Wednesday, October 30, 2013

A recurrent dream of castration

A man in his mid thirties, who suffers from paranoid illness, is single, still lives with his mother, her only child, reported that for the last two weeks he is troubled with a dream that won't leave him alone.

I feel there is a baby on my back, like a backpack. I feel responsible for it and have to worry about its safety. I want to do things but cannot because of the burden.  My dreams which use to be full of adventures now are cut short because I have to worry about the baby coming to harm. 
When I wake out of the dream I find my head hard pressed against the pillow. 
Initially the only association the patient could come up with was that the backpack reminds him of going to school.  But that association led to no where. And soon we drifted into his usual paranoid complaints about neighbors keeping a watch on him and how he cannot get away with any transgression no matter how minute.
"Every time I have sex with a woman I get in to trouble. It is not like I am having sex with married women. But neighbors look at me as if I am trying to have sex with their wives. If I just wear a different style of cloth they start wondering if I am up to something. Recently I was hired by a lady to drive with her to New York to help her load some mattresses for her business, and while I was eating at the White Castle she was watching me as if I was wolfing down my food.  If I exercise in my backyard my neighbors come to their windows and stare at me. Even my mother doubts my abilities. She tells me that I am a dreamer. But so was Martin Luther King. My mother accuses me of doing nothing that has any practical value and for earning no money. But hardly out of school I became a connoisseur of classic cars and flipped a couple at a profit. I have a collection of old comic books which one day will fetch me a neat sum."

By expressing to me all these persecutory thoughts and feelings, which his mind is constantly conjuring and no doubt to keep a lid (inhibition) upon his taking chances with the world - even his ability to free associate -  undid the repression partially, and the patient now could come up with the following association, "I read, or perhaps saw on TV, that if you see a child in a dream it is yourself."

This immediately solved the riddle of who the child represented. And I asked him, "Behind the facade of protecting the child is it yourself that you are protecting?"

"That makes sense. But why I am protecting myself through creating a double of me as that child instead of protecting myself directly?"

"Because when the fear of harm coming to oneself is overbearing, the mind plays a trick to lessen its impact. It starts worrying about somebody else who if harmed will cause one even greater pain. This way one's fear for one's safety is lessened. The focus shifts to somebody else getting harmed instead of oneself. This reduces the autonomic and other physiological responses that are triggered if one is anticipating danger. For the harm coming to somebody else, even if to somebody very close to oneself like one's child, still does not pose as much terror as harm happening to oneself. Or at least does not mobilize body's physiological responses to the same degree. The body does not have to activate the cascade of stress factors to protect oneself, because the injury is going to happen to somebody else. It is a very important defense: shifting worry from one's own person to worry for one's child's, or a spouse, or a favorite nephew or the federal deficit or the future of mankind or the disappearing rain forests, or the global warming.

"Since in real life you do not have a child, in fact you do not have anybody close to you who you really care for, you are working out your fear of some harm happening to you by creating an imaginary child who you must protect. And since you deny your fears in daytime, and in fact do not feel much emotions when you feel threatened by your neighbors, for that matter the world in general, for you experience the world as a hostile place, these fears emerge in the night when you are sleeping and you try to work them out of your system in your dreams.

"But why did this dream start just two weeks ago?"

"Because for the last two weeks I am struggling with a bad crook in my neck?" the patient replied

"Crook in your neck? What in the world is that?"

"I don't know what you call it. But us black people call it crook in the neck when we sleep badly and wake up with our neck stiff and hurting. Generally it clears up in a day or two. But this one has been a bugger and has persisted for two weeks."

This explained the immediate cause of the dream. The pain in the neck was disturbing the sleep and the patient who is always anticipating grave harm because of his paranoia had raised its significance to that of a mortal danger. This was consistent with how he experiences the world: a dangerous place. The need to do something about "this impending catastrophe - the crook in the neck" would have woken him out of sleep. But to protect the sleep - for him to continue sleeping - the brain mechanisms responsible for dreaming generated the dream. And the dream, by showing that the mortal danger was not coming to him but to his dream child, lessened the overbearing emotion of fear which otherwise would have woken him out of sleep.

"Why is your head getting buried into the pillow?"

Patient countered it by stating that the dream was in color. Now we know that if the dream is  vivid, feels very real, is in color, it symbolizes intensity and it is reflection of the intensity of the wishes/desires that are invoking the dream. Many scenarios of wish fulfillment have been condensed in to one. Not unlike how in some movies the director starts in black and white to portray the emptiness of the lives of the characters, and then, as circumstances change, and the characters meet new people and new sources of pleasure, their lives become multidimensional and full of happenings and the director shifts gears and ratchets it up from black and white to color.

The patient then gave some more associations which hinted that his burying his head in the pillow was trying to retreat from these intense wishes. For intense wishes are often accompanied with heightening of danger. Striving for things invites competition, threats and actual aggression upon one's person. In digging himself into the pillow he was actually retreating from the dangerous world and seeking to hide in its crevices - it was a variation of the fantasy to return to the womb. It was this intense fear too that was perhaps causing him to keep his muscles defensively tight while sleeping, causing "the crook" of his neck.

The correctness of this view was further confirmed when patient said that his dreams are full of adventures, or rather a wish to embark on adventures, which are cut short because "I cannot be involved with dangers and cannot accept daring challenges because I have this burden, this responsibility for the baby."

When asked to give specific examples of adventures which are cut short by the fear of harm coming to the child the patient said, "Like climbing up a mountain or some other steep structure. Or to get out of a tense situation, like being in a small space with so many people around me."

Now we know that climbing symbolizes sexual intercourse. In fact in Hindi the vulgar term for sexual intercourse is a man climbing on a woman akin to mounting in English. Being in a tight spot with so many other people around perhaps symbolized competition with siblings and father over exclusive possession of mother's genital passage. And considering that a little child often symbolizes penis I made the following construction.

"Is it possible that the adventures are symbolic of sexual adventures and the danger is of castration, with the little child being your penis which will come to harm because of it?"

Little child symbolizing penis is a well known psychoanalytic fact - people often refer to their genitals as their little one -  and this kind of conjecture could be made with this particular patient for he has been seeing me for many years and is quite familiar with the concepts of Oedipus Complex, castration, and dream symbols.

To my great surprise patient said, "It is interesting you say that because the child who I am saving always is naked, he has an erect penis, despite his being a baby, and I may as well add that it is over my left shoulder that I look at the child."

This association strengthened  the view that the dream was an attempt on part of the patient to avert castration for forbidden sexual wishes.

I asked the patient why the child had erect penis and he recalled:
"When I was 11 I developed torsion of the testicles. My mother took me to the Children's Hospital. But they did not treat me right away, and sent us home and told us to come another time for there were so many children who had to be treated before me. And my problem could wait. But then a few days later the problem suddenly worsened. I was rushed to the hospital and they did the surgery right away. The White doctor who operated upon me said that the condition had gone so bad that he was about to cut them [testicles] off. He added that the left one looked worse than the right. The White doctor had a serious look on his face as if he really meant what he said. I did not want to lose my manhood. For I knew one could not have kids without the testicles. After that I had dreams of that white doctor cutting of my testicles for quite some time. I also thought that they would have operated upon me when I first went there if I was a white kid. And for them to operate upon me so quickly when we went the second time, I must have bumped off some white kid who was scheduled for surgery that day."

The patient at this point added another element of the dream.

"The child on my back is whiteI was pretty white when I was born. Just like my grandmother."

So the patient's genetically determined excessive castration fear was further worsened by this unfortunate episode when the possibility of castration in hands of a White man almost became a reality. And to defend against it he had taken refuge in the belief that he was not black but white just like his grandmother. If he could turn white then the likelihood of getting castrated would disappear. And so in the dream he was defending himself from the fear of castration by making a double of himself as a white child. And a child who was not just white but who had an erect penis all the time - denial of castration through impudent defiance.

In his next session, a month later, he brought the following dream.

 I am a few streets away from my house playing basketball with my friends, two brothers, who I grew up with and who were nice to me and treated me with respect. Then another kid, a  neighbor of theirs, and I start fighting with each other. It is a martial art fight. The kid's uncle comes out who is blind. He has a white cane with red tip. We stop fighting and apologize to him for fighting like that and I explain to him that I live on Anna street. Then I return home and find that the boy with whom I was fighting had done a break-in and entry in to my mother's house. I call the police and grab hold of the boy. I see the boy wrapped around my hand as a backpack. I feel as if the burden of the boy who was always on my back as a back pack has disappeared for he is now wrapped around my hand.

We will not go in to analysis of the whole dream but only the parts that deal with the baby on the back.

The patient spontaneously associated that the boy who he is fighting with his own self. It is the part of him which he wants to [reject, project out, and] fight with. It is that part of him which if one follows the dream has failed to resolve the Oedipal conflict and is still seeking to find libidinal satisfaction through his mother - the boy with whom I was fighting had done a break in and entry in to my mother's house -and which was at the root of his illness.

Patient claimed that once he had this dream the  recurrent baby-on-the-back stopped. The patient and I agreed that the baby now instead of being a monkey on his back had shifted to getting wrapped around his wrist. So instead of the fear of castration completely controlling his life- sitting like a monkey on his back - it was now wrapped around his hand and thus under greater control.   

Wednesday, October 9, 2013

The humbug of Induction phase in Suboxone (Buprenorphine) Therapy

A shameful chapter of American medicine is the way the doctors authorized to prescribe Suboxone (buprenorphine)  have abused this privilege to financially exploit narcotic addicts. The latter are no match for the doctors. Not only because the balance is so much in favor of the doctor with the prescription pad in his hands, which the addict knows has the power to immediately end  withdrawal symptoms, but years of drug seeking life style leaves them emotionally and cognitively scarred, and they often feel like a thief, unworthy of asking anything of anybody. Finally when you are feeling physically sick from withdrawal you are incapable of negotiating with the doctor on his fees. 
Addicts are one group of patients whom the doctors should not charge more than what they charge their other patients for equivalent amounts of time.
It therefore comes as a surprise that while for their regular patients - who actually may require more medical skill, time, attention, and coordination with other medical personnel - doctors charge anywhere from 35 to 120 dollars, with Suboxone patients they want to charge 400 dollars for the first visit, and anywhere from 100 to 200 dollars for subsequent visits.
At least these were the rates when Suboxone first came to the market. The rates have gone down some since DEA now allows 100 instead of 30 Suboxone patients in one's practice, but, still,  most Suboxone-doctors nevertheless want at least 200 dollars for the first visit, and anywhere from 65 to 150 for return visits.
Also it is not uncommon for Suboxone-doctors to ask for additional monies besides what the insurance pays, which really is illegal.
Why they do it? And what has enabled them to indulge in this kind of highway robbery?
To prescribe Suboxone,  DEA requires special training - it can hardly be called special for it requires all of 8 hours of listening to lectures on a single day - and submission of the proof of having done so. DEA then issues a special unique identification number and voila the Suboxone doctor is born. Does that much of effort deserves charging 400 dollars to the patient and then hundreds more on subsequent visits?
Anyway, without this identification number, which is really the doctor's DEA number with letter X in front of it, the pharmacy does not honor the doctor's order for Suboxone.
It is this number which since only few doctors go through the special training empowers them to charge exorbitantly.
How difficult is that special training?
The training requires eight hours of passive listening to lectures in a one-day conference, delivered usually by two Suboxone specialists, majority of whom I have found to be just the kind who will gouge 400 dollars from some down-and-out kid who does not have a dime to his name, having blown all his money on drugs, and whose medical fees in all likelihood is being paid by a struggling spouse or a beleaguered parent.
Why more doctors don't take this training?
Because doctors like the rest of us are neophobic. If their practice is going good they don't want to get out of their comfort zone and acquire a new skill. But more so because of the prejudice we harbor towards drug addicts as trouble makers. And this contempt and fear of narcotic addicts has some merit. Addicts can be very difficult population to deal with when they are not as much interested in giving up their addiction but in procuring Suboxone to actually support their habit through selling it on the street and using the money to buy their drug of choice.
Yet charging these sick people - yes, some of whom who do indulge in crime, including prostitution, to support their habit, are often liars par excellence and on rare occasions can be hostile and outright assaultive to the doctor when he refuses to give them as much medications as they would like - such high medical fees is unethical.
Why did the DEA place this special training hurdle?
The need for special training to prescribe Suboxone arose because the way Methadone Clinics had degenerated into turning narcotic dependency - from the mildest to the severest - into a life long affair of going to those Clinics.  Anybody who came to them instead of being put on appropriate dose of Methadone which would have been equivalent to what they were abusing were actually put on way higher doses of Methadone than were necessary to prevent withdrawal and then instead of tapering down, believe it or not, the dosages were  ratcheted upwards to make their habit worse. This was the standard modus operandi of these Methadone Clinics and its logic was to make whoever came to the Clinic its permanent client. It may not be too out of the way to add here that many of the Pain Management Clinics also are nothing more than fronts to hook people on narcotics, spinal steroid shots, and other medical shenanigans for life.
So it was to prevent Suboxone treatment turning into another Methadone Clinic fiasco that the DEA, with good intentions, made it compulsory for doctors to get that 8-hour special training before they could prescribe Suboxone, and to restrict the doctor from not having more than 30 Suboxone patient at a time in his practice. The latter of course was placed there for the doctor to not give up his medical practice and become a Suboxone pill mill.
Alas DEA did not succeed! It may not be wrong to mention here that quite a few of these specially trained doctors are doing with Suboxone what the Methadone Clinic entrepreneurs did and still do. They often start patients on three Suboxone a day, 90 tablets at a time, and tell them that they should be at such a high dose for a whole year, before they will be ready for tapering, and thus hook them on Suboxone, which by the way is as addicting as any other opiate.
And finally, after this long introduction we come to the issue of the need for special induction phase in initiating Suboxone treatment.
Much of the mystique of prescribing Suboxone lies in its complex induction phase. Many doctors even after getting that special training and identification number will not take the first step of seeing opiate addicts because they find the induction phase of treatment too complex, confusing and impractical. They are too scared that they will mess up the treatment of the patient by not following the induction phase protocol and thus get in to trouble. And this reasoning is not entirely baseless. Not the fear that they will somehow harm the patient but that they will not be able to adhere to the protocol.
If one reads the drug company's information package insert, one is not supposed to just prescribe Suboxone and tell the patient to not take the first dose of it till the withdrawal symptoms become unbearable, but to have the patient come and sit in your office till you decide that  his withdrawal symptoms have become unbearable and then personally give him the first dose.
And there are further hurdles. The first dose is supposed to be not that of Suboxone - which is a combination of Buprenorphine and Naloxone - but of Subutex - which is Buprenorphine without Naloxone. The rationale is that Naloxone which is an opiate antagonist will worsen the opiate withdrawal. This is a bunch of nonsense. If you instruct the patient to not take the first dose of Suboxone till the withdrawal symptoms become unbearable the Naloxone in the Suboxone hardly has a worsening effect upon the withdrawal.
The guidelines also want the doctor to write the first prescription for just two or three Sabutex tablets and ask the patient to go and get them from the pharmacist. Then the doctor is supposed to assess him hourly or bihourly with a special rating scale called COWS - Clinical Opiate Withdrawal Scale - and only when the rating scale tells the doctor that the patient is in sufficient withdrawal the doctor is supposed to give him the first dose of Subutex. And then the patient is supposed to wait further for the doctor to keep doing the rating scale periodically and decide if he requires more than one Subutex tablet or not. And this assessment shenanigans is supposed to be carried on for the next few days.The guidelines require the patient to come multiple times in the first week for doctor to assess him daily with the rating scale to further fine tune what is the most appropriate dose of Subutex/Suboxone for him - one, two or three. And since it is illegal for the doctor to hold medication in the office that is prescribed for a specific patient, the latter is supposed to go every day to the pharmacist to get his daily supply of two or three Subutex.
 If one wants to avoid sending the patient to the drug store repeatedly, the guideline also gives the doctor the wonderful option to keep a supply of Subutex in the office. An option that given the penchant for American Justice to trap and turn one and all into the category of criminals to expand their business, can land the doctor, if he is not dotting every i and crossing every t in his bookkeeping, in serious trouble.
Does any doctor really follows these guidelines or more importantly is it really possible to follow all these commands in private practice? Are drug addicts capable of complying with this kind of quackery? Do they have the money, resources, gas in their car, if they have a car to begin with, to go daily to the pharmacy and get a fresh round of Subutex? Does their insurance - most of them have Medicaid or are uninsured - covers these Subutex prescriptions? Is it really practical for withdrawing opiate addicts to sit in your waiting room with your regular patients for hours at a stretch without scaring them? Does the mumbo-jumbo of COWS, for that matter any rating scale, really superior to clinical assessment of the patient through observation and common sense questioning by the doctor? Is any drug addict really capable of  coming to your office, get the prescription of Sabutex, take it to the pharmacy, wait there for it to be filled, return to your office, sit there for hours for assessments and then go home, only to repeat the routine the next day? And finally after giving the first dose of Sabutex and making the patient sit in your waiting room and periodically assessing him really tells you much whether the patient requires one, two, or three Suboxone a day?
The answer to all the above questions is a resounding no.
No doctor really follows these guidelines? They do some half-ass going through the motions of them, enough to convince themselves that their charging 400 dollars for the first visit is justified.
Yet these top-down guidelines exist, and turn away many doctors from treating narcotic addiction which has become such a large problem across the nation.
I have been prescribing Suboxone for eight years and must have treated hundreds of narcotic addicts with good results and without practicing any of these complicated rules of Induction Phase of therapy.
All I do is to make a careful clinical assessment of how much opiate the patient was abusing, how severe is his withdrawal, how honest and sincere he is in giving up his habit, and if he is not there to get some Suboxone as a temporary fix because he has run out of money and wants to stave off the withdrawal till he can go back to his drug of choice.
The first visit lasts for 45 minutes if he pays me 110 dollars, or for 30 minutes if he can afford no more than 70 dollars. And through this assessment, which is not corrupted with stupid rating scales - which are made for subnormal doctors who cannot think of medicine in qualitative terms but must turn everything into numbers - I can almost always make out whether the patient requires one, one and one-and-a-half, or two 8-mg. Suboxone tablets a day. Almost 90 percent of the patients fall in to these three categories. Very rare ones require three tablets a day. Patients who are switching from Methadone to Suboxone almost always require three tablets - incidentally of Subutex instead of Suboxone - because they have a very bumpy withdrawal.
I give the patients 7 or 11 or 14, and for very few 21 tablets, for the first week and ask them to come back when that period elapses. I emphasize to them to not take their first dose of Suboxone till their withdrawal becomes unbearable. Most of the patients are not Suboxone na├»ve, having already taken  Suboxone here and there, obtained from friends or bought on the street, and they know very well how not to take it till the withdrawal symptoms are intense. Their knowledge of their withdrawal symptoms is first hand and much superior to any assessment done by the doctor directly or through his rating scale.
In a week when they return, I reassess their Suboxone need and titrate the dosage up or down. It is rarely that I have to titrate upwards. In my practice there is always a constant pressure to keep ratcheting down the Suboxone, for it is as addicting as any other opiate.
I have never had any failure with this simple approach. It is also not a huge deal if some patient was given 14 tablets for first week when 11 or 7 would have sufficed. Also it is a rare patient who has gotten 7 tablets when 11 or 14 would have been more appropriate. And such a patient always has the option to come a couple of days earlier if he runs out of his Suboxone before the 7 days.
Why if initiation of treatment with Suboxone is so simple have the DEA, the doctors, and other interested parties have made it into such a rocket science?
Because there is always a tendency in humans to make their profession look more complicated - which justifies them charging more money and makes them feel more important than they are - than it is. Also it increases the scope of employment. There is a huge industry to treat narcotic addiction. The government regulators if they can make medical business more complicated and time consuming then their power increases and their department size increases.
Finally this kind of bullshit masquerading as evidence-based science is a significant component of  medicine. The art or science or quackery of medicine is heavily laced with many such useless protocols and  unnecessary regulations. The reason for this is because the payment for much of medical activity is made by third parties. So there is a built in mechanism to make medical treatment as dilatory and nonsensical as one can get away with. When one analyzes these protocols carefully most of the steps present there are useless, if not outright counterproductive, often harming than helping patients.
I remember in 1976, when I started my residency in psychiatry to admit a mental patient through ER would take all of 30 minutes. There was no money in keeping them in the ER. Now on average it takes 17 hours. For everybody and his mother, aunt, and brother are having a go at the patient in the ER in the name of triage and multi-disciplinary approach.  Are these multiple assessments by the clerk, nurse, social worker, ER doctor in the ER have any real meaning in improving patient's psychiatric condition. All they achieve is to exhaust the patient, and his relatives who have to sit through this period of ordeal in the waiting area, without doing any good to him.  But all this has become necessary to generate a stackful of medical notes so they can bill thousands of dollars to the government and private insurances and have documentation to prove it.