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.