Sunday, May 12, 2013

Paranoid Illness changing into Bipolar Disorder

A woman in her early forties came to her monthly session, primarily to get her medications for she does not like to talk about herself or her illness, and complained that she is once again in her down mood.

"It started a week ago and it is so bad that my son - the only one who still lives at home - left the house. To add insult to injury I flipped my finger at him as he was leaving, which is insane. For the poor boy had done nothing wrong.  All week long I had been on his case. It is good he left on his own because last night given my nasty mood I could have physically kicked his ass out. When I am in that down mood I want nobody around. My son called me this morning to ask if it was safe to return. Thank God he is not upset because he knew it was my mood and not me which was making me behave like that. What lies behind such nastiness of mood?"

Patient denied that anything triggers it. With no leads to go upon as to why she went nasty the session shifted into talking the next thing that was bothering her. It was her anger at her mother. Patient could not be more angry, "She has chest pain but refuses to go to a doctor, treating herself with cold water and aspirin. I am afraid she will die just like my father did."

It too had started a week ago. What came first her worrying about the mother and getting angry over it or her nasty mood.

Patient first claimed that they had started simultaneously but then after being forced to carefully examine had to admit that mother's chest pain had begun a few days earlier. She also recalled that when her anger towards mother could not be contained it was only then some of it had escaped control and despite her best intentions to not do so had begun to get displaced upon her son.

"Why did you think that she will die just like your father?"

"Yes, that is my fear. All I can think of is that she is going to die like my father did. It was traumatic seeing my father die in 2009. He had clogged arteries, just like my mother has."

"Did your mood swings start when your father died?"

"No. His illness and death did not affect me quite that way. I did not get upset. I did not care for him that much. He was not around. For that matter my mother was not around either."

"Then what started the bad moods?"

"The death of my grandmother in 2010. But in the beginning they were not bad moods. It began as a slowly emerging conviction the house in which she had lived and died was haunted. I missed my grandmother very much. She was my real mother. My father and my mother were never really available to me. After her death I started hearing her voice and could feel her presence. I was admitted to the hospital and diagnosed as paranoid schizophrenic because of those voices. They put me on a lot of Seroquel which was the only thing that could block out the hallucinations and allow me to sleep. Even now I am afraid to go off the Seroquel despite your warning that it is making me fat and may cause me diabetes, because I am afraid of the return of the voices.  When I came back from hospital I moved out of my grandmother's house. But her presence followed me to the new house."

"When did the mood swings start?"

"They came gradually. As my fear of my grandmother's presence hovering over me decreased the mood swings started. They are always accompanied by anger towards my mother."

"You became sick after your grandmother's death, but your anger is always directed towards your mother, why is that?"

"Because I think I have a big time grudge against my mother. I loved my grandmother but hated my mother."

"Why you hated your mother?"

"Because she favored my brother over me. He was my half-brother. She preferred him over me, because his father was not around, while mine was,  and she felt he deserved special treatment because of that."

This patient's illness which started as paranoid schizophrenia shows no trace of it now. She is quite warm and social in her interactions when she is not in her down mood. This transformation occurred when she could allow her rage to emerge against her mother. This happened after the death of her grandmother. Prior to that her loving relationship with her grandmother kept her rage bound. Once her grandmother died her rage emerged unchecked and could only be contained through developing a paranoid projection . She started hearing voices that kept her rage from being acted out.  

Once the rage could be expressed against others - the latest being her son - it did not have to be projected and come against her in forms of voices. However since she could not be permanently in a state of rage her psyche developed bipolarity. A time was allotted to be in rage and a time to be nice and good to other people.

Thursday, May 2, 2013

A transference dream

A patient of mine who has been with me for more than two decades and treats me with great familiarity and friendliness, came for his biweekly session and said I had this hilarious dream from which I woke up laughing, because it is something that could never happen in real life.

The dream is about you. I come to the office at our usual time. But the location of your office has changed. It is not this old ranch building - not that anything is wrong with it, I love your place -  but  a magnificent high rise, all glass and beautiful. The staff has changed too. They are young, spiffy and professionally dressed, not like how your staff dresses so casually.  But what is funny is that they are not one bit friendly.  In fact they are nasty and hostile. They ask me who I was, and do I really have an appointment. I tell them what are you talking. I have been seeing Dr. Kelwala for 22 years, and you all should know I come here every other Friday at 11 or 11.30 am. 

I at once knew that it was an expression of hostility towards me that was being "projected" into my being hostile towards him though I was being represented by my staff.

When I told the patient that perhaps behind accusing my staff as being nasty and hostile it is me who he is accusing of being nasty and hostile, he said that that is impossible for he respects me too much. Then he suddenly remembered another section of the dream which confirmed that the interpretation was in the ballpark.  

"A part of the dream that I had forgotten now comes back to me. While I am being blown off by your staff you come out of your office and say that my appointment is at 8.30 pm. And I woke up laughing aloud as to how you could be so ridiculous, for you never see patients that late in the evening. 

"That I don't even know as to what time I see my patients, is it an expression of contempt ?" I asked him.

The patient protested that in no way he can be contemptuous towards me for he respects me too much but then immediately confirmed the accuracy of the interpretation by stating that recently he has been talking big-time in his sleep, and waking out out of his dreams laughing. For example the other day "I woke out of a dream laughing because I was calling my Dad you son-of-a-bitch, you crazy man. Which is  surprising for I never ever said anything like that to him when he was alive."

"Calling your father son-of-a-bitch and telling me that I don't even know the timing of my own office hours appear to have the same origin: contempt for authority/father figures. Where is the contempt coming from?"

"I dreamt the dream this morning, a few hours before coming for the therapy session. Around 8.30 a.m to be exact for I looked at the clock on waking out of the dream. I had run out of my Suboxone and Xanax couple of days ago, because I had been taking them more than the prescribed dosage. I was withdrawing and feeling nasty and could not wait for 11.30 to arrive when I could see you and get new prescriptions. Then I dozed off and had the dream. Now you know how you get mad when I take too much of these medicines and have at times refused to refill them or told your staff to not call them in if I have demanded them on phone if they are not due. So I always have this fear when I take too much of these medications that you will not refill the prescriptions or the appointment will get cancelled or you will fill them but not right away."

So his fear of that I may not refill his prescriptions which will prolong his withdrawal symptoms was making him think of all kinds of insulting thoughts towards me.

"Why the building was tall and magnificent?"

"It was eight stories high too!" the patient added

"Why eight?"

"It has to do with the 8 mg. of Suboxone tablets. I was craving for them and if only I could have gotten the 2 mg. tablet [Suboxone comes in two strengths 2 and 8 mg.] it would have eased the suffering. But 8 mg. would have been ideal. So I was granting you an eight stories high office building instead of this modest ranch of yours if you would prescribe me that dosage right away."

The magnificent office and professional looking neatly dressed staff were expressing two other concepts which were diametrically opposite to each other. On one hand it was an attempt to exalt my position. If only I would fill his prescription without any problem he would value me as a real upper class doctor whose office    was in a magnificent high rise building with professionally dressed staff instead of the humble office in which I see patients and the unpretentious staff who work for me. On the other hand it was an expression of contempt that given your humble office and even humbler staff and the fact that you don't even know your own hours of practice you better not make me wait for my prescriptions. And the dream was expressing this contempt by showing the offices of the more magnificent doctors with their sparkling glass offices.