Friday, November 10, 2017

The underlying cause for seeing hallucinatory faces in a schizophrenic patient

A patient who is in her late fifties and has suffered from paranoid schizophrenia since her twenties, which, fortunately, for the most part, remains in remission, came to the session and reported that after her Primary Care Physician started her on Gabapentin (Neurontin) 400 mg. three times a day for peripheral neuropathy and knee pain, she started feeling miserable and began seeing faces in everything she laid her eyes upon. "I see faces in clouds, on my wall, on the patterns of my couch, the knickknacks on your windowsill, even the mug from which you are drinking your coffee."
"Are you just inferring faces from the random lines and patterns that are always present in these objects like one does in Rorschach test or are they actual hallucinations?" I asked her.
"Well, I don't see too much difference between mistaking the patterns on objects as faces and their popping up as pure hallucinations. And you know in the past I have had florid hallucinations so I know what I am talking about. Also when I close my eyes and try to go to sleep faces pop up then too without my looking at any objects. In fact, they are even more intense when they emerge while my eyes are closed; so intense they prevent me from falling asleep."
Now the purpose of all mental symptoms is to prevent one from getting out of control (going wild/going crazy). What looks like crazy behavior (madness) to an outside observer is actually a watered down (relatively harmless) versions of something totally unacceptable and violent behavior.  When one's unacceptable impulses (internal world/id) become overwhelming and threaten to disintegrate the ego, or act against one's moral precepts (the superego/conscience) or come into conflict with others (the external world/reality) then one gives outlets to these impulses in form of bizarre behaviors (mental symptoms).  By restraining one from acting out the impulses in their pure (directly destructive) forms, one protects oneself from the wrath of others and one's conscience. The agency that suffers by this seeking of refuge in madness is the ego which instead of seeing reality correctly, sees it in distorted forms, that make it easier for it to act out the destructive impulses in their displaced relatively harmless substitutes.
Were these hallucinations there to prevent her from doing or thinking something unacceptable?
"Do these faces scare you and keep you from doing wrong things?"
"They are not scary but they do prevent me from thinking weird thoughts. I get so caught up with these faces, I can think of nothing else."
"What kind of weird thoughts?"
"Like my son coming to harm. You know he acts as head of security for rock bands when they go on tours. He is right now with a rock band which is touring South America. I was worrying about the crowds getting out of control and his security team unable to contain them, resulting in his and his people getting injured or even killed."
The patient who has been with me for over twenty years and therefore I know she suffers from great fears of harm coming to her loved ones (which is a displacement of harm coming to herself). She harbors, in her unconscious, very strong impulses to destroy the world and everybody in it. These wishes emerge in her conscious mind as fear of world falling apart and coming to an end (because of her). And the guilt over causing world-catastrophe, when it becomes too strong, emerges as hallucinations.
I asked her "Who are the people whose faces pop up?"
"Faces of people I don't even know. Especially at night, when I try to sleep, the faces of people emerge who I have never seen before."
Now we know from psychoanalytic study of dreams that people who we are very close to us, especially family members, to hide their identity, the dream-work substitutes them with faces of total strangers. So the fear of harm coming to herself was displaced on to harm coming to the family member - now we also know that irrational fears of harm coming to one's family members and altruistic worries about their safety is really projection of fear of harm coming to oneself. - and the hallucinatory faces were of family members who were coming partly as a retaliation for thinking of harm coming to them and partly to prevent her from thinking such weird thoughts.
At this point, she recalled that the faces started popping up after she had a very frightening dream. In this nightmare, a nuclear explosion had occurred. She was in her car trying to get away from its after effects. She noticed as she drove that there were people all over who had been afflicted by the nuclear fallout and needed help. But she could not help them because her dead relatives and friends were there too, but now appearing alive, and were warning her not to touch or help any of the people on the road because they had been afflicted by the nuclear explosion and she would suffer the same fate as them if she touched them.
The dream had woken her up in fright and from that time onward the hallucinations of popping faces had begun.
Patient went on to say that besides what the gabapentin had done to her mental stability, the frightening exchange of words between Trump and the leader of North Korea about nuclear war that had triggered her fears of world coming to an end and which had triggered the nightmare and seeing on TV the devastation that had occurred n Texas and Florida due to hurricanes Harvey and Irma, they had all contributed to the emergence of the hallucinations.
Then she remembered that this  hallucinations of faces had once before occurred and that time it was a premonition of some disaster happening and to her surprise a few days later 9/11 and World Trade Center collapse had occurred.
Patient opined, "The faces were popping up as a premonition of what was to occur due to Hurricane Irma and Harvey. Just like in 2001 the same hallucinations occurred as a premonition of what was to happen on 9/11."
Patient lays great store by her ability to cause massive destruction by her thoughts.
The patient added, "You know how I worry about the world coming to an end soon. I worry about going to sleep and not waking up (because in my sleep when I have less control over my thoughts I can cause world destruction). I have to pray in the night for God to make sure that I wake up in the morning with the world still there and I still alive. But all this happens when I am down and depressed. I think that gabapentin made me depressed and triggered my fear of world coming to an end and the faces emerged to prevent me from doing so.

1 comment:

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