Saturday, March 30, 2013

Panic Attacks as imitation of death

A woman in her forties who has suffered from relentless panic attacks and chronic anxiety from the age of 19 gave the following reason as to why she came down with the illness.
She was a newly married young girl who had moved with her husband to a small town in Upper Michigan near an Air Force base. She already was mother of two children, an year old boy and a 2 month old perfectly healthy girl.
Her arrival at the town was immediately followed by her newborn getting sick. The baby stopped tolerating whatever was fed to her. Numerous brands of formula were tried, but she just threw up all of them. And one day, when she was barely 3 months old, she took turn for the worse. The mother begged her sister-in-law to drive her baby to the doctor for she did not have a car but the latter found some excuse to not do so. Two days later the little girl, just 3 months old, died.
Just before death, a 911 call was made, and the policeman who had accompanied the paramedics to her house, told her, that his son too had died a similar death, and it was all the fault of the Air Force base who were discharging their chemical wastes into the water system.
The death caused a devastating depression in the mother, which only abated, and partially, when she started investigating the cause of the death, spurred by that policeman's remark, and found that 8 other similar deaths had occurred in that small town. All eight were children, all below the age of one, and all had died of arsenic poisoning. The more she explored this matter the less depressed she felt, but at a price. It seems as if another affect had to emerge in place of depression to extricate herself from the latter - a rage at the Air Force base for allowing the arsenic to seep in to the drinking water. She became convinced that the planes that were flying above her - the air force base was just a mile away from the apartment complex - were dumping chemicals in the Huron Lake - which was right next to the complex - and that was seeping in to the well water. Her investigation also led her to ask the local health authorities as to why she and her husband had not gotten sick from that contaminated water and was told because they were older and could tolerate small amounts of arsenic that was present in the well water. The same explanation was given to her as to why her year-old had not gotten sick, for his water needs were mainly being met by the same food and drinks that the adults were eating -  obtained from the local supermarket which got all its supplies from outside the town.
She approached the Air Force personnel but they refused to take the responsibility for the deaths, claiming that the arsenic in the well water had nothing to to do with them but was naturally present in that region. This did not satisfy the patient, and the rage she felt towards them continued to deepen, finally culminating in panic attacks. The panic was a defensive maneuver to prevent the rage turning into actual destructive behavior towards the Air Force people. The panic attacks which soon spilled from discrete episodes into chronic anxiety and were accompanied by the emergence of agoraphobia. The rationale of agoraphobia was to prevent her from coming anywhere near the Air Force base where losing control completely she could have attacked those people. Within months the agoraphobia worsened and was no longer limited to avoiding the Air Force base but extended to every thing that was of any distance from the house, the radius of which kept on shrinking. At this point she had a big fight with her sister-in-law who had reneged from her promise to take the child to the doctor and who lived in the same apartment complex. She stopped talking with this sister-in-law on whose invitation they had moved to that town and then their apartment itself came under prohibition and she had to leave town.
She came back to Metro Detroit where she had grown up. But this physical distancing herself from the site of the trauma did not resolve the problem. Her husband, the only living representative of that painful period now became the reminder of the Air Force base, and the object of the phobia. She blamed him for moving them to that infernal town at the invitation of his sister, it was he who had failed to take heed when she pointed that the water looked cloudy and which he had dismissed as a joke by quipping that the water must be full of vitamins and hence cloudy and good for your health rather than bad, and any contact with him provoked the same panic reaction. This left her with no choice but to divorce him. His becoming an alcoholic, perhaps to deal with his own sorrow at the little girl's death, also played a significant role in her opting for the divorce.
Twenty-five years later, when she came to me, she still suffered from panic attacks, which were characterized now primarily by the feeling that she is about to die. Analysis showed that behind this feeling of dying, which provoked the 'flight response' and gave rise to the phenomenology of panic attacks - sinking spell, breathlessness, rapid heart rate, sweating, all physiological responses that one would experience if one was physically running - lay fantasies of going and murdering the Air Force base people and then getting killed as a punishment. And as the illness progressed this aim went beyond its original purpose - the hatred of the Air Force base changed into hatred of the world in general and even her husband.  And when she could not move away any further from people physically her mind started running away from people in imagination, which was reflected in her racing thoughts and pressure of speech.
But the rage which was fed by the loss of her daughter and which was permanent and incapable of getting undone in reality, still pressed for discharge and still wanted some live person to be punished. After leaving that town her husband had served the role of the whipping boy. But once she divorced him and he was no longer available, the rage was forced to find complete strangers as representative of the Air Force Base. But since one cannot attack every person one runs in to unless one goes outright psychotic, she had to express this hatred by becoming eccentric and goofy-headed in dealing with people. This goofiness which made people think of her as mentally imbalanced and someone to be avoided was now her expression of revenge.
But the rage was still not quelled. Even after the isolation was more or less complete, the rage persisted. And finally with no live person left to kill she made part of herself as that object, the representative of the Air Force Base. And it was this part of herself that she felt as dying when she would have panic attacks.
It is interesting that her nightmares repeated this process in sleep. They were PTSD like in their structure. The dreams would start as typically wish fulfilling. They would first show her daughter alive. The patient would then be filled with happiness. The daughter would not just be alive but would be shown blossoming through different stages of life, from 3 months onward to a young school girl, to a teenager, to a fully grown young woman. She would be surprised at knowing that she had not really not died but had survived the arsenic poisoning and that they had moved back to Detroit where she had grown up. But even the dream would not maintain the facade for too long, the underlying rage would rear its ugly head and reality would break through. And soon all the villains, including her ex-husband, would take the central stage of the dream. And finally she would wake up in a panic fearful of her own death.
I would not be surprised if a similar imitation of death underlies the sleep apnea - an imitation of one's death to satisfy murderous impulses towards others. Even "the sinking feeling" that patients describe that precedes full blown panic attack may be a premonition of death. For we know that in dreams death and rebirth are often depicted by the same symbol: drowning.       

Thursday, March 21, 2013

A mourning dream and what Hospices will do to seriously ill

A woman in her early thirties, whose father had died just 2 weeks ago, declared that she was too upset to talk and if I could just write her prescriptions and end the session. Then added that she had the strangest dream last night about her father but could not be persuaded to tell it.

Soon the reason for being upset - besides the father's death of course - emerged. She felt that the hospice people who were entrusted with his care were more interested in seeing him dead than restoring his health. She felt she had been robbed of her father by them.

"I am so angry at myself for not being able to help him. He still had life left in him and did not want to die yet. He would frequently get fully alert and did respond with warmth when his life long buddy Joe came to see him the day before he died.

"He had a heart attack in 2002, had COPD and bad knees, periodic blood clots in his calf muscles, and he could not walk because of the peripheral neuropathy. But none of these conditions were bad enough to kill him. I think there was something more to his death than natural causes. How in the world could that woman tell us that he was going to die in two weeks with such surety unless she was secretly engineering it? And when I asked her as to what was she seeing in his condition that made her so certain about the exact time of his death she got really nasty. And then suddenly the prediction was changed from 2 weeks to 48 hours. And when I reexpressed my doubts, she went ballistic and told me to stop asking her such questions for she was a professional hospice nurse who had overseen the death of countless people, and it is very humiliating for her to be questioned like that. And I could do nothing about the callousness of those evil people. For even my  mother sided with them, and so did my brothers and sisters who were like 'well it is time for him to go, let us not interfere with what is going on'. They are such cowards when it comes to confronting authorities. They would not let me take him to hospital and ask some real doctors at the ER as to why he must die in 48 hours. There was nothing going on to explain his rapid decline except for that morphine drip which I think that bitch was ratcheting up every few hours. And then her prediction changed from to 48 to 24 hours, though she managed to kill him in 18."

I commented that in my experience whoever goes under the care of Hospice never comes out of it alive. Perhaps they are paid a fixed sum to take care of someone presumed to be terminally ill and therefore earlier the person dies the more money they make. And perhaps they are penalized if a person is admitted into their facility as terminally ill and later this assumption is proven wrong. This impression of Hospice I had formed based upon seeing every single patient, with the exception of two, sent by to me to Hospice dying in matter of days to weeks. And even these two could only be saved because I was requested by the family to intervene. One was an 82 year old lady who was terminally ill because they had had her comatosed with excessive amounts of morphine and antipsychotics. Simply stopping her medications not only brought her back to normalcy but such a dramatic improvement that today, eight years later, she is still alive and, believe it or not, went on a Caribbean cruise on her 88th birthday.

Another incident that convinced me of of the lethality of hospice was the untimely death of a friend of mine. He suffered from pulmonary fibrosis, a medical condition which leaves very little capacity to breath. He was undoubtedly going to die but in my judgment still could hang on to dear life for an year or two. He went into the hospital walking, gasping for breath of course,, but still walking. Once stabilized I thought he would go home. But his internist, instead, referred him to a hospice. They came over and took charge of his care even before he was discharged because there were no beds available in hospice and managed to kill him with their morphine drip in less than 24 hours.

On hearing with what contempt I hold Hospices a floodgate of anger was opened in the patient enabling her finally to tell the dream.

I was at the funeral home in which his viewing had taken place. There were a number of mangy cats crowding the parking lot, strangely some resembled my father. Next scene was of his being laid out in the coffin. I was kneeling down before him. The coffin was rather high as if on stilts. I saw him move. He looked alive. I thought to myself that he must be thirsty and therefore he is moving like that. [Just before dying he was thirsty and I gave him juice and water on a sponge which he drank  greedilyThose hospice people were so focused upon his death they had no time to quench his thirst.] Then he started walking out of the coffin as if he had a surge of energy. I was worried how he will get out from that height. But he was strong and vigorous, just the way he had been all his life.  But as he made his way out of thet room,  the hospice people and my mother went in to action.  I noticed that he was still embalmed. I was in pains for him to not notice it. I tried to stand in front of the coffin to hide it from his captors and prevent him from realizing that he was dead.  But they managed to force him back into it and he died all over again.

The dream was obviously an attempt to undo her father's death to whom she was very tenderly attached. The mangy cats were the hospice people and her siblings ( who resembled her father). They were mangy for they hastened his death. But it was also a projection of her own ambivalence towards her father, which is present in all children towards their parents. "She is the one who is doing everything possible to keep her father alive while the siblings, the mother and the hospice people are trying to kill him." His coffin being high up, almost unreachable, was exalting his status to such heights that it would prevent her and others from doing him any harm (desecration) now that he lay dead and helpless.Seeing his father strong and vigorous as he moved out of the coffin was of course the desire to bring him back to his former self that she had loved all her life and undo his death. Preventing him from seeing the coffin and noticing that he was embalmed was to prevent him from noticing her wishes for him to be dead (the ambivalence) .With hospice people and her family bringing him back into coffin and killing him again was absolving herself from all guilt for his death. For much of her day time now is being spent upon feeling guilty for not fighting enough on his behalf with the Hospice folks. A guilt which all of us feel no matter what the cause of the parent's death and whose roots lie in the invariable presence of unconscious death wishes towards one's parents.

Saturday, March 16, 2013

An assurance dream in an overly conscientious teacher

A young school teacher who worries too much about making mistakes in her life and professional work,  who dots every i and crosses every t dreamt the following:

A student of her approaches her on the school corridor and states that she is a girl but wants to be equal and therefore wants to become a boy.

There was nothing more to the dream, she insisted.

Associations revealed that she had attended a LGBT conference for teachers a few days earlier. The conference could not emphasize enough the need to be sensitive to budding lesbians, gays, bisexual and transgender children, even in the elementary school. She teaches the sixth grade.

After the conference she had begun to worry whether she had missed out on some lesbian, gay, bisexual, transgender student's needs and was not utilizing her 'skill sets' up to par. Now all this worrying was taking place in her unconscious, for in the conscious mind other than feeling pressured and running from one thing to another to have everything perfect, which she anyway always does, she gave no further thought to the conference till she ran in to the girl who became the subject of her dream. In fact she had no idea that she had had this dream till the girl, who was not in her class but had been her pupil in a previous year and of whom she was fond of, had waved at her on the school corridor. This girl had always amused her by her high spirits and tomboyish ways. And so she served as a good object for the dream to weave fulfillment of the wish.

But what wish?

Was she identifying with that girl and accepting her own wish to be a boy in this world where the female sex is often subjected to so much disadvantage? This could have been a possibility though at the deepest level, for she is quite happy with her boyfriend living with him and looking forward to getting married in near future.

At this point another dream that she had related to me in a previous session came to the rescue.

This was a laconic dream too. Her obsessive nature objects to every form of transgression, which also reflects in her dreams. She rarely dreams, and if she does, they are just one liner, more or less repetition of some scene from daytime, as if any massive enjoyment or excessive emotions is objected to by her overly watchful conscience.

In the dream: She was driving to work and had forgotten to pack her breakfast with her.

Even in the dream she had felt that this was impossible, since she never ever forgets to take her breakfast which is invariably a nutritionally fortified shake, and which she drinks while driving to work.

Analysis had revealed that this dream had occurred on a night when she had some important thing to do at school the next day and she was worrying about reaching on time and doing it right. The worry was disturbing the sleep and the dream had emerged to counter the worry by assuring her that she is as likely to be late and not know how to do the job as she is likely to forget to pack and take her breakfast with her in the morning.

The dream of the tomboyish girl approaching her and declaring that she wants to become a boy was constructed on the same pattern. It was to assure her that she can stop worrying that she is not using her newly acquired skills on how to help her pupils with LGBT issues. For in the dream a girl had approached her with gender and orientation issues and she was being sensitive to her needs. 

Wednesday, March 13, 2013

The purpose of yawning is to stall sleep

Two score and two years ago, as a medical student, I learnt that the medical science does not know why we yawn.

Yesterday, I came across a patient whose yawning and the accompanying behavior threw some light on at least one of its functions in humans. It was but natural then to Google and see if some whippersnapper had not already arrived at the same conclusion. To my pleasant surprise - for that gives me justification to post my observation - researchers are still in dark as to why we yawn.

The most interesting link was to a New York Times article by Nicholas Bakalar - date Dec. 13 2010. And this is what he had to say : Everyone yawns, but no one knows why. Yawning starts in the womb, and most vertebrate species, even birds and fish yawn, or at least do something of the sort, but its physiological mechanisms, its purpose and its survival value remain a mystery.

My patient is an interesting middle-aged single man who carries the diagnosis of Developmentally Disabled though his intelligence is normal. His pathology which erroneously gives the impression of mental retardation is confined to stuttering, autistic traits, social awkwardness, OCD, occasional chastising hallucinations, and a surplus of rage.

The patient had come to the office all set to enthusiastically embark on his session. But that day I was running unusually late, and this extremely controlling patient, who wants everything on his term, did not like the put-down one bit. And therefore when his turn came, he had nothing to say. In fact within minutes of starting the session he declared that he was all done and ready to leave because he had errands to do.

It was a classic tit-for-tat for making him wait.

When told he cannot leave earlier than his allotted time per rules of treatment, he first felt his bald pate by sliding his open palm over it as if to make sure he was there, then closed his eyes and brought his hand down to squeeze the root of his nose between his thumb and middle finger as if in deep thought, and then wearily opening his eyes began to yawn.

The purpose of his yawning to the trained eye of the psychoanalyst was crystal clear:

it was unequivocally saying: I rather be somewhere else and if I cannot do so by walking out of here I can at least do so by becoming oblivious to you through falling asleep and dreaming of being somewhere else.

But there was more than just an avoidance through sleep. There was also a contrary impulse: a struggle to not fall asleep as well. As if outright sleep would be too contemptuous and would upset the social balance between him and me. And though it looked as if the yawning was to usher sleep its true purpose was just the opposite: to prevent him from doing so.

There was no doubt that the whole behavior taken together was a show of counter-contempt and expression of boredom - if I had been uppity towards the value of his time he too had nothing of worth to tell me either. But yawning by itself was not promoting sleep but activating him to keep awake.

So this observation contradicts the view lay people and many scientists take it as self evident: yawning occurs when we want to go to sleep and no doubt it is there to aid sleep. In reality it is an attempt to halt it.

In my patient's case full blown asleep would have been too defiant, and anyway it was not practical to do so in the middle of the day. So he was trying to stall sleep and the physiological mechanism that was being used to achieve the aim was activation of the yawning reflex.

But how does yawning promote wakefulness?

I think by opening the mouth wide, gulping a huge bolus of oxygen and tensing up the muscles around the face and upper torso, the person [at unconscious level] signals to the brain that "look you got to be awake. It is not the right time or the place to fall sleep." The increase in oxygen supply and the rise in muscle tension sends the message to the neuronal circuits that promote wakefulness that it is time to stiffen and gear up, not cut down on your oxygen consumption and call it a day.

In my patient every yawn was followed by a clear, though brief, increase in alertness. And in those moments of flickering arousal he would look at me with an expression which seemed to say "don't take my rejection too seriously, I still respect you, I am still paying attention to what is happening, you are not boring, look I am trying my best not to fall asleep on you."

But this heroic effort to honor me was contending with the counter impulse to break contact with a painful world which had shown no respect for his time and had undervalued him. The ambivalence on the patient's face was clear: aggression/contempt/disdain for me alternating with the counter-impulse to not push the envelope too far.

Now the New York Times article tells us that the scientists have given up on the theory that yawning occurs to increase oxygen supply to the brain. The argument goes that increased oxygen supply can be more effectively achieved by increasing the rate of breathing.

Perhaps the scientists abandoned the oxygen theory prematurely. For it has some merit. Yawning increases the oxygen supply not on a sustained level, as would be required while exercising, or playing sports, and which would be best achieved by rapid breathing, but a brief bolus of oxygen in to the system could be used as a signal to the brain that it is not time to decrease your oxygen consumption but to continue it at the current level to maintain the waking state.

If the purpose of yawning is to activate some parts of the brain to produce wakefulness, why does the person not become fully awake after a yawn of two? Why do humans go into serial yawning and why it is so infectious?

We have already discussed that yawning expresses an ambivalent state of mind. There are two contrary impulses wanting to find expression together and a compromise is reached in which the boredom and sleepiness alternates with yawning which wants to kick-start re-engagement with the world.

It may not be amiss to add that this re-engagement is psychologically effected by activating some quiescent pleasant memory which is somehow associated with the boring situation/person and may induce a fresh interest in what is going on. And this mechanism is perhaps mediated by dopaminergic neurons.

Why dopaminergic neurons and do I have anything to back up such a speculation?

Well there is a chemical which artificially activates yawning. It is called Apomorphine. Since it is attenuated form of morphine it is a narcotic and promotes sleep. Yet, it is a dopamine agonist, a stimulant, which simultaneously promotes arousal and attention. So the chemical apomorphine seems to be heaven sent to confirm my hypothesis that yawning is like a front that expresses two contrary impulses: withdrawal/sleepiness and struggle to maintain wakefulness. And from my previous entries in my blog, specially on the matter of addiction and ADHD, we know that dopamine is a neurotransmitter whose main purpose is to repeat experiences of satisfaction [produce stereotypy of pleasant behavior]. So the release of dopamine in a yawning person is to stimulate pleasant past associations with the current situation/person and reawaken new interests.

Yawning is catchy because if one person signals that I am bored and I have to yawn to keep my focus on you then others counter it by sending the same signal back - you are not worth my attention/wakefulness either. It is similar to how children handle insults. If a child tells somebody that you are a liar, you can count upon getting an immediate retort: "And you are another."

But imitation of yawning may not necessarily be a retort. In a group if one person finds the situation/ surrounding boring and yawns then others follow suit as if to lend support to him: "yes, yes, we second your feelings. What is happening here is not worth our attention either." Here it is more following the leader than tit-for-tat.

Yawning as an expression of disdain as well as an attempt to not make the contempt too blatant was first driven home to me a long time back when I was being ousted as the Acting Chief of Psychiatry at the VA hospital Allen Park. Having brought too many changes too soon and never the one to mince my words when expressing contempt of superiors if they were on the wrong or foolish, I was being stripped off the post.

And the ousting took place in a board room where a bunch of doctors were assembled. They were all tense as the Chief of Staff started reading to me the riot act. The tension was palpable because they expected a spirited comeback on my part. But to their surprise and mine as well, I had hard time keeping my eyes open to what was being said. I found their anger towards me stupid, and knowing that protest was useless, and the whole affair not worth even paying attention to for my fate was sealed, I had tough time keeping awake, and that is what must have triggered the yawning reflex. For I yawned with abandon. And I could not help but notice that the pain of getting dressed down and stripped of the post would temporarily abate while I would be tensing the muscles of chest and my face for the act of yawning. As if that muscle tension was discharging the aggression towards the people who were harming me and consequently generating sensation of pleasure.

Is there any condition where yawning occurs pathologically?

Yawning is a prominent symptom of narcotic withdrawal. Along with diarrhea, muscle and abdominal cramps, runny nose, sweating, tremors, irritation, anxiety, goosebumps there is yawning. Yawning in severe withdrawal can happen every couple of minutes.

One of my patients reported that when she is withdrawing from narcotics she yawns continuously. She gave the following explanation for doing so. Her withdrawal is always marked by high anxiety which turns into nightmares and cold sweats when she falls asleep. So sleep becomes a dreadful and frightening affair which causes insomnia. However, one part of her mind tired from days of abuse and pressured living craves for rest. So the tug-a-war between keeping awake out of fear of dreaming dreadful things and the wish to sleep out of exhaustion sparks the yawning.

She added that only other way to combat sleepiness besides yawning for her is to get absorbed and keep the mind super active with something like cleaning the house or going back to her job as a waitress and make some money. Now both these activities obsessively cleaning house and feeling good about working and making tips are pleasurable activities which secrete dopamine. She reported that yawning also results in a slight improvement in her mood. While yawning her dysphoric feelings abate, though only while she is stretching and tensing the muscles and there is a definite feeling of pleasure though very slight in intensity. In her case yawning is interchangeable with other pleasurable activities and all of which are mediated by dopaminergic neurotransmission.

The original physiological purpose of yawning appears to be part of the orchestrated neurodevelopment which no doubt occurs as a sequential activation of one part of the brain after another. Yawning may play a role in this complex activity through activation of motor neurons which tense the muscle around the mouth and upper torso. This tensing of muscles perhaps releases dopamine which may play a role in making bridges between already active neuronal circuits with freshly activated ones. This physiological reflex which evolved for neurodevelopment appears to have found a side purpose in humans to signal boredom, express contempt and counter the impulse to go to sleep.

ps 3-13-13 Today I saw a patient who once again confirmed by hypothesis that yawning developed as a mechanism to stall sleep. This young man is not getting along with his girlfriend. In the session when he broached this issue within a short time he was flooded with painful emotions and instead of going further with what he had to tell he indulged in a giant yawn. From his expressions I could not help but notice that as soon as his conflict with his girlfriend emerged in his consciousness he first tried to talk about it but as the pain associated with the memory followed in to consciousness he lost interest in the talking and tried to withdraw in to sleep where he could turn the painful memories into pleasant ones through the mediation of dreams but on realizing that it would be not appropriate to fall asleep in front of me he yawned to activate the neuronal circuits connected with wakefulness.  

ps. In the Wall Street Journal 7-16-2013 I read a small write up titled "Why you may yawn less in the summer." It quoted a study which conducted an experiment with two groups of people. One in early summer and the other in winter. They were made to look at pictures of yawning and encouraged to talk about their own yawning behavior. It was found that people were more likely to yawn during winter than early summer months. The reasoning given was that in winter yawing would reduce the brain temperature more. This is not a joke. The study was published in impressive sounding Frontiers in Neuroscience so it got to be true. Yet the question arises why would anybody want to reduce his or her brain temperature especially in winter when you would want to conserve heat. The article claimed in summer the outside temperature was closer to body temperature so the cooling effect was not as robust as during the winter so there was less benefit from yawning.

Now my own experience is that in  uncomfortably hot weather too the tendency to yawn increases. And the explanation may be simpler. When it is uncomfortably hot in the present then a person wants to go to sleep so he can dream of being in the Alps or better still on the peaks of Himalayas. If one is in cold weather the desire to go to sleep and conserve energy is even stronger. So whenever one is in unpleasant surroundings one way to escape from it is to go to sleep. But if it inappropriate to fall asleep in the situation then the yawning mechanism kicks in to activate the wakefulness centers of the brain. Since cool air is a sharper stimulant than air that is nearer to more comfortable temperature it acts as a sharper arousing agent and is gulped in larger quantity through yawning. 

Saturday, March 9, 2013

Distractibility of ADHD is a reflection of anxiety/fear

A young man in his early twenties came to my office for Adderall to help him concentrate upon his studies. When asked how Adderall would help him, he claimed he has ADHD which causes him to be distracted by  anything and everything.
He declared himself to be an anxious individual who has to constantly worry about disaster striking upon all different aspects of his life and so his mind is busy putting out fires everywhere to pay attention to what is happening right in front of him. The only thing that stops his trying to be in 10 different places at the same time is marijuana. But its effects last only for an hour or so and then he feels tired, bored and sleepy, so it does not help him with his studies, and he was hoping that Adderall would be able to help him concentrate for longer periods.
But what has prompted me to write this blog is a statement which he made which got me thinking whether the tendency of ADHD children to immediately pay attention to whatever noise or activity is occurring around them rather than the lesson that is being taught in the classroom itself is not an attempt to avert imaginary disasters.
The patient stated that any conversation happening around him immediately shifts his attention to what is being said there rather than what the teacher is saying. "If somebody is talking about going to the zoo then my mind is there in the zoo with them. If I hear some noise from the ceiling then I am thinking about some animal is hiding there. In fact I cannot sleep soundly at night because every noise startles me in to thinking that thieves are about to break in and enter. Anything and everything that is happening around me gets me immersed in that instead of just filtering it out and focusing upon reading."
So his distractibility was no different then how an anxious mind keeps thinking of all the situations where harm could come to oneself or those who are dear to one. And just like how this fear of harm coming to oneself or one's loved ones leads one to undertake protective obsessive rituals the shifting of attention from what the lecturer is saying to the distracting talk or noise is also done to take some action to prevent harm. His ADHD was based upon a mind-set that was constantly anticipating harm and constantly working upon its prevention. And every distraction was used as a convenient excuse to project upon one's fear upon that and then search for actions to protect whoever was being endangered. For example when he heard somebody talking about going to zoo his mind was seeing that person getting endangered by some animal there and then his attention had to be focused upon imagining himself with that person in the zoo protecting him from animal attacks.
Another patient, a woman in her thirties, claimed that she has ADHD because she has to be on the go go go all the time. "I have to be doing things for others because I am afraid they will not do it right. With my children I am finishing their sentences for them. Poor babies. They cannot speak for themselves because I take over for them."
 Analysis showed she was projecting her own fears of not doing things right upon her children and then doing the job correctly for them.