Monday, January 30, 2012

Psychogenic etiology of Sleep Paralysis, Hypnagogic Hallucination and Sleep Apnea

It is taken for granted that parasomnias like "sleep paralysis" and "sleep apnea" are organic/somatic disorders. If there are psychogenic factors in these illnesses,  it is assumed that they play an ancillary role, and in all likelihood have nothing to do with the primary etiology. The medical logic used to justify such an assumption is that stress is a non-specific noxious factor. It has a psychophysiologic role but there is no evidence that  the nature of the psychological conflicts determines as to what part of the body and what pathophysiological process will succumb to the stress.

Recently I came across a patient who remembered the exact time period when her sleep paralysis started and the specific conflict [psychological stressor] that started it. The woman who is now in her mid-twenties reported the following:

"When I was 10 my parents got divorced. They explained to us as what was going to happen, so I cannot blame them that they kept us in dark and the horrible surprise traumatized us. But what they did, did not make sense, and perhaps it did traumatize me. My dad was a nice man. My mom should not have divorced him. Though they fought a lot. Most of the time he was gone. And I think she felt trapped for getting married too early in life, because he got her pregnant. She was not ready to give up being single when I came in to this world. She resented me and resented the marriage. She did not really love him. She wanted out. Anyway, my mom's complaints against him appeared unjustified to me. I felt so sorry for him.

"One day mom took us to our aunt, her sister, and told us that she will be gone for a while to help move somebody. That somebody was us. She had got us, the children, out of the way to go and pack and move. But she did not pack some of the stuff that I specially liked. She left many things behind.

"The next we knew we were living with our grandparents, her parents.

"I did not like staying there a bit, and wanted to be in my house, with my Dad. And that's when the sleep paralysis started. In the night, when I would fall asleep, I would see myself walking out of the bedroom only to realize that I was not really walking but dreaming. But it felt as if I was really walking. It was scary. And I would struggle to come out of the sleep. But unable to do so. I would feel like I was trapped. My brain would be awake, but my body will stay paralyzed. I would moan and whisper. From the awake part of the brain I would keep sending messages to the asleep part to get up. I would imagine myself rocking. Finally the messages would succeed in moving my head and neck. And then I would  actually rock back and forth, waking up at last, my stomach in knots"

This narration immediately made me think whether "sleep walking" too at its core does not start with some disturbing conflict which requires the person to leave the cocoon of his bed.  It was not difficult to analyze that what she was trying to do in her dream was to leave her grandparents house and reunite with her father. But this wish was against the wishes of her mother and would have aroused the latter's ire. And it was this fear that was generating the scary affect. For it makes no sense otherwise as to why the dream imagery of just walking out of the room would generate so much fear. 

From that point onwards the girl regularly dreamt of walking out of her bedroom, only to realize that it was a  dream. But a dream in which part of her mind was awake, and a dream from which she could not wake out of because of sleep paralysis.  And the dream was so vivid, and so scary, that it had the character of hallucination.

Over time another factor got added to the dream. Paranormal entities! She could feel the presence of other people in the dream but whom she could not see, This led her to start believing in ghosts, and her house being haunted. Sometimes the fear of ghosts was so strong that out of fright she would stop breathing as not to make those ghosts aware of her presence.

Does the germ of sleep apnea lies in such fright emerging in sleep/dream?

Over time these ghosts became more aggressive and she would feel them covering her face and nose, or submerging her in water. She would hold her breath in response, till she could hold the breath no more, forcing her to swim upwards to the surface, ending with her waking up gasping for air. 

The ghost like entities would walk past her, watch over and touch her, sit or stand next to her bed. She hated the touching. It would make her twitch and jerk. Sometime touching would go to the extent of moving her hand or caressing her face. She described the experience as if she was being messed around with. But she rejected the construction that the touching perhaps had its roots in sexual touching that she may  have experienced as a child. She said she was never sexually or physically abused. 

However, the construction led her to admit that lately this ghost like character which messed with her, had been taking on the visage of her father and her boyfriend. And their presence in the dream gave her some comfort and lessened the scary feeling. It also lessened the fear associated with the dream of drowning and struggling to come to the surface for air, the sleep apnea dreams. 

So the original overwhelming wish to reunite with her father which had started the sleep paralysis, and which had progressed into, or rather had found another dimension in sleep apnea, found some relief when she turned her father, and her boyfriend (a father substitute), into guardians watching over her while she dreamt forbidden things. So while they appeared to cause the scare, they really had been conjured up by the dream to give a face to the scary feeling and deep down they were comforting in nature and had the stamp of her father, her childhood protector.

Some other things the patient brought up with regard to her sleep paralysis that are worthy of additional  comments.  She considered these dreams symbolic of being out of control. And the scary feeling that emerged while dreaming was at bottom a fear of  being out of control. And the way she tried to regain control was to keep reminding herself, even while dreaming, that it was a dream and try to wake herself out of it through moaning, groaning and sending messages to rock back and forth and overcome the sleep paralysis.

Patient also brought a recurrent dream which bolstered the view that behind the sleep paralysis there was fear of going out of control. Ever since her teenage years - perhaps around 15 or 16 years when she started driving - she would have dreams in which she would be driving and would suddenly find that her brakes are not working. The accompanying affect was that of fear. "For I am a very controlled person. Though at times I have been reckless and irresponsible. But for the most part I hate being out of control."

Now we know from psychoanalytic literature that brakes failing in one's vehicle in dreams is a typical symbol of one's libido being out of control. So once again the theme of this recurrent dream of her vehicle being out of control was continuation of the dream of her passion for her father - walking out of the grandparents house for him - being out of control

In the next session she reported that before the sleep paralysis dreams started at age 10, she had another set of dreams. It was less of a dream and more a weird feeling. It was not a normal dream. For there were no pictures. No people. No faces. It was just a lot of sadness. There was anxiety and fear. "It started when my parents moved in to the house they built. Just before the divorce." 

When I objected that if there were no pictures could it be considered a dream she said well there were two visual objects. Two identical objects one small and other big; somehow communicating with each other.

And she added, "Nothing could make me more miserable than dreaming this very big object communicating with the very small one. I would wake up bowling my eyes out. I would be so scared too."

First she could give no association to the dream of the big and small object. Very reluctantly she said may be the bigger object is being mean to the smaller one.

A construction was made that perhaps it was her mother being mean towards her.

The patient immediately associated to this construction by giving details of how the mother was the disciplinarian at the house and would go overboard with it. "I remind her of my father. But I also remind her of her own mother, who she hates." And then she added, "You are right about the big object being my mother and the small one myself.  For the two objects are always identical. And I am a spitting image of my mother."

So the sadness accompanying the dream of the two objects was sadness over her poor relationship with her  mother.

With help of some more associations, the details of which I will spare you, we could find two further meanings that lay behind that dream.

The big and small objects symbolized the differences between the sexes. Her utter sadness, anxiety and fear attached to the dream were connected with her comparing her genitals with that of male sex and feeling  miserable about it. She claimed that she really feared her father, and felt greatly inferior to him specially when she compared her subdued squeaky female voice to his deep masculine one.
The other mental complex that had found expression was the most interesting. The big object stood for her mother and the smaller one for her father. For her father was short and the mother was tall, and she was always yelling and being mean to him.

It was this meanness of her mother to her father that made her feel sad, miserable and sympathetic towards  her dad. And it was this sympathy for her dad, and the counter impulse that she should side with her mother lest it provokes her wrath that had weaved the dream of sleep paralysis. 

Wednesday, January 25, 2012

The sequence of mood changes in Manic-Depressive illness

After seeing a number of manic-depressive patients I have found that there is a typical sequence to their mood changes.

First there is a high spirited sense of triumph and superiority that is so overabundant that it spills into enjoyment of others miseries and inferiority. This is based on a burst of self confidence and appreciation  - and well justified for manic-depressive folks are generally beautiful people with superior looks, attractive bodies and quick mind - of one' excellent attributes. The person is completely self centered and feels no hesitation in thinking of the death of anybody who crosses one's path.

This phase is followed by emergence of guilt and anticipation of punishment. These two negative emotions are clearly relate to the earlier joy at the plight and inferiority of others. The anticipation of punishment - forewarning of pain - creates great anxiety. To control the anxiety and guilt - guilt itself is kind of anxiety (anticipation of punishment from one's conscience) - all kinds of obsessive thinking and rituals emerge in those whose preferred mode of defense is obsessive, while in the hysterics, body aches and pains emerge to assuage the guilt (through suffering). These obsessive/hysterical symptoms are kind of repentant activities. If the fear of punishment is not placated by these obsessive/hysterical maneuvers, the patient resorts to actually punishing herself - the most favored way to torture is to start dreading the impending poverty which sometimes becomes frank delusions that one soon will be a destitute homeless bag-lady. The psychodynamics behind punishing oneself even before fate (parents) does lies in the following reasoning: let me punish myself which will placate my parents and avert their wrath from falling upon me. When self-torture goes way beyond one's capacity to handle, the person goes into frank depression and ceases partaking of all enjoyments and all activities. The excessive delight at one's superiority during the manic phase is now fittingly punished with the belief that one is utterly worthless.

Today a patient of mine, who I have been seeing for over 15 years, and who has classic manic-depressive illness, and who was in good remission for a long time, came with the complaint that she is very shaky and her son stated that her manic-depressive confusional state is round the corner. When patient was asked as to what could be causing this sudden deterioration, she said that a friend of hers, who she has known for years, and with whom she rode every morning to go to dialysis had died.

When asked how had she died, the patient's face showed a triumphant pleasure. This was certainly against her good sense and perhaps without even her knowledge. She followed it up with the following statement, "She got a kidney transplant. But it did not last for even 2 months. She died. She would have been better off not getting it." I could feel her secret joy at the death of someone who had got the kidney transplant while she had not. But mixed with it was the sadness at her friends death and guilt over the triumph.

Sunday, January 22, 2012

Dream of Jesus coming to one's house and its meaning

A man in his mid-fifties who has suffered from Paranoid Schizophrenia since his teenage years came to the session and requested that I raise his Loxapine from 150 to 200 mg.-   for he is unable to sleep at night.  He cannot fall asleep till 3, sometimes even 4, and to make matters worse he is unable to sleep beyond 7 am, leaving him irritable and feeling out of control for most of the day.

The patient could give no real reason for the decompensation. But when asked if anything has happened which disturbed him, he reluctantly admitted that two people in his church passed away, but he is not sure if something like that could have bothered him to this extent. "They were not that close to me. One was a 60 year old woman, a friend of my sister, but who I knew from 1975, when we were in high school. The other  was an 80 year old man, a retired pastor and his wife is so tiny, like those small people you see on TV, a dwarf, but awfully nice and pleasant woman. But I have a wife at home."

The non sequitur last sentence perked up my ears. And I had no choice but to deduce that "I have a wife at home" emerged at that point to block the full realization of his strong attraction towards that diminutive lady.

Based upon some other associations especially regarding his father, also a retired pastor, when it was suggested that the death of the 80 year old pastor is causing a vicarious satisfaction of his death wishes towards his own father - arising from brutal treatment he and his mother had received from the father while growing up - and the guilt over it was keeping him awake, the patient rejected the construction.

"These two people's death could not have disturbed me that much,"  he got defensive.

But he immediately remembered a dream that he had seen a few days after the death of those two.

The dream was short: Jesus comes to my house and asks me how I am doing. And tells me that when you die you will go to heaven.  I tell Him that I am not ready to die. He says don't worry about it. Your time is not up yet.

The dream was interpreted on the following lines. That since he took responsibility for the death of the pastor and her sister's friend, he deserved punishment. In the dream the wish for punishment had been fulfilled according to the law of talion - eye for an eye - and he had died and was meeting his Maker. However, the wish to continue living was making its presence felt as well. And so instead of his going to heaven to meet his Maker, his Maker was coming to him and far from declaring that he was dead was actually assuring him that his time was not up yet.  Further assurance that on death he will go to heaven was to nullify his fear of going to hell for causing the death of those two church people. Patient had grown up listening to fire and brimstone sermons from his pastor father.

At this interpretation, which the patient fully agreed with, led him to confess that he lied when he said that the death of those two people had nothing to do with his insomnia. In fact he is unable to sleep because he is having racing thoughts ever since their death. But strangely they are exclusively about his wife 's death and not theirs.

"My racing thoughts are all about my wife's funeral and what will happen to me if she dies. I am already mourning for her death. I was doing the same once before in the 1990's when the psychiatrist who I was seeing then said there is a psychological term for mourning for somebody's death even before they die. He told me the exact word, but it was such a mouthful that I assumed it was not meant for the patients to remember it."

"Is it possible that behind the advanced mourning for your wife's death lies the wish for her to actually die so you can be free to marry that tiny wife of the pastor?" I could make that construction because I knew how much that patient, who is over 300 pounds, is attracted towards petite women.

"What an idea." The patient protested. This was expected as he is a very religious man and being unfaithful is out of question for his conscious mind. But he indirectly confirmed the accuracy of the interpretation by stating "it is strange that recently my wife cannot cuddle up enough to me, as if she is afraid I will leave her," and added "I must say that I feel very sorry for that little woman, who is in her fifties, and already a widow.  I always felt sorry for her for being just 54 and married to that 80 year old man. But that is my nature, I get easily attached to people who are suffering."

Saturday, January 21, 2012

Dread of passive homosexual contact underlying obsessive handwashing in a young man

A young man, reported that he has to wash his hands whenever he comes home from outside. He has been seeing me, though very sporadically for the last 8 years for his obsessional neurosis. His symptoms wax and wane, and on this visit he was especially proud that other than for washing hands most other compulsions were under control.

When casually asked as to what must lie behind such a compulsion to wash hands, he replied, "People touch door knobs, gas pumps, grocery carts, and the thought that I must have touched the same objects after them makes me feel so dirty. I have never liked feeling dirty. That I may be taking my hand that has touched these dirty things,  loaded with germs, to my face and mouth, makes me feel so yucky.

"I bite my nails, so it is important that I don't bring those germs inside my mouth."

The last statement made me pay special attention to what he was saying. For we know behind germ phobia lies fear of contamination which is basically a fear of sexual contact. Ultimately the phobia of touching is dread of sexual contact.

And I wondered whether in this young man's case the fear of germs coming in to contact with his mouth and face was not fear of inadvertently submitting himself to passive oral homosexual submission which his ego revolts at and demands that such a repugnant thought must be undone by washing his hands over and over again.

Tuesday, January 17, 2012

Racing thoughts not always indicator of Bipolar Disorder

'Racing thoughts' is a very common symptom, and the knee-jerk reaction of the psychiatrist is to immediately chalk it as a manifestation of  Bipolar Disorder and reach for his prescription pad to prescribe Depakote or Lamictal or some other mood stabilizer.

Today a patient of mine came to the office complaining of racing thoughts which on analysis showed themselves to be the result of an interesting psychological conflict, and if their origin was in some bipolarity gene the connection was not easy to see.

Patient initially was not too enthusiastic about giving any details, declaring that they were nothing more than  random everyday stuff. But on imploring her to describe them anyway, for however fragmentary the recall it may still have something to teach us,  she hesitantly summarized them as brother and sister thoughts and  religious thoughts.  And added that they have been driving her crazy for over a week, and stated that if they persist in this fashion she is headed for another breakdown. She has a long history of slipping in to confusional psychosis when her anger gets out of bounds; a legacy of sexual abuse she suffered in hands of her brothers as a child.

Then the session drifted to some other themes and in some connection she mentioned that her sister-in-law's brother died the other day, which upset her greatly.

"Are you talking about the family of the brother who lives in St. Clair Shores?" I asked her.

"No the one who lives in Florida. It is his wife's brother who died."

"Why would death of someone so remotely related to you, living in another state, get you so upset?"

"Well, I knew him well too. He was a billionaire - [in reality a multimillionaire, but in her eyes as good as a billionaire] - and therefore it would not surprise me if my sister-in-law - for she is that kind of woman - would not go to the court to get part of the inheritance."

"Is that what lies behind your racing brother and sister  thoughts?"

"There is a definite connection. For they started after I heard of his death. But the actual brother and sister  about whom I cannot stop thinking are the lady I take care of - Darla - and her brother. You know Darla, the 93 year old lady, who I have been looking after her for years, doing practically everything for her, taking her to doctors, her hair appointments, the bank, cleaning her house, it is she who I was thinking about, along with her 87 year old brother. It is Darla and her brother who are the subject of the brother and sister thoughts."

"And what exactly are the thoughts?"

"That she is the oldest of the siblings - all her brothers and sisters are dead except for this 87 year old brother - so she must be wanting him to die first, while he being the oldest of the boys  must want her to die first. They both must think they have the first right to outlive the other, she being head of the family, girl wise, and he head of the family, boy wise. But mind you, it is not that they who think that way. All that warped thinking is mine. They are both sick and in hospitals, and God knows what they are thinking. For all you know they are too sick to think at all."

"You would not be thinking about their deaths in this bizarre fashion, and on and on, unless there was some  advantage to you from one of them dying earlier. By the way, the religious thoughts that alternate with brother and sister thoughts must be to counter the evil of the death thoughts."

"Yes, I feel very ashamed and disturbed for thinking about their death in this manner. So to neutralize it I think of holy thoughts which will make God forgive me for indulging in the horrible ones."

"Now these thoughts were provoked by your thinking that your sister-in-law will sue her brother's family to get some of the inheritance. So what is about Darla and her brother that if one dies before the other you stand to profit?"

"Well, if she dies first, he will inherit everything she possesses. Except for her jewellery, which she has specifically willed to me. But if he dies first then I will inherit not just the jewellery but everything else as well. Because she cannot stand her sister-in-law. She has willed her possession to her brother. But if he dies before her, she does not want her sister-in-law to inherit anything for she is not part of the family, in her eyes. She is 93, her brother is 87, and her sister-in-law is up their too. And all three have no children or any other  relatives.

"And funny thing is that none of them have any use for the money. For they are either in the hospital or in hospice or in nursing home, barely hanging on to life. While I can use that money. I have children and grandchildren, and they are struggling in this economy. But I feel bad about thinking so crassly and so I do my best to block such thoughts out. But without success. For they keep returning, especially when I go to bed.  Then I resort to religious thoughts to keep the base ones out of my mind. In fact, I pray that I should get nothing for thinking this way. Not even get the jewellery. For that is what I deserve."

Theoretical discussion:

The racing thoughts which have become such a part and parcel of the symptomatology of Bipolar Disorder are really obsessive thinking. They occur in Bipolar Disorder, but can occur in lot of other illnesses as well. They were viewed as deliria of obsessional neurotics by Freud, and he considered them as secondary and tertiary elaboration of the original obsessive conflict. Mood swings occur to control the obsessions. When one triumphs over thinking of the bad thoughts, the person goes into uplifted spirits, till the obsessions return and anxiety takes over. A blockage of all thinking results in melancholic mood.

Behind the racing thoughts lie anxiety/fear. The affect which compels one to run away from dangerous fearful situation/object. When we cannot run away with our feet, we run away with our thoughts. The woman was really running away from her wish that the brother die first. But such death wishes were contrary to her religious upbringing and therefore she was invoking the religious thoughts to help her suppress the unacceptable death thoughts. But the idea that her children and  grandchildren can use that money much better than those octagenarian sister-in-law who has no children and on whose death all that money would go to the State, would not leave her thinking process at rest. So it was these two contrary impulses, unable to cancel each other out, that were fueling her racing thoughts.

Monday, January 9, 2012

Dream within a dream and its psychoanalysis

A young man in his late twenties reported the following dream which he had dreamt two nights in a row. He labelled it as dream within a dream.

I awaken out of a dream only to find myself in my own bed in my own apartment. My wife is standing next to the bed , fully dressed, shaking me and asking me if I would like her to make me a cup of coffee. I say "yes please", and as soon as my wife leaves the bedroom I fall back to sleep only to find myself in a dream within a dream in which I remember no details.

I didn't even realize I was dreaming until I got up and had to make my own cup of coffee. For only then I realized that my wife could not have asked me if would like coffee for me for she was at work. So my waking out of the dream, and the subsequent interaction in the awake state with my wife, was also part of the dream.

When asked if there was any difference in that recurrent dream from one night to the next, the patient said on one night she offered to make coffee while on the second night she offered to bring a 4-hour energy drink.

Neither the patient nor me initially could make any sense out of the dream. The associations were scanty and soon we drifted into exploring his other dreams, one of which was of his getting chased through an underground sewer with his wife, with menacing authorities, like policemen from some science fiction movie,  shooting at them. The menacing authorities were without difficulty analyzed as father substitutes.

Patient then recalled that on both the nights he was feeling extremely angry towards his uncle which was preventing him from falling asleep for hours.  From previous therapy sessions I was aware as to how much hatred and anger he harbors towards his father and his uncle, his father's brother. For the father had been physically and verbally abusive towards the patient throughout his childhood. "Always pissed and always critical" was his judgment upon his father. His uncle had become entangled with the imago of his father for in his late adolescence, to escape the tyranny of his father, he had moved to Indiana to live with his uncle and had found, after a short honeymoon period, that the uncle was a spitting image of his father - verbally abuse, bipolar in his anger, and highly critical.

His current rage towards his uncle - behind which lay his rage towards his father - was precipitated because around Christmas time the uncle had ordered him to take his mother - patient's grandmother - to her Florida home for the winter.  The patient had declined to do so because of his agoraphobia. The uncle had then flown in a rage at the refusal, and the patient was anticipating harm from him. He declared, "My  uncle is still holding a grudge against me, despite my calling him three times to make amends."

On the nights of the dream, he could not fall asleep until 6 in the morning, fuming at his uncle and also fearing that if he [patient] runs in to him [uncle], the latter will physically attack him. "My uncle is a man who is always talking guns, going to gun ranges and getting even with all those who have crossed his path. He is truly bipolar and you can never predict when he will flip his lid and lunge at you."

It was easy to analyze the dream then. The anger at, and hence fear of retaliation from, his uncle was preventing him from falling asleep. Finally the sleep had come. But the angry thoughts and fear of retaliation which had retained their cathexis (charge)/strength - could not quieted.  And they were acting as a disturber of sleep. The disturbance was handled by the emergence/creation of the dream which was telling him to not bother getting up because he was already up and in the safety of his apartment and not only that but also getting catered to by his wife.  This was what the dream was showing, taking away the need to actually get up, and allowing him to continue his sleep. The dream's purpose was to show him not in a dangerous place where he had to fear his father and his uncle, and other menacing forces,  but in the safety of his own apartment, in his own bed, and with his protective wife around.

His falling back asleep and then dreaming inside the dream where there were no details was the fulfillment of the wish to sleep with no disturbances. A sleep in which there were no arousing factors,  no return of the memories of his abusive father, his revengeful uncle, and host of other enemies, for he had been repeatedly victimized growing up by his peers. So his wish for a dreamless peaceful sleep was getting fulfilled by dreaming of a dream which had no details - a dream with no disturbing elements.

The 4-hour energy drink was a kind of reassurance that no you are not asleep but awake because your wife has given you a drink which will keep your alert and vigilant for at least four hours. He told me that when he woke up at around 10 O clock he noticed he had slept for exact 4 hours. 

Sunday, January 1, 2012

Tracing the psychogenic origin of psychogenic polydipsia in an anxious woman

A woman in her late forties, a divorced mother of two children, who sees me for anxiety and insomnia, revealed that she loves to drink water, especially when she can put lots of ice in it, and loves the sound of the ice cubes clicking in that tall glass.

"How much water do you drink?"

"As much as I can. Easily 15 to 16 glasses a day."

The patient was astonished to learn that so much water is bad for her, and that anxiety and insomnia could be getting worse due to excessive water intake and shot back, "I always thought the more water you drink, the better it is for you. It flushes everything 'bad' out of you."

"I am not quite sure how much bad it flushes out of you, but it sure flushes the salt out of your system, and if the serum sodium gets too low, it causes anxiety, and if your heart and kidneys get overwhelmed with water, unable to pump or excrete it out respectively, a whole lot of other problems start, including swelling of your legs, and other areas of your body, including your brain."

Patient stretched out her hands to show me her fingers and admitted that her fingers are swollen, but could not believe that water could be harmful. She insisted that everybody tells you to drink more water. Every health  guru tells you to flush your system. Can they all be wrong? For besides cleaning your system, water fills up your stomach so you don't feel hungry. "You kill two birds with one stone."

"But at a huge price," I added. "It keeps you anxious, ruins your kidneys in the long run, and is an extraordinary burden upon your heart, which has to pump extra fluid through the circulatory system. So don't drink water unless you feel thirsty."

"I only drink when I am thirsty. I am always thirsty."

But then she changed her mind, and admitted that it is not thirst that makes her drink but perhaps an obsession to drink, and an obsession to hear the sound of clicking ice. She confessed that she drinks so much water that she has to go to the bathroom all night long. She is up every hour of the night emptying her bladder, and no wonder gets no sleep.

Tracing this obsession of hearing the sound of clicking ice led us to discover that her father and mother both were alcoholics. And it is the ambiance of drinking that she wants to create in her life."It is like the drug addicts. They too are more in the ambiance of doing drugs than seeking the actual effects of the drugs. I too perhaps want the ambiance of drinking but without the stupid effects of alcohol upon my mind," she said.

Patient added that she hates drinking. She cannot stand the smell of alcohol and can spot someone who has had even a single drink. She had to share a bedroom with an older sister who was a drinker, and she detested her drinking, and it was not hard to decipher analytically that behind that detestation of alcohol lay her dislike of her sister and behind that her Oedipal rivalry with her mother.

Further comments by the patient revealed that under the excessive water drinking was the unconscious wish to flush her mother out of her system. The clicking of ice was connected with her mother taking two glasses of brandy every night. The mother worked hard all day long and felt she was entitled to two tall glasses of brandy at night. She (mother) did not consider herself an alcoholic.

"My mother was an obsessive like myself. And did everything in excess. If she smoked, she smoked a packet of cigarettes in 2 hours. She did not all day long, but once she poured that brandy in that glass, she had to chain smoke and finish that entire packet in couple of hours. Quite often there would be two or three cigarettes lighted at the same time. When she drank she developed "ratchet jaw". She was afraid of my father, and his ugly drunk self. She was always inhibited and quiet. But when drinking she could talk and talk. She would call one person after another and gab endlessly.

"I am the same way but with water. I don't want to drink or smoke. But perhaps my desire to imitate my mother and be a drinker and smoker like her I do so through obsessively drinking water. The only thing I permit myself in which I actually become my mother is to click those ice cubes in the glass. Rest of everything about my mother and all the other damn alcoholics I detest, and want to flush them out of my system."