A mourning dream and what Hospices will do to seriously ill

A woman in her early thirties, whose father had died just 2 weeks ago, declared that she was too upset to talk and if I could just write her prescriptions and end the session. Then added that she had the strangest dream last night about her father but could not be persuaded to tell it.

Soon the reason for being upset - besides the father's death of course - emerged. She felt that the hospice people who were entrusted with his care were more interested in seeing him dead than restoring his health. She felt she had been robbed of her father by them.

"I am so angry at myself for not being able to help him. He still had life left in him and did not want to die yet. He would frequently get fully alert and did respond with warmth when his life long buddy Joe came to see him the day before he died.

"He had a heart attack in 2002, had COPD and bad knees, periodic blood clots in his calf muscles, and he could not walk because of the peripheral neuropathy. But none of these conditions were bad enough to kill him. I think there was something more to his death than natural causes. How in the world could that woman tell us that he was going to die in two weeks with such surety unless she was secretly engineering it? And when I asked her as to what was she seeing in his condition that made her so certain about the exact time of his death she got really nasty. And then suddenly the prediction was changed from 2 weeks to 48 hours. And when I reexpressed my doubts, she went ballistic and told me to stop asking her such questions for she was a professional hospice nurse who had overseen the death of countless people, and it is very humiliating for her to be questioned like that. And I could do nothing about the callousness of those evil people. For even my  mother sided with them, and so did my brothers and sisters who were like 'well it is time for him to go, let us not interfere with what is going on'. They are such cowards when it comes to confronting authorities. They would not let me take him to hospital and ask some real doctors at the ER as to why he must die in 48 hours. There was nothing going on to explain his rapid decline except for that morphine drip which I think that bitch was ratcheting up every few hours. And then her prediction changed from to 48 to 24 hours, though she managed to kill him in 18."

I commented that in my experience whoever goes under the care of Hospice never comes out of it alive. Perhaps they are paid a fixed sum to take care of someone presumed to be terminally ill and therefore earlier the person dies the more money they make. And perhaps they are penalized if a person is admitted into their facility as terminally ill and later this assumption is proven wrong. This impression of Hospice I had formed based upon seeing every single patient, with the exception of two, sent by to me to Hospice dying in matter of days to weeks. And even these two could only be saved because I was requested by the family to intervene. One was an 82 year old lady who was terminally ill because they had had her comatosed with excessive amounts of morphine and antipsychotics. Simply stopping her medications not only brought her back to normalcy but such a dramatic improvement that today, eight years later, she is still alive and, believe it or not, went on a Caribbean cruise on her 88th birthday.

Another incident that convinced me of of the lethality of hospice was the untimely death of a friend of mine. He suffered from pulmonary fibrosis, a medical condition which leaves very little capacity to breath. He was undoubtedly going to die but in my judgment still could hang on to dear life for an year or two. He went into the hospital walking, gasping for breath of course,, but still walking. Once stabilized I thought he would go home. But his internist, instead, referred him to a hospice. They came over and took charge of his care even before he was discharged because there were no beds available in hospice and managed to kill him with their morphine drip in less than 24 hours.

On hearing with what contempt I hold Hospices a floodgate of anger was opened in the patient enabling her finally to tell the dream.

I was at the funeral home in which his viewing had taken place. There were a number of mangy cats crowding the parking lot, strangely some resembled my father. Next scene was of his being laid out in the coffin. I was kneeling down before him. The coffin was rather high as if on stilts. I saw him move. He looked alive. I thought to myself that he must be thirsty and therefore he is moving like that. [Just before dying he was thirsty and I gave him juice and water on a sponge which he drank  greedily. Those hospice people were so focused upon his death they had no time to quench his thirst.] Then he started walking out of the coffin as if he had a surge of energy. I was worried how he will get out from that height. But he was strong and vigorous, just the way he had been all his life.  But as he made his way out of thet room,  the hospice people and my mother went in to action.  I noticed that he was still embalmed. I was in pains for him to not notice it. I tried to stand in front of the coffin to hide it from his captors and prevent him from realizing that he was dead.  But they managed to force him back into it and he died all over again.

The dream was obviously an attempt to undo her father's death to whom she was very tenderly attached. The mangy cats were the hospice people and her siblings ( who resembled her father). They were mangy for they hastened his death. But it was also a projection of her own ambivalence towards her father, which is present in all children towards their parents. "She is the one who is doing everything possible to keep her father alive while the siblings, the mother and the hospice people are trying to kill him." His coffin being high up, almost unreachable, was exalting his status to such heights that it would prevent her and others from doing him any harm (desecration) now that he lay dead and helpless.Seeing his father strong and vigorous as he moved out of the coffin was of course the desire to bring him back to his former self that she had loved all her life and undo his death. Preventing him from seeing the coffin and noticing that he was embalmed was to prevent him from noticing her wishes for him to be dead (the ambivalence) .With hospice people and her family bringing him back into coffin and killing him again was absolving herself from all guilt for his death. For much of her day time now is being spent upon feeling guilty for not fighting enough on his behalf with the Hospice folks. A guilt which all of us feel no matter what the cause of the parent's death and whose roots lie in the invariable presence of unconscious death wishes towards one's parents.

An assurance dream in an overly conscientious teacher

A young school teacher who worries too much about making mistakes in her life and professional work,  who dots every i and crosses every t dreamt the following:

A student of her approaches her on the school corridor and states that she is a girl but wants to be equal and therefore wants to become a boy.

There was nothing more to the dream, she insisted.

Associations revealed that she had attended a LGBT conference for teachers a few days earlier. The conference could not emphasize enough the need to be sensitive to budding lesbians, gays, bisexual and transgender children, even in the elementary school. She teaches the sixth grade.

After the conference she had begun to worry whether she had missed out on some lesbian, gay, bisexual, transgender student's needs and was not utilizing her 'skill sets' up to par. Now all this worrying was taking place in her unconscious, for in the conscious mind other than feeling pressured and running from one thing to another to have everything perfect, which she anyway always does, she gave no further thought to the conference till she ran in to the girl who became the subject of her dream. In fact she had no idea that she had had this dream till the girl, who was not in her class but had been her pupil in a previous year and of whom she was fond of, had waved at her on the school corridor. This girl had always amused her by her high spirits and tomboyish ways. And so she served as a good object for the dream to weave fulfillment of the wish.

But what wish?

Was she identifying with that girl and accepting her own wish to be a boy in this world where the female sex is often subjected to so much disadvantage? This could have been a possibility though at the deepest level, for she is quite happy with her boyfriend living with him and looking forward to getting married in near future.

At this point another dream that she had related to me in a previous session came to the rescue.

This was a laconic dream too. Her obsessive nature objects to every form of transgression, which also reflects in her dreams. She rarely dreams, and if she does, they are just one liner, more or less repetition of some scene from daytime, as if any massive enjoyment or excessive emotions is objected to by her overly watchful conscience.

In the dream: She was driving to work and had forgotten to pack her breakfast with her.

Even in the dream she had felt that this was impossible, since she never ever forgets to take her breakfast which is invariably a nutritionally fortified shake, and which she drinks while driving to work.

Analysis had revealed that this dream had occurred on a night when she had some important thing to do at school the next day and she was worrying about reaching on time and doing it right. The worry was disturbing the sleep and the dream had emerged to counter the worry by assuring her that she is as likely to be late and not know how to do the job as she is likely to forget to pack and take her breakfast with her in the morning.

The dream of the tomboyish girl approaching her and declaring that she wants to become a boy was constructed on the same pattern. It was to assure her that she can stop worrying that she is not using her newly acquired skills on how to help her pupils with LGBT issues. For in the dream a girl had approached her with gender and orientation issues and she was being sensitive to her needs. 

The purpose of yawning is to stall sleep

Two score and two years ago, as a medical student, I learnt that the medical science does not know why we yawn.

Yesterday, I came across a patient whose yawning and the accompanying behavior threw some light on at least one of its functions in humans. It was but natural then to Google and see if some whippersnapper had not already arrived at the same conclusion. To my pleasant surprise - for that gives me justification to post my observation - researchers are still in dark as to why we yawn.

The most interesting link was to a New York Times article by Nicholas Bakalar - date Dec. 13 2010. And this is what he had to say : Everyone yawns, but no one knows why. Yawning starts in the womb, and most vertebrate species, even birds and fish yawn, or at least do something of the sort, but its physiological mechanisms, its purpose and its survival value remain a mystery.

My patient is an interesting middle-aged single man who carries the diagnosis of Developmentally Disabled though his intelligence is normal. His pathology which erroneously gives the impression of mental retardation is confined to stuttering, autistic traits, social awkwardness, OCD, occasional chastising hallucinations, and a surplus of rage.

The patient had come to the office all set to enthusiastically embark on his session. But that day I was running unusually late, and this extremely controlling patient, who wants everything on his term, did not like the put-down one bit. And therefore when his turn came, he had nothing to say. In fact within minutes of starting the session he declared that he was all done and ready to leave because he had errands to do.

It was a classic tit-for-tat for making him wait.

When told he cannot leave earlier than his allotted time per rules of treatment, he first felt his bald pate by sliding his open palm over it as if to make sure he was there, then closed his eyes and brought his hand down to squeeze the root of his nose between his thumb and middle finger as if in deep thought, and then wearily opening his eyes began to yawn.

The purpose of his yawning to the trained eye of the psychoanalyst was crystal clear:

it was unequivocally saying: I rather be somewhere else and if I cannot do so by walking out of here I can at least do so by becoming oblivious to you through falling asleep and dreaming of being somewhere else.

But there was more than just an avoidance through sleep. There was also a contrary impulse: a struggle to not fall asleep as well. As if outright sleep would be too contemptuous and would upset the social balance between him and me. And though it looked as if the yawning was to usher sleep its true purpose was just the opposite: to prevent him from doing so.

There was no doubt that the whole behavior taken together was a show of counter-contempt and expression of boredom - if I had been uppity towards the value of his time he too had nothing of worth to tell me either. But yawning by itself was not promoting sleep but activating him to keep awake.

So this observation contradicts the view lay people and many scientists take it as self evident: yawning occurs when we want to go to sleep and no doubt it is there to aid sleep. In reality it is an attempt to halt it.

In my patient's case full blown asleep would have been too defiant, and anyway it was not practical to do so in the middle of the day. So he was trying to stall sleep and the physiological mechanism that was being used to achieve the aim was activation of the yawning reflex.

But how does yawning promote wakefulness?

I think by opening the mouth wide, gulping a huge bolus of oxygen and tensing up the muscles around the face and upper torso, the person [at unconscious level] signals to the brain that "look you got to be awake. It is not the right time or the place to fall sleep." The increase in oxygen supply and the rise in muscle tension sends the message to the neuronal circuits that promote wakefulness that it is time to stiffen and gear up, not cut down on your oxygen consumption and call it a day.

In my patient every yawn was followed by a clear, though brief, increase in alertness. And in those moments of flickering arousal he would look at me with an expression which seemed to say "don't take my rejection too seriously, I still respect you, I am still paying attention to what is happening, you are not boring, look I am trying my best not to fall asleep on you."

But this heroic effort to honor me was contending with the counter impulse to break contact with a painful world which had shown no respect for his time and had undervalued him. The ambivalence on the patient's face was clear: aggression/contempt/disdain for me alternating with the counter-impulse to not push the envelope too far.

Now the New York Times article tells us that the scientists have given up on the theory that yawning occurs to increase oxygen supply to the brain. The argument goes that increased oxygen supply can be more effectively achieved by increasing the rate of breathing.

Perhaps the scientists abandoned the oxygen theory prematurely. For it has some merit. Yawning increases the oxygen supply not on a sustained level, as would be required while exercising, or playing sports, and which would be best achieved by rapid breathing, but a brief bolus of oxygen in to the system could be used as a signal to the brain that it is not time to decrease your oxygen consumption but to continue it at the current level to maintain the waking state.

If the purpose of yawning is to activate some parts of the brain to produce wakefulness, why does the person not become fully awake after a yawn of two? Why do humans go into serial yawning and why it is so infectious?

We have already discussed that yawning expresses an ambivalent state of mind. There are two contrary impulses wanting to find expression together and a compromise is reached in which the boredom and sleepiness alternates with yawning which wants to kick-start re-engagement with the world.

It may not be amiss to add that this re-engagement is psychologically effected by activating some quiescent pleasant memory which is somehow associated with the boring situation/person and may induce a fresh interest in what is going on. And this mechanism is perhaps mediated by dopaminergic neurons.

Why dopaminergic neurons and do I have anything to back up such a speculation?

Well there is a chemical which artificially activates yawning. It is called Apomorphine. Since it is attenuated form of morphine it is a narcotic and promotes sleep. Yet, it is a dopamine agonist, a stimulant, which simultaneously promotes arousal and attention. So the chemical apomorphine seems to be heaven sent to confirm my hypothesis that yawning is like a front that expresses two contrary impulses: withdrawal/sleepiness and struggle to maintain wakefulness. And from my previous entries in my blog, specially on the matter of addiction and ADHD, we know that dopamine is a neurotransmitter whose main purpose is to repeat experiences of satisfaction [produce stereotypy of pleasant behavior]. So the release of dopamine in a yawning person is to stimulate pleasant past associations with the current situation/person and reawaken new interests.

Yawning is catchy because if one person signals that I am bored and I have to yawn to keep my focus on you then others counter it by sending the same signal back - you are not worth my attention/wakefulness either. It is similar to how children handle insults. If a child tells somebody that you are a liar, you can count upon getting an immediate retort: "And you are another."

But imitation of yawning may not necessarily be a retort. In a group if one person finds the situation/ surrounding boring and yawns then others follow suit as if to lend support to him: "yes, yes, we second your feelings. What is happening here is not worth our attention either." Here it is more following the leader than tit-for-tat.

Yawning as an expression of disdain as well as an attempt to not make the contempt too blatant was first driven home to me a long time back when I was being ousted as the Acting Chief of Psychiatry at the VA hospital Allen Park. Having brought too many changes too soon and never the one to mince my words when expressing contempt of superiors if they were on the wrong or foolish, I was being stripped off the post.

And the ousting took place in a board room where a bunch of doctors were assembled. They were all tense as the Chief of Staff started reading to me the riot act. The tension was palpable because they expected a spirited comeback on my part. But to their surprise and mine as well, I had hard time keeping my eyes open to what was being said. I found their anger towards me stupid, and knowing that protest was useless, and the whole affair not worth even paying attention to for my fate was sealed, I had tough time keeping awake, and that is what must have triggered the yawning reflex. For I yawned with abandon. And I could not help but notice that the pain of getting dressed down and stripped of the post would temporarily abate while I would be tensing the muscles of chest and my face for the act of yawning. As if that muscle tension was discharging the aggression towards the people who were harming me and consequently generating sensation of pleasure.

Is there any condition where yawning occurs pathologically?

Yawning is a prominent symptom of narcotic withdrawal. Along with diarrhea, muscle and abdominal cramps, runny nose, sweating, tremors, irritation, anxiety, goosebumps there is yawning. Yawning in severe withdrawal can happen every couple of minutes.

One of my patients reported that when she is withdrawing from narcotics she yawns continuously. She gave the following explanation for doing so. Her withdrawal is always marked by high anxiety which turns into nightmares and cold sweats when she falls asleep. So sleep becomes a dreadful and frightening affair which causes insomnia. However, one part of her mind tired from days of abuse and pressured living craves for rest. So the tug-a-war between keeping awake out of fear of dreaming dreadful things and the wish to sleep out of exhaustion sparks the yawning.

She added that only other way to combat sleepiness besides yawning for her is to get absorbed and keep the mind super active with something like cleaning the house or going back to her job as a waitress and make some money. Now both these activities obsessively cleaning house and feeling good about working and making tips are pleasurable activities which secrete dopamine. She reported that yawning also results in a slight improvement in her mood. While yawning her dysphoric feelings abate, though only while she is stretching and tensing the muscles and there is a definite feeling of pleasure though very slight in intensity. In her case yawning is interchangeable with other pleasurable activities and all of which are mediated by dopaminergic neurotransmission.

The original physiological purpose of yawning appears to be part of the orchestrated neurodevelopment which no doubt occurs as a sequential activation of one part of the brain after another. Yawning may play a role in this complex activity through activation of motor neurons which tense the muscle around the mouth and upper torso. This tensing of muscles perhaps releases dopamine which may play a role in making bridges between already active neuronal circuits with freshly activated ones. This physiological reflex which evolved for neurodevelopment appears to have found a side purpose in humans to signal boredom, express contempt and counter the impulse to go to sleep.

ps 3-13-13 Today I saw a patient who once again confirmed by hypothesis that yawning developed as a mechanism to stall sleep. This young man is not getting along with his girlfriend. In the session when he broached this issue within a short time he was flooded with painful emotions and instead of going further with what he had to tell he indulged in a giant yawn. From his expressions I could not help but notice that as soon as his conflict with his girlfriend emerged in his consciousness he first tried to talk about it but as the pain associated with the memory followed in to consciousness he lost interest in the talking and tried to withdraw in to sleep where he could turn the painful memories into pleasant ones through the mediation of dreams but on realizing that it would be not appropriate to fall asleep in front of me he yawned to activate the neuronal circuits connected with wakefulness.  

ps. In the Wall Street Journal 7-16-2013 I read a small write up titled "Why you may yawn less in the summer." It quoted a study which conducted an experiment with two groups of people. One in early summer and the other in winter. They were made to look at pictures of yawning and encouraged to talk about their own yawning behavior. It was found that people were more likely to yawn during winter than early summer months. The reasoning given was that in winter yawing would reduce the brain temperature more. This is not a joke. The study was published in impressive sounding Frontiers in Neuroscience so it got to be true. Yet the question arises why would anybody want to reduce his or her brain temperature especially in winter when you would want to conserve heat. The article claimed in summer the outside temperature was closer to body temperature so the cooling effect was not as robust as during the winter so there was less benefit from yawning.

Now my own experience is that in  uncomfortably hot weather too the tendency to yawn increases. And the explanation may be simpler. When it is uncomfortably hot in the present then a person wants to go to sleep so he can dream of being in the Alps or better still on the peaks of Himalayas. If one is in cold weather the desire to go to sleep and conserve energy is even stronger. So whenever one is in unpleasant surroundings one way to escape from it is to go to sleep. But if it inappropriate to fall asleep in the situation then the yawning mechanism kicks in to activate the wakefulness centers of the brain. Since cool air is a sharper stimulant than air that is nearer to more comfortable temperature it acts as a sharper arousing agent and is gulped in larger quantity through yawning. 

Distractibility of ADHD is a reflection of anxiety/fear

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

Two unusual therapeutic effects of Adderall - promotion of sleep and control of paranoia

One thinks of  Adderall (Dextroamphetamine), the prototypical psychostimulant, as something one would avoid to get restful sleep. Yet, two of my patients use Adderall as a sleep agent. Since this paradoxical effect throws some light on how dopamine activation helps in ameliorating symptoms of ADHD, I will give a brief account of these two cases, and then make some theoretical comments.

A single woman, in her early forties, never married and with no issues, attractive and shy, who lives a lonely life, a result of excessively fearful disposition, and whose temperamental sensitivity is so high that the slightest social or environmental threat during the day causes affective disturbance for hours, and, at night, the slightest noise wakes her out of sleep, requested Adderall. Someone she knew had suggested it to her, and after reading about it on the Internet she claimed that she has many of the symptoms that Adderall is supposed to help with, and since none of the other therapeutic efforts have made a dent in her condition I should give her what she was asking for.

But I was reluctant to prescribe her Adderall. None of the previous medications had produced lasting results. She came to me burdened with the label of schizoaffective disorder, probably tacked on her by biological psychiatrists to justify giving her all kinds of medications without having to know what was really wrong with her, and had been tried by them on numerous antipsychotics - dopamine neurotransmission blockers.  Except for Zyprexa, all other neuroleptics had made her miserable. Even with Zyprexa, her mood had not been quite right. When asked what she meant by "not quite right", she stated that Zyprexa made her feel that she was "part of a system", and it left her "high strung". Antidepressants had been equally useless. Only Prozac had helped, but for just a few months. Diazepam and Clonazepam had helped with agitation and anxiety but they did not ameliorate the fatigue, body aches and pains, and while they helped her with falling asleep their effectiveness had dulled over time. But my greatest concern was the presence of what looked like a predisposition to develop paranoid psychosis. She showed phobic fear of people and going to places away from home, especially if she was likely to run into African-American men. These were clearly hysterical defenses and projection of her own hostility - rather ambivalence; unconscious attraction and consequent fear -  towards black men. But then she sometimes - pointing more to some genuine paranoid process - complained that neighbors talked and criticized her as a "freeloader" living on welfare because they did not see her going to work and just hanging at the apartment complex. In reality, her expenses were taken care of by her elderly parents who barely could make both ends meet and she felt very guilty about taking money from them.

When she would not take no for an answer I went ahead and prescribed her Adderall. Very low dose, just 10 mg., and reluctantly, for though she protested that my recall was wrong I had the memory of her once complaining to me that she could actually hear the neighbors talking about her which sounded like frank auditory hallucinations.  And amphetamines are known to exacerbate paranoia. In fact, one of the most used animal model of psychosis in pharmaceutical research is to give very high doses of intravenous amphetamine to rats and other lab animals.

But when she returned in a month - she has no insurance and cannot afford to see me more often than that - my apprehension that Adderall will worsen her paranoia proved to be wrong. She had shown a good response to it across the board. The best proof of which, she claimed, was her restored ability to watch TV and read books by sitting down for a while instead of running from one place to another trying to calm herself down. When asked as to how the medicine achieved this she said because it stopped her mind from racing excessively.  What was even more surprising was that even her paranoia was better. Now she felt comfortable talking with neighbors, including a black couple, and added that they should reclassify Saphris and Latuda as not anti-paranoid drugs - both had failed to help her - and declare Adderall as the true anti-psychotic. In praise of Adderall, she also added that it gives her a boost of energy and makes her more confident of herself. A further benefit she claimed was that since she is less fearful during the day she can interact better with people and as a consequence sleep better at night.

The second case is a little more complex for though superficially it appeared as simple manic-depressive illness, it was highly complicated by a traumatic neurosis. She was subjected to a shocking, humiliating and painful rape that occurred when she was just twelve and a half years old. She had been pulled inside a car near her house, by two 17-year-old men, and after being driven for a short distance into an alley, subjected to the rape. The psychological content of her manic-depressive illness was entirely about undoing this trauma and getting even with the perpetrators. During the upswings she would be suffused with energy to take revenge and would drive aimlessly for hours hoping to run into the two rapists and subjecting them to the exact same pain, humiliation and physical act through the agency of another man that was perpetrated upon her, despite the fact that the trauma had occurred more than 25 years ago and the prospect of meeting them was almost zero. The only thread she had to reach them was overhearing them while they were molesting her that one of them was going to have his 18th birthday next week and from their conversation, she could also make out that they lived locally. She remembered their faces clearly and assumed that if they were 17 years old then that year's high school yearbook would have their pictures and names and from there she could research further and finally trace them out. Despite driving around for endless number of hours for decades she could never take the final step of getting to the yearbook. These upswings would start with the search for those rapists but soon would change from euphoria into tense dysphoria and a great dread of going completely out of control like turning into a serial killer and then she would seek company of a trusted friend, counting upon her to keep tabs upon her and not enter into complete craziness. When asked if she would really turn into a serial killer she said that it happens only to those who do not receive their mother's love. In her case though her mother was not at all nurturing her grandmother was and the latter's memory would act as a barrier to her becoming totally evil.

The downswings would be filled with pessimism, suicidal thoughts, inability to get out of the house, sleeping through the day, inability to do house chores and go to work. Fortunately, her boss was her friend, who accepted her mental limitations and expected her to come only if she was feeling up to it. The trauma had also generated in her fibromyalgia which required Tramadol a borderline narcotic. To make matters worse she had extensive obsessive-compulsive behaviors and rituals, including the tendency to hoard, the etiology of which owed heavily to the fact that after the rape her mother had taken no steps to take her to the police station and take action against the rapists, and in fact had cast doubts at  her story, suspecting her to have been compliant with it,  provoking a tremendous rage in her towards the mother, the flare-up of which now was handled by turning the affect and the accompanying aggressive impulses into obsessive-compulsive rituals. The rage towards her mother, however, was present even before the trauma, a precipitate of an intense Oedipal conflict. The mood swings also existed before the sexual trauma and were a reflection of her high intelligence and talents. She was on Topomax and Saphris to control her mood swings. Which as the case history shows were doing a very limited job, and she often felt completely out of control during the upswings.

What however is the real subject of this communication is the role Adderall played in her daily functioning. Without Adderall-XR she could neither motivate herself to go for work nor could she sleep. She took 15 mg. of Adderall-XR around noon to help her step out of the house and go to work. But additionally, she took 15 mg. of Adderall-XR every morning at 7 am to get two hours of very intense sleep. She rarely slept at night, and after tossing and turning all night long would get up at 5 am to get her children ready for school. After sending them to school she would take the morning dose of Adderall and go into very deep sleep till 9 am.

When asked how does Adderall help her to sleep, she claimed it stopped her racing thoughts. Her brain stopped trying to be in 100 different places allowing her to concentrate upon sleep. Analysis revealed that her mind was racing to all these different places to prevent harm coming to herself and her children. Her mind would not shut off busy trying to put out fire everywhere.  But once she took Adderall she felt protected and did not worry as much. She added, "You know how I sleep with lights and TV on. The brightness of the light and the noise from the TV act as my companions." When asked why does she not take Adderall at night and sleep through the night she said that that Adderall does not work at night. To get into a real deep sleep which requires that mental vigilance/ego tension be dropped she needed the additional protection of daylight. With the TV on and daylight there she did not feel alone and vulnerable. It may be mentioned here that she was abducted and raped while walking home from a friend's house at dusk and blames her mother who ordered her to return before dark and wonders if that phone call had not come at that particular point of time would she have escaped running into those two boys.

Why does Adderall a dopaminergic agent which wakes her up and keeps her alert during the day and while at work, works in just the reverse fashion in early morning hours, enabling her to sleep?

In both my patients what Adderall appears to have been doing was to act as a barrier against fear. This surmounting of fear with the aid of dopamine - a sympathomimetic compound - made the first patient more social and less paranoid and by getting more satisfaction out of life during the day she did not have to take her conflicts to bed and dreams and thus sleep restlessly. In the second patient, the daylight and the noisy TV  were protection against fear but were insufficient by themselves and only with the addition of Adderall the balance was tipped in favor of allowing her to fall asleep deeply, though for no more than two hours. Daylight may have signified that most of the world was awake now and could be summoned for help in case danger came her way.

 In both cases, Adderall reduced the racing thoughts. Fear makes one want to run away, and if one cannot run on their feet they run in their imagination (daydreams) and racing thoughts. So at the root of racing thoughts lies the motive to run away from the situation in hand and when the conflict reemerges at the new locale to run from there to the next and so on, resulting in trying to be in 100 different places at the same time putting out fires everywhere. Children with ADHD cannot concentrate either because they are running away from their internal fears - in most cases unresolved Oedipal conflict where the  residual (unconscious) sexual attachment to the mother and corresponding fear of the father keeps generating fear/anxiety - and thus their mind is racing and unable to concentrate on what is happening in "here and now". Amphetamines by enforcing dopamine secretion and thus giving a sense of something positive happening raises the person's interest in the immediate surroundings. This sense of something positive happening gives the feeling that this situation is pleasure giving, therefore not dangerous, and where one should focus one's attention to get more of similar pleasure.

One must caution that these two cases are not typical and as a rule amphetamine prevents sleep and exacerbates paranoia.

Autism may be precipitated in vulnerable OCD inclined people because of too early separation-individuation from the mother

There is little doubt that autism is more likely to occur in children whose parents are high functioning, socially well off, and obsessional neurotics.

Watching an autistic gentleman who is now in his early Sixties, and who possesses some remarkable abilities though lacking in the most basic skills to live on his own - he lives in a Group Home and requires 24 hour supervision, I was impressed as to how solid his ego was in some areas and yet so remarkably childlike in others. He knows the names and intersections of virtually all major streets of Detroit Metro area, and quite a few of many other cities which he has visited in the past, the birth dates of countless acquaintances, the lyrics of hundreds of songs with all kinds of facts about the ones who sang them. For example this week in the session out of the blue he told me in one breath that Kid Rock was born in 1971, his real name is Robert James Ritchie, he once lived in Taylor and Wyandotte, his son is 18 years old, his first song was Cowboy baby. Then he mumbled something incomprehensible - as if he was having a mini-tourettes - and said that makes him 51 years old. When I contradicted him and said that should be 41, the patient counting on his fingers the decades insisted that no he should be 51 for  between 1971 to 2012 there are 51 years. As to why behind the tremendous memory of obsessional neurotic lies the desire to insult and defy through distorting some aspect of the other person, usually their name or their age, and as a reaction formation (over compensation) one memorizes every trivia about the other person see my post of 9/10/10 "The phenomenal memory of Obsessional Neurotics and Autistic Patients."

But anyway why does this man who is full of knowledge of these trivia cannot use his great abilities in knowing and mastering things that have practical value? What strikes one about him is how the slightest disturbance in his routine throws this man in to a tantrum. Everything has to be done in the same way, and beyond his routine he enjoys nothing. He wants everything to be predictable and in order. The thing that gives him greatest joy is watching a train come down the rails. The train on its tracks is absolutely predictable as to where it will go and how one carriage will follow the next. Nothing in the movement of the train ever goes out of order. The joy in it was not dissimilar to how some autistic children are completely fascinated by revolving musical discs or ceiling fans where the motion is completely predictable with one blade following the next and never getting out of its circle.

In this patient a most telling characteristic is how he wants his needs to be taken care of immediately. The slightest delay makes him angry. In order that his needs get fulfilled immediately he wants very few things. But what he wants he wants right away, without interruption and in a predictable manner. For example when he comes to my office he wants his first cup of coffee the second he enters and the second one about 10 minutes later. He wants exactly same amount of cream and sugar and wants the empty cup to be thrown in the garbage can in exactly the same fashion while he is giving me directions on how to do it. One wonders  whether at a very tender age when his needs (id impulses) were intense and they all wanted to rush out pell-mell, the mother instead of having a feel for it and helping him to let their emergence take place in an orderly manner just left him to deal with it by himself. Or even if tried to help him with it did not have the right sensitivity to the overwhelming emotions that were being generated in the child.  And as a consequence the patient dealt with his helplessness midst the pressure of so many needs to pay attention to a few of them and just ignore the rest, leading to development of an ego organization which became remarkably good and precocious in some areas and completely useless (indifferent) in others. No wonder he had such a remarkable appreciation of the orderly manner of trains where each bogie (need) followed the next in a most consistent fashion unlike the chaos that existed with his needs when his mind chose the autistic path.
It appeared to me as if in many mothers there is lack of fluidity in their feel for their child. Instead of the child being seen as part of oneself and the ego boundaries between mother and child being porous, the mother has too much sense of her own discrete self, separate from the child. Perhaps our highly educated latter day parents belonging to higher socioeconomic strata and having their highly organized career oriented life styles are dealing with their children also in the same highly organized cerebral ways. So in the earliest months of life when the child needs a mother who is not too differentiated from him, who feels one with him and who can sense his needs instinctively as her own, he is saddled with a mother who is full of knowledge from books and other media sources on how to be a good mother without having sufficient emotional and instinctive feel for the child's needs.

This affects the child's development of the ego in two ways. One it encourages him to prematurely develop his own ego, very strongly, very rigidly and very exclusive of anything that looks alien and beyond mastering.  Secondly, the child identifying with the mother develops his ego in her footsteps which due to its high functioning obsessive style has little place for emotions and which values organization and success in the outside world as of greater importance than emotional enjoyment and being one with one's offspring.

The massive size of the brain of autistic child in the first few years of life also may be a reflection of this premature and strong ego development. If a child does not have his mother empathically available to him then he has to hypertrophy his own brain to take care of his needs. The neuronal pruning which is so important for normal growth much of it must occur as a sympathetic response to the behavior of empathic caretakers. A failure of such pruning, along with excessive generation of neurons for strong ego development, may underlie the abnormally large size of autistic children's brains. In our earliest years we are all id (drives) and very little ego. It is the parental ego that serves as "auxiliary ego" providing the necessary wherewithal for the child to survive and develop necessary skills to communicate with others and learn to discharge its id drives in association with others. In autistic children there is a premature attempt to develop an ego when the parental ego behaves in a manner which is not quite right for the child's needs.

8-22-2014

Today I read in New York Times an article that supports my above contention: it is failure of neuronal pruning  - because of lack of empathic caretakers - that lies behind the abnormally large size of autistic child's brain. The article titled "Study find that brains with Autism fail to trim synapses as they develop", which was published in the journal Neuron on 8-21-2014,  summarized the findings that at younger age the normal and autistic children have same amounts of synapses. But as they get older autistic children's brains fail to prune normally and their synaptic connections are far more dense.

The author, David Sulzer, of the study summed up his  observation with the quote, "You need to lose connections in order to develop a fine-tuned system of brain networks, because if all parts of the brain, all you get is noise."  Ralph-Axel Muller, another neuroscientist, commented on the study with the statement that autism is problem of overconnectivity.

So in autistic children there is too much internal brain activity going on. And it stands to reason why. If the mother (and other caretakers) are not emotionally and empathically available in the outside world then the baby will start communicating with his own self (his brain instead of communicating with the brains of his caretakers - and thus prune those synaptic connections that are unnecessary for communicating with others - will start communicating within itself.)

It is interesting that Sulzer does not look for the etiology of this failure in pruning to the obsessive-compulsive rigidity of the parents in understanding the needs of the baby. Instead they look for it in malfunction of proteins and other biochemical processes.

It is still not politically correct to look for the primary problem of autism in defective human interactions rather than biology.  

Recurrent dream of being left behind by one's siblings and highschool classmates

A woman in her mid-fifties, mother of three children and couple of grandchildren, who suffers from anxiety and depression and smokes to control that anxiety, asked the meaning of a recurrent dream, which she has had throughout her life, but recently, after she was hospitalized for COPD and pneumonia, was having it with greater frequency.

The dream is about myself and my sisters. As you know I have two sisters.

I am being left behind by my sisters. This is the basic theme, with minor variations. The one I saw couple of nights ago, we were on vacation in Las Vegas, in a Mall.  The two were together, ahead of me, while I was left behind. I never see them but I knew they are in the Mall. I go from one floor to the next but never reach them. Everything looked unfamiliar. I just keep looking for them in a daze.  

"Are your sisters older than you, and you are attempting to catch up to them to dissolve the age gap? You know how small age disadvantage with siblings is so acutely felt when one is young."

"I am the oldest. So that could not be the explanation.Though we are all just one year apart from the next. So we are more or less of the same age."

"Why the dream takes place in Las Vegas?"

"Because we take vacations together, and not too long back we took one in Las Vegas. The last one was in Florida.  Both my sisters live in California. [Las Vegas is in between California and Florida though much closer to the former so the dream may have chosen a venue closer to the two sisters than to me]. But though both live in California, they are not closer to each other than to me.  I am not the one who felt left out in Florida. They were the ones fighting while I got along with both. In Vegas too I was never left behind. We sometimes would go our own way to different sections of the casinos but we never were like lost to each other.

"Now I remember that being left behind also occurs in another set of dreams.  In these dreams my sisters are replaced by my classmates from high school.  The theme is the same, of being left behind. I am trying to catch up with my friends who have gone ahead and are already in class. I am like excluded which is odd for I never had problems fitting in with my peers in those days. The dream scene usually is of my trying to open the locker in the school corridor where my books are without which I cannot go to the class. But I cannot recall the combination to the locker. I try hard and almost get every number right but while punching the last one or two, some error occurs. There is nobody around to help either.  Not even the girl who shared the locker with me. Even if I had got the combination right, and the books out, it would not made a difference for I would not have found the classroom." 

After she drifted in to some other issues and I had some time to think over the dream, I conjectured that it was perhaps a punishment dream.  "Could it be possible that your getting left behind by your sisters and classmates is punishment for your belief that you have done them some wrong. Perhaps it is propitiation for some guilt arising from your unconscious hostile intentions towards them?"

"Could be. But why would I dream of getting punished. I have not done them or anybody else any wrong."

"The need for punishment in humans has very little to do with having actually done something wrong. In fact the less harm one does to others more is the psychological impulse to harm oneself. It is not carrying through the intention to harm others that creates guilt that seeks punishment. The guilt turns the intention to harm others in to harming oneself. It is a vicious cycle. It sounds paradoxical but true. One would think that one would feel more guilty if one actually harmed others. But people who actually harm others do not feel as guilty as those who suppress it. For the intention to harm others does not find a discharge and sits inside the psyche requiring creation of more guilt to keep it under control. "

"I don't understand what your are saying. But I don't feel any guilt in me."

"The sense of guilt is generally unconscious. The ego blocks its entry in to consciousness. In our conscious mind we just feel a sense of uneasiness and impulse to create a situation which is harmful for our self interest.  Even this self-harm is done in such subtle ways that they appear to be act of fate or bad luck rather than cleverly manipulated by oneself. We do know as a child you had quite a bit of rage against your parents for their constant fighting. Perhaps that rage to prevent it from being acted out has been been transformed into sense of guilt."

"Yes, that is true. I was angry at my parents, and I left home at age of 16 to escape their constant fighting. I don't remember having any resentment towards my sister. I do recall feeling guilty for leaving them behind in that stressful house and making my escape. I was their protectoress, and I abandoned that role and left to get married. So if anything I was the one who left them, but in the dream it is just the reverse. It is they who are leaving me. I don't think your interpretation that the dream is about punishing myself for having evil thought holds good."

"You were the first born, and your two sisters came right after you, one year apart. You must have resented their appearance. There may have been wishes towards them when they were first born to disappear. Later there may have been fear of their disappearing and thoughts of deserving punishment for having entertained such thoughts. So the dream may be showing the fulfillment of this wish for them to disappear and then the fear that you will be all alone, for you love them too and enjoy their company, is making you search for them and undo the wish."

"I don't think the dream is about punishment.  Or at least it is not the whole explanation. For I wake up not so much with guilt as with anger for their having left me behind."

So we were at an impasse.

The patient then came up with the idea that the dream of being left behind, though, has periodically recurred, has been emerging with far greater frequency since the doctor at the hospital scared her by saying if you don't stop smoking you are going to die. 'He was very mean and kept shouting at me, you are going to die, you are going to die."

In one stroke the meaning of the dream became clear. Being left behind and never being able to find her sisters was nothing but the fulfillment of the wish that it is my sisters who will die before me, and in fact I will never meet the same fate and will never be able to reach the end of my journey (death). The unfamiliarity of that Las Vegas Mall was a reversal of the great familiarity of this world. "The world is still so unfamiliar and new to me and still so much in need of exploration that I cannot die yet" was the rationale behind it. "My sisters can die, but I still have a lot to discover and I therefore will keep on living."

The patient readily agreed with the interpretation and added, " I just came back from Florida where we sisters had got together for our annual vacation. And the two were fighting with each other. No doubt a continuation of the bickering that existed in the house when we were growing. And one of them looked sick and yes I felt sorry for her and did worry about her dying.

"Thought of death has always played a very strong role in my psyche. My first born died when he was 18 days old. He was premature. That left a deep scar in my mind. Even now I dread something terrible happening to the ones close to me. I think of macabre things happening to my children and grandchildren. I hate those thoughts. But they are the core of my illness."

"Yes. The thought of their death is just a displacement of the thought of your own death, which you want to avert by thinking of somebody else's death, just like fear of your own death implanted by the doctor who scared you, you were working it out of your system  by thinking of the death of your sisters and your classmates. They emerged in your dreams for dreams are nothing but your everyday thoughts couched in the language of dreams."

"Interesting you say that. I must have a grudge against my classmates too, for I had to leave school because of pregnancy in final year and I could not graduate with them. Instead I got my diploma through GED. I felt odd returning to the school once I had to leave for pregnancy. So I may be getting even with them by thinking that just like they left me behind and graduated earlier than me they can once again leave me behind and die earlier than myself. For when I wake out of the dream it is not feeling of guilt and feeling of being punished that fills my heart but an anger at those girls for having left me behind."

I wondered if the locker box was not symbolic of the coffin, and inability to find the right combination a struggle against the wish to die and be over with life.

Patient stated, "I never thought of that," which is like music to a psychoanalyst's ear, for it invariably means that the interpretation is correct. By these words the patient confirms yes, it is true, but it was in my unconscious, and consciously I never thought to it.

"Could it be possible that the classroom also stood for coffin or burial room and inability to find it was fulfillment of the wish to never find the final resting place?"

"Perhaps," the lady responded.