Saturday, April 27, 2013

Fear as the driving force behind an 8 year old boy's ADHD

An eight-year-old boy, his older sister, his mother, and I went out to look at some foreclosed homes. I was going to buy one as an investment property, and she was going to rent it if we found one which suited her needs and her budget, and the purchase price of which was within my investment comfort zone.

I was really enjoying the boy's high spirits, his rushing out of the car to be the first to climb up the porch steps of the houses, his patter about how he wants a place that has second floor so he can climb up and down, and a bathroom that has shiny black toilet as he had seen on a TV show, a fireplace, and all the other cool things that his friends' houses had.

The mother declared him to be a child who gets into everything but told me to diagnose him less as an  ADHD and more as an Irish child: "they must stick their nose into everything."

Now we were driving from one house to another without a Realtor, who could open the lockbox with the code and show us the houses from inside. We had printed out a list of foreclosed homes from the Internet and were assessing their worth from the outside and by looking through the windows. Though most of the houses had some window latch somewhere not properly secured, or a sliding back door that could be slid open, or a main entrance that despite the lockbox hanging from the doorknob could just be pushed open, and the mother, endowed with the same Irish genes as the son, would with an uncanny ability manage to find and stick her nose into these deviant openings , and voila we would be inside, free to explore the in and out of the house.

But what really caught my attention about that child was that the last house that we went to see that  afternoon, instead of rushing out as he had done earlier, he refused to come out altogether on grounds that somebody was inside the house.

The mother said that is nonsense. The house is bank owned, and foreclosed, so nobody could be inside.

But when the son could not be persuaded to leave the car, the rest of us decided to go inside the house without him.  However, when we climbed up the porch steps and peeked through the stained glass panes, lo and behold, there was somebody inside.The house indeed was occupied. We rushed down the three steps,  ran over the grass and quickly got in to the car so we do not get subjected to rude shooing off for trespassing. The mother had not done her homework right. The house was not in foreclosure but in short sale.

The mother asked the child how in the world did he know the house was occupied.

"Because the smoke was coming out of chimney,' the boy replied.

"And what does that mean?"

"It means that either the furnace is on or somebody is drying his clothes in the dryer."

So this hyperactive boy was constantly scanning the environment wherever he went making lightening fast deductions whether it was safe to go ahead with his exploratory urges or take to his heels.

 Later we went to a restaurant to eat and once again he was observing everything. As we waited for the waiter to bring out the food,  the boy remarked that there is a gold record of some singer mounted on a plaque inside a glass case on the wall next to the cash register. He wanted very badly to examine it at close quarters, but could not be persuaded to do so.

The mother remarked Zach has grown now. Before he would have rushed to it physically. But now he is afraid to do so.

And I wondered if the boy was very high spirited and full of observations to fulfill a bundle of inborn (genetically determined) needs and since they all had to be satisfied in a limited time he was rushing from one thing to another and which was behind his ADHD.

But the mother said no, that cannot be entirely true. Because Zach, if you encourage him, or if he is genuinely interested in something, he can sit on it for a long time without getting distracted.

So despite having all these needs to be fulfilled, all clamoring for expression, and all wanting exploration of the environment for the objects of their desire, the boy could stay and concentrate on something if he was given proper encouragement (output of dopamine generated through pleasure experienced due to parental appreciation?) or through his own intrinsic enjoyment of it (self generated dopamine?).

I asked the mother then what is the cause of his ADHD.

And she said his exploratory urges have been prematurely blocked by a frightening world. It is the fear of getting into trouble with grown ups [with their superior power/authority] that keeps him going from one exploratory behavior to another. If you are exploring something and get yelled at, and a fear arises in you that you will get into trouble doing that, then at the slightest hint of somebody coming after you makes you give up what you are doing and pick up something else to explore.

And now my child instead of rushing into whatever interests him [out of fear of everything and everybody] first scans the environment to locate all the possible sources of danger and if he sees any, quickly abandons that avenue of exploration and moves on to the next. Only if I am around to encourage him to continue exploring which implies that I will be at his side to deal with the danger, or if the exploratory behavior has high dividends such as when he is playing sports, that he continues his activity without bolting to another.

And I wondered if both these factors: presence of the mother while he is doing his exploratory behavior and big rewards that he obtains from sports and other activities that he enjoys improve his attention via the medium of higher dopamine secretion.

Saturday, April 20, 2013

Reversal of letters in a dyslexic boy a manifestation of opposition/defiance

A woman in her late thirties came to the session and flat out declared herself to be a borderline personality,  in treatment since age of 9, and having been tried on every psychiatric medication under the sun.

When asked why she was borderline she replied, "Besides that I am also bipolar, schizoaffective, obsessive-compulsive, ADHD, in short a pain in the ass, and therefore psychiatrists [pejoratively] find me borderline. When they do not know what to make of you they call you Borderline."

"Why are you a pain in the ass?"

"Because I fight with everybody."

"And why do you fight with everybody?"

"Because I always have to be in opposition."

Then she added that her two children, and they are the same way. They oppose everything too. Though they have different styles. The older does by having emotional meltdowns. Slightest thing can spark a major upheaval in him and then everything around has to come to a halt. So he stops everything and everybody by overreacting emotionally. The younger one, his oppositionalism, is expressed through his refusal to cooperate with learning. I even think that his tendency to write letters and numbers backward is just an extension of this stubbornness. He must do everything in  reverse of what is expected of him.

And I wondered how much of dyslexic tendencies in children is initiated and maintained by this oppositionalism, perhaps an expression of grudge against parents or simply as a symbolic manifestation of one's life agenda being at loggerheads with that of the world's.


Last week I came across a dream the analysis of which further confirms that much of dyslexia arises from an opposition existing between one's agenda versus society's.

A woman who is now in her forties, who had a traumatic upbringing, where both of the parents were more interested in their own agendas than that of their two daughters, divorcing when the latter were 10 and 12, going their own ways, bringing step-children in to their respective houses, to which the daughters were shuttled back and forth, sometimes wanted, when they could be used to do chores or to get even with the other parent, sometimes despised, when they came in their way, often beaten, sometimes even boxed, to keep them in line, and who naturally harbored great grudges towards the parents, brought in the following dream, a year after her mother's death.

It is a very short dream. I would call it snap of a dream. For all it shows is my mother. She looks so pretty. The whole dream is like white. For there is a beautiful white silk gown that she is wearing. And my baby, who I lost,  is in her arms, held inside a white blanket, like they use for christening, as if he was being accepted in Kingdom of Heaven and becoming alive again. Everything about the dream is white except for a red ribbon that is over the blanket like a bow, and the natural colors of my mother's hair and face. Which enhance her beauty. 

She is getting prettier and prettier with each new dream, ever since she died. 

Patient added that the dream is refusing to go out of her mind and expressed surprise how can one single dream image affect a person so much. "I am trying to keep doing everything else to forget the image but cannot. Ever since the dream I have been crying, remembering my mother, and the baby I lost." 

Since the patient is familiar with the technique of dream interpretation I asked her without any preliminaries, "What sparked the dream?"

"The dream occurred on Sunday afternoon, while, after an exhausting night, in which I was awake for the most part, I fell asleep. In the morning my husband had come from his bedroom to mine, to lie next to me, and we talked and talked, like we have not done in years, for four full hours, at the end of which I nodded off and had the dream."

"What was the conversation about?"

"Everything under the sun. It was the frankest discussion we ever had. Things that we never ever bring up. Things no other couple would bring up, like mortality rates, life insurance, my mother's death last year. She was just 63. My grandfather died when he was 42, my grandmother's in her fifties. So I told him I won't be living for too long. And he better start getting serious about my funeral. At most I will live for another decade." She said half as a joke, half because of actual fear that she may die early like her mother.

"So the dream was sparked by the fear of your own death. But instead of your own death you saw the death of your mother, and to compensate her for thinking of her death, your shrouded her with the most beautiful white gown. White generally symbolizes death. Why the gown was silky?"

"My mother loved silk. My favorite image of her is in her wearing silk gown."

"Why is the baby in white blanket?"

"So he can be christened and be eligible to enter heaven and be with my mother. White stands for purity. He is pure and it was not his fault that he was subjected to abortion. He should be living in heaven." The patient began to cry.

"Why your mother has everything about her white?

"It symbolizes purity. Absence of evil. When I had the abortion they were real nasty about it. Just pushed me in to it. I don't think they gave anesthesia properly. The whole thing was so painful. But there was a nurse. She was wearing a white sweater. She was very kind. And talked to me throughout the procedure. She behaved to me how my mother should have behaved. The white of the dream is taken from the white of that sweater."

"What is the meaning of the red bow?"

"Yes, why couldn't it be blue, pink or another color? It had to be red." The patient exclaimed in anger. 

"Why? What does red mean?

"It means blood  It means murder.  It means abortion. The abortion, which I did not want. It was the most painful thing I ever experienced. I never got over it. I never will. My mother forced me to do it. I could not do anything about it, because I was living with her. That time Arthur was just an year old. I was already separated from his father and my mother did not want another child. I was barely twenty, and could not stand up for myself." 

"So the dream was sparked by the wish for death, which quickly changed into fear of death, and wishing that upon your mother, or rather contemplating about her death - though making up for it by making her most beautiful and living in heaven - to shift away the fear of your own death, and then the wish was countered by the thought that you cannot afford to die yet, because you have to reverse that abortion and make that baby alive again. In the dream you are succeeding in doing so, according him christening in heaven."

"Yes. Since my mother died I think that the baby I lost, he is now in heaven with my mother."

"Why is your mother becoming prettier and prettier with every new dream?"

"Because she was real ugly to me in my real life. She was selfish and did not think twice before having an affair which broke the marriage and tore the family apart. But she was beautiful too. She had lovely face and lovely hair. That is what comes in the dream without being converted into white. Because they do not need changing. Rest of her I want to change and make her into how my mother should have been. Now that she has died. I am mourning for her and changing her into Madonna - pure white, holding my baby like Jesus, instead of sending him to death.

"And now I realize why for the last three days I am doing everything backwards. I am writing orders backwards, dropping 'n's or 'g"s at end of the words, reversing my letters, even writing whole words backwards, turning into a new Leonardo Da Vinci, with all my childhood dyslexia coming back. Soon I will be using a white-out more than the pen. And I know it is happening to reverse that abortion. I am surprised I am not writing down-upwards, given how I hate my mother for forcing me to do what I did."

Sunday, April 14, 2013

Mother appearing as an evil impostor in a dream and its analysis

A woman in her early thirties, who had lived with her parents all her life because they had had her when the  mother was in her early forties and the father almost 60, and therefore they had subtly prevented her from separating and forging a life of her own, a few weeks after the death of her father, began having the following recurrent dream.

She prefaced that the dream could equally well be considered a hallucination. She was kind of awake  while dreaming it, aware that the frightening thing that she was seeing was a dream and that her mother and daughter were sleeping in adjacent rooms, and that she should get out of the bed to end the nightmare, though whenever she would attempt to do so she would find herself paralyzed to move and thus unable to get up and stop the dream/hallucination. 

I told her that for practical psychotherapeutic purposes dreams and hallucinations can be treated alike. One has to pay attention to the associations that emerge in both cases to reach to the mental complex from where the dream/hallucination was originating.

And she narrated the following:

I am in my room, sometime in my mother's room. It really does not matter. The point is I have to reach her. And whether she comes to my room or I go to hers it is the same. But on seeing her I notice that she is not my mother.  Well, she is my mother but at the same time something  has changed.  Her hair is jet black, her face pale, her body just bones, skeleton-like. She even moves in a jerky fashion, like a zombie would do in horror movies. But before I can get away from her I realize I am frozen.  My arms and legs are paralyzed.  I want to scream and move but I cannot. Then she is on top of me and is tickling me. I cannot breath because of the tickling. I have always hated being tickled, because I am an asthmatic and it triggers my asthma. But I cannot get away.  As a last resort I bite her, taking a chunk out from her lower jaw. She kind of enjoys getting bit. 

Patient bitterly complained that the dream which can occur up to three or four times a night is mentally draining her. 

Her dreaming in a state of partial wakefulness in which she could not move despite her desire to do so, accompanied by frightening emotions and impulse to scream for help led to the diagnosis of sleep paralysis and the dream to be viewed as hypnogogic/hypnopompic hallucinations. 

The practical value of making these diagnostic impressions however is of little value. Such distinctions and the pompous and tongue twisting medical terms used to label them may be very precious for those who have to come up with multiple choice questions for Psychiatry and Neurology Board Examinations - which is a ridiculous idea for it is insane to believe that the complexity of psychiatric illnesses can ever be understood by reading books with the aim of choosing the correct option in multiple choice formats - and also for those who have to concoct hundreds of diagnoses to give their diagnostic and statistical manuals (DSMs) ring of profundity, but for the psychoanalyst all dreams - for that matter hallucinations too - are basically the same: they are various ways to reduce mental tension (fulfill wishes).

Her inability to breath while getting tickled raised the possibility of sleep apnea - for sleep apnea sparks dreams of drowning, getting buried alive in a coffin or being subjected to other forms of suffocation - and I wrote a prescription for her to get sleep studies done to see if she does stop breathing in her sleep and would benefit from CPAP,  and then we returned to psychoanalysis.

That the dreams were occurring immediately after the death of her father left us no choice but to deduct that they were a reaction to it. The patient then talked as to how her siblings, all of whom were 10 or more years older than her, even before the funeral rituals were over were talking as to how the house should be sold and  she should move somewhere else and the mother should go to a condominium or an apartment and be relieved of the burden of maintaining that big house which would be too costly for her without the father's social security. She correctly deduced that this was less motivated by the wish to help their mother and more out of sibling jealousy as to why she should be allowed to live there for free of charge. Patient added that it is totally unfair for them to view her as someone who has exploited her parents for all these years for she had provided them with valuable companionship and for quite sometime had been nursing her father through his terminal illness. But added that she sees the writing on the wall and must make preparations to move out and part ways with her mother.

"Perhaps than the dream is about your need to go to your mother and get a closure on some unfinished business, perhaps a desire to get even with her, perhaps a last attempt to get something out of her that you feel she has withheld from you?"

"That makes lot of sense. We have in past therapy sessions addressed the theme of whether I am not leaving home because I have an ax to grind with my mother. And you are right. My mother is nice and a good mother but then there is this horrible side to her. She can be totally cold and abusive. I grew up never knowing when she would change colors. Out of the blue she would hit me, berate me, tell me that she is sick and tired of me and my father, and is leaving the house with no intention of ever coming back, that it was a mistake getting pregnant with me - you know I am the oops baby, and she always had mixed feelings towards me."

"And you reciprocated that mixed feelings towards her."

"Yes, I love and hate her. And that is why perhaps I never left home. Since I wished her harm when she would hit and threaten to not come back to counter my thoughts becoming reality I could never leave her. I had to be there to watch over her and prevent harm falling upon her. That also may be the reason I could not deepen any relationship with any of the boyfriends that came in my life. The minute it looked like I was about to have a life of my own, away from my mother, the guilt would kick in and I would panic and break off the relationship. Even Dick, my current boyfriend, if you can call him that, sticks around with me because he knows I will never demand to live with him. Because he is as useless about taking on the responsibility of a family life and being the man of the house, despite his being quite attached to me and  fond of my daughter. He will  freak out if we two decide to move in with him. Our relationship is primarily based upon our handicap -our fear of separating from our parents, growing up and being our own people.

"But why does my mother change in to that evil person?"

"It must be projection of your own feelings towards her. If your unfinished business with her is to attack her/punish her the dream may have reversed the depiction of it out of guilt. The fact that you are frozen shows that the dream censor is preventing you from acting out some impulse, in this case it is obviously an evil impulse towards your mother. If you cannot move your muscles then you cannot harm her. Making her come after you with similar intentions is making you doubly under control - in fact putting you on a self-protective instead of destructive mode."

"That reminds me," the patient added, "Another part of the dream which I had forgotten to tell you.  Before she can get on top of me and start tickling me sometimes I make an escape.  But she pursues me. Sometimes I fly. Sometimes I can fly so high that she cannot reach me. Often the chase goes into my running out of the house.  But the outside looks so ominous. The trees are barren. It is lonely and cold and though I have managed to leave her far behind I still fear running in to her. 

"And let me tell you it is not a projection of my own evil nature and her preventing me from acting out my evil intentions but a reflection of her evil nature too. For she has a split personality and I do fear her. Especially if my going to her is to get something from her. You know she was a wonderful artist. Her paintings are incredibly beautiful. She would have been world famous if she had devoted her life to it. In fact as a young girl she had got a scholarship to go to a prestigious Arts School but her parents overruled it and instead encouraged her to just become a housewife. And then when she finished raising her children I came along and ruined it for her one more time. She could never get that great adulation from public that she deserved. And the anger over it is what is reflected in her evil appearance."

"Where does the tickling fit in?"

First the girl could not come up with any associations but then after going through some intermediate links recalled that when she was a very little girl a sister's boyfriend - who was a "jerk" - would tickle her till she could not breath. "I would go into asthmatic attack and almost pass out and they would treat it as funny,  and my mother who knew how much distress I was in would make no move to stop that son-of-a-bitch from torturing me in the guise of just kidding."

"So that is another grudge you have against your mother. And before you leave the house and part ways with her mother you want to subject her to what she failed to protect you from, but because of your guilt and fear you are reversing the situation and repeating that childhood trauma with mother replacing the boyfriend. But why is her face pale, her hair jet-black and she looks like a zombie?"

"That is taken from a TV show which my mother and I watch together and which has a character that looks as if she was death warmed over. But that character is not a zombie so I don't know why I make my mother appear as a zombie?"

"Zombies are our projected death wishes [that uses paranoid process of imputing the ones we want to harm as the ones trying to harm us]. It is you who wants to attack your mother - hesitatingly, in a zombie like fashion, for the impulse to protect her is putting brakes upon the impulse to harm giving the movements the staccato character. However the dream under the influence of filial piety reverses it and projects your motor movements on your mother. You inability to move is being imputed to her."

"But I thought you said I could not move and scream because I was in Sleep Paralysis!"

"You were in sleep paralysis but the dream will use any physical event to fulfill its psychological motives. Your sleep paralysis was used to find expression for your guilt over wanting to attack your mother. Your sleep apnea was used to give expression to the memory of that abusive tickling and to show in visual language your ambivalence towards your mother. Using the mechanism which is present in Capras Sydrome - where the person sees a close family member or someone close as not the real person but an impostor with evil intentions. You see your mother as an impostor and an evil one."

"Where is the biting of the jaw coming from?"

This was very difficult to explain to the patient  for the only association to it that the patient could come up with was that zombies do it.

So we had to resort to psychoanalytic theory and my knowledge of her complexes from previous sessions. Now the girl had never separated from the parents, partly to control her worries that if she was not there with them some harm will befall on them, but there was another motive. Being highly competitive she was saddled with intense penis envy and much of her inexplicable and pathological behaviors arose from the wish to possess one so she could stand up to the men who had done wrong to her. She had been raped at the age of 14 by a boy who she had trusted and the pain of the trauma and unfairness of the world towards women had worsened because the mother had blamed her and instead of taking steps to punish that boy. She knew the family of the boy and not to spoil relations with them had hushed it.  If only she could obtain the organ that put women in the role of the second sex she would not have to rely upon other men to redress wrongs done to her and she could stand up for herself. She could never leave the house until she obtained from her mother - if necessary by force - what she was seeking.

The mother's feeling at the biting could not be analyzed but in all likelihood it was affirmation to her that her basic love bond with her mother despite the ambivalence was strong enough that she will be happy at her daughter getting what she desires so much even if it means losing part of herself.