A psychological theory to explain rise of sugar, lipids and triglycerides causing metabolic syndrome in chronically stressed

A long time back, when I was in my late thirties, Single, and somewhat of a hypochondriac -a common affliction in people in mid-life and still without wife and children - one day, feeling out of sorts, slightly nauseous and light-headed, I asked a nurse to check my blood pressure.
And lo and behold, instead of the usual 140/90 it came as 155/98. I could not believe that my body was betraying my mandate to always serve me without a fault, and I was instantly filled with anger, apprehension, vague forebodings, and a desire to go on a rampage.
The nurse told me to calm down and handed me a candy bar. On my expressing surprise - for wouldn't sugar worsen my emerging metabolic syndrome, hastening diabetes alongside the hypertension - she said, "No. Eat the candy. The sugar in it will bring down your blood pressure."
And she was right. In a matter of minutes the blood pressure returned to its baseline - 140/90.
The nurse explained that sugar made me feel good, which brought down the blood pressure. Sugar, according to her, works like a reward and when you eat sugar, or any food, but especially food that is loaded with calories, it makes you feel like an instant winner. Winning and getting rewarded is what life is all about and for eons of evolutionary years the reward was basically one of two things - food or sex. When you eat or finish having sex, you feel like you have reached your goal and are getting rewarded. This sends a signal to your brain to turn off "the strife mode", which brings down your blood pressure. As long as you are in a state of strife your blood pressure remains high, for your body is geared up for "fight or flight". But when you have a feeling that you are getting rewarded, the body relaxes and the blood pressure comes down.
The nurse set me thinking. And I began to notice that when I am stressed, or feeling anxious, or agitated, I do reach - sometimes even without paying attention - for food, and the eating does help the mood. If I receive bad news, or am gearing up for confrontation, for example like having to argue with an insurance company rep. over discharging a patient from hospital prematurely, or doing even such a minor stressful activity like dictating medical charts, I do feel tension, or pressure, or presence of something like a foreign object, in my chest. And eating a cookie, or sipping coffee, or eating hot salty harsh food like jelapeno chips, helps. In fact all the while I am masticating the food, and feeling its passage through the esophagus, I feel virtually no stress and my mind gets distracted away from whatever is bothering me into concentrating upon the pleasure arising from eating and swallowing.
So eating lowers stress and takes away depression and anxiety, at least in me, and perhaps in all those who can use this mode of gratification to block out painful emotions arising from adversities. The pleasure from eating blocks out the perception of pain arising from the stress as if our conscious mind can handle only one affective tone at a time.
People who are couch potatoes, and eat all day long, must suffer from subtle dysphoria, or even overt depression and anxiety, and much of their eating is not for nutritional reasons but to counter their depression, I reasoned.
I wondered too whether people who live stressful life - especially that had its beginnings in childhood, when pleasure from eating is most profound - overeat to handle stress, and thus get overweight, and develop diabetes, and other metabolic problems.
And is it possible that not just the process of eating that lowers the stress but a rise in blood sugar also plays a role in bringing down the stress?
If the latter is true as well such people may be pathologically seeking to keep their blood sugar at high levels to create a continuous source of pleasure. And in an attempt to keep high supply of sugar to their system is it possible that their body turns on genes that lower their basal metabolic rate, and gear up metabolic processes that start storing lipids and fats more than what is good for them, and all in order to have a readily available internal source of energy, in case food becomes scarce in the stressful and dangerous outside world.
How does this constant high level of sugar consumption affects the glycobiology of these people? The purpose of high levels of sugar is of course for it to be readily available not just in the blood but inside the cells, especially in muscle and brain cells, which must function at a higher level of activity in order to deal with stress. For it is with brain that we scan our surroundings for danger and make strategic multi-step planning in our neurons to combat the enemy, and it is with muscles that we fight or flee away from the enemy and keep it taut to prevent any foreign object penetrating through its shield.
This assumption that blood sugar quickly moves into intracellular space when under stress also may explain as to why anxious people, at least in their youth, often show hypoglycemic attacks that go as low as 40 mg/dl. Panic pumps insulin out of the pancreas to move the sugar rapidly into the intracellular space for quick burning to face the danger.
Could this constant moving of blood sugar into intracellular region to prepare the body for flight and fight finally leads to the development of insulin resistance to prevent excessive conversion of intracellular glucose to lipids and triglycerides?
The insulin resistance in diabetics perhaps results from the following sequence of events.

• High level of stress and anxiety, due to genetic predisposition and environmental stressors, especially childhood abuse and neglect.

• High sugar consumption to deal with this anxiety by keeping the body's flight or fight mechanism on high alert.

• Excessive insulin secretion to keep moving this sugar into intracellular region.

• Development of insulin resistance to prevent movement of sugar into intracellular region where it is getting converted to way too much lipids and triglycerides.

• Finally development of diabetes where there is high level of sugar in extracellular space while intracellular space is in sugar starvation.

The degeneration of various organs especially the nervous system, which exclusively uses sugar for its energy needs, occurs because of this intracellular sugar starvation.
Couple of additional points are worth taking up here.
Why does anxiety or stress cause lump in the throat, queasiness in the stomach, pressure on the chest?
Per my theory stress should activate the drive to search for food to raise blood sugar, but that does not explain the emergence of these physical symptoms in the upper GI tract.
Now it is not real hunger that primarily causes stress related eating. Eating is indulged in as a quick attempt to raise blood sugar but more so as a means to deny the magnitude of the stress. If one is eating then it gives a false signal to the mind that one is in a state of plenty and therefore there is no need to get too worked up and collapse altogether by overestimating the danger. Its mechanism is similar to addictive behavior. As long as one is indulging in addictive behavior all other realities of the world, including all sense of danger and worries, disappear. There is a psychologically adaptive mechanism in play here.
These physical sensations in throat, chest and stomach - almost like irritants - emerge not as much to invite eating - as an attempt to douse them with food - but because of an entirely different psychologically adaptive mechanism. They arise to give a sensation of there being a foreign body in the upper GI tract which must be got rid off; irritants that must be either doused with food or dug out from one's flesh with a counter-irritant.
From where does this sensation of the presence of a foreign body/irritant arise?
They owe their existence to anxiety -a somatic manifestation of anxiety. They are basically no different than other somatic processes of anxiety like irritation in lower GI tract causing different forms of colitis; irritation in bronchial tree causing allergic respiratory problems like asthma; irritation in the bladder with urinary frequency and in more extreme cases Interstitial cystitis; irritation in the sinus mucosa with secretion of tears and sinus fluids; irritation in the skin causing psychogenic pruritis; irritation in heart causing arrhythmias.
Why does anxiety causes these foci of somatic irritation?
If we turn to current psychiatry to get an answer as to why anxiety causes such somatic disturbances we find nothing. Yes, modern psychiatry does catalogue beautifully all manifestations of anxiety - plagiarized straight from Freud's earliest psychoanalytic writings, never crediting him - but gives no explanation as to why this happens. Actually current psychiatry despite its hoopla about being very biological and molecular based tells us nothing about soma and forget about psyche. All it does is to catalogue symptoms.
Now here I venture into a very far out hypothesis. Somatic anxiety, which is really not so much affect of anxiety but activation of mucosal tracts and surrounding tissues and muscles in various tracts of the body through which the interior of the body communicates with the outside world, is actually a psychological attempt by the mind to fight and do away with the agent that is causing the stress.
Before we evolved into humans anxiety/fear gave us two options: run away or fight. But by turning in to humans these two options have increasingly turned into non-options. In a civilized human society we have to stay our ground and deal with the agent of stress without running or attacking it. Animals also face this quandary, but not in such a regular fashion as humans. And when you have to deal with an enemy without the choice of making him disappear by running away or annihilating it, you are forced to use different strategies.
Creating somatic anxiety is one such strategy. The object [forces] that is causing the stress and from which one cannot run away or attack because of social restraints is as if "internalized" by the mind into one of the body tracts and the battle against it is waged there. It is "fight in displacement" which has psychological as well as biological/evolutionary roots.
The hated stressful object is as if swallowed inside one of the body tracts and the fight against is launched there. It the enemy is felt within the lower GI tract it is as if extruded into oblivion with the force of violent colitis. If it is in the urinary tract it is flushed out repeatedly. If it is in bronchial tree it is subjected to asthmatic choking by clamming up of the muscles. If it is in the skin it is treated as an irritating bug. In the upper GI tract it is treated as if it is a bad piece of food that was taken in by mistake and now either should be placated with sweet food and sent down the tract or burnt alive as with stomach acid using some harsh food or spirit such as particularly hot jalapeno or whiskey or thrown-up as vomit.
Here we are reminded of the phrases: eating someone alive, eating and spitting them out, burning in hell fire [of stomach acid].
The appearance of lump or heaviness in the chest is a recreation of the source of stress [the enemy] inside one's own body - in the GI tract - and then an attempt to destroy it there, because one cannot destroy it in the outside world. Granted it is not a real elimination of the enemy but a make-belief elimination done inside one's body and since it is make-belief, it keeps recurring as long as the external enemy exist, but it does give temporary relief. Preference for hot and spicy food over sugar is like using harsh tools against one's own flesh where the enemy is perceived to be launched.
This creation of enemy within one's system and then treating it as a foreign object and how it provokes secretion of steroids and activates body's immune responses and causes stress-induced autoimmune disorders are interesting fields of enquiry. Secretion of steroids in stress appears to be an attempt on part of the body to block body's immune response against one's own tissues that are being harnessed to play the role of foreign body.
A discussion about stress and rise of blood sugars and lipids cannot be ended without touching upon a puzzling clinical phenomena. Why do psychiatric medications raise blood sugar and worsen lipid profile?
This is an even more far fetched hypothesis but perhaps I am justified in putting it forward. Anti-psychotics and antidepressants at least partially work by raising the levels of carbohydrates and related compounds in the body. This is looked upon as an unwanted side effects of these medications. But perhaps it is more than side effect and may lie central to its therapeutic efficiency. After all the three most efficacious antipsychotics - Clozaril, Zyprexa and Seroquel - they all cause the greatest increase of blood sugar and lipids. In fact there seems to be a high correlation between greater disruption of carbohydrate metabolism and better antipsychotic efficacy. As if antipsychotic medication efficacy is dependent upon how much side effect they cause. A phenomena that was remarked upon by researchers when the first generation antipsychotics came into practice and it was noticed that therapeutic dose is often one that produces extrapyramidal symptoms. As if antipsychotics work by shifting the overactive dopamine activity from higher centers of the brain which do cognitive activities, and where madness lies, to lower centers which regulate autonomic activity including derivation of pleasure from eating and other body functions.
If there is indeed a psychotherapeutic angle to this rise in fat and sugar in body what could be the psychological factors that run parallel to the physical processes?
I speculate that a high storage of lipids and triglycerides and high blood sugar levels gives the patients a false sense of security and makes them stand up to their fears/stressors/enemies. For after all we were most secure on our mother's breast getting suckled by her sugar and fat laden milk. A rising levels of these "goodies" transports us back - even if in a very limited sense - to the days when we enjoyed the security of being one with our mothers through her breast, getting all our nutritional and love needs met without any effort.

Aggressive impulse at the root of easy distractability and multi-tasking

A 29 year old girl who came for Suboxone treatment reported that the reason she was addicted to Vicodin, and now kind of addicted to Suboxone, is because they attenuate her distractability. She claimed she can rarely keep her focus on a task long enough to complete it unless she is taking Vicodin or Suboxone. Every task undertaken, after sometime, is interfered by a creeping anxiety and premonition of disaster happening somewhere else, and her mind begins to search for some other project that she was supposed to do, and forgot, and which, if not immediately attended to, will cause problems and she abandons whatever she is doing to take up the new task. The cycle repeats itself with the new project, leading her to pick up yet another project, till there are so many open projects that she feels overwhelmed and gives up on all of them.
If she can't find something to do that has the potential to distract her in the outside world than she searches for pimples on her face and bursts them lest they grow too big and offensive and make her object of ridicule. When asked as to why others would they find the pimples offensive she said because they are ugly and it will invite them to attack her.
Now we know that Attention Deficit Disorder and Obsessional Neurosis are two sides of the same coin. The aggressive/destructive impulse, which these people are plagued with more than others, has to be suppressed and an impulse opposite in its intent [constructive in nature] has to be put in its place to keep the hostile impulse from getting hold of the motor apparatus. The hyperactivity of the ADHD child is a compromise formation between these two motor trends, to wit, destructive and constructive.
The easy distractability of ADHD patients is also a play between these two opposing impulses. The person is beseeched with an impulse to cause harm. This he suppresses with doing something constructive that will not only occupy his motor apparatus so the harmful impulse cannot take hold of motor movements, but also because by doing something constructive he hopes to please the person/s towards towards whom the destructive impulse was aimed at.
In this girl, the destructive impulses were directed towards her mother. In her conscious mind, she was completely unaware that she harbored extensive rage towards her mother.
Her mother was abused as a child, and had numerous mental problems herself, and she was mean towards her children. However, mother had also been in therapy all her life, and had taken the kids to her therapist to undo the damage her erratic and mean behavior was possibly doing to them. In these therapy sessions, the children had learnt not to hate their mother for her meanness on the rationalization that she was mentally ill. So the girl had learnt to not consciously feel angry towards her mother and also to believe that she harbored no resentment because she understood the roots of her mother's behavior. Nevertheless in her unconscious the desire to give tit for tat for her mother's meanness had persisted.
It was these revenge impulses, laced with furious rage, that sought motor actions and had to be kept at bay by doing some constructive project [that would please her mother].
Now in mild cases of obsessional neurosis, or where obsessional neurosis is sublimated towards useful goal, and this includes majority of mankind, for our world's do-gooders are no more than those who have harnessed their destructiveness to fuel the opposite impulse of constructiveness in such a fashion that the latter almost always manages to triumph over the former, the pathology is only apparent in that the person obsessively wants to do good - herein lies the psychology of hyperfocusing in ADHD.
But where the destructiveness is too powerful, as was the case in this girl, the constructive activity fails to keep the former in check for too long. The person gets a premonition that her good intention is going to be trumped by the evil one, which will result in some disaster happening [anticipation of punishment for the evil designs], and the conscious mind perceives it as a rising anxiety. And to take care of this anxiety she looks around for some project that was supposed to be done but which has not been done and which she deems as a potential candidate for causing trouble and she leaves whatever she was doing to take care of this new project. Herein lies the psychology of distractability. The destructive and constructive impulses are equally matched and the projects undertaken get interminably procrastinated.
The phenomena of multi-tasking arises from the same complex as well. Here projects are not abandoned but pursued simultaneously. When the anxiety arises about destructive impulse messing up the task at hand, the person, instead of putting additional energy in the constructive efforts, or abandoning the project and moving on to something else as the ADHD distractable person does, does not abandon the first project but takes on another, and then yet another, and juggles between all of them, and if he does it successfully then he is looked upon with admiration and if he messes it up he is viewed as a bumbling fool.
Now to her preoccupation with pimples. They symbolized siblings. She was trying to hurt her mother by identifying herself with her mother and destroying the mother's potential children. As if the desire to harm her mother had been displaced on to harming her mother's children. The penance for such fratricidal behavior was also expressed from the same act. The pimples stood for her children too, which she was destroying as a retribution for doing the same to her mother's children. It is interesting that despite her being at the peak of her femininity she had no interest in settling down and having children. As if all her interest in life had been consumed in managing this interplay between aggression and love impulses which strove to fight with each other in every aspect of her life.

The phenomenal memory of Obsessional Neurotics and Autistic Patients

People who suffer from obsessional neurosis take special pride in their excellent memory. After a therapy session when you try to give them your business card, where you write their next appointment date and time, they are apt to brush it aside with a contemptuous wave of hand, "Ah! I don't need that. I'll remember." And then they give you that smile of superiority which says unmistakably "I am better than you when it comes to remembering things like that and how could you even doubt that I won't remember."

And the remarkable thing is that they do remember. And they are there, on the dot. And you are impressed, and cannot wonder enough at the reliability of their memory, especially because it is not just in keeping their appointments, but in all spheres of life.
Of course this wonderful memory, as the treatment proceeds, takes a fall. The patient who was coming as a clockwork, one day as you go to fetch him from the waiting room, you are surprised to find there is nobody there but empty chairs staring back at you.

And you wonder as to what went wrong with your patient's wonderful memory?
You have a nagging feeling it is something you did in your therapy that has resulted in the loss of his high regard for you, and to the point, that he has forgotten to use his wonderful memory.
And you are right, it is the result of your psychotherapy.
But therapy is suppose to improve a patient's mental faculties not cause them to lose whatever little brains they have left. And their memory is one thing the obsessional neurotics are very proud of. As a counterweight to their involuntary appearing crazy obsessions, compulsions and images of harm coming to their dear ones, they hang on to their phenomenal memory as a badge of pride. It is as if to assure themselves, and others, that whatever else may have gone wrong with them they have at least not lost their mind, and their good memory is a proof of it.
And though we must concede that the lessening of the tautness of their memory is the result of therapy we must not despair that it is because we have done something wrong.
It is part of the course. What has happened is that the patient who was using his excellent memory to show his extreme consideration towards you, now that he is allowed to talk freely in the session, has become bolder in showing his hostility - that was underlying the consideration and was being suppressed by it - and its first victim is, of course, you.
Yes, you, because you were the one who told him to take courage and take cognizance of his ambivalence towards others.

Obsessional neurotics deny the entrance of their hostile unconscious impulses into their consciousness and they do so by putting at the fore exactly opposite thoughts and behaviors; acting as highly concerned, kind and responsible individual; someone who will not hurt a fly. Though the underlying destructive and cruel impulses do, from time to time, break through. In fact, all senseless obsessions and compulsions are manifestations of these aggressive tendencies in a disguised and muted form. They are in essence a compromise between the two trends - the impulse to do harm and its opposite to save you from the destructiveness. Through behaving nicely and showing all kinds of thoughts and impulses to help and save you they tend to "undo" the aggression.

Now the phenomenal memory of the obsessional neurotic is for the most part the opposite of his aggressive tendencies - an expression of the impulse to show oneself to be the most decent and reliable person. When the patient states that he will remember your appointment without fail what he is saying is that you are so important to me that your word is my command and I will make sure that in no way I will insult you by not showing up at the appointed time. It is kind of proclamation of how much they honor you.

But underneath this honoring lies the suppressed opposite impulse. The impulse to defy and insult you. The impulse to say something like: "Oh yeah, come for your appointment, why don't you tell your grandmother to take a piss too." Crazy, absurd counter commands, or ridiculous situations that by their very nature cannot be done. The absurd conditions on whose fulfillment depends honoring your request are a form of defiance. In the above example what the patient is saying is that ask me to come for the appointment after you ask your grandmother to take a piss. An unfulfillable condition. However, as a rule the command or condition does not emerge in the patient's mind in its entirety but as a chopped part of it, and generally entering the consciousness after a reasonable period of time and in a context which makes no sense. He may for instance see his grandmother taking a piss, without any clue as to why that image is recurring and with the only emotion accompanying it is none or annoyance, and it will keep returning as an obsessive image till the rage towards the therapist is exhausted.
Of course, one should not underestimate not showing up for the session and thus causing monetary loss is an excellent way to show negative feelings towards the therapist.
Now what the work of psychotherapy does is to give the patient a voice in the sessions and subsequently courage to take a stand against authorities in his actual conduct. And one of the ways he does so is by indulging in an error of memory; something that he felt so secure about hitherto. The chink in his armor occurs right at the spot where he has the most confidence in his ability to suppress the opposite impulse.

But why? And in the first place why memory is one faculty that becomes so extraordinarily developed in the obsessional neurotics when compared to other mental illnesses?

But does it really? How about other illnesses? Doesn't hysterical people repeat their attacks over and over again, and their attack is nothing but symbolic and muted expression of a traumatic sexual event, whose basic structure was laid down at the earliest period of childhood? That is memory too.

But there is a difference between the memory of a hysteric versus an obsessional neurotic. In hysteria the memory of the trauma is deeply ingrained, but its repetition occurs without the conscious knowledge of the patient. Patient does not recall the trauma, just acts out the traumatic event, or parts of it. It happens under the inexorable law of "Repetition Compulsion." It is not a memory that the patient can use in his day to day behavior or make use of as a feat of memory. It is unconscious memory. So we can't truly call it a faculty of memory. Also in hysterical patients facts and fiction are inextricably mixed, and instead of taking pride in adroitness of their memories, the patients take pride in being "so cutely" forgetful. The forgetfulness becomes a character trait which the hysterical woman - usually a pretty woman, hysterics are as a rule good looking, the proverbial goofy blond - starts taking pride in, and quite often uses it as an excuse for getting special consideration.
In psychosis there is wholesale assault upon memory and a replacement of it with delusional material. Instead of recalling things accurately, the psychotic recalls his fantasies and sees them as real. The memories are remodeled without taking regard for reality.
But there is one condition, a severe form of illness, in fact more severe than ordinary psychosis, where the patient shows even more remarkable memory than the obsessional neurotic.
In many autistic patients the memory is not just phenomenal it is mind-boggling.
An autistic patient of mind, who is now in his early Sixties, remembers thousands upon thousands of streets and their intersections, not only in all the cities he has lived but also some of the streets of the cities where some of the people he has interacted with have lived. He asks you where you live, and then remembers that street forever. But the memory is not just regarding streets, he will ask your birthday, the names of your children, their birthdays, and commits them to his memory. He remembers details about all kinds of musical groups and what song they wrote in which year. Another autistic patient remembers every Led Zeppelin songs and can tell you how long each one lasts to the exact second.
What is the purpose of such a phenomenal memory in these autistic men? One thing is for sure that they have no practical utility. The man who remembers virtually every major street of Metro Detroit, and which one intersects with which one where, is confined to a group home, and not allowed to take a step out of the place on his own. Far from working, he cannot even cook and clean for himself. His day is spent from dawn to dusk complaining about other residents of the home. He cannot tire calling them troublemakers and doing this and that in a wrong and foul fashion. This has no basis in reality. If anything he is the biggest troublemaker in the Group Home. He has the keenest eye for noticing everybody else's errors and he makes no bones lamenting about it all day long. Interestingly he hears them calling him "the stinkie boy."
Is the mystery of the phenomenal memory lies in his phenomenal fault finding ability? And from where did this fault finding tendency emerge in his mental life and became the central feature of his character?
I can only account for this state of affairs in autistic patients, and in obsessional neurotics as well, by assuming that at a very young age, in autistic patients chronologically much earlier than the obsessional neurotics, the child did something aggressive/destructive for which he was severely reprimanded. Or perhaps it was not one major reprimand but a series of them. For in such autistic/obsessional neurotic families there is a culture of not tolerating even the slightest aggressive/deviant behavior. And this culture of intolerance has a cumulative effect in muzzling the child in expressing his emotions. The parents are quick to criticize or mete out harsh punishment or hold off love when the child expresses destructiveness. He is not allowed to mess up things. The house has to be in perfect order. And in autism prone families this non-acceptance of child' nature is practiced with the child as far back as to when he first begins to verbalize to his emotionally deaf parents. Or perhaps in these parents the language is devoid of much emotions. Perhaps the parents themselves grew up in homes where there was great parsimony in showing emotions or even feeling them, where words were used without the richness of emotions suffusing them. Perhaps the child has great difficulty in making emotional connections between what he is verbalizing and what the parents are verbalizing.
To deal with this non-acceptance of his destructiveness - the manifestation of the great destructive instinct - the child develops some characteristic defense mechanisms. These can be broadly put in three categories.
The most disturbing, and which causes the severest damage, and herein lies the secret of autistic disorder, is a profound turning away from the world and the loss of the significance of other people as targets/objects of one's emotional life. The parents become as good as strangers, and subsequently all new people who enter one's life are subjected to the same rejection. There is a fundamental emotional withdrawal from the world, with aggression now directed primarily towards one's own self. The massive increase in brain size of the autistic children perhaps occurs to accommodate this turning of hostility inwards. Outside objects no longer exists and one has to play the role of both subject and the object. The brain increases in size to accommodate this dual role.
A less damaging defense is not to give up others as objects of aggression and turn it against oneself but to indulge in aggressive/destructive behavior but shift the blame for it on others. This is the defense of the autistic patient of mine, who remembers every street. His mental processes go something like this: Granted something nasty is going on, but it not me who is the author of it, it is other residents in the Group Home, folks like me ( my siblings), who are the evil, who wish you ill and want to destroy you. Punish them, not me. This accounts for my patient's constant blaming of others, while in reality he was the biggest trouble maker there. This defense mechanism allows him to discharge some of his aggression with external objects (other people), saving himself from the severest form of autism. He thus preserves his relationship with others - his parents/authorities - through discharging his aggression, but by not owning to it, and blaming (projecting) it upon others, he escapes the fear of impending punishment to some extent. In his unconscious he reasons, whatever punishment will come, it will fall upon others, because they are the trouble makers not him.
The fact that he hears others call him "stinkie boy" which infuriates him, is a pointer that the aggressive and destructive behavior that he attributes to others - in his unconscious his siblings - is arising from him, and he acknowledges to it albeit in a very tangential fashion by first converting it to auditory hallucination.
The choice of Geographical locations, streets, cities etc. in my patient arose from the same "sibling complex". There is a great love for order here. The punishment that is to be meted out for aggressive behavior should be in the exact proportion to each sibling's crime. Also the [meager] love that exists in the parent, when it is meted out should be in exact order and of the exact amount based upon the degree of aggression displayed by the children. That explained his keenest eye for finding faults in all those who could represent his siblings. This fault finding in siblings by displacement and reversal had become finding the minutest details about cities and the roads. There was another causation for the choice of streets and cities to symbolize his siblings. He had four or five of them, and the order in which they were born and the age differences between them was now represented by the geographical sites and their exact relationship with each other.
The patients love of order was also manifested in his great fascination with trains. He could sit all day long at railway lines, watching the orderly progression of one coach after another. It was again an appreciation of the order in which the siblings should be gratified. But at a deeper level it was a manifestation of the most fundamental aspect of autism. His illness arose because of unbridled eruption of his aggressive/destructive tendencies at an age when he was not mature enough to master it and his caregivers were too emotionally cold to help him in dealing with it. His fascination with trains and the orderly appearance of the bogies was a wistful longing for his own emotional life to have unfolded in a similar gentle and orderly fashion. "If only my instinctual life had erupted in proper order and not burst forth pell mell I would not have suffered this ill fate."
The fascination with music and things that went in loop, like fans and gramophone records, appeared to have arisen in him from the same complex. Music is very precise, and beats have to appear in precise order. Which reminds us of the second patient who knew each of Led Zeppelin songs to the precise second. Once again it was demand for justice and an appeal that the punishment that is to be meted out to me must fit the crime. But the fascination with mechanical things that do the same thing over and over again without any chance of deviation was also a projection of wistful longing for a complete control over one's aggression and for a hope to not deviate from the straight and narrow. The total preoccupation with controlling aggression becomes like a loop in the mind of the autistic to the exclusion of every other interest.

It is interesting that even in this defense mechanism of autistic patients, one can easily see the opposite impulse from time to time breaking through. For example my autistic patient who has phenomenal memory for the cities and birthdays invariably makes subtle errors. He does not remember quite correctly that I live in Bloomfield Hills, always recalling it as West Bloomfield, an adjacent city. He remembers the month I was born correctly, but invariably misses out on the correct date by a day. Another autistic patient of mine remembers quite a few dates about me - in my honor of course - but when he recalls it as a way of paying complement, he stutters so miserably that it is more a pain than pleasure and I rather do away his praising of me. Behind the phenomenal memory of facts about you lies the opposite impulse - to distort facts about you.

The least harmful of the three set of defenses in order to deflect aggression away from the parents to avoid the dread of punitive retaliation, and the one which is most characteristic of obsessional neurotics, is covering up of the aggression by "pleasing" behavior. In a little child who is confronted with the spectacle of a newborn sibling and whom he hates as an unwanted rival, he may instead of hitting or pinching show hypocritical professing of tender love. When a four year in throes of Oedipal hatred is tormented with wishes for his father to get lost and never show up again, to counter the hateful impulses he may go and kiss his father's hand and do other little things to please him. It is this doing of just the opposite of destruction that lies behind the phenomenal memory of obsessives no less than it does with autistics. The obsessional neurotic's mind has to be constantly "on alert" to quash the destructive tendencies and replace it with tender ones. Before the thought comes that I should not show up for his appointment "the alert mind" sparks the counter resolve that not only you will come to the appointment you will remember the appointment so well that in no way you will ever forget it. It is this alertness, and a resolve to remember doing the right thing forever, that lies behind the extraordianry memory.
Interestingly even the phenomenal memory which originally arose to show one's love and regard for others in most cases often results in doing just the opposite. An obsessive who knows everything about the road patterns of a city when giving directions may give so many factual information, never coming to the point, that you are left with confusion and are worse off in finding your way with directions than without them.
The question naturally arises as to why some people choose profound withdrawal from the world turning all the aggression inwards, while others indulge in the aggression but project it on to others taking no responsibility for it, and in the process lose that sense of self so characteristic of autism, and yet others cover their aggression by tenderness and thus maintain relationship with others albeit a highly ambivalent one.
Of course the obvious answer is the age at which one's destructiveness is not tenderly mirrored and gently modified but either meets with cold response or is brutally suppressed - the basic psychopathological process in these illnesses. Earlier the age of this subtle rejection, the more likely the child will be unable to displace it upon the siblings or to cover it up with the opposing impulses.
But the role of fear should not be overlooked in these illnesses either. When autistic people are closely examined behind their varied psychopathologies lies a core and profound fear of the world. This fear appears to be the sine qua non of autism, and obsessions, and of so many other mental illnesses. Earlier the age, the greater is the fear of anticipatory punitive retaliation. If the infant feels helpless in discharging his aggression at others at a very young age, he is likely to turn away from the world completely. It is a profound flight from others. A complete shutting out of the world. When he is a little older, and has some sense of his siblings, and has some confidence that he can manipulate or rather influence his caregivers, by his words and by blaming others, he will indulge in the second type of defense. In the third type of defense which is usually seen in obsessives and not so much in autism - though in the latter too there is a tendency to protect others by picking up litter and other out-of-place objects from which harm can possibly come to others - the child has already entered the Oedipal period before the problem arises.
And one more point upon the phenomenal memory of obsessives. The extreme desire for revenge and turning the table upon authorities should not be underestimated. There is an element of hypocrisy in the tenderness/concern/love which is put forward to deflect attention from the underlying hostility. Behind obsessions are desires to get even with the Oedipal father. The fear of castration in hands of the father for one's sexual proclivities provokes the impulses of revenge. And it is these revenge impulses that appear as defiance and destructiveness. Now the original threat of castration is entirely forgotten. And in its place as if by compensation arises a remarkable ability to remember every situation of life, where one is threatened. Every threat and humiliation becomes at bottom a threat of castration and defeat at the hands of the Oedipal father respectively. And the obsessive tries to remember them all with utmost accuracy so he can come back another day and win the fight.

A quartet of psychosomatic symptoms and their obsessional neurotic roots

In his "Notes on a case of Obsessional Neurosis" Freud remarks how Obsessional Neurosis is a rich and rewarding field of inquiry, and how many closely associated patterns of symptoms exist in this illness that would be worth inquiring into. The most famous constellation of this kind is Freud's delineation of a regular association between parsimony, obstinacy and orderliness, all components of anal eroticism

I have been struck by the following four psychosomatic symptoms that seem to occur together in quite a few of my obsessive patients.

Migraine headaches
Stomach pains and cramps
Insomnia
Panic Attacks with fear of leaving familiar surroundings.

Underlying these symptoms, on careful observation one finds a surfeit of undischarged aggression. The patient who cannot discharge the aggression by normal means does so by taking it out on himself; by creating the suffering in his own body. I will give two such cases where I could make some headway into their psychopathology.

A 26-year-old very attractive girl suffered from horrendous headaches, inability to sleep despite massive doses of benzodiazepines, stomach pains at the thought of leaving the house, throwing up and diarrhea at the slightest bad news, and Panic attacks that would leave her exhausted.
She had highly charged destructive thoughts towards men which she struggled against with all her might. The struggle was reflected in her feeling a constant tension in her head which would quite frequently escalate into frank migraine headaches. She was so ashamed of her evil thoughts towards men, which were connected with the possibility of their being unfaithful, that she had married inter-racially, thinking that a black man would not be unfaithful to her, valuing her highly for being white.

On exploration of her insomnia it was found that she slept in a fetal position in one corner of the bed as if she was anticipating somebody attacking her. She had to go through obsessive rituals like checking and rechecking windows and doorknobs to fall asleep and even then it would take her a long time. The insomnia was connected with her fear of dreaming rather having nightmares. The nightmares were 'anxiety dreams' in which young girls were abducted and tortured and raped and subjected to extreme sexual humiliation. The immediate source of it was watching a cable channel where real life stories of little girls getting abducted by sexual perverts was the staple, but its deeper roots were her unresolved attachment to her father from the oedipal phase. The guilt over her love for her father was handled by regression to anal erotic (obsessional) level marked by fantasies of getting beaten, tortured and killed by a rapist.

The reaction to this desire to abjectly submit herself to men and be beaten and humiliated by them found expression in a great [coexisting] hostility towards them. It was this hostility which caused the panic attacks at the thought of leaving the house. The actual thought of leaving the house and be exposed to strangers whom one may solicit or who may abduct one and then subject one to act out the sexually humiliating fantasies caused churning of the stomach and diarrhea.

The second case is of an adolescent boy who also suffered from migraine headaches, insomnia, stomach cramps and pains, a great urgency to defecate when stressed, but not frank diarrhea, panic attacks and inability to leave the house. Added to this quartet were attention problems, hyperactivity, and motor tics. Motor tics were predominantly around the eyes but also posed difficulty in swallowing that emerged as complex motor movements through the upper torso of his body. He was capable of suppressing these motor manifestations of aggression by actively concentrating upon them, but it would leave him exhausted and give him migraine headaches. The headaches were always there as low lying muscle tension becoming frank migraines if there was parental conflict or if he had to do some trying activity like taking a test. He also had inflammation of the sinuses causing sinus headaches, also probably a manifestation of the same psychosomatic pathology.

The boy was insightful enough to figure out that his attention problems were connected with death wishes towards his parents. In classrooms, instead of listening to his teachers, he would be struggling mightily to prevent the death of his parents by doing some day dreaming or some complex mathematical activity designeded to ward off the evil that was to befall his parents. This animistic thinking also found expression in some compulsive motor movements like having to tap the door or other objects a fixed number of times, generally three, symbolizing his mother, father and himself.

Additional symptoms that confirmed he was struggling against his death wishes towards his father were his castration fears that his hair needed cutting, or his shirt was not trendy enough or marked by defects, or he smelled, or he had body deformities which would subject him to ridicule in public. These are all manifestations of a hypochondriacal and social displacement of castration anxiety. He would take a long time to groom which was displacement/regression of his castration anxiety escalating to an anal-erotic phase.

His great rage towards his father was a reaction to his fear of getting castrated by him for his sexual proclivities towards his mother arising from the oedipal phase, but now buried in the unconscious. He also reacted at the thought of leaving the house with panic and churning of stomach. The panic was at the thought of humiliating himself with strangers by abjectly submitting himself to them. This was a passive dissimulating reaction to hide his desire to murder them, a displacement of the murderous rage towards the father on to strangers.

The Madness of Multi-axial Diagnostic System in Psychiatry

About eight months ago I had a site-visit by a Behavioral Management Company (BMC) contracted by a Medicaid HMO to keep down service costs. In other words, this company is contracted to find ways to minimize a patient's visit to doctors and other medical activities. Ostensibly it's contracted to perform the above tasks, but in practice it is to cut down medical consumption across the board whether for good or for greed. The purpose of this particular site visit was to use a little fear mongering because I did not fit their mold.

It is very unusual in the world of psychiatry to include psychotherapy as part of patient treatment. Today's standard practice is for the psychiatrist to quickly make some monolithic diagnosis such as Major Depression or Schizophrenia or Bipolar Disorder, write a few prescriptions, and hand over the patient to a social worker or psychologist to then tinker with their mind. A psychiatrist's role is limited.

I find something drastically wrong with this picture. In such a system the psychiatrist is unlikely to allow any patient who comes his way to escape without putting him on at least one medication. If the patient does not respond to the first medication, in all likelihood the psychiatrist will keep adding more and more medications until the patient, if not healed, is at least completely out of it. I do my own psychotherapy with my patients and do not split my patient's treatment with therapists. I manage not only their medications, but their psychological world as well.

The BMC was not happy with such a state of affairs. They were not unhappy that I was getting good results. They were not unhappy because I was prescribing medications very sparingly (which alone saves them tons of money). They were not unhappy because I rarely admit patients (which again saves tons of money). They were not unhappy because my patients are not unhappy with my psychotherapy or my medication management. They were not unhappy because Medicaid was not saving money by my doing both aspects of treatment: medications and therapy.
So, what was making this BMC so unhappy?

The BMC was unhappy because my patients were happy seeing me and almost all of them wanted to avail themselves to the full 20 sessions allotted annually by Medicaid. The BMC prefer to utilize therapists who are so poorly trained and are so stinking bad that people would rather commit suicide than have a psychologist see them beyond a few sessions.

The BMC had decided that as a psychiatrist I was not authorized to bill for psychotherapy; I could only bill code 90862 (medication management) which reimburses $27.00. I could not bill code 90806 that pays $54.00 for a full session. The BMC stated that code is reserved for psychologists and social workers. When I offered the services to do psychotherapy, bill code 90806 and throw in the medication management for free, I was told there is no such thing as a psychiatrist doing psychotherapy without tinkering with the patient's medications and for that I would have to bill code 90807 to receive $32.00 because the BMC does not think psychiatrists are capable of doing psychotherapy. When I stated I would take this issue to the Mental Health Board and to the American Psychiatric Association they decided to do another site visit in an attempt to scare the bejeezus out of me.

The social worker who visited to review my charts was pleasant and was astonished that most of my records were primarily analyses of patients' dreams. She was very impressed with that. She had seen nothing like it in her entire career. That must have been a mind blower. Nevertheless, since I failed to make the five-storied multi-axis diagnoses at the end of psychiatric evaluations, I was faulted. Her notes read, "This psychiatrist appears to be capable of making the five-storied multi-axial diagnoses when he chooses as he does when filling forms for disability or sending reports to courts, but he does not do so for his clinical work and this is a serious lapse."

Now is it? Really?

The five-tiered diagnostic system that the American Psychiatric Association has thrown at the psychiatric profession like the ten plagues of Egypt is the biggest heap of bull ever crapped upon a profession and on patients who must adhere to that discipline for their treatment.

Yes, yes, it does make the psychiatrist feel he has done a wonderful job of evaluating his patient and he can feel so without having a whit of understanding what is really wrong with that patient.
It gives the psychiatrist a sense of having done something very complete, something very profound, something very complex, something that looks so long and mighty in comparison to a one or two word diagnoses of other medical specialties; and he can get that "feel good all over" feeling without having done anything really meaningful.

Diagnostic labels have no real meaning in psychiatry, no matter which DSM diagnostic category they belong to. Every symptom, complaint and problem has to be deciphered on its own right, regardless of what diagnostic rubric it is subsumed under.

For example, if one is diagnosed as having depression, it is no big feat. Anyone with even the most elementary clinical sense and a modicum of intelligence can make that out if a person is listened to for even a few minutes. As far as psychopharmacology is concerned we treat all forms of depression with the same broad brush; the same psychopharmacological agents. When one goes to other diagnoses, like obsessions or disturbances of the periodicities of mood (various forms of manic-depressive illnesses), the story is exactly the same. Making the diagnosis is child's play.

The difficulty is getting behind the diagnosis to figure out why the patient became depressed and what difficulties the patient is trying to master with the periodic mood shifts. What is the meaning of his obsessions and what contradictory impulses is the patient trying to express through his obsessive thinking and compulsive actions? These tasks, unfortunately, are not made easy, but become even more difficult when one must think through the foggy glasses of the multi-axial system.

In fact, once one makes a complete diagnosis with its impressive five or more lines, there is no motivation left to do anything more with patient's complaints. Now, even if one grants that the Axis I and the primary psychiatric diagnoses have some value, at least for the purpose of coding and billing, and as scaffolding for broadly conceptualizing patients' problems at gross level, the other Axes are totally useless if not outright harmful.

Axis II, the personality disorders, have no specific psychopharmacological agents that alter them. As far as psychotherapy is concerned it is outright nonsense to say that the therapists use one form of psychotherapy for one personality disorder and something else for another.

Axis III is a joke among therapists. Only medical doctors are truly capable of filling that section correctly. No psychiatrist performs thorough physical examinations. When it comes to writing that section of the multi-axial system the only thing the psychiatrist does is throw in a couple of patient's medical problems as an afterthought. The medical problem to mention is the same as picking a rabbit out of a hat. No attention is ever given to it again.

Axis IV is even more ridiculous. Naming a couple of psychosocial stressors and guessing their severity doesn't have any meaning in actually comprehending the patient's real life situation. These factors cannot be captured in one or two lines. By declaring that the stressor is legal versus marital versus school based, has no relevance to how one approaches patients. Does saying it is a very severe stressor versus a moderately severe stressor change one's approach to handling the patient? Does any psychiatrist ever declare a patient has less than moderately severe stressors.

Axis V is a worthless apex other than knowing some broad markers like Medicare will object to paying for inpatient care unless the GAF score is less than 40. In fact, it is now a clinician's game to start with a ridiculously low initial GAF score and gradually peg it upwards on paper to show progress.

The multi-axial diagnostic system in psychiatry is the biggest hoax and monstrosity perpetrated upon mental patients by the American Psychiatric Association. It was done at the behest of the pharmaceutical industry and it has primarily benefited them. With the advent of the multi-axial system psychiatrists slowly but surely abandoned listening to patients beyond getting enough information to pigeon-hole them into the DSM multi-axial system and then start medicating him as if there is no tomorrow.

Excessive and instant gratification and the rise of ADHD

The last fifty years have been decades of unprecedented prosperity. This has had a profound effect on the way we are bringing up children. Our children are growing up in homes where they are constantly placated and amused. Whenever some situation ceases to provide them satisfaction and they feel bored they can instantly go to something else on their PlayStation, computer, television, or just phone a friend or text him. Their every need is instantly acknowledged and fulfilled.

This state of affairs is perhaps at least partially responsible for the explosive rise in the incidence of ADHD. I see an intimate connection between instant gratification which has become the norm in bringing up children in today's culture and the proliferation of the disorder of Attention.
Obtaining constant success through their endless toys they develop a very high rate of dopamine secretion and a mental makeup that seeks pleasure continuously and instantly. When such children attend classrooms and have to learn tasks that are rarely a matter of instant gratification they quickly lose interest and attention.

A child who grows up in a culture of instant gratification is used to getting immediate success. If one toy ceases to give pleasure his modus operandi has been to move on to the next one. If one show on television does not keep him amused he changes the channel. His video games have allowed endless shooting of the bad guys and therefore quick successions of dopamine secretion.
Tasks required at school are neither highly rewarding, at least not immediately, nor do the rewards occur frequently. One must go through a number of stages of hard work before attaining success. Consequently, the secretion of dopamine, the reward neurotransmitter, does not happen that readily. The task has to be painfully mastered before pleasure happens. The child who has grown up in a culture of instant gratification loses interest quickly at hard tasks that school demands and starts daydreaming of scenarios that promise instant pleasure. He is also fidgety because in his unconscious he is conjuring up scenes where he would rather be instead of where he is at the moment. His body, without his conscious knowledge, squirms, and moves to get out of his seat. This is the "hyper" part of ADHD.

If a child comes from a background where taking on the challenge of hard tasks is considered worthwhile because there is a big reward at the end, in other words where there is a great desire in the child, constitutionally or because of upbringing, to please parents and teachers, he may overcome this need for instant gratification. Otherwise, he starts developing defiant attitude towards authority if they keep on pressuring him to pay attention to the task at hand rather than daydream. This is the oppositional defiant aspect of ADHD.

Of course, there is also another very important factor in the cause of oppositional defiance of ADHD children. When a child goes to school and finds that other children perform better because they can pay attention to what is being taught while he cannot - the same humiliation also in all likelihood occurs at home where siblings without ADHD do better than him - revengeful rage is generated. This rage finds expression in defiance, failure to perform tasks, stubbornness, arguing, and doing just the opposite of what is demanded. Later, obsessional defenses emerge to control this rage.

Dopaminergic drugs work by keeping a constantly high level of dopaminergic activity. This removes from the child the motivation to be some other place doing tasks that will boost up his dopamine secretion. Since it is already artificially high from the dopamine pills the child does not have to daydream nor fidget to be "elsewhere" where there is better promise for immediate gratification. This enables him to pay attention to what is being taught.

Also, the function of dopamine is not so much to give pleasure as to use the generation of pleasure as the stepping stone to pay attention. Whatever situation gives us pleasure we learn to focus upon it.   The high rate of dopamine activity brought on by the dopaminergic neurotransmission enhancing drug gives the illusion to the ADHD afflicted child that what is being taught is what is giving pleasure/satisfaction, so he focuses upon whatever is happening right then and there instead of his attention to wander away into his fantasies.