Interpreting a dream just by Manifest Content

 I received the following on my email.

 I hope you can give me insight into a dream I accidentally ran across your blog. Thought you can help me decipher the symbols. So I'm sitting holding my son in my lap looking out into a bunch of chickens, one turns around and it turns out to be a small baby cockatoo with one big green right eye. It starts going toward me is picked up by a child and its carried toward me. It opens its beak and out comes a white cobra, super long it keeps coming and coming. I'm calling out to my father and he is taking his time. I comment good in an emergency you are taking long enough.. Here I wake up.

Should one interpret a dream without obtaining the associations to its individual elements from the dreamer? Or more correctly can a dream be interpreted at all without being privy to the associations?

Some dreams are transparently simple composed entirely with typical symbols and one can guess its hidden meaning quite accurately. But most dreams will have quite a few obscure elements which are quite personal to the dreamer and unless one is familiar with the patients life experiences one's interpretation can be way off mark Nevertheless some elements of a dream can be made sense of in most dreams. The one I have been challenged to decipher has few elements like that. I must admit I could be totally wrong in deducing the following.

I'm sitting holding my son in my lap

This immediately conjures up the image of Madonna with baby Jesus. The dreamer appears to relish her role as mother and is looking out into a bunch of chickens for another child - chickens symbolizing children. Patient apparently had access to watching chicken coop in her childhood where her first sexual curiosity was satisfied and where she first saw parallels between chicken and human family lives.  The fact that one turns around and it turns out to be a small baby cockatoo strengthens the conjecture that the chicken were symbol of children.  Cockatoo being more colorful and nearer to human child, and the fact that it was being carried by a child towards her confirms that she is wishing for another child.

It is difficult to say what one big green right eye means. One will have to get her associations to why the eye is green, why just one and why exclusively the right one. Each of these elements will have their own meanings. Perhaps some relative of hers has green eyes which she would like to have in her own child or perhaps the man she is attracted to and from who she wants to have the child has green eyes. Right in dream usually alludes to what is moral or correct while left signifies sinister or wrong or against the norms.

It opens its beak and out comes a white cobra

The beak and cobra both are symbols of penis. The dream perhaps is alluding to the fear of sex and male genitals, something that the woman has to bear to obtain a baby. The fear may be a childhood fear and only traces of it may be present in her present state but it is present in all women at least in childhood - a fear of sex and the fear of being harmed by the sexual act because of the large size of the penis. This fear is alluded to in the dream by and out comes a white cobra, super long it keeps coming and coming

Why it is white is difficult to say. Generally white alludes to death or purity.

I'm calling out to my father and he is taking his time. I comment good in an emergency you are taking long enough.. Here I wake up

This is call to help from her father to save her from having sex with a man and coming to harm. She is trying to reactivate her love for her father as a shield against succumbing to the charm of another man and for the wish to have another child. There is a wish for sex and recoiling from that wish for the former could prove dangerous.

A dream of teeth falling out.

Psychoanalytic theory considers dream of losing teeth a punishment for autoerotic indulgence. Recently I came across a case which supports this formulation.

The patient who is in her early thirties, but behaves more like a child because of hysterical defenses that were erected early in life to control her overarching sexual drives, and who currently lives with her boyfriend, opened the session with the statement "I have a dream for you to analyze," and proceeded to tell me the following:
 
I have finished my studies and got my diploma, and I am now all set to work. But my boyfriend instead of being happy at what I have accomplished wants to kick me out of the house.

She added, "What is so strange is that my boyfriend, fiance, whatever you want to call him, for he plans to marry me next year when I am done with my studies, in real life cannot tell me enough how he cannot wait for me to finish school and get a job so we can have extra money. But in the dream he is doing the reverse: telling me to leave.  It makes no sense. If he really wants me to leave he should be telling me that now, when I contribute nothing, not when I am done with my studies. But the dream keeps recurring. Which reminds that there is another dream that I am dreaming quite a bit too.

My teeth are falling out. I reach for my mouth with my hand and a whole bunch of them fall in to my hand. It is not like they are bloody or anything.  Just saliva and spit.

Now when somebody reports two dreams back to back, we take it for granted that there is a connection between the two. So I asked her if the two dreams occurred on the same night. She said no, but added that both dreams emerged around the same period and have been recurring with some regularity.

"Anything else you can think of which connects the two dreams?"

"The only connection between the two I can think of is that it weighs heavy on my chest that he is kicking me out. I looked up in a dream book that I have as to what falling out of teeth could mean and it said it means something heavy is weighing upon your chest.

So the affect in both the dream is that of some burden upon her chest.

Now the feeling of heaviness or burden upon the chest is like weight of some sin or guilt upon one's conscience. As to why a sense of guilt or anxiety generated from anticipation of punishment appears as a heavy feeling in the chest I don't know. But that is the part of the soma that is most preferred by the psyche to express this form of anxiety. 

So it was she who was feeling guilty about her boyfriend kicking her out of the house. But should it not have been the boyfriend who should have been feeling guilty?

The dream only makes sense when we assume that it was she who was planning to leave him once she finished studies and was not financially dependent upon him and was feeling guilty about using him for that end. And while the affect of guilt had remained unaltered in the dream the visual representation of the crass behavior had been reversed. It is not me who is ungrateful and leaving him but he who is leaving me. 

The dream-work can change the perceptual contents of dreams from one thing to another (distort, displace, condense, even reverse it), but with affects it has much harder time. At best it blocks it out completely. But putting the reverse affect is at best fleeting. So the affect of guilt was sailing through into consciousness quite unaltered.

Before I put forward the construction to her that it was she who wants to leave him I asked her how the dream shows the boyfriend kicking her out.

"He is telling me 'you go, you can work now, you have a job now, you can look after your daughter without my help, you can support yourself'."

"Is it possible that these are the reasoning you want to give to yourself so you can muster the courage to leave him? And it is not him that wants to leave you, but you who want to leave him, but feel guilty about it?"

The girl confessed that leaving him has often been on her mind. "Many a times I have thought of getting all my shit in the house together and just leaving. I am not the happiest person on earth. We don't have sex anymore. He is horny only in the mornings, when he wakes up. That is not normal. If he was really in to me wouldn't he want me all day and night? If he is horny only when he wakes up in the mornings it means that he was dreaming of somebody else who excited him and now wants to use my body while in reality making love to that person."

"Why is he not more in to you?"

"Because he is 56 and figgin' 20 years older than me. I am actually barely older than his daughters. I cannot nail the donkey's tail but there is something not right about his being so much in to me."

"It would make more sense for you to have started dreaming this when you were about to finish your studies. You still have a year to go."

"I am having second thoughts about continuing with my studies. I want to go back to dancing. There is phenomenal money in it. Whatever you want you have the money for it. I could take care of myself financially and every other way. I am not used to somebody else taking care of me. With all my previous boyfriends I was the one who made the money and paid the bills. He is the first one who takes care of me. It is a complete role reversal and actually I don't like it. I rather take care of myself."

The way she said taking care of herself made me think of her taking care of herself sexually as well. And considering that falling of teeth is symbolic of punishment for masturbation I put forward the construction, "Do you think the falling of teeth is punishment for taking care of yourself sexually. Since you don't have sex with your boyfriend you are finding sexual satisfaction in your own body?"

She began to laugh and said, "No. I don't have time to do that. I am too busy. I am having no sex altogether.  But I use to in the past. In fact I would do it everyday."

"Is it possible that the wish to revert to that form of sexual satisfaction is becoming strong in you? And you want to leave the studies, leave your boyfriend and go back to dancing and to finding sexual satisfaction in your own self?"

"I don't know I will agree with that or not. But let me tell you, you are a smart man." 

Three weeks later when she came back for her next session she reported that both the dreams had disappeared and she has been sleeping better.

Depression as a deferred response to narcissistic injury

Recently  I came across a case where betrayal of trust, that had caused the patient great mental pain, anger and desire for revenge, had eventually found discharge in depression when the winter months came.

The patient a robust lad in his late twenties, half-Japanese, half-American, who is helpful to a fault, partially because he seeks acceptance, a reflection of his not being an all American kid and thus not quite the in-crowd, and partially because of his inborn obliging nature, had co-signed for two of his friends to get them motorbikes.

He was warned by others to not be a fool, but he did not know how to say no. The motorbike dealership worked out a plan where his friends would have to pay just 99 dollars a month for six months, and if that was done on time, a new financing would take place and the patient would no longer be a co-signer.

Both the motorbikes were repossessed. One friend never made any payment after he totaled the motorbike within 48 hours of getting it. The other made just one payment, and his bike was taken away 45 days later.

The sucker was filled with rage, and developed extensive fantasies of revenge. None of which he could put in action. The friends were no where to be found and secondly he was in trouble with the law for possession of a controlled substance in his car which was not in the prescription bottle - a victim of American law enforcement's love for bullying its youth and criminalizing everybody so they can have a lucrative supply of money through their probation departments- which precluded a fight which could have violated his probation. And so he just sucked it up, as the saying goes.

This debacle happened in Summer.  By Fall he thought he had put the whole unpleasant experience behind. But when winter came he noticed he was feeling melancholic. Analysis revealed this melancholic feelings towards the world to be the anger towards his treacherous friends getting discharged upon his own self. As if he identified with those two scumbags and was trying to beat them up through playing the dual role of the beater and the beaten. The misery that he was experiencing through the depression was the suffering he so badly wanted to cause the two former friends and to restore his sense of himself as not their victim but superior to them. His narcissistic pride had been injured and now it needed to be mended by causing damage to those who had succeeded in doing so.

Now why didn't the man get depressed right away but wait for the winter?

The patient stated that he has always been a summer person. When it is sunny and the days are longer, he feels good. Winter with its cloudy and dark skies has always meant gloom and doom for him. On dreary days he always felt more fearful and pessimistic. 

So through the summer while the sun was out there longer he could cling on to his optimism that there is still time to put the revenge - the aggressive motor plans and thoughts that were constantly getting generated in him - in to action. But once the days shrank the possibility of getting even shrank too, and he became depressed. It is interesting that the patient when he was prescribed buproprion, an anti-depressant, did not find it useful for his depression, but nevertheless insisted upon taking it, because he felt "by simply taking those pills I am somehow destroying those two bastards." As if he was poisoning those two hated people by poisoning himself with that pill.


He confirmed this conjecture by stating that even in winter as long as the sun is shining brightly and it is day he feels no depression. He feels like the sun is on his side [now we know how sun is symbol of the father]. So as long as he had his father at his side  - the sun shining over him - he could hope to get even with his enemies.  As if sun - the father - had his back and so he felt upbeat and ready to face the world, confident of his ability to triumph over the competition.

It may sound far fetched and it does not quite fit in with rest of the composition but it may be of some value to insert the following here.

I once got an insight into an old lady's love for sun bathing. She too would be depressed when it was cloudy and dismal outside, and felt buoyant when she could lie down on her balcony soaking up the sun. The unmistakable bliss that was present on her face as she let the sun rays penetrate the pores of her skin reminded one of the bliss that suffuses the face of the woman when she is truly enjoying  sexual intercourse. The fascination of mankind with sunbathing may have its origin in the primal fantasy of mankind of making love to the father while witnessing parental intercourse during the intrauterine phase of one's existence. See my previous posts on this wish to return to the womb fantasy. The way people line up on the decks of vacation cruises and on the beaches, their eyes closed, as if they are soaking up the ultimate pleasure perhaps arises from this equating of the sun with the father.

It is of some clinical interest that this deferment of depression is not limited just from Summer to Winter but it sometimes happens diurnally as well.  In our patient he told me that in the evenings his anxieties build up real high, and he has to take a little Suboxone to keep the depression at bay.

This phenomena of shifting one's conflicts from day to the evening and nights was brought home to me by the care taker of a developmentally disabled patient that I once treated. This patient would be completely passive during the day, often asleep, but agitated and wide awake during the night. The care taker summed up his problem by declaring that he does not deal with his problems during the waking hours but postpones it for the night, to do it in his sleep and dreams, and that is what keeps him awake at night. His days and nights have got reversed and I should give him a medicine that would readjust that.

Perhaps much of the insomnia in humans owes to this phenomena of not facing up to the challenges of life during the day because of actual inadequacy in dealing with them or because of other mental illnesses or because of adverse life circumstances that precludes one from doing what is required, and then keeping awake at night trying to solve them or even when managing to fall asleep entering only in partial sleep with the mind failing to shut off adequately.

A highly anxious patient of mine claimed that by taking Xanax (alprzolam) and suboxone (buprenorphine) during the day he can keep his anxiety at bay and his spirits buoyant. "But then I keep awake worrying all night. The medicines just postpone [defer] my fears." He added that when he went to hospital and they suddenly cut him off from all Xanax he was hearing voices. He could hear people plotting against him outside his room, on the corridor of the ward. When asked what exactly were they plotting he replied all the different methods by which they would kill him. "And why would they want to kill you", I asked him. And he said well they were falsely accusing him of being an asshole and other good things, and were trying to make up their mind as to what would be the best method to kill him. This case along with confirming the reality of postponement of affects from day to night as the main cause of insomnia in humans also tells us as to how behind anxiety lies paranoid thoughts. 

I had another instructive case of deferred depression. An Italian immigrant, who came to the US in his twenties, worked very hard in produce business, raised his children and grandchildren, saw all of them doing good, developed cancer in his Sixties. He was an indefatigable worker, who could not ever even catch cold and cough lest his work suffers, so when he came down with such a drastic disease he felt very betrayed by what fate had done to him. He had led an ideal and virtuous life. He reflected with envy upon  all those who were lazy and careless and had not been struck by such a dreadful disease. But quickly suppressed all these useless thoughts and applied himself diligently to the cure of the cancer. Once his whole attention was directed upon conquering his disease he felt no bad emotions.

Till the winter came. And then he slipped into a profound melancholic depression, the chief feature of which was constant worrying about the fate of others. He felt as if the end of the world was nigh. He felt everybody's future was bleak. He especially pitied those factory workers, and other lower middle class folks, who were getting laid off. He worried about the bag ladies, and urchins who were living in Shelters, and about the homeless sleeping under the viaducts in the devastatingly cold weather.

It was not hard to analyze the underlying logic. It was abreaction of the thought that how come these low class worthless people are not getting cancer and dying while I the virtuous one is. And a constant concern for them was to hide, even to his own self, the evil wishes towards them. His slipping into depression (exhaustion) was secondary to the paralyzing effect these two contrary impulses were doing to his psyche.

It is interesting in his case too, the depression did not occur as long as it was warm and the sun was shining brightly when he could engage himself in doing something productive. Only when the gloom and doom of winter set in, did he get depressed.

The much discussed Post Christmas Depression that is so common in Western societies may have its root in this phenomena of deferment. Christmas is time for families to get together and compare how one is faring in relationship to others, mainly one's siblings, our most hated rivals. And since grass always looks greener on the other side of the fence, one always returns from these gatherings with lingering bitterness and anger, which one abreacts with winter blues in the subsequent month or two. 

Dream within a dream

A patient came crying to the session, extremely distraught. Her father had an auto accident in which he had suffered multiple fractures. The injuries were life threatening, he was in Intensive Care Unit, and there was a good possibility he would not live beyond a week.
After she abreacted the shock and pain of this trauma, she mentioned that every night she was having disturbed dreams, but one which had puzzled her greatly.


She dreamt that she was dreaming that the accident had happened. She felt so happy that the accident was after all only a dream.  She  could now continue to sleep because when she wakes up the nightmare will end too.  
But anyway she woke up and immediately reached for her smartphone to call her father to tell him as to what a terrible dream she had had about him, only to realize that she had pictures of her father on life support in that very phone, which on checking she found yes they were there, and all her pain came flooding back. 

Here is Freud on the issue of dream within a dream

The interesting and allied problem, as to what is meant when some of the content of a dream described in the dream itself as "dreamt' - the enigma of the 'dream within a dream' - has been solved in a similar sense by Stekel, who has analysed some convincing examples. The intention is, once again, to detract from the importance of what is 'dreamt' in the dream, to rob of its reality. What is dreamt in a dream after waking from the 'dream within a dream' is what the dream-wish seeks to put in the place of an obliterated reality. It is safe to suppose, therefore, that what has been 'dreamt' in the dream is a representation of the reality, the true recollection, while the continuation of the dream, on the contrary, merely represents what the dreamer wishes. To include something in a 'dream within a dream' is thus equivalent to wishing that the thing described as a dream had never happened. In other words, if a particular event is inserted into a dream as a dream by the dream-work itself, this implies the most decided confirmation of the reality of the event - the strongest affirmation of it. The dream-work makes use of dreaming as a form of repudiation, and so confirms the discovery that dreams are wish-fulfilments.

The dream within a dream of my patient confirms the correctness of Freud's explanation of this puzzle.
I may add here that sadly the patient's father did not make it out of the ICU and left the patient's dream of keeping him alive against all odds unfulfilled.

An unfettered expression of the wish for a penis in a woman's dream

A patient, who is relatively well settled, married, with two children and a steady job, and who other than suffering from moderate life-long anxiety, that compels her to be constantly busy to bind the anxiety, brought in the following dream, prefacing it with the comment that it is the weirdest dream I ever had.

In my dream I look down and see that I have a penis. It sends a shock through my system. What the hell is down there.  I was completely freaked out.  I was like majorly upset. But then I must have accepted it because it became part of me and everything became fine.  I don't know how long this acceptance goes on for I lift it up to inspect whether it was the whole package or no and to my horror I see there is a hole in it. A black hole. I knew at once there was something majorly wrong.  It was scary. Then I notice it is infected. As if gangrene was going to set in, and it would fall off.  I felt like I would die, for it had by now become a part of me. Not that I wanted it to be there. In the beginning at least I did not. But now I had become accepting of it.  But there was a huge frigging hole in it. One could see through it,  I went into shock again.
I tried to take my problem to the doctors. I was like in a room in a hospital. But they would not realize that there was penis on me or that it could fall off. Like they were not understanding the problem. I had so many emotions go through me.  I cannot even describe the range of complex feelings that emerged during the course of this dream. There was bad anxiety, and sense of hopelessness and despair, as if I was going to die. They were dismissive in their attitude. They were like we can't help you, we can't help you. They would not like even comprehend or acknowledge what was happening to me. 
That room in the hospital it always comes in my dream. I always go there when my dream has to show hospital or medical treatment of any sort. It is a very familiar room. I know I have seen it before. It is always the same room. As if I have been there before, a million times.
Incidentally, there was none of the appendages with the deal. No testicles, just the shaft was there. And that did not matter, it was only the hole in the penis that was freaking me out.

Patient to hide the embarrassing nature of the dream assured me a number of times that she never ever has dreamt anything remotely similar to it before.
Now this patient is relatively new, sees me just once a month, for half an hour, primarily for medications for her anxiety and depression, and we had never ever subjected any of her dreams to analysis. So it surprised me that she narrated so frankly a dream which most people would have great reservations admitting to having let alone talking frankly about it to a relative stranger, even if he is  their psychiatrist.
She explained to me that she could talk so freely because she saw on the board outside my clinic that I do dream interpretation. But then she indicated that she was not shy about the dream for she had shared it with her sister, who is almost 15 years older than her, though they are very close and confide everything to each other, and also to her ex-boss, both of whom laughed at it, and dismissed it in exactly the same manner as the doctors in her dream did, her sister even burst out in a laughter with the exclamation, "E, only you would dream something like that."
Associations to the individual elements of the dream could not be obtained because the half hour flew quickly and there was another issue that had to be addressed in the session. So I will proceed with the analysis just based upon psychoanalytic theory.  
The shock and horror that she experienced on first discovering that she had a penis was actually the shock and horror that she must have experienced during the Oedipal period on discovering that she did not have a penis. In dream the affect had been shifted [displaced] from its absence to it presence. Such is the power of the wishes in our psyche.
The ever present wish in woman to have a penis of her own, and not through her husband or male child, emerged in this lady's dream in all its nakedness. Her statement: But then I must have accepted it because it became part of me and everything became fine is an excellent confirmation of the fact that dreams are wish fulfillment.  
But whatever experience during the day - some humiliation which she would not have been subjected to if she was not a woman - the unpleasantness of which was disturbing her sleep, and which was being negated through the fulfillment of the wish, reared its ugly head too, and the original trauma of the absence of penis, which she no doubt had become aware at a very tender age, reasserted in springing the doubt whether she had really gotten the coveted thing, and if she had was it defective, and would it not disappear again as a result of some misfortune like an infection or gangrene.  

 ....I lift it up to inspect whether it was the whole package or no and to my horror I see there is a hole in it. A black hole.  I knew at once there was something majorly wrong.  It was scary. Then I notice it is infected. As if gangrene was going to set in, and it would fall off.  I felt like I would die....


This is an excellent description of the reaction that occurs in the little girl on discovering the presence of the penis in a little brother or a playmate or even a adult and its absence in one's own self. It is immediately assumed that some injury has occurred, there was a penis there which was taken away from her by violence and foul play, perhaps as a result of some punishment for erotically playing with it, and in its place there is now a wound, an illness.
Not only woman's discomfort and shame from her genitals, which she sees as a defect -  at least in her early childhood she does so - occurs from this discovery, her considering it as an illness leads her to search for all kinds of remedies from myriad of sources all through life. Women's much complained enigmatic nature, and the irrationality of her actions, springs from this never ending search for a cure for the mutilation. Not just real doctors - actually they are often avoided because they are more difficult to be convinced that there is a problem, and are less likely to go along with "the game" -  all kinds of healers, hustlers, soothsayers, medicine men, shamans, quacks, charlatans, mendicants and other holy men, especially those who practice tantra, witchcraft and sorcery, are searched for and the problem is laid upon their feet.
Our dreamer is in medical field and believes in the power of doctors to heal things and therefore in the dream was in the hospital asking them to straighten her problem. Herein lies the psychology of Munchhausen's Syndrome and of Briquet's Disorder. Under the sway of this very same complex the  patient goes from doctor to doctor, begging for medical treatment, medical procedures and surgeries with one wish in mind - a wish they can never bring to their lip, out of shame but more so because they themselves do not know what exactly is wrong about them for which they are seeking a cure.
And they show the doctors everything else about themselves except for the genitals where (in their  unconscious) they believe they have the illness/defect. In fact they show a hysterical prudishness about covering their genitals while dramatizing the sexuality of other body parts, proclaiming loudly about the defects and afflictions of these parts, demanding and seeking treatment, subjecting themselves to all kinds of surgical mutilations, in hope of getting cured by some lucky chance, by some halo effect. It is like repetition of the original trauma of the discovery that they had been cheated when it came to genitals. And by undergoing further mutilations they are hoping to have a better result this time around.
Their contempt for the doctors for failing to recognize their real problem and their inability to give them the cure is acted out in Munchhausen's Syndrome by misleading the doctors through giving fake symptoms. The logic being : you cannot cure my real problem so you are a charlatan and I will prove it to you for you will be conned in to believing that I have an illness when I really don't. You are a quack because you cannot see the problem where it exists but you will see one where it does not. The penchant for hysterical women - those who suffer from Somatization Disorder - to sue doctors and get  compensation, owes to the same castration complex. Doctors were not believing me that I had it. They were dismissive in their attitude. They were like we can't help you, we can't help you. They would not like even comprehend or acknowledge what was happening to me.  So they must compensate me for their idiocy and their failure to heal me.
There is an interesting difference between Munchhausen 's Syndrome and Somatization Disorder. In the former the person is not that eager to have procedures done and have parts of the body removed as in the latter. The former have a more narcissistic personality structure, and are more into playing the game of showing that the doctor is an idiot. It's aim is to show that the doctor (parent substitute) does not know what he is doing and he has done me wrong. And this is done through verbal game  playing and ruse. In Briquet's Disorder the patient has hysterical personality structure and she actually wants to be cured through losing parts of her body to the doctors' instruments in order to be compensated for it with the coveted penis. The complaints of hysterical patients do not correspond to the laws of anatomy and physiology - the source of much irritation to doctors - because their complaints arise from their grievance over the injustice done to them when it came to genitals, and they are complaining about being shortchanged and having a problem in that region which are superimposed upon some actual physical malady present in more respectable part of the body. 

Moving back to couple of other elements of the dream
  
Incidentally, there was none of the other appendages with the deal. No testicles, just the shaft was there. And that did not matter, it did not bother me. It was only that black hole in the penis that was freaking me out.

This part of the dream which the patient added as an afterthought is a great confirmation of Freud's statement that the interest in male genitals in both sexes is exclusively limited to the penis and the rest of the appendage is totally ignored.  
It is a very familiar room. I know I have seen it before. It is always the same room. As if I have been there before, a million times.

This room could be no other than her mother's womb. A place which was once the most familiar and where one lived for nine months. A place where the dreamer wants to return and be part of the sexual intercourse which gave her life, but in which sandwiched between the mother and father she wants to have a more favorable outcome, to be born as a boy instead of girl, wresting the penis off the father while the process is taking place, something she failed to do the first time. 
The patient kept apologizing for dreaming such a weird and bizarre dream and wondered if there was something wrong with her. But when told that what she dreamt is something that one reads in textbooks of psychiatry and one rarely comes across such a transparent dream in practice, and that it is a wish that is present in all women, but is withdrawn from consciousness at a very young age, between ages of 3 to 5, and that she is kind of unique in dreaming it so close to how its original nature is, without any distortions, as most women do, which makes it so hard to decipher the real nature of the wish, the patient felt that she was not crazy and took a sigh of relief.
But then added that she is very happy being a woman, and the last thing she wants in life is to be a man.
"You may not want to be a man. And are very happy with being a woman, granted. But you may still wish you had a penis."
"I don't want a penis. Never wanted it. They are not beautiful to look at. And in the beginning of the dream I distinctly remember getting upset that it was there."
"Being upset also could have been displacement of being upset at not having one which got reversed in the dream.. And why would you dream that you had one unless you wanted it? And why would you have so much anxiety and dread over losing it, unless possessing it meant so much for you?"
"I got to admit. Many a times I have wished I was a man. Life is so much easier for men than for women."

The psychology behind the phenomenal rise in adorning oneself with tattoos in recent years

While approaching a young patient of mine who was sitting in the waiting area, I was struck by the extensive tattoos on his arms. One could barely see the skin for the lacework of  tattoos. The charm of the white skin was well hidden by the criss-crossing dark designs. 
Now this patient who suffers from obsessive compulsive neurosis avoids facing the world and uses his OCD rituals to accomplish that end. The compulsive senseless  movements of his arms and body not only divide his attention and detract him from noticing others in any depth,  others too are distracted from noticing him, the focus transfixed upon his motor restlessness instead of his total self.
His obsessive rituals made me wonder if the modern world en masse has now not been granted a socially sanctioned obsession that serves us the same purpose as his individualized private OCD - fiddling with Smartphones in public. Being tuned into Whats Up and Facebook enables us to avoid any deep emotional interactions with people we are in company of. Is modern world's tuning out of actual physical interaction with each other in favor of cyber interaction is a new world religion? A new mass obsessional neurosis?
Coming back to the patient.
As if these obsessive motor activities of his hands, fingers, legs and trunk are not enough, every now and then he cracks his knees, neck or finger joints. These cracking of joints, which are compulsive in nature, also give the impression of being another attempt to avoid social give and take which is what life is all about.
And the violence with which he cracks these joints, gives a distinct impression that the rituals are some kind of symbolic punishment meted out to his legs, neck and fingers - [for attempting to get out of bounds?] It appears as if since his whole self is under some form of hold (repression) the individual parts of his body want to  reach out and touch others and are being slapped on the wrist for doing so. For after all the raison d'etre for OCD lies in preventing one from sexually [and aggressively] touching others. Freud did say once that if the term obsessional neurosis had not been already coined, and so well accepted, he would have named this disorder the touch neurosis. The fear of touching others and getting [sexually] contaminated lies at the very heart of OCD.
And this compulsion to keep running away from others follows this patient in to his sleep. He also suffers from severe Restless Leg Syndrome.
He is undoubtedly a man on the run.
Now one would expect that someone who has such dread of the world will at least groom and dress himself well, put on jewelry and perfume, deck himself with other accessories to make up for his lack of self confidence. But he does nothing of the sort. He puts on sleeveless shirts, torn jeans, dilapidated sneakers and no socks. Majority of his skin remains exposed.
Or does it?
The tattoos block whatever parts of himself escape getting covered by clothes.
If his compulsions and joint cracking are ways to create a wall between him and others, do his tattoos serve the same function?
And at this point one recalls how motorbike club members adorn themselves with tattoos; uninviting, and hostile appearing monstrosities, etchings of skulls and daggers, cobras, scorpions, ghosts, ghouls and goblins, swastika and other wild creepy things.
But anybody, whose body exudes such aggression, at the core of his being must be a frightened soul. And since bikers are usually pussycats in isolation and feel sure footed only when feeding upon each others' swagger, one wonders if their tattoos serve them the same function, give them the bluff to face the world that they are so afraid of?
But this cannot be the whole explanation for why people today are so obsessed with tattoos.
For there is another class of tattoos which are distinctly inviting in nature, and it is not hard to guess which sex favors them. Roses, flowers, creepers, colorful designs, butterflies, ornate hearts, entwining patterns that remind one of lingerie, and other soft and cuddly objects, welcoming and aesthetically pleasing, also appear as tattoos.
So it appears that tattoos are another exaggerated display of our masculinity and femininity, props to enhance the active and passive aspects of our individuality.
But then why aren't we all tattooing ourselves? If it enhances our secondary sexual characteristics then why aren't we all rushing to do so? The great majority of us scoff at the idea.
Here we come across the phenomena of a great divide between those who have it and those who don't.
If the display of one's masculinity and femininity depends upon subtle cues, one's natural good looks and intelligence, one does not have to drum it up by adding on to oneself disparate extraneous objects.
Tattoos are a tacky enhancement of one's persona. No different than the plumes jutting out of the Indian Chief's head gear, the rows of ribbons and medals hanging from army brass's shirt, the shiny  jewellery and super-dyed hair of a homosexual, the endless acronyms of credentials following the name of a college professor. They are the bells and whistles of those who do not feel they are anybody unless they can display their trophies. It is a man who is not sure of his manhood and who has doubt if he can be effective with others through his natural pluck who shows swagger in the gait, gruffness in the voice, hostility in the muscle tone, and the gaudy display of sunglasses,  sport cars, and flashy jewellery. A naturally feminine woman, especially one who has natural good looks, far from using tattoos to enhance her femininity may prefer not to put any make-up on herself.
The expression of masculinity and femininity in more refined individuals is through modulated and untrammeled speech and rich personality. It is half filled vessel that spills its contents. Deep waters run still.
Has there been a decline in the masculinity of men and femininity of women in recent decades?
Is there any doubt about that? As our culture has become more androgynous there has been a surprising decline in sperm count of men and rise of polycystic ovaries in women. In behavior too more and more folks are practicing LGBT  than becoming the model representative of their anatomical sex. Thus when the need arises for us to emphasize ourselves in a heterosexual fashion we are often relying less upon our actual selves and more upon adorning ourselves with extraneous objects that emphasize our original sexual nature.
But there is another great transformation that has occurred in the last few decades. The sexual revolution of the Sixties has fundamentally changed the way people communicate.  All through history human behavior was highly ritualized. There was  a script for everything. It spelled out in magnificent detail what and how to speak with the opposite sex, the children, the elderly,  the postman, the milkman, the car mechanic, the handyman; who to be deferential with and who to boss around.  There were stock phrases, stock motor movements, stock greetings, stock goodbyes, and stock feelings and display of emotions all handed down by the previous generation ready made for for every occasion. Everything was predictable and based upon what we had observed from birth. Even the clothes we wore were predetermined - white collars for those in management, and there too higher the rank the more silky and fancy was the tie. Bow ties were reserved for the eccentric professorial type or those in corporate world who had castration issues. A blue collar worker occasionally wore tie too, but the coarseness or at least its dated design gave away his lower station in life.
All these moorings which allowed us to interact with others without feeling anxious, and often with  grace, granted modeled after somebody from one's past,  have evaporated, or at least greatly eroded, in the last few decades. In the aftermath of the two World Wars the flower children came upon the scene as if to make up for that orgy of violence and fundamentally changed the way we behave with each other. The television, computers and the Internet did the rest. Now every conceivable human behavior was available to model after at the click of a button. Differences in wealth and social privileges ceased to matter as well. No matter how poor, with cyber information available to all, the poor kid has same degree of access to cultural accessories as the rich one.
But there is a  catch when there is abundance of something. One may fail to take possession of any of it. As long as something is rare we value it. If something is available for the asking one may have no interest in permanently acquiring it. If you give a child few toys he will treasure them.  If you give him a whole roomful, he may develop no attachment to any. The idea of possessing the greater quantity of them may become more important than mastering a few. In olden days when finding somebody to marry was not that easy a task, with all financial and cultural hurdles, not to speak the elaborate wedding that one had to go through, one valued the woman one was paired with. For if you lost her, it was not that easy to replace her. But today when women are available to have sex with without any effort and as readily changeable as Kleenex, one often shows no appreciation for any one of them.
Hence we are growing up culturally denuded. While submerged in sea of information we are  growing up culturally thirsty. We know so much but we cannot translate it into words or behaviors. We can tell so little of ourselves to others with refined behavior that was taught to us in past generations with mother's milk. And hence we feel naked, inadequate and anxious in dealing with others.
Tattoos give us a protection from this nudity. It tells others who we are and how to behave with us and how to keep your distance. They have become our credentials, our substitute for cultured behavior.

The psychopharmacological interchangeability of narcotic pain killers, anti-anxiety agents, psychostimulants and ordinary success in maintaining sense of well being in addictive personalities

I treat quite a few opiate addicts with Suboxone (buprenorphine). Buprenorphine is an opiate too, but with a very unique property. Unlike regular narcotics, such as Vicodin, Oxycontin, heroin, morphine etc., the patient does not become habituated to Suboxone, and does not keep increasing the dosage to get the same effects.
And Suboxone is not just for preventing the horrible withdrawal symptoms, which, by the way, is the main reason the addicts shudder at the thought of giving up opiates, despite knowing that it is destroying their body and their life, it also - unlike Methadone - helps patients resume their pre-addiction life style. Quite a few are able to start working again, take up family responsibilities,  emotionally respond to others, and start feeling like their normal selves. In many it ameliorates their anxiety and depressive symptoms better than antidepressants. 
Despite all these wonderful properties, Suboxone cannot be used indefinitely. It cannot be viewed as a drug like insulin that a patient must take for the rest of his life for his diabetes. While many so called addctionologists want addiction to be looked upon as a physical disease - so they can maintain their belief that they know how to treat these complex problems without knowing a whit about depth psychology - addiction, or for that matter all mental diseases, are fundamentally different from physical illnesses. Mental illnesses can accentuate and wane remarkably with the aid of just psychological inputs and life circumstances.  And therefore however well the patient is doing on Suboxone, it is natural for the psychiatrist to be biased towards getting him off of such a medical crutch. One knows not what harm, in the long run, such brain altering medications do to the person. And so a good doctor is always pressuring his patient to keep cutting down on his Suboxone dosage, with the aim of eventually making him totally drug free. 
But here one runs in to a problem. Suboxone itself is incredibly addicting. The patient tolerates its tapering to a point, and then refuses to go further. At a certain threshold, which is different for different people, in some surprisingly as homeopathic as half a mg.a day, the symptoms return, and not just the physical ones of body aches and pains, diarrhea, sweating etc., but the psychological malaise too. Depression, anxiety, sleep problems, easy distractability, diffidence, emotional withdrawal, even something so basic to human nature as taking care of one's own children, they all start raising their ugly heads. In short the patient falls back in to his or her doldrums.

It is difficult to say whether these withdrawal symptoms are due to some property of buprenorphine itself, which the addicts cannot do without, or the return of the underlying psychopathology which drove them to get addicted to the opiates in the first place. Perhaps it is both.
Now an interesting feature, and which is the reason for this blog entry, is that these symptoms can be ameliorated to a great extent if Suboxone is supplemented with an anti-anxiety agent or a psycho-stimulant. Addition of Xanax or Ativan or Adderall considerably reduces the need for buprenorphine. 
Why does this happen?
I have a far fetched theory.
 People take drugs when the ego-syntonic heterosexual outlets for their love needs get blocked. Humans basically live for love. If they have no one to love, or do not feel loved by anybody, they might as well curl up in a corner and die. And when they (rather their system) cannot find love in an adult genital fashion, their libido (love need) regresses and starts emerging through autoerotic activities (through pregenital channels).
Generally this regression of psychosexual organization occurs silently and invisibly, and has to be deduced. For the patient himself is not aware as to when and how the regression is taking place. Furthermore, the slipping back into autoeroticism primarily does not occur at the physical plane but in fantasies, and  in displacement, so their true nature remains obscure, and to make matters even more difficult to decipher, the fantasies which bring about the discharge of sexual tensions, are mostly played out in the unconscious.
The narcotic analgesics, the antianxiety agents and the psycho-stimulants, despite their acting upon different aspects of the brain/mind, and through different neurotransmitter systems, facilitate this regression.
How do these drugs  do it?
Once we reach the genital stage, our body creates psychological and physiological barriers to prevent  sexuality from finding easier discharge through pregenital channels. These barriers are basically  psychological and physical reactions that follow when a person indulges in pregenital sexual satisfaction.  The libido has very many ways of discharging sexual tension through pregenital channels. But they all have one thing in common: the use of one's own body instead of somebody else's, as the sexual object. And herein lies the trouble. At the end of the sexual act one does not feel fully liberated and unbound, with the spirit soaring, but rather in throes of mixed feelings;  some relief of tension and paradoxically some increase of it.
For autoeroticism requires playing both the masculine and the feminine roles. And there is always a conflict over that. The superego/conscience objects to playing the feminine role in man and vice versa in woman. So after the autoerotic/pregenital sexual activity, whether done through actual masturbation (physical action), or through (conscious and/or unconscious) fantasies, or even done in dreams, the person emerges from it with all kinds of body aches and pains, and whole range of mild depressive and anxious affects.
This dysphoria and pain occurs for two reasons. One, when non-genital somatic points of the body are used as genital organs they show inflammatory response. Not quite full blown inflammation, but some processes akin to the tumescence and detumescence of genital organs, corresponding to sexual excitement and its discharge, and since these body parts are not primarily designed to play the role of the genitals, the inflammation like process that takes place there leaves the body sore and in fibromyalgia-like state.
The muscular spasms and mucosal secretions  at the deepest level are masculine (active) and feminine (passive) sexual responses. The destructiveness of narcotics towards one's physical appearance - one can always spot the unhealthy looks of those who are strung out on drugs -  perhaps owes to this use of non-genital organs as genitals - surge of auto-eroticism over genital sex - in drug addicts.
There is also anticipation of physical and mental punishment for finding sexual satisfaction through pregenital routes, which adds psychic malaise to the physical misery.
Now when we examine these dysphoric physical and mental states which are physical and mental responses to autoeroticism and anticipation of punishment, we find some interesting correlates to the sexual fantasies that are indulged in to achieve the sexual discharge.
 If the associated fantasies to autoeroticism are oral cannibalistic in nature, then the inflammatory response and the punishment emerges through the sensations of disgust, repugnance, nausea, vomiting, stomach acid secretion, teeth grinding, migraines etc.
If the sexual fantasies resort to anal-sadistic designs then the punishment for sadism occurs through  increase in motor restlessness and spasms of the GI, urinary and respiratory tracts, while the passive masochistic fantasies cause the reaction of excessive mucosal activity of the colon, respiratory tract and the linings of paranasal sinuses [continuation of the opthalmic mucosal lining, and in essence an extension of crying].
These pathological reactions are like "undoing" of the gratification.
Now this painful reaction and overactivity of the GI tract and other mucosal tracts and muscular system is inhibited when one takes narcotics. Disgust, nausea, vomiting, migraines, spasms and excessive secretions of GI, respiratory and urinary tracts which would have put brakes upon indulging in forbidden pregenital sexual behaviors are put on "off mode" by the narcotics, giving free reins to the addict to indulge in autoeroticism. It does so by suppressing the pain reaction to such behaviors. Popularity of narcotics, in no small measure, lies in this easy way out for one's sexual needs; discharging them upon one's own self instead of going out and finding a heterosexual partner and competing with others for his or her love.
While narcotics are par excellence in enabling one to indulge in forbidden fantasies and autoeroticism, anti-anxiety agents and dopamine enhancing drugs can also be used for the same purpose. Narcotics do it by blocking the psychological and physical pain that follows on doing the forbidden. This is based upon previous experiences of painful consequences that occurred after such deeds (that were risky and dangerous) and which not infrequently led to actual physical punishment, or at least scolding and threats of doing so from the parents. It is kind of simple Pavlovian response - classical conditioning - pairing of pain with indulgence in off-limit activities.
Benzodiazepines achieve the same end by taking away the fear of the consequences. Here the pain that follows on indulgence in autoeroticism is not blocked, only the anxiety over treading in to the forbidden territory is wiped out. With GABA blocking drugs, the person ceases to fear the tomorrow, lives for the moment so to speak, and gives into forbidden behaviors. The dread of the consequences is taken away from the psyche as the drugs put the highest cognitive centers of the brain in sleep mode.
Dopamine enhancing drugs like Adderall work by a completely different mechanism. They shift the attention from the pain and suffering to finding pleasure in whatever one is doing at the moment - hyperfocusing upon the immediate. So the malaise, fibromyalgia like pain, headache and guilt feelings that follow the indulgence are pushed in to the background and the person can go on with the activities of the day instead of crawling into bed and sleeping through the suffering. The energy that emerges from this artificial boosting of dopamine acts like a separate fountain of mental activity. So while the body is smouldering in the subterrain the person continues to feel good on the surface.
At this point it may not be inappropriate to add that ordinary success has the same effect upon lessening the need for opiates as the taking of psychostimulants. As one of my patient put it: "As long as I am busy I don't feel the need for Suboxone. As long as things are going good drugs are furthest from my mind. As long as I am making money, getting tips at work, and I have enough money for my children I have no need for Suboxone. But the minute I have fight with other waitresses or the boss is mean with me, I start getting withdrawal symptoms."
This phenomena of success, which no doubt secretes dopamine in the brain, and reduces the need for Suboxone and other opiates is exemplified by the fact that professional people like doctors, lawyers, nurses and other high rankers of society have far greater success in kicking their habit and getting off the Suboxone faster than people who are in low paying jobs or are unemployed.
Am I then suggesting that one should routinely put people who come for Suboxone therapy on benzodiazepine and amphetamines as well? Or at least make use of them as adjunctive therapy to get off Suboxone?
This is a hard call. We know addition of Xanax reduces the need for Suboxone and so does the addition of Adderall. But by doing so in the long run are we going to make the patient dependent upon three classes of drug?
I think it depends upon the personality of the patient. In some the combination of all three at low doses may be better strategy for keeping them off the street drugs. In some Suboxone alone at higher doses and longer tapering off period will be the ideal strategy
My main point here is that clinically the requirement for opiates and Suboxone are lessened when the patient is given benzodiazepine or Adderall concurrently.  Whether in the long run this makes him  more or less prone to addiction I do not know.