A dream of a self divided against itself

A 24-year-old man who complained of an inability to focus, problems at work because of his tendency to daydream, and chronic moderate depression, was put on Zoloft (Sertraline) 25 mg. He discontinued it after 3 days on the grounds that it clouded his mind. Instead, on his next visit, he requested Adderall (dextroamphetamine) for his attention problems.

Adderall immediately improved his work performance and mood, but he began having, as he put it, very strange dreams. They were violent in nature and intensely vivid.

The way he narrated all this gave the impression that the unconscious conflicts that were responsible for his depression and for dividing his attention were now emerging in violent dreams and as a direct consequence of Adderall-induced redistribution of his mental energies (cathexis). Perhaps Adderall's dopamine enhancing properties were boosting the pleasure (feeling of reward) in whatever tasks he was doing during the day and because of that his attention was focused upon it undivided; instead of getting diverted into daydreams through which his intrapsychic conflicts were indirectly presenting themselves to his consciousness. But this reconfiguration of mental forces due to Adderall was getting reversed at night, when with effects of Adderall gone his unconscious conflicts, gaining cathexis (charge) from lying fallow all through the day, were emerging with greater vigor, forming vivid and violent dreams.

When asked to give an example of his "strange, violent and vivid dreams" he narrated the following which he added he had dreamt two or three times since he was put on Adderall. 

Three guys are doing a hold up at a McDonald's. Two of them approach the counter while the third one waits at the door. Then the guy at the door shoots one of the two at the counter.  The head splatters,  blood and gore fly all over the place. The scene is still so vivid in my mind. In fact the whole dream was incredibly vivid. Strangely I did not panic or feel any other negative emotions despite the vividness of the violence.

"Who were the three guys?"

"They were thin and tall with shaved heads like myself, that is all I can say about them."

"Well you do not have shaved head, though your hair are pretty short."

"Those three guys had hair like mine - shaved or short whatever you prefer. I shave my head whenever my hair grows to any measurable length. Those three guys had hair like myself and they looked thin and tall like myself."

I looked at his physical dimensions and had to agree he was thin and tall.

"Were those three people yourself?"

"I never thought of it like that. But they were remarkably like each other, so what you are saying makes some sense. But I was there too, watching them, so I couldn't be them."

"You could be watching yourself in the dream.

"Anything else about the three guys, any other association, or detail in the dream itself,  that comes to your mind about them?"

"Two of them are wearing thin rimmed glasses. The third one is not."

"Why two of them are wearing glasses? You don't wear glasses. Why do the glasses come into the dream?"

"That is interesting. I know someone who wore glasses like that in my elementary school. We were very close. I haven't seen him in 10 years. Strange that he suddenly popped up in my dream. But yes those are his glasses and he shaved his head too."

"He shaved his head in elementary school?!"


"No, in middle school."

"Did you shave your head then too?"

"No, not then. He did, but not me. I started shaving my head after my grandmother came down with cancer and lost her hair to chemotherapy. I don't know why I did it. But when she died I shaved my head. And ever since I have keep my hair short."

Based upon the background knowledge I had of him I made the following conjecture,"You shaved your head because you felt guilty about your grandmother's plight. You blamed yourself for it and tried to subject yourself to the same misfortune that had struck her. It was making of amends in the way unconscious thought processes do. It is a form of mourning for losing an "ambivalently" loved person. You feel somehow you are responsible for their suffering and death and subject yourself to same torture that they experienced in the process of dying. You identify with people who are suffering and take on their problems as your own as if to compensate for what you assume you have caused them. Of course you had no choice over developing cancer, and certainly you would not have gone that far, but cutting your hair off was something you could sacrifice without too much trouble.*"

The patient did not quite follow my explanation but added, " I shave my head because it saves me 15 dollars each time I do not go to the barber. Punishing myself for my grandmother's cancer I don't know if that is true or not. But I did feel quite bummed out about it as if I should have done something to prevent it from happening."

"Since you have a tendency to do yourself what you do to others, is it possible that in that holdup there was intent to shoot someone, but before you did that your conscience - as one of the guys - shot yourself as the other guy?"

"Whoa that is deep. But there was no intention to shoot anybody during the holdup."

"There is gun in the dream and somebody is shot violently, so the intent to brutally kill someone was there in the latent dream-thoughts all along. All we have to explain is as to why instead of shooting the person who you were robbing - by making him show resistance, which would have provided the motive for killing him - you make one of the partners in crime shoot another which on face makes no sense. But it would make sense if we assume that you had ambivalence about shooting the person who you went to rob and kill and who in your unconscious is equated with McDonald's

"And if the three guys are different aspect of yourself then one one part of yourself, your conscience, the moral part, is shooting the other part, the murderous part.

"And as to who this person is who you want to rob and shoot we may be able to decipher if we figure out as to why the holdup was at McDonald's rather than a bank or convenience store. Any association to McDonald's?"


"My mother would not let us eat at McDonald's. We were not allowed to eat fast food as kids. So for a while when I could do it without anybody telling me what I could or could not eat I was eating at the McDonald's all the time. Actually for good three years that was my favorite food joint, at times I may have eaten breakfast, lunch and dinner there on the same day.

"So McDonald's is somehow connected with your mother.  You ate at McDonald's all the time to make up for the love your mother did not give enough of?"

"No, I never felt that way. Nor did my brother, who is four years younger than me, but my father may have felt that way."

"Why your father?"

"She cheated on him. He forgave her. But was depressed about it all the time. Finally she left him for the same guy that she had been cheating on him for 10 years, and for a while my father was very depressed; and tried to kill himself."

"So are your going to the McDonald's to shoot your mother, or her boyfriend, perhaps both to avenge your father?"

[I did not tell this to the patient but thoughts arose in my mind that the situation was identical to what Hamlet had faced when his mother had affair with his father's brother which resulted in his father's death, and he was faced with the dilemma of killing his mother and her mother's lover, but his conscience did not permit it since he was guilty of the same impulse that his mother's lover harbored, and he ended up killing a whole slew of people and finally himself instead of straightaway putting his mother and her lover to death. In my patient's case too instead of straightaway taking revenge upon his mother and her lover, who had made his father suicidal, he had in the dream chosen to kill himself and his childhood friend. In Hamlet too, Hamlet's two childhood friends meet the same fate as himself - death.]  

"The three guys went to the McDonald's to rob not to kill anybody. But who knows. You are the doctor you know better than me what goes on in my head."

"Now if McDonald's symbolizes your mother then it makes sense to rob her. During our first phase of sexuality, which reaches its peak around 4 to 5 years of age, there are sexual impulses towards the mother which is often felt as an impulse to rob her and which is tantamount to taking away from the  father something that  belongs to him**. So under the layer of going to McDonald's and shooting someone who symbolized your mother and her lover, there is another, and more ancient layer, of robbing your father of his wife for the satisfaction of your own love impulses. Which makes your guilt doubly strong, and leads to your shooting yourself for having such evil thoughts."

This piece of analysis did not quite make sense to the patient and in reality was conveyed to him quite partially, not in quite the same words, and was actually fully formulated while writing it now. But he did hint at its possible correctness by stating, "I never thought that my robbing of McDonald could be symbolic of my robbing my mother. But all my life I have felt as if she stole something from me." This feeling of having been robbed by her was projection of his own unconscious impulses to rob her***.

I asked the patient,"When did your mother leave your father?"

"When I was 19."

"When did you start eating at McDonald's morning, noon and night?"

"When I was 19."

So these revenge fantasies were there in his unconscious draining his energies and causing depression and robbing his focus and causing his attention deficit for five years but only when he was put on Adderall did they gain enough cathexis to get a foothold in his consciousness and that too in dream and not waking consciousness using the crutches of weirdness (dream distortion) and disguise (dream displacement). It was no doubt the intensity of his violent wishes that had kept them buried for so long, and only when he entered treatment and received the chemical boost from the amphetamine, that he could allow them to emerge in his sleep, when the muscular paralysis made sure that they could not be acted out.

The two details of the dream which were not analyzed but constructed by me needs a few comments. The two guys were wearing thin rimmed glasses and one was not. And it was one of the glass- wearing guys who shot the one who had no glasses. The one who was shot was himself and the one who was wearing glasses was his friend symbolizing his conscience. The friend was imported in to the dream to make a distinction between that part of himself which was connected to his conscience from the part which harbored revengeful impulses.

His comment that he did not panic and felt no emotions was triumph of the wish fulfillment. Such a violent and gruesome action could be enacted without feeling fear and other negative emotions because they were being enacted in the dream-pictures against his own self. Perhaps the glasses with their function of seeing more clearly symbolized the conscience.

Footnotes:

* One recalls here how Hindus shave their hair as an expression of mourning when one's parent dies. Since hair serves as an excellent symbol of penis one wonders if the cutting of hair in mourning symbolizes the following train of thought: since my phallic sexual impulses generated the wish for sex with my mother and death of my father, as well as sexual wishes for my father and death of my mother (negative Oedipal Complex), and now that the wish has come true, I must symbolically castrate myself by shaving off my hair.
In olden days Brahmins keep their head permanently shaved as if to symbolize that due to their unusually strong sexual drive, which consequently emerged with the most violent force during the oedipal phase, they have to live their entire life under the weight of the oedipal guilt. Only through the aid of a very strong oedipal guilt could they control the strength of their genital impulse, preventing it from regressively flowing into neuroses and perversions.
It is interesting as to how the Brahmins leave a small strand of hair at the back of the head like a thin ponytail - their choti - reminiscent of how the Mohawk Indians shaved their heads but for a thin strip of hair. Perhaps this hair ritual gives expression to the following train of thoughts: Under the pressure of Oedipal guilt  I have self castrated myself in most spheres of my life. Only a narrow band of direct sexual expression is left for me, rest of it restricted to aim-inhibited modes of discharge.  It may not be too far fetched to conjecture that the prohibition of cutting hair in Jews - a practice which Muslims and Sikhs plagiarized for their religions  - may be expression of this psychological complex but in reverse.

 
** Much of bank robbery, forgery, con games, cheating in money transactions,  and other forms of sociopathy in human affairs, originate from this impulse  - from the oedipal phase - to rob the mother and father too - because whether the mother belongs to oneself or the father is in dispute in child's mind.

*** In women the obsession to rob the mother for having robbed something from oneself lies at the heart of shop-lifting.

Fear as the driving force behind an 8 year old boy's ADHD

An eight-year-old boy, his older sister, his mother, and I went out to look at some foreclosed homes. I was going to buy one as an investment property, and she was going to rent it if we found one which suited her needs and her budget, and the purchase price of which was within my investment comfort zone.

I was really enjoying the boy's high spirits, his rushing out of the car to be the first to climb up the porch steps of the houses, his patter about how he wants a place that has second floor so he can climb up and down, and a bathroom that has shiny black toilet as he had seen on a TV show, a fireplace, and all the other cool things that his friends' houses had.

The mother declared him to be a child who gets into everything but told me to diagnose him less as an  ADHD and more as an Irish child: "they must stick their nose into everything."

Now we were driving from one house to another without a Realtor, who could open the lockbox with the code and show us the houses from inside. We had printed out a list of foreclosed homes from the Internet and were assessing their worth from the outside and by looking through the windows. Though most of the houses had some window latch somewhere not properly secured, or a sliding back door that could be slid open, or a main entrance that despite the lockbox hanging from the doorknob could just be pushed open, and the mother, endowed with the same Irish genes as the son, would with an uncanny ability manage to find and stick her nose into these deviant openings , and voila we would be inside, free to explore the in and out of the house.

But what really caught my attention about that child was that the last house that we went to see that  afternoon, instead of rushing out as he had done earlier, he refused to come out altogether on grounds that somebody was inside the house.

The mother said that is nonsense. The house is bank owned, and foreclosed, so nobody could be inside.

But when the son could not be persuaded to leave the car, the rest of us decided to go inside the house without him.  However, when we climbed up the porch steps and peeked through the stained glass panes, lo and behold, there was somebody inside.The house indeed was occupied. We rushed down the three steps,  ran over the grass and quickly got in to the car so we do not get subjected to rude shooing off for trespassing. The mother had not done her homework right. The house was not in foreclosure but in short sale.

The mother asked the child how in the world did he know the house was occupied.

"Because the smoke was coming out of chimney,' the boy replied.

"And what does that mean?"

"It means that either the furnace is on or somebody is drying his clothes in the dryer."

So this hyperactive boy was constantly scanning the environment wherever he went making lightening fast deductions whether it was safe to go ahead with his exploratory urges or take to his heels.

 Later we went to a restaurant to eat and once again he was observing everything. As we waited for the waiter to bring out the food,  the boy remarked that there is a gold record of some singer mounted on a plaque inside a glass case on the wall next to the cash register. He wanted very badly to examine it at close quarters, but could not be persuaded to do so.

The mother remarked Zach has grown now. Before he would have rushed to it physically. But now he is afraid to do so.

And I wondered if the boy was very high spirited and full of observations to fulfill a bundle of inborn (genetically determined) needs and since they all had to be satisfied in a limited time he was rushing from one thing to another and which was behind his ADHD.

But the mother said no, that cannot be entirely true. Because Zach, if you encourage him, or if he is genuinely interested in something, he can sit on it for a long time without getting distracted.

So despite having all these needs to be fulfilled, all clamoring for expression, and all wanting exploration of the environment for the objects of their desire, the boy could stay and concentrate on something if he was given proper encouragement (output of dopamine generated through pleasure experienced due to parental appreciation?) or through his own intrinsic enjoyment of it (self generated dopamine?).

I asked the mother then what is the cause of his ADHD.

And she said his exploratory urges have been prematurely blocked by a frightening world. It is the fear of getting into trouble with grown ups [with their superior power/authority] that keeps him going from one exploratory behavior to another. If you are exploring something and get yelled at, and a fear arises in you that you will get into trouble doing that, then at the slightest hint of somebody coming after you makes you give up what you are doing and pick up something else to explore.

And now my child instead of rushing into whatever interests him [out of fear of everything and everybody] first scans the environment to locate all the possible sources of danger and if he sees any, quickly abandons that avenue of exploration and moves on to the next. Only if I am around to encourage him to continue exploring which implies that I will be at his side to deal with the danger, or if the exploratory behavior has high dividends such as when he is playing sports, that he continues his activity without bolting to another.

And I wondered if both these factors: presence of the mother while he is doing his exploratory behavior and big rewards that he obtains from sports and other activities that he enjoys improve his attention via the medium of higher dopamine secretion.

Reversal of letters in a dyslexic boy a manifestation of opposition/defiance

A woman in her late thirties came to the session and flat out declared herself to be a borderline personality,  in treatment since age of 9, and having been tried on every psychiatric medication under the sun.

When asked why she was borderline she replied, "Besides that I am also bipolar, schizoaffective, obsessive-compulsive, ADHD, in short a pain in the ass, and therefore psychiatrists [pejoratively] find me borderline. When they do not know what to make of you they call you Borderline."

"Why are you a pain in the ass?"

"Because I fight with everybody."

"And why do you fight with everybody?"

"Because I always have to be in opposition."

Then she added that her two children, and they are the same way. They oppose everything too. Though they have different styles. The older does by having emotional meltdowns. Slightest thing can spark a major upheaval in him and then everything around has to come to a halt. So he stops everything and everybody by overreacting emotionally. The younger one, his oppositionalism, is expressed through his refusal to cooperate with learning. I even think that his tendency to write letters and numbers backward is just an extension of this stubbornness. He must do everything in  reverse of what is expected of him.

And I wondered how much of dyslexic tendencies in children is initiated and maintained by this oppositionalism, perhaps an expression of grudge against parents or simply as a symbolic manifestation of one's life agenda being at loggerheads with that of the world's.

8/16/2014

Last week I came across a dream the analysis of which further confirms that much of dyslexia arises from an opposition existing between one's agenda versus society's.

A woman who is now in her forties, who had a traumatic upbringing, where both of the parents were more interested in their own agendas than that of their two daughters, divorcing when the latter were 10 and 12, going their own ways, bringing step-children in to their respective houses, to which the daughters were shuttled back and forth, sometimes wanted, when they could be used to do chores or to get even with the other parent, sometimes despised, when they came in their way, often beaten, sometimes even boxed, to keep them in line, and who naturally harbored great grudges towards the parents, brought in the following dream, a year after her mother's death.

It is a very short dream. I would call it snap of a dream. For all it shows is my mother. She looks so pretty. The whole dream is like white. For there is a beautiful white silk gown that she is wearing. And my baby, who I lost,  is in her arms, held inside a white blanket, like they use for christening, as if he was being accepted in Kingdom of Heaven and becoming alive again. Everything about the dream is white except for a red ribbon that is over the blanket like a bow, and the natural colors of my mother's hair and face. Which enhance her beauty. 

She is getting prettier and prettier with each new dream, ever since she died. 

Patient added that the dream is refusing to go out of her mind and expressed surprise how can one single dream image affect a person so much. "I am trying to keep doing everything else to forget the image but cannot. Ever since the dream I have been crying, remembering my mother, and the baby I lost." 

Since the patient is familiar with the technique of dream interpretation I asked her without any preliminaries, "What sparked the dream?"

"The dream occurred on Sunday afternoon, while, after an exhausting night, in which I was awake for the most part, I fell asleep. In the morning my husband had come from his bedroom to mine, to lie next to me, and we talked and talked, like we have not done in years, for four full hours, at the end of which I nodded off and had the dream."

"What was the conversation about?"

"Everything under the sun. It was the frankest discussion we ever had. Things that we never ever bring up. Things no other couple would bring up, like mortality rates, life insurance, my mother's death last year. She was just 63. My grandfather died when he was 42, my grandmother's in her fifties. So I told him I won't be living for too long. And he better start getting serious about my funeral. At most I will live for another decade." She said half as a joke, half because of actual fear that she may die early like her mother.

"So the dream was sparked by the fear of your own death. But instead of your own death you saw the death of your mother, and to compensate her for thinking of her death, your shrouded her with the most beautiful white gown. White generally symbolizes death. Why the gown was silky?"

"My mother loved silk. My favorite image of her is in her wearing silk gown."

"Why is the baby in white blanket?"

"So he can be christened and be eligible to enter heaven and be with my mother. White stands for purity. He is pure and it was not his fault that he was subjected to abortion. He should be living in heaven." The patient began to cry.

"Why your mother has everything about her white?

"It symbolizes purity. Absence of evil. When I had the abortion they were real nasty about it. Just pushed me in to it. I don't think they gave anesthesia properly. The whole thing was so painful. But there was a nurse. She was wearing a white sweater. She was very kind. And talked to me throughout the procedure. She behaved to me how my mother should have behaved. The white of the dream is taken from the white of that sweater."

"What is the meaning of the red bow?"

"Yes, why couldn't it be blue, pink or another color? It had to be red." The patient exclaimed in anger. 

"Why? What does red mean?

"It means blood  It means murder.  It means abortion. The abortion, which I did not want. It was the most painful thing I ever experienced. I never got over it. I never will. My mother forced me to do it. I could not do anything about it, because I was living with her. That time Arthur was just an year old. I was already separated from his father and my mother did not want another child. I was barely twenty, and could not stand up for myself." 

"So the dream was sparked by the wish for death, which quickly changed into fear of death, and wishing that upon your mother, or rather contemplating about her death - though making up for it by making her most beautiful and living in heaven - to shift away the fear of your own death, and then the wish was countered by the thought that you cannot afford to die yet, because you have to reverse that abortion and make that baby alive again. In the dream you are succeeding in doing so, according him christening in heaven."

"Yes. Since my mother died I think that the baby I lost, he is now in heaven with my mother."

"Why is your mother becoming prettier and prettier with every new dream?"

"Because she was real ugly to me in my real life. She was selfish and did not think twice before having an affair which broke the marriage and tore the family apart. But she was beautiful too. She had lovely face and lovely hair. That is what comes in the dream without being converted into white. Because they do not need changing. Rest of her I want to change and make her into how my mother should have been. Now that she has died. I am mourning for her and changing her into Madonna - pure white, holding my baby like Jesus, instead of sending him to death.

"And now I realize why for the last three days I am doing everything backwards. I am writing orders backwards, dropping 'n's or 'g"s at end of the words, reversing my letters, even writing whole words backwards, turning into a new Leonardo Da Vinci, with all my childhood dyslexia coming back. Soon I will be using a white-out more than the pen. And I know it is happening to reverse that abortion. I am surprised I am not writing down-upwards, given how I hate my mother for forcing me to do what I did."

Distractibility of ADHD is a reflection of anxiety/fear

A young man in his early twenties came to my office for Adderall to help him concentrate upon his studies. When asked how Adderall would help him, he claimed he has ADHD which causes him to be distracted by anything and everything.
He declared himself to be an anxious individual who has to constantly worry about disaster striking upon all different aspects of his life and so his mind is busy putting out fires everywhere to pay attention to what is happening right in front of him. The only thing that stops his trying to be in 10 different places at the same time is marijuana. But its effects last only for an hour or so and then he feels tired, bored, and sleepy, so it does not help him with his studies, and he was hoping that Adderall would be able to help him concentrate for longer periods.
But what has prompted me to write this blog is a statement which he made which got me thinking whether the tendency of ADHD children to immediately pay attention to whatever noise or activity is occurring around them rather than the lesson that is being taught in the classroom itself is not an attempt to avert imaginary disasters.
The patient stated that any conversation happening around him immediately shifts his attention to what is being said there rather than what the teacher is saying. "If somebody is talking about going to the zoo then my mind is there in the zoo with them. If I hear some noise from the ceiling then I am thinking about some animal is hiding there. In fact, I cannot sleep soundly at night because every noise startles me into thinking that thieves are about to break in and enter. Anything and everything that is happening around me gets me immersed in that instead of just filtering it out and focusing upon reading."
So his distractibility was no different than how an anxious mind keeps thinking of all the situations where harm could come to oneself or those who are dear to one. And just like how this fear of harm coming to oneself or one's loved ones leads one to undertake protective obsessive rituals the shifting of attention from what the lecturer is saying to the distracting talk or noise is also done to take some action to prevent harm. His ADHD was based upon a mind-set that was constantly anticipating harm and constantly working upon its prevention. And every distraction was used as a convenient excuse to project upon one's fear upon that and then search for actions to protect whoever was being endangered. For example, when he heard somebody talking about going to zoo his mind was seeing that person getting endangered by some animal there and then his attention had to be focused upon imagining himself with that person in the zoo protecting him from animal attacks.
Another patient, a woman in her thirties, claimed that she has ADHD because she has to be on the go go go all the time. "I have to be doing things for others because I am afraid they will not do it right. With my children, I am finishing their sentences for them. Poor babies. They cannot speak for themselves because I take over for them."
  The analysis showed she was projecting her own fears of not doing things right upon her children and then doing the job correctly for them.

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.

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.