Dream within a dream

A patient came crying to the session, extremely distraught. Her father had an auto accident in which he had suffered multiple fractures. The injuries were life threatening, he was in Intensive Care Unit, and there was a good possibility he would not live beyond a week.
After she abreacted the shock and pain of this trauma, she mentioned that every night she was having disturbed dreams, but one which had puzzled her greatly.


She dreamt that she was dreaming that the accident had happened. She felt so happy that the accident was after all only a dream.  She  could now continue to sleep because when she wakes up the nightmare will end too.  
But anyway she woke up and immediately reached for her smartphone to call her father to tell him as to what a terrible dream she had had about him, only to realize that she had pictures of her father on life support in that very phone, which on checking she found yes they were there, and all her pain came flooding back. 

Here is Freud on the issue of dream within a dream

The interesting and allied problem, as to what is meant when some of the content of a dream described in the dream itself as "dreamt' - the enigma of the 'dream within a dream' - has been solved in a similar sense by Stekel, who has analysed some convincing examples. The intention is, once again, to detract from the importance of what is 'dreamt' in the dream, to rob of its reality. What is dreamt in a dream after waking from the 'dream within a dream' is what the dream-wish seeks to put in the place of an obliterated reality. It is safe to suppose, therefore, that what has been 'dreamt' in the dream is a representation of the reality, the true recollection, while the continuation of the dream, on the contrary, merely represents what the dreamer wishes. To include something in a 'dream within a dream' is thus equivalent to wishing that the thing described as a dream had never happened. In other words, if a particular event is inserted into a dream as a dream by the dream-work itself, this implies the most decided confirmation of the reality of the event - the strongest affirmation of it. The dream-work makes use of dreaming as a form of repudiation, and so confirms the discovery that dreams are wish-fulfilments.

The dream within a dream of my patient confirms the correctness of Freud's explanation of this puzzle.
I may add here that sadly the patient's father did not make it out of the ICU and left the patient's dream of keeping him alive against all odds unfulfilled.

An unfettered expression of the wish for a penis in a woman's dream

A patient, who is relatively well settled, married, with two children and a steady job, and who other than suffering from moderate life-long anxiety, that compels her to be constantly busy to bind the anxiety, brought in the following dream, prefacing it with the comment that it is the weirdest dream I ever had.

In my dream I look down and see that I have a penis. It sends a shock through my system. What the hell is down there.  I was completely freaked out.  I was like majorly upset. But then I must have accepted it because it became part of me and everything became fine.  I don't know how long this acceptance goes on for I lift it up to inspect whether it was the whole package or no and to my horror I see there is a hole in it. A black hole. I knew at once there was something majorly wrong.  It was scary. Then I notice it is infected. As if gangrene was going to set in, and it would fall off.  I felt like I would die, for it had by now become a part of me. Not that I wanted it to be there. In the beginning at least I did not. But now I had become accepting of it.  But there was a huge frigging hole in it. One could see through it,  I went into shock again.
I tried to take my problem to the doctors. I was like in a room in a hospital. But they would not realize that there was penis on me or that it could fall off. Like they were not understanding the problem. I had so many emotions go through me.  I cannot even describe the range of complex feelings that emerged during the course of this dream. There was bad anxiety, and sense of hopelessness and despair, as if I was going to die. They were dismissive in their attitude. They were like we can't help you, we can't help you. They would not like even comprehend or acknowledge what was happening to me. 
That room in the hospital it always comes in my dream. I always go there when my dream has to show hospital or medical treatment of any sort. It is a very familiar room. I know I have seen it before. It is always the same room. As if I have been there before, a million times.
Incidentally, there was none of the appendages with the deal. No testicles, just the shaft was there. And that did not matter, it was only the hole in the penis that was freaking me out.

Patient to hide the embarrassing nature of the dream assured me a number of times that she never ever has dreamt anything remotely similar to it before.
Now this patient is relatively new, sees me just once a month, for half an hour, primarily for medications for her anxiety and depression, and we had never ever subjected any of her dreams to analysis. So it surprised me that she narrated so frankly a dream which most people would have great reservations admitting to having let alone talking frankly about it to a relative stranger, even if he is  their psychiatrist.
She explained to me that she could talk so freely because she saw on the board outside my clinic that I do dream interpretation. But then she indicated that she was not shy about the dream for she had shared it with her sister, who is almost 15 years older than her, though they are very close and confide everything to each other, and also to her ex-boss, both of whom laughed at it, and dismissed it in exactly the same manner as the doctors in her dream did, her sister even burst out in a laughter with the exclamation, "E, only you would dream something like that."
Associations to the individual elements of the dream could not be obtained because the half hour flew quickly and there was another issue that had to be addressed in the session. So I will proceed with the analysis just based upon psychoanalytic theory.  
The shock and horror that she experienced on first discovering that she had a penis was actually the shock and horror that she must have experienced during the Oedipal period on discovering that she did not have a penis. In dream the affect had been shifted [displaced] from its absence to it presence. Such is the power of the wishes in our psyche.
The ever present wish in woman to have a penis of her own, and not through her husband or male child, emerged in this lady's dream in all its nakedness. Her statement: But then I must have accepted it because it became part of me and everything became fine is an excellent confirmation of the fact that dreams are wish fulfillment.  
But whatever experience during the day - some humiliation which she would not have been subjected to if she was not a woman - the unpleasantness of which was disturbing her sleep, and which was being negated through the fulfillment of the wish, reared its ugly head too, and the original trauma of the absence of penis, which she no doubt had become aware at a very tender age, reasserted in springing the doubt whether she had really gotten the coveted thing, and if she had was it defective, and would it not disappear again as a result of some misfortune like an infection or gangrene.  

 ....I lift it up to inspect whether it was the whole package or no and to my horror I see there is a hole in it. A black hole.  I knew at once there was something majorly wrong.  It was scary. Then I notice it is infected. As if gangrene was going to set in, and it would fall off.  I felt like I would die....


This is an excellent description of the reaction that occurs in the little girl on discovering the presence of the penis in a little brother or a playmate or even a adult and its absence in one's own self. It is immediately assumed that some injury has occurred, there was a penis there which was taken away from her by violence and foul play, perhaps as a result of some punishment for erotically playing with it, and in its place there is now a wound, an illness.
Not only woman's discomfort and shame from her genitals, which she sees as a defect -  at least in her early childhood she does so - occurs from this discovery, her considering it as an illness leads her to search for all kinds of remedies from myriad of sources all through life. Women's much complained enigmatic nature, and the irrationality of her actions, springs from this never ending search for a cure for the mutilation. Not just real doctors - actually they are often avoided because they are more difficult to be convinced that there is a problem, and are less likely to go along with "the game" -  all kinds of healers, hustlers, soothsayers, medicine men, shamans, quacks, charlatans, mendicants and other holy men, especially those who practice tantra, witchcraft and sorcery, are searched for and the problem is laid upon their feet.
Our dreamer is in medical field and believes in the power of doctors to heal things and therefore in the dream was in the hospital asking them to straighten her problem. Herein lies the psychology of Munchhausen's Syndrome and of Briquet's Disorder. Under the sway of this very same complex the  patient goes from doctor to doctor, begging for medical treatment, medical procedures and surgeries with one wish in mind - a wish they can never bring to their lip, out of shame but more so because they themselves do not know what exactly is wrong about them for which they are seeking a cure.
And they show the doctors everything else about themselves except for the genitals where (in their  unconscious) they believe they have the illness/defect. In fact they show a hysterical prudishness about covering their genitals while dramatizing the sexuality of other body parts, proclaiming loudly about the defects and afflictions of these parts, demanding and seeking treatment, subjecting themselves to all kinds of surgical mutilations, in hope of getting cured by some lucky chance, by some halo effect. It is like repetition of the original trauma of the discovery that they had been cheated when it came to genitals. And by undergoing further mutilations they are hoping to have a better result this time around.
Their contempt for the doctors for failing to recognize their real problem and their inability to give them the cure is acted out in Munchhausen's Syndrome by misleading the doctors through giving fake symptoms. The logic being : you cannot cure my real problem so you are a charlatan and I will prove it to you for you will be conned in to believing that I have an illness when I really don't. You are a quack because you cannot see the problem where it exists but you will see one where it does not. The penchant for hysterical women - those who suffer from Somatization Disorder - to sue doctors and get  compensation, owes to the same castration complex. Doctors were not believing me that I had it. They were dismissive in their attitude. They were like we can't help you, we can't help you. They would not like even comprehend or acknowledge what was happening to me.  So they must compensate me for their idiocy and their failure to heal me.
There is an interesting difference between Munchhausen 's Syndrome and Somatization Disorder. In the former the person is not that eager to have procedures done and have parts of the body removed as in the latter. The former have a more narcissistic personality structure, and are more into playing the game of showing that the doctor is an idiot. It's aim is to show that the doctor (parent substitute) does not know what he is doing and he has done me wrong. And this is done through verbal game  playing and ruse. In Briquet's Disorder the patient has hysterical personality structure and she actually wants to be cured through losing parts of her body to the doctors' instruments in order to be compensated for it with the coveted penis. The complaints of hysterical patients do not correspond to the laws of anatomy and physiology - the source of much irritation to doctors - because their complaints arise from their grievance over the injustice done to them when it came to genitals, and they are complaining about being shortchanged and having a problem in that region which are superimposed upon some actual physical malady present in more respectable part of the body. 

Moving back to couple of other elements of the dream
  
Incidentally, there was none of the other appendages with the deal. No testicles, just the shaft was there. And that did not matter, it did not bother me. It was only that black hole in the penis that was freaking me out.

This part of the dream which the patient added as an afterthought is a great confirmation of Freud's statement that the interest in male genitals in both sexes is exclusively limited to the penis and the rest of the appendage is totally ignored.  
It is a very familiar room. I know I have seen it before. It is always the same room. As if I have been there before, a million times.

This room could be no other than her mother's womb. A place which was once the most familiar and where one lived for nine months. A place where the dreamer wants to return and be part of the sexual intercourse which gave her life, but in which sandwiched between the mother and father she wants to have a more favorable outcome, to be born as a boy instead of girl, wresting the penis off the father while the process is taking place, something she failed to do the first time. 
The patient kept apologizing for dreaming such a weird and bizarre dream and wondered if there was something wrong with her. But when told that what she dreamt is something that one reads in textbooks of psychiatry and one rarely comes across such a transparent dream in practice, and that it is a wish that is present in all women, but is withdrawn from consciousness at a very young age, between ages of 3 to 5, and that she is kind of unique in dreaming it so close to how its original nature is, without any distortions, as most women do, which makes it so hard to decipher the real nature of the wish, the patient felt that she was not crazy and took a sigh of relief.
But then added that she is very happy being a woman, and the last thing she wants in life is to be a man.
"You may not want to be a man. And are very happy with being a woman, granted. But you may still wish you had a penis."
"I don't want a penis. Never wanted it. They are not beautiful to look at. And in the beginning of the dream I distinctly remember getting upset that it was there."
"Being upset also could have been displacement of being upset at not having one which got reversed in the dream.. And why would you dream that you had one unless you wanted it? And why would you have so much anxiety and dread over losing it, unless possessing it meant so much for you?"
"I got to admit. Many a times I have wished I was a man. Life is so much easier for men than for women."

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.

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.   

A religious dream

A woman in her early sixties complained that she was recently having a lot of intense senseless dreams. When asked for an example gave the following, labeling it as a religious dream.

We are in some religious place - strange since we never go to Church or anything like that - and a man comes and says don't worry, you will be alright. Larry, my husband, is with me. I knew wherever we are going we will be going there together.

Patient recently has been under lot of stress. A number of her close relatives are dying, her daughter is in throes of bitter divorce and is having numerous medical problems, she feels completely overwhelmed and sometimes feels she should just give it all up. Based upon that knowledge, without asking for associations, which usually she is not keen on giving anyway, I hazarded a guess and made the following construction:
"Is it an assurance that if you die you will go to heaven and since Larry would be  with you, you need not fear such a fate?"
It is technically not correct to interpret without first asking for associations unless, as once in a blue moon happens, one can see through the structure of the dream at a single glance.
 "You are right. Because the man who was telling me that I will be alright was no other than Jesus Christ himself. And lately death and dying is lot on my mind. Larry's brother suddenly died of heart attack you know. "
"Why does Larry come in to the dream?"
"Because if I am going down he is coming with me. I am not going anywhere alone.  If I die he better die too. He will be completely lost here without me anyway. We have been together for fifty years."
At that point she recalled another dream which confirmed the accuracy of the interpretation of the first.

"Every now and then I dream this. We are at a street which ends at a beautiful house. The house has two floors and a basement. It is abandoned and ready to be occupied. It has beautiful furniture on both floors. The basement has three shelves where my children's toys, trucks, dolls and games, everything connected with their childhood, is stored."

The dream was another version of the assurance that there is no need to fear death so much. It is not going to be end of your existence. The road symbolized her life trajectory, the end of which had an abandoned house just waiting for her to walk in to and continue living with her husband and all the precious memories of her children. The two floors symbolized herself and her husband, the three shelves her two children and her only grandchild.
Patient's illness is due to extreme fear of death. She often wakes out of her sleep in panic, fearing the end of life.

Haunted by a Flipino ghost

A patient dreamt the following:

A ghost with a beard was standing in the room. I took a swipe at him. That is all I recall of the dream. Everything was hazy and the dream was very short anyway.

He wanted to dismiss the dream as of no consequence, but we still had 15 minutes of the session left, and with nothing else pressing to deal with, we embarked upon its analysis.
"Why the ghost has a beard?"
"The beard actually belongs to Rob. He is my boss at the bookstore. In fact, he is second in command there."
"And why his beard comes in to the picture? What comes to your mind regarding Rob?"
"Rob is nice to us [by the plural, he was referring to his brother Michael, who works with him at the same store]. You know how much problems I have had with whoever has been in charge at that bookstore, since the old boss retired.
" But for a change in Rob we finally have somebody who is protective of us."
"Why then would you take a swipe at him?"
"Not at him! I took a swipe at the ghost."
"Well if the ghost had Rob's beard then he had something in common with Rob. So at least some aspect of Rob was being attacked, even if the ghost represented more persons (and/or concepts) than Rob."
This led to his recalling that within a day or two prior to the dream he had seen the movie Avenger. There was plenty of swiping there. Aliens and strange metallic characters, which made him think of ghosts, fought and took swipes at each other in it.
He added "I believe in ghosts and spirits. When I had my nervous breakdown, I thought my house was full of  them. I could hear the campus security guards, dressed in black, talking about me outside my window, while inside the house the spirits were sitting in my attic with a voice recorder. They could see, hear and record my thoughts.
"So yes, the dream is a direct response to seeing the movie. There was so much violence in it, with dust and debris flying all over [the haziness of the dream?].  My brother and I love action films, especially the ones which have Marvel Comic heroes - Superman, Batman, Spiderman."
Now the two brothers are the poster children of meekness and timidity. Christians to the bone, they will not dream of taking a swipe at anybody or more correctly only in the dreams they will dare to do so. And yes they will do it in waking life too, but only in proxy; through watching the actions of the ultimate good guys - the Marvel Comic superheroes.
For when they were boys - they are just a year apart - they were relentlessly teased, bullied and beaten by their schoolmates. Every attempt on their part to resist was dealt with even more bullying. Why they became the target of  bullying was partly due to their frail frames, but also because of emotional problems in the parents, and disturbed family dynamics, which had greatly exaggerated their sense of guilt, their need for punishment and their fear of everything unfamiliar,  traits which were genetically strong in them to begin with. And the bullies picking upon these traits found them easy prey. They had adjusted to these adverse circumstances by turning into pious Christians. It was not difficult for them to do so because their parents were devout Catholics. The buck of the vengeance was then easy for them to pass on to the Lord [and the action heroes], and all the energies were henceforth diverted to becoming extraordinarily considerate towards their ill wishers [and then to everybody], always ready to turn the other cheek when slapped.
"Are you taking a swipe at Rob because it is safe to do so? With others in that bookstore you are always on the run, fearing for your life at any prospect of confrontation, and naturally the co-workers take advantage of your timidity, knowing that more they will push you around, the more you will bend over backwards to accommodate them, and as icing on the cake hold no grudges. But while you think that you forgive and forget their transgressions,  the revenge feelings continue to exist in your subterranean mind, and finally seek discharge when you fall asleep, in your dreams. But the fear of retaliation comes to haunt you there too, and though you are a little bolder in dreams, and do strike back, the fear forces you to swipe only at those with whom it is safe to do so - like Rob."
"That is very interesting and perhaps true."
Then the patient proceeded on his own accord. "A day or two before the dream there was an interaction in the bookstore between Rob and a businessman which may explain why I took a swipe at him. You know our bookstore is for college students. And currently the trend is for renting the  books instead of selling them. But there is a big penalty if the books are not returned on time, even by a day or two. Now this guy cones in and on learning he was slightly late and will have to pay a hefty fine for it, got real nasty.  It looked like he was going to take a swipe at Rob. But Rob was as patient and as unruffled as his trimmed beard, and without giving an inch, listened to the man's boast as to how he is owner of two businesses and how he will get Rob in to trouble. I was impressed by Rob who did not react or retaliate. He behaved just the opposite of Tracy, who is a new girl at the store, very kind and nice to everybody, and who broke in to tears and ran to the back room when somebody called her names on the phone, so sensitive she is to anybody being nasty to her."
After listening to some other related thought chains, I intervened, and asked him if there were any other associations to the ghost independent of the beard.
Hesitatingly he volunteered that the ghost was a Filipino.
"A Filipino? Why in the world a Filipino's ghost will come to haunt you?"
The patient replied that he is really in to ghosts and spirits. And tried to convince me that ghosts exist for real, and that there was a Montel Williams show which conclusively proved the existence of a parallel spirit world from which spirits crossover to this side every now and then.
But when it came to psychoanalyzing why a Filipino's ghost was making his way into this side and specially in to his dream, he was as puzzled as me. Then the session's theme shifted to ghosts and spirits in general, and I learnt that the patient had started hearing voices not with his first nervous breakdown, 6 months after his father's death, but even before while his father was alive but dying.
His father had died of liver failure. Patient stated that it was caused by his TB test - which really measures any exposure to TB, not actual infection - coming positive which led to the overzealous public heath officials putting him on a highly toxic TB drug. The drug was subsequently withdrawn from the market because of its liver damaging property. Patient bitterly stated that his father did not have TB, and they just pushed him in to that unnecessary treatment to abuse their power.
"Did you sue them for causing his liver failure and death?"
"No. We are Christians, and we don't believe in suing. Also it would have been hard to prove. He was in WWII and stationed in Philippines and perhaps got his liver problems from there. They use so much agent orange and other chemicals during wars. Maybe it was not the TB drug but the chemicals he was exposed to in the Philippines."
"So along with those public health doctors you may be holding a grudge against Philippines for giving him the fatal liver disease and by association with Filipinos?"
"I don't know about that but when my father was very sick and dying I was in throes of some weird  emotions which ended with my hearing voices."
"What were you hearing?"
 "They were more orders than anything. Ordering me to do pushups etc."
"Do pushups?!"
"Yes, they would not let me alone, demanding I exercise all the time. Some days they would not let up till I did 250 to 300 pushups."
A number of associations at this point, which will be too tedious to describe here, led to the following conclusion. The motive behind the command to do the pushups was for him to become so strong that if he took revenge upon the TB doctors and the World War II Filipinos, both of whom he held responsible for his father's death, and as a consequence they came after him, he will be able to protect himself.
But there was an additional motive for him to become highly muscular. It was to protect himself from his father as well, who was now terminally ill and helpless and hence at his mercy. In his unconscious he harbored extensive death wishes towards his father. He was not a kind father. He was distant, looked down upon them, and had failed protect them from the bullies. And to make matters worse, he was a barber, who when his business took a nosedive in the Sixties with everybody growing their hair long, had punished his sons severely when they tried to do the same and had given them the most short hair cuts imaginable, worsening their fate in hands of the bullies. In his unconscious his father was just another bully. It is interesting that once they reached adulthood they started sporting Beatles' style hair cut, and to this day they do so even though with extreme thinning, it borders on the bizarre. 
Was the ghost then his father's? But if so why did he come in to his dream on that particular night or more accurately why he entered in to patients thoughts that night - for dreams are nothing but our regular thoughts just clothed in the language of sleep/dream.
And then patient was not even sure if the ghost was a return of his father. Why would somebody as standard American as his father, return back from the spirit wold as a Filipino?
With no associations forthcoming, the session drifted to other topics. And the patient talked about how once as a teenager he had idolized Rocky Balboa and had learnt to do pushups in an attempt to become like him. He had even memorized the movie's theme song, and when playing baseball would sing it to himself hoping it will enable him to hit home runs. But the breaking of his spirit by the bullies easily overrode the courage-boosting properties of the song and he remained a dud as a hitter.   
And that reminded him of his brother playing baseball with two other kids, Jerry and Joe, both of whom went on to become doctors. "My brother was as good as them in studies, but I guess my brother became too afraid to do anything as high class as a doctor"
"Why?"
"I guess my brother and I are not meant to rise above our humble station." Behind this bitter complaint of course was lamentation that if only they had had more support from their father and if they had not been bullied, his brother would have become a doctor.
"Though I guess in a way it was good. For Jerry got killed the other day in Afghanistan. He was such a nice man. Just like Michael. I don't understand why they would kill him. He was running a children's hospital there.
"And now I know why the ghost was Filipino. It was Jerry's ghost. Jerry is Filipino-American. And the dream occurred I think on the night when I first learnt of his fate on the news."
While the patient was not aware of any of it, it was my analytic deduction that Jerry's ghost came to haunt him as a revenge for taking satisfaction at his death out of loyalty to his brother. This satisfaction took place completely out of his consciousness, and of course it does not mean that he did not feel sorrow for Jerry's death. But there was also there anger and jealousy of those who he knew were equal of him and his brother, but had succeeded in life more than them.
The psychological processes were similar to what happened when his father was terminally ill. At an unconscious level there was some satisfaction that finally my father will be dead and I will be free to do as I please. But there was also sorrow at the thought of losing him. And it was the guilt over the satisfaction that was making him do 250 to 300 pushups. The guilt was also peopling his house and his yard with malevolent spirits and security guards respectively who could keep an eye on him and prevent him from hastening his father's death. The pushups were punishment, but also the means to make him strong so he would be able to fight the doctors and the Filipinos who were responsible for causing his father's liver disease. Taking the swipe at the ghost was similar to doing pushups - defending oneself from the punishment which he anticipated from those whose death (in father's case his impending death) had given him satisfaction.
It may not be out of the way to make a few comments upon why people see ghosts or believe in ghosts as our patient did. In his case he had lot of reasons to hope that after we die we continue to live as ghosts. His childhood had been marked by abuse and bullying. If we continue to exist beyond our death then the possibility of getting even with the bullies also existed. If you have an ax to grind,  if you feel that the fate has not dealt you the right cards, and people have harmed you and escaped getting punishment for it, then there is powerful motive to believe in the world of spirits, in hell and heaven, divine justice and for those hailing from the East in reincarnation. 
Ghosts ultimately are nothing but resurrection of demons from our past. Conjuring up the dream images/illusions/hallucinations of those with whom we still have unfinished business but who have passed away. We can still deal with them but only by conjuring up their spirits.
It is interesting that in Hindi the word for ghost and past is exactly the same: "bhoot".

Ringing of doorbell in dream as symbol of death knocking on the door

A man in his early fifties who suffers from agoraphobia and cannot go beyond a few miles from his house brought in the following dream to the therapy session

I am sitting with my eldest sister on a couch, along with her ex-husband. The door bell rings and her ex-husband and I feel that we must protect her. 


There were no associations to any element of the dream, which was laconic to begin with.

I asked him,"Is there anything in common between your sister's ex-husband and yourself?"

"Their daughter who is my niece."

But this association did not help and knowing how much the patient dislikes this sister of his, who was oldest in a family of four children, while he was the youngest, and who would hit him, lock him in the closet, scare him in other ways, after their mother died due to breast cancer, when the patient was just four, I asked him if her ex-husband also dislikes her.

"Yes, he must. She is a pit bull. A mean mean bitch. She cheated on him and then took him to the cleaners. Just like she cheated me and my brother. She, and my other sister went to my father's house just before he died, and took everything of any value there, including all the family pictures, albums,  including  the pictures of my mother's and her family, so I have nothing left to show my children and my grandchildren. My father was a prolific picture taker, and we had tons of pictures from Polaroid instant camera."   

"So there is something in common between you and your sister's ex-husband. Both of you got cheated by your sister and have a reason to wish her ill. So the compulsion to protect her must have arisen to counter the ill wish.."

"But I have not seen her for 10 years. Neither her ex-husband. Why would they come in my dream now?"

"Yes, good question. Why now?" Though both of us knew the answer.

Recently his son had gone in to ancestry.com and had unearthed that his mother had a half-sister, who lived just a few miles from his home, and from her he had learnt a whole lot of family history and also viewed a lot of pictures of his mother when she was a child and of other relatives of theirs. He also saw pictures of a second cousin of his who looked identical to the dream sister. The wish had then arisen for him to meet his sister and demand to get some of the pictures that she had taken from their father's house. But his past attempts to contact this sister to do so, even request that if he could just come to her house and scan those pictures into his laptop, had been refused, arousing death wishes towards her.

So there was a renewed wish to contact his sister, anticipation of rejection, and arousal of death wish. The dream however, under the influence of conscience (superego), showed the counter-wish: to protect her sister from his death wish and sharing of the blame with his ex-brother-in-law.

 I conjectured that the death wish was given a concrete pictorial representation in the doorbell's ringing.  This was based upon my observation as to how old people at the eve of their life,  dread so much a knock on the door, or any other noise or unusual sound, which signifies that someone is trying to make an entry in to their house. Some of them stack chairs and other objects at the door so as to prevent messenger of death making an entry. Some of them will try to caulk or put insulation on every nook, corner and crack, as if to seal every single entry point and window of vulnerability through which death in the garb of cold air may sneak into the house - the house itself symbolizing themselves.

When I conveyed these thoughts to the patient he remarked, "Yes, ringing of the bell probably did mean death knocking on the door."