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].


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