Wednesday, May 11, 2011

Nervous stomach, bruxism, OCD, death wishes and the mechanism of action of the SSRIs

A man in his late twenties who for years suffered from "nervous stomach" and who gnashed his teeth in sleep (bruxism), and who frequently got in to trouble with the law for petty transgressions, declared that the reason he is addicted to narcotic pills is because they control his anxiety.
For his narcotic dependency he was put on Suboxone which stopped his abuse of Hydrocodone and Oxycodone. In psychotherapy, it emerged that his penchant for getting into trouble with the law was a form of self-punishment for harboring unconscious evil thoughts towards his father. These two interventions: substitution of Suboxone (Bupronorphine) for street narcotics, and a realization that his ambivalence towards his father, for he loved his father very much too, was emerging against the local police, straightened his life considerably.
Once he squared up with the probation department and the court, and started showing up at his work reliably, he wanted some medication to straighten out his other problems - the teeth-grinding and the stomach churning. He bemoaned that the former kept him awake at night with sore jaws and the latter had him in knots during the day.
He was put on Zoloft (Sertraline). A SSRI (selective serotonin reuptake inhibitor) was chosen because he attributed his anxiety to excessive worrying. As a psychoanalyst I had to correct him that it is not worrying that causes anxiety but anxiety that causes the person to find one reason or another to worry about. The affect of anxiety makes the person restlessly scan for dangers in the environment and if there is no real danger he is left with no choice but to make mountains out of a molehills. Anxiety can pick up the most trivial danger to mull over.
The patient admitted that he is always taking precautions to avert lurking dangers. Though, he admitted, it is ludicrous to even label them as dangers.
For example he worries almost every day as to who will give him ride to work - he had lost his license to drunk driving - even though he knows his girlfriend faithfully will. Or he'll worry that she will be late, which she never is. Or he will go into deep consternation over having wasted his money on paying rent all these years instead of buying a house which would have built equity, even though he knows that his brother and his friends had lost their houses to foreclosure due to housing-bubble collapse and he had done better by renting.
The Zoloft dramatically eased his queasy stomach, teeth grinding, and petty worrying.
But what emerged in its place were classic compulsive rituals. He began checking and rechecking the stove and the press iron to make sure they had not been left on by mistake which would burn down his apartment.
The anxious worrying was replaced by obsessive daydreaming. He would play scenarios in his mind of his house catching on fire due to a careless mistake of his causing his pet cat to get roasted.
Couple of other interesting compulsions which I made a note of were his great discomfort at the slightest hint of growth of his facial hair and the immediate need to shave and getting gripped with a compulsion to clean his house. He called it his "cleaning mania" and it came in waves. First would be the impulse to mess up things which most of the time he could successfully avoid giving in to. After the urge to mess would come the wave to clean.
The only explanation he could give for his fear that his house will burn down was that his uncle and his wife had actually burnt down their house to ashes due to carelessness. They had then moved to his grandparents - uncle's father's house - and had burnt that one too, a few months later.
Patient claimed that his fear of his burning down the apartment was justified because it had happened to his family twice.
This explanation did not sound sufficient enough to produce the whole range of his obsessive symptoms. People witness fires destroying houses all the time yet it does not lead to their getting obsessively preoccupied with their own house burning down.
Also it fails to explain the roots of his bruxism, stomach pangs, anxious worrying that some harm will come from his surroundings.
The primary pathology in this young man was a legacy of an excessively strong Oedipal struggle - an early and strong flowering of love impulses directed towards the mother accompanied by equally strong destructive impulses directed towards the father. Because of his great love for his father, the destructive impulses had gotten prematurely suppressed and could never emerge as such in the consciousness. Willy-nilly they had found an outlet but not against his father but against the law enforcement folks of his city. His father was General Manager of an auto plant and his authoritative persona, with which the boy had gripe, had got displaced on to the authority of his city's police force.
But not all his aggression towards his father had found this unadaptive outlet. Some of it had found expression in ego-syntonic and socially rewarding endeavors of beating the competition. He became a star athlete. And once when he was shipped off to Tennessee to live with his relatives to keep him out of the hair of the city's police department, he had gotten so good at baseball that his coach thought he would one day be a Major League player. Away from his father he could dare outshine him, at least on the baseball diamond. But something soured this healthy outlet for his aggression, and he started getting in to trouble in Tennessee too and had to return to Michigan. Back in his father's house where he had to abide by the latter's rules, he gave up baseball and was back on the streets challenging the police and getting arrested for speeding and doing drugs.
The analysis of his bruxism showed it to be the same aggressive streak emerging in sleep. It was an attempt to chew and spit out his father/authorities. The churning of the stomach was continuation of the oral aggression lower down the GI tract.
How did the Zoloft (SSRI) took away these two somatic symptoms of anxiety? Here one has to get speculative because we know so little about how the neurochemicals modulate our behavior.
One thing for certain is that the SSRI ended the somatic anxiety of bruxism and stomach- churning and replaced it with checking and rechecking rituals, the cleaning mania, and daydreams of destructive scenarios.
So the SSRI had shifted the mode of expression of his aggression - from the soma to the psyche.
Does this tell us something about how SSRIs work?
Perhaps they work by taking away the aggression from destroying one's own body - in this case through unnecessary grinding of the teeth and excessive acid secretion of the stomach - to the mental sphere and directing upon others. Instead of moving the muscles of the jaw (bruxism) and the involuntary muscles of the stomach which was destroying his own body, now the movement had shifted to producing obsessive thoughts of burning the house down and roasting the cat and in the rituals of checking and rechecking and endlessly cleaning the house to prevent others from coming to harm.
Along with the disappearance of bruxism and the overactivity of the stomach the SSRI also improved his affective status. He was no longer as anxious, worrisome and inhibited. So with the shift of the problem - discharge of aggression from somatic to the psychic sphere - the affects lessened too.
This throws light upon the obscure problem of the generation of affects.
Affects appear to be internal sensations/perceptions generated in the psychic sphere when there is anticipation of some physical harm coming to the body. Originally the affect was a psychic reaction to some actual physical harm that had occurred to the organism - either phylogenetically or ontogenetically. Later the affect began to be generated even before the harm occurs just at the anticipation of harm. As if the organism senses something is about to happen to the body, generates the appropriate affect to deal with it which guides the organism to take appropriate motor action to get out of harms way and to start releasing stress hormones/chemicals/antidbodies in case actual injury occurs.
So are SSRI the ultimate answer to dealing with somatic anxiety and affects?
Not really.
For the man reported that the cure of his somatic problems and lessening of anxiety came with a price. He stopped feeling things deeply, his affective response to people and situation became flat and he felt like he was not quite in touch with the world. So one cannot do away with affects without taking away the feeling of being alive and human. As if the right combination and strength of affects gives us the sensation of being ourselves and as if each person has his own unique repertoire of affects which give him his individuality.
And there was another disadvantage. While the anxiety and pain in the jaw and stomach had him hobbled in his pre-SSRI days, the appearance of checking and rechecking, the cleaning mania, and the daydreaming wasted his time no less. So in some sense all the antidepressant did was to replace one set of problems with another.
Even the somatic problem of stomach churning and teeth gnashing were not just wiped away. Some very deep somatic problems emerged in their place. The patient began gaining weight and began sleeping 10 to 12 hours a day. Granted they were not very painful but perhaps in the long run as destructive. It was surprising that he did not develop loss of libido, which is a frequent somatic problem with SSRIs.




7 comments:

  1. Most non- infectious diseases involve the disruption of complex feedback loops and processes. The "science" of medicine seems not to focus on the entire feedback control pathway but focuses instead on one small aspect of the manifestation of the disease. This is almost analogous to " treating the symptoms and not the disease itself". Psychiatric diagnosis and treatment seem to follow the same trend with the additional complexities of buried and superficial thought and perception processes. I say that if you can diagram the entire feedback and subfeedback loop of each condition, the better off we are in understanding the non understanding and understanding the entire picture...

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  2. In psychiatry, there is the external world consisting of stimuli and inputs to the internal world of the brain and mind consisting of chemical and electrical processes with interactions and reactions between memory and neurons, much if all this being chemically mediated through complex feedback loops. I see a common thread in your attempts to redefine/ define the disease process by involving the " external" aspects of the "condition" rather than focus narrowly on the disrupted chemical pathways.

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  3. Jay,
    What you write is a completely unique way of conceptualizing medical illnesses. I have never come across anybody who has tried to look at diseases in this fashion. But then my reading is limited and mostly confined to psychoanalytic and psychiatric literature.
    If you are the first one to suggest that illnesses should be looked upon as disruption of multiple feedback control systems I think you have hit upon something unique and should develop and publish this concept. I would be glad to supply psychiatric examples that completely validate your contention.
    If we take this patient of mine his illnesses can be tackled at various feedback loops. At least his churning stomach and bruxism can be looked upon as disruption of the feedback mechanisms at various levels.
    The gastroenterologist will conceptualize the disruption at the level of proton pumps causing too much acid secretion and the feedback to stop this as defective. To stop the vagal over-activity he will give anticholinergics and proton pump inhibitors. If he wants to incorporate the infection loop he will try to break the feedback of H Pylori in to the equation of keeping the ulcers active.
    The biological psychiatrist will take up a higher level feedback and will try to correct the over-activity of the proton pumps by giving benzodiazepine like Librium. Activation of gaba-aminergic system will inhibit the vagal over-activity and consequently the acid secretion and the muscle churning.
    There are even more complex circuits at the level of the brain. Serotonin neurotransmission enhancers (SSRI) also stop the over-activity of the stomach muscles and proton pumps on being given for few weeks as happened in my patient's case. How does serotonin does that we don't know. It does calm the organism down and the discharge of aggression through vagal/parasympathetic discharge in visceral system/stomach/ jaws/teeth becomes less. Perhaps when we were hurt as a child, and wanted to react with aggression and secretion of stress hormones/steroids that increased stomach acid secretion, the soothing presence of parents/caretakers lessened the hurt, and made us think instead of wildly flailing at others, and perhaps it did it by activation of serotonergic pathways.
    In my patients case the SSRI shifted the aggressive outlet from stomach and the jaws to thinking about harm coming to others through his inadvertent burning down his apartment or by not cleaning it enough.
    There must be even higher feedback mechanism operating at the cognitive/cortical level, which when adequately dealt with by cognitive-behavioral approaches, or better still with psychoanalysis, may decrease the stomach acid secretion and grinding of teeth with purely psychological means.
    As for your statement that in psychoanalysis we redefine disease process by involving the external aspects of the condition and get caught with describing buried and superficial thought and perception processes instead of focusing narrowly on the disrupted chemical pathways and drawing blue prints of each of these pathways all I will say is that those who are trying to reduce the complexity of the mind to simple chemical disruptions - the majority of psychiatrists - they are reducing their whole business to no more than giving drugs which work rather poorly in the long run in correcting psychological problems. As for giving comprehensive diagrams of psychological feedback loops they are so complex and endless that even a mathematically gifted person like you will go crazy trying to do so

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  4. People think bruxism is just a bad habit, but actually it could be worse. If you think you have it, better consult your dentist and see what can be done to remedy that serious dental problem.

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  5. Doris,
    Thanks for bringing up the issue of the crippling long term effects of bruxism. It not just ruins the teeth, causes TMJ problems, and keeps the person exhausted from poor sleep.
    The patient should certainly consult a dentist. However, dealing with the issue on the psychological sphere, another feedback control pathway as Jayanth would put it, cannot harm the patient.

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