Saturday, November 24, 2012

Recurrent dream of being left behind by one's siblings and highschool classmates

A woman in her mid-fifties, mother of three children and couple of grandchildren, who suffers from anxiety and depression and smokes to control that anxiety, asked the meaning of a recurrent dream, which she has had throughout her life, but recently, after she was hospitalized for COPD and pneumonia, was having it with greater frequency.

The dream is about myself and my sisters. As you know I have two sisters.

I am being left behind by my sisters. This is the basic theme, with minor variations. The one I saw couple of nights ago, we were on vacation in Las Vegas, in a Mall.  The two were together, ahead of me, while I was left behind. I never see them but I knew they are in the Mall. I go from one floor to the next but never reach them. Everything looked unfamiliar. I just keep looking for them in a daze.  

"Are your sisters older than you, and you are attempting to catch up to them to dissolve the age gap? You know how small age disadvantage with siblings is so acutely felt when one is young."

"I am the oldest. So that could not be the explanation.Though we are all just one year apart from the next. So we are more or less of the same age."

"Why the dream takes place in Las Vegas?"

"Because we take vacations together, and not too long back we took one in Las Vegas. The last one was in Florida.  Both my sisters live in California. [Las Vegas is in between California and Florida though much closer to the former so the dream may have chosen a venue closer to the two sisters than to me]. But though both live in California, they are not closer to each other than to me.  I am not the one who felt left out in Florida. They were the ones fighting while I got along with both. In Vegas too I was never left behind. We sometimes would go our own way to different sections of the casinos but we never were like lost to each other.

"Now I remember that being left behind also occurs in another set of dreams.  In these dreams my sisters are replaced by my classmates from high school.  The theme is the same, of being left behind. I am trying to catch up with my friends who have gone ahead and are already in class. I am like excluded which is odd for I never had problems fitting in with my peers in those days. The dream scene usually is of my trying to open the locker in the school corridor where my books are without which I cannot go to the class. But I cannot recall the combination to the locker. I try hard and almost get every number right but while punching the last one or two, some error occurs. There is nobody around to help either.  Not even the girl who shared the locker with me. Even if I had got the combination right, and the books out, it would not made a difference for I would not have found the classroom." 

After she drifted in to some other issues and I had some time to think over the dream, I conjectured that it was perhaps a punishment dream.  "Could it be possible that your getting left behind by your sisters and classmates is punishment for your belief that you have done them some wrong. Perhaps it is propitiation for some guilt arising from your unconscious hostile intentions towards them?"

"Could be. But why would I dream of getting punished. I have not done them or anybody else any wrong."

"The need for punishment in humans has very little to do with having actually done something wrong. In fact the less harm one does to others more is the psychological impulse to harm oneself. It is not carrying through the intention to harm others that creates guilt that seeks punishment. The guilt turns the intention to harm others in to harming oneself. It is a vicious cycle. It sounds paradoxical but true. One would think that one would feel more guilty if one actually harmed others. But people who actually harm others do not feel as guilty as those who suppress it. For the intention to harm others does not find a discharge and sits inside the psyche requiring creation of more guilt to keep it under control. "

"I don't understand what your are saying. But I don't feel any guilt in me."

"The sense of guilt is generally unconscious. The ego blocks its entry in to consciousness. In our conscious mind we just feel a sense of uneasiness and impulse to create a situation which is harmful for our self interest.  Even this self-harm is done in such subtle ways that they appear to be act of fate or bad luck rather than cleverly manipulated by oneself. We do know as a child you had quite a bit of rage against your parents for their constant fighting. Perhaps that rage to prevent it from being acted out has been been transformed into sense of guilt."

"Yes, that is true. I was angry at my parents, and I left home at age of 16 to escape their constant fighting. I don't remember having any resentment towards my sister. I do recall feeling guilty for leaving them behind in that stressful house and making my escape. I was their protectoress, and I abandoned that role and left to get married. So if anything I was the one who left them, but in the dream it is just the reverse. It is they who are leaving me. I don't think your interpretation that the dream is about punishing myself for having evil thought holds good."

"You were the first born, and your two sisters came right after you, one year apart. You must have resented their appearance. There may have been wishes towards them when they were first born to disappear. Later there may have been fear of their disappearing and thoughts of deserving punishment for having entertained such thoughts. So the dream may be showing the fulfillment of this wish for them to disappear and then the fear that you will be all alone, for you love them too and enjoy their company, is making you search for them and undo the wish."

"I don't think the dream is about punishment.  Or at least it is not the whole explanation. For I wake up not so much with guilt as with anger for their having left me behind."

So we were at an impasse.

The patient then came up with the idea that the dream of being left behind, though, has periodically recurred, has been emerging with far greater frequency since the doctor at the hospital scared her by saying if you don't stop smoking you are going to die. 'He was very mean and kept shouting at me, you are going to die, you are going to die."

In one stroke the meaning of the dream became clear. Being left behind and never being able to find her sisters was nothing but the fulfillment of the wish that it is my sisters who will die before me, and in fact I will never meet the same fate and will never be able to reach the end of my journey (death). The unfamiliarity of that Las Vegas Mall was a reversal of the great familiarity of this world. "The world is still so unfamiliar and new to me and still so much in need of exploration that I cannot die yet" was the rationale behind it. "My sisters can die, but I still have a lot to discover and I therefore will keep on living."

The patient readily agreed with the interpretation and added, " I just came back from Florida where we sisters had got together for our annual vacation. And the two were fighting with each other. No doubt a continuation of the bickering that existed in the house when we were growing. And one of them looked sick and yes I felt sorry for her and did worry about her dying.

"Thought of death has always played a very strong role in my psyche. My first born died when he was 18 days old. He was premature. That left a deep scar in my mind. Even now I dread something terrible happening to the ones close to me. I think of macabre things happening to my children and grandchildren. I hate those thoughts. But they are the core of my illness."

"Yes. The thought of their death is just a displacement of the thought of your own death, which you want to avert by thinking of somebody else's death, just like fear of your own death implanted by the doctor who scared you, you were working it out of your system  by thinking of the death of your sisters and your classmates. They emerged in your dreams for dreams are nothing but your everyday thoughts couched in the language of dreams."

"Interesting you say that. I must have a grudge against my classmates too, for I had to leave school because of pregnancy in final year and I could not graduate with them. Instead I got my diploma through GED. I felt odd returning to the school once I had to leave for pregnancy. So I may be getting even with them by thinking that just like they left me behind and graduated earlier than me they can once again leave me behind and die earlier than myself. For when I wake out of the dream it is not feeling of guilt and feeling of being punished that fills my heart but an anger at those girls for having left me behind."

I wondered if the locker box was not symbolic of the coffin, and inability to find the right combination a struggle against the wish to die and be over with life.

Patient stated, "I never thought of that," which is like music to a psychoanalyst's ear, for it invariably means that the interpretation is correct. By these words the patient confirms yes, it is true, but it was in my unconscious, and consciously I never thought to it.

"Could it be possible that the classroom also stood for coffin or burial room and inability to find it was fulfillment of the wish to never find the final resting place?"

"Perhaps," the lady responded.

Monday, November 12, 2012

Self cutting behavior precipiated by Abilify and the psychology of self cutting

A woman in her mid forties, who suffers from extensive psychiatric problems, the core of which is her extremely high level of anxiety, reported that on being put on Abilify 10 mg., instead of getting better, began cutting herself.

She at once added that it is not a suicidal behavior, though everyone is viewing it that way, and repeatedly hospitalizing her when she goes to the ER to get the cuts stitched.  She had had four admissions in two months. After a little reflection she said that it could be suicidal behavior too, because at one point, in between the cuttings, she tried to hang herself.

On stopping the Abilify, the thoughts to cut herself went away.

When I stated to her that Abilify by itself could not have caused the behavior, and some other experiences in the past must have set the stage for Abilify to enable the self-destructiveness, she said that she was constantly hearing the warning that they blare at the end of drug commercials as to what the drug can do to you and Ability commercial tells you that it will make you suicidal.

"Maybe it was the commercial playing at the back of my mind impelling me to cut myself."

This conjecture was, of course, rejected by both of us. The commercial alone could not have had such a powerful effect, and the psychogenic roots of self-cutting had to be searched for elsewhere.

Patient then recalled that the self-cutting had began 10 years ago, and after a few years had gone away, only to reemerge on being placed on Abilify.

She could recall the very first time she cut herself.

"I was fighting with my husband and could not defend myself. So I broke a bottle and cut myself with it, and it felt so good. Cutting relieved myself of anger."

"Why did you not cut your husband instead?"

"I wanted to hurt him. But he was huge. In one move he would have strangled me. So I had no choice but to take the anger out on myself. I cannot describe the relief it gave me. After that anytime something would upset me very much I just knew how to end it. You know I have psoriasis. Whenever I get bad nerves I break out terrible. But cutting myself helped with the nerves. If I did not cut myself the psoriasis flared up even worse."

"Why would cutting yourself help with nerves?"

"If you cannot win them, join them. If I get really pissed off with someone, that person sits in my chest like a knot. The only way to get relief from that knot is to create a split in myself and see my body as somebody else's body and to cut it up. Once it becomes an alien then I can cut it and I feel no pain. Just tremendous relief. Though the next day its hurts."

"What do you mean you see your body as somebody else's?"

"I have to treat my body as a non-self before I can cut it. But before I turn it into non-self, I have to see myself as evil and full of hatred towards others that must be destroyed. In fact sometimes I do destroy my whole house. From one end to the other. The house symbolizes me. I am destroying myself for being evil. I even hit myself. I don't feel any pain while doing it. Just relief from anger. And when it is over calm. Though tired and sleepy. Only the next day I feel as if a truck has ran over me."

My construction that this beating herself up and getting a great release from it could be a form of sexual discharge, and the immense relief and calmness and falling asleep afterwards a form of orgasm, was rejected by the patient.

Another girl confirmed that what you are cutting in yourself is the person you hate but to whom you cannot do anything by stating the following: "When I get real mad I cut my wrist and that takes away the pain. It started with my parents. I was so angry at my father that I went to stab him with the pencil I was holding but at the last minute I stabbed it on my own self. It was a tremendous relief. After that whenever my parents made me mad, I would see myself stabbing them, but it would be my wrist that I would be cutting."

Sunday, November 4, 2012

Exhaustion following Panic Attack

A young Lithuanian immigrant, who came to the States when he was about 10, and who is now 27 years old, reported that after an intense Panic Attack, that lasted for 45 minutes, he went into a state of severe exhaustion that went on relentlessly for 8 days. After emerging out of his exhaustion he showed up for therapy session couple of days later and remarked that though he is out of the phase of severe exhaustion and somewhat energetic again some symptoms linger for example like there is no desire to talk to anybody. Then he expressed hope that in a few days he should be completely out of this funk.

The patient added, "The state of exhaustion was characterized by a feeling that it will never end. I tried everything mentally and physically to get my body going but it was of no use. In fact I could hardly feel my body. As if I did not exist. I missed school. I could not do homework. I slept for 13 to 14 hours a day but still felt exhausted on waking up. Physical work including even exercising, which, as you know, I am such an enthusiast of, could not motivate me. What do you think was happening to me?"

"Your system generated a massive depressive reaction to control your anxiety. When anxiety looks like it is completely out of control there is triggering of depression in some people to put an end to anxiety. The severe fear, which is what panic really is except that you don't know the cause of the fear, must have triggered an excessive secretion of neurochemicals, primarily acetylcholine,  that caused mental inhibitions on an entire range of functions, including  muscular activities, your thoughts and your emotions. This appears to be a mechanism that goes way back in to our phylogenetic past, perhaps as far back as when we were insects. Not just higher organisms but even the fish in the oceans go into a freeze when they are confronted by the predator face to face. If escape is not an option, for the killer is too close, then the last ditch effort is to play dead and hope that lack of any activity will make the predator mistake you to be part of the inorganic background. Perhaps the melancholic reaction in humans has its origin in this freezing behavior as a response to fear of death that got genetically implanted when animal organisms had not even emerged out of the oceans."

"Could it be a reaction to my stopping Zoloft ?" The patient had been put on Zoloft (Sertraline) sometime back for panic and depression. About 8 weeks before it had been stopped because of alarming weight gain.

"Yes, perhaps it is a reaction to the Zoloft being stopped. Zoloft had blocked out your panic attacks and was keeping your depression at bay. And then we stopped it. So perhaps the bottled up anxiety and depression returned with a vengeance. All these medications more or less work by suppressing some brain functions to allow others to work with less competitive interference. Antidepressants suppress emotions thus enabling a person to be not overwhelmed with emotions and once engage in the general concerns of the world. So when they are stopped these inhibitory emotions - anxiety and depression - may come back with renewed vigor."

Patient agreed with that and added, "Since I stopped the Zoloft I am waking up from sleep drenched in sweat. I do not feel any anxiety, but this kind of sweating must be a form of anxiety. For during the day, if things are rough, I get similar sweat attacks. At night when I am about to drift into REM sleep, I think the anxiety emerges to block me from doing so, perhaps because I must dream terrible things in my REM. I don't remember my dreams because I don't enter the REM state, which I believe must happen in order for the dreams to become recallable on waking. Anyway, the net result is that I am not getting enough REM sleep. I am always falling asleep during the day because at night I don't enter in to the REM phase and then my system tries to make up for that loss REM by attempting to do so in daylight. But here too the anxiety frustrates the attempt, and instead of falling asleep I break into a sweat."

Impressed by patient's metapsychological speculation, and feeling that he is in all likelihood right, I responded, "So that massive attack of panic was a breakthrough of the anxiety/fear. Your defense mechanisms failed to keep that anxiety muted, allowing only one component of it the sweating to emerge as actual behavior, and instead a full blown panic attack followed. But why did it happen? Is it because Zoloft was still exerting some lingering protection up to two months but then when its influence was completely lost a full blown panic attack became possible?"

"No," the patient disagreed. "Zoloft's discontinuation did not have that much of a role. The panic came after I did bad in an examination. The last couple of years have been nothing but my putting myself down. I constantly berate myself for not having done this or that in the past. I put tremendous pressure upon myself and I feel there is a tremendous pressure upon me from my family.  This must be a reaction to what I put my family through with my addiction. My family suffered greatly when I was abusing heroin. Now that I am on Suboxone, and not abusing drugs, and back to college, my family is happy. But I am able to do all these good things by constantly putting pressure upon myself and imagining that my family is really counting upon me. And how proud they will be if I do really well in the classes. After all that I have put them through they deserve that from me. And then when I nearly failed in the exam, I had the panic attack." At this point he broke down and started crying.
So the panic made its appearance when there was a failure of obsessive defenses. The metapsychological process in this young man must have gone through some such process: his aggressive/cruel tendencies, mostly arising from genetic predisposition, had first found expression against his family, whom he put through hell by abusing drugs. Perhaps drugs played another role in that by taking them he could lower the inhibitions that were preventing him from acting out his aggressive impulses towards others. Once the aggression had found enough satisfaction, the remorse had set in, and with the aid of Suboxone and psychotherapy, he could put a stop to his drug abuse and torturing of his family. Then to make amends, and to "undo" the cruelty of the past, he built up a whole range of obsessive thinking, which was mainly berating himself that he should have done this or that better, and keeping his mind occupied with other good intentions like getting good grades at school. As long as he could take refuge in these obsessive thoughts and do other good deeds obsessively like getting good grades he could keep the fear that he will be punished by fate (parental substitute) for his past misdeeds at bay. Though this fear of punishment was trying to make a breakthrough in sleep and dreams from which he would wake up in cold sweat. The fear would also emerge every now and then during the day, when he would have attacks of sweating (muted panic attacks).  

Why did the exhaustion came after the panic? The exhaustion was a muted form of depression. Once again the patient did not feel sad, just profound motor inhibition that extended to his thinking. But that appears to be the modus operandi of his defense system: have a somatic instead of a psychic reaction, at least in the first stages. Instead of feeling the affect of anxiety and fear all he did was to sweat profusely. Similarly, instead of feeling sadness and pain following the failure at his exam he felt a profound motor inhibition. After 8 days of punishment the cyclothymic neuronal circuits of his system kicked him out of the depressive phase and put him in the upswing. The above in a way describes how anxiety leads to obsessions and how when obsessive defenses fail and massive anxiety emerges depressive reaction is triggered to control the anxiety and then manic behavior follows to reverse the melancholia. So origins of Bipolar Disorder too can be traced to anxiety.

The patient asked as to why did not he continue to be just anxious and not fall in to depression. And I tried explaining to him that perhaps anxiety takes greater toll upon the body by keeping all the body's, including the cardiovascular, revved up. It is far more painful to anticipate punishment than to take control and just inflict punishment upon oneself and get it over with. The pain of depression is sometimes preferable over anticipation of impending harm.

Wednesday, October 17, 2012

Equivalency of Pleasure from Social Interaction and Eating and the role of dopamine system in attention and addiction

A 62 year old man, who is moderately overweight, reported that when he is not around people he eats. He  recently had ended an unhappy marriage, the last twenty years of which were quite loveless. He was overeating even while married, but, after the divorce, the problem had worsened.
Then he met someone, started a satisfying relationship and his mood improved. An interesting side-benefit of this companionship was that he did not compulsively eat when she was around. This led him to make a further observation that it was not just his girlfriend's company, but others' too, that kept his mind away from  food.
In therapy he remarked, "I got to be doing something pleasurable all the time. That is my nature. I am in horse business - and as you know how passionate I am about it - where if I make a deal, and it does not matter whether buying or selling, it gives me great pleasure. And greater the margin of profit, say if I make a steal, getting a 500-dollar horse for just 300, and then turning around and selling it for 2000 instead of  a 1000, then I am like in heaven. But coming to think of it, it is not just horses. This sense of pleasure extends to a lot of other things, like helping others. The other day when the hurricane went through Dexter, and knocked down those houses, I was the first one on the spot with my tractor, helping people sort through their rubble. And it gave me so much joy being a rescuer. It made me feel like a winner. And it is this feeling of being a winner that generates the sensation of pleasure. And if nothing else is going on which affirms this belief in my superiority then I am there eating. I guess it has to do with one's childhood when if you were into something good like eating an ice cream, while your siblings and playmates were not then you were like ahead of them."
Now we know that whenever something pleasurable happens to us, the brain immediately secretes the neurotransmitter dopamine. Why does this happen?  And is it the sensation of pleasure that causes dopamine release or is it dopamine release that stimulates some reward center in the brain which creates the sensation of pleasure?  But does it make sense for the brain to have developed a whole neurotransmitter system and a reward center just to give the subjective feeling of pleasure? And finally it raises the question as to what in the world is pleasure and why the brain needs that sensation for its functioning, and how dopamine release generates the subjective feeling of pleasure in the consciousness?
Sensation of pleasure -it is actually signal to the subjective consciousness of a relief from sensations - happens when the level of tension or stimulation in the brain goes down. Less the brain is bombarded with stimuli, whether arriving from inside the organism - hunger, thirst, sexual needs, pain - or from the external world - heat, cold, competition for food, attack from predators, pain - or from its own reflective activities  (reactivation of the past experiences as a preparation for future), the more at ease it becomes.
Brain appears to have evolved as a means to keep the level of stimulation in the whole organism at the minimum possible without the organism dying. It should not surprise us that what humans prize more than anything else in the world, more than gold, silver, and sex, is to have the deepest sleep possible; sleep free of any disturbance; sleep free of even the pleasantest dream; sleep that is just one step this side of death. No wonder narcotic addicts sometimes actually die trying to get the greatest peace/pleasure/high of their life through creating near death experience.
As to how this toning down of the brain activity creates subjective feeling of pleasure in the consciousness is beyond the scope of human understanding, at least at present, perhaps it will remain so forever. We do know that more active the brain is greater is the feeling of unpleasure, unless of course that activity is being undertaken to lessen the rising stimulation at some other point. 
And here lies the reason why people are constantly doing something. They are constantly preparing themselves to avert a more massive increase of tension in the future. This gives an illusion that we actively seek stimulation.
If we take my patient's case it can be seen that his interaction with his girlfriend and other people while raising the tension at one level also promises of lesser stimulation and thus lesser tension in the future. Interactions with girl friend are pleasurable in that they assure that the dreaded unmanageable rise in sexual tensions will not become a reality with her being around and permitting their periodic release. Helping hurricane victims is assurance that such a good deed will be noticed by the heavenly father, or whichever authority now substitutes for the parents, and he will either not be subjected to similar disaster as a reward, or if similar disaster strikes him people will come to his rescue as a payback.
How does the brain learn not to run away from these humps of increase stimulation and correctly evaluate them as unpleasant necessities that must be faced to avoid over-stimulation in the long run? In other words what mechanism the brain utilizes to override one's natural inclination to immediately avoid any overstimulation. The mechanism lies in the love that we received from our parents when we undertook painful tasks that promised future pleasure. It is  for the sake of parental love - and fear of punishment in their hands that would have caused greater increase in tensions that the unpleasant task itself - that we learn to become stoical towards the difficulties of life.  The pleasure that was generated from the love and attention given by the parents outweighed the unpleasure that arose from undertaking the tasks.
And the earliest and most momentous token of that love was being fed.
While eating is a pleasure in its own right - it brings relief from the tension of hunger  - it is also the first and the most important means to reward the child when he does not run away from mastering exigencies of life.  Promise of food - promise of parental love - can lead humans to bear great amounts of suffering.
Thus eating becomes the most important methods to tolerate suffering. It is in fact the first addiction of humans. Our first experience of satisfaction occurs on mother's breast. Even after nutritional need is taken care of, the child will keep sucking upon the pacifier, and later the thumb, to recreate this experience of pleasure, and through it, when under stress, the illusion of parental protection. This first experience of satisfaction is the prototype of all later addictions. Later when thumb sucking is no longer permissible under the critical and forbidding eyes of society, munching of food substitutes it. Other addictions may follow, but their nature is basically the same. They are all undertaken to produce pleasure at one point of the brain so it will distract the attention away from anxiety, tension and pain happening at another region.
A patient of mine recently confirmed this viewpoint with the following statement:
"I am an emotional eater. When I am in pain I eat bowls after bowls of cereals. It eases the pain. It is similar to cutting that I use to do. When the emotional pain from the molestation [which I was subjected to from the age of 7 to 14] would get overbearing I would cut myself. The physical pain would take away the emotional pain. In fact I would not even feel the physical pain, just relief from the emotional one."
So eating by producing pleasure from the positive sensations occurring at the taste buds in the mouth, feeling of fullness in the stomach, and the muscle movements of the mouth and the gullet takes away the pain happening at some other spot, just like cutting oneself physically at the wrist takes away the emotional pain that one feels inside. One of my patients stated that when the memory of molestation grips her the pain is so severe that she feels that her chest is going to cave in and she cannot even breath, and only cutting herself allows her system to breath and live again.
Fortunately most people do not have to cut themselves to generate enough counter/irritant/counter-pleasure  to combat the internal pain, they just have to reach out and eat something. And while the food is in the mouth or traveling down the gullet, and muscles of mastication and swallowing are active, the pleasure generated takes away the attention from emotional pain.
And so was the case in my horse trader patient. As long as he could drown out the unhappiness of his life by finding pleasure in making deals on buying and selling horses, or in socializing with his girlfriend, or with other people he was fond of, or helping those who he hoped would help him in return in his hour of need, he would not think of food. But when nothing else was happening and all his unfulfilled needs and ambitions would start clamoring for expression and stimulate his brain to do something worthwhile - which his age, circumstances and abilities precluded him from undertaking - then the only recourse left for him to do something meaningful was to eat.
How does the attention shift from the painful stimuli to areas which are producing pleasurable sensation?
Here comes the role of dopamine. Whichever behavior decreases overall brain activity - that is overall level of mental stimulation/tension - that behavior is strengthened - given more attention - through dopamine input. Dopamine's function appears to be to further charge/cathect/facilitate the neuronal circuitry that underlies pleasure giving behavior. Dopamine-producing neuronal circuits are not activated as a reward when something pleasurable happens. Pleasure happens when there is decrease in mental activity and dopamine is secreted to give attention to all those environmental factors and one's motor actions that brought about the pleasure. This increased attention makes the memory traces of these environmental factors and actions stronger. It is a kind of error to look upon the neuronal circuits that produce dopamine as reward circuits. They should be looked upon as attention producing circuits which make the perceptions and behaviors existing at that point of time more vivid and consequently their memory traces stronger.
At this point a few words on Attention Deficit Disorder (ADD) are in order. This malady appears to emerge as a response to some inner turmoil. As if the child is running away from some revved up inner neuronal circuits - in most boys it is running away from turmoil of the Oedipal Conflict which did not come to quiescence/dissolution with beginning of the latency period - seeking pleasure to distract attention from the tension. If this running away cannot be undertaken in motor movements, it is in racing thoughts or in daydreams. All these motor movements/racing thoughts/daydreams occur to seek winnings which will reverse the memory of the Oedipal defeat and having to give up the mother as love object out of fear of father. This fear of the father underlies the constant anxiety that is the substratum of ADD and which drives the boy to keep running and running. As the child matures, obsessive thinking and motor rituals emerge to control the anxiety and hyperactivity (running).
Careful examination of these ADD children shows that all their motor hyperactivity and day dreaming are an attempt at winning either in real life or in imagination to lessen the fear of  and to come even with "the Oedipal father". And through winning produce a decrease in level of tension, which is same as production of pleasure, and which results in secretion of dopamine from attention producing circuits. Stimulants - dopamine enhancing drugs - work in ADD because they boost dopamine and thus attention to whatever is going on in the environment. Here the dopamine is secreted not because some winning has occurred and therefore there is decrease in tension but by the means of drug. Nevertheless the release of dopamine temporarily takes away the child's attention from his revved up painful neuronal circuits and focuses upon what is happening in his environment then and there. As one of my ADHD patient remarked,"Whenever I take Ritalin all my thinking becomes immediate, current. All the past hurts and memories that rob me of my present vanish. My mind instead of being all over the place from the past are now focused in what is happening here and now."
It may not be totally out of the way to make couple of remarks on the distractibiliy/hyperactivity that occurs  due to lack of sleep and which we try to rectify by various means the most favored of which is munching upon food through the day. The purpose of sleep is to bring down the level of excitation of the revved up neuronal circuits that had occurred as a response to day's challenges so they can start afresh the next day. If this cannot be accomplished by simple withdrawal of cathexis/activation from the cares of the day dreams are generated that show the happenings of day in more favorable light allowing the vigilant and tense neuronal circuits that were on guard to discharge and become ready to undertake fresh responsiibilities the next day.  If their discharge cannot take place even in dreams because the distortion of real life circumstances in dream would have been too great to bear, leading to waking out of the dream/nightmare or unable to fall asleep in the first place out of fear of dreaming dreadful dreams, then during the day one would go around still preoccupied with the affairs of the past, unable to pay proper attention to the present. And to bring back the attention from these internal conflicts to the real world one would eat. For the pleasure generated from eating releases dopamine and draws back the attention to food and the real world from where the food is coming.
The question naturally arises that if pleasure (reduction in tensions) causes dopamine release which in turn stimulates the attention and there certainly could not be any pleasure arising from inner turmoil why the mind pays any attention to the latter in the first place. And there is little doubt that when something is bothering us  we have no interest in the affairs of the world and all our attention is to keep mulling over the painful inner turmoil. Why would one want to focus upon painful happenings? This is a tricky issue. We know that whatever causes pain we want to run away from it. And if we cannot physically run away from it then we at least don't want to look at it, think of it or pay attention to it. But this cannot be entirely true. If something painful strikes us, our first inclination is to run but if we cannot then we are forced to pay attention to it. Something gnawing inside, we may ignore it in the beginning, but finally if it does not go away by distracting ourselves with other things, we are forced in to dealing with and yanking it out of our vicinity and our system if its source is within the body.
Let us try to make some headway into the mechanisms behind this attentiveness to pain. The first and the oldest must be the reflex attention. Its evolution had to be before the emergence of Central Nervous System when the brain was multilocular, spread all over the body, and each sensory modality (taste, sound, touch) brought its own independent motor response through ganglionic cluster of neurons. This reflex attention must have evolved as a biological necessity at the discovery that by not paying attention to whatever is bothering oneself the trouble does not go away, especially if the source of stimulation is from within the organism as hunger and thirst, and the way to deal with it is not through creating a distance from it but paying attention to what is causing the excessive stimulation and taking steps to eliminate it. Perhaps release of endorphins and other anti-pain chemicals in the brain, and also at the body site from where the pain was arising, was a necessary step in the development of this mechanism of generating attention. With further development of the brain the dopamine system must have also come into play. Once endorphins would have brought about the cessation of pain and thus decrease of tension, dopamine would have been secreted to enhance attention. High addiction potential of narcotics appears to be based upon not just their ability to stop pain, but their ability to generate high level of attention; at least in some addicts. There is no doubt that some ADHD patients prefer narcotics over stimulants as a attention generating chemical.
The other mechanism behind the paying of attention to painful things has already been discussed at some length above. In the earliest years of our life when we were in pain and required relief from it, but did not have ability nor the experience to do so, it was our parents who paid attention to our needs and came to our rescue. Over time this behavior becomes internalized, and we took over the actions of our parents who instead of running away from painful situation paid attention, took cognizance and got rid of it for our sake.
Finally, we must try to answer as to why attention is generated whenever there is reduction in tension.
This requires examining as to what life itself is. An organism is alive as long as it is indulging in give and take with other organic entities. It is this exchange which bring reduction in tension. When a desirable thing like food is ingressed and added to the organism or an unwanted part of oneself like feces is extruded there is reduction of tension. Higher this rate of  exchange with the outer world more alive is the organism.. As one of my patient put it, "When I was healthy I was into everything and everybody, so full of life. Now that I am bogged down with stress, everything has ceased. Even my intestines have gone in a shutdown mode, and I get constipated for days. Last thing I want to do is to deal with people. And I am gaining weight and my cholesterol is shooting up, because even my metabolism has slowed down, refusing to burn the calories I take in."
Attention, with the aid of dopamine secretion, is an additional attempt to enhance life processes. Whatever perceptions and behaviors enable life's give and take, attention is paid to them so they have higher priority in getting activated when similar situation arises in future.

Monday, September 3, 2012

Women playing with their hair on approaching stoplights

In an Internet site where I banter with my classmates from my medical school, one of them raised the following question.

why women play with their hair when they approach stoplights ?

And he answered it himself, of course as a joke, Unlike men they do not have b---- to scratch.

While he meant it as a joke the fact that he had noticed this phenomena, and had found it humorous enough to quip on it, and then had associated it with - rather had  found equivalency with - touching of genitals, points to the presence of some psychological riddle here. 

First of all we have to decide whether it is a phenomena worthy of psychoanalytic investigation by which I mean that it is a distinct behavior present not just as a quirk in one particular person, which would be a manifestation of his or her individual neurosis, but a universal neurosis, present in all of us, ready to emerge as a defense mechanism if the circumstances demand; a repetitious behavior arising from our phylogenetic past as a response to the experiences of countless generations that have left genetic imprints in all of us, and whose raison d'etre remains shrouded in mystery because the underlying motives and processes of the phenomena have become unconscious due to repression

There is little doubt that some women under stress do reach for their hair - usually the frontal locks - and run their fingers through it as if searching for something hidden. On being questioned they dismiss it as just a habit or as simple straightening of hair and may even get irritated as to why one would nitpick over a little extra grooming.  

Now superfluous grooming is a sign of obsessional neurosis. In a subset, the compulsion to clean and groom reaches ridiculous proportions. The patient, especially in the mornings, may literally spend hours in front of the mirror, straightening hair, looking for flaws on the face, clothes and other aspects of one's appearance, as if one has to wipe out every trace of what may be construed as offensive by others, before leaving the house. Trying to put the hair in order seems to be a specially favored aspect of this ritual, as if these individuals are having a-bad-hair-day everyday, and they may accumulate an impressive array of shampoos, gels, conditioners, sprays, and shaving paraphernalia as counter measures against these (unconscious) harmful impulses. 

And here we cannot help but reflect whether patients who suffer from trichotillomania - a malady where the person compulsively pulls out her hair in clumps sometimes to the point of going completely bald - are not taking this fear to an extreme.

Now sometime back on this blog I discussed a case of trichotillomania: "A childhood screen memory of penis envy and its connection with trichotillomania" (April 16 2011). There we saw how the patient, under the sway of penis envy, wanted to pull out anything that reminded her of the difference between the sexes and the underlying motive was to equalize the playing field between the two.

Could it be possible that such apparently purposeless playing with hair under stress is just an embryonic trichotillomania?

We do know that trichotillomania is another manifestation of obsessive-compulsive disorder. To the patient the hair feels as something alien and hostile that one must get rid of. Anything out of place, anything not fitting in with rest of the pattern; littered pieces of papers, dirty linen dropped on the bathroom floor, magazines thrown haphazardly upon the coffee table, hair in the bathtub, they all have to be put in the general scheme or yanked out altogether, so goes the reasoning of the obsessive, and hair become another object in the series.

What surprises us, and fills us with not a little fascinated horror, is that here what the obsessive is finding incongruous is not something external but part of his own self. But a little reflection tells us that  feeling and treating part of oneself as a foreign object is perhaps not all that strange but quite common. We just do not see it that way and therefore it unpleasantly surprises us when somebody brings to our attention as to how we can treat part of our own body as something vile and foreign. In fact picking upon pimples and other flaws of complexion is almost a rite of passage in adolescence; women in throes of post partum depression may consider their own child - which just so recently was part of their body - as incarnate of evil, the devil himself and kill it;  and in psychotics it is not all that rare to actually castrate themselves or enucleate their eyes [where eyes symbolize the penis]. Those suffering from psychogenic pruritis can relentlessly dig their own skin convinced that under it lie bugs or other contaminants, and psychogenic poludipsics are known to gorge themselves with gallons of water in order to wash out the impurities of the environment that has got lodged inside their bodies. Recently a patient of mine, who for years had been digging her skin and her torso and arms were puddles of sores, stopped doing it, when her Remeron (Mirtazapine) was stopped. She was perhaps feeling the side effects of Mitrazapine as something foreign inside her. A mechanism that I will not be surprised is common across the board in causing psychogenic polydipsia in patients on psychotropic medications.  

Now coming back to the analysis of these obsessive patients who are forever trying to get rid of the incongruities in their environment or in themselves. At the deepest level they are fearful of contamination of others by the bad aspects of themselves. Incongruities in the environment is just a reminder of their own unacceptable impulses, and they are forever straightening out the environment to banish from their sight everything that will provoke further activation of their own incongruent/evil/extruding impulses. And these extruding impulses show themselves to be the intimate aspects of themselves that should be hidden from the environment. While immediate examination shows them to be arising from the anal-sadistic phase of sexuality - we recall here that the fear of leaving the house is associated with not being cleaned and groomed enough - at the deepest level they arise from the fear of the destructive power of the phallic impulses. The fear that one's anal-sadistic impulses will show is but a regression from the fear that one's phallic/genital impulses are out of control and will be seen by people/society. 

Why the penis and the impulses originating from it are felt to be destructive? 

Sexual drive is often felt as evil and incongruous with the rest of the self; an anomaly, something gross, physical, material, smelly, crude and not refined or spiritual enough. 

And with good reason. People who are so dignified in every other respect when under the sway of the sexual drive can behave most incongruously. A man huffing and puffing in the act of sex looks ridiculous if not outright animal. There is nothing dignified about one human being mounting and humping another. And the phallus/penis is the most visible manifestation of this drive which turns us into such a coarse being. In women there is further fear of it being a harbinger of cooties - diseases - if not outright pregnancy, which is the beginning of the destruction of one's own body and ultimately death. No wonder people often develop neurosis in order to suppress/escape from this coarse drive. We cannot help but reflect here that in the Hindu Trinity of Brahma, Vishnu and Shiva the latter is symbolized by the penis and is attributed the function of both the procreator and its exact opposite the destroyer.

But what exactly is the connection between women playing with their hair on crossroads, trichotillomania and fear of getting touched by the penis, you want to ask me. 

This question cannot be answered directly and instead I will take up two instructive cases. The first one is actually not even a case but someone I worked with 25 years ago. He was a Jewish doctor who stammered quite badly; a malady that I could see had arisen as a mean to control his inordinate ambition which must have begun as an excessively powerful aggressive drive. Coupled with this was his habit of relentlessly twirling and untwirling a lock of hair that he still had upon his balding head. The underlying psychological mechanism behind the obsession was easy to discern. His extreme competitiveness wished nothing less than castration for anyone who even hinted of crossing his path. But living in society and hampered by its rules  and unable to do anything of the sort even with words, for stammering would arise to block the discharge of aggression through speech, he wanted to do it with his bare hands. But the danger involved in laying his hands upon others had deflected the impulse to find discharge upon his own self and in the form of twirling and untwirling his hair - castrating and uncastrating himself, symbolically of course.

The second case is that of a woman who was in early thirties, eager to settle down but unable to do so because of undischarged anger towards men, stemming from growing up in a divorced household where the mother was absent and the girl was dumped with the responsibility of taking care of the father and her brother, both of whom had lorded over her because she was the girl. Her relationships were predictable. After a brief  period or romance, she would lapse into continuous arguments with whoever she was courting.  All her lovers after a few months of honeymoon would metamorphose into her brother behind which lay the image of her father. Her life was a series of her old battles with the new incarnations of her brother and father. 

And her brother gave her fresh justifications to do so. She had a regular job while her brother, older than her, was more or less of a bum. Whenever she talked about him she showed contempt for his inability to hold down a job and this would be followed up with expressions of outrage that he still remains their father's favorite. And she knew that the only reason  this was happening was because he was the boy and she was the girl. "If only I had a penis," in her unconscious she reasoned, "I would have been my father's favorite." 

Now whenever she talked about her brother in this fashion, and additionally whenever she felt I was putting her down through my 'interpretations' of her psychological conflicts, she would get excited and start playing with her hair. And the way she played it looked like as if she was searching for something there. The movement of her fingers through her hair would remind me of how homosexual hair dressers fiddle with their clients' hair fetishistically as if they are searching there for something as well.  Now one of the most common subtype of homosexuality occurs in those who cannot forgo the idea of the lack of penis in their love object. These homosexuals love everything about women and their beauty but cannot tolerate the dread of the missing penis in them. They often turn to feminine looking youthful boys for their love needs. And it is this type of homosexuality that marks the hair dressers who cannot give up the idea of finding the penis in the tresses of the hair while grooming and straightening it out. The facial expression and behavior of this girl was so similar to those homosexual hairdressers, the unconscious motives behind such playing with hair became easy to fathom. "You jerk," she wanted to say, "You are shoving those interpretations down my throat with such surety because being a man, and possessing a penis, you consider yourself naturally superior to me. Now I know that I too have a penis. It is hidden somewhere, deep inside me, perhaps hidden behind these lock of hair of mine. And if only I get hold of it, which will place both of us on a level field, I will teach you a lesson as to who is better between the two of us."

If we take the Jewish doctor who played with the hair to symbolically self-castrate, and this girl's search for the hidden penis which would put her on equal footing with men, then we can extrapolate that perhaps many women when stopped at crossroads experience the situation as stressful and also deal with the anxiety by reaching for the penis that would put them on equal footing with men and make them not feel so vulnerable. 

But why would a woman feel vulnerable on stoplights? 

Here we run into the psychology of agoraphobia. Agoraphobia - which literally means fear of the marketplace - arises from fear of coming to harm in interacting with others especially in public places. Analysis reveals that behind the fear of interaction lies fear that one would be tempted to exchange one's goods - displacement from exchanging one's sexual goods - and would come out a loser. In the agoraphobic the give and take of life has gone sour. Iron has entered the soul especially in the matter of the most pleasurable of all exchanges - the give and take of sex.

What causes this fear and sourness?

Throughout our existence we are in search for somebody with whom we can exchange our bodily goods. The very process of life depends upon such exchange. In this love exchange, only in the beginning we are generous, and this more so the case in women. In her, if the culture and men has taken advantage of her, and given as to how exploitative cultures are towards women it is invariably the case, she may show increasing ambivalence towards this search for love. She may rather not exchange 'her treasures' with that of a man, or do it in a manner where she gives less and takes more. She may even resort to deception, ruse and tricking. It is these negative impulses behind her love that makes folks lament at the femme fatale and her enigmatic and unfathomable nature.

The woman's inner conviction that she has been shortchanged in life adds a further twist to this search for love.  Her sense of lacking something which she must make good and complete by getting it from a man makes her approach him with poor self esteem and trepidation and leads her to adorn herself with all kinds of jewelery, make-up, and other shiny trinkets that she hopes will be a match for that one jewel that he possesses. Women's endless shopping is also the search for that jewel that would deflect attention from her  great defect/wound  and would make the man believe that he is getting more than what he is giving. The term "turning tricks" for the act of prostitution perhaps arose from this attitude of exchanging and tricking the man into giving what she wants without his getting anything in return. For the prostitute convinces herself that she feels nothing and gives nothing in the sexual exchange and gets the man's money through just tricking him.  

But the attitude of tricking, deceiving, stealing, and in the more spirited one pulling it out as a tuft of hair, provokes the fear of retaliation and subjection to physical harm and other dangers as getting the cooties (venereal diseases) and pregnancy. The  revolt at the thought of playing the passive sexual role and a stranger's dirty organ penetrating one's body adds to the disgust and provokes further withdrawal from the impulse.

No wonder at the stoplights, in a situation to meet somebody - for crossroads are like a marketplace offering choices as to which direction to take and who to choose from amongst all the other stopped passengers - tempted and yet fearing the retaliation for her evil intention, she reaches for her hair and searches for the penis, which she has a conviction she does possess, and it is only a matter of searching. For if she is successful this time in that eternal search, she does not have to bother exchanging her goods with another; for what she so ardently desires she already has.

Sunday, August 5, 2012

Ambivalence towards boyfriend emerging as death wish against one's child

A young woman, mother of 9 month old baby, dreamt the following:

A am at a clinic or in hospital where I keep going to doctors asking what to do with my baby who is dead, but with whom I am still pregnant. They keep telling me that they can do nothing about it. And I keep imploring them that if she is dead what is the point of my carrying her. I am afraid I will  be pregnant with the dead baby forever.

The patient is new to me so I hesitated to jump to the conclusion that some kind of death wish towards the baby had manifested in the dream. More difficult than arriving at the deduction was the difficulty in deciding whether to communicate it to the patient or not lest it provokes serious negative transference. For it was her second or third session with me. So I asked her how old was the baby in the dream.

"The baby is same age as she is now."

"So how did the dream show your carrying, if she was already 9 months old?"

"I was carrying her like a kangaroo carries its young one in the pouch."

"So your baby was outside your womb in the pouch."

"No, it was inside. But I had like an extra flap of skin over my stomach, and I could hold that flap up to the light and see her shadow through it."

"That behavior of holding up the flap up to the light, it must have some point of contact with something else you did perhaps on the day of the dream?"

" No, I always do that. Whenever I need to examine something in depth, I take it to the lamp in that fashion and look for flaws in it. Its a habit. I do it all the time."

Now looking for flaws, especially doing it as a habit (ritual) is a component of obsessional neurosis. And behind all obsessional rituals lie death impulses and countermeasures to nullify them. The end behavior is a compromise formation between the two which makes no sense till you analyze it and often then the two opposite impulses can be seen clearly. So I took the chance of asking her if behind the dream element of her daughter being dead could it be possible that there was a wish for her to not to be alive. Perhaps at times you find her a burden to you.

"No she is not a burden to me. I love her very much. But I cannot say the same thing about her father.If there is anybody I wish dead, it is him."

So here was an indirect confirmation that there was an element of death wish in the dream though emerging against the father of the baby, perhaps because it was more acceptable. There was greater guilt associated with seeing her daughter dead and the unacceptable wish could rear its ugly head only while she was asleep and only as a dream.

"Why would you wish her father dead?"

"Because he is good for nothing.  Does not support her. Never comes around. I cannot stand him. Yes I want him dead. If he dies I can be free of the anger that the jerk is ignoring us like that."

"Was it an accidental baby? And did you know her father when you got pregnant by him?"

"Oh I knew him very well. For 2 years. And it was planned. In fact to get pregnant I had my IUD removed."

"Why would you want to have a baby from someone you wish dead?"

"He was not like that when I knew him. But the minute he heard I was pregnant, he took off. And has never come back."

"Did it affect your attitude towards your pregnancy?"

"Did it! I could not make up my mind about abortion. I almost went for abortion at the first, the second and the third month. Even during the baby shower I was thinking of giving her up for adoption."

"Why was that?"

"For the baby has brought me so much trouble. I almost died when I was 4 months pregnant from profuse bleeding. She ruined my health. I developed heart condition and diabetes. Added weight. Thank God my diabetes is gone. But the problem with my heart valve remains."

"So you have reasons for wishing for her to have never been born. For only if she was not born you would not have had these complications."

"Yes, but at the same time I cannot imagine ever parting with her."

"No wonder the dream shows her dead and yet at the same time as a part of you forever."

There perhaps was another wish behind of making the baby a part of her forever - as a compensation for lack of penis. A wish that has to come to an end with the delivery and which is the central issue behind post-partum depression. But the patient was certainly not ready to explore this aspect of herself, and no attempt was made to do so either.

Friday, August 3, 2012

The Philosophy of Idealism, Descartes negation of the material world, Depersonalization Disorder and the game of peekaboo

For many centuries Philosophy was fascinated with the idea that the world around us is a product of our  mind. This system of thought called "idealism"  must have originated with the ancient Hindus and Greeks, but its modern version seems to have started with Locke and Berkeley, reaching its zenith with Kant and Schopenhauer.

I do not for a minute want to claim I understand the deep thinking of these philosophers, and in reality I cannot even picture how the world existing around us, which you and I so reliably comprehend with our senses, and find it to be so alike when we compare notes on it, is primarily the product of our mind.

I try to make sense of this idealistic worldview by summarizing it as: What we see and perceive from our senses of the world existing around us has very little to do with how reality is but more with the way our mind functions, capturing only those aspects of reality which have relevance to our existence  as human creatures.

Kant goes so far as to claim - which is mind boggling to me - that even the space and time are a function of our mind. These two modalities have been created by the mind to organize our knowledge of reality.

While what Kant says makes sense - kind of - some philosophers have gotten so excited over this concept of world being one's idea that they have tried to negate the very existence of any reality outside one's mind. Descartes famous statement "that I am because I think" is similar to this kind of negation of the certainty of anything existing beyond our thoughts. What he is saying is that only thing that we can be totally sure of as having definite existence is our thoughts. Everything else may not be there at all.

Now whenever I read Descartes above quotation I think of Depersonalization Disorder. A person in grip of severe depersonalization finds the world dull and drab, lacking in qualities if not outright unreal. People appear wooden and mechanical. Nothing excites the senses and one's feelings freeze. Actions become automatic and there is no pleasure in their execution. In extreme cases one is not sure if it is not all a dream or if even one exists. During such times one may resort to forcing oneself  to think in certain directions like doing multiplication tables, to assure that one's brain is still working..

Was Descartes suffering from depersonalization and behind the famous statement was a desperate  assertion, "No I am not dead. I am still alive because I can still think"?

It reminds me of Rudyard Kipling's short story "The Phantom Rikshaw." Set in the year 1885, in Colonial India, it is about the descent of Jack Pansay, an Anglo-Indian civil servant, into the dark underworld of the mind, which is about to press him in to insanity. He has a torrid love affair with a Mrs. Agnes Wessington, while they are ship-bound from England to India. She is older than him, somebody else's wife, and therefore a clear mother substitute.

After a period of great intimacy, which leads to his getting weary of her, he unilaterally and cruelly ends the relationship. In the end stages of the affair, in an attempt to hold him back, Mrs. Agnes Wessington keeps repeating what he contemptuously calls 'her eternal cuckoo cry': "Jack, darling! I'm sure it's all a mistake--a hideous mistake; and we'll be good friends again some day. Please forgive me, Jack, dear."

 Mrs. Wessington dies of broken heart when on getting engaged to young pretty Miss Kitty Mannering, Pansay tells Agnes about it in a most cruel fashion on a roadside, while she is sitting in her rikshaw. It cut the dying woman before him like the blow of a whip. She dies a week later.

Eight months later, he is back in Simla and could not be more in love with Miss Kitty Mannering. But the deepening relationship with Kitty Mannering while bringing him joy, by his own claim 'the happiest man in India', also brings him strange happenings. They begin with his hearing his name Jack being called from some very vast distance immediately after he gets Kitty fitted for the diamond engagement ring. It strikes him that he had heard the voice before, but when and where he could not at once determine. A little later while cantering with Kitty on the same road where he had parted with Agnes for the last time and had heard a faint call of Jack from her, but had shrugged it off as imagination, he runs into Agnes' yellow-paneled rikshaw and the four coolies, with their white and black "magpie" liveries.. He assumes that the rikshaw must now belong to somebody else and he resolves to buy it from its new owner to destroy it and to find new liveries for the coolies when he to his unutterable horror sees Kitty and her horse pass through men and carriage as if they had been thin air. He then hears the cuckoo cry, "Jack, darling! I'm sure it's all a mistake--a hideous mistake; and we'll be good friends again some day. Please forgive me, Jack, dear." Later he learns that the four coolies were also dead, all brothers, victim of an outbreak of cholera on their way to Ganges, and the rikshaw had been broken to pieces to avoid bad luck.

Following is the soliloquy on part of Jack Pansay as he struggles to extricate himself from the ghosts of Mrs. Wessington and her coolies.

"But I am in Simla," I kept repeating to myself. "I, Jack Pansay, am in Simla, and there are no ghosts here. It's unreasonable of that woman to pretend there are. Why couldn't Agnes have left me alone? I never did her any harm. It might just as well have been me as Agnes. Only I'd never have come back on purpose to kill her. Why can't I be left alone--left alone and happy?"
It was high noon when I first awoke: and the sun was low in the sky before I slept--slept as the tortured criminal sleeps on his rack, too worn to feel further pain.
Next day I could not leave my bed. Heatherlegh told me in the morning that he had received an answer from Mr. Mannering, and that, thanks to his (Heatherlegh's) friendly offices, the story of my affliction had traveled through the length and breadth of Simla, where I was on all sides much pitied.
"And that's rather more than you deserve," he concluded, pleasantly, "though the Lord knows you've been going through a pretty severe mill. Never mind; we'll cure you yet, you perverse phenomenon."
I declined firmly to be cured, "You've been much too good to me already, old man," said I; "but I don't think I need trouble you further."
In my heart I knew that nothing Heatherlegh could do would lighten the burden that had been laid upon me.
With that knowledge came also a sense of hopeless, impotent rebellion against the unreasonableness of it all. There were scores of men no better than I whose punishments had at least been reserved for another world; and I felt that it was bitterly, cruelly unfair that I alone should have been singled out for so hideous a fate. This mood would in time give place to another where it seemed that the 'rickshaw and I were the only realities in a world of shadows; that Kitty was a ghost; that Mannering, Heatherlegh, and all the other men and women I knew were all ghosts; and the great, grey hills themselves but vain shadows devised to torture me. From mood to mood I tossed backward and forward for seven weary days; my body growing daily stronger and stronger, until the bedroom looking-glass told me that I had returned to everyday life, and was as other men once more. Curiously enough my face showed no signs of the struggle I had gone through. It was pale indeed, but as expressionless and commonplace as ever. I had expected some permanent alteration--visible evidence of the disease that was eating me away. I found nothing.
On the 15th of May I left Heatherlegh's house at eleven o'clock in the morning; and the instinct of the bachelor drove me to the Club. There I found that every man knew my story as told by Heatherlegh, and was, in clumsy fashion, abnormally kind and attentive. Nevertheless I recognized that for the rest of my natural life I should be among but not of my fellows; and I envied very bitterly indeed the laughing coolies on the Mall below. I lunched at the Club, and at four o'clock wandered aimlessly down the Mall in the vague hope of meeting Kitty. Close to the Band-stand the black and white liveries joined me; and I heard Mrs. Wessington's old appeal at my side. I had been expecting this ever since I came out; and was only surprised at her delay. The phantom 'rickshaw and I went side by side along the Chota Simla road in silence. Close to the bazar, Kitty and a man on horseback overtook and passed us. For any sign she gave I might have been a dog in the road. She did not even pay me the compliment of quickening her pace; though the rainy afternoon had served for an excuse.
So Kitty and her companion, and I and my ghostly Light-o'-Love, crept round Jakko in couples. The road was streaming with water; the pines dripped like roof-pipes on the rocks below, and the air was full of fine, driving rain. Two or three times I found myself saying to myself almost aloud: "I'm Jack Pansay on leave at Simla--at Simla! Everyday, ordinary Simla. I mustn't forget that--I mustn't forget that." Then I would try to recollect some of the gossip I had heard at the Club: the prices of So-and-So's horses--anything, in fact, that related to the workaday Anglo-Indian world I knew so well. I even repeated the multiplication-table rapidly to myself...

To me there appears to be a parallel between Jack Pansay's telling himself:  "I'm Jack Pansay on leave at Simla--at Simla! Everyday, ordinary Simla. I mustn't forget that--I mustn't forget that." and Rene Descartes telling himself "I think therefore I am."

Jack Pansay  loses his mind when dead Agnes' memory returns as a ghost (hallucination). Its purpose appears to be to force him to stay loyal to Mrs. Agnes Wessington and not marry Kitty. So it has to be some ancient attachment on his part to his mother which comes as a hindrance right at the point when he wants to consolidate his relationship with Kitty with a diamond ring. Descartes mother died when he was just 13 months old and he also could not succeed in marrying somebody respectable but settled for an illegitimate affair with a servant girl. In Descartes case too perhaps there was some kind of loyalty to the mother which prevented him from replacing her with any other, a loyalty stemming from the earliest months of his life?

Jack Pansay's giving himself to Kitty and marrying her would have been betrayal of his love for his mother. His "mother fixation", at least its intensity, appears to have had its root in penance for some destructive impulse towards her, which manifested later in his loving Agnes so passionately and then treating her so cruelly. He had used Agnes as a stepping stone to progress from the Oedipal love to an extra-familial object (Kitty), but  had failed. The progression could not reach its final destination. He could not emancipate himself from his bond with his mother. As his love for Kitty deepened his ancient love for his mother returned - though in the form of Agnes' hallucination - guaranteeing alienation with Kitty. 

Why do some people have such strong "mother complex" that they can never make a transition to a new woman? The attachment to mother serves as a protection against dangers of loving strange women. The man carries all his life the image of his mother in his psyche as a yardstick to measure the suitability of all the women who will come into his life as potential mate. If they are too different than his mother then the fear arises and one harks back to the memory of the mother as a counter balance to the current attraction.

Returning back to Descartes and depersonalization. Descartes was affirming to himself that I exist because I am.  Jack Pansay does the same when he keeps repeating to himself,  "But I am in Simla, I, Jack Pansay, am in Simla, and there are no ghosts here." Pansay was desperately clinging to his thoughts to reassure that he was not going insane. Could it be that Descartes was doing the same? Using hyperactive thinking as a last ditch effort to halt himself from some kind of nervous breakdown? Perhaps Descartes got so immersed in his lonely philosophical pursuits, in the world of words and abstractions, that the real material/physical world around him became as relevant as the world of ghosts. And if the world around ceases to exist it is not too long before one begins to doubt one's own existence as well. For these two feelings - of the world perhaps not existing and its counterpart that I do not exist - go hand in hand. This was clearly the case with Pansay who declares:  This mood would in time give place to another where it seemed that the 'rickshaw and I were the only realities in a world of shadows; that Kitty was a ghost; that Mannering, Heatherlegh, and all the other men and women I knew were all ghosts; and the great, grey hills themselves but vain shadows devised to torture me.

While Jack Pansay could not prevent his descent into psychosis by obsessively reassuring himself that he is Jack Pansay -  In my room I sat down and tried calmly to reason out the matter. Here was I, Theobald Jack Pansay, a well-educated Bengal Civilian in the year of grace 1885, presumably sane, certainly healthy, driven in terror from my sweetheart's side by the apparition of a woman who had been dead and buried eight months ago. These were facts that I could not blink - Descartes could manage to hold on to his thoughts as a mooring to the real world and not let the dark underworld of his mind escape and choke him into insanity.   

But it seems by taking up the case of fictional Jack Pansay I have strayed too far off from my original intention which was to show that the fascination with Idealism on part of the philosophers has its root in an early phase of our lives. When I was around 4 I remember standing in a  grocery shop with my mother. It was late in the evening, past my bedtime, the shop was crowded - Indian shops have a counter that separates the shopkeeper and his goods from the customers who have to verbally ask for whatever they want. Generally there is uncomfortably narrow space for the standing customers between the entrance to the shop and the dividing counter - and I wanted to be out of there. But my mother did not want to budge, deep in conversation with the shopkeeper and on a mission to stock up on goodies -  a form of hoarding - and so what I did to tune them out was to close my eyes. If I could not disappear from there I could at least make them disappear from my sight by closing my eyes.

But the funny part was that I really did think that the minute I closed my eyes the whole place became dark. For when I made darkness for my myself I thought that it made darkness descend upon the whole shop. In fact I asked my mother if it was making them mad by my turning the lights on and off by opening and closing my eyes.

So here was the kernel from where the belief system arises that the world exists because I perceive it and if I don't perceive it then it vanishes.

So this philosophical fascination with idealism, which gripped that discipline for centuries, and which believes that the world exists because I perceive it has its source in this phase of our development. The phase which is so popular with children - the phase of peekaboo. If one watches children playing peekaboo and the delight that they show in the game it is obvious that they really believe that when they cover their eyes and make you disappear from their perception they have really banished you from existence.   

Sunday, July 15, 2012

Two dreams showing mourning for an ambivalently loved mother

Around her mother's first death anniversary, a woman in her forties, who suffers from various psychosomatic ailments, a somatic abreaction of childhood trauma, dreamt the following:

I am in my kitchen. The window facing the front yard is boarded up. But there is a chink in it through which two eyes are peering inside. From their color and the rim of the glasses I know it is my mother. I go outside to ask her as to what she is up to. However, I see her not at the window  but inside her car crocheting. The car is parked illegally, facing the wrong way and encroaching upon the grass. The door is open and she is talking on the cellphone sitting on a wooden chair. I tell her that the police will arrest you for parking in that fashion and anyway your presence here is ridiculous to begin with. 
All throughout my mother does not speak a word. 

Before we could proceed with the analysis the session veered into her usual complaints, which are mostly about her mother's neglect and harshness when the patient was a child. The mother was having an affair which led to divorce, followed by very unstable living condition for her and her sister. She still gets filled with fury at her mother's rush to marry their step-father, with whom she was having the affair. These usual grievances in the current session were sparked by her guilt over failing to call her step-father on her mother's death anniversary.

Then she mentioned a friend Marci with whom she use to clean houses, and suddenly the memory of another dream crept up in her mind.

My mother is in my kitchen. She is drinking coffee. Then I see her sitting in the living room with an off-white blanket spread across her lap. 
All throughout she does not speak a word. 

"Why does the dream show you in the kitchen?" I asked her.

"Because that is where you can expect me to be when I am at home."

"So the dream is showing that your mother is looking for you?"

"I guess so. It is so strange though. When I was a little girl it would be me looking for her and she was nowhere to be found, gone, running all over town, sometimes gone for the entire night, with no consideration that we two girls, my sister and me, were too young to be left alone like that. We were barely 10 and 11. And I was so worried too about having to keep the secret from our father, who worked the night shift. And now it is not I who is desperately looking for her to come back to home but she who wants to come into my house and I could not care less."

"Why she is peering through the window and from outside?"

"I read in a dream book that looking through a window has to do with abandonment and desertion issues. My childhood was nothing but one abandonment after another."

But I was not quite convinced that peering through the window was symbolizing abandonment issues. The concept 'abandonment issues' was too abstract. Dreams may try to give abstract concepts pictorial representations, but the first step in analyzing them is to find the actual people, real events, particular memories, concrete conflicts that lie behind the dream pictures. The recall from the dream book may have immediately emerged in her mind actually as a defense and a superficial explanation perhaps to deflect her going into the deeper underlying hidden meaning. Though there was no doubt some abandonment issues there as well. Preventing her mother from getting inside the house and just letting her watch through a boarded up window and thus excluding her from her life could be viewed as reversal of abandonment and desertion.

To me however, steeped in psychoanalytic theory, peering through the window,  appeared more likely to be  reversal of spying upon parental intercourse than desertion. It is one of the primal fantasies of mankind: to watch parental intercourse. The  point from which one watches - from outside looking in versus from inside looking out has its own meaning. Watching from outside, while painfully excluded is the opposite of  watching from inside and being part of the process. In fact the fantasy often expands into watching the intercourse from as early as when one was inside the womb and as the third participant in the intercourse, sandwiched between the parents, and by doing so favorably changing one's life trajectory. In women it is changing  of her gender through this intrauterine sex; stealing part of father's coveted penis and being reborn as a boy. In men too the impulse is to steal, exchanging one's own puny penis and acquiring primal father's magnificent potency.  In both cases the fantasy is having sex with the father while in the womb itself, and wresting away from the father what one has been denied.  It sounds very bizarre and may arouse suspicion that perhaps I have a deranged mind. But one has only to recall as to how common it is for pornographic movies to use this fantasy in developing their story line where three people have sex in various positions.

The associations of the patient did not lead to any of these phylogenetic sources of the dream. Patient instead brought in her conversation with her friend Kathy with whom she had discussed the dream and who had agreed with the patient that the dream was about abandonment.

"You specially emphasized the silence on part of your mother in both the dreams. Why such an emphasis on that?"

Having heard her voice in my head incessantly for 43 years, it is a relief to not hear it anymore.  I can shut it off now by telling myself that she is dead."

The association revealed the central theme of the dream. It was a "mourning dream" where she was bringing her mother back to life only to take satisfaction at the realization that she was nevertheless dead. The silence symbolized death. Her silence was an assurance that she is now dead and therefore incapable of retaliation at this filial defiance.

"Why is she sitting in the kitchen drinking coffee?"

"That is where she always sat and lorded over me, drinking coffee, watching me as I slaved, doing all the housework which was simply not fair to be dumped upon a child. I was barely 12."

"Is it possible that you are sending her out of the kitchen into the living room in the second dream? Putting an end to her lording days?"

"Yes. Out of my house altogether. And if possible out of my memories."

"What is the significance of the off-white blanket upon her lap?

"That off-white blanket is the reminder of her  non-stop crocheting. She was always crocheting. Anyone who knew her got a blanket or two from this fascination of hers. In fact now I recall that we cremated her along with her chair and that off-white blanket. She died while crocheting it. She was always upon that wooden rocking chair crocheting. It is interesting in the dream those constant companions of her make a comeback,  sitting inside the car."

"What was the object she was crocheting  in the dream?"

"The same off-white blanket."

"So you are trying to rid of her lock, stock and barrel. So the dream is that of mourning for your mother's death; bringing her back to life, airing your grievances and sending her and everything connected with her out of your life."

"But I had already mourned for her many years ago."

"She just died, barely an year ago. So tell me about this other mourning."

"15 years ago I mourned for her and for my grandfather."

"You mourned for your mother when your grandfather died 15 years ago?"

"No my grandfather was already dead for 10 years, when I mourned for him and my mother. When my grandfather died I had just given birth to my first child and had no time to mourn for him. So I mourned for him 10 years later. And while I was mourning for him, I mourned for my mother as well though she was still alive."

"That is interesting. One was already dead for ten years and the other had yet to die, and here you were mourning for them.  Some loss must have occurred during that period to precipitate this outpouring of grief?"

"Yes. My friend Marci betrayed me. I loved Marci very much. I worked for her and cleaned houses for her. I became dependent upon her and trusted her with all my heart. She became the mother that I did not have.  Then Marci betrayed me. It was such a shock. I cried for three days non-stop. And I decided to say goodbye to all the human race. The good, the bad and the ugly. I was going to trust nobody and expect nothing from nobody. And so I mourned over the end of my relationship with the world."

"But why did you specifically choose your grandfather? Was he mean to you as your mother, and symbolized  the other sex of the human race whom you should shun henceforth?"

"No he was nice. He and my grandmother were the only nice one. But they lived down south and we could visit them only once a year. Those were the happy memories. But I was mourning for them too. For after what Marci did, I wanted to trust nobody. Did not matter whether they were good or bad. They were all painful once you trusted them and became too fond of them. So my grandfather symbolized all the people who were good to me and my mother the opposite, and I mourned for the end of all of them after Marci's betrayal."

"What is the meaning of that car parked illegally, the wrong way, encroaching upon the grass?"

"After making me work to my bones, not just by my mother but my father too, for he was not quite right after the divorce, and I reminded him of my mother, and I was shuttled between the two, both primarily interested in me for what work they could extract out of me, I was lectured endlessly how I was wrong about this and  that, and why I should not be there but at my father's or my mother's if I was at the former's, and more than once threatened to be handed over to the police for my transgressions, which were no more than breaking some glass dish once in a great while. I can still hear the glass crashing and the fear how my mother would whup me. And now I remember that the police were once actually called in. Fed up of the abuse I once ran away from my mother's house and the police were actually called to trace me. They found me at Marci's, who was my best friend then, and in whose house I was hiding." 

Finding the mother at fault in the dream was a way of turning the tables. It was she who was in control, it was the mother who was making all kinds of mistake and subject to being threatened with arrest. 

Thursday, June 28, 2012

Determinism in dreams even with phone numbers

An all-American burly man, approaching Sixty, pillar of the community,  father of half a dozen children, grandfather of twice as many, comfortably retired, volunteering for all community activities, church-going to the boot, including donning the red coat - he already has a flowing white beard - and playing the Santa Claus in the malls at Christmases, rescuing stray animals, brought in the following laconic dream:

I dreamt of someone named "Martin Had" and his phone number which was "628-0967" [the phone number has been slightly changed to preserve the anonymity.

Patient declared that he absolutely knows no Martin, that he has looked in the phone book and there is nobody by the name of Martin Had,  and he could understand dreaming someone called Head: but Had!?). Why would anybody be named Had, and yes he did call up that number and it went to the answering machine. And yes, he left no message.

So we tried to start playing with various permutation and combination of the numbers hoping to correlate it with his age, his daddy's age, his wife's age, lotto numbers, but came up with nothing. Finally he said that all he could think in connection with it was that 0967 reminds him of the year 1967. Around that time he was in the army, Vietnam war was at its height, though he got stationed in Germany, and the year was 1971 not 1967.

But I said that there can be no smoke without fire. That name and those numbers got to have meaning, and he knows it in his unconscious, and the only way to reach it is through his associations and at least one of the dream's origin must lie in the circa 1967-1971. Perhaps some Martin he knew during that era.

The patient suddenly went into a reverie as if he was listening to some distant drums. When he came out of it I remarked that the way his mind was preoccupied, something associated with Martin perhaps came to his consciousness and he said  "Yes, I did know somebody called Martin. Father Martin Phillip. He was a major in the army and a chaplain. I was his assistant and did odd jobs for him and sang in the choir when he conducted the service. Very brilliant man. I learnt a lot from him. He is still alive. I have been thinking of visiting him. But I guess I have already made my peace with him. I called him a few months ago to make sure I had paid my respect before he died.  

The way he said it all, especially about making peace with him and paying respect before he died, sounded to my third ear as if Major Martin Phillip was a father figure to him and towards whom he harbored the same ambivalence that men harbor towards their father. But instead of exploring further on this angle, curious as to what the numbers could mean, I asked him if they had something to do with the girl friend he had during those years. Now I know this patient fairly well, and he had a torrid love affair with a German girl  to whom he almost got married but did not while stationed there. This German girl subsequently came to the US and lives in an unhappy marriage, and in the last few years every now and then calls him up and tempts him to leave his wife and join her.

The patient immediately began talking about this old flame: a girl who was very high spirited, loved sex, traveled with him on trains across Europe to all kinds of places and was game for something exciting all the time.  As he went on to describe how he almost got married to her but did not, and how she is willing to leave her husband for him, for the latter is a no good drunk, and how he finds the whole thing ludicrous because he does not believe in divorce, I wondered if Major Martin was not indirectly substituting for this drunk husband of the lady.

He had called Major Martin recently out of the blue to pay his respect before he died. Could it be looked upon as making amend for a death wish? Perhaps a death wish displaced from the lady's husband to Major Martin?

"Could the phone number be that of the girl who is pursuing you? For we know from your dreams in the past that you do have temptations to reciprocate her overtures."

"If it is true then you should get the Nobel Prize. Let me look into my cell phone and see if the phone number is that of hers."

He pulled up three numbers. None of them were remotely close to 628-0967.

"Could it be possible that the name Martin Had is fragment of the wish:  if only Martin had married that girl and me."

Patient was impressed. "You may be on to something. It that girl and I would have got married certainly Father Martin would have done it. Anything Father Martin asked of me I couldn't refuse. If Father Martin had approved of my marrying her it would have been a done deal. Coming to think of it I spent so much time during that period making up my mind to approach Father Martin but did not for if I had and he had said yes  it would have been a done deal."

"Could then dream be showing the desire to see the fantasy "if Martin Had married us two" coming true? And that the phone number emerges so you could redo your past? In the dream it is not the girl's number but perhaps Father Martin's number that is coming up so you can approach him to make that fantasy a reality. What is the number of Major Martin?"

 He looked up in his cell phone. "His number is 291--0966."

The patient immediately noticed that 0966 the last four digits were common  with the last four numbers of the dream -0967except for the last number which was off by one.

We looked at the first three numbers but could only see that the 2 is common between 291 and 628 and there is no other similarity.

Suddenly the patient said if we take the last number of 291-0966 (Father Martin's number) and put it in the beginning then it becomes 629 (1)-096. Now 629(1)-096 is quite similar to 628-0967 the dream number.

Based upon other associations which were not clear enough to write here, mostly because they are connected with many other facts about the patients which I as his psychiatrist knew about him but which will be impossible to describe here, the difference in the two numbers 629-0966 and 628-0967 which were off by 1 number in the lay in the fact that it involved subtracting and adding of 1 from those digits in a manner that was to make it possible for him to minus himself from his wife and be an addition to the woman who he once loved.

As to why the dream transposed 6 from end of 291-0966 to its beginning, converting it to 629(1)-096, lay the desire to go  back to his past and make the wish that Father Martin had married them a reality and which was only possible by taking the present to the past - transposition of the last digit to the first.

Interestingly while in the dream he is wishing to go back in time and change his life trajectory and make a life with his German ex-girlfriend, in his waking life he is totally devoted to his wife, and would not change his big happy family for all the temptations in the world.