath the punishment was wishes for sexual satisfaction.

The love making with this stranger (father) was being depicted in regressed sado-masochistic fashion. Instead of being spattered with sexual substance from the father the scene was replaced with being shot in the face with a gun. So it was a typical anxiety dream where sexual act was being shown in sado-masochistic language. The fright of genital sex had caused the sexual process to regress into seeking satisfaction in the sadistic visual imagery of getting shot at.  Children regularly conceptualize sexual act as something forcibly done by man to a woman. In fact the most common way of describing sexual intercourse in Hindi is: man hitting the woman on her vagina or buttocks.

Anyway, the dream of using had occurred because of the stress of failing marriage. The forbidden wishes were oedipal in nature in which she could not indulge without being intoxicated with drugs even in her dream. 

Tuesday, March 15, 2011

Body piercing -a counterphobic mechanism to combat hysterical fear of genital sex?

I recently came across two women who had great fear of being penetrated by needles and in both cases I found that the phobic fear of needles had found its pathological reinforcement from a hysterical fear of genital sex.
Now almost everybody has some queasy aversion to being poked by hypodermic needles even for vaccination or blood drawing which are no more painful than a mild pinch. But when the fear is completely out of proportion to the pain involved, the psychoanalyst is forced to assume that some neurotic process is at work, and the source of fear is from some other conflict of which the person is not aware of in his conscious mind.
The easiest way out is to explain it away as some higher sensitivity to pain in these individuals, because of this gyrus or that cortex of the brain or some other neurological gobbledygook. But when we find that these same individuals show no hypersensitivity to pain in so many other areas of life, in fact they eagerly court pain, then the neurological explanations start ringing hollow.
In both of my patients there was great fascination for body piercing and adorning themselves with rings, nails, and other shiny stuff. One of them had 10 piercings through her nose and lips and the other 12 through her ears. And both had tattooed their bodies as well.
In both the patients it could be confirmed that there was disinclination for genital sex, a fright at being poked by some strange man, of being violated genitally, and a fear of the pain that they anticipated, or must have once anticipated, that must be involved in the process, and the shame associated with playing the passive role in sex and of being treated as a sexual object by a man.
Both the women were highly tomboyish in their younger years and even now took pride in never taking any nonsense from any man.
One even had nails pierced through her lips, and analysis showed this nailing of her mouth was to prevent herself from biting the penis off of any man who behaved like "a prick" with her. An interesting fantasy [neurotic fear] of this girl was of zombies taking over the world and cannibalizing humans. The man-eating zombies, of course, were projection of her own ambivalent desire to have oral sex with a man and then bite off his penis for being subjected to the humiliation of placing her mouth on his penis.
That her nailing of the lips was a symbolic, though unconscious, attempt to prevent her from acting out her oral aggression was further bolstered by the fact that she had recurring dreams of her teeth falling out. These appeared to be punishment wishes for the impulse to bite off the penis.
The nails she had placed on her lips after piercing them looked unmistakably like fangs. So while they had been placed there to block her oral aggression, the original impulse had broken through and they nevertheless looked like fangs of a tigress. She had tattoos etched on her forearms that proclaimed prominently give respect on one side and get respect on the other. The explanation she gave for having these tattoos was that for others to get respect from her they must first give respect to her. It was once again rejection of the humiliation involved in being the object of genital sex.
So it appears that aversion to genital sex, and a neurotic inhibition in dealing with genital areas, was being handled by great adornment of the face, and upper body, with shiny jewelery and intriguing tattoos, and all in order to deflect attention from the lower to the higher parts of the body.
Now we know that hysterical women and men often get accused for being a tease. They love to flaunt their sexuality a la Marlyn Monroe, and are easily excitable and flamboyant like Elton John and Liberace. However, when it comes to actual genital sex they flee from it. Of course some of them can overindulge in sex - some even to the point of nymphomania - but a little analysis shows that it is more a show of sex to convince oneself and others of one's lack of fear of sex. It is a cover up for the humiliating realization that one cannot derive normal pleasure from genital sex. Their steamy sexual behavior on analysis shows to be fantasies of how sex should be and modeled after what one has watched, head, or read about sex.. Their sexuality is more about flamboyant display of non-genital body parts, with bright makeup, gaudy dresses, and shocking plumes, feathers and hairdos. Sex is "a big act" for such artistic folks.
Could all those piercing and putting of nails and rings in the nostrils and ears may also not be displacement of the sexual act from the genitals to the face? Now we do know that in hysteria other parts of the body take over the role of genitals. Globus hystericus occurs when the mouth and esophagus start acting like the genitals. In fact the Greeks defined hysteria as "wandering uterus". Could piercing and putting nails through also may not be symbolic creation of another genital passage that is being penetrated by the nail? Now Freud has considered hysteria as a fright and fleeing away from genital sex because of premature exposure to adult sexuality - sexual demands made upon the child when her genitals are devoid of sexual sensations, hence incapable of reacting to the demand appropriately, and thus compelled to discharge the stimulation from other parts of the body than the genitals. High erotogenicity of pregenital sexuality in hysterics can be explained as a result of this displacement.
But why does not fear of genital sexuality cause a simple inhibition without the need to recreate symbolic genital sexuality on face and other parts of the body? Why the displacement? It appears as if the original fright of the genital penetration makes the child flee, but later in life she regroups to try to brave the trauma once again, this time with more experience and courage. However, not at the original spot where the trauma has left permanent scars but in areas where she feels she has greater strength to handle the pain.
This first sounds too far fetched, but let us not forget that fear can have very diverse effects. The fear of castration in hands of the father leads one to abandon all Oedipal sexual striving, giving up of infantile masturbation, and a regular arousal of fear whenever one is tempted towards having sex with anybody who reminds one of the mother. Yet, the same boy who is full of fear of father in matter of sex can show tremendous fearlessness in other areas of masculinity. In fact their behavior becomes full of defiance and opposition to make a show of their masculinity.
Many wrestlers who give up heterosexuality out of fear and deference to the father may show no fear at all in entering into mortal combat with other wrestlers. So inhibition due to fear in one area of psyche may provoke a compensatory excessive boldness in another. Dare devils who are looking to climb up the highest mountain or descend in to the deepest valley, and sky dive from breathless heights, are in some sense undoing the psychic trauma of facing the fear of the father in which they were bested by him and which produced a permanent damage to their sexual potency. Now they seek father figures, which include anything majestic in nature to turn the tables.
And we see the same overcompensation in the people who pierce and seek tattoos. They look so brave and fearless but at the very core it is an exaggerated reversal of one's inability to bear pain of genital sex, and all the problems that come attached with having genital sex, including pregnancy which destroys woman's youth. And we know how narcissistic hysterical women are about their beautiful bodies.

Thursday, March 10, 2011

A dream of competition with siblings

A 23 year old girl reported the following dream which she had periodically dreamt since the earliest childhood and once again a few days before coming to the session.

My sister Jackie, my cousin Kellie, who might be my sister, for we were inseparable growing up, and myself, walk up this mountain. At the bottom we are young, around four or five, the age when this dream first made its appearance, but by the time we reach the top we are grown up.
On reaching the top Kellie goes to the edge of the cliff to look down and starts to fall. Jackie and I rush and hold her hands to prevent her from falling. But her hands slip through ours, despite our best effort. As she falls, I find it is not she but me who is falling. Without realization I have changed places with her. I wake up with great fright before I hit the bottom.

She added the following to the dream.

In earlier dreams it was always I who would go to the edge of the mountain and fall and Jackie and Kellie would try to save me. It is only in the most recent dream that Kellie is the one falling. But even here not for too long, for I change places with her.

The girl brought the following associations.

Jackie, Kellie and I are one year apart, Jackie is the oldest, I am the yongest. We are highly competitive. Always trying to best the other. Since Jackie is the oldest, Kellie and I always competed to be in the same team with Jackie. So there is greater competition between Kellie and me than between Jackie and me [which explains why Kellie is falling instead of Jackie].

The mountain is taken from my great grandmother's house in Georgia. It was right across the house, but more of a hill than mountain, though it looked so huge as little girls. We spent our vacations there and would run up and down that mountain, sometimes even rolling down the grass.

For Kellie's slipping through the hands' of Jackie and herself, she brought the following two associations.

As children we watched a lot of horror movies. One of them was Child's Play II. There is one scene where Chucky the doll, who has soul of a serial killer trapped inside him, goes after a girl who is in the basement of a warehouse. There is a step like thing which leads to an escape door. The girl's brother is on the other side of the door and safe, but the girl has to climb up the steps to reach safety, with Chuck the killer right behind her. And she slips and is held by her hand by her brother just like the way Jackie and I hold Kellie's hand in the dream. As children we would play this game over and over again. One of us acting the role of the killer, one of the brother and the third as the girl who is slipping through the hand. Since I was the youngest, generally I had to play the role of the falling person.
The other association is of my playing at the bunk beds which were at Kellie's house. Her brother who is eight years older than us would jump from the top bunk on to the floor. I was very young and admired the feat very much, and one day decided to do it myself. But at the last minute I had second thought and instead of jumping off away from the bed, changed my mind, half-turned and caught the edge of the top bunk. As I began to slip I shouted to Kellie to help or call someone to help me. But she did not. No doubt out of jealousy, and from a competitive desire to see me suffer. I finally slipped and hit my thigh real bad on the lower bunk, which left a big bruise. Kellie was badly punished for not helping me.
The patient then went on to describe how she was always a tomboy and unlike Jackie and Kellie who as they grew up became more and more passive and non-challenging to men, she continues to have a strong streak of competitiveness and if any man tries to act superior with her he gets a taste of his own medicine. She described her jealousy of her boyfriend and how she imagines him in situation of infidelity which tortures her to no end, and that she does recognizes it as her problem and not his. For she thinks behind the fantasy lies her own excessive competitiveness and to be able to love the world [substitute for mother] actively as men can do.
She attributed the change of age, in the dream, from very young at the bottom to their current ages at the top as a competitive run between the three from earliest years to now. "As a child I always felt inferior to the two, who were 2 and 1 year older than me, and they could not rub off on me their superiority. That must have made me wish for them to fall and me to triumph."
This wish for their fall was countered by her conscience, turning tables on her, and making her fall instead of the other two. So it was a punishment dream.

Monday, March 7, 2011

What exactly is death? Panic Attack as an escape from the wish to die, and the role of dopamine neurotransmitter in all of this

A young man, in his mid-twenties, reported the following dream which had woken him up in panic, cold sweat, and a fear that was so profound that he had difficulty in catching his breath.

I see my mother dying of cancer. I can do nothing about it. When she dies my dad - really my step-dad - and I look at each other as if we understand the other's sorrow. Then we start crying. My dad is moving since my mother has died, and I see my mother's belongings being taken out of the house in boxes.
The dream was so real and my sorrow in it so profound that I called up my mother right away to make sure that she was still alive.

Now we know that dream of somebody's death accompanied by guilt or sorrow, especially where there are attempts to halt the process, is expression of death wish towards that person and the reaction and regrets for having allowed the wish to become reality [even if in the reality of dream].
So our patient was dreaming of his mother's death, feeling guilty about doing so, and trying to halt the process though not too well - I can do nothing about it. The guilt over allowing the the wish to come true was causing the profound sorrow.

Why was he wishing for her to die?

He has great ambivalence towards his mother. His father had left the family when he was just 3. Mother was the only permanent parent figure he knew and the possibility of her abandoning them, the way his father had done, was an ever present fear throughout his life. To prevent this fear from becoming a reality he loved his mother dearly, as if his love would hold her back from leaving.
Now the mother was a "partier", as he put it. And her evenings were often spent in the bars instead of taking care of him and his sister. He often hung around with her in bars, even learning to sing on stage, giving his first performance at the age of 9. As if this neglect was not enough she showed a genius in picking up just the wrong kind of men as boyfriends. They would beat her brutally. Which the boy witnessed. Unable to save his mother from these frightening ordeals - he was too young to physically confront those men - he developed elaborate fantasies of revenge and death wishes against these men, and, since she was the author of their endangerment, towards her as well.
Furthermore, she was always broke and getting evicted. Evictions meant packing of boxes and having to leave ingloriously, and the cloud of frightening uncertainty as to what will happen now. He hated his mother for subjecting them to these humiliations. And it was this that the dream was showing once again, but with a difference. Now he was not on the receiving end. He was the author of her death and the spectator of her belongings getting taken out of the house. The understanding look between his step-father and himself was the sympathy they felt for each other, for he was the man she finally married and which had brought some stability to his life. And he was not just kind - unlike the string of brutal boyfriends that had come in to their lives before - but somebody with whom the patient could identify, for the mother was as erratic and negligent towards him as she was with her children.

Now why did he woke up in cold sweat and panic and could not catch his breath?

The inability to breath in panic attack appears to be imitation of death. In fact the patients will readily admit that the most frightening thing about panic attacks is the sense of impending death. In our boy's case the wish for his mother's death was seen with such horror - for it conjured the images of being left a destitute - that it provoked an immediate counter wish for punishment by death for the unthinkable.
Now death, in the unconscious, is often represented as a complete withdrawal from the world [and return to the womb].
It is this fantasy of dying, and returning to the womb where one cannot breath in the confined space, that provokes an energetic countermeasure of panic. For panic attack, when closely examined, is nothing but activation of all the physiological responses that the newborn resorts to when his oxygen supply through the umbilical cord comes to an end and the sense of impending death by the rising tide of CO2 makes him gasp desperately for breath and oxygen and gets his heart going at breakneck speed. Gasping for breath, pounding heart, and sweating due to muscular tension, is exactly what characterizes a panic attack.
So panic attack is a form of escape from death, or activation of all those physiological responses that the newborn had to mobilize to escape death from asphyxiation.

But what exactly is death?

If a complete withdrawal from the world, and return to the womb, is how death is perceived in the unconscious then it leaves us no choice but to go to the next logical step and consider death as a state where the organism ceases to communicate and make exchanges with others.
As long as we are communicating with others and indulging in give and take we are alive. The minute this input and output with others ceases we die.
So the degree of our aliveness is a reflection of how much of ourselves we are exchanging with others. Of course, this give and take is primarily with one's own species, though other animals and even inanimate objects may become symbols of significant others from our past, and it is not a mechanical input and output as that of networking computers, but something where there is some degree of awareness and choice over one's give and take. A choice which gives a sense of individuality and self awareness, in higher animals consciousness, and in humans self-consciousness as well.
Now this aliveness is not based upon just physical exchange, though during youth exchange of sexual substances at the physical level becomes the most importnat part of being alive. Exchange at mental level is of even greater importance, and as long as we are exchanging ideas with each other we stay alive. And even when we cease to exchange our mental activity with others, we can stay alive by imbibing others' ideas through reading and through visual arts. If all these streams of input and output cease we die.
The most extreme case of clinging on to life is when we exchange and reshape ideas and memories from one part of the mind to the other, settling scores with the folks from the past. Old people, especially those whose spouse die, often create divisions in the mind and assign roles of significant people from the past to them, and through creating back and forth communications between them find a new reason/outlet to stay alive. The most common scenario of this is creation of a a monitoring agency - representatives of parental figures - that keeps a running commentary on the person on how to conduct his or her affairs, and the person keeps a running conversation with these superego figures, sometimes complying, sometimes rebuking them, generally under the breath, but quite often aloud.
In psychotic illnesses where the person withdraws from others, and the input and output with the world ceases a great deal, there is a tremendous rise in conflictual communication between the different divisions/agencies of the mind, and the mind rapidly turns into a highly charged hothouse. In Hindi a mad person is often called a hot head. The dopamine blocking drugs work in psychosis because dopamine seems to be the neurotransmitter which builds bridges between different agencies of the mind, including with the minds of other people, and by bringing down this excessively charged mind to less alive status, it stops its complete disintegration.
While on the topic of dopamine one may mention its role in acting as antidote to panic. Any activity that raises brain's dopamine activity - increases input and output of the mind with the external world or with different divisions inside the mind- brings down the panic. For example many people find eating as an antidote to panic. The sense of impending death [panic] is countered by the act of eating, especially something sweet, for it restores the desire to be alive - to do some more give and take. With eating something pleasurable is being taken in and getting added to the organism. Similarly nervous diarrhea, simple destruction of something or somebody outside, who is perceived as the cause of one's panic, or even destroying one's own precious possession, or cutting, piercing or tattoing oneself, often gives relief from the panic. And all of these behaviors activate the dopamine system. For as soon as pleasure as generated there is activation of the dopamine system whose role appears to be to repeat the behavior which was giving pleasure through giving it additonal attention.
Dopamine is not a neurotransmitter which generates pleasure as the current science believes but wherever there is pleasure - something desirable entering the organism or something undesirable getting extruded or destroyed - the dopamine system activates the mechanism of attention to take special notice of the areas from where the pleasure is arising and further faciliates the redoing of the pleasure producing behaviors. So whichever activity gives the orgaism plesure - relief - that is where dopamine mediated neurotransmission, through some feedback mechanism, will sprout its wings.
Dopamine appears to be a neurotransmitter that became specialized in giving additional boost to continue the pleasurable activities of the organism. Its function appears to be to further facilitate communications between different sections of the mind, and the organism's communication as a whole with the outside world. As if dopamine is a neurotransmitter that has specific role of building bridges between different sections of the brain, and with the brains of outside people. Of course, the function of all neurotransmitters is to communicate, to excite or to inhibit, but dopamine appears to have the unique property of acting as gateways between large chunks of specialized brain functions [qualitative aspects of our psyche].

Sunday, March 6, 2011

The psychology of piercing and putting metal rings through lips and tongue

Recently a woman, in her mid-twenties, came to my office who attracted my attention by the extremely striking metal rings and nails that were at the two ends of her lips. They were so close to the edge of her mouth that they made one wonder if they would not impede activities associated with the mouth, including speaking. When I asked her as to why would she pierce her body and put rings in them and especially at such awkward spots, she could give no reason other than she likes body piercing, she is in to tattoos, and it is an expressive art.
It was obvious that this was a superficial explanation and the deeper unconscious motives that lay behind her compulsion to disfigure herself were unknown to her. For body piercing is a form of disfigurement - though we should not forget that it is as much adornment as disfigurement - and to practice it one has to undergo pain. So it is a form of beautifying oneself, by adding something external on to one's body [because one feels as if one is lacking something?], and is achieved through masochistic punishment of oneself.
Patient admitted that at one time she had nine holes pierced through her nose, and even had rings through her eyelids. Since harm coming to the eyes in dreams is often used as a symbol of harm coming to the penis - threat of castration - one has to wonder whether her masochistic tendencies were not a symbolic punishment for aggressive tendencies towards male genitals. For the girl freely admitted that she was completely tomboyish, took no put-downs from anybody, and did not hesitate to take a swing at her men if they behaved like a dick.
Since the rings and the nail were positioned to obstruct normal oral activities I could not help but speculate that it was a symbolic attempt to put a nail through her oral aggressive inclinations. She suffered from mood swings, and there was little doubt that she had strong oral love needs. She was very attached to her mother.
In past I have observed that stammering and stuttering often occurs in individuals who were on the path to develop Tourette like explosive speech, and that the speech impediment had occurred to block the aggression from emerging via the medium of speech. Behind the explosive speech lie abusive epithets directed towards the parents for inhibiting one from Oedipal sexual exploration and activities, and it is the fear of retaliation from parental figures for such aggressive oral tendencies that the little child develops a stutter or stammer. The speech impediment nullifies the aggression by putting a block in the expression of abusive words. In fact the block is so complete that it occurs prior to the expression of the abusive word, stammer getting attached to harmless words leading up to the abusive epithets.
Now is putting the nail through lips and tongues a similar attempt to keep control over one's oral aggressive tendencies?
I speculate that when pathological oral aggression occurs during Oedipal phase it causes speech impediment, but when it happens later in life, the person tries to control it by external means. Its psychology is not too different from how in olden days mothers would wash the mouth and tongue of the child with soap and water for using abusive language.
Piercing the lips or tongue are form of punishment for using the mouth for discharging aggressive tendencies. The nail or jewelery act as a reminder to not put one's mouth in proper gear and not to spew abuse. As the saying goes: put your mouth in the right gear before speaking.
Perhaps some people's fascination to have braces put on their teeth, or to replace natural teeth with gold,or as in singer Little Waynes case with diamond, is also an attempt to prevent oral aggression.
A lady I knew, who was a high executive in a hospital, suffered so much from her obsession with oral sex- behind which lay powerful impulses to castrate men - she went and got braces on her mouth at the age of 45 years. An example of such an attempt to prevent one's oral tendencies to express aggression through devouring others is Dr. Hannibal the Cannibal in the movie "The Silence of the Lambs."
The shiny rings and other precious stones that adorn the pierced part serve the purpose of deflecting attention from aggression to something alluring and inviting. They are as if to say: "Oh I don't mean any harm to you. Look I have just the opposite tendencies, to give you something shiny and precious."
While I do not have sufficient observations but I won't be surprised if all these piercing and placement of metal through varied parts of the body, including navel, breasts and genitals do not have same psychological explanation, to wit, putting an inhibiting nail through the expression of aggression and sexuality from all pores of the body.