A man in his mid-fifties who has suffered from Paranoid Schizophrenia since his teenage years came to the session and requested that I raise his Loxapine from 150 to 200 mg.- for he is unable to sleep at night. He cannot fall asleep till 3, sometimes even 4, and to make matters worse he is unable to sleep beyond 7 am, leaving him irritable and feeling out of control for most of the day.
The patient could give no real reason for the decompensation. But when asked if anything has happened which disturbed him, he reluctantly admitted that two people in his church passed away, but he is not sure if something like that could have bothered him to this extent. "They were not that close to me. One was a 60 year old woman, a friend of my sister, but who I knew from 1975, when we were in high school. The other was an 80 year old man, a retired pastor and his wife is so tiny, like those small people you see on TV, a dwarf, but awfully nice and pleasant woman. But I have a wife at home."
The non sequitur last sentence perked up my ears. And I had no choice but to deduce that "I have a wife at home" emerged at that point to block the full realization of his strong attraction towards that diminutive lady.
Based upon some other associations especially regarding his father, also a retired pastor, when it was suggested that the death of the 80 year old pastor is causing a vicarious satisfaction of his death wishes towards his own father - arising from brutal treatment he and his mother had received from the father while growing up - and the guilt over it was keeping him awake, the patient rejected the construction.
"These two people's death could not have disturbed me that much," he got defensive.
But he immediately remembered a dream that he had seen a few days after the death of those two.
The dream was short: Jesus comes to my house and asks me how I am doing. And tells me that when you die you will go to heaven. I tell Him that I am not ready to die. He says don't worry about it. Your time is not up yet.
The dream was interpreted on the following lines. That since he took responsibility for the death of the pastor and her sister's friend, he deserved punishment. In the dream the wish for punishment had been fulfilled according to the law of talion - eye for an eye - and he had died and was meeting his Maker. However, the wish to continue living was making its presence felt as well. And so instead of his going to heaven to meet his Maker, his Maker was coming to him and far from declaring that he was dead was actually assuring him that his time was not up yet. Further assurance that on death he will go to heaven was to nullify his fear of going to hell for causing the death of those two church people. Patient had grown up listening to fire and brimstone sermons from his pastor father.
At this interpretation, which the patient fully agreed with, led him to confess that he lied when he said that the death of those two people had nothing to do with his insomnia. In fact he is unable to sleep because he is having racing thoughts ever since their death. But strangely they are exclusively about his wife 's death and not theirs.
"My racing thoughts are all about my wife's funeral and what will happen to me if she dies. I am already mourning for her death. I was doing the same once before in the 1990's when the psychiatrist who I was seeing then said there is a psychological term for mourning for somebody's death even before they die. He told me the exact word, but it was such a mouthful that I assumed it was not meant for the patients to remember it."
"Is it possible that behind the advanced mourning for your wife's death lies the wish for her to actually die so you can be free to marry that tiny wife of the pastor?" I could make that construction because I knew how much that patient, who is over 300 pounds, is attracted towards petite women.
"What an idea." The patient protested. This was expected as he is a very religious man and being unfaithful is out of question for his conscious mind. But he indirectly confirmed the accuracy of the interpretation by stating "it is strange that recently my wife cannot cuddle up enough to me, as if she is afraid I will leave her," and added "I must say that I feel very sorry for that little woman, who is in her fifties, and already a widow. I always felt sorry for her for being just 54 and married to that 80 year old man. But that is my nature, I get easily attached to people who are suffering."
The patient could give no real reason for the decompensation. But when asked if anything has happened which disturbed him, he reluctantly admitted that two people in his church passed away, but he is not sure if something like that could have bothered him to this extent. "They were not that close to me. One was a 60 year old woman, a friend of my sister, but who I knew from 1975, when we were in high school. The other was an 80 year old man, a retired pastor and his wife is so tiny, like those small people you see on TV, a dwarf, but awfully nice and pleasant woman. But I have a wife at home."
The non sequitur last sentence perked up my ears. And I had no choice but to deduce that "I have a wife at home" emerged at that point to block the full realization of his strong attraction towards that diminutive lady.
Based upon some other associations especially regarding his father, also a retired pastor, when it was suggested that the death of the 80 year old pastor is causing a vicarious satisfaction of his death wishes towards his own father - arising from brutal treatment he and his mother had received from the father while growing up - and the guilt over it was keeping him awake, the patient rejected the construction.
"These two people's death could not have disturbed me that much," he got defensive.
But he immediately remembered a dream that he had seen a few days after the death of those two.
The dream was short: Jesus comes to my house and asks me how I am doing. And tells me that when you die you will go to heaven. I tell Him that I am not ready to die. He says don't worry about it. Your time is not up yet.
The dream was interpreted on the following lines. That since he took responsibility for the death of the pastor and her sister's friend, he deserved punishment. In the dream the wish for punishment had been fulfilled according to the law of talion - eye for an eye - and he had died and was meeting his Maker. However, the wish to continue living was making its presence felt as well. And so instead of his going to heaven to meet his Maker, his Maker was coming to him and far from declaring that he was dead was actually assuring him that his time was not up yet. Further assurance that on death he will go to heaven was to nullify his fear of going to hell for causing the death of those two church people. Patient had grown up listening to fire and brimstone sermons from his pastor father.
At this interpretation, which the patient fully agreed with, led him to confess that he lied when he said that the death of those two people had nothing to do with his insomnia. In fact he is unable to sleep because he is having racing thoughts ever since their death. But strangely they are exclusively about his wife 's death and not theirs.
"My racing thoughts are all about my wife's funeral and what will happen to me if she dies. I am already mourning for her death. I was doing the same once before in the 1990's when the psychiatrist who I was seeing then said there is a psychological term for mourning for somebody's death even before they die. He told me the exact word, but it was such a mouthful that I assumed it was not meant for the patients to remember it."
"Is it possible that behind the advanced mourning for your wife's death lies the wish for her to actually die so you can be free to marry that tiny wife of the pastor?" I could make that construction because I knew how much that patient, who is over 300 pounds, is attracted towards petite women.
"What an idea." The patient protested. This was expected as he is a very religious man and being unfaithful is out of question for his conscious mind. But he indirectly confirmed the accuracy of the interpretation by stating "it is strange that recently my wife cannot cuddle up enough to me, as if she is afraid I will leave her," and added "I must say that I feel very sorry for that little woman, who is in her fifties, and already a widow. I always felt sorry for her for being just 54 and married to that 80 year old man. But that is my nature, I get easily attached to people who are suffering."
