Two unusual therapeutic effects of Adderall - promotion of sleep and control of paranoia

One thinks of  Adderall (Dextroamphetamine), the prototypical psychostimulant, as something one would avoid to get restful sleep. Yet, two of my patients use Adderall as a sleep agent. Since this paradoxical effect throws some light on how dopamine activation helps in ameliorating symptoms of ADHD, I will give a brief account of these two cases, and then make some theoretical comments.

A single woman, in her early forties, never married and with no issues, attractive and shy, who lives a lonely life, a result of excessively fearful disposition, and whose temperamental sensitivity is so high that the slightest social or environmental threat during the day causes affective disturbance for hours, and, at night, the slightest noise wakes her out of sleep, requested Adderall. Someone she knew had suggested it to her, and after reading about it on the Internet she claimed that she has many of the symptoms that Adderall is supposed to help with, and since none of the other therapeutic efforts have made a dent in her condition I should give her what she was asking for.

But I was reluctant to prescribe her Adderall. None of the previous medications had produced lasting results. She came to me burdened with the label of schizoaffective disorder, probably tacked on her by biological psychiatrists to justify giving her all kinds of medications without having to know what was really wrong with her, and had been tried by them on numerous antipsychotics - dopamine neurotransmission blockers.  Except for Zyprexa, all other neuroleptics had made her miserable. Even with Zyprexa, her mood had not been quite right. When asked what she meant by "not quite right", she stated that Zyprexa made her feel that she was "part of a system", and it left her "high strung". Antidepressants had been equally useless. Only Prozac had helped, but for just a few months. Diazepam and Clonazepam had helped with agitation and anxiety but they did not ameliorate the fatigue, body aches and pains, and while they helped her with falling asleep their effectiveness had dulled over time. But my greatest concern was the presence of what looked like a predisposition to develop paranoid psychosis. She showed phobic fear of people and going to places away from home, especially if she was likely to run into African-American men. These were clearly hysterical defenses and projection of her own hostility - rather ambivalence; unconscious attraction and consequent fear -  towards black men. But then she sometimes - pointing more to some genuine paranoid process - complained that neighbors talked and criticized her as a "freeloader" living on welfare because they did not see her going to work and just hanging at the apartment complex. In reality, her expenses were taken care of by her elderly parents who barely could make both ends meet and she felt very guilty about taking money from them.

When she would not take no for an answer I went ahead and prescribed her Adderall. Very low dose, just 10 mg., and reluctantly, for though she protested that my recall was wrong I had the memory of her once complaining to me that she could actually hear the neighbors talking about her which sounded like frank auditory hallucinations.  And amphetamines are known to exacerbate paranoia. In fact, one of the most used animal model of psychosis in pharmaceutical research is to give very high doses of intravenous amphetamine to rats and other lab animals.

But when she returned in a month - she has no insurance and cannot afford to see me more often than that - my apprehension that Adderall will worsen her paranoia proved to be wrong. She had shown a good response to it across the board. The best proof of which, she claimed, was her restored ability to watch TV and read books by sitting down for a while instead of running from one place to another trying to calm herself down. When asked as to how the medicine achieved this she said because it stopped her mind from racing excessively.  What was even more surprising was that even her paranoia was better. Now she felt comfortable talking with neighbors, including a black couple, and added that they should reclassify Saphris and Latuda as not anti-paranoid drugs - both had failed to help her - and declare Adderall as the true anti-psychotic. In praise of Adderall, she also added that it gives her a boost of energy and makes her more confident of herself. A further benefit she claimed was that since she is less fearful during the day she can interact better with people and as a consequence sleep better at night.

The second case is a little more complex for though superficially it appeared as simple manic-depressive illness, it was highly complicated by a traumatic neurosis. She was subjected to a shocking, humiliating and painful rape that occurred when she was just twelve and a half years old. She had been pulled inside a car near her house, by two 17-year-old men, and after being driven for a short distance into an alley, subjected to the rape. The psychological content of her manic-depressive illness was entirely about undoing this trauma and getting even with the perpetrators. During the upswings she would be suffused with energy to take revenge and would drive aimlessly for hours hoping to run into the two rapists and subjecting them to the exact same pain, humiliation and physical act through the agency of another man that was perpetrated upon her, despite the fact that the trauma had occurred more than 25 years ago and the prospect of meeting them was almost zero. The only thread she had to reach them was overhearing them while they were molesting her that one of them was going to have his 18th birthday next week and from their conversation, she could also make out that they lived locally. She remembered their faces clearly and assumed that if they were 17 years old then that year's high school yearbook would have their pictures and names and from there she could research further and finally trace them out. Despite driving around for endless number of hours for decades she could never take the final step of getting to the yearbook. These upswings would start with the search for those rapists but soon would change from euphoria into tense dysphoria and a great dread of going completely out of control like turning into a serial killer and then she would seek company of a trusted friend, counting upon her to keep tabs upon her and not enter into complete craziness. When asked if she would really turn into a serial killer she said that it happens only to those who do not receive their mother's love. In her case though her mother was not at all nurturing her grandmother was and the latter's memory would act as a barrier to her becoming totally evil.

The downswings would be filled with pessimism, suicidal thoughts, inability to get out of the house, sleeping through the day, inability to do house chores and go to work. Fortunately, her boss was her friend, who accepted her mental limitations and expected her to come only if she was feeling up to it. The trauma had also generated in her fibromyalgia which required Tramadol a borderline narcotic. To make matters worse she had extensive obsessive-compulsive behaviors and rituals, including the tendency to hoard, the etiology of which owed heavily to the fact that after the rape her mother had taken no steps to take her to the police station and take action against the rapists, and in fact had cast doubts at  her story, suspecting her to have been compliant with it,  provoking a tremendous rage in her towards the mother, the flare-up of which now was handled by turning the affect and the accompanying aggressive impulses into obsessive-compulsive rituals. The rage towards her mother, however, was present even before the trauma, a precipitate of an intense Oedipal conflict. The mood swings also existed before the sexual trauma and were a reflection of her high intelligence and talents. She was on Topomax and Saphris to control her mood swings. Which as the case history shows were doing a very limited job, and she often felt completely out of control during the upswings.

What however is the real subject of this communication is the role Adderall played in her daily functioning. Without Adderall-XR she could neither motivate herself to go for work nor could she sleep. She took 15 mg. of Adderall-XR around noon to help her step out of the house and go to work. But additionally, she took 15 mg. of Adderall-XR every morning at 7 am to get two hours of very intense sleep. She rarely slept at night, and after tossing and turning all night long would get up at 5 am to get her children ready for school. After sending them to school she would take the morning dose of Adderall and go into very deep sleep till 9 am.

When asked how does Adderall help her to sleep, she claimed it stopped her racing thoughts. Her brain stopped trying to be in 100 different places allowing her to concentrate upon sleep. Analysis revealed that her mind was racing to all these different places to prevent harm coming to herself and her children. Her mind would not shut off busy trying to put out fire everywhere.  But once she took Adderall she felt protected and did not worry as much. She added, "You know how I sleep with lights and TV on. The brightness of the light and the noise from the TV act as my companions." When asked why does she not take Adderall at night and sleep through the night she said that that Adderall does not work at night. To get into a real deep sleep which requires that mental vigilance/ego tension be dropped she needed the additional protection of daylight. With the TV on and daylight there she did not feel alone and vulnerable. It may be mentioned here that she was abducted and raped while walking home from a friend's house at dusk and blames her mother who ordered her to return before dark and wonders if that phone call had not come at that particular point of time would she have escaped running into those two boys.

Why does Adderall a dopaminergic agent which wakes her up and keeps her alert during the day and while at work, works in just the reverse fashion in early morning hours, enabling her to sleep?

In both my patients what Adderall appears to have been doing was to act as a barrier against fear. This surmounting of fear with the aid of dopamine - a sympathomimetic compound - made the first patient more social and less paranoid and by getting more satisfaction out of life during the day she did not have to take her conflicts to bed and dreams and thus sleep restlessly. In the second patient, the daylight and the noisy TV  were protection against fear but were insufficient by themselves and only with the addition of Adderall the balance was tipped in favor of allowing her to fall asleep deeply, though for no more than two hours. Daylight may have signified that most of the world was awake now and could be summoned for help in case danger came her way.

 In both cases, Adderall reduced the racing thoughts. Fear makes one want to run away, and if one cannot run on their feet they run in their imagination (daydreams) and racing thoughts. So at the root of racing thoughts lies the motive to run away from the situation in hand and when the conflict reemerges at the new locale to run from there to the next and so on, resulting in trying to be in 100 different places at the same time putting out fires everywhere. Children with ADHD cannot concentrate either because they are running away from their internal fears - in most cases unresolved Oedipal conflict where the  residual (unconscious) sexual attachment to the mother and corresponding fear of the father keeps generating fear/anxiety - and thus their mind is racing and unable to concentrate on what is happening in "here and now". Amphetamines by enforcing dopamine secretion and thus giving a sense of something positive happening raises the person's interest in the immediate surroundings. This sense of something positive happening gives the feeling that this situation is pleasure giving, therefore not dangerous, and where one should focus one's attention to get more of similar pleasure.

One must caution that these two cases are not typical and as a rule amphetamine prevents sleep and exacerbates paranoia.

Autism may be precipitated in vulnerable OCD inclined people because of too early separation-individuation from the mother

There is little doubt that autism is more likely to occur in children whose parents are high functioning, socially well off, and obsessional neurotics.

Watching an autistic gentleman who is now in his early Sixties, and who possesses some remarkable abilities though lacking in the most basic skills to live on his own - he lives in a Group Home and requires 24 hour supervision, I was impressed as to how solid his ego was in some areas and yet so remarkably childlike in others. He knows the names and intersections of virtually all major streets of Detroit Metro area, and quite a few of many other cities which he has visited in the past, the birth dates of countless acquaintances, the lyrics of hundreds of songs with all kinds of facts about the ones who sang them. For example this week in the session out of the blue he told me in one breath that Kid Rock was born in 1971, his real name is Robert James Ritchie, he once lived in Taylor and Wyandotte, his son is 18 years old, his first song was Cowboy baby. Then he mumbled something incomprehensible - as if he was having a mini-tourettes - and said that makes him 51 years old. When I contradicted him and said that should be 41, the patient counting on his fingers the decades insisted that no he should be 51 for  between 1971 to 2012 there are 51 years. As to why behind the tremendous memory of obsessional neurotic lies the desire to insult and defy through distorting some aspect of the other person, usually their name or their age, and as a reaction formation (over compensation) one memorizes every trivia about the other person see my post of 9/10/10 "The phenomenal memory of Obsessional Neurotics and Autistic Patients."

But anyway why does this man who is full of knowledge of these trivia cannot use his great abilities in knowing and mastering things that have practical value? What strikes one about him is how the slightest disturbance in his routine throws this man in to a tantrum. Everything has to be done in the same way, and beyond his routine he enjoys nothing. He wants everything to be predictable and in order. The thing that gives him greatest joy is watching a train come down the rails. The train on its tracks is absolutely predictable as to where it will go and how one carriage will follow the next. Nothing in the movement of the train ever goes out of order. The joy in it was not dissimilar to how some autistic children are completely fascinated by revolving musical discs or ceiling fans where the motion is completely predictable with one blade following the next and never getting out of its circle.

In this patient a most telling characteristic is how he wants his needs to be taken care of immediately. The slightest delay makes him angry. In order that his needs get fulfilled immediately he wants very few things. But what he wants he wants right away, without interruption and in a predictable manner. For example when he comes to my office he wants his first cup of coffee the second he enters and the second one about 10 minutes later. He wants exactly same amount of cream and sugar and wants the empty cup to be thrown in the garbage can in exactly the same fashion while he is giving me directions on how to do it. One wonders  whether at a very tender age when his needs (id impulses) were intense and they all wanted to rush out pell-mell, the mother instead of having a feel for it and helping him to let their emergence take place in an orderly manner just left him to deal with it by himself. Or even if tried to help him with it did not have the right sensitivity to the overwhelming emotions that were being generated in the child.  And as a consequence the patient dealt with his helplessness midst the pressure of so many needs to pay attention to a few of them and just ignore the rest, leading to development of an ego organization which became remarkably good and precocious in some areas and completely useless (indifferent) in others. No wonder he had such a remarkable appreciation of the orderly manner of trains where each bogie (need) followed the next in a most consistent fashion unlike the chaos that existed with his needs when his mind chose the autistic path.
It appeared to me as if in many mothers there is lack of fluidity in their feel for their child. Instead of the child being seen as part of oneself and the ego boundaries between mother and child being porous, the mother has too much sense of her own discrete self, separate from the child. Perhaps our highly educated latter day parents belonging to higher socioeconomic strata and having their highly organized career oriented life styles are dealing with their children also in the same highly organized cerebral ways. So in the earliest months of life when the child needs a mother who is not too differentiated from him, who feels one with him and who can sense his needs instinctively as her own, he is saddled with a mother who is full of knowledge from books and other media sources on how to be a good mother without having sufficient emotional and instinctive feel for the child's needs.

This affects the child's development of the ego in two ways. One it encourages him to prematurely develop his own ego, very strongly, very rigidly and very exclusive of anything that looks alien and beyond mastering.  Secondly, the child identifying with the mother develops his ego in her footsteps which due to its high functioning obsessive style has little place for emotions and which values organization and success in the outside world as of greater importance than emotional enjoyment and being one with one's offspring.

The massive size of the brain of autistic child in the first few years of life also may be a reflection of this premature and strong ego development. If a child does not have his mother empathically available to him then he has to hypertrophy his own brain to take care of his needs. The neuronal pruning which is so important for normal growth much of it must occur as a sympathetic response to the behavior of empathic caretakers. A failure of such pruning, along with excessive generation of neurons for strong ego development, may underlie the abnormally large size of autistic children's brains. In our earliest years we are all id (drives) and very little ego. It is the parental ego that serves as "auxiliary ego" providing the necessary wherewithal for the child to survive and develop necessary skills to communicate with others and learn to discharge its id drives in association with others. In autistic children there is a premature attempt to develop an ego when the parental ego behaves in a manner which is not quite right for the child's needs.

8-22-2014

Today I read in New York Times an article that supports my above contention: it is failure of neuronal pruning  - because of lack of empathic caretakers - that lies behind the abnormally large size of autistic child's brain. The article titled "Study find that brains with Autism fail to trim synapses as they develop", which was published in the journal Neuron on 8-21-2014,  summarized the findings that at younger age the normal and autistic children have same amounts of synapses. But as they get older autistic children's brains fail to prune normally and their synaptic connections are far more dense.

The author, David Sulzer, of the study summed up his  observation with the quote, "You need to lose connections in order to develop a fine-tuned system of brain networks, because if all parts of the brain, all you get is noise."  Ralph-Axel Muller, another neuroscientist, commented on the study with the statement that autism is problem of overconnectivity.

So in autistic children there is too much internal brain activity going on. And it stands to reason why. If the mother (and other caretakers) are not emotionally and empathically available in the outside world then the baby will start communicating with his own self (his brain instead of communicating with the brains of his caretakers - and thus prune those synaptic connections that are unnecessary for communicating with others - will start communicating within itself.)

It is interesting that Sulzer does not look for the etiology of this failure in pruning to the obsessive-compulsive rigidity of the parents in understanding the needs of the baby. Instead they look for it in malfunction of proteins and other biochemical processes.

It is still not politically correct to look for the primary problem of autism in defective human interactions rather than biology.  

Recurrent dream of being left behind by one's siblings and highschool classmates

A woman in her mid-fifties, mother of three children and couple of grandchildren, who suffers from anxiety and depression and smokes to control that anxiety, asked the meaning of a recurrent dream, which she has had throughout her life, but recently, after she was hospitalized for COPD and pneumonia, was having it with greater frequency.

The dream is about myself and my sisters. As you know I have two sisters.

I am being left behind by my sisters. This is the basic theme, with minor variations. The one I saw couple of nights ago, we were on vacation in Las Vegas, in a Mall.  The two were together, ahead of me, while I was left behind. I never see them but I knew they are in the Mall. I go from one floor to the next but never reach them. Everything looked unfamiliar. I just keep looking for them in a daze.  

"Are your sisters older than you, and you are attempting to catch up to them to dissolve the age gap? You know how small age disadvantage with siblings is so acutely felt when one is young."

"I am the oldest. So that could not be the explanation.Though we are all just one year apart from the next. So we are more or less of the same age."

"Why the dream takes place in Las Vegas?"

"Because we take vacations together, and not too long back we took one in Las Vegas. The last one was in Florida.  Both my sisters live in California. [Las Vegas is in between California and Florida though much closer to the former so the dream may have chosen a venue closer to the two sisters than to me]. But though both live in California, they are not closer to each other than to me.  I am not the one who felt left out in Florida. They were the ones fighting while I got along with both. In Vegas too I was never left behind. We sometimes would go our own way to different sections of the casinos but we never were like lost to each other.

"Now I remember that being left behind also occurs in another set of dreams.  In these dreams my sisters are replaced by my classmates from high school.  The theme is the same, of being left behind. I am trying to catch up with my friends who have gone ahead and are already in class. I am like excluded which is odd for I never had problems fitting in with my peers in those days. The dream scene usually is of my trying to open the locker in the school corridor where my books are without which I cannot go to the class. But I cannot recall the combination to the locker. I try hard and almost get every number right but while punching the last one or two, some error occurs. There is nobody around to help either.  Not even the girl who shared the locker with me. Even if I had got the combination right, and the books out, it would not made a difference for I would not have found the classroom." 

After she drifted in to some other issues and I had some time to think over the dream, I conjectured that it was perhaps a punishment dream.  "Could it be possible that your getting left behind by your sisters and classmates is punishment for your belief that you have done them some wrong. Perhaps it is propitiation for some guilt arising from your unconscious hostile intentions towards them?"

"Could be. But why would I dream of getting punished. I have not done them or anybody else any wrong."

"The need for punishment in humans has very little to do with having actually done something wrong. In fact the less harm one does to others more is the psychological impulse to harm oneself. It is not carrying through the intention to harm others that creates guilt that seeks punishment. The guilt turns the intention to harm others in to harming oneself. It is a vicious cycle. It sounds paradoxical but true. One would think that one would feel more guilty if one actually harmed others. But people who actually harm others do not feel as guilty as those who suppress it. For the intention to harm others does not find a discharge and sits inside the psyche requiring creation of more guilt to keep it under control. "

"I don't understand what your are saying. But I don't feel any guilt in me."

"The sense of guilt is generally unconscious. The ego blocks its entry in to consciousness. In our conscious mind we just feel a sense of uneasiness and impulse to create a situation which is harmful for our self interest.  Even this self-harm is done in such subtle ways that they appear to be act of fate or bad luck rather than cleverly manipulated by oneself. We do know as a child you had quite a bit of rage against your parents for their constant fighting. Perhaps that rage to prevent it from being acted out has been been transformed into sense of guilt."

"Yes, that is true. I was angry at my parents, and I left home at age of 16 to escape their constant fighting. I don't remember having any resentment towards my sister. I do recall feeling guilty for leaving them behind in that stressful house and making my escape. I was their protectoress, and I abandoned that role and left to get married. So if anything I was the one who left them, but in the dream it is just the reverse. It is they who are leaving me. I don't think your interpretation that the dream is about punishing myself for having evil thought holds good."

"You were the first born, and your two sisters came right after you, one year apart. You must have resented their appearance. There may have been wishes towards them when they were first born to disappear. Later there may have been fear of their disappearing and thoughts of deserving punishment for having entertained such thoughts. So the dream may be showing the fulfillment of this wish for them to disappear and then the fear that you will be all alone, for you love them too and enjoy their company, is making you search for them and undo the wish."

"I don't think the dream is about punishment.  Or at least it is not the whole explanation. For I wake up not so much with guilt as with anger for their having left me behind."

So we were at an impasse.

The patient then came up with the idea that the dream of being left behind, though, has periodically recurred, has been emerging with far greater frequency since the doctor at the hospital scared her by saying if you don't stop smoking you are going to die. 'He was very mean and kept shouting at me, you are going to die, you are going to die."

In one stroke the meaning of the dream became clear. Being left behind and never being able to find her sisters was nothing but the fulfillment of the wish that it is my sisters who will die before me, and in fact I will never meet the same fate and will never be able to reach the end of my journey (death). The unfamiliarity of that Las Vegas Mall was a reversal of the great familiarity of this world. "The world is still so unfamiliar and new to me and still so much in need of exploration that I cannot die yet" was the rationale behind it. "My sisters can die, but I still have a lot to discover and I therefore will keep on living."

The patient readily agreed with the interpretation and added, " I just came back from Florida where we sisters had got together for our annual vacation. And the two were fighting with each other. No doubt a continuation of the bickering that existed in the house when we were growing. And one of them looked sick and yes I felt sorry for her and did worry about her dying.

"Thought of death has always played a very strong role in my psyche. My first born died when he was 18 days old. He was premature. That left a deep scar in my mind. Even now I dread something terrible happening to the ones close to me. I think of macabre things happening to my children and grandchildren. I hate those thoughts. But they are the core of my illness."

"Yes. The thought of their death is just a displacement of the thought of your own death, which you want to avert by thinking of somebody else's death, just like fear of your own death implanted by the doctor who scared you, you were working it out of your system  by thinking of the death of your sisters and your classmates. They emerged in your dreams for dreams are nothing but your everyday thoughts couched in the language of dreams."

"Interesting you say that. I must have a grudge against my classmates too, for I had to leave school because of pregnancy in final year and I could not graduate with them. Instead I got my diploma through GED. I felt odd returning to the school once I had to leave for pregnancy. So I may be getting even with them by thinking that just like they left me behind and graduated earlier than me they can once again leave me behind and die earlier than myself. For when I wake out of the dream it is not feeling of guilt and feeling of being punished that fills my heart but an anger at those girls for having left me behind."

I wondered if the locker box was not symbolic of the coffin, and inability to find the right combination a struggle against the wish to die and be over with life.

Patient stated, "I never thought of that," which is like music to a psychoanalyst's ear, for it invariably means that the interpretation is correct. By these words the patient confirms yes, it is true, but it was in my unconscious, and consciously I never thought to it.

"Could it be possible that the classroom also stood for coffin or burial room and inability to find it was fulfillment of the wish to never find the final resting place?"

"Perhaps," the lady responded.

Self cutting behavior precipiated by Abilify and the psychology of self cutting

A woman in her mid forties, who suffers from extensive psychiatric problems, the core of which is her extremely high level of anxiety, reported that on being put on Abilify 10 mg., instead of getting better, began cutting herself.

She at once added that it is not a suicidal behavior, though everyone is viewing it that way, and repeatedly hospitalizing her when she goes to the ER to get the cuts stitched.  She had had four admissions in two months. After a little reflection she said that it could be suicidal behavior too, because at one point, in between the cuttings, she tried to hang herself.

On stopping the Abilify, the thoughts to cut herself went away.

When I stated to her that Abilify by itself could not have caused the behavior, and some other experiences in the past must have set the stage for Abilify to enable the self-destructiveness, she said that she was constantly hearing the warning that they blare at the end of drug commercials as to what the drug can do to you and Ability commercial tells you that it will make you suicidal.

"Maybe it was the commercial playing at the back of my mind impelling me to cut myself."

This conjecture was, of course, rejected by both of us. The commercial alone could not have had such a powerful effect, and the psychogenic roots of self-cutting had to be searched for elsewhere.

Patient then recalled that the self-cutting had began 10 years ago, and after a few years had gone away, only to reemerge on being placed on Abilify.

She could recall the very first time she cut herself.

"I was fighting with my husband and could not defend myself. So I broke a bottle and cut myself with it, and it felt so good. Cutting relieved myself of anger."

"Why did you not cut your husband instead?"

"I wanted to hurt him. But he was huge. In one move he would have strangled me. So I had no choice but to take the anger out on myself. I cannot describe the relief it gave me. After that anytime something would upset me very much I just knew how to end it. You know I have psoriasis. Whenever I get bad nerves I break out terrible. But cutting myself helped with the nerves. If I did not cut myself the psoriasis flared up even worse."

"Why would cutting yourself help with nerves?"

"If you cannot win them, join them. If I get really pissed off with someone, that person sits in my chest like a knot. The only way to get relief from that knot is to create a split in myself and see my body as somebody else's body and to cut it up. Once it becomes an alien then I can cut it and I feel no pain. Just tremendous relief. Though the next day its hurts."

"What do you mean you see your body as somebody else's?"

"I have to treat my body as a non-self before I can cut it. But before I turn it into non-self, I have to see myself as evil and full of hatred towards others that must be destroyed. In fact sometimes I do destroy my whole house. From one end to the other. The house symbolizes me. I am destroying myself for being evil. I even hit myself. I don't feel any pain while doing it. Just relief from anger. And when it is over calm. Though tired and sleepy. Only the next day I feel as if a truck has ran over me."

My construction that this beating herself up and getting a great release from it could be a form of sexual discharge, and the immense relief and calmness and falling asleep afterwards a form of orgasm, was rejected by the patient.

Another girl confirmed that what you are cutting in yourself is the person you hate but to whom you cannot do anything by stating the following: "When I get real mad I cut my wrist and that takes away the pain. It started with my parents. I was so angry at my father that I went to stab him with the pencil I was holding but at the last minute I stabbed it on my own self. It was a tremendous relief. After that whenever my parents made me mad, I would see myself stabbing them, but it would be my wrist that I would be cutting."

Exhaustion following Panic Attack

A young Lithuanian immigrant, who came to the States when he was about 10, and who is now 27 years old, reported that after an intense Panic Attack, that lasted for 45 minutes, he went into a state of severe exhaustion that went on relentlessly for 8 days. After emerging out of his exhaustion he showed up for therapy session couple of days later and remarked that though he is out of the phase of severe exhaustion and somewhat energetic again some symptoms linger for example like there is no desire to talk to anybody. Then he expressed hope that in a few days he should be completely out of this funk.

The patient added, "The state of exhaustion was characterized by a feeling that it will never end. I tried everything mentally and physically to get my body going but it was of no use. In fact I could hardly feel my body. As if I did not exist. I missed school. I could not do homework. I slept for 13 to 14 hours a day but still felt exhausted on waking up. Physical work including even exercising, which, as you know, I am such an enthusiast of, could not motivate me. What do you think was happening to me?"

"Your system generated a massive depressive reaction to control your anxiety. When anxiety looks like it is completely out of control there is triggering of depression in some people to put an end to anxiety. The severe fear, which is what panic really is except that you don't know the cause of the fear, must have triggered an excessive secretion of neurochemicals, primarily acetylcholine,  that caused mental inhibitions on an entire range of functions, including  muscular activities, your thoughts and your emotions. This appears to be a mechanism that goes way back in to our phylogenetic past, perhaps as far back as when we were insects. Not just higher organisms but even the fish in the oceans go into a freeze when they are confronted by the predator face to face. If escape is not an option, for the killer is too close, then the last ditch effort is to play dead and hope that lack of any activity will make the predator mistake you to be part of the inorganic background. Perhaps the melancholic reaction in humans has its origin in this freezing behavior as a response to fear of death that got genetically implanted when animal organisms had not even emerged out of the oceans."

"Could it be a reaction to my stopping Zoloft ?" The patient had been put on Zoloft (Sertraline) sometime back for panic and depression. About 8 weeks before it had been stopped because of alarming weight gain.

"Yes, perhaps it is a reaction to the Zoloft being stopped. Zoloft had blocked out your panic attacks and was keeping your depression at bay. And then we stopped it. So perhaps the bottled up anxiety and depression returned with a vengeance. All these medications more or less work by suppressing some brain functions to allow others to work with less competitive interference. Antidepressants suppress emotions thus enabling a person to be not overwhelmed with emotions and once engage in the general concerns of the world. So when they are stopped these inhibitory emotions - anxiety and depression - may come back with renewed vigor."

Patient agreed with that and added, "Since I stopped the Zoloft I am waking up from sleep drenched in sweat. I do not feel any anxiety, but this kind of sweating must be a form of anxiety. For during the day, if things are rough, I get similar sweat attacks. At night when I am about to drift into REM sleep, I think the anxiety emerges to block me from doing so, perhaps because I must dream terrible things in my REM. I don't remember my dreams because I don't enter the REM state, which I believe must happen in order for the dreams to become recallable on waking. Anyway, the net result is that I am not getting enough REM sleep. I am always falling asleep during the day because at night I don't enter in to the REM phase and then my system tries to make up for that loss REM by attempting to do so in daylight. But here too the anxiety frustrates the attempt, and instead of falling asleep I break into a sweat."

Impressed by patient's metapsychological speculation, and feeling that he is in all likelihood right, I responded, "So that massive attack of panic was a breakthrough of the anxiety/fear. Your defense mechanisms failed to keep that anxiety muted, allowing only one component of it the sweating to emerge as actual behavior, and instead a full blown panic attack followed. But why did it happen? Is it because Zoloft was still exerting some lingering protection up to two months but then when its influence was completely lost a full blown panic attack became possible?"

"No," the patient disagreed. "Zoloft's discontinuation did not have that much of a role. The panic came after I did bad in an examination. The last couple of years have been nothing but my putting myself down. I constantly berate myself for not having done this or that in the past. I put tremendous pressure upon myself and I feel there is a tremendous pressure upon me from my family.  This must be a reaction to what I put my family through with my addiction. My family suffered greatly when I was abusing heroin. Now that I am on Suboxone, and not abusing drugs, and back to college, my family is happy. But I am able to do all these good things by constantly putting pressure upon myself and imagining that my family is really counting upon me. And how proud they will be if I do really well in the classes. After all that I have put them through they deserve that from me. And then when I nearly failed in the exam, I had the panic attack." At this point he broke down and started crying.
So the panic made its appearance when there was a failure of obsessive defenses. The metapsychological process in this young man must have gone through some such process: his aggressive/cruel tendencies, mostly arising from genetic predisposition, had first found expression against his family, whom he put through hell by abusing drugs. Perhaps drugs played another role in that by taking them he could lower the inhibitions that were preventing him from acting out his aggressive impulses towards others. Once the aggression had found enough satisfaction, the remorse had set in, and with the aid of Suboxone and psychotherapy, he could put a stop to his drug abuse and torturing of his family. Then to make amends, and to "undo" the cruelty of the past, he built up a whole range of obsessive thinking, which was mainly berating himself that he should have done this or that better, and keeping his mind occupied with other good intentions like getting good grades at school. As long as he could take refuge in these obsessive thoughts and do other good deeds obsessively like getting good grades he could keep the fear that he will be punished by fate (parental substitute) for his past misdeeds at bay. Though this fear of punishment was trying to make a breakthrough in sleep and dreams from which he would wake up in cold sweat. The fear would also emerge every now and then during the day, when he would have attacks of sweating (muted panic attacks).  

Why did the exhaustion came after the panic? The exhaustion was a muted form of depression. Once again the patient did not feel sad, just profound motor inhibition that extended to his thinking. But that appears to be the modus operandi of his defense system: have a somatic instead of a psychic reaction, at least in the first stages. Instead of feeling the affect of anxiety and fear all he did was to sweat profusely. Similarly, instead of feeling sadness and pain following the failure at his exam he felt a profound motor inhibition. After 8 days of punishment the cyclothymic neuronal circuits of his system kicked him out of the depressive phase and put him in the upswing. The above in a way describes how anxiety leads to obsessions and how when obsessive defenses fail and massive anxiety emerges depressive reaction is triggered to control the anxiety and then manic behavior follows to reverse the melancholia. So origins of Bipolar Disorder too can be traced to anxiety.

The patient asked as to why did not he continue to be just anxious and not fall in to depression. And I tried explaining to him that perhaps anxiety takes greater toll upon the body by keeping all the body's, including the cardiovascular, revved up. It is far more painful to anticipate punishment than to take control and just inflict punishment upon oneself and get it over with. The pain of depression is sometimes preferable over anticipation of impending harm.

Equivalency of Pleasure from Social Interaction and Eating and the role of dopamine system in attention and addiction

A 62 year old man, who is moderately overweight, reported that when he is not around people he eats. He  recently had ended an unhappy marriage, the last twenty years of which were quite loveless. He was overeating even while married, but, after the divorce, the problem had worsened.
Then he met someone, started a satisfying relationship and his mood improved. An interesting side-benefit of this companionship was that he did not compulsively eat when she was around. This led him to make a further observation that it was not just his girlfriend's company, but others' too, that kept his mind away from  food.
In therapy he remarked, "I got to be doing something pleasurable all the time. That is my nature. I am in horse business - and as you know how passionate I am about it - where if I make a deal, and it does not matter whether buying or selling, it gives me great pleasure. And greater the margin of profit, say if I make a steal, getting a 500-dollar horse for just 300, and then turning around and selling it for 2000 instead of  a 1000, then I am like in heaven. But coming to think of it, it is not just horses. This sense of pleasure extends to a lot of other things, like helping others. The other day when the hurricane went through Dexter, and knocked down those houses, I was the first one on the spot with my tractor, helping people sort through their rubble. And it gave me so much joy being a rescuer. It made me feel like a winner. And it is this feeling of being a winner that generates the sensation of pleasure. And if nothing else is going on which affirms this belief in my superiority then I am there eating. I guess it has to do with one's childhood when if you were into something good like eating an ice cream, while your siblings and playmates were not then you were like ahead of them."
Now we know that whenever something pleasurable happens to us, the brain immediately secretes the neurotransmitter dopamine. Why does this happen?  And is it the sensation of pleasure that causes dopamine release or is it dopamine release that stimulates some reward center in the brain which creates the sensation of pleasure?  But does it make sense for the brain to have developed a whole neurotransmitter system and a reward center just to give the subjective feeling of pleasure? And finally it raises the question as to what in the world is pleasure and why the brain needs that sensation for its functioning, and how dopamine release generates the subjective feeling of pleasure in the consciousness?
Sensation of pleasure -it is actually signal to the subjective consciousness of a relief from sensations - happens when the level of tension or stimulation in the brain goes down. Less the brain is bombarded with stimuli, whether arriving from inside the organism - hunger, thirst, sexual needs, pain - or from the external world - heat, cold, competition for food, attack from predators, pain - or from its own reflective activities  (reactivation of the past experiences as a preparation for future), the more at ease it becomes.
Brain appears to have evolved as a means to keep the level of stimulation in the whole organism at the minimum possible without the organism dying. It should not surprise us that what humans prize more than anything else in the world, more than gold, silver, and sex, is to have the deepest sleep possible; sleep free of any disturbance; sleep free of even the pleasantest dream; sleep that is just one step this side of death. No wonder narcotic addicts sometimes actually die trying to get the greatest peace/pleasure/high of their life through creating near death experience.
As to how this toning down of the brain activity creates subjective feeling of pleasure in the consciousness is beyond the scope of human understanding, at least at present, perhaps it will remain so forever. We do know that more active the brain is greater is the feeling of unpleasure, unless of course that activity is being undertaken to lessen the rising stimulation at some other point. 
And here lies the reason why people are constantly doing something. They are constantly preparing themselves to avert a more massive increase of tension in the future. This gives an illusion that we actively seek stimulation.
If we take my patient's case it can be seen that his interaction with his girlfriend and other people while raising the tension at one level also promises of lesser stimulation and thus lesser tension in the future. Interactions with girl friend are pleasurable in that they assure that the dreaded unmanageable rise in sexual tensions will not become a reality with her being around and permitting their periodic release. Helping hurricane victims is assurance that such a good deed will be noticed by the heavenly father, or whichever authority now substitutes for the parents, and he will either not be subjected to similar disaster as a reward, or if similar disaster strikes him people will come to his rescue as a payback.
How does the brain learn not to run away from these humps of increase stimulation and correctly evaluate them as unpleasant necessities that must be faced to avoid over-stimulation in the long run? In other words what mechanism the brain utilizes to override one's natural inclination to immediately avoid any overstimulation. The mechanism lies in the love that we received from our parents when we undertook painful tasks that promised future pleasure. It is  for the sake of parental love - and fear of punishment in their hands that would have caused greater increase in tensions that the unpleasant task itself - that we learn to become stoical towards the difficulties of life.  The pleasure that was generated from the love and attention given by the parents outweighed the unpleasure that arose from undertaking the tasks.
And the earliest and most momentous token of that love was being fed.
While eating is a pleasure in its own right - it brings relief from the tension of hunger  - it is also the first and the most important means to reward the child when he does not run away from mastering exigencies of life.  Promise of food - promise of parental love - can lead humans to bear great amounts of suffering.
Thus eating becomes the most important methods to tolerate suffering. It is in fact the first addiction of humans. Our first experience of satisfaction occurs on mother's breast. Even after nutritional need is taken care of, the child will keep sucking upon the pacifier, and later the thumb, to recreate this experience of pleasure, and through it, when under stress, the illusion of parental protection. This first experience of satisfaction is the prototype of all later addictions. Later when thumb sucking is no longer permissible under the critical and forbidding eyes of society, munching of food substitutes it. Other addictions may follow, but their nature is basically the same. They are all undertaken to produce pleasure at one point of the brain so it will distract the attention away from anxiety, tension and pain happening at another region.
A patient of mine recently confirmed this viewpoint with the following statement:
"I am an emotional eater. When I am in pain I eat bowls after bowls of cereals. It eases the pain. It is similar to cutting that I use to do. When the emotional pain from the molestation [which I was subjected to from the age of 7 to 14] would get overbearing I would cut myself. The physical pain would take away the emotional pain. In fact I would not even feel the physical pain, just relief from the emotional one."
So eating by producing pleasure from the positive sensations occurring at the taste buds in the mouth, feeling of fullness in the stomach, and the muscle movements of the mouth and the gullet takes away the pain happening at some other spot, just like cutting oneself physically at the wrist takes away the emotional pain that one feels inside. One of my patients stated that when the memory of molestation grips her the pain is so severe that she feels that her chest is going to cave in and she cannot even breath, and only cutting herself allows her system to breath and live again.
Fortunately most people do not have to cut themselves to generate enough counter/irritant/counter-pleasure  to combat the internal pain, they just have to reach out and eat something. And while the food is in the mouth or traveling down the gullet, and muscles of mastication and swallowing are active, the pleasure generated takes away the attention from emotional pain.
And so was the case in my horse trader patient. As long as he could drown out the unhappiness of his life by finding pleasure in making deals on buying and selling horses, or in socializing with his girlfriend, or with other people he was fond of, or helping those who he hoped would help him in return in his hour of need, he would not think of food. But when nothing else was happening and all his unfulfilled needs and ambitions would start clamoring for expression and stimulate his brain to do something worthwhile - which his age, circumstances and abilities precluded him from undertaking - then the only recourse left for him to do something meaningful was to eat.
How does the attention shift from the painful stimuli to areas which are producing pleasurable sensation?
Here comes the role of dopamine. Whichever behavior decreases overall brain activity - that is overall level of mental stimulation/tension - that behavior is strengthened - given more attention - through dopamine input. Dopamine's function appears to be to further charge/cathect/facilitate the neuronal circuitry that underlies pleasure giving behavior. Dopamine-producing neuronal circuits are not activated as a reward when something pleasurable happens. Pleasure happens when there is decrease in mental activity and dopamine is secreted to give attention to all those environmental factors and one's motor actions that brought about the pleasure. This increased attention makes the memory traces of these environmental factors and actions stronger. It is a kind of error to look upon the neuronal circuits that produce dopamine as reward circuits. They should be looked upon as attention producing circuits which make the perceptions and behaviors existing at that point of time more vivid and consequently their memory traces stronger.
At this point a few words on Attention Deficit Disorder (ADD) are in order. This malady appears to emerge as a response to some inner turmoil. As if the child is running away from some revved up inner neuronal circuits - in most boys it is running away from turmoil of the Oedipal Conflict which did not come to quiescence/dissolution with beginning of the latency period - seeking pleasure to distract attention from the tension. If this running away cannot be undertaken in motor movements, it is in racing thoughts or in daydreams. All these motor movements/racing thoughts/daydreams occur to seek winnings which will reverse the memory of the Oedipal defeat and having to give up the mother as love object out of fear of father. This fear of the father underlies the constant anxiety that is the substratum of ADD and which drives the boy to keep running and running. As the child matures, obsessive thinking and motor rituals emerge to control the anxiety and hyperactivity (running).
Careful examination of these ADD children shows that all their motor hyperactivity and day dreaming are an attempt at winning either in real life or in imagination to lessen the fear of  and to come even with "the Oedipal father". And through winning produce a decrease in level of tension, which is same as production of pleasure, and which results in secretion of dopamine from attention producing circuits. Stimulants - dopamine enhancing drugs - work in ADD because they boost dopamine and thus attention to whatever is going on in the environment. Here the dopamine is secreted not because some winning has occurred and therefore there is decrease in tension but by the means of drug. Nevertheless the release of dopamine temporarily takes away the child's attention from his revved up painful neuronal circuits and focuses upon what is happening in his environment then and there. As one of my ADHD patient remarked,"Whenever I take Ritalin all my thinking becomes immediate, current. All the past hurts and memories that rob me of my present vanish. My mind instead of being all over the place from the past are now focused in what is happening here and now."
It may not be totally out of the way to make couple of remarks on the distractibiliy/hyperactivity that occurs  due to lack of sleep and which we try to rectify by various means the most favored of which is munching upon food through the day. The purpose of sleep is to bring down the level of excitation of the revved up neuronal circuits that had occurred as a response to day's challenges so they can start afresh the next day. If this cannot be accomplished by simple withdrawal of cathexis/activation from the cares of the day dreams are generated that show the happenings of day in more favorable light allowing the vigilant and tense neuronal circuits that were on guard to discharge and become ready to undertake fresh responsiibilities the next day.  If their discharge cannot take place even in dreams because the distortion of real life circumstances in dream would have been too great to bear, leading to waking out of the dream/nightmare or unable to fall asleep in the first place out of fear of dreaming dreadful dreams, then during the day one would go around still preoccupied with the affairs of the past, unable to pay proper attention to the present. And to bring back the attention from these internal conflicts to the real world one would eat. For the pleasure generated from eating releases dopamine and draws back the attention to food and the real world from where the food is coming.
The question naturally arises that if pleasure (reduction in tensions) causes dopamine release which in turn stimulates the attention and there certainly could not be any pleasure arising from inner turmoil why the mind pays any attention to the latter in the first place. And there is little doubt that when something is bothering us  we have no interest in the affairs of the world and all our attention is to keep mulling over the painful inner turmoil. Why would one want to focus upon painful happenings? This is a tricky issue. We know that whatever causes pain we want to run away from it. And if we cannot physically run away from it then we at least don't want to look at it, think of it or pay attention to it. But this cannot be entirely true. If something painful strikes us, our first inclination is to run but if we cannot then we are forced to pay attention to it. Something gnawing inside, we may ignore it in the beginning, but finally if it does not go away by distracting ourselves with other things, we are forced in to dealing with and yanking it out of our vicinity and our system if its source is within the body.
Let us try to make some headway into the mechanisms behind this attentiveness to pain. The first and the oldest must be the reflex attention. Its evolution had to be before the emergence of Central Nervous System when the brain was multilocular, spread all over the body, and each sensory modality (taste, sound, touch) brought its own independent motor response through ganglionic cluster of neurons. This reflex attention must have evolved as a biological necessity at the discovery that by not paying attention to whatever is bothering oneself the trouble does not go away, especially if the source of stimulation is from within the organism as hunger and thirst, and the way to deal with it is not through creating a distance from it but paying attention to what is causing the excessive stimulation and taking steps to eliminate it. Perhaps release of endorphins and other anti-pain chemicals in the brain, and also at the body site from where the pain was arising, was a necessary step in the development of this mechanism of generating attention. With further development of the brain the dopamine system must have also come into play. Once endorphins would have brought about the cessation of pain and thus decrease of tension, dopamine would have been secreted to enhance attention. High addiction potential of narcotics appears to be based upon not just their ability to stop pain, but their ability to generate high level of attention; at least in some addicts. There is no doubt that some ADHD patients prefer narcotics over stimulants as a attention generating chemical.
The other mechanism behind the paying of attention to painful things has already been discussed at some length above. In the earliest years of our life when we were in pain and required relief from it, but did not have ability nor the experience to do so, it was our parents who paid attention to our needs and came to our rescue. Over time this behavior becomes internalized, and we took over the actions of our parents who instead of running away from painful situation paid attention, took cognizance and got rid of it for our sake.
Finally, we must try to answer as to why attention is generated whenever there is reduction in tension.
This requires examining as to what life itself is. An organism is alive as long as it is indulging in give and take with other organic entities. It is this exchange which bring reduction in tension. When a desirable thing like food is ingressed and added to the organism or an unwanted part of oneself like feces is extruded there is reduction of tension. Higher this rate of  exchange with the outer world more alive is the organism.. As one of my patient put it, "When I was healthy I was into everything and everybody, so full of life. Now that I am bogged down with stress, everything has ceased. Even my intestines have gone in a shutdown mode, and I get constipated for days. Last thing I want to do is to deal with people. And I am gaining weight and my cholesterol is shooting up, because even my metabolism has slowed down, refusing to burn the calories I take in."
Attention, with the aid of dopamine secretion, is an additional attempt to enhance life processes. Whatever perceptions and behaviors enable life's give and take, attention is paid to them so they have higher priority in getting activated when similar situation arises in future.

Women playing with their hair on approaching stoplights

In an Internet site where I banter with my classmates from my medical school, one of them raised the following question.

why women play with their hair when they approach stoplights ?

And he answered it himself, of course as a joke, Unlike men they do not have b---- to scratch.

While he meant it as a joke the fact that he had noticed this phenomena, and had found it humorous enough to quip on it, and then had associated it with - rather had  found equivalency with - touching of genitals, points to the presence of some psychological riddle here. 

First of all we have to decide whether it is a phenomena worthy of psychoanalytic investigation by which I mean that it is a distinct behavior present not just as a quirk in one particular person, which would be a manifestation of his or her individual neurosis, but a universal neurosis, present in all of us, ready to emerge as a defense mechanism if the circumstances demand; a repetitious behavior arising from our phylogenetic past as a response to the experiences of countless generations that have left genetic imprints in all of us, and whose raison d'etre remains shrouded in mystery because the underlying motives and processes of the phenomena have become unconscious due to repression. 

There is little doubt that some women under stress do reach for their hair - usually the frontal locks - and run their fingers through it as if searching for something hidden. On being questioned they dismiss it as just a habit or as simple straightening of hair and may even get irritated as to why one would nitpick over a little extra grooming.  

Now superfluous grooming is a sign of obsessional neurosis. In a subset, the compulsion to clean and groom reaches ridiculous proportions. The patient, especially in the mornings, may literally spend hours in front of the mirror, straightening hair, looking for flaws on the face, clothes and other aspects of one's appearance, as if one has to wipe out every trace of what may be construed as offensive by others, before leaving the house. Trying to put the hair in order seems to be a specially favored aspect of this ritual, as if these individuals are having a-bad-hair-day everyday, and they may accumulate an impressive array of shampoos, gels, conditioners, sprays, and shaving paraphernalia as counter measures against these (unconscious) harmful impulses. 

And here we cannot help but reflect whether patients who suffer from trichotillomania - a malady where the person compulsively pulls out her hair in clumps sometimes to the point of going completely bald - are not taking this fear to an extreme.

Now sometime back on this blog I discussed a case of trichotillomania: "A childhood screen memory of penis envy and its connection with trichotillomania" (April 16 2011). There we saw how the patient, under the sway of penis envy, wanted to pull out anything that reminded her of the difference between the sexes and the underlying motive was to equalize the playing field between the two.

Could it be possible that such apparently purposeless playing with hair under stress is just an embryonic trichotillomania?

We do know that trichotillomania is another manifestation of obsessive-compulsive disorder. To the patient the hair feels as something alien and hostile that one must get rid of. Anything out of place, anything not fitting in with rest of the pattern; littered pieces of papers, dirty linen dropped on the bathroom floor, magazines thrown haphazardly upon the coffee table, hair in the bathtub, they all have to be put in the general scheme or yanked out altogether, so goes the reasoning of the obsessive, and hair become another object in the series.

What surprises us, and fills us with not a little fascinated horror, is that here what the obsessive is finding incongruous is not something external but part of his own self. But a little reflection tells us that  feeling and treating part of oneself as a foreign object is perhaps not all that strange but quite common. We just do not see it that way and therefore it unpleasantly surprises us when somebody brings to our attention as to how we can treat part of our own body as something vile and foreign. In fact picking upon pimples and other flaws of complexion is almost a rite of passage in adolescence; women in throes of post partum depression may consider their own child - which just so recently was part of their body - as incarnate of evil, the devil himself and kill it;  and in psychotics it is not all that rare to actually castrate themselves or enucleate their eyes [where eyes symbolize the penis]. Those suffering from psychogenic pruritis can relentlessly dig their own skin convinced that under it lie bugs or other contaminants, and psychogenic poludipsics are known to gorge themselves with gallons of water in order to wash out the impurities of the environment that has got lodged inside their bodies. Recently a patient of mine, who for years had been digging her skin and her torso and arms were puddles of sores, stopped doing it, when her Remeron (Mirtazapine) was stopped. She was perhaps feeling the side effects of Mitrazapine as something foreign inside her. A mechanism that I will not be surprised is common across the board in causing psychogenic polydipsia in patients on psychotropic medications.  

Now coming back to the analysis of these obsessive patients who are forever trying to get rid of the incongruities in their environment or in themselves. At the deepest level they are fearful of contamination of others by the bad aspects of themselves. Incongruities in the environment is just a reminder of their own unacceptable impulses, and they are forever straightening out the environment to banish from their sight everything that will provoke further activation of their own incongruent/evil/extruding impulses. And these extruding impulses show themselves to be the intimate aspects of themselves that should be hidden from the environment. While immediate examination shows them to be arising from the anal-sadistic phase of sexuality - we recall here that the fear of leaving the house is associated with not being cleaned and groomed enough - at the deepest level they arise from the fear of the destructive power of the phallic impulses. The fear that one's anal-sadistic impulses will show is but a regression from the fear that one's phallic/genital impulses are out of control and will be seen by people/society. 

Why the penis and the impulses originating from it are felt to be destructive? 

Sexual drive is often felt as evil and incongruous with the rest of the self; an anomaly, something gross, physical, material, smelly, crude and not refined or spiritual enough. 

And with good reason. People who are so dignified in every other respect when under the sway of the sexual drive can behave most incongruously. A man huffing and puffing in the act of sex looks ridiculous if not outright animal. There is nothing dignified about one human being mounting and humping another. And the phallus/penis is the most visible manifestation of this drive which turns us into such a coarse being. In women there is further fear of it being a harbinger of cooties - diseases - if not outright pregnancy, which is the beginning of the destruction of one's own body and ultimately death. No wonder people often develop neurosis in order to suppress/escape from this coarse drive. We cannot help but reflect here that in the Hindu Trinity of Brahma, Vishnu and Shiva the latter is symbolized by the penis and is attributed the function of both the procreator and its exact opposite the destroyer.

But what exactly is the connection between women playing with their hair on crossroads, trichotillomania and fear of getting touched by the penis, you want to ask me. 

This question cannot be answered directly and instead I will take up two instructive cases. The first one is actually not even a case but someone I worked with 25 years ago. He was a Jewish doctor who stammered quite badly; a malady that I could see had arisen as a mean to control his inordinate ambition which must have begun as an excessively powerful aggressive drive. Coupled with this was his habit of relentlessly twirling and untwirling a lock of hair that he still had upon his balding head. The underlying psychological mechanism behind the obsession was easy to discern. His extreme competitiveness wished nothing less than castration for anyone who even hinted of crossing his path. But living in society and hampered by its rules  and unable to do anything of the sort even with words, for stammering would arise to block the discharge of aggression through speech, he wanted to do it with his bare hands. But the danger involved in laying his hands upon others had deflected the impulse to find discharge upon his own self and in the form of twirling and untwirling his hair - castrating and uncastrating himself, symbolically of course.

The second case is that of a woman who was in early thirties, eager to settle down but unable to do so because of undischarged anger towards men, stemming from growing up in a divorced household where the mother was absent and the girl was dumped with the responsibility of taking care of the father and her brother, both of whom had lorded over her because she was the girl. Her relationships were predictable. After a brief  period or romance, she would lapse into continuous arguments with whoever she was courting.  All her lovers after a few months of honeymoon would metamorphose into her brother behind which lay the image of her father. Her life was a series of her old battles with the new incarnations of her brother and father. 

And her brother gave her fresh justifications to do so. She had a regular job while her brother, older than her, was more or less of a bum. Whenever she talked about him she showed contempt for his inability to hold down a job and this would be followed up with expressions of outrage that he still remains their father's favorite. And she knew that the only reason  this was happening was because he was the boy and she was the girl. "If only I had a penis," in her unconscious she reasoned, "I would have been my father's favorite." 

Now whenever she talked about her brother in this fashion, and additionally whenever she felt I was putting her down through my 'interpretations' of her psychological conflicts, she would get excited and start playing with her hair. And the way she played it looked like as if she was searching for something there. The movement of her fingers through her hair would remind me of how homosexual hair dressers fiddle with their clients' hair fetishistically as if they are searching there for something as well.  Now one of the most common subtype of homosexuality occurs in those who cannot forgo the idea of the lack of penis in their love object. These homosexuals love everything about women and their beauty but cannot tolerate the dread of the missing penis in them. They often turn to feminine looking youthful boys for their love needs. And it is this type of homosexuality that marks the hair dressers who cannot give up the idea of finding the penis in the tresses of the hair while grooming and straightening it out. The facial expression and behavior of this girl was so similar to those homosexual hairdressers, the unconscious motives behind such playing with hair became easy to fathom. "You jerk," she wanted to say, "You are shoving those interpretations down my throat with such surety because being a man, and possessing a penis, you consider yourself naturally superior to me. Now I know that I too have a penis. It is hidden somewhere, deep inside me, perhaps hidden behind these lock of hair of mine. And if only I get hold of it, which will place both of us on a level field, I will teach you a lesson as to who is better between the two of us."

If we take the Jewish doctor who played with the hair to symbolically self-castrate, and this girl's search for the hidden penis which would put her on equal footing with men, then we can extrapolate that perhaps many women when stopped at crossroads experience the situation as stressful and also deal with the anxiety by reaching for the penis that would put them on equal footing with men and make them not feel so vulnerable. 

But why would a woman feel vulnerable on stoplights? 

Here we run into the psychology of agoraphobia. Agoraphobia - which literally means fear of the marketplace - arises from fear of coming to harm in interacting with others especially in public places. Analysis reveals that behind the fear of interaction lies fear that one would be tempted to exchange one's goods - displacement from exchanging one's sexual goods - and would come out a loser. In the agoraphobic the give and take of life has gone sour. Iron has entered the soul especially in the matter of the most pleasurable of all exchanges - the give and take of sex.

What causes this fear and sourness?


Throughout our existence we are in search for somebody with whom we can exchange our bodily goods. The very process of life depends upon such exchange. In this love exchange, only in the beginning we are generous, and this more so the case in women. In her, if the culture and men has taken advantage of her, and given as to how exploitative cultures are towards women it is invariably the case, she may show increasing ambivalence towards this search for love. She may rather not exchange 'her treasures' with that of a man, or do it in a manner where she gives less and takes more. She may even resort to deception, ruse and tricking. It is these negative impulses behind her love that makes folks lament at the femme fatale and her enigmatic and unfathomable nature.

The woman's inner conviction that she has been shortchanged in life adds a further twist to this search for love.  Her sense of lacking something which she must make good and complete by getting it from a man makes her approach him with poor self esteem and trepidation and leads her to adorn herself with all kinds of jewelery, make-up, and other shiny trinkets that she hopes will be a match for that one jewel that he possesses. Women's endless shopping is also the search for that jewel that would deflect attention from her  great defect/wound  and would make the man believe that he is getting more than what he is giving. The term "turning tricks" for the act of prostitution perhaps arose from this attitude of exchanging and tricking the man into giving what she wants without his getting anything in return. For the prostitute convinces herself that she feels nothing and gives nothing in the sexual exchange and gets the man's money through just tricking him.  

But the attitude of tricking, deceiving, stealing, and in the more spirited one pulling it out as a tuft of hair, provokes the fear of retaliation and subjection to physical harm and other dangers as getting the cooties (venereal diseases) and pregnancy. The  revolt at the thought of playing the passive sexual role and a stranger's dirty organ penetrating one's body adds to the disgust and provokes further withdrawal from the impulse.

No wonder at the stoplights, in a situation to meet somebody - for crossroads are like a marketplace offering choices as to which direction to take and who to choose from amongst all the other stopped passengers - tempted and yet fearing the retaliation for her evil intention, she reaches for her hair and searches for the penis, which she has a conviction she does possess, and it is only a matter of searching. For if she is successful this time in that eternal search, she does not have to bother exchanging her goods with another; for what she so ardently desires she already has.