An unconscious conspiracy by the pharmacists, physicians and drug companies to overmedicate patients

When a doctor writes a prescription for medications that should be taken only when the need arises he puts the abbreviation p.r.n. It is an acronym for Pro Re Nata which is Latin and therefore Greek for 99% of the doctors. Nevertheless it does not prevent them for using its Latin origin to make their profession look more mysterious and prescriptions unfathomable, justifying charging patients more than their labor warrants.
My problem with p.r.n. is not that it should not be ordered, and that many medicines should not be taken only when needed. For example instead of taking Tylenol routinely it is better to take it only when pain or fever arises. My problem is the way pharmacies label the p.r.n. orders.
If I write:
Xanax 1 mg. tid p.r.n. [t.i.d is another Latin obfuscation]
which means that 1 tablet of 1 mg Xanax can be taken up to three times a day but only if there is a need for it, the pharmacy will write on the label: take three a day as needed.  
Writing it this way gives the impression to the patient that he should take three tablets of Xanax a day as [it is] needed.
It is a very subtle way of encouraging patients to take more medications than they should. This is especially true with anti-anxiety agents and narcotic pills where there is a tendency to take more medications than prescribed to begin with. As needed is interpreted tendentiously that they should take the maximum allowable dose.
Wouldn't it be better if the instruction reads: take up to three a day if needed.
If needed is much better than as needed when labeling prn orders.
Perhaps the ideal way would be: take up to three a day but only if needed.

A Problem Solving Dream

A man in his late fifties, happily married, presented the following dream, which he had dreamt the night before the therapy session:

In the dream, my wife and I were in some kind of workplace together. We both worked at the same place and for the same manager. I suddenly found I was working on a phone modem. The modem was in the form of a metallic bag, kind of like potato chip bag made out of the foil, wrinkled and a silver/black color. As I sat at a desk trying to flatten this bag out, the person I understood to be our manager said, "I can't get through on this phone line." To which I commented "That's because I am working on the modem for that line. I'm just about done and you can use it in a moment. It will be faster because I've adjusted the settings."

The desks of my wife and I were close to one another in the first row of the office. Suddenly, the outside wall of the office where our desks sat and the ceiling were gone. An open, grassy field appeared next to our desks. Walking into the field right next to our desks was a musical band of about 10 Caucasian men and women.  They formed the shape of 'L' and started playing instruments which was loud. Some of he women in the band started dancing by lifting their legs to their right side but I noticed they were not in sync with each other. I thought at the time that it would be almost impossible to work with that much noise (from the band) in our office. My wife was on the phone at the time looking at the band and laughing about the circumstances.

The patient had written out the dream but when asked to narrate it anyway, made one addition. His wife and he were facing the East.

Associations to the elements of the dream were not readily available. As to why he was facing the East he could just say that he is generally aware of the directions as to which way is North or South while dreaming. This peculiar feature of his dreams had been subjected to analysis previously and it had to do with his great need to be moored to reality even while indulging in dreaming (fantasy life). His parents had got divorced when he was 10 and this had had a cataclysmic influence upon his psyche and for a while he had felt as he had no direction to his life.  He did not know which parent he should live with, whether to live or not live at all, and whether he will be able to face the future without the joint protection of his parents. He had emerged out of this great turmoil quite well but with a scar. He had a tendency to go into states of mild depersonalization. He would suddenly go in to brief periods in which he would feel as if he was there and yet not there. To counter these attacks of derealization in all his other affairs he had become hypercathected to reality and even in his dreams he could not abandon the necessity to know as to which way was North, South, East etc.

When asked where did the dancing band came from he said that next week he is going to Key West where there is a bar called Sloppy Joe, where Hemingway use to hang out. Every year they have a Hemingway-look-alike contest around this time. His wife and he are going to it. The patient does have quite a resemblance to Papa Hemingway - flowing white beard, generous body girth and a benevolent facial expression, and he is hoping to score big in the contest.

He expressed some misgivings about being there and not just because it is crazy to go to Key West in July - he hates the heat and humidity of Florida in summer - but because he and his wife are very religious and conservative and the bar represents for them dancing, singing, partying and other kinds of "debauchery".

When asked if the singing and dancing band in the dream were representing the fear of giving in to the   temptation the patient said, "I'll be damned if that is not what it means. For those people in Key West area are a lascivious lot while I and my wife are just the opposite, and I have mixed feelings about getting into that revelry."

Once established that the singing band had come into the dream to represent the much anticipated visit to  Key West which was to take place the next week, we had to find from where was the actual visual imagery  taken from. And here the patient told me that the night before he ordered on pay-per-view a movie called "After Shock" where a bunch of young Americans go to Chile and while living a licentious life are struck by an earthquake of the magnitude of 9.5  which causes a cataclysmic upheaval; disasters of every kind are unleashed with criminals escaping out of prison, looting and raping women.

So the singing band was imagery of crime and punishment. Indulging in sin and suffering its consequences.

On being asked if anything else happened on the day before the dream he recalled that all evening his wife was complaining about her problems at work. She is a nurse who works as a case manager in a hospital where she has to make a judgment call whether the patients admitted to the ICU meet the insurance company's criteria for inpatient care or not. It is a difficult and thankless job where there is constant confrontation with irate doctors and insurance company representatives. That particular day her immediate supervisor was not present in the hospital and she had to go to the manager of the entire department to resolve an impasse with a doctor. She had been unable to reach the manager on phone. 

The patient who is retired is the sounding board for his wife. All her frustrations at work she relates to him when she comes home, and he sits with her, and tries to find solutions for her and sometimes feels as if he works along with her. It was from here that the visual picture of their sitting together at the workplace was composed. We could not decipher as to why they were on the first row. It was perhaps related to the fact that before retirement he was head of security in a Multinational Corporation where he always felt cut above the rest and he was bringing that same attitude and skill in helping his wife.

So when his wife lamented to him about how difficult it was for her to reach her manager and how frustrated she felt about it, his mind at once began to work upon resolving the issue and the problem-solving continued into his sleep, emerging in the dream as trying to fix the modem.

As to why the modem was shaped like a potato chip bag with wrinkles the only association that came and which to some extent was suggested by me was that the women  with whom his wife works are all getting up in years and are kind of old bags with wrinkles. The manager who she tried to reach unsuccessfully is a younger woman who really does not know what she is doing and is not a nurse but a social worker, a political appointee, and who per his wife lacks proper training to have the correct feel for medical complexities of the ICU, even a correct understanding of medical terminologies. His wife therefore dislikes calling her. In the dream the patient was reversing the situation and displacing the frustration of his wife trying to reach the manager in to its opposite. It was now the manager trying to reach out on phone and unable to do so and the patient was in the position of power and only through his efforts could the manager use the phone line. So the dream though it had to do with his wife's frustrations at work was showing him as the central character. Dreams truly are totally egoistical.

As to why the modem was black and white the patient said that the case managers who are about 10 in number are distributed in two sections of the hospital. Some of them are in the new wing and have a better work venue while others are in cramped quarters and have to share desks and computers with doctors of the ICU and they are constantly being interrupted by the patients and their relatives. This was given a pictorial representation in the dream:  I thought at the time that it would be almost impossible to work with that much noise (from the band) in our office .

Per patient the silver/black of the modem was taken from the silver and black stethoscopes of the doctors which often lie around in the area which they share with the case managers.

He added that the case managers in the old section of the hospital dislike the lack of space and having to share the desks and computers with doctors with whom they are often at odds. I wondered to the patient if the lack of coordination between the case managers with the doctors was reflected in the out of sync dancing of the musical band.

The patient said that the whole situation there is out of sync. They have a difficult job with constant wrangling over who should stay, who should be discharged and who should be sent to the observation unit. She is often worked up over what happens in that hospital but sometimes we have a good laugh at what takes place there. In the dream this laughing at her co-workers was shown as laughing at the performing band.

"Why did the walls and the ceiling suddenly disappear and you were transported to the open grassy field?"

Patient claimed it was the wish to get out of her stifling work environment and be on vacation.

"Why were the dancing band 10 in number?"

 "It has to do with The Ten Commandments. Whenever I think of number 10 I think of the Ten Commandments. You know how religious I am. Whenever in doubt I think of how God would have handled the situation. We went to sleep talking about my wife's problems and then this worry was in back of my mind how to deal with those wild people in Florida. So I must have been thinking of God and The Ten Commandments as guidance to deal with the two situations."

I wondered if the L shape of the dancing band was not taken from the epithet 'lascivious' but I did not communicate this to the patient and it could not be confirmed. I asked him instead, "Why were you facing the East?"

"Whenever I think of the Holy Land I think of the East. So I am looking to the East as if God resides there,  like how the Muslims pray to Mecca."

"Why are all the band members Caucasian?"

"This has to do with Zimmerman case. Yesterday I was watching his trial. That must have activated the issue of black and white in my mind and and you know how I scapegoat Blacks when anything goes wrong politically. I blame Obama for everything that is wrong in the country. So when my wife was complaining about the manager and the work I must have been thinking that she is Black and therefore she was not to be found on the phone. But she is white and so are all other case managers and her supervisor. And that may  the reason why my dream is making my wife laugh at that unsynchronized dancing as if to say that you all may be Caucasian to the boot but still haven't got your act together."

The modern scientific research on sleep and dreams makes a big deal of how during sleep and especially during dreams we become smarter than we are normally. And this kind of praise of our abilities gets a lot of media coverage and we lionize the researchers who come up with some corny experiments to show those who sleep or dream show astonishing improvement in their memory and creativity. And they all quote the historical example of how the structure of benzene ring came to the mind of that great scientist in a dream. Hundreds of millions of dollars worth of research money goes into showing how wonderful our mind becomes when it is oblivious to the world and snoring. All this belief that in dreams we become super smart  is bunch of baloney. There is often intense problem solving activity shown in dreams and it is often  accompanied by strong emotions as if one is really trying to do some intensely important work. But careful examination shows that the problem solving was all a facade. Behind it was just some wish or another trying to get fulfillment. In this dream too, the dreamer was doing some intense problem solving - full of sound and fury - on a modem. But on closer examination that problem solving was being done on a potato chip bag with wrinkles. And it was all for enabling someone to make a phone call through repairing the blinking lights of a modem! Something which even a child will see through as problem solving worthy of three stooges. 

A dream confirming Zombies are our own evil impulses projected upon others

A high spirited woman, in her early thirties, mother of two, 12-year-old boy and  a 2-year-old girl, living with latter's father, whom she must incessantly criticize, because of a constant need to not feel inferior to men, brought in the following dream:

[Though even before telling the dream she broke into laughter as to how silly it was and declared, embarrassingly, that the dream could not possibly mean anything. In fact she wanted reassurance that every dream - and every single detail of a dream, I interpolated - has a meaning and there will be some normal thoughts behind her dream before she would proceed further.]

I am in a car with my friends - not my family members now - going to a mall. I am passenger [not driver]. Though they are my friends, only one of them I know, or at least can remember well enough now. She has been my best friend since childhood. Though recently we had a falling out.
In the mall - it is a big mall - we find out that it has been taken over by zombies. [The girl could not restrain herself from laughing at this point.] They are not mindless zombie who don't know what they are doing but intelligent zombies. They bite my friends who turn into zombies as well. It is not a violent bite. Not like how zombies devour and tear you in to pieces. But a gentle bite. Finally seeing everybody turning into zombie I let my friend bite my hand and I turn in to a zombie too. [she laughed again at such a girlie conclusion of the dream and added that I am surprised I agreed to it so readily. For my nature is to kick ass and not give into anything so easily].

The girl's correction that she was not with her family members but her friends gave the clue that the friends were 'replacing' the family in the dream for the purpose of repression. When two thoughts like that follow each other then one can immediately assume an internal connection between the two and in her case the disclaimer confirmed that the process of repression was trying to make it doubly sure that she tell us that the two thoughts have nothing to do with each other. In reality she was using her friends as a substitute to work out her conflicts with her family [through the medium of dream].

This construction was immediately rejected by the patient, but only to tell me in the next breath that the  friend whose identity she can still recall is as good as family, almost a sister. They grew up together and she is like an alterego. "Her father and my father were alcoholics and both died young. She is 4 days older than me. We did drugs together as teenagers. We always got into trouble and together. But there were differences. While, her parents would ground her for a month for each transgression my parents within hours would forget what punishment they had given me, and I would be free to do whatever I wanted to by the next day.

"One would have thought she would have turned better than me with all the discipline she got. But it happened just the reverse. Though both of us did drugs, and no doubt to escape from the horrible conditions that existed in the house, especially the death of our fathers, she went downhill far more than me, and became far more boy-crazy than me. In fact she had no self esteem and would sleep with anyone who praised her slightly. She lost her kids to protective services because she was so far gone into drugs. I think the discipline did not work because her parents did not practice what they preached. My father was alcoholic too, but he did not hold me to higher standards than what he could practice. Her parents were druggies as well, but punished her severely for doing the same thing they were doing. It made her a chameleon. While I take punishment on the chin. She escapes them. As long as she can lie her way out of it she will do drugs and other creepy things. Not me."

"Why are you two going to the Mall?"

"We both are adventurous; Libra. We liked doing things spontaneously. However, there is a difference. I like to go against the grain, but she is a girlie sort. She likes to gossip. I think we are going to the Mall for different purposes. She is going there for buying soft stuff. Catty stuff. To make herself look vulnerable. I am going there to meet someone to kick his ass."

I have always found that Malls in dreams symbolize meeting place. Like a fair where one will meet someone for adventure, romance and life partnership. Agoraphobia arises from the same complex. A dread of coming out a loser in such an encounter provokes anxiety attack. One ceases to go to marketplace/mall out of fear that on not getting what one wants one may lose control and do something drastic.

"Where are the zombies taken from?"

"I don't know; they come all the time in my dreams. But usually they are mindless and aggressive, killing and devouring people, and I am afraid of them. But this time I find them half way decent, feel a little sorry for them, and they are even not mindless."

Recent work in therapy sessions had softened her attitude towards her boyfriend who she always criticized as mindless. So the criticism of Zombie was criticism of men. "They are dickheads and mindless, as good as zombies," was her frequent attitude towards men. Underneath, of course was her fear of them. Her father's aggressive and alcoholic ways had made her fearful of men. But she had also strongly identified with his aggression and had rejected her femininity. She took great pride in being adventurous. She had declared in other context her dislike for knitting, gossiping, wearing high heels, buying frilly things, and eating chocolate and hanging around in shopping plaza for hours."

"Why are they biting your friends and turning them into zombies?"

The girl insisted that the zombies were girls and boys. By getting bitten they were becoming ordinary people who go along with the program. "I on the other hand will never go with the flow. I refuse to be like all these girls, who will suck up to men."

"Why are you putting your hand out to be bitten then?"

"I guess, I am tired of sticking up for my rights and denying my feminine side. Remember the dream where I go to the Mall and shop around and buy high heel shoes with my mother and you interpreted that deep down I have a very strong feminine side which wants to find expression. It perhaps is making its comeback again in this dream. For now I remember the last part of the dream, which just came back to me.

We come out of the Mall and I don't know where I should sit. Like I lose my perspective. Everything looks different.

I guess it means I am ready to look at the world from a woman's point of view, even if I feel I am lost and cannot find my bearings. I went to the Mall as a passenger in the car. I think I am ready to let other women, chiefly this friend of mine, who acts so girlie, to show me how to be more like a woman."

There was element of the dream that had not yet been explained. Why were the zombies quick and full of vitality instead of moving stiffly, mindlessly tottering and barely able to stand up straight as would happen in her previous dreams?

The patient and I could only come up with the following explanation:

During the period when she was very competitive and hateful towards men she was full of evil impulses towards them. These impulses emerged as constant criticism of males during the day but in  night, in sleep and dreams, they were shorn of their verbiage and appeared as pure visual images. The visual images and behavior of zombies gave the best  representation to these evil impulses.  What she wanted to do to those mindless/dickhead men now appeared through the defense mechanism of projection as zombies attacking and devouring her.

As to why the dreams did not show evil men attacking her directly we could only conclude that in dreams while the brain is not completely asleep still parts of it are resting and whatever action and behaviors have to be done they have to be undertaken with limited abilities. So zombies have to attack people but with a lack of proper muscle tone - in dreams we actually have motor paralysis - which makes them totter and move as if a ton of weight is on their shoulders and their feet are shackled. All their motor actions lack smoothness and their brain seems to function like a lobectomy has been done to it. But that is how the brain does function during dreams where verbal, conceptual and abstract forms of thinking are resting/sleeping and the unsatisfied wishes and their satisfaction have to be given expression through visual imagery alone. So the dreams find it easier to give representation to one's ambivalence about attacking others - the patient wanted to attack men out of jealousy but also saw that giving expression to such evil impulses was wrong and part of her mind did not want to do so - by making use of the limited activity of the brain during dreaming and showing the evil being carried out by idiotic semi-humans - the zombies. While the zombies do not carry their evil intentions smoothly because of the ambivalence they never die but keep coming on and on because the evil in us despite our best intention to extinguish, or at least to give no expression to it, persists on and on and can never be completely eliminated.

In this particular dream the zombies were not acting like morons with cerebral palsy because her attitude towards men was changing and it was with love she was approaching them and hence the zombies were biting her back too with love and with absence of ambivalence there was no need for the zombies to groan, lurch, totter and fall all over the place.

One cannot leave the subject of zombies without making a remark upon the frequency with which psychiatric patients complain that the medications you are prescribing them has turned them into zombies. Now our evil impulses which remain in check during the day because we are conscious and alert and under pressure from people around us, during the night, in dreams, can emerge as zombies because parts of the brain are asleep. Is it possible that psychiatric medications do the same: put parts of our brain in to sleep mode and so we feel  we are in a dream state and are more "living-dead" than truly alive? It also raises the question whether the  modus operandi of psychotropic medications is not to put aspects of our brain to sleep so other aspects can  find expression without inhibitions.  

Fear of needles and fear of going to the dentist.

I recently came across a gentleman, who is now in his early Sixties, who boasted that he has no fear of dentists. "Others chicken out at the very thought of going to the dentist but I can face without fear their prying in to my mouth, their giving injections in to my gum, and their putting in of those frightening instruments to keep my mouth open."
Now fear of the dentist arises from the castration complex. Teeth serve as an excellent symbol of the penis and any thought of harm coming to them provokes castration anxiety and a desire to run from the dentist's venue in a hurry.
What lay behind this nonchalance and absolute lack of fear?
Later in the session - it was his first session with me - when I suggested that he get some blood tests done for he had not seen an internist for a long time, he declared that that is out of question. He dreads needles and has avoided going to a doctor for God knows how long because the very thought of needle makes him faint. He bitterly complained that it is just not needles but the idea of  blood coming out of his arm in to the test tubes that makes him queasy and he falls to the ground when he witnesses it. He went on to declare that the medical profession should do the blood drawing while a person is lying down so he does not pass out, fall  and hurt himself.
Now the phobia of needles also arises from the castration complex. So this man's extraordinary castration anxiety found an outlet in the fear of needles with medical professions but as if by reaction formation he developed a completely opposite attitude towards the dentists.
The psychology of daredevils and those who climb the highest peaks and do bungee jumping etc. appear to be operating under the influence of the same reaction formation; a defensive maneuver designed to overcome their exquisite sensitivity to and fear of danger. 

A dream of revenge getting discharged upon the wrong person

A young man, recently divorced, had two dreams on the same night, back to back. He claimed the first dream was premonitory.

The First Dream:

I receive a text from K -the girl he had broken off a few weeks ago after dating her for couple of months- that she wants to meet, and not because she wants to get back together but for the sake of children [they have a child each from previous marriages who had begun to get used to each other].  I message back: absolutely not.

He added that surprisingly a few days later he did receive a text making the exact same request but so far he has not replied to it.

The Second Dream:

I am back in the house where I grew up. It is Christmas. My ex-wife is taking down ornaments from the Christmas tree. But it is not she who is doing it. A pair of sneaky hands just emerge and take away the ornaments.  It is difficult for me to explain how, but the best I can describe is that the hands belong to nobody, they just emerge out of nowhere and are taking off the decorations from the tree. I am watching all this through a camera that is monitoring the entire proceeding. I want so much to hug her. My love for her, which I no longer feel when I am awake because she cheated on me, returns in the dream. Then slowly the realization comes that we are divorced and I feel great sadness. I wake up missing her terribly.  

Patient initially was only interested in talking about how the first dream predicted what was to take place a few days later. There was an element of pride in his premonitory power and a desire for me to be impressed by it.

Since I hear all kinds of premonitory dreams especially from my obsessive patients who cannot dream enough the death of others and therefore once in a while their dream does turn premonitory, I was not very impressed by it and we quickly proceeded to analyse rather than appreciate this psychic gift of his.

But the task was not that easy. Why would he dream of receiving that text before it actually arrived? It is not that he needed some extra time to think over it before the reply. In fact in real life he had just sat upon it unable to make up his mind to accept this veil invitation to rekindle the relationship. If he was psychic and could foresee the future, even if only in dreams, couldn't his psychic abilities have done a better job and shown him dreaming of something more important than a mundane instant message text. Perhaps the clue to decipher the dream lay in his reply: absolutely not. He had ruthlessly rejected her.

Why did he reject the offer from K, who possibly really loves him, to get back together, and then immediately proceeded on to another dream where he is craving to hug and love his ex-wife, who had cheated on him and had broken his heart?

Now we know all the dreams on the same night arise from the same circle of ideas; same dream-thoughts. So unable to make head ways with the first dream, it was but natural to abandon it and go on with the second one in the hope of finding the common dream thoughts behind the two dreams.

To figure out the wish which had motivated the second dream was not rocket science. It was a desire to hug and love his ex-wife again.

But why on Christmas day, why was there a Christmas tree and what could be the meaning of those sneaky hands taking down the ornaments from it?

"Why was it Christmas day?" I asked him.

"That is when everything came to a head - on the Christmas day year and a half ago.  For weeks we had been arguing on how the Christmas day should be spent between the two families. I was exhausted by the bickering as to whose parents' house we will go for what, and for how long, yet I was looking forward to the Christmas day hoping that somehow the spirit of the holidays will straighten things out between us. Then came the shock. She disappeared, leaving me and my son waiting for her all day, not returning till the next morning. I had no choice left but to do some detective work, which, in this day and age with electronic trail everywhere is not hard, and found that she was having an affair. So I guess in the dream I was going back to that Christmas day, a time when I was still not aware that she was cheating on me and when my love for her was still untainted."

"Why was the dream taking place in the house you grew up instead of the house where you lived with your ex-wife?"

"My fight with my ex-wife at least partly arises from my anger at my mother. She was addicted to prescription medications for many years and could not take care of us the way she should have. She was either depressed or busy partying and drinking with a bunch of card players in a bar not too far from home. And I think my anger at her for this neglect has become generalized to all women and it emerges as a need to control them. I drove my ex-wife away because of my subliminal anger at her and my need to reform her. I could not control my mother from her self-destructive behavior because she was my mother and I had little power over her, but that impulse found an outlet with my wife. And I think she could not handle my controlling nature and finally copped out of the marriage by having the affair."

"Whose hands were removing the ornaments?"

"They are my wife's. Perhaps my mother's. Perhaps the snake who broke our marriage. He was my close friend, he grew up with me, I trusted him, and he stabbed me in the back by having an affair with my wife. The hands are doing the job sneakily because the destructive influence upon the marriage of the three was not visible. They were all working behind my back, or at least out of my consciousness, to pull the plug on my marriage. I think the dismantling of my marriage is being symbolized by the ornaments being pulled off the Christmas tree.

"But also by making those sneaky hands do that dastardly deed I was protecting my ex-wife from blame. If I could convince myself that she cannot be faulted for cheating on me then I could love her again. My pride cannot  forgive her. Without forgiving her I cannot love her again.  But in the dream I found the way to love her by making the blame as much as my mother's and my friend's as her's.

"The camera monitoring the dream field itself is a reflection of my need to control everybody. I drive my mother crazy too by trying to control every aspect of her life which comes in guise of stopping her from smoking and taking all the medications that doctors prescribe her which I think have worsened her in the long run than helped her. And I think I drove my wife away by trying to improve her beyond her ability to improve and micromanaging our marriage."

After getting the associations to the second dream [which have been condensed and put as a monologue here for easy reading] from the patient it was not hard to decipher the first one.

The condition for his loving his ex-wife was for him to absolve her from the guilt of having cheated on him. One way to do was to reject that aspect of his ex-wife which had cheated and only remember the part that he had loved till that Christmas day. And this rejection was being practiced against the girl K from whom he had recently separated from. In the dream he was making K, the innocent one ,as the culprit, who had done nothing wrong to him, in order to salvage his love for his ex-wife.

Patient told me that he meets his ex-wife many times a week to pick up or drop off their son and though he still finds her extremely beautiful, he no longer feels any love for her.  But, he added, in the dream it is another matter. Perhaps his pride goes to sleep allowing him to forgive her and to love her with all his heart the way he had done once upon a time.

Paranoid Illness changing into Bipolar Disorder

A woman in her early forties came to her monthly session, primarily to get her medications for she does not like to talk about herself or her illness, and complained that she is once again in her down mood.

"It started a week ago and it is so bad that my son - the only one who still lives at home - left the house. To add insult to injury I flipped my finger at him as he was leaving, which is insane. For the poor boy had done nothing wrong.  All week long I had been on his case. It is good he left on his own because last night given my nasty mood I could have physically kicked his ass out. When I am in that down mood I want nobody around. My son called me this morning to ask if it was safe to return. Thank God he is not upset because he knew it was my mood and not me which was making me behave like that. What lies behind such nastiness of mood?"

Patient denied that anything triggers it. With no leads to go upon as to why she went nasty the session shifted into talking the next thing that was bothering her. It was her anger at her mother. Patient could not be more angry, "She has chest pain but refuses to go to a doctor, treating herself with cold water and aspirin. I am afraid she will die just like my father did."

It too had started a week ago. What came first her worrying about the mother and getting angry over it or her nasty mood.

Patient first claimed that they had started simultaneously but then after being forced to carefully examine had to admit that mother's chest pain had begun a few days earlier. She also recalled that when her anger towards mother could not be contained it was only then some of it had escaped control and despite her best intentions to not do so had begun to get displaced upon her son.

"Why did you think that she will die just like your father?"

"Yes, that is my fear. All I can think of is that she is going to die like my father did. It was traumatic seeing my father die in 2009. He had clogged arteries, just like my mother has."

"Did your mood swings start when your father died?"

"No. His illness and death did not affect me quite that way. I did not get upset. I did not care for him that much. He was not around. For that matter my mother was not around either."

"Then what started the bad moods?"

"The death of my grandmother in 2010. But in the beginning they were not bad moods. It began as a slowly emerging conviction the house in which she had lived and died was haunted. I missed my grandmother very much. She was my real mother. My father and my mother were never really available to me. After her death I started hearing her voice and could feel her presence. I was admitted to the hospital and diagnosed as paranoid schizophrenic because of those voices. They put me on a lot of Seroquel which was the only thing that could block out the hallucinations and allow me to sleep. Even now I am afraid to go off the Seroquel despite your warning that it is making me fat and may cause me diabetes, because I am afraid of the return of the voices.  When I came back from hospital I moved out of my grandmother's house. But her presence followed me to the new house."

"When did the mood swings start?"

"They came gradually. As my fear of my grandmother's presence hovering over me decreased the mood swings started. They are always accompanied by anger towards my mother."

"You became sick after your grandmother's death, but your anger is always directed towards your mother, why is that?"

"Because I think I have a big time grudge against my mother. I loved my grandmother but hated my mother."

"Why you hated your mother?"

"Because she favored my brother over me. He was my half-brother. She preferred him over me, because his father was not around, while mine was,  and she felt he deserved special treatment because of that."

This patient's illness which started as paranoid schizophrenia shows no trace of it now. She is quite warm and social in her interactions when she is not in her down mood. This transformation occurred when she could allow her rage to emerge against her mother. This happened after the death of her grandmother. Prior to that her loving relationship with her grandmother kept her rage bound. Once her grandmother died her rage emerged unchecked and could only be contained through developing a paranoid projection . She started hearing voices that kept her rage from being acted out.  

Once the rage could be expressed against others - the latest being her son - it did not have to be projected and come against her in forms of voices. However since she could not be permanently in a state of rage her psyche developed bipolarity. A time was allotted to be in rage and a time to be nice and good to other people.

A transference dream

A patient of mine who has been with me for more than two decades and treats me with great familiarity and friendliness, came for his biweekly session and said I had this hilarious dream from which I woke up laughing, because it is something that could never happen in real life.

The dream is about you. I come to the office at our usual time. But the location of your office has changed. It is not this old ranch building - not that anything is wrong with it, I love your place -  but  a magnificent high rise, all glass and beautiful. The staff has changed too. They are young, spiffy and professionally dressed, not like how your staff dresses so casually.  But what is funny is that they are not one bit friendly.  In fact they are nasty and hostile. They ask me who I was, and do I really have an appointment. I tell them what are you talking. I have been seeing Dr. Kelwala for 22 years, and you all should know I come here every other Friday at 11 or 11.30 am. 

I at once knew that it was an expression of hostility towards me that was being "projected" into my being hostile towards him though I was being represented by my staff.

When I told the patient that perhaps behind accusing my staff as being nasty and hostile it is me who he is accusing of being nasty and hostile, he said that that is impossible for he respects me too much. Then he suddenly remembered another section of the dream which confirmed that the interpretation was in the ballpark.  

"A part of the dream that I had forgotten now comes back to me. While I am being blown off by your staff you come out of your office and say that my appointment is at 8.30 pm. And I woke up laughing aloud as to how you could be so ridiculous, for you never see patients that late in the evening. 

"That I don't even know as to what time I see my patients, is it an expression of contempt ?" I asked him.

The patient protested that in no way he can be contemptuous towards me for he respects me too much but then immediately confirmed the accuracy of the interpretation by stating that recently he has been talking big-time in his sleep, and waking out out of his dreams laughing. For example the other day "I woke out of a dream laughing because I was calling my Dad you son-of-a-bitch, you crazy man. Which is  surprising for I never ever said anything like that to him when he was alive."

"Calling your father son-of-a-bitch and telling me that I don't even know the timing of my own office hours appear to have the same origin: contempt for authority/father figures. Where is the contempt coming from?"

"I dreamt the dream this morning, a few hours before coming for the therapy session. Around 8.30 a.m to be exact for I looked at the clock on waking out of the dream. I had run out of my Suboxone and Xanax couple of days ago, because I had been taking them more than the prescribed dosage. I was withdrawing and feeling nasty and could not wait for 11.30 to arrive when I could see you and get new prescriptions. Then I dozed off and had the dream. Now you know how you get mad when I take too much of these medicines and have at times refused to refill them or told your staff to not call them in if I have demanded them on phone if they are not due. So I always have this fear when I take too much of these medications that you will not refill the prescriptions or the appointment will get cancelled or you will fill them but not right away."

So his fear of that I may not refill his prescriptions which will prolong his withdrawal symptoms was making him think of all kinds of insulting thoughts towards me.

"Why the building was tall and magnificent?"

"It was eight stories high too!" the patient added

"Why eight?"

"It has to do with the 8 mg. of Suboxone tablets. I was craving for them and if only I could have gotten the 2 mg. tablet [Suboxone comes in two strengths 2 and 8 mg.] it would have eased the suffering. But 8 mg. would have been ideal. So I was granting you an eight stories high office building instead of this modest ranch of yours if you would prescribe me that dosage right away."

The magnificent office and professional looking neatly dressed staff were expressing two other concepts which were diametrically opposite to each other. On one hand it was an attempt to exalt my position. If only I would fill his prescription without any problem he would value me as a real upper class doctor whose office    was in a magnificent high rise building with professionally dressed staff instead of the humble office in which I see patients and the unpretentious staff who work for me. On the other hand it was an expression of contempt that given your humble office and even humbler staff and the fact that you don't even know your own hours of practice you better not make me wait for my prescriptions. And the dream was expressing this contempt by showing the offices of the more magnificent doctors with their sparkling glass offices.