Saturday, April 23, 2011

A death-wish dream followed by a confirmatory dream in an obsessive girl

A young attractive girl, in her early twenties, reported the following dream:

I am traveling in a car with my boyfriend Jerry, who is driving. My sister Maggie is sitting next to him on the passenger side. I am in the back with Brad, Maggie's boyfriend, and Ashley, their son is between us.
I have to be dropped while they are to continue on with the journey. I have an ominous feeling that Brad is going to die. I don't remember being dropped and the car leaving. Instead, I am in a bowling alley. It could be a restaurant. There are plenty of people there. In fact everyone we knew in high school are there. Jerry and I enter together. Then Jerry kind of disappears. I am really interacting with the crowd.
Then the scene changes and I am with Maggie. She tells me that Brad died. I am inconsolable with grief. I call Jerry's mother to give her the bad news. And though I am on phone, I can still see her grief and facial expressions.
I look at Maggie, as to how she is taking Brad's death. There is no reaction from her. She is the one who should be freaking out, but it is me who is bowling my eyes out. I am little surprised at my grief and hysterical crying for it is sister's fiance who has died. In fact Maggie is comforting me rather than the other way around. I cannot even talk because of sadness. I blame myself and feel horribly guilty for I had forewarning of what was going to happen. I should have stopped his death before it happened.
Though I was not in the car when Brad died I could still see in the dream as to how it happened. I was looking at Brad's neck when a pen like thing went into the back of his neck and killed him.
I should have resisted getting dropped and letting them go on. I could have prevented it. At that point in the dream I started hyperventilating and woke up.
I had to call Brad the first thing in the morning to make sure he was alright.


I am traveling in a car with my boyfriend Jerry. My sister Maggie is sitting next to him on the the passenger side. I am in the back with Brad, Maggie's boyfriend. Their son Ashley is sitting between us.

The patient had recently taken a trip to Georgia for a family reunion. The five of them were in the car together. So the dream was just reenactment of the scene.
But why?
Patient could not give any direct associations to this question. But some other associations, too cumbersome to report here, revealed that the journey was symbolic of her own life journey. Her and her sister's boyfriends are always together. "They are connected at the hip," was the expression she used.
So she was envisaging her life journey as always being with her sister, her boyfriend Brad, their son Ashley, and her own boyfriend who she plans to marry and live with for the rest of her life.

"Why would you wish Brad dead?"

The girl could be asked that question directly because many of her obsessive symptoms have been traced in past sessions as expression of death wishes towards family members and she is no longer shocked at the idea.
And she had already guessed that if she was bowling her eyes out and feeling guilty about not staying back in the car to prevent Brad's death, there lay death wishes against him

"I don't. It makes no sense. I really like Brad. We get along so well. He treats my sister well too. Though I must admit that in Georgia they were having their usual tiffs which bothered me but not enough to have such a strong death wish against him."

I have to be dropped while they are to continue on with the journey. This causes an ominous feeling that Brad is going to die.

"Why you have to be dropped off and separated from the rest?"

The associations [too voluminous to report] led us to conclude that the death wish was so strong that she had to get out of the car to prevent it from becoming a reality.
Now this ambivalence of wishing death and then undoing it lies at the center of her obsessions. Here the obsession was being depicted in the dream, using the language of the dream.
Now the patient and I knew from past analysis that her death wish is primarily directed towards her boyfriend Jerry. In real life she has high ambivalence towards him and cannot make up her mind whether to marry or leave him. The reason why she cannot commit herself to him is because she is not comfortable with her aggressive impulses [death wishes] towards him.
Before her death wishes [destructiveness] towards Jerry [her boyfriend] gets out of control, she wants to get out of his car [his life] and discontinue their life journey together.
But if the death wish was towards Jerry why in the dream it emerged against Brad?
We puzzled over this and she rejected my construction that she must have some grudge against Brad which found an outlet in the dream. She is very fond of him, she claimed, and the death wish could not have been expressed with such vehemence against him.
Then after the session drifted in to some other issues, out of nowhere she brought up the following memory from couple of years ago.
Jerry and Brad were in a Sports Bar, and texting a girl called Christina to come and join them. She does not like Christina because there was another girl called Christina with whom Jerry once slept with when they had broken up for a few months.
Sensing this memory was vitally connected with the dream I asked,"Where were you, when Jerry and Brad were in the bar?"
"Maggie and I were at a church function volunteering, till midnight. They were to return by midnight, but did not till 3 in the morning. I was really mad.
Then next day I found that they were texting to that Christina girl. So naturally I was furious."
"You think the death wish came from there? With Brad texting a hated rival, even though this was a different Christina than the one Jerry cheated upon you."
"That is true, but there has to be more than that to the dream, " the girl insisted.
"Why is Maggie next to Jerry in front seat, while you are at the back with Brad and Ashley?"
"Because Maggie has a bad back. She always sits in the front."
But the girl thought for a second and added that does not explain it quite fully. "For all the way to Georgia and back, it was Maggie and I who sat in the front and Jerry and Brad who were at the back. We two girls did all the driving. Could it be that I am changing places with Maggie?"
"If you are changing places with Maggie then there has to be another reversal somewhere."
It is a rule of dream interpretation that if there is a reversal at one point in the manifest content of the dream there will be another reversal somewhere else as if to counterbalance it.
"Maybe the reversal lies in your exchanging Jerry for Brad. And you want to change places with Maggie." I conjectured.
The girl thought for some time and said that is right. "I always wanted to change places with Maggie. But not with Brad but in relation to our father. She was closer to him than me. He was cool with her while I was petrified of him. She would act so coy with him like calling him Daddie instead of Dad when she wanted something from him, which I found distasteful. I could never bring myself to do that."
So she was changing places with Maggie and was also changing Jerry for Brad. But behind Brad lay the figure of her father. It was with her father that she wanted to get even with for preferring her sister over her.
From previous analysis we also knew that her ambivalence and death wishes towards her father had now got displaced upon her boyfriend Jerry. So the dream was showing her death wish towards Jerry and her father but in the person of Brad.
This interpretation was further confirmed by the fact that the person she calls to give the bad news is not Brad's but Jerry's mother. Also the watching of Jerry's mother's suffering clearly points to an obsessive-sadistic satisfaction directed towards Jerry's mother. If Brad was the primary target of her death wish then she should have been calling his mother not Jerry's.
Furthermore it was she who was hysterically crying over Brad's death and not Maggie. So it was her fiance's death that she was mourning for and feeling guilty about and not Maggie's. For it was Maggie who was consoling her and she was the one who was speechless.

I blame myself and feel horribly guilty. For I knew the tragedy was going to happen. I should have stopped it before it happened.

This was the affect of guilt over wishing/causing Jerry's death. Dream has less difficulty in distorting the visual contents of the dream thoughts, but the affects associated with them are much harder for the dream-work to alter. Generally the affective tone persists in the dream unchanged.
In the dream she had been dropped off the car when the death took place so manifestly she was not responsible for his death. But her conscience was still holding her responsible for the crime. It still berated her for not stopping the death before it happened.
She also saw the crime occurring with the pen going through Brad' neck despite the fact that she was not physically present in the car.

I was looking at Brad's neck, when a pen like thing went into the back of his neck and killed him

This part of the dream was connected to a complex which both patient and I were aware from previous analytic work. The girl, who is with her boyfriend for more than 8 years, had lost her virginity to him at age of 14, when she was just not ready for it. The experience was very painful, and the penetration had been experienced as a bullet or knife searing through her. It had embittered her towards him and to some extent men in general.
The first sexual experience and losing her virginity had become a "traumatic event" leaving permanent traces upon her psyche of wanting revenge from her boyfriend and men in general for what they did to her and do to women in general. We had analyzed numerous dreams in the past in which she was confronting her father, and shooting him, to reverse this trauma. Her father was the original prototype of all men. In this dream she was taking courage to reverse the pain of losing her virginity by killing the one who had deflowered her. However, here too, the revenge was not expressed directly but displaced from her boyfriend to his best friend out of fear. The pen obviously was a phallic symbol and its stabbing of it on his neck was tit for tat for his stabbing her with his penis.

in the next scene I am in a bowling alley, could be a restaurant, - where there are plenty of people, in fact all the people we know from high school. We go in there together, but Jerry kind of disappears. I am really interacting with those people.

The city where they live has only one bowling alley, and one high school, and everybody goes there to meet each other. The patient's ambivalence towards her boyfriend for deflowering her and for being unfaithful when they had temporarily broken up and also because she was by nature highly competitive with men - she had once stated that she is never a doormat for any man; anybody who treats her condescendingly because of her sex gets the same treatment in return; she never ever lets a man get away treating her badly - was leading her to explore other men.
The return to the bowling alley was rolling back of time. Since he was once unfaithful, and had done her wrong and had betrayed her, she was going to betray him. So she made him disappear as soon as they went into that meeting place and she started looking for somebody else.
But to her credence she was doing only in her dreams. In real life she has no intention to cheat her boyfriend. She remains extremely busy at work and at school, and whatever little time she gets she stays at home. Even in the dream she does not act upon her revengeful impulse, for despite her ambivalence towards her boyfriend she remains very attached to him.
Unable to get even with her boyfriend through making love to somebody else, her revenge feelings go back to visualizing his death and taking satisfaction at his mother's suffering.
The guilt over this unacceptable wish finally woke her up in a panic and she had to make sure with Brad if her magical (obsessive) thoughts had not caused his death.

The correct interpretation led her to dream a confirmatory one a couple of days later.

Maggie tells me that Dad died. Actually he got murdered. And as soon as she tells me I can see how it happened though I was not there. Just like in the other dream even though I was not there I could see how exactly Brad was killed with pen knife, I could see my father getting pummelled. It starts as road rage. The two cars are stopped and a huge muscular guy comes out of one, throws my Dad on the top of the other car and starts pounding him. My dad does not fight back because he knows he deserves it for all the wrong he has done to Maggie and me. Then the muscular guy takes out a gun and shoots my dad and just walks off.

I was so upset by the dream that I called him the next day, apologized and cried for what happened to him in the dream.

She associated this dream with an actual incidence of road rage she had witnessed as a very young girl. Her father had a temper and he cut off another guy. They both came out and her father had actually punched the other guy in the stomach. He was a black belt in karate. As a child she was very afraid of her father, especially from that point onwards, because he was big and strong and brusque. It was the major factor behind her ambivalence towards men and her fear of them.
Patient even in dream felt that the huge muscular guy was her revengeful masculine ego ideal. The shooting of her father by this masculine guy [her masculine ego ideal] was revenge against her father, the person she once loved very much till with the ending of Oedipal phase it had changed predominantly to hostility.

Both the dreams were sparked by the wish to take revenge on the two most important men in her life her boyfriend and her father for the belief that they had done harm to her because of the passivity and weakness of her sex.

Stuttering - defiance and fear of father during Oedipal phase

A woman in her thirties, whose 11 year old son lives with her brother, reported that at times he stutters.
Since I had never seen her son, on theoretical grounds, I conjectured that his stuttering could be a reaction to the fear of father during the oedipal phase.

My theoretical reasoning was as follows:

At the height of Oedipal Phase the little Oedipus has to halt his sexual inquiries and sexual interest, primarily directed towards the mother, out of fear of his father - the fear of castration in father's hands for encroaching upon father's domain. In fact the Urdu/Hindi word for stuttering is haklaana which is derived from the word hak meaning "rights over a domain". Haklaana, which is a composite word, when teased apart means - bringing in one's right over something.
So mother becomes the domain over which father and son's interests collide. Who has more right over her - the father over his wife or the son over his mother. In normal development the son bows out of the conflict, correctly judging the father's superior power, skills, material possessions and experience and gives up the sexual claim over the mother. But not without making a resolve to come back another day and turn the tables. If this wish to reverse the fortunes is too strong - because of unfavorable genes or disturbed relationships in the household - then all kinds of psychopathologies result. The wish to prematurely attack back the father in the sphere of language causes speech impediments such as stuttering.
The process behind the stuttering appears to undergo following twists and turns. The Oedipal sexual fantasies are primarily sadistic in nature. The conception of sex at that stage is that man does cruel, humiliating, punishing things to the woman, like overpowering her and beating her on her private parts. In fact the popular Hindi word for coitus is literally "man beating the woman on her buttocks". Therefore the fantasies provoke feelings in the child that they are dirty and wrong; along with guilt and anxiety that if these fantasies are found out by the father, he will brutally punish him. In fact he imagines that the father will subject him to the same humiliating thing that he is fantasizing doing to the mother. So the sadistic designs towards the mother - along with infantile masturbation which accompany these fantasies - are given up out of fear of the father. But it is not given up without an interesting development. The boy develops a keen eye for evidence/clues that will confirm his suspicion that the father does to the mother the very same things that he has compelled the boy to give up. [Herein lies the psychology of the human fascination with detective novels, murder-mysteries, whodunit, and scandals and corruption in high places.]
And these inquiries lead him to conclude that yes indeed the one who has scared me out of being a "mother f*****" is actually guilty of that crime himself. He is a mother f***** himself. And then comes the bitterness and revolt towards the father which lies behind human distrust of authorities and our fascination with dark deeds of those in high places. "What right has he to prohibit me from masturbating and indulging in sexual fantasies towards my mother when he does to her the very same thing. In anger he wants to inflict the epithet mother f****** upon his father [which lies at the core of Tourettes]. But as he imagines reproaching the father, the fear grips him that the father will retaliate and punish him for challenging his authority. So he cannot allow the insulting words to slip off his tongue. Therein lies the psychology of stuttering. The fear (inhibition) block the insulting words from getting enunciated. It is interesting that only certain sounds he has inhibition towards getting hold of. I will not be surprised if it turns out these particular sounds that he is forbidden from getting hold of to make his word and complete his sentence, which causes the stuttering, symbolize the penis, which he is now forbidden to get hold of to prevent masturbation and the accompanying sexual fantasies.
It will not be superfluous to add that the whole complex [disturbance] is thrown into unconscious through repression and the struggle now shifts on - gets displaced - to words and sounds that are far removed from words connected to sexual processes making it difficult to understand the roots of the disturbance and tempting us to believe that stuttering is more a neurological than a psychological disorder.
It is ironic that the child who is precocious in the sphere of words and language, and thus immediately resorts to words to put a halt to father's hegemony is the one who develops stuttering.

Now after the above theoretical discussion lets return to the case.

I of course did not give all these theoretical details to the mother who would not have followed them anyway. But whatever I told her did leave an impression upon her.
She commented that her son has not known his father at all. He had left the family soon after the child was born, and has not maintained any contact with the child. She herself had been quite irresponsible, indulging in drugs, when the child was in his Oedipal period. It is her brother, who is a fireman, and is stable and responsible, who took over the boy's parenting. But he is not strict at all. So she does not understand why the child would have fear of his uncle (the father figure).

I explained, "The fear may have less to do with actual parenting and the presence of real father than with the fear of phylogenetic father. The fear of the father may be hereditary and it may have emerged during the Oedipal phase affecting the speech regardless of what the family constellation was at that time."
Mother agreed with that and said that despite my brother not being authoritarian, my son does show shyness and fear around him. And she will tell what I have said to her brother.
A couple of months later, the patient informed me that she did have a talk with her brother who approached the boy and told that behind the stuttering lies a fear of him.
Per patient the stuttering gradually but surely has shown a remarkable lessening because of this conversation with the boy.

In another case of stuttering, this time of a young man, 30 years old, and professionally quite successful, I noticed that he shows remarkable duality of fear and defiance in approaching authorities. Sometimes he shows abject compliance and humility in his dealing with me at other times he is defiant, challenging, and even contemptuous at my respectability.
When he is challenging and contemptuous, bordering on insulting, if I counter him forcefully and try to put him in place he starts stuttering, as if he realizes that he went too far with me and should have bitten his tongue before speaking to me in such an equal if not superior fashion.

Monday, April 18, 2011

A neurotic fear of giving into exhibitionism in dreams causing insomnia

A woman in her early forties and still very attractive but housebound because of severe anxiety complained that she worries about the silliest things that keeps her awake much of the night. When asked to describe one, she said:

Like I can start worrying that do I have socks and clean underwear for the next day. I will have to get out of the bed, go to the drawers and check it out to make sure that yes I do have clothes for tomorrow. Isn't this silly?

The obsession was quickly seen through as a component instinct of exhibitionism, passive counterpart of scoptophilic drive. Scoptophilia is a desire to look at objects for sexual purposes and its passive form is to show oneself. The original impulse is to look at one's own body and genitals and derive [sexual] pleasure from it. It further develops into looking at others' bodies and genitals, as if for comparison. The original impulse to exhibit oneself stays side by side with the desire to look at others.
Desire for fame appears to be derived from this sexual component of showing off one's body. In cases of actors and actresses and other visual arts it is primarily showing off of one's body. It is often couched in dramatics or in case of figure skating and dancing etc. it is laced with extraordinary motor skills. In many, showing off sublimates into showing off of one's intellectual abilities.
So I told her, "You must have loved to exhibit yourself at one time in your life. Now showing off has come under repression. So whenever the impulse to exhibit yourself arises, there is a counter force [conscience/superego] opposing it. It is this counter force that finds expression in the worry whether you have clean socks and underwear or not. For going out without them would be equivalent to going out naked and exhibiting dirty [sexual] aspects of yourself. The fear of going out and exhibiting your naked body has shifted by displacement into fear of going out without socks and underwear."
"On the contrary," she said, "I hate showing my body. Unlike other people who can lie down on the couch half naked even while company is at house and love to wear bikinis and go to the beach, I am absolute shy about showing any part of my body. My ex-husband, with whom I had 3 kids, I never ever allowed him to look at my naked body. So you are wrong."
But then she reflected and added, "Wait a minute. You always come up with these weirdest things which only make sense to me weeks or months later. And I do recall, as a child, once, in Pennsylvania, where we had gone to visit relatives, I walked out of the bathroom, where my dad was getting ready to give me a bath, all naked, to finish the conversation I was having with my cousin. It shocked them greatly, because I was already 6 or 7 then."
She then confirmed that she was a motormouth as a child and could not get enough attention upon herself. And added that her constant talking was perhaps exhibitionism.
Interpretation was made that she cannot sleep because these exhibitionistic urges - for they will get her in to trouble if she gives into them in public even if only in sleep - are keeping her from falling asleep. She is afraid she will dream about them and so she does not fall asleep.
She brought further associations to this. She stated that she worries all night long about other silly things like serial killers will break into her house, or gas stove will be left in on position that will cause the gas to explode and kill all of them, or some harm will come to her daughter while she is out.
Analysis revealed they were all connected with her strong desire to be loved and equally strong repression of these desires. She had unconscious fantasies of going out in the public and seducing men by displaying her beautiful body - the exhibitionistic fantasy/her obsessive fear of going out in the public without socks or underwear/going out naked - and stealing those men's coveted part. Such a daring deed would require killing of them first , which was provoking the fear of retaliation on their part that was emerging as obsessions in her mind of serial killers coming to her house and killing her and her children.
Serial killers killing her was also a secondary revision of the fantasy of them having their way with her sexually. The intercourse was being show in sado-masochistic form of getting knifed and killed by them.

Friday, April 15, 2011

Fear as the key etiological factor in Autism

In most cases of autism, that I have come across, there were extensive obsessive-compulsive disturbances in the mother. And whenever I got the opportunity to examine the father, which was not often, for most mothers were divorced or single, they were quite likely to be rigid and distant as well.
The most striking thing about the mothers was their lack of feel, or rather defective feel, for the child's correct needs. They were often grossly out of tune with the affective and cognitive world of the child. Their expectations not only were unrealistic but often bizarre, paradoxical and not synchronous with the child's developmental stage. In areas where the child could excel there was little interest and appreciation. In contrast, where the child was a laggard, and could not perform, there were unreasonable hopes and demands.
The following case whom I treated for about six months - the treatment came to an abrupt halt when one day the mother realized that the boy was getting emotionally attached to me and gaining strength from it would pose opposition to her dictatorial control - best exemplifies this type of oddity in mothers of autistic children.
He was 19-year-old autistic boy, an only child, completely dependent on her; as much as she was dependent upon him. It was not quite a case of folie a deux but close to it.
What piqued my special interest in him was his exceptional gift in drawing cartoons. He could draw a person in remarkable details and in no time. And he noticed everything about your facial features, every quirk and flaw. But, as if he paid a prize for such profound interest in the physiognomy, by not noticing much else about you, especially your emotional nuances. As if a disproportionate share of his cognitive abilities got concentrated upon noticing the physical aspects of your face and the physical contours of the body and so none of it was left for noticing other things about you. Or was it that he had been prohibited from noticing the emotional aspects of his mother and other people under fear of getting punished and so his interest in them had got shifted (displaced) on to just noticing the physical aspects of them? 
He showed me his portfolio of comic strips, the quality of which was professional. They were about a Japanese adolescent [his alterego, he was African-American], who lived in a magical world, abounded with goblins, ghouls, villains and pretty girls, where wizardry ruled the day. It. The theme was typical action adventure where the hero after meeting the usual life threatening obstacles (father substitutes) and witchcraft (mother's spell to hold him back from rising up in the world) would impress the heroine so much by these feats that she would fall head over heels fall in love with him. All the heroines were exquisitely beautiful and blond [his ego ideal]. They all dressed in overflowing and frilly dresses - compensation for their lack of penis - a sharp contrast to his mother's drab flat style that eschewed all adornments.
Now, amazingly, the mother frowned upon this great gift. She considered his passion for art an obsession that would deviate him from his true vocation which was to become a professor at the University of Michigan. And she was making active efforts in grooming him for that wonderful achievement. As to what kind of professor he would become at the university was of no concern. The subject in which he would specialize was of no consequence. What mattered was becoming a professor at the University at any cost. But one glance at the boy and you knew how grossly off target the mother was. The boy spoke like a computer. He could barely make himself understandable. There was something completely rigid and artificial about his speech. It lacked variations of tones, which rendered him unfit for delivering lectures. And in his choice of words he was so pedantic that he verged on incomprehensibility And as if this was not enough, he spoke in a pompous British accent, sometimes so inappropriately that it was obvious he would be laughed out of any lecture room.
Yet she was convinced that he had in him to become a professor, and one day demanded of me that I double his dose of Abilify, an antipsychotic, to achieve this aim.
When I enquired as for what the poor boy had done to deserve such a punishment, and how would a medication that straitjackets one would help him become a University of Michigan professor, she said that at his school - which was exclusively for developmentally disabled and autistic children- he had flown in a rage  and physically attacked his teacher. 
 I asked the boy the reason for the violence and he replied that they were discussing the issue of capital punishment and the very idea was so barbaric to him that anybody who even suggested that it had some  value deserved physical attack. [To understand the boy's pathological abhorrence for capital punishment I must mention that in his unconscious mind he harbored extensive death wishes against his mother, and as a consequence feared for his life for he believed that his thoughts were powerful enough to cause her death one of these day, and the punishment for it then would be his own death. He even heard voices urging him to kill her - projection of his wishes/thoughts from inside his head to the outside world - and strongly believed that if under the promptings of the voices if he does kill his mother it is the voices who should be hanged and not him. So behind the attack upon his teacher was his fear that if capital punishment becomes legal then one day he would be hanged, for it is only matter of time before he will cause the death of his mother, though in all fairness he should not be held guilty of it because it is not him but the voices that were wishing her death.]
When I asked the mother how doubling Ablify will help, since he is already on 30 mg., maximum FDA approved dosage of that medication, she said that she expects him to go to University of Michigan - he was 19 and had still not cleared high school - and behaviors such as physically attacking one's professors in a prestigious University like that would not be tolerated for a minute and as a psychiatrist I should know that Abilify controls aggression.
Now to the Biological Psychiatrists the mother's logic would have made perfect sense and in fact they might have made her an honorary member of the College of Neuropsychopharmacology for such profound  thinking, but to us, governed more by common sense than mutual back scratching, there is something not quite right about the way the child and the mother were using the language. The boy just on hearing the teacher say that capital punishment could have merit physically attacked the teacher. The teacher was just facilitating the topic and had nothing to do with the actual capital punishment with real criminals. But the language, or rather the words of the language, were not quite correctly connected to the underlying concepts which those words were conventionally suppose to capture. And they certainly were not connected to the right emotional nuances that had accompanied them when he had first heard them, while acquiring language in his formative year. So while the discussion on capital punishment would have provoked at worst a little horror and queasiness in a sensitive individual, in this boy it provoked outright violence - he attacked the messenger (teacher) instead of dealing with the message.
And this disturbance in language was present in mother as well. Ambition for her son was associated in her mind with his becoming professor at the University of Michigan. The word 'ambition' in a regular mind would be associated with studying hard, burning the midnight oil, getting good grades, applying to different universities, entrepreneurship  invention etc. But in her mind there was only one association: her son giving a lecture at the University of Michigan.  What entails in becoming a professor and what her son could realistically achieve were not associated with her conception of ambition.  The way the mother and son used words, rather language as a whole, did not make comprehending the world easier but more confusing. The language was more a means of obfuscation than enlightenment.
In fact in this mother-and-child-autistic-bond, all communications occurred in a cloistered fashion and in a verbose and schizotypal language. Additionally, to make things worse with language, the mother often dealt with the son by keeping "morally uplifting" books in her reach from which she would quote to win  arguments, which they were always having. Her conversation with him was littered with references to the exemplary and literary people from the past, and as to what they would have said about the matter under discussion. So instead of teaching the child using normal language, she dealt with him, rather dealt with her  aggressive impulses towards her by bringing impersonal language of the high class books. The language, the faculty of communicating through sound, was being used to create distance not closeness between them.
And taking the cue from the mother the boy had developed his own peculiar way of speaking. Since mother had the upper hand because of her age, greater experience, and the means to support them, the boy to counter her aggression had acquired the British accent  to match mother's pedantry and pomposity. The mother was so out of touch with the boy's real emotional needs that she had made no attempt to understand as to why the boy had abandoned his Detroit ghetto accent for an English Lord's. She had accepted it as a matter of course, and made it a point to tell me that his speaking like a cartoon character - for that perfect English accent in the boy from Detroit appeared cartoonish - did not bother her a bit. She was completely insensitive as to how such an accent had made him an object of ridicule with his peers. She had no curiosity as to its psychological origins and had made no attempt to stop it.
In the six months that I treated the boy and the mother - for she always barged in in the sessions, convinced that what she had to say about him was infinitely more important and meaningful than what he had to say about himself - it became apparent to me that behind the pomposity, peculiar language, and high-mindedness lay excessive fear of the world from which the two were escaping not only from each other but with the world as a whole too together by denying its fearfulness through a deviant use of language. 
Instead of becoming physically aggressive - though that would break through once in a while as it happened against the teacher who dared to talk about - that happens in a lot of people as an adaptation towards fear, they had become pompous and full of stilted words, by which they could look down upon those who they feared. The pompous and peculiar use of words had become a shield (defense) against the frightening world.
However pedantry alone could not allay the fear completely and sometimes one could hear the fear behind the stilted language. Adoption of the British accent was the next step in dealing with that anxiety. By imagining himself to be a pompous Englishman the boy was trying to convince to himself and others that he was way above fearing them. Occasionally the fear would break through the British accent as well and strike upon individual syllables. For example he had to drop the sound "r" in many words to avoid a panic attack. Rabbit had to be enunciated as "vabbit" to forestall panic.  On other hand he could say r in many other words such as road with no problem at all. While he could say the word "thumb" perfectly well he could not say 'thought' or 'think' and had to substitute 'fought' and 'fink' respectively. Interestingly the mother showed same kind of difficulty with the language though not in pronouncing words. She one day claimed that it is the astrologist who predicts the weather. It took me some time to figure out that what she meant was that it is the meteorologist who predicts the weather The distortion in language and use of words and even sounds of words at its very bottom was nothing but ways to deal with fear..
What lies behind this extreme fear? Deep down these mothers - at least a majority of them that I came across - have great ambivalence towards their autistic child. Hatred exists alongside love. And the fear arises as a means to check acting out their hatred with punitive aggression. The aggression is not completely eliminated by fear though. It finds outlets in distortion and in obsessive behaviors. Trying to control obsessive impulses - behind which lie hatred of the child - exhausts the mother and leaves little room for love and understanding to emerge in her interactions with the child.
What are the roots of this hatred? Is the hatred primary because the mother did not find herself equal to the task of being an ideal mother - obsessive people place high demands upon themselves to be perfect parent and many postpone or never get married fearful that they will be too inadequate/intolerant towards their children - from the beginning, or does it arise from the emotional exhaustion that occurs in a parent from taking care, day in and day out, of such a time consuming task as bringing up an autistic child.
There is no question that an autistic child is a burden for the parents. Here we are reminded of high prevalence of autism in children who are born to older parents - in the eve of their birthing years - and with less ability to be spontaneous and truly emotionally interactive with their children. Autism also occurs more frequently in higher socioeconomic strata. The same class which has least number of children. As if the person who has all his or her desires fulfilled easily has little motivation left to beget children, postponing it to the very end of his/her biological clock. The greatest motivation for having children is to see fulfillment of one's own thwarted ambitions; to vicariously achieve through them the successes that one could not in one's own life. Successful people have little motivation to enjoy life vicariously. Even when they have children they have greater ambivalence towards them for having to give up their own pleasures in order to take care of the little ones.
It is not that these parents do not have love for their children. In fact the love by noisy exaggeration hides the true state of affairs to even experienced clinicians. Their [unconscious] realization that they are out of sync with the emotional world of the child makes them try their utmost to obsessively search for some wonder drug or some fancy gluten free or manganese loaded diet or some other snake-oil to cure their child magically.
Sometimes they spend a fortune chasing the newest fad even going as far away as Afghanistan or Mongolia to prove to themselves and the world at large as to how much they care for their child.
And how does the fear manifest in autistic children? There is little doubt that autistic children are extremely sensitive to noise and other stimuli. They startle easily and overreact to any unusual or jarring stimuli. This appears to be a genetic endowment. An exaggerated inborn fear of the outside world. As Freud put it in his "Instincts and their vicissitudes": The relation of hate to objects is older than that of love. It is derived from the primal repudiation by the narcissistic ego of the external world whence flows the stream of stimuli. This fear provokes premature and strong aggressive drives in children genetically predisposed to autism and in pell-mell. Their love for complete order such as fascination with trains whose compartments follow in such a sequence, or fans that go in a completely predictable fashion appears to be a reaction to this emergence of their aggressive drives in such a helter-skelter fashion.
When this premature aggessive way of relating meets a stonewall, and little emotional acceptance for aggression on part of the mother who herself is struggling vainly with her aggressive/obsessive drives and wants everything perfect and in order, the child withdraws into his own autistic world, taking out the aggression on his own self and in internal secretions.

Thursday, April 14, 2011

A childhood screen memory of penis envy and its connection with trichotillomania

A patient in her mid-fifties, who never got married because she wanted the world absolutely on her terms and thus could not make room in her life for a husband, recalled the following memory from her childhood:

As a child I would take a slice of Wonder Bread and squeeze that whole big thing into the smallest size, then eat it up. It never amazed me as to how I could squeeze all the air out of that big slice and turn it into such a tiny ball.

This memory emerged while the patient was describing her obsession with eating nothing but the healthiest food. Recently she is in a kick to eat rare grains and goes the distance to buy some exotic varieties. She does not quite enjoy their taste because of lack of previous exposure - for it is difficult to acquire new tastes in one's fifties - nevertheless she eats those grains [religiously] to enhance her health.

The childhood memory emerged as a contrast to her current health consciousness. As a child she cared two hoots for eating right, and the processed Wonder Bread which she now finds "so terrible for you" was a much sought after item.

Another contrast between then and the present is that as a child she was free as a bird, but now is bound up with all kinds of controls. She not only controls everything she eats - not a trace of any unhealthy food can go into her mouth - she controls all other aspects of her life as well.

A good example would be the way we struggle over scheduling her next appointment. If I suggest for her to come in 4 weeks she is bound to say how about 6 weeks. If  the suggestion is to return in 6 weeks, I can count upon her to pipe in I rather come in a month.

Now this kind of competition is sine qua non of obsessional neurosis. It is continuation of the oppositional defiance of latency age. In males its roots can be traced to phallic competition with the father. However, it is more a legacy of the anal-sadistic phase and continuation of anal-retentive struggles (anal defiance) over who has control over one's possessions (feces) parents or one self.

Just not scheduling she also wants to control what transpires in the sessions. What she talks in the office is  never free associations; never reporting of what is transpiring in her mind's eye here and now, but prepared material and mostly the notes she has made of educational TV shows on mental health issues, which she reads to me from pieces of paper and then comments upon them. There is no question of learning anything from me about her illness, just teaching me nuggets of wisdom she has jotted down from TV, Internet and magazines about neurobiology of OCD and ADHD, stigma attached to mental illnesses and other assorted topics on psychiatry. It is psychoeducation at its best and done to teach the analyst as to what psychiatry is all about. She would have made an excellent biological psychiatrist for they too cannot see anything beyond psychoeducation.

Her psychoeducating me is just a tip of the iceberg of doing good deeds and favors to others. But it is always doing unto others never letting others do unto her. She refuses to accept anything from anybody. Even I can never get anything to her about her neurosis but edgewise.

It is interesting too that while she is prolific with free advice - notes gathered from TV and the Internet which one get for free - she is niggardly in giving anything that is solid and has any material/monetary value. Her giving of actual things is as puny as the tiny ball of the Wonder Bread slice. She has equal difficulty in  parting with her money. For example on one Christmas she gave me the present of two packets of hot chocolate, which were bought from a dollar store and wrapped in an old newspaper.

Her inability to accept anything from others on analysis showed itself to be a compensation for inability to spend on others. It is a form of punishment. The reasoning goes: "If I am so petty in giving things to others then I should make up for it by accepting even less." She never ever accepts a cup of coffee from me which I sometimes offer my patients at the beginning of the session with an invariable, "No thanks. But you go ahead and please have one for yourself."

An example of her intense need to do favors is reflected in her regularly wanting to cut short her session with me so I can have a few minutes to myself. And she always adds that she won't mind a bit if I bill for the whole session. So as long as somebody else is picking the tab for her generosity she can spend. If I am running late, she is delighted at the prospect of offering to end the session early so I can get back on schedule.

However her extreme considerateness does not make one feel thankful but slightly irritated. As if her favors to you are done not for your sake but for the gratification of some internal need of hers. As if her goodness is not truly altruistic but to override a contrary impulse. Her analysis showed that behind this desire to do things for you there lies a powerful drive to snatch things away from you. It is this evil impulse which she has to constantly keep in check by doing just the opposite.

She is always grabbing magazines from my office, and though they are next to worthless, she makes a big show of it, as if  it is as big a deal as asking the moon from me. She gives an impression, at least to my analytic eyes, that she will violently take things away from others if that impulse is not kept under suppression by a forceful reaction formation of always doing just the opposite.

But this impulse to take something away from others by force does find an outlet in her, escaping the reaction formation,  in her neurosis/displacement. It emerges in her grabbing and pulling out her hair. She pulls them out in gobs and has practically no natural hair left. So the impulse has found an outlet but by turning upon her own self and in pulling out a valuable part of her. Herein lies the psychology of trichotillomania.

As for the analysis of her memory I made the construction that her squeezing the Wonder Bread slice was a screen memory for something momentous that happened to her at a very ancient period of her life [during the Oedipal phase].

Screen memories are disparate flashes of memories from early childhood, which seem to have nothing  significant about them. Snatches of memory with neutral and nothing out of ordinary content that makes one wonder as to why someone would keep them in the repertoire of conscious memories so tenaciously. Their importance lies in that they contain in shorthand something of great importance that happened during that period, or even earlier, the memory of which has been overtaken by childhood amnesia. The important memory undergoes repression and the neutral memory which seems to be without significance contains the content of the important memory in a coded form.

Then on theoretical grounds and because I knew her conflicts well from years of observing her added that the playing with the slice of bread and changing it from the big size to next to nothing was connected with solving the riddle of the differences between the sexes. It arose from the castration complex of Oedipal period. The little girl when she first sees the male genital, while playing with a brother or another child, quickly and decidedly concludes that she has been shortchanged on this most important matter.  Their reaction is to not  believe - rather refuse to accept - that they have been shortchanged permanently and often think that they did have genitals no different than boys, and that it either got lost, or taken away from them for some misdeed, and the tiny clitoris, whose pleasure giving significance they have just begun to appreciate from playing with it (childhood masturbation) will grow to the same size as that of boys or by some effort, trick, or maneuvering they will be able to get the right size genitals (clitoris/penis).

The maneuvering by which they hope to get the right genitals has oral overtones. As if by eating something right they will be able to get what they want. [Patient's memory had emerged while talking about her extra carefulness in not eating something that is harmful to her. This obsession with not eating anything incorrect was counter measures against acquiring a penis (getting orally impregnated) through the oral route. The wish for penis and obtaining it by eating it or eating something that will get one one and its rejection.]
[One of my patient who was sexually abused at the age of 3 by his older sister, the latter would routinely make him hide his penis and testicles between his legs, so the distinction between him and her would disappear.
This impulse on part of the sister towards her brother is the same impulse that was being given an expression by the patient, who had no brother or sister, through playing with bread slice and making it almost disappear.

A more melovalent expression of this impulse to take away the distinction between the sexes explains the behavior of women who actually attempt to castrate men - recall the case of Lorena and John Bobbit - and I will not be surprised if the same impulse lies behind women who become serial killers - one is reminded here of the drama "Arsenic and Old Lace".
Also notice how in describing the screen memory she talks about snuffing out every bit of air out of the bread slice. ]

The construction to explain her screen memory was of course not accepted by the patient. Who far from being enlightened, or even amused, was outright turned off at my imposing such Freudian views on something which she claimed every kid in her street in those days at that age would have experimented with. She was not mollified by the explanation that the memory emerged with such clarity and exactly while she was telling about her dread of letting in any unhealthy food to enter her mouth - dread of oral impregnation - and therefore it is a "Screen Memory" and the psychoanalytic theory gives us no choice but to interpret it as a plastic expression of the desire to turn her genitals into that of a male or for the sake of equality/justice to turn the male genitals into that of female.

"That is sick. Don't interpret anything sick," she said.

Nevertheless the interpretation must have hit home for in the very next session she brought up a question followed by an observation which picked up the theme of "penis envy".

She began the session by asking,"How does a person adjust moving from a very warm climate to a very cold one, or vice versa, and how long does it take for the person to adjust to such a drastic change?"

I could not immediately get the significance of the question but as the session proceeded and she started talking about how she pulls out weeds in her garden, and how the flies circle around the pulled weed, wondering why did you take away my weed, and she wonders how they adjust to the loss of the weed around which their whole life had revolved till then, I could see that the question of how one adjusts from one climate to another was forerunner of the same theme. The theme being how does a girl adjust to the fact of the difference in the genitals between males and females, when she first discovers this, realizing that she is not the same but the contrast to male sex and that her penis has been pulled out, and how she will adjust to this new life [new climate] with the absence of this important organ.

While listening to her, I could figure out how her weed pulling, zit puncturing, magazine grabbing, and trichotillomania they were all in a series. This was not communicated to the patient. She was not ready for that interpretation.

The patient though was made aware of connection between the previous session of her fascination with making wonder bread from big to small to the point of disappearance and the theme of the disappearance of weed and the wonderment on the part of the flies and its overall connection with her psychopathology being closely related to her never getting comfortable with her gender and being afflicted with the impulse to pull out anything that reminds her of the difference between the sexes to equalize things.

Patient rejected any connection between the two and said that she has no fascination with male genitals, never had any, and has no desire to get one for herself, so forget about her wanting to be like them. "Forget about my wanting to copy you guys," she declared with disdain.

At that point I had some stomach rumblings (borborygmi) which was quite loud and could be heard across the room. The patient burst out laughing and said it is so loud and strange, I never heard you do it. You must be hungry, your stomach if growling.

I explained to her that stomach growling, and other intestinal movements, have very little to do with hunger but are an expression of nervousness.

She disagreed with that but was immediately afflicted with stomach rumbling herself.

She rejected my interpretation that it was a sympathetic response to my statement and very indirect confirmation of the correctness of the interpretation.

She said, "There is no psychiatric meaning to all this and I do not see any point in your reading meaning in my love for pulling out weed and things which one has no choice over. One got to keep one's garden clean. I do not see any disadvantage in lacking a penis. However, she immediately followed this by talking about how she does see disadvantage of being mentally retarded and how public reacts to the handicapped differently than to guys who are labeled as normal. She proceeded on to declare that how closed head injury patients are never treated the same after the trauma and how people avoid them.

These associations arose from the parallel that exists in the disadvantages suffered by women [in a male dominated society] and those suffered by mentally handicapped and closed head injury patients.

Saturday, April 9, 2011

Lifestyle of living for drugs a substitute for grand succes on the world stage and the role of dopamine in all of this

A young man reported that the hardest part of giving up drugs is "the rush" that came with the search for the next fix. "Addiction is not so much about doing drug as about the thrill of the chase; going the whole nine yards in search for it. Every right step that brings one closer to where the drugs can be found has its own quota of thrill; its own mini-rush.
He sounded as if looking for drugs was a feat akin to searching for the "Holy Grail".
He then declared that "the rush" must have deep psychological pockets for even when one gives up the drug and goes into abstinence for a long time, the craving for the rush continues to haunt one in "dreams of using".
Then he talked about his dreams of using. The script is stereotypical, he declared, with some insignificant variations. The dream typically begins with "the craving" followed by calling up of the drug buddies and "the contacts", worrying over the relative dangers of different drug houses, taking the trip, dodging the dangers and finally getting the drug.
The rush strangely is not reserved for the endpoint when the drug is finally done. In fact, the dreams rarely reaches the stage of doing it. Some interruption or another always prevents that. The rush - or rather mini-rushes - occur at each step of the way. So the function of the rush has more to do with guiding one correctly through the maze of difficulties that lie on one's way to procuring the drug rather than appearing as one great burst of pleasure at the endpoint.
"His dreams," the patient continued, "always ended before he could snort the drug. Either the powder got spilled, or could not be found at the last minute even after being paid for, or the "rock" rolled out of reach, or some problems arose in assembling the paraphernalia. His description of these interruptions reminded me of the phrase "there are many a slip betwixt the cup and the lip".
Since the man had grown up in the world transformed by video games, I asked him if the rush [mini-euphoria] at each successful step was similar to how one felt shooting the enemies, overcoming the obstacles, and rising from one level to the next, in those computer games, and he said the simile had merit.
Now let us see if we can make some psychoanalytic sense as to what must be going on at the level of psyche, brain and consciousness when a person is experiencing the mini-rushes as he goes hunting for drugs whether in real life or in dreams.

"The mini- rushes" in the psychoanalytic language should be looked upon as quotas of pleasurable feelings getting generated in the consciousness from reports arriving of successful progression towards reaching the goal.
Whenever something is done successfully - success means discharge of physical and mental tensions - a report of relief from the tension is sent to neurons that generate consciousness ( Freud proposed that a separate system of neurons generate consciousness and he termed them omega neurons; see his Project for Scientific Psychology) and it is felt there as pleasure. Simultaneously, it is my conjecture, that whenever there is discharge of tensions (experience of satisfaction) there is activation of dopamine neurons and a release of dopamine from its axonal projections on those neurons that were involved in bringing the relief from tension.
Why there is release of dopamine?
Dopamine appears to be the neurochemical that makes one repeat things - dopamine causes stereotypy. And it appears that whenever a behavior brings satisfaction (brings relief from tension) perceptual and motor neurons that underlie and made that behavior possible are subjected to dopaminergic stimulation through some feedback mechanism. And the purpose of this dopamine feedback is to further prime those specific perceptual and motor neurons which were responsible in noticing the desired object and in bringing it in a position that the person could consume/ incorporate it to end the tensions/the state of craving.
For example in a hungry person, who is in a state of craving, those perceptions - of smell and sight - which locate the food and those motor neurons which bring the food - like plucking the fruit off the tree; successful chasing of the prey, cutting the vegetables and putting them in a dish and on the stove - to one's mouth will get primed once the food is consumed/incorporated (reaches the stomach and the blood stream) ending the state of craving (relief from the tension of hunger).
In a drug addict the behaviors that take the person nearer to the drug get similarly primed by dopamine by using the same feedback mechanism.
The purpose of this dopaminergic priming is for these specific neurons to be more readily activated when the state of craving arises. Already primed (cathected) neurons make the search for the desired object more expedient because one does not have to waste time on fruitless motor activities, concentrating the efforts exclusively upon those neurons that have brought success in the past. Dopamine primes only those neurons which brought success in the past and when similar situation arises more focus/attention falls upon these neurons via fresh release of dopamine - this is the mini-rush that the patient was so enthusiastically talking about - and it is done to further facilitate the sequences of behaviors which will end the state of craving and bring relief from tension.
As if anything done successfully demands that its repetition in future should take less effort. And dopamine appears to be the neurotransmitter which is used for this purpose. As if any activity that is biologically useful causes release of dopamine and strengthening of that activity while those behaviors (and the neuronal circuits underlying them) which do not bring success and thus do not get dopamine input get pruned away.
Now we also know that drug use activates dopamine release. If we claim that any successful activity causes dopamine release should we also then say that doing drugs is a biologically successful activity? We can without any ado reject such a conclusion. Doing drugs, which withdraws the person from all other interests of the world to the exclusive preoccupation with finding drugs and doing them, something that has no nutritional and questionable reproductive rewards, cannot be considered a biologically successful behavior.
So what is going on? How do we explain the paradox?
It appears that addictive drugs bring a spurious sense of success. The brain is tricked into believing that one is doing something good while searching for and doing drugs. Even if in reality/biologically one may be doing just the opposite.
And how does this happen?
Let us first try to examine what exactly is success.

Success at the most basic level means the organism reaching its aim to procure some substance/object to add to itself - or to expel some substance that has become an irritant within one's system like CO2 in blood stream, feaces in alimentary canal, a nagging spouse - to maintain its status quo/homeostasis. This is the principle of constancy/inertia - everything in the universe, including living organisms, have this most fundamental property: to resist change and conserve/preserve its current state forever.
Let us go further on this line of reasoning. What do we mean by saying that the organism procures some substance/object to add to itself to maintain status quo? Easiest example would be of hunger. Hunger can be looked upon as reports reaching the consciousness (omega neurons) of a changing status quo, due to depleting energy and body contents, through the gnawing of the stomach muscles and through the activation of receptors in the brain that are sensitive to chemical changes in blood like falling blood sugar levels. And this sensation of hunger initiates a series of actions that will result in procuring of food. Freud calls such series of actions, which end the state of craving, "specific action". Once the food is procured it replenishes one's energy and bodily contents and restores homeostasis. Now the series of motor actions that bring the organism closer to the food (specific action) produces pleasure [through decrease of tension]. Every step which brings the desired object - food in this case - closer to one's sensory vista (perceptual sphere) causes a fresh secretion of dopamine. While every wrong move which allows the satisfying object to get further away from oneself, produces unpleasure [through increase in tension]. Every move that brought the desired object closer to our sensory vista and lowered tension was rewarded with secretion of dopamine and strengthening/priming of that motor behavior.

Now what happens when the organism meets failure? Every move that results in allowing the desired object to get away from oneself because of defeat by the competition - others also seek the same object - or by meeting some disaster like falling off the cliff while chasing the object or by misjudging the direction in which that object grows is met with increase in tension and avoidance of the behavior in future through generation of pain. And through these strengthening/priming and extinguishing/pruning of behaviors through eons of biological/evolutionary/phylogenetic experiences the release of dopamine has become a method to direct focus upon those memory traces that point the way to satisfaction. And the release of neurochemicals (acetylcholine? and other neurochemicals?) that are generated with lack of success, injury and pain, act as warning to not go any further in that direction.
Pain is like a watchdog over us, it prevents wrong moves. Success/experience of pleasure strengthens the series of behavior that led one to it, while pain warns us not to go on a particular path because it will bring no good, and instead of discharging tension may raise its level further because of encounter with danger.
Now what the addicting drugs do is to knock out this protective mechanism of pain and make dangerous and harmful activities not look all that dangerous and capable of causing pain. Narcotics achieve this aim directly. They block the perception of pain, and the memories of pain which had occurred when the forbidden activity was first undertaken. Anti-anxiety agents do the same job by taking away the fear of meeting with painful consequences.
The result is that the person starts indulging in those pleasurable activities that once had brought pleasure but now, because of maturity (developmental changes), are no longer age appropriate and should cause more pain than pleasure. Each age has its own aims and own sources of pleasures, but as one goes to the next stage of development, pursuit of these earlier goals results in more pain than pleasure. For example the auto-erotic pleasure of thumb sucking and masturbation which were age appropriate during the first and fourth and fifth years of life respectively, have to be abandoned through generation of pain, when indulged in as an adult, for, as one matures more complex and challenging aims as courting a woman and having proper genital satisfaction with her becomes more age appropriate outlet. However, these more mature and difficult aims can be abandoned in favor of regressive auto-erotic satisfaction if the negative emotions - of pain and fear of pain - attached to them are blocked out with narcotics and/or anti-anxiety agents.
For example discharge of sexual tensions through oral, anal and other pregenital mechanisms is a shorter route to procuring sexual pleasures than going the whole nine yards of searching for a woman, falling in love with her, and having consensual genital sex only after proving oneself as worthy of her love. It is easier to take cocaine and indulge in sexual fantasies that were once the province of masturbation than actually woo a woman and bring all aspects of one's psyche in harmony with her to enjoy complete union with her.
Similarly a beautiful girl who at the age of 3 enjoyed exhibiting her naked body, and the behavior was perfectly successful with her parents, and other grown-ups, and brought lot of release of sexual tension and release of dopamine then, she can no longer do so once she grows up. If she wants to indulge in erotic pleasure of showing her body, she has to sublimate the original instinct of exhibitionism by developing some further skills in that direction like ballet dancing or fashion show modeling or designing clothes for others and enjoying the exhibitionism by proxy. However, such a girl can take a short cut. She can take drugs like Oxycontin or Vicodin along with anti-anxiety agents like Xanax, and by blocking the memory of the pain and fear associated with exhibiting herself blatantly meted out, or dangled as a possibility, for indulging in it during the latency period and puberty - can now go to strip joints and indulge in showing off her nude body again without much art.
The lure of drugs and other addictive behaviors appears to be motivated by a desire to indulge in one's childhood fantasies and other autoerotic shortcuts to pleasure by silencing the objecting conscience which demands that we find satisfaction in real world and with other people. The strife of the real world and the pain associated with it makes one withdraw and create a mini world where all those grand fantasies of success are acted out in a childlike manner with age inappropriate objects with the aid of drugs.
For example a patient of mine said that once he was a very successful fellow, having a restaurant in partnership with somebody else. "I was busy in it from 6 in the morning till midnight. There was so much excitement, pleasure and give and take in our little enclave. Then my wife left me for not paying her enough attention and caring more for the restaurant than her. I fell apart and started doing drugs. My partner kicked me out of the business after buying my share for a song. Now I have a new world, which is built around finding drugs. Instead of hobnobbing with my restaurant customers now I hobnob with my drug buddies. Before my partner and I would cheat each other a few bucks here and there. Now my drug buddies and I cheat each other on who owes how much drug to whom. In the past I would sometimes be magnanimous with my customers in the restaurant giving them free deserts. In the drug house we can be ten times more generous but also extremely cruel. We do not hesitate to cut someone's hand if that hand is suspected of stealing one's last fix. Everything is taken to extreme when one is on drugs. Let me tell you, living for procuring drugs is a way of life too, full of dangers and frustrations granted, but when you are in it it becomes more important than anything else, your children, your wife, even the opportunity to become the President of the United States."

Friday, April 8, 2011

The psychology of hoarding, cluttering and the fantasy of returning to the womb

The phenomena of hoarding, which recently has become such a darling of media because of their discovery that humans are fascinated and repelled at the same time by coprophilic mess, lends itself to easy psychoanalytic interpretation.

It is another manifestation of obsessional neurosis.

That is nothing new you want to tell me. Any second year psychiatric resident can flip through his  his DSM IV [The Diagnostic and Statistical Manual of APA] and take me to the exact spot where hoarding is given as another symptom of Obsessive Compulsive Disorder (OCD).
But the issue is not so much as to which diagnostic category hoarding should be officially lumped with but as to why people hoard in the first place. Why the thought of separation from his piles of relics from the past provokes such a dreadful panic in the afflicted?
And here we find that our strutting experts who spent years and years composing the DSMs are as much in the dark as the laity.
Perhaps worse off than the non-experts who by naming the TV show that gives us a voyeur's perspective into this phenomena as "Buried alive" make us wonder whether hidden in that laconic phrase is not the essence of this strange illness.
For hoarding, which all of us suffer from in varying degrees, in its extreme form is nothing short of burying oneself alive in the safety of one's home.
The hoarder does turn his house into a tomb out of which he rarely comes out. He wants to deal with the world from the safety of his own home, on his terms and not other people's. For one is king in one's own castle. 
Now we know that obsessional neurotics are forever competing with others. They have to take measure of every person they come across and come out a winner against them. If they cannot win outright they try to get even through stubbornness and refusing to go along with other people's agenda. The more defeats they suffer they more obstinate they become.
Refusing to go along with other people (world's) agenda they increasingly turns into withdrawing themselves from the common goals of society, taking up esoteric and eccentric hobbies. In these solitary pursuits the person continues to battle with his enemies [the world]. But now done in displacement and symbolic fashion which makes it difficult to recognize that in these behaviors there is intent to harm one's [original] enemies. 
Instead of going face to face with the people he has an ax to grind with, the obsessional neurotic now starts collecting the objects that in his unconscious he can somehow connect with his enemies. He holds on to these objects with as much tenacity as to the memory of the original humiliation that embittered him towards the world. It is nursing of the past humiliations to get even one day which lies at the heart of hoarding. 
Hoarder to use a somewhat ridiculous analogy is the opposite of a Christian. A hoarder cannot forgive and forget his past slights. He nurses them by holding on to objects that he can connect with his enemies, even if it requires great leaps of displacement in his unconscious. Also by holding on to these objects he not only keeps the memory of humiliation green, but he hopes to understand the functioning of his enemies as well. He hopes to learn from those objects things about the enemies, that will make his revenge successful when the day of confrontation finally arrives. This explains as to why hoarders are especially inclined to not discard newspapers and magazines. There is so much valuable information about the world in these publications which one wants to master before discarding it, and all in order to get even with the world. He is especially fascinated by articles on health and prolongation of life. By mastering those articles he hopes to outlive everyone else and emerge a winner at least in this respect.
You may be wondering if this kind of revengeful thinking has a parallel in some other human behavior which may bolster my contention. I find such a parallel in the logic of Voodoo magic. Practitioners of voodoo get even with their enemies by making their effigies (voodoo dolls) and  sticking needles where they think the enemies vital organs reside. The voodoo logic is that by sticking the pin in those spots the enemy's vital organs are getting diseased. The hoarder also hopes to harm his enemies through such mumbo jumbo means and hence wants to collect all kinds of things which he hopes to use in some remote future.
Another parallel that springs to mind is the behavior of the pharaohs of Egypt who on their last journey [death] would take their important possessions into the pyramid (tomb) to continue their earthly struggles into the afterlife. In ancient China the emperors would take armies of terra cotta soldiers to their grave no doubt to continue waging wars in heaven where they expected their deceased former enemies to be now residing.
While it is the pile of junk in the hoarders house that we want to gawk at when the TV show starts, the primary illness is not so much a gluttony for material objects on part of the hoarders, but a pathological intensification of the womb fantasy.
What is womb fantasy?
Before I explain that let me tell you a little about a phobia that quite a few people possess. It is the fear of being buried alive by mistake. Many of these phobic folks shudder at the thought of entering old buildings, dilapidated mansions, ruins, museums, churches, and funeral homes. These old statuesque structures represent the mother to them, and entering them symbolizes return to mother's womb. And the phobic reaction is generated to prevent the overwhelming desire to reunite with the mother. These phobic folks sometimes dream of being trapped inside a coffin, a nightmare from which they wake up in cold sweat.
What is common factor linking the hoarders and those who dream of being buried alive?
It is a wish to be dead to a painful world but yet not giving up on dear life altogether. It is fulfillment of the wish to retire from the strife ridden world but not to the point of becoming totally dead.
What is the normal prototype of this wish to be dead and yet alive?
It lies in our daily ritual of sleep. Every night we try to shut out all the worldly disturbances, create a womb like ambiance of warmth and security, and then fall asleep. Babies who are still not far from their womb existence, even regularly adopt the fetal position.
Now this withdrawal from the world and the wish to return to the womb, where there was no danger, and life's every need was taken care of without effort, may become pathologically intensified in some.
Is hoarding another variation of this wish to return to the womb, carried from sleep to the waking state?
The only case of severe hoarding that I came across in my practice suffered from incredibly severe agoraphobia. She did treat her home as a sanctuary from a dangerous and frightening world.
And why did she find the world dangerous?
Behind the fear of the world was her own hostility towards men. Her father was abusive towards her throughout her childhood and adolescence. To get even with him she had eloped with a Mexican at age of 17. This was in the 1940's, when for a WASP debutante to do something like that was highly frowned upon. She did that to spite her father who, along with his wife, patient's step-mother - her mother had died when she was just one - had used her from earliest childhood to do the work more befitting a maid, to run his restaurant.
Since it was a marriage of revenge, it lasted for less than an year. But not before creating a permanent wedge between the father and daughter and the bitterness persisted to his deathbed. He not only disowned her but made sure to not leave a penny for her in his will, despite her being his only child.
Now her revenge against her dead father had to find outlet against all other men. Her second marriage which was with somebody from her own class, soon turned into turning her husband into a father substitute and making his life miserable. But not without giving him plenty of love and happiness as well. But the discharge of revenge against the father became the primary purpose of the marriage.
She had four sons, and had highly ambivalent relationship with all of them. It was unclear if her love for them or her hate for them was the stronger emotion. One of her son became a homosexual out of fear of women and their dominant ways, anticipating his mother's image and behavior in them. Another turned into a severe alcoholic. The third turned into a great musician with a voice as good as the greatest tenor of the world. Perhaps his resounding voice was a magnified shouting for help from a mother who he feared to the core of his being. Only one son turned out average, having tuned her out from early childhood.
Once the children grew up, her rage towards men ran out of outlets. Only her husband was left as the whipping boy. But this father substitute made his escape too by hardly spending time at home, choosing to be always on the golf course.
With no men left in her life she had only memories of them to get even with.
And thus begun the hoarding in earnest. Prior to that she had difficulties in throwing away trivia, but now the obsession reached ridiculous heights.
She resorted to not throwing anything that could even vaguely be connected with the past. And analysis repeatedly revealed that holding on to these useless objects was to find a way to reverse the original humiliations and defeat and to come out a winner this time.
Herein lies the psychology of hoarding. All the hoarded material are somehow connected with a past which cannot be let go. Obsessional neurotics have memory of an elephant. In autistic disorders, which are extreme form of OCD, the memory can be astounding. And behind the phenomenal memory of autism lies the impulse to harm the person who put a block to their first steps to discharge aggression upon the world [their first caretaker] and forced that aggresion to turn against one's own self. The autistic person, carrying the genes common to OCD and autism, does not want to let go off the slight, even from the tenderest age, when his immature nervous system and psychic development does not allow him to develop obsessive symptoms, and thus develops the bizarre autistic defenses. And autistic patients, no less than obsessives, want to come back another day and turn tables upon the enemy. And in order for the revenge to be successful try to remember the terrain where the original defeat occurred, and everything that subsequently can be connected with that terrain, to a phenomenal extent. Interestingly the person of the original enemy is always forgotten. Instead everything connected with that person is memorized and soon this starts getting displaced on to ever new things till what is committed to memory is so remote from the person towards whom it was originally directed that one is hard pressed to understand as to why the autistic person commits to memory such trivia. For example an autistic patient of mine remembers the streets and city where someone lives and their birthday after hearing it once. And he can recall these details on hundreds of people that he considers his friend - in his unconscious his enemies. But when he recalls, he often makes subtle mistakes. For example he knows that I live in Bloomfield and that I was born in 1951. On recalling these factoids he will usually declare that I live in West Bloomfield and I was born in 1950. Making this slightest error is his way of taking revenge on me. Knowing the trivia about me is honoring me while making the error in its recall is cutting me down and saying, in his autistic way, that after all you are not so high and mighty as to be remembered with perfection.
Hoarding is another form of remembering. Objects which are reminder of people with whom one has to take revenge are now accumulated. They are reminder of those people with whom one has to get even with. The hoarder cannot discard the object lest he dilute the resolve to avenge. It is similar to putting knots in one's handkerchief to remind one that something has to be done yet. I will not be surprised if the psychology behind people's fascination with trivia and trivial pursuit is identical with those who hoard objects instead of mental facts.
We know how people with OCD love to make lists and then scratch off one item after another. As if with each scratch they have triumphed [wiped out an enemy]. With hoarders each item that is held back and not discarded is like a knot. Unless the enemy associated with that knot is vanquished it is impossible for the person to throw the item away.
With time the fight against the wider world keeps receding into ever smaller circle. The ambition shrinks from the desire to conquer the entire world, like Alexander the Great, to just one's immediate circle. The original wish for revenge had originated within the family circle anyway. In our patient's case, she had ceased to interact with anybody but her husband. And her revenge on him had narrowed to making it impossible for him to even move in his own house. Hoarding had found a new way of seeking revenge. The clutter was used as an obstruction to her husband's path. The revenge had shrunk from destroying the enemy to putting obstructions in his path. And herein lies the psychology of clutter.
Clutter is a way of getting even with other people by misplacing things and putting them out of order to obstruct them from reaching their goal. Currently I am treating a hoarder, or more specifically a clutterer, who has turned her house into a maze of obstructions for her children. Yet, interestingly she made her living by cleaning houses, and would beg me to find her hoarders whose house she could go to and declutter. The impulse to clutter in her was finding expression in her own house and the reaction formation to it was being given outlet in houses of others. I will not be surprised if this neurotic mechanism underlies behind the fascination of many otherwise quite intelligent people to take up the lowly profession of janitor.
Along with choosing ever trivial enemy to find revenge, and in ever more trivial ways, there is also withdrawal into ever more smaller space, with the person restricting himself to not emerge out of his own house, sometime his or her own basement, which of course once again symbolizes the mother's womb. The only place where the person hopes to find complete peace without dying.

Monday, April 4, 2011

Incestual dream causing severe anxiety of falling from a height

An Irish-American married man in his late twenties reported:
"Last night while sleeping on the couch - instead of in our bedroom, because my wife and I are not getting along - I dreamt the following, and I might as well tell you right away that the dream occurred because I was lying stiff and uncomfortable in one position on my back on that narrow couch all night long. Well here is what I can recall of the dream.

I am on top of my house. The roof is steeper and taller than my real house. I am at the very top. I am scared as hell of falling and therefore stiff as a board, clasping, clinging, almost clawing with my feet and toes, afraid to even breath. I see a shredded cable and I want to reach out to it to prevent myself from falling. But I am afraid that its knife like serrated edges will cut my hands. I must have lay there like that dreaming for half an hour. One time I tried to reassure myself that it is a dream. Finally I wake up with anxiety and my feet and toes were like on fire, for I had kept my toes in that clawed position just like in the dream.
It took me some courage to look at the clock across the room, it was 3:35."

The patient attributed the dream's instigation to the fear of losing his house to foreclosure. "We are having a rough time. My wife has lost her job. I am not getting enough work. May be I am holding on to the house to prevent foreclosure - not letting it go away from me by lying on top of it."
We both agreed that while this wish contributed to the formation of the dream, it could not be the main one. There had to be some deeper wish that provided the energy for such an intense dream. The patient reported that the dread felt in the dream was out of this world to be explained by the fear of impending foreclosure.
The patient then brought in another day residue - a fight between him and his wife the night before. His wife had threatened to leave if he did not change his ways and made more money.
"We are not getting along. We have not slept together for couple of months. One time when we did, it was more for the sake of doing it than either of us being really in to it."
Patient could come up with no other associations to other elements of the dream so I asked him
associations to the report he made after coming out of the dream, that the time was 3:35.
"Because 33 is a homo number. I don't know whether I heard this joke in the college or made it up myself but the number 33 is number for gays. I saw the clock at 3:35, but I must have got up couple of minutes earlier, I think at 3:33. So I must have woken up exactly when I was turning gay in my dream."
"And why number 33 is for gays?"
"Because two 3s, one behind the other look like one guy is sticking his dick in the others."
Since the patient had risen out of the dream out of anxiety, and the number 33 and its allusion to homosexuality emerged in his mind, it was natural for me to look for other elements of homosexuality in the dream, along with fear of castration which always accompanies homosexuality and which would explain the massive anxiety, so I asked him, "Why the shredded cable? "
"Yes it is shredded with serrated edges which are like knives and I am afraid to hold on to it lest they cut my hand."
I made the following construction: "That is an unmistakable allusion to castration. Climbing on the top of the house could be depiction of homosexuality, the house being one of the 3 and you clinging on to it the other 3. The castration that may follow from indulging in homosexuality is being depicted by the shredded cable and the element of your falling down from the house is representation of your falling down from your high standards."
The patient rejected the construction."I don't think so. I have no interest in homosexuality. I cannot stand the thought. I feel no attraction towards men."
"We are not talking about overt homosexuality. Nor do I think you have any interest in the actual homosexual act. Nevertheless all humans beings are highly bisexual. The homosexual impulse which you are dreading in the dream may have arisen from a very ancient period of your life, and it perhaps came to a stop at that stage out of fear of castration, allowing your heterosexuality to flourish. But like in every other human being it remains in the background in the unconscious. "
"If there is such an ancient homosexuality in me, it got to be very ancient, for I have no conscious desire to go homo. And I am glad it is in the unconscious."
Based upon certain other things that he started talking about his wife's family and his hostility towards her parents the following construction was made:
"Do you think the house is your mother. And it is the thought of incest that is being threatened by castration (shredded cable)?"
Patient rejected that construction immediately. And it was to be expected. For sexual thoughts towards the mother are subjected to the greatest repression and its uncovering is
never accepted immediately.
But the rejection was immediately followed by following confession.
At a very young age he discovered some pornographic VHS tapes and how it changed his life,
because watching it provoked great fear of being discovered and by his mother. "I would come home at 2.30 from school which would leave about 45 minutes to watch those tapes, because my mother would return from work at 3.15. So I would watch the tapes furtively."
Now looking at pornography at that tender age invariably provokes incestuous fantasies. For the child knows no other objects but his family for the libido to flow towards. So despite his immediate rejection that the dream was representing incestuous thoughts he went on to confirm the construction by bringing the memory of the pornography and its connection with his mother.
Then the patient suddenly recalled another piece of dream which till then was in repression and the correct interpretation had now given it a passage to consciousness. "while I was lying stiff on that roof lying next to me was a brown pair of pants with a patch of green.
For the world why would I think of that pant. It got thrown away years ago, all tattered, for I wore it all the time."
"How is the pant connected with your mother?"
"That patch of green on those brown pants symbolize my mother. She was as Irish as they come. She was a Mulligan before she took my father's name. The green symbolizes her Irish heritage. I know too why the roof is so much steeper and higher than the house in which we live, because
it stands for my mother who is so much higher and steeper than my wife.'
So the dream was depicting the return of his libido from his wife to his mother, because of the tension between the two. But trying to climb such a steep target - one's mother - was fraught with danger of castration and falling from his high standards.
The danger of castration was displaced on to fear of his hands getting cut by the serrated edges of the cable. Cutting of the hand is especially preferred for depiction of castration because it is with hand that one masturbates to discharge the sexual tension and incestuous fantasies. Since
the castration was expected from the father, to whom the mother belongs, there was also an attempt to compensate for this high transgression (treason): submission of oneself to the father to appease him. It was the negative Oedipus Complex: taking the passive (feminine) role with the father. It was this homosexual impulse, trying to find expression in the dream alongside the positive oedipal striving, that had made him observe so intently the time of 3:35, which he ingenuously changed it to 333, the time he presumed he had woken up, because of its better connection with homosexuality, the link being provided by the gay joke.
And so the panic which woke him was as much over his sexual impulses getting directed towards his father and homosexuality as towards the mother. His great stiffness was a defense against emergence of incestuous thoughts - see my blog on fibromyalgia - and a defiance of the fear of castration - a stiff body being equivalent to an erect penis. We can recall here Freud's essay on how seeing Medusa's head - reality of castration - turns a man into stone. But this conjecture could not be confirmed for we ran out of time.