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.

8 comments:

  1. I enjoy your explanation for the religious thoughts ...to nullify/neutralize the evil ones.


    Is this generally accepted hypothesis? Is it only in Manics/obsessions that the theory would apply?

    lm

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  2. Religious thoughts also have other functions, but ritualistic chanting of mantras or doing Hail Marys or counting rosaries while praying they are all maneuvers to keep the evil thoughts at bay or to neutralize them.
    It was first described by Freud.
    It is true, and to anybody who knows how to listen to his patients, it is a fact and not a hypothesis. The phenomena is not limited to manic-depressive illness and obsessional neurosis but true across the board.

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