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.

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