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.

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