Friday, May 25, 2012

Restless Leg Syndrome, Cracking of joints, Fibromyalgia, Catatonia: different manifestations of Obsessional Neurosis

A young man, now  21, developed severe obsessional neurosis at the age of 16 when a disfiguring bone tumor emerged on his left upper arm. The tumor, though benign, could not be removed right away because the growth plate next to it had not matured and early resection would have shortened the arm. So he had to live with this growing menace for a couple of years before the surgeons finally went in and removed the unsightly growth.

 During this waiting period, the obsessions grew by leaps and bounds.

In the session the patient insisted, and the mother who came with him, agreed that the whole of his mental problems could be accounted for as a reaction to the  emergence of this misfortune. But a more careful history taking revealed that he was given to severe temper tantrums even earlier, and in fact they were already so severe by the time he was 13 that in his fits of anger he would put holes through the walls of his house, one time he had shattered a flat screen TV, and mother added that every cell phone bought for him had been smashed via getting violently hurled upon the floor.

It was easy to see that the narcissistic injury that had changed this wellspring of anger to frank obsessions was the disfigurement - the tumor was very embarrassing and scary to him - but its pathological strength appeared to have been derived from the repressed wish  for the misfortune to have struck his younger brother instead of him. This younger brother was his rival from the earliest childhood. His earliest memory is of his rage at his brother and the  first time he put a hole in the wall was when he saw his brother wearing his clothes.  

The patient then gave a whole series of obsessive symptoms which were all manifestations of saving his mother from his death wishes or getting even with his father. These obsessions the patient had to admit were present even before the tumor emerged. From a young age he would check and recheck the stove twice, and sometime three times, to make sure that some bad luck does not befall his mother or him or his entire family.  Patient added that it is crazy for he loves his mother very much so he does not understand why he is preoccupied with her death.

The patient then shifted to describing his obsession with symmetry which were to get even with his father who had left the family when he was 2. Anything that was done towards right side - all activities had to be initiated by the right hand - had to be countered by similar action towards the left. Also the number of times something was done towards the right side had to be counter-balanced with exact same number of times towards the left.  He then added that this obsession for symmetry is what lies behind his Restless leg Syndrome. He may spend hours moving his body right and then left, leaving him awake and exhausted through the night.  His mother added that yes, he has RLS. It is painful to watch him in his bed, for he  moves his leg this way and then the other way all night long, vainly trying to fall asleep and even after he falls asleep, often the movements continue.

Patient added that his Restless Leg Syndrome extends to his hands as well and coming to think of it to his whole body and that Restless Leg Syndrome is just a mini-version of Restless Body Syndrome. "I am always on the run, day and night, and my body is still running mentally as I lay there in bed. Restless Leg Syndrome is nothing but my running away from the disaster that is about to happen to me or my family." He then gave some details of his Restless Hand Syndrome. He had to  move his wrist in clockwise and then counterclockwise direction. This process started with having to make wrist motions to make sure that the stove is turned on and off : starting the fire and then undoing it.

All these movements causes constant muscle tension and pain which is only relieved when he cracks the joints. Patient said that the cracking of his joints gives him pleasure and it is part of his OCD. It is no different than checking and rechecking the stove.  He demonstrated this cracking of joints, which were, as claimed, impressively loud, in his knees and neck. He did not say so, but the way he described his body aches and pains they could easily be viewed as fibromyalgia.

When asked why he has to crack the joints, the patient claimed the tension in his muscles locks them up. In my mind this raised the thought that catatonia itself perhaps is no more than an extreme form of muscular intent in cross purposes rendering the person immobile (catatonic) - and mobility is restored to them only if the joints to which they are attached is cracked.

That the cracking of joints is a from of OCD is furthered bolstered by the following case that I saw recently.

A 15 year old girl, who is depressed for years over her parents separation and their neglect of her, and who because of her overweight gets bullied at school, and who fights with her sister all the time to discharge her aggressive impulses, reported that she has a tough time stopping herself from cracking her knuckles.

She gave the usual explanations that it is a habit, that it makes her feel good, but there was little doubt that it was continuation of her obsessional defenses. For every time she cracked her knuckles in her right hand she had to do it in her left in a symmetrical fashion. At one telling demonstration in my office she cracked her knuckles, then touched the mobile phone which she was holding between her thighs and which was sticking up from her pubic area as a symbolic penis, and then symmetrically touched her right and left knees. The touching of the upstanding phone was no different than how obsessive-compulsive must touch a particular part of the body which is symbolic of the penis every few minutes. In many obsessives the touching is quite openly of the genital area.

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