The Stuff the dreams are made of

While going through my sent mail for some other purpose I ran into something I had sent to National Geographic. As expected it was way above their intelligence. However, since it sums up the nature of sleep and dreams quite well, I am posting it here.

Wed, May 5, 2010

National Geographic Magazine

PO Box 98199

Washington D C 20090-8199

Dear Sir/Madam:

The Stuff the dreams are made of

The reason why Sleep Researchers are Rodney Dangerfield of Medicine (The secrets of Sleep, May, 2010) and have not got more funding because they have done precious little with whatever they have received. Nay, it is worse, for for the sake of climbing the academic ladder and petty glory, all they have done for the last three decades is to put the carefully observed classical psychoanalytic knowledge about sleep and dreams upon its head, causing tremendous harm to psychiatric treatment and education.

Dreams which were the window to the unconscious mental activities, and the most valuable tool to unearth the person’s secret infantile wishes, of which he himself was not aware of, has now become, in hands of modern sleep researchers, periods of brain stem generated chaos devoid of any meaning or value. But we dream of cars, girls, White Christmas, because what is beyond our reach during the day, kind nature lets us have it in the privacy of our sleep and dreams. While such wish fulfillments occur in disguise and often accompanied by intensely contradictory emotions, no language or artist ever makes a mistake as to what the dreams are really about.

All the modern sleep research can boast of finding is that sleep and dreams are there for us to enhance our memory and that sleep is a period where the brain does a second shift. This contradicts the most fundamental observation about sleep. We sleep because we want to have nothing to do with the world whenever we can extricate ourselves from its demands. It is an attempt to shut out all stimuli, external and internal, and take a flight back to the intrauterine existence – explaining as to why children and sometimes even adults assume the fetal position in sleep - and in case of those who show sleep apnea, even further down the evolutionary process right back to our inorganic roots. For the natural state of the universe is inorganic, and life processes are a miniscule rarity, into which we come reluctantly and try to escape from as soon as we see no reason to give into the tumultuous clamor of life.

Yours truly,

Surendra Kelwala MD

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 Dream portraying hysterical ambivalence towards mother

A 17 year old girl, whose sister had died in an auto accident a year ago dreamt the following:

I have to save my mother. She is far away in a building, it could be a barn. A fire starts. I try to reach her but it is too late. By the time I arrive she is already burnt to ashes. I see the ashes on a bench. It is in form of her shadow, as if in her shadow she is still sitting on the bench.

This girl is having great difficulty in getting over her sister's death who was just 3 years older than her, and the two did quite a few things together. She has difficulty in sleeping at night. She is always anxious. She misses her sister so much that she has to often pretend when she goes to Mall or to places where they did things together that she is her sister. Fun things can only be done when she is pretending to be her sister, that way the sister does not miss out on fun. It is a mental mechanism to avoid guilt for having fun without the sister. Often she has to bargain with unknown entities that if her sister comes back to life even for a day, she will gladly go to jail for a year or for all her life. In desperation to bring back her sister she once shop lifted and hoped she will get put in jail. She had developed a special obsession to pay homage to the memory of her sister. Her sister's name had 7 letters. She would often repeat her sister's name visualizing the fact that it was made up of 7 letters and had also developed a superstition that number 7 was lucky for her. Whenever she could convert any number to 7 or some number connected with 7 such as 17 and would come across such a number as in receiving change back of 7 or 70 cents she would feel better and not guilty as if she had saved her sister's existence in some sense.

Now in contrast to her sister she has great ambivalence towards her mother. The mother is highly anxious person as well. She is always anticipating harm, and rarely leaves home. This fear of harm coming to her is also projected on to all those who are near and dear to her, including her children. She always has to know the whereabouts of the patient. The patient has to be in mother's vicinity lest something happens to her. If she goes out she had to keep in touch on phone every so often to reassure that she is doing OK.
As a consequence a dominant wish in the patient is for her mother to disappear (die). And to negate such an evil thought there also exists in her the counter wish that her mother should never come to harm and that she should save her mother from some ill befalling her.

The dream was expressing this ambivalence.

She is far away in a building

This was expression of the wish for her mother to go away as possible.
The fire started on its own but was giving expression to her own burning jealousy of her mother from an earlier period when she envied her mother and was burning to be like her mother. Now she was turning tables and making her mother burn. It was an act of revenge.
The saving of mother was expressing her love for her mother. This was the counter-wish - to save her mother from her hatred.
The bench could not be deciphered, but perhaps stood for the comfort her mother had once provided her.
The ash was taken from her sister's ashes. The sister was cremated and her ash is still with them. It was expressing the wish for her sister to be saved and her mother to die in her place.

It is in form of her shadow, as if in her shadow she is still sitting on the bench.

It is once again negation of death. Negation of her death-wish towards her mother - my mother did not die but is still alive and sitting on the bench

On successful analysis of the first dream another dream emerged in her consciousness.

I am in my bed and sleeping. Or may be I am awake. Because the room in dream is exactly the way it is in real life, and I am sleeping exactly the way I sleep. Or maybe I am dreaming while I am still awake because it is weird how my mind never shuts off, and even in my sleep my thoughts never cease to keep running in the background. In the dream - or may be she really did come - my sister appears and tells me that is is not all that bad here.

Now this patient has great difficulty in sleeping. She suffers from high level of anxiety like her mother, and one of its consequence is that she worries about harm coming to herself and those close to her. He obsessive fear of harm coming their way extends even to her dead sister, as if she will come to harm in the after life. To counter these thoughts of impending doom there is always counter thoughts running in her mind to block the anticipated harm. The background thoughts are also a method to constantly reassure herself that she is not going to disintegrate - a reflection of excessive anxiety - if she abandons her caution and falls asleep.
This state of affairs was present even before her sister's death, and was a result of her excessively high level of anxiety, which itself was a reflection of her highly sexual nature - she is suffused with sexuality - but it had worsened since her sister's death.
Now she had to be vigilant throughout the night, even in her sleep to prevent harm coming to her sister in afterlife.
Her mind had conjured up the dream to reassure her that her sister was doing fine in afterlife and so she could relax a little, and continue to sleep instead of waking up in fright.
When the dream was interpreted the patient exclaimed, "That is kind of creepy. I never quite looked at it that way. But it kind of makes sense." Confirming the correctness of the interpretation.

Fear of exposure of one's autoerotic sexual fantasies as the reason behind the excessive concern with privacy

One occasionally comes across a patient who places a great premium upon privacy. He does not want your secretary to call his house to remind him of his appointment. He is especially disturbed if your secretary leaves the message about his appointment with a family member or on the answering machine. In the office, he reverts to hushed tones when he is criticizing others or talking about sexual matters as if the subject of his criticism or sexual desires can overhear him, even if they are hundreds of miles away. He periodically wonders if your secretary or other patients in the lobby can overhear what he is telling you. When you are writing a letter to his work for something like medical leave he does not want you to let them know that you are more than a MD and a psychiatrist, and certainly does not want you to mention that he is on psychiatric medications. One such patients refused to go for sleep study in the hospital which is across my office, preferring to go across the city, on grounds that the neighborhood will overhear his snoring if he sleeps in the hospital here instead of the hospital yonder. In short he is ashamed about having a mental illness and wants to hide that fact from the world. Now the public relations department of the American Psychiatric Association will tell you that all this is result of that nefarious "stigma" - a word which has reached the status of a battle cry among the rank and file of that association and something they all feel noble fighting about - attached to mental illnesses. The official position of the APA is that this stigma has no psychological basis and if we all pretend and assure each other that mental illnesses are no different than other medical illnesses the problem will just go away. Really? A man is not ashamed to declare that he has been stricken with a serious heart attack or cancer; illnesses that leave him far more handicapped, and debilitated, and which should make him far more cautious about admitting to their existence in himself than something like obsessions or anxiety which at least in their initial stages cause hardly any limitations. Yet it is only mental illnesses that a man is terribly ashamed of and feels as if some great secret will be exposed, and he will be humiliated in public, if he admits to having them. In a few patients who showed this excessive concern with privacy I was able to establish that this sense of shame was intimately connected to masturbatory activities. It is not necessary that the patient is actively indulging in it. He may be just tempted towards it or vigorously struggling against it or just practicing it in his thoughts. Mental symptoms, at least those which are not due to gross injury to the brain, are substitutes for frustrated sexuality. Since frustrated sexuality finds satisfaction either in perversions or in neurotic formations, and often finds discharge in auto-erotic activities, a person is ashamed of these formations (mental symptoms). Stigma of mental illnesses is at bottom mankind's shame with sexuality and masturbation. An interesting fact about these patients of mine who show the greatest concern about privacy, they all have shown themselves to be primarily Obsessional Neurotics. Now we know that obsessional neurotics show the greatest predilection for discharging their sexual tensions through masturbation. Much of their compulsions and other rituals are displaced and elliptical imitation of touching their genitals and vigorously fighting against it. Behind this struggle lies their fear that by touching they will cause harm to the person touched. These obsessive patients of mine with great concern for privacy as a rule refuse my offering them coffee at the beginning of session to avoid any touching and to avoid getting poisoned by me. They show equal concern in giving me anything lest they poison or kill me. Now this paranoid/compulsive behavior throws some light upon their concern for privacy. In their masturbatory thoughts sadistic destructive thoughts predominate. They are full of thoughts of causing harm, especially death, to others. It is this that they are really ashamed of. Also they do not want the world to know as to how much death wishes they have towards everybody in general. Now in their conscious thoughts they have hardly a clue as to how much destructiveness towards others they possess. In fact in their conscious mind they see themselves as very kind, conscientious fellows who will give the shirt off their back to help others. And this is generally true of their actual behavior or at least most of it. A lady, not a patient of mine, was the greatest do-gooder in her community, and who was excessively concerned about all kinds of privacy regarding people knowing her business in the region where she practiced her philanthropy. Behind the philanthropy there were lot of anger and rage against the elected officials of that region, against whom she was discharging her obsessional destructiveness, but which she wanted no one to get a whiff of. Now these privacy lovers are most concerned about their family knowing that they are seeking treatment. Why? Because these patients communication in the session is invariably about their obsessions and compulsions. [ On examining they overwhelmingly show themselves to be destructive/erotic thoughts towards their family members.] No wonder they do not want the family to have any clue that that they are talking such evil stuff about them in therapy. In this context it is worthwhile to mention how privacy has become such a great issue with the banks/investment firms, the medical industry and the American government. Now we know how banks took the whole world for a financial ride, in secrecy, causing so much destruction and misery. No wonder they make so much fetish out of privacy and to assure you as to how conscientious they are about guarding your money from unscrupulous folks, while in reality they have been the biggest looter of your money. Doctors and insurance companies show similar fetish about informed consent and transparency about side effects of drugs, and research trials and medical procedures, trying to convince you that everything is being done according to rules and ethics, while in reality most of their rules and show of ethics are how to secretly milk their patients to bare bones in name of practicing high class medicine. The government's increasing fetish with privacy is to deflect our attention from its ever widening intrusion in to our lives, including now the right to spy upon us 24/7. Just one last point about stigma of mental illnesses. Is there a justification for the world to attach stigma to mental illnesses? The psychiatric profession will consider it sacrilegious for any of its member to question such a sacrosanct war cry for the patients, but the truth remains that the world will always consider mental illnesses as something on which a derogatory value judgement should be attached. And they are to some extent right. People instinctively know that mental problems are not entirely chemical imbalance or genetic problems or something in which the sufferer is totally innocent. They sense behind those mental symptoms there are aggressive designs and desire to harm society or at least not be a part of it [a neurosis is finally nothing but a withdrawal from the world and to find satisfaction in one's private world. It is for this reason the world holds mentally ill with contempt.

A Primal Fantasy dream expressed as a three-car accident

A woman of 26, related the following dream in a therapy session:

I am inside a car on the driveway of a house. The house is on a hill. I am four years old. Somehow I get out of my seat and mess with the gear which goes in reverse. The car starts to roll down the hill towards the main road where a car and a semi are coming from opposite directions and hard as I try I cannot stop my car's rolling down and it is crushed between the oncoming two vehicles.

When asked where is the house taken from? She said it is the house where she was born and where she lived the first years of her life.

Why the hill comes in the dream? The house was actually in a suburb which had rolling grounds. The dream was conveniently using the location of the house, without any need for modification, to represent coming down from a height and to represent the feeling of losing control over one's vehicle.

Now we know from "The Interpretation of Dreams" that climbing up or down stairs and romping on hills almost always signifies intercourse.

Playing with the gears could it refer to masturbatory activity? The patient drew a blank here but did not object to the construction.

Why are you going back? I guess I am going back in time to my childhood [to bring a closure to some unfinished business from that period].

At this point a construction was made based upon the theoretical knowledge of typical dreams from The Interpretation of Dreams:

Could it be possible that the car and the semi that crush your car represent your mother, father and yourself?

This provoked a gasp and confirmation of the correctness of the interpretation with:

"I would have never thought of that."

Now we know from Freud's article on "Negation" that no other sentence is greater music to the analyst's ear than patient proclaiming, "I never thought of that," or "I never quite looked at it that way." It says in effect "Oh I always knew that in my unconscious, but, now that you have directly confronted me with it, I guess I can admit to it, but only with a negative prefix." It is a best signpost that one is on the right track.

The patient, who I know quite well, is unhappy with her life. A most powerful wish in her is to return to the beginning of it and rewrite her destiny. The script of this wish/fantasy was carved when she was four. Till then the only child, she had to confront the unpleasant reality of the birth of her brother. Noticing the penis in this unwelcome addition (from her point of view) to the family, she had gone into intense jealousy and rage. The emotions had found outlet by resurrecting from her phylogenetic memory the fantasy of returning to the womb, participating in the parental intercourse there, sandwiched between the two (getting crushed between the two oncoming vehicles), and in the process wresting the coveted penis from her father, as her brother had done.

This fantasy had become more and more powerful with years as life had brought more disappointments. Birth of a second brother and the realization that she amongst all the siblings who had been specially chosen to be wronged.

When the interpretation was made that getting caught between the car (mother) and the semi(father) can be viewed as getting sandwiched between parental intercourse and satisfying the wish to make love to both the parents at the same time, she recalled another dream.

I am trying to escape from zombies. I am first running on foot then in a car. My husband is with me. I run out of gas and have to stop at a gas station. The gas station attendant who pumps my gas, when he turns around, shows himself to be a zombie too. He pours the gasoline on the car and then flicks a match. Then he goes back to purgatory.

Since the second dream was resurrected out of repression on analyzing the first dream, it indicates that our interpretaion of the first dream was hitting the right spots and undid the repression of the second dream enough for it to be recalled. It also indicates that the two dreams are most likely dealing with the same complex.
The second dream was not fully interpreted because of lack of time. But the two zombies turned out to be no other than her brothers who were now coming after her for stealing something (penis) from them. They set her car on fire. It probably symbolized her burning jealousy of her brothers. The theme of zombie was taken from her unconscious wishes for their death and her fear that they will return as zombies and take revenge.

Sleep Apnea and Death Wish

Is sleep apnea an ultimate expression of Death Wish?
Yes, yes, I know scientists have shown its causes, beyond a shadow of doubt, to be physical, psychology therefore has no place in its etiology. Pulmonary scientists have shown that sleep apnea is merely a lack of muscle tone which occurs in apnea folks more strongly than normals, and this factor, along with overgrowth of soft tissues in the airway passage, explains the pathophysiology of Apnea. Why do I want to complicate the matter by bringing in such a funny concept as Death Wish into the equation?
And why would anyone have death wish in the first place? Don't we want to live forever, and what makes me think that this most primary of instincts - to cling tenaciously to dear life - is abandoned in sleep?
But I have a nagging feeling that sleep apnea which is closest thing to death perhaps may be a premature expression of the wish to die and to be free of the rigmarole of life.
In "Beyond the Pleasure Principle" Freud put forward the view that the ultimate purpose of all living organism is to die. Our drives/instincts are conservative in nature and their aim is to restore an earlier state. As soon as life arose - the first drive - it sought to undo the act and strove to restore the earlier inorganic state. It was the bombardment with a fresh trauma and creation of a fresh drive that prevented life from reaching its goal of death in a linear fashion. With addition of each fresh trauma and fresh drive, life became more and more complicated, with each drive seeking death in its own unique way. It is the cross-purposes of these different drives in their endeavor to reach death [eternal peace] which produces the clamor of life.
Sleep is a state of partial death. The real aim of sleep is to die completely. To do absolutely nothing. To give up all our tensions. But we cannot do that. Some basic activity, like the activities of respiration, circulation and temperature must still go on, while the rest of us lies there practically dead.
Yet, when life if hard and the tensions through the day high, in sleep the wish to give up all tensions completely, including breathing and heart activity, to give up the ghost entirely, becomes tempting.
It is this wholesale abandonment of tensions - the stressed man throwing off the yoke of all the cares and worries of the day - that is reflected in the drop in the tone of respiratory muscles. In milder cases in the form of snoring and in extreme cases as sleep apnea. Obesity and hypertension, themselves a reflection of unmanageable stresses of life, act as contributory factors.
Now it is a matter of everyday observation that when we are having a difficult time during the day we sleep poorly and we snore. There is a definite correlation between the loudness of a person's snoring and the stress he is having in his life. So perhaps all these factors obesity, hypertension, snoring and sleep apnea are end points of a person's inability to deal with the tensions of life.

Now do I have anything clinical to bolster such a hypothesis? Do I have dreams that show that in sleep we seek to be free of life's tension and wish for death?

Well, the theme of taking a journey -symbolizing the journey of life - and recoiling from it in horror is perhaps the most frequent dream of humans. And this typical dream, in all its variations, after interpretation, show in it, the two contrary wishes: to die and to cling on to life. The prototypical manifest content is generally framed in imageries such as taking a plane journey and being late for it and missing the flight or trying to reach one's childhood home but never quite making there, getting lost on the side roads, or taking a train journey but getting left behind on the platform or in a very interesting twist a patient of mine, a retired man in his Eighties, would dream of seeing himself back at work and working like a dog. The distress of having reached the end of one's life transposed to distress at having to once again live the drudgery of factory work.
Do I have dreams of a person who actually has Sleep apnea which can support the hypothesis?
One of my patient does have sleep apnea and it was very instructive as to how his dreams changed once he was put on C-pap machine and his apnea got treated.
And what was the change?
During his apnea day his dreams were very vivid and real. In fact they were so real that he would feel that he could actually bring back things from his dream to real life. Pieces of candy, a slice of pie, a mug of coffee; they would appear so real in the dream that he would have a feeling that all he had to do was to grab them and bring them out of his dream into the waking world.
There were other intense dreams as well. Dreams about his family when he was young, romping with his brothers in the countryside - he grew up in rural area, about being on a vacation in a resort hotel, gambling in casino.
Yes, there were dreams of falling off a bridge or drowning in water (fantasy of rebirth) and these pointed to the symbolic representation of death. But majority of dreams were of being intensely alive.
Now such dreams of being intensely alive contradicts the assumption that a common factor produces sleep apnea and the wish to take refuge in death away from life's tensions. In fact the apnea was accompanies by just the very opposite wishes - to be intensely alive. Is there anyway out of the difficulty?
Perhaps there is.
When the patient was asked about the affect accompanying the dreams of playing blackjack in casino and about romping with his brothers in the countryside, he admitted that while the visual pictures were those of enjoyment, the emotions accompanying them were unmistakably those of anxiety and distress.
So those dreams were not so much celebration of life as a denial of death and the dream was showing that "Oh no, you are not dying but you are in casino having time of your life. Or you are about to get a piece of the pie or you are once again a child and having fun with your brothers." So here we see the familiar element of wish fulfillment trying to reverse the fear of death by showing just its opposite - living life to the fullest. However, the wish fulfillment fails to reverse the distress/fear of death perhaps because it was fueled by the real situation of death - the actual apnea - and emotionally the patient continued to experience distress despite the visual imagery being that of enjoyment.
One last point. Since dreams of taking one's last journey and dying -and its denial by showing oneself busily engaged with life - are so universally present regardless whether the dreamer has sleep apnea or not, one must assume that whenever life frustrates us we dream of abandoning this world [and being reborn] and only when this wish becomes pathologically strong does it make a move from a purely psychic process to a psychosomatic one and gives rise to the disorder of Sleep Apnea.

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.