Sunday, November 23, 2014

Psychological underpinnings of Racing Thoughts in a woman with Bipolar Disorder

When a patient reports racing thoughts the psychiatrist immediately thinks of Bipolar Disorder, especially of mania, and generally writes a prescription for Lithium, Depakote or Lamictal, the traditional mood stabilizers, or recently, being a captive audience of the pharmaceutical industry, brand name antipsychotics like SeroquelAbilify and Latuda.

However, racing thoughts are a reaction to anxiety and have only an indirect relationship with mania. Anxiety itself is the organism's preparation for running away from danger. And when a person cannot run with his feet he runs with his thoughts. It is the perception of this frantic mental running that he reports as racing thoughts, or more colorfully with phrases like "my mind is running million miles a minute" or "my mind is all over the place" - by which he means he is putting out fire at every front from where the lurking danger may strike him.

Recently I could analyze to some extent the mental processes underlying racing thoughts in a Bipolar patient who was rapidly losing her euthymic state. The analysis threw some light on the underpinnings of racing thoughts.

The patient, who is in her late forties, cut her clonazepam dosage - a benzodiazepine - to half. This self-attempt to wean herself off the psychotropics triggered a partial relapse, the first manifestation of which was racing thoughts. She at once raised back her clonazepam but by then the cat was out of the bag.  Her morbid thoughts were no longer amenable to the benzodiazepines and demanded a running of their full course before going in to quiescence. 

When I inquired of the patient if her racing thoughts were the beginning of her mania she said,"No. They are the beginning of my depression. In mania I have this tremendous energy and I can actually control my anxiety by doing something like obsessively cleaning the house, washing walls, doing jigsaw puzzles etc. But the racing thoughts are not quite the mania itself.  In fact in all my three states I have a slight different reaction to anxiety. When I am in my normal state I still do the same obsessive activities as when I am in mania, but it is not accompanied by the agitation and nervousness that characterizes my mania. It is in depression that I have true racing thoughts and frank anxiety. I have no energy to do the obsessive rituals that control my anxiety. You know the purpose of my obsessions is to do something constructive that will ward off the impending doom. I can do that easily when I am euthymic, with some difficulty when I am manic, but I am completely paralyzed and cannot do my motor rituals when I am depressed. It is then that the racing thoughts start. As if recurrent thoughts replace the motor rituals. They are an attempt to run away from the disaster that is about to happen. When I am depressed I have no energy left to physically deal with the wolf on the door. I can only run and run and that too only in my thoughts."

Her statement about the racing thoughts made me wonder if we should not treat them more as a symptom of depression than mania, or, rather, as a symptom of both the phases of Bipolar Disorder.

"Can you tell me the content of your racing thoughts? That may give a clue as to their purpose."

But what she brought up as the substrate of her racing thoughts could hardly be seen as something that would cause anxiety. They were about a Stuart family and their son John. He was her first  boyfriend. As to why she was thinking about them was hard to tell. The scenes that she was playing in her mind were exact replaying of things that had happened to her in their company. Some of it  boring routine stuff, some of it tender, romantic and intimate moments with John. But she was repeating these memories obsessively through the night, especially in the morning hours, when she would wake up around 3 or 4, in great anxiety, her mind racing out of control."

"Why of all people you chose the Stuarts to think about obsessively?"

"You know when I left my home I was a minor. I had to live with strangers. Stuarts were one such family. They were nice to me. In fact they were the only ones who did things for me without any expectation of reciprocation. And then John and I became lovers. That was my first love. It was such a relief after the icky feelings I had developed towards sex because of the sexual abuse that I was subjected to by my father, which, as you know, is the reason I ran away from home at the age of 15."

"But why would you think about the Stuarts 30 years later? They are not in your life anymore.  John got married, divorced and now lives on the West Coast. There is no trace of the rest of the Stuarts, at least here in Michigan. You are not going to run in to them. You met John a few years ago and he aroused no passion in you. You were completely indifferent to him romantically. You have no expectation or desire to get back with him. Why would your mind race on and on about the Stuarts? And if the memories of the Stuarts is pleasant why do they leave you so exhausted in the morning?"

Patient then confessed that behind the thoughts of Stuarts, and her love-making with John, there were also thoughts about her father, that were simultaneously running in the background, though so faint, they were barely perceptible.  And yes they were connected with the sexual abuse. So the racing thoughts of her sexual relationship with John, and her pleasant memories of the Stuart family, were running in the foreground to cover up and replace the memories of the sexual abuse that was flooding the unconscious. She was running away from the memories of the sexual abuse, just like she had actually run away from the real abuse when she was 15.

"But why would you want to run away from the memories of the sexual abuse?"

"Wouldn't you?" the patient was incredulous. And then she realized I was not condoning it but wanted to know as to what were the underlying psychological processes that had made the abuse so distasteful to her, and if it was distasteful why it kept coming back to her mind every night.

 She went on,"A father is not suppose to do things like that to his daughter. Even then I knew it was wrong. I felt sorry for him, because our mother had left when we were very young, and he had to look after four children, and he was lonely and short with us, but that is no excuse for him to have done what he did to me."

So the pleasant memories of Stuarts were obsessively appearing in her mind to block out the unpleasant memories of the sexual abuse. So the racing thoughts do not emerge out of the blue when a person becomes depressed or manic, but have their own raison d'etre, and there is some psychological advantage to be derived from them. The depression and mania and the obsessions are a defense against the trauma. In this patient they were the preferred mode of dealing with adversities.

And the racing thoughts are better looked upon not so much as illness but as an attempt to prevent worsening of the psychopathology. In this case of her slipping into outright depression.

But why were the memories of the sexual abuse causing her to run away from them? Even if they were unpleasant  - or rather one part of it was unpleasant because it was something that should not happen between father and daughter -  there had to be some missing link that would account for why she had to run away from these memories. And if running away, and its mental counterpart racing thoughts, are due to fear/anxiety, what it is that she is fearing when she thinks of the sexual abuse?

Here the clue was provided by a series of dreams that had been analyzed over the years.

Whenever she would get into depression she would have anxiety dreams. It would be instructive to examine a couple of them.

She dreamt that she was destroying the top floor of her house with a bulldozer. There was awful din made by the bulldozer. After destroying it she just walked away. The dream was sparked by the garbage truck that was going back and forth next to her house. But it was reminiscent of her father telling her to keep awfully quiet during the furtive sexual activity lest her grandmother who lived in the lower flat would get woken up. They lived on the top floor and in the dream she was destroying it to erase the memory of the sexual abuse, and destroying her father at the same time as a revenge for doing what he did to her.

Another dream was of cutting grass. There were black snakes in the grass which were getting chopped off. This was again revenge fantasy of castrating the father for using his penis to violate her.

So the emergence of memories of sexual abuse were there to take revenge upon the perpetrator. And it was connected with intense fear that her father would retaliate if she attempted to kill or castrate him. And that is what she was running away from.

When she would wake up from these dreams she would be very shaky and spend all morning and early part of the afternoon till about 2 pm doing obsessive activities to control the fear. These obsessive activities were symbolic acts of repentance for wishing evil for the father. They were undoing of all the aggressive thoughts and actions she had dreamt in the night for being subjected to all the sexual things her father did to her. When all the penance had been done, which was by mid afternoon, she was free of obsessions, anxiety and racing thoughts.

There was an interesting diurnal variation to her racing thoughts. They would start when she would wake up at 3 or 4 in the morning, reach their peak by 7 or 8 am, and quit by the afternoon. She would feel somewhat OK for a few hours and then would go to bed by 7 or 8 pm. Analysis showed that once she started feeling good the thoughts of abuse, hidden behind which was wish for sexual satisfaction, would start emerging. But since these thoughts were intimately connected with shame, feelings of being take advantage of and of being wrong in eyes of others (morally reprehensible), they would provoke more unpleasure than pleasure and they would be accompanied by thoughts of revenge. And it is to escape this unpleasure that the patient would take to bed and sleep. However, they would continue on in sleep become too powerful by midnight and unable to be handled by dreaming of pleasant things like her relationship with Stuart family by 3 or 4 am. It was then that she would wake up with racing thoughts.

I cannot resist taking a swipe at all those drug company touts who come as experts and give CME and drug company sponsored lectures to us private practitioners, flaunting their professorships and other ivory tower badges of honor. Their psychiatry is limited to giving drugs and whenever I have asked them what they do in terms of psychotherapy they, one and all, as if they all get handed out a pamphlet in their annual neuropsychopharmacology conference how to deal if they ever get cornered with this question, reply with, " Well, I recommend my patients to take a walk. So you see I am not averse to mental factors having a role in mental illnesses."  With this declaration they seem to believe that they have discharged all their obligation to study and teach psychology's role in causing and sustaining mental illnesses. And well one cannot fault them either for there is some truth in that walking away from one's problems does give temporary relief. Running away from true understanding of the patient through zonking them with drugs or telling them to take a walk is the alpha and omega of their practice.

Wednesday, November 12, 2014

A dream of a self divided against itself

A 24-year-old man who complained of an inability to focus, problems at work because of his tendency to daydream, and chronic moderate depression, was put on Zoloft (Sertraline) 25 mg. He discontinued it after 3 days on the grounds that it clouded his mind. Instead, on his next visit, he requested Adderall (dextroamphetamine) for his attention problems.

Adderall immediately improved his work performance and mood, but he began having, as he put it, very strange dreams. They were violent in nature and intensely vivid.

The way he narrated all this gave the impression that the unconscious conflicts that were responsible for his depression and for dividing his attention were now emerging in violent dreams and as a direct consequence of Adderall-induced redistribution of his mental energies (cathexis). Perhaps Adderall's dopamine enhancing properties were boosting the pleasure (feeling of reward) in whatever tasks he was doing during the day and because of that his attention was focused upon it undivided; instead of getting diverted into daydreams through which his intrapsychic conflicts were indirectly presenting themselves to his consciousness. But this reconfiguration of mental forces due to Adderall was getting reversed at night, when with effects of Adderall gone his unconscious conflicts, gaining cathexis (charge) from lying fallow all through the day, were emerging with greater vigor, forming vivid and violent dreams.

When asked to give an example of his "strange, violent and vivid dreams" he narrated the following which he added he had dreamt two or three times since he was put on Adderall. 

Three guys are doing a hold up at a McDonald's. Two of them approach the counter while the third one waits at the door. Then the guy at the door shoots one of the two at the counter.  The head splatters,  blood and gore fly all over the place. The scene is still so vivid in my mind. In fact the whole dream was incredibly vivid. Strangely I did not panic or feel any other negative emotions despite the vividness of the violence.

"Who were the three guys?"

"They were thin and tall with shaved heads like myself, that is all I can say about them."

"Well you do not have shaved head, though your hair are pretty short."

"Those three guys had hair like mine - shaved or short whatever you prefer. I shave my head whenever my hair grows to any measurable length. Those three guys had hair like myself and they looked thin and tall like myself."

I looked at his physical dimensions and had to agree he was thin and tall.

"Were those three people yourself?"

"I never thought of it like that. But they were remarkably like each other, so what you are saying makes some sense. But I was there too, watching them, so I couldn't be them."

"You could be watching yourself in the dream.

"Anything else about the three guys, any other association, or detail in the dream itself,  that comes to your mind about them?"

"Two of them are wearing thin rimmed glasses. The third one is not."

"Why two of them are wearing glasses? You don't wear glasses. Why do the glasses come into the dream?"

"That is interesting. I know someone who wore glasses like that in my elementary school. We were very close. I haven't seen him in 10 years. Strange that he suddenly popped up in my dream. But yes those are his glasses and he shaved his head too."

"He shaved his head in elementary school?!"

"No, in middle school."

"Did you shave your head then too?"

"No, not then. He did, but not me. I started shaving my head after my grandmother came down with cancer and lost her hair to chemotherapy. I don't know why I did it. But when she died I shaved my head. And ever since I have keep my hair short."

Based upon the background knowledge I had of him I made the following conjecture,"You shaved your head because you felt guilty about your grandmother's plight. You blamed yourself for it and tried to subject yourself to the same misfortune that had struck her. It was making of amends in the way unconscious thought processes do. It is a form of mourning for losing an "ambivalently" loved person. You feel somehow you are responsible for their suffering and death and subject yourself to same torture that they experienced in the process of dying. You identify with people who are suffering and take on their problems as your own as if to compensate for what you assume you have caused them. Of course you had no choice over developing cancer, and certainly you would not have gone that far, but cutting your hair off was something you could sacrifice without too much trouble.*"

The patient did not quite follow my explanation but added, " I shave my head because it saves me 15 dollars each time I do not go to the barber. Punishing myself for my grandmother's cancer I don't know if that is true or not. But I did feel quite bummed out about it as if I should have done something to prevent it from happening."

"Since you have a tendency to do yourself what you do to others, is it possible that in that holdup there was intent to shoot someone, but before you did that your conscience - as one of the guys - shot yourself as the other guy?"

"Whoa that is deep. But there was no intention to shoot anybody during the holdup."

"There is gun in the dream and somebody is shot violently, so the intent to brutally kill someone was there in the latent dream-thoughts all along. All we have to explain is as to why instead of shooting the person who you were robbing - by making him show resistance, which would have provided the motive for killing him - you make one of the partners in crime shoot another which on face makes no sense. But it would make sense if we assume that you had ambivalence about shooting the person who you went to rob and kill and who in your unconscious is equated with McDonald's

"And if the three guys are different aspect of yourself then one one part of yourself, your conscience, the moral part, is shooting the other part, the murderous part.

"And as to who this person is who you want to rob and shoot we may be able to decipher if we figure out as to why the holdup was at McDonald's rather than a bank or convenience store. Any association to McDonald's?"

"My mother would not let us eat at McDonald's. We were not allowed to eat fast food as kids. So for a while when I could do it without anybody telling me what I could or could not eat I was eating at the McDonald's all the time. Actually for good three years that was my favorite food joint, at times I may have eaten breakfast, lunch and dinner there on the same day.

"So McDonald's is somehow connected with your mother.  You ate at McDonald's all the time to make up for the love your mother did not give enough of?"

"No, I never felt that way. Nor did my brother, who is four years younger than me, but my father may have felt that way."

"Why your father?"

"She cheated on him. He forgave her. But was depressed about it all the time. Finally she left him for the same guy that she had been cheating on him for 10 years, and for a while my father was very depressed; and tried to kill himself."

"So are your going to the McDonald's to shoot your mother, or her boyfriend, perhaps both to avenge your father?"

[I did not tell this to the patient but thoughts arose in my mind that the situation was identical to what Hamlet had faced when his mother had affair with his father's brother which resulted in his father's death, and he was faced with the dilemma of killing his mother and her mother's lover, but his conscience did not permit it since he was guilty of the same impulse that his mother's lover harbored, and he ended up killing a whole slew of people and finally himself instead of straightaway putting his mother and her lover to death. In my patient's case too instead of straightaway taking revenge upon his mother and her lover, who had made his father suicidal, he had in the dream chosen to kill himself and his childhood friend. In Hamlet too, Hamlet's two childhood friends meet the same fate as himself - death.]  

"The three guys went to the McDonald's to rob not to kill anybody. But who knows. You are the doctor you know better than me what goes on in my head."

"Now if McDonald's symbolizes your mother then it makes sense to rob her. During our first phase of sexuality, which reaches its peak around 4 to 5 years of age, there are sexual impulses towards the mother which is often felt as an impulse to rob her and which is tantamount to taking away from the  father something that  belongs to him**. So under the layer of going to McDonald's and shooting someone who symbolized your mother and her lover, there is another, and more ancient layer, of robbing your father of his wife for the satisfaction of your own love impulses. Which makes your guilt doubly strong, and leads to your shooting yourself for having such evil thoughts."

This piece of analysis did not quite make sense to the patient and in reality was conveyed to him quite partially, not in quite the same words, and was actually fully formulated while writing it now. But he did hint at its possible correctness by stating, "I never thought that my robbing of McDonald could be symbolic of my robbing my mother. But all my life I have felt as if she stole something from me." This feeling of having been robbed by her was projection of his own unconscious impulses to rob her***.

I asked the patient,"When did your mother leave your father?"

"When I was 19."

"When did you start eating at McDonald's morning, noon and night?"

"When I was 19."

So these revenge fantasies were there in his unconscious draining his energies and causing depression and robbing his focus and causing his attention deficit for five years but only when he was put on Adderall did they gain enough cathexis to get a foothold in his consciousness and that too in dream and not waking consciousness using the crutches of weirdness (dream distortion) and disguise (dream displacement). It was no doubt the intensity of his violent wishes that had kept them buried for so long, and only when he entered treatment and received the chemical boost from the amphetamine, that he could allow them to emerge in his sleep, when the muscular paralysis made sure that they could not be acted out.

The two details of the dream which were not analyzed but constructed by me needs a few comments. The two guys were wearing thin rimmed glasses and one was not. And it was one of the glass- wearing guys who shot the one who had no glasses. The one who was shot was himself and the one who was wearing glasses was his friend symbolizing his conscience. The friend was imported in to the dream to make a distinction between that part of himself which was connected to his conscience from the part which harbored revengeful impulses.

His comment that he did not panic and felt no emotions was triumph of the wish fulfillment. Such a violent and gruesome action could be enacted without feeling fear and other negative emotions because they were being enacted in the dream-pictures against his own self. Perhaps the glasses with their function of seeing more clearly symbolized the conscience.


* One recalls here how Hindus shave their hair as an expression of mourning when one's parent dies. Since hair serves as an excellent symbol of penis one wonders if the cutting of hair in mourning symbolizes the following train of thought: since my phallic sexual impulses generated the wish for sex with my mother and death of my father, as well as sexual wishes for my father and death of my mother (negative Oedipal Complex), and now that the wish has come true, I must symbolically castrate myself by shaving off my hair.
In olden days Brahmins keep their head permanently shaved as if to symbolize that due to their unusually strong sexual drive, which consequently emerged with the most violent force during the oedipal phase, they have to live their entire life under the weight of the oedipal guilt. Only through the aid of a very strong oedipal guilt could they control the strength of their genital impulse, preventing it from regressively flowing into neuroses and perversions.
It is interesting as to how the Brahmins leave a small strand of hair at the back of the head like a thin ponytail - their choti - reminiscent of how the Mohawk Indians shaved their heads but for a thin strip of hair. Perhaps this hair ritual gives expression to the following train of thoughts: Under the pressure of Oedipal guilt  I have self castrated myself in most spheres of my life. Only a narrow band of direct sexual expression is left for me, rest of it restricted to aim-inhibited modes of discharge.  It may not be too far fetched to conjecture that the prohibition of cutting hair in Jews - a practice which Muslims and Sikhs plagiarized for their religions  - may be expression of this psychological complex but in reverse.

** Much of bank robbery, forgery, con games, cheating in money transactions,  and other forms of sociopathy in human affairs, originate from this impulse  - from the oedipal phase - to rob the mother and father too - because whether the mother belongs to oneself or the father is in dispute in child's mind.

*** In women the obsession to rob the mother for having robbed something from oneself lies at the heart of shop-lifting.

Sunday, November 2, 2014

A Unified Theory of Physical and Mental Illnesses

All chronic illnesses - mental no less than physical - at the deepest level are an inflammatory response to an external object that has made an unwelcome entry inside the organism - broken through its protective shield - and disturbed its homeostasis. Entry of objects from one body system to another, like the intestinal bacterial flora entering into the peritoneum or blood stream, are reacted to as if they are an external object.

The inflammation is the organism's method of creating a wall around and extruding the unwelcome object out of the system and restore the earlier state. If the object cannot be expelled, excreted or exhaled then the organism works towards nullifying its harmful effects through embedding it and eventually making it a part of the organism, finding some 'secondary use' for it.

The process is assumed to happen just with physical objects that have traumatically entered into the organism, but the phenomena is equally applicable to the mind. Unpleasant experiences are treated as something foreign that should not be made part of the self (ego), and provoke mental (ego) defenses that try not to think about them any further, sometimes sealing them out of consciousness permanently by subjecting them to repression. They remain embedded in the unconscious memory banks, continuously subject to modification till they can be made part of one's self and 'secondary use' can be found for them.

These ego defenses are like the inflammatory response of the mind.  Ego originates from the mental representation of body surface - eyes and ears being the most specialized parts of this body surface - and other body sensations including those that give report of one's muscular activities (kinesthetic sensations), and just like skin, and other body organs, heighten their activities to expel an unwanted foreign object at the physical level, ego mechanisms gear up their activities to nullify the harmful effects of mentally painful experiences. The id impulses - sexual and aggressive drives - that originate from inside the organism, if they cross a certain threshold and cannot be safely discharged without provoking a retaliation from the outside world, are treated as if they are arising from the outside and ego defenses are mobilized against them as if they are not part of oneself. An extreme example would be how a paranoid schizophrenic may enucleate his eyes to reject the scopophillic id impulses, treating the eyes not as part of one's body but as an alien evil force that is inimical to one's self.  

Most interestingly an unpleasant psychosocial experience not only activates mental defenses, it simultaneously provokes the same somatic reactions that happens when some physical trauma  occurs. This latter phenomena has far reaching consequences. It is as if the body has a tendency to sympathetically respond to any inflammatory activity anywhere and it does not matter whether the provocative agent is mental or physical. As if the organism anticipates that one traumatic event is likely to be followed by some more, and all defensive processes must be put on alert if there is stressful assault on any part of it.

The above idea which has been with me for a long time, and bits and pieces of which have appeared in my previous posts, found its impetus to be written in greater detail while listening to a patient of mine who commented that her throat was inflamed which means that her Crohn's (autoimmune inflammatory bowel disease) will follow suit in a few days. She claimed that any inflammatory reaction anywhere in her body becomes generalized and her intestines, because of previous vulnerabilities, show this sympathetic inflammatory response the most.

Inflammation is mobilization of body's counter-attack mechanisms to deal with anything unwanted from the outside. But when these counterattack mechanisms go beyond their call of duty and start overdoing their job then we get chronic diseases. The body's reaction to an external object should be commensurate to the strength of the trauma. If, however, the organism is genetically oversensitive and/or has been subjected to too many traumas in the past, the hatred/rejection of the outer world becomes so strong that response to any assault, no matter how minor, becomes pathologically disproportionate. Every unpleasant encounter with the outside gets under one's skin so to speak. All chronic diseases are kind of Post Traumatic Stress Disorder if one may be allowed to express the above idea in psychiatric parlance. In psychoanalytic terminology they are "Traumatic Neurosis": abreaction of stress through exaggerated (displaced) mental and somatic processes.

Now our body comes into contact with the external world via limited portals. Skin of course is  phylogenetically the oldest organ, evolved to form a barrier between the subject and the object -  between the self and the universe. Modifications of the skin occurred to create various portals to more efficiently imbibe aspects of the world essential to one's existence while keeping the unwanted objects at bay. The gastrointestinal tract evolved from the protoplasmic wall inlets that increased the cell (skin) surface to more effectively incorporate food and water and excrete the superfluous; the respiratory tract developed to provide infinitely greater oxygen and carbon dioxide exchange area in the lungs along with a long passageway to trap subtle pollutants in the nostril hair and block food particles at the larynx; the circulatory system became specialized for taking the nutrients and oxygen from GI and respiratory tracts to distant organs of the body and to bring excretions back to the same tracts and also to the renal-urinary system; the optic, nasal and oral passages for taking in visual, olfactory and gustatory impressions respectively; and finally the brain which is the most marvelous extension of the skin, and where impressions impinging upon the five senses are converted to complex perceptions - which are further refined into concepts (brain's 'shorthand') - to more quickly react to danger and to more expediently search for food and sexual objects.

Now with mental trauma if its effect cannot be countered by pure psychological means (ego defenses) the reaction spills into physical sphere - modeled after hysteria in which psychological conflicts and excitations are expressed through bodily innervations - and different body organs react as if they are dealing with an intrusion of an unwanted foreign physical object in their system.

A full appreciation of this phenomena forces us to correctly realize as to how most chronic diseases, even those that appear to be solidly somatic, are psychosomatic in nature, and are initiated and maintained by psychological traumas. Chronic somatic diseases are not so much a reaction to some physical insult as a result of psychological stresses that generate compulsions to rid the memory of the offensive person in displacement. In respiratory tract one finds that the spasms of bronchial muscles and asthmatic attack are motivated to symbolically choke the psychological irritant in the bronchial passage. In an analogous manner, in the upper GI tract, we pour excessive acid to burn the source of our stress and then regurgitate, after 'eating alive' the hated person, through the reverse peristalsis of Gastro-Esophageal Reflux Disease. The psychology of binging and purging may show itself to have its roots in the desire to ingest the ambivalently loved object (person) and then throwing him up as a hated (foreign) object. In lower GI tract we try to eliminate him through various forms of colitis; as if we want to 'bury him in excreta'. In urinary tract the desire to flush out the person who is 'pissing us off' is reflected in various forms of irritable bladder syndrome and interstitial cystitis. In eyes and surrounding paranasal sinuses inordinate amounts of mucosal secretions (post-nasal drip) occur as if to 'drown in tears' the person who is causing us the pain. In the circulatory system we gear up to deal with the hostile outside world by increasing our blood pressure, by mobilizing inappropriate amounts of sugar inside the cell to make it more readily available for instant energy in case we have to indulge in fight or flight, by gearing up various other components of metabolic syndrome like increasing the rate of oxidation and mobilizing various forms of immune mechanisms, the excessive activity of which leads to autoimmune disorders. In the skin lopsided production of dermal tissue, as if to 'make oneself thick skinned' against the sling and arrows of life, causes psoriasis, neurodermatitis and other skin blemishes. It may be mentioned that the suppurative skin reactions in which the unwanted intruder is embedded in a pocket of pus to be eventually spilled out, gives us in a most transparent fashion the raison d'etre of inflammatory reaction. Finally in the brain, the most important extension of skin, where perceptions correspond to the touch sensations of the skin and muscle (motor activities) of the body correspond to thought processes of all kinds, exaggerated perceptions (hysterical disturbances) and excessive thinking (obsessive disorders) occur when a person is subjected to a traumatically intruding outside world. 

If I may be allowed to do so I may expand a little upon an interesting observation I have made upon  GI tract's role in dealing with psychological irritants. Perhaps people's love for eating hot and spicy food and drinking harsh spirits - the latter's intoxicating/anesthetic effect act as an additional motive of course  - may be a way to use the abrasive food as a symbol of the caustic world outside over which they can triumph by voluntarily swallowing its roughness. It is as if they are convincing themselves that no I am not subject to this hostile world against my wishes but it is I who is subjecting myself to this corrosiveness and enjoying it too. [It is not too different than how a woman who was sexually abused as a child repeatedly gets in to relationships with men who will repeat the sexual experience but over whom she has greater control now that she is an adult.]  The human obsession with eating some food and not others, in Obsessional Neurosis and Autism reaching ridiculous proportions, is a way to reject the painful aspects of the outside world by symbolizing it in some foods. Thrill seekers and those who court other forms of troubles, their psychology is similar to those who eat highly seasoned food. They expose themselves to dangerous situations or lure worthless people into intimacy, those who are sure to harm them, so they can triumph over these unpleasant objects and purge them out of their system.

Finally in this context one may mention that pregnancy, which during my student days was an object of  mirthful debate whether it should be looked upon as a physiological process or a disease - for it shows all the pathphysiological processes of an illness - can be conceptualized as an inflammatory response to a foreign irritant too.  The man's spermatazoa is treated as an outside object, its impact is lessened by walling it off from rest of the organism with uterine muscles which are also used to extrude the final product, the baby, out of the system. Excessive cautionary fear of the woman towards the larger world may lead to infertility in her. Such an attitude is often present in highly narcissistic women who finds sex and its consequences at variance with their life trajectories.  Such narcissism, where pregnancy and babies are looked upon as having no place in one's conception of ideal life, may pervade a culture to such an extent that the people belonging to it may slowly non-breed themselves in to extinction.