Sunday, June 29, 2014

The psychology behind the phenomenal rise in adorning oneself with tattoos in recent years

While approaching a young patient of mine who was sitting in the waiting area, I was struck by the extensive tattoos on his arms. One could barely see the skin for the lacework of  tattoos. The charm of the white skin was well hidden by the criss-crossing dark designs. 
Now this patient who suffers from obsessive compulsive neurosis avoids facing the world and uses his OCD rituals to accomplish that end. The compulsive senseless  movements of his arms and body not only divide his attention and detract him from noticing others in any depth,  others too are distracted from noticing him, the focus transfixed upon his motor restlessness instead of his total self.
His obsessive rituals made me wonder if the modern world en masse has now not been granted a socially sanctioned obsession that serves us the same purpose as his individualized private OCD - fiddling with Smartphones in public. Being tuned into Whats Up and Facebook enables us to avoid any deep emotional interactions with people we are in company of. Is modern world's tuning out of actual physical interaction with each other in favor of cyber interaction is a new world religion? A new mass obsessional neurosis?
Coming back to the patient.
As if these obsessive motor activities of his hands, fingers, legs and trunk are not enough, every now and then he cracks his knees, neck or finger joints. These cracking of joints, which are compulsive in nature, also give the impression of being another attempt to avoid social give and take which is what life is all about.
And the violence with which he cracks these joints, gives a distinct impression that the rituals are some kind of symbolic punishment meted out to his legs, neck and fingers - [for attempting to get out of bounds?] It appears as if since his whole self is under some form of hold (repression) the individual parts of his body want to  reach out and touch others and are being slapped on the wrist for doing so. For after all the raison d'etre for OCD lies in preventing one from sexually [and aggressively] touching others. Freud did say once that if the term obsessional neurosis had not been already coined, and so well accepted, he would have named this disorder the touch neurosis. The fear of touching others and getting [sexually] contaminated lies at the very heart of OCD.
And this compulsion to keep running away from others follows this patient in to his sleep. He also suffers from severe Restless Leg Syndrome.
He is undoubtedly a man on the run.
Now one would expect that someone who has such dread of the world will at least groom and dress himself well, put on jewelry and perfume, deck himself with other accessories to make up for his lack of self confidence. But he does nothing of the sort. He puts on sleeveless shirts, torn jeans, dilapidated sneakers and no socks. Majority of his skin remains exposed.
Or does it?
The tattoos block whatever parts of himself escape getting covered by clothes.
If his compulsions and joint cracking are ways to create a wall between him and others, do his tattoos serve the same function?
And at this point one recalls how motorbike club members adorn themselves with tattoos; uninviting, and hostile appearing monstrosities, etchings of skulls and daggers, cobras, scorpions, ghosts, ghouls and goblins, swastika and other wild creepy things.
But anybody, whose body exudes such aggression, at the core of his being must be a frightened soul. And since bikers are usually pussycats in isolation and feel sure footed only when feeding upon each others' swagger, one wonders if their tattoos serve them the same function, give them the bluff to face the world that they are so afraid of?
But this cannot be the whole explanation for why people today are so obsessed with tattoos.
For there is another class of tattoos which are distinctly inviting in nature, and it is not hard to guess which sex favors them. Roses, flowers, creepers, colorful designs, butterflies, ornate hearts, entwining patterns that remind one of lingerie, and other soft and cuddly objects, welcoming and aesthetically pleasing, also appear as tattoos.
So it appears that tattoos are another exaggerated display of our masculinity and femininity, props to enhance the active and passive aspects of our individuality.
But then why aren't we all tattooing ourselves? If it enhances our secondary sexual characteristics then why aren't we all rushing to do so? The great majority of us scoff at the idea.
Here we come across the phenomena of a great divide between those who have it and those who don't.
If the display of one's masculinity and femininity depends upon subtle cues, one's natural good looks and intelligence, one does not have to drum it up by adding on to oneself disparate extraneous objects.
Tattoos are a tacky enhancement of one's persona. No different than the plumes jutting out of the Indian Chief's head gear, the rows of ribbons and medals hanging from army brass's shirt, the shiny  jewellery and super-dyed hair of a homosexual, the endless acronyms of credentials following the name of a college professor. They are the bells and whistles of those who do not feel they are anybody unless they can display their trophies. It is a man who is not sure of his manhood and who has doubt if he can be effective with others through his natural pluck who shows swagger in the gait, gruffness in the voice, hostility in the muscle tone, and the gaudy display of sunglasses,  sport cars, and flashy jewellery. A naturally feminine woman, especially one who has natural good looks, far from using tattoos to enhance her femininity may prefer not to put any make-up on herself.
The expression of masculinity and femininity in more refined individuals is through modulated and untrammeled speech and rich personality. It is half filled vessel that spills its contents. Deep waters run still.
Has there been a decline in the masculinity of men and femininity of women in recent decades?
Is there any doubt about that? As our culture has become more androgynous there has been a surprising decline in sperm count of men and rise of polycystic ovaries in women. In behavior too more and more folks are practicing LGBT  than becoming the model representative of their anatomical sex. Thus when the need arises for us to emphasize ourselves in a heterosexual fashion we are often relying less upon our actual selves and more upon adorning ourselves with extraneous objects that emphasize our original sexual nature.
But there is another great transformation that has occurred in the last few decades. The sexual revolution of the Sixties has fundamentally changed the way people communicate.  All through history human behavior was highly ritualized. There was  a script for everything. It spelled out in magnificent detail what and how to speak with the opposite sex, the children, the elderly,  the postman, the milkman, the car mechanic, the handyman; who to be deferential with and who to boss around.  There were stock phrases, stock motor movements, stock greetings, stock goodbyes, and stock feelings and display of emotions all handed down by the previous generation ready made for for every occasion. Everything was predictable and based upon what we had observed from birth. Even the clothes we wore were predetermined - white collars for those in management, and there too higher the rank the more silky and fancy was the tie. Bow ties were reserved for the eccentric professorial type or those in corporate world who had castration issues. A blue collar worker occasionally wore tie too, but the coarseness or at least its dated design gave away his lower station in life.
All these moorings which allowed us to interact with others without feeling anxious, and often with  grace, granted modeled after somebody from one's past,  have evaporated, or at least greatly eroded, in the last few decades. In the aftermath of the two World Wars the flower children came upon the scene as if to make up for that orgy of violence and fundamentally changed the way we behave with each other. The television, computers and the Internet did the rest. Now every conceivable human behavior was available to model after at the click of a button. Differences in wealth and social privileges ceased to matter as well. No matter how poor, with cyber information available to all, the poor kid has same degree of access to cultural accessories as the rich one.
But there is a  catch when there is abundance of something. One may fail to take possession of any of it. As long as something is rare we value it. If something is available for the asking one may have no interest in permanently acquiring it. If you give a child few toys he will treasure them.  If you give him a whole roomful, he may develop no attachment to any. The idea of possessing the greater quantity of them may become more important than mastering a few. In olden days when finding somebody to marry was not that easy a task, with all financial and cultural hurdles, not to speak the elaborate wedding that one had to go through, one valued the woman one was paired with. For if you lost her, it was not that easy to replace her. But today when women are available to have sex with without any effort and as readily changeable as Kleenex, one often shows no appreciation for any one of them.
Hence we are growing up culturally denuded. While submerged in sea of information we are  growing up culturally thirsty. We know so much but we cannot translate it into words or behaviors. We can tell so little of ourselves to others with refined behavior that was taught to us in past generations with mother's milk. And hence we feel naked, inadequate and anxious in dealing with others.
Tattoos give us a protection from this nudity. It tells others who we are and how to behave with us and how to keep your distance. They have become our credentials, our substitute for cultured behavior.

Tuesday, June 17, 2014

The psychopharmacological interchangeability of narcotic pain killers, anti-anxiety agents, psychostimulants and ordinary success in maintaining sense of well being in addictive personalities

I treat quite a few opiate addicts with Suboxone (buprenorphine). Buprenorphine is an opiate too, but with a very unique property. Unlike regular narcotics, such as Vicodin, Oxycontin, heroin, morphine etc., the patient does not become habituated to Suboxone, and does not keep increasing the dosage to get the same effects.
And Suboxone is not just for preventing the horrible withdrawal symptoms, which, by the way, is the main reason the addicts shudder at the thought of giving up opiates, despite knowing that it is destroying their body and their life, it also - unlike Methadone - helps patients resume their pre-addiction life style. Quite a few are able to start working again, take up family responsibilities,  emotionally respond to others, and start feeling like their normal selves. In many it ameliorates their anxiety and depressive symptoms better than antidepressants. 
Despite all these wonderful properties, Suboxone cannot be used indefinitely. It cannot be viewed as a drug like insulin that a patient must take for the rest of his life for his diabetes. While many so called addctionologists want addiction to be looked upon as a physical disease - so they can maintain their belief that they know how to treat these complex problems without knowing a whit about depth psychology - addiction, or for that matter all mental diseases, are fundamentally different from physical illnesses. Mental illnesses can accentuate and wane remarkably with the aid of just psychological inputs and life circumstances.  And therefore however well the patient is doing on Suboxone, it is natural for the psychiatrist to be biased towards getting him off of such a medical crutch. One knows not what harm, in the long run, such brain altering medications do to the person. And so a good doctor is always pressuring his patient to keep cutting down on his Suboxone dosage, with the aim of eventually making him totally drug free. 
But here one runs in to a problem. Suboxone itself is incredibly addicting. The patient tolerates its tapering to a point, and then refuses to go further. At a certain threshold, which is different for different people, in some surprisingly as homeopathic as half a mg.a day, the symptoms return, and not just the physical ones of body aches and pains, diarrhea, sweating etc., but the psychological malaise too. Depression, anxiety, sleep problems, easy distractability, diffidence, emotional withdrawal, even something so basic to human nature as taking care of one's own children, they all start raising their ugly heads. In short the patient falls back in to his or her doldrums.

It is difficult to say whether these withdrawal symptoms are due to some property of buprenorphine itself, which the addicts cannot do without, or the return of the underlying psychopathology which drove them to get addicted to the opiates in the first place. Perhaps it is both.
Now an interesting feature, and which is the reason for this blog entry, is that these symptoms can be ameliorated to a great extent if Suboxone is supplemented with an anti-anxiety agent or a psycho-stimulant. Addition of Xanax or Ativan or Adderall considerably reduces the need for buprenorphine. 
Why does this happen?
I have a far fetched theory.
 People take drugs when the ego-syntonic heterosexual outlets for their love needs get blocked. Humans basically live for love. If they have no one to love, or do not feel loved by anybody, they might as well curl up in a corner and die. And when they (rather their system) cannot find love in an adult genital fashion, their libido (love need) regresses and starts emerging through autoerotic activities (through pregenital channels).
Generally this regression of psychosexual organization occurs silently and invisibly, and has to be deduced. For the patient himself is not aware as to when and how the regression is taking place. Furthermore, the slipping back into autoeroticism primarily does not occur at the physical plane but in fantasies, and  in displacement, so their true nature remains obscure, and to make matters even more difficult to decipher, the fantasies which bring about the discharge of sexual tensions, are mostly played out in the unconscious.
The narcotic analgesics, the antianxiety agents and the psycho-stimulants, despite their acting upon different aspects of the brain/mind, and through different neurotransmitter systems, facilitate this regression.
How do these drugs  do it?
Once we reach the genital stage, our body creates psychological and physiological barriers to prevent  sexuality from finding easier discharge through pregenital channels. These barriers are basically  psychological and physical reactions that follow when a person indulges in pregenital sexual satisfaction.  The libido has very many ways of discharging sexual tension through pregenital channels. But they all have one thing in common: the use of one's own body instead of somebody else's, as the sexual object. And herein lies the trouble. At the end of the sexual act one does not feel fully liberated and unbound, with the spirit soaring, but rather in throes of mixed feelings;  some relief of tension and paradoxically some increase of it.
For autoeroticism requires playing both the masculine and the feminine roles. And there is always a conflict over that. The superego/conscience objects to playing the feminine role in man and vice versa in woman. So after the autoerotic/pregenital sexual activity, whether done through actual masturbation (physical action), or through (conscious and/or unconscious) fantasies, or even done in dreams, the person emerges from it with all kinds of body aches and pains, and whole range of mild depressive and anxious affects.
This dysphoria and pain occurs for two reasons. One, when non-genital somatic points of the body are used as genital organs they show inflammatory response. Not quite full blown inflammation, but some processes akin to the tumescence and detumescence of genital organs, corresponding to sexual excitement and its discharge, and since these body parts are not primarily designed to play the role of the genitals, the inflammation like process that takes place there leaves the body sore and in fibromyalgia-like state.
The muscular spasms and mucosal secretions  at the deepest level are masculine (active) and feminine (passive) sexual responses. The destructiveness of narcotics towards one's physical appearance - one can always spot the unhealthy looks of those who are strung out on drugs -  perhaps owes to this use of non-genital organs as genitals - surge of auto-eroticism over genital sex - in drug addicts.
There is also anticipation of physical and mental punishment for finding sexual satisfaction through pregenital routes, which adds psychic malaise to the physical misery.
Now when we examine these dysphoric physical and mental states which are physical and mental responses to autoeroticism and anticipation of punishment, we find some interesting correlates to the sexual fantasies that are indulged in to achieve the sexual discharge.
 If the associated fantasies to autoeroticism are oral cannibalistic in nature, then the inflammatory response and the punishment emerges through the sensations of disgust, repugnance, nausea, vomiting, stomach acid secretion, teeth grinding, migraines etc.
If the sexual fantasies resort to anal-sadistic designs then the punishment for sadism occurs through  increase in motor restlessness and spasms of the GI, urinary and respiratory tracts, while the passive masochistic fantasies cause the reaction of excessive mucosal activity of the colon, respiratory tract and the linings of paranasal sinuses [continuation of the opthalmic mucosal lining, and in essence an extension of crying].
These pathological reactions are like "undoing" of the gratification.
Now this painful reaction and overactivity of the GI tract and other mucosal tracts and muscular system is inhibited when one takes narcotics. Disgust, nausea, vomiting, migraines, spasms and excessive secretions of GI, respiratory and urinary tracts which would have put brakes upon indulging in forbidden pregenital sexual behaviors are put on "off mode" by the narcotics, giving free reins to the addict to indulge in autoeroticism. It does so by suppressing the pain reaction to such behaviors. Popularity of narcotics, in no small measure, lies in this easy way out for one's sexual needs; discharging them upon one's own self instead of going out and finding a heterosexual partner and competing with others for his or her love.
While narcotics are par excellence in enabling one to indulge in forbidden fantasies and autoeroticism, anti-anxiety agents and dopamine enhancing drugs can also be used for the same purpose. Narcotics do it by blocking the psychological and physical pain that follows on doing the forbidden. This is based upon previous experiences of painful consequences that occurred after such deeds (that were risky and dangerous) and which not infrequently led to actual physical punishment, or at least scolding and threats of doing so from the parents. It is kind of simple Pavlovian response - classical conditioning - pairing of pain with indulgence in off-limit activities.
Benzodiazepines achieve the same end by taking away the fear of the consequences. Here the pain that follows on indulgence in autoeroticism is not blocked, only the anxiety over treading in to the forbidden territory is wiped out. With GABA blocking drugs, the person ceases to fear the tomorrow, lives for the moment so to speak, and gives into forbidden behaviors. The dread of the consequences is taken away from the psyche as the drugs put the highest cognitive centers of the brain in sleep mode.
Dopamine enhancing drugs like Adderall work by a completely different mechanism. They shift the attention from the pain and suffering to finding pleasure in whatever one is doing at the moment - hyperfocusing upon the immediate. So the malaise, fibromyalgia like pain, headache and guilt feelings that follow the indulgence are pushed in to the background and the person can go on with the activities of the day instead of crawling into bed and sleeping through the suffering. The energy that emerges from this artificial boosting of dopamine acts like a separate fountain of mental activity. So while the body is smouldering in the subterrain the person continues to feel good on the surface.
At this point it may not be inappropriate to add that ordinary success has the same effect upon lessening the need for opiates as the taking of psychostimulants. As one of my patient put it: "As long as I am busy I don't feel the need for Suboxone. As long as things are going good drugs are furthest from my mind. As long as I am making money, getting tips at work, and I have enough money for my children I have no need for Suboxone. But the minute I have fight with other waitresses or the boss is mean with me, I start getting withdrawal symptoms."
This phenomena of success, which no doubt secretes dopamine in the brain, and reduces the need for Suboxone and other opiates is exemplified by the fact that professional people like doctors, lawyers, nurses and other high rankers of society have far greater success in kicking their habit and getting off the Suboxone faster than people who are in low paying jobs or are unemployed.
Am I then suggesting that one should routinely put people who come for Suboxone therapy on benzodiazepine and amphetamines as well? Or at least make use of them as adjunctive therapy to get off Suboxone?
This is a hard call. We know addition of Xanax reduces the need for Suboxone and so does the addition of Adderall. But by doing so in the long run are we going to make the patient dependent upon three classes of drug?
I think it depends upon the personality of the patient. In some the combination of all three at low doses may be better strategy for keeping them off the street drugs. In some Suboxone alone at higher doses and longer tapering off period will be the ideal strategy
My main point here is that clinically the requirement for opiates and Suboxone are lessened when the patient is given benzodiazepine or Adderall concurrently.  Whether in the long run this makes him  more or less prone to addiction I do not know.