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.