Fear as the driving force behind an 8 year old boy's ADHD

An eight-year-old boy, his older sister, his mother, and I went out to look at some foreclosed homes. I was going to buy one as an investment property, and she was going to rent it if we found one which suited her needs and her budget, and the purchase price of which was within my investment comfort zone.

I was really enjoying the boy's high spirits, his rushing out of the car to be the first to climb up the porch steps of the houses, his patter about how he wants a place that has second floor so he can climb up and down, and a bathroom that has shiny black toilet as he had seen on a TV show, a fireplace, and all the other cool things that his friends' houses had.

The mother declared him to be a child who gets into everything but told me to diagnose him less as an  ADHD and more as an Irish child: "they must stick their nose into everything."

Now we were driving from one house to another without a Realtor, who could open the lockbox with the code and show us the houses from inside. We had printed out a list of foreclosed homes from the Internet and were assessing their worth from the outside and by looking through the windows. Though most of the houses had some window latch somewhere not properly secured, or a sliding back door that could be slid open, or a main entrance that despite the lockbox hanging from the doorknob could just be pushed open, and the mother, endowed with the same Irish genes as the son, would with an uncanny ability manage to find and stick her nose into these deviant openings , and voila we would be inside, free to explore the in and out of the house.

But what really caught my attention about that child was that the last house that we went to see that  afternoon, instead of rushing out as he had done earlier, he refused to come out altogether on grounds that somebody was inside the house.

The mother said that is nonsense. The house is bank owned, and foreclosed, so nobody could be inside.

But when the son could not be persuaded to leave the car, the rest of us decided to go inside the house without him.  However, when we climbed up the porch steps and peeked through the stained glass panes, lo and behold, there was somebody inside.The house indeed was occupied. We rushed down the three steps,  ran over the grass and quickly got in to the car so we do not get subjected to rude shooing off for trespassing. The mother had not done her homework right. The house was not in foreclosure but in short sale.

The mother asked the child how in the world did he know the house was occupied.

"Because the smoke was coming out of chimney,' the boy replied.

"And what does that mean?"

"It means that either the furnace is on or somebody is drying his clothes in the dryer."

So this hyperactive boy was constantly scanning the environment wherever he went making lightening fast deductions whether it was safe to go ahead with his exploratory urges or take to his heels.

 Later we went to a restaurant to eat and once again he was observing everything. As we waited for the waiter to bring out the food,  the boy remarked that there is a gold record of some singer mounted on a plaque inside a glass case on the wall next to the cash register. He wanted very badly to examine it at close quarters, but could not be persuaded to do so.

The mother remarked Zach has grown now. Before he would have rushed to it physically. But now he is afraid to do so.

And I wondered if the boy was very high spirited and full of observations to fulfill a bundle of inborn (genetically determined) needs and since they all had to be satisfied in a limited time he was rushing from one thing to another and which was behind his ADHD.

But the mother said no, that cannot be entirely true. Because Zach, if you encourage him, or if he is genuinely interested in something, he can sit on it for a long time without getting distracted.

So despite having all these needs to be fulfilled, all clamoring for expression, and all wanting exploration of the environment for the objects of their desire, the boy could stay and concentrate on something if he was given proper encouragement (output of dopamine generated through pleasure experienced due to parental appreciation?) or through his own intrinsic enjoyment of it (self generated dopamine?).

I asked the mother then what is the cause of his ADHD.

And she said his exploratory urges have been prematurely blocked by a frightening world. It is the fear of getting into trouble with grown ups [with their superior power/authority] that keeps him going from one exploratory behavior to another. If you are exploring something and get yelled at, and a fear arises in you that you will get into trouble doing that, then at the slightest hint of somebody coming after you makes you give up what you are doing and pick up something else to explore.

And now my child instead of rushing into whatever interests him [out of fear of everything and everybody] first scans the environment to locate all the possible sources of danger and if he sees any, quickly abandons that avenue of exploration and moves on to the next. Only if I am around to encourage him to continue exploring which implies that I will be at his side to deal with the danger, or if the exploratory behavior has high dividends such as when he is playing sports, that he continues his activity without bolting to another.

And I wondered if both these factors: presence of the mother while he is doing his exploratory behavior and big rewards that he obtains from sports and other activities that he enjoys improve his attention via the medium of higher dopamine secretion.

Reversal of letters in a dyslexic boy a manifestation of opposition/defiance

A woman in her late thirties came to the session and flat out declared herself to be a borderline personality,  in treatment since age of 9, and having been tried on every psychiatric medication under the sun.

When asked why she was borderline she replied, "Besides that I am also bipolar, schizoaffective, obsessive-compulsive, ADHD, in short a pain in the ass, and therefore psychiatrists [pejoratively] find me borderline. When they do not know what to make of you they call you Borderline."

"Why are you a pain in the ass?"

"Because I fight with everybody."

"And why do you fight with everybody?"

"Because I always have to be in opposition."

Then she added that her two children, and they are the same way. They oppose everything too. Though they have different styles. The older does by having emotional meltdowns. Slightest thing can spark a major upheaval in him and then everything around has to come to a halt. So he stops everything and everybody by overreacting emotionally. The younger one, his oppositionalism, is expressed through his refusal to cooperate with learning. I even think that his tendency to write letters and numbers backward is just an extension of this stubbornness. He must do everything in  reverse of what is expected of him.

And I wondered how much of dyslexic tendencies in children is initiated and maintained by this oppositionalism, perhaps an expression of grudge against parents or simply as a symbolic manifestation of one's life agenda being at loggerheads with that of the world's.

8/16/2014

Last week I came across a dream the analysis of which further confirms that much of dyslexia arises from an opposition existing between one's agenda versus society's.

A woman who is now in her forties, who had a traumatic upbringing, where both of the parents were more interested in their own agendas than that of their two daughters, divorcing when the latter were 10 and 12, going their own ways, bringing step-children in to their respective houses, to which the daughters were shuttled back and forth, sometimes wanted, when they could be used to do chores or to get even with the other parent, sometimes despised, when they came in their way, often beaten, sometimes even boxed, to keep them in line, and who naturally harbored great grudges towards the parents, brought in the following dream, a year after her mother's death.

It is a very short dream. I would call it snap of a dream. For all it shows is my mother. She looks so pretty. The whole dream is like white. For there is a beautiful white silk gown that she is wearing. And my baby, who I lost,  is in her arms, held inside a white blanket, like they use for christening, as if he was being accepted in Kingdom of Heaven and becoming alive again. Everything about the dream is white except for a red ribbon that is over the blanket like a bow, and the natural colors of my mother's hair and face. Which enhance her beauty. 

She is getting prettier and prettier with each new dream, ever since she died. 

Patient added that the dream is refusing to go out of her mind and expressed surprise how can one single dream image affect a person so much. "I am trying to keep doing everything else to forget the image but cannot. Ever since the dream I have been crying, remembering my mother, and the baby I lost." 

Since the patient is familiar with the technique of dream interpretation I asked her without any preliminaries, "What sparked the dream?"

"The dream occurred on Sunday afternoon, while, after an exhausting night, in which I was awake for the most part, I fell asleep. In the morning my husband had come from his bedroom to mine, to lie next to me, and we talked and talked, like we have not done in years, for four full hours, at the end of which I nodded off and had the dream."

"What was the conversation about?"

"Everything under the sun. It was the frankest discussion we ever had. Things that we never ever bring up. Things no other couple would bring up, like mortality rates, life insurance, my mother's death last year. She was just 63. My grandfather died when he was 42, my grandmother's in her fifties. So I told him I won't be living for too long. And he better start getting serious about my funeral. At most I will live for another decade." She said half as a joke, half because of actual fear that she may die early like her mother.

"So the dream was sparked by the fear of your own death. But instead of your own death you saw the death of your mother, and to compensate her for thinking of her death, your shrouded her with the most beautiful white gown. White generally symbolizes death. Why the gown was silky?"

"My mother loved silk. My favorite image of her is in her wearing silk gown."

"Why is the baby in white blanket?"

"So he can be christened and be eligible to enter heaven and be with my mother. White stands for purity. He is pure and it was not his fault that he was subjected to abortion. He should be living in heaven." The patient began to cry.

"Why your mother has everything about her white?

"It symbolizes purity. Absence of evil. When I had the abortion they were real nasty about it. Just pushed me in to it. I don't think they gave anesthesia properly. The whole thing was so painful. But there was a nurse. She was wearing a white sweater. She was very kind. And talked to me throughout the procedure. She behaved to me how my mother should have behaved. The white of the dream is taken from the white of that sweater."

"What is the meaning of the red bow?"

"Yes, why couldn't it be blue, pink or another color? It had to be red." The patient exclaimed in anger. 

"Why? What does red mean?

"It means blood  It means murder.  It means abortion. The abortion, which I did not want. It was the most painful thing I ever experienced. I never got over it. I never will. My mother forced me to do it. I could not do anything about it, because I was living with her. That time Arthur was just an year old. I was already separated from his father and my mother did not want another child. I was barely twenty, and could not stand up for myself." 

"So the dream was sparked by the wish for death, which quickly changed into fear of death, and wishing that upon your mother, or rather contemplating about her death - though making up for it by making her most beautiful and living in heaven - to shift away the fear of your own death, and then the wish was countered by the thought that you cannot afford to die yet, because you have to reverse that abortion and make that baby alive again. In the dream you are succeeding in doing so, according him christening in heaven."

"Yes. Since my mother died I think that the baby I lost, he is now in heaven with my mother."

"Why is your mother becoming prettier and prettier with every new dream?"

"Because she was real ugly to me in my real life. She was selfish and did not think twice before having an affair which broke the marriage and tore the family apart. But she was beautiful too. She had lovely face and lovely hair. That is what comes in the dream without being converted into white. Because they do not need changing. Rest of her I want to change and make her into how my mother should have been. Now that she has died. I am mourning for her and changing her into Madonna - pure white, holding my baby like Jesus, instead of sending him to death.

"And now I realize why for the last three days I am doing everything backwards. I am writing orders backwards, dropping 'n's or 'g"s at end of the words, reversing my letters, even writing whole words backwards, turning into a new Leonardo Da Vinci, with all my childhood dyslexia coming back. Soon I will be using a white-out more than the pen. And I know it is happening to reverse that abortion. I am surprised I am not writing down-upwards, given how I hate my mother for forcing me to do what I did."

Mother appearing as an evil impostor in a dream and its analysis

A woman in her early thirties, who had lived with her parents all her life because they had had her when the  mother was in her early forties and the father almost 60, and therefore they had subtly prevented her from separating and forging a life of her own, a few weeks after the death of her father, began having the following recurrent dream.

She prefaced that the dream could equally well be considered a hallucination. She was kind of awake  while dreaming it, aware that the frightening thing that she was seeing was a dream and that her mother and daughter were sleeping in adjacent rooms, and that she should get out of the bed to end the nightmare, though whenever she would attempt to do so she would find herself paralyzed to move and thus unable to get up and stop the dream/hallucination. 

I told her that for practical psychotherapeutic purposes dreams and hallucinations can be treated alike. One has to pay attention to the associations that emerge in both cases to reach to the mental complex from where the dream/hallucination was originating.

And she narrated the following:

I am in my room, sometime in my mother's room. It really does not matter. The point is I have to reach her. And whether she comes to my room or I go to hers it is the same. But on seeing her I notice that she is not my mother.  Well, she is my mother but at the same time something  has changed.  Her hair is jet black, her face pale, her body just bones, skeleton-like. She even moves in a jerky fashion, like a zombie would do in horror movies. But before I can get away from her I realize I am frozen.  My arms and legs are paralyzed.  I want to scream and move but I cannot. Then she is on top of me and is tickling me. I cannot breath because of the tickling. I have always hated being tickled, because I am an asthmatic and it triggers my asthma. But I cannot get away.  As a last resort I bite her, taking a chunk out from her lower jaw. She kind of enjoys getting bit. 

Patient bitterly complained that the dream which can occur up to three or four times a night is mentally draining her. 

Her dreaming in a state of partial wakefulness in which she could not move despite her desire to do so, accompanied by frightening emotions and impulse to scream for help led to the diagnosis of sleep paralysis and the dream to be viewed as hypnogogic/hypnopompic hallucinations. 

The practical value of making these diagnostic impressions however is of little value. Such distinctions and the pompous and tongue twisting medical terms used to label them may be very precious for those who have to come up with multiple choice questions for Psychiatry and Neurology Board Examinations - which is a ridiculous idea for it is insane to believe that the complexity of psychiatric illnesses can ever be understood by reading books with the aim of choosing the correct option in multiple choice formats - and also for those who have to concoct hundreds of diagnoses to give their diagnostic and statistical manuals (DSMs) ring of profundity, but for the psychoanalyst all dreams - for that matter hallucinations too - are basically the same: they are various ways to reduce mental tension (fulfill wishes).

Her inability to breath while getting tickled raised the possibility of sleep apnea - for sleep apnea sparks dreams of drowning, getting buried alive in a coffin or being subjected to other forms of suffocation - and I wrote a prescription for her to get sleep studies done to see if she does stop breathing in her sleep and would benefit from CPAP,  and then we returned to psychoanalysis.

That the dreams were occurring immediately after the death of her father left us no choice but to deduct that they were a reaction to it. The patient then talked as to how her siblings, all of whom were 10 or more years older than her, even before the funeral rituals were over were talking as to how the house should be sold and  she should move somewhere else and the mother should go to a condominium or an apartment and be relieved of the burden of maintaining that big house which would be too costly for her without the father's social security. She correctly deduced that this was less motivated by the wish to help their mother and more out of sibling jealousy as to why she should be allowed to live there for free of charge. Patient added that it is totally unfair for them to view her as someone who has exploited her parents for all these years for she had provided them with valuable companionship and for quite sometime had been nursing her father through his terminal illness. But added that she sees the writing on the wall and must make preparations to move out and part ways with her mother.

"Perhaps than the dream is about your need to go to your mother and get a closure on some unfinished business, perhaps a desire to get even with her, perhaps a last attempt to get something out of her that you feel she has withheld from you?"

"That makes lot of sense. We have in past therapy sessions addressed the theme of whether I am not leaving home because I have an ax to grind with my mother. And you are right. My mother is nice and a good mother but then there is this horrible side to her. She can be totally cold and abusive. I grew up never knowing when she would change colors. Out of the blue she would hit me, berate me, tell me that she is sick and tired of me and my father, and is leaving the house with no intention of ever coming back, that it was a mistake getting pregnant with me - you know I am the oops baby, and she always had mixed feelings towards me."

"And you reciprocated that mixed feelings towards her."

"Yes, I love and hate her. And that is why perhaps I never left home. Since I wished her harm when she would hit and threaten to not come back to counter my thoughts becoming reality I could never leave her. I had to be there to watch over her and prevent harm falling upon her. That also may be the reason I could not deepen any relationship with any of the boyfriends that came in my life. The minute it looked like I was about to have a life of my own, away from my mother, the guilt would kick in and I would panic and break off the relationship. Even Dick, my current boyfriend, if you can call him that, sticks around with me because he knows I will never demand to live with him. Because he is as useless about taking on the responsibility of a family life and being the man of the house, despite his being quite attached to me and  fond of my daughter. He will  freak out if we two decide to move in with him. Our relationship is primarily based upon our handicap -our fear of separating from our parents, growing up and being our own people.

"But why does my mother change in to that evil person?"

"It must be projection of your own feelings towards her. If your unfinished business with her is to attack her/punish her the dream may have reversed the depiction of it out of guilt. The fact that you are frozen shows that the dream censor is preventing you from acting out some impulse, in this case it is obviously an evil impulse towards your mother. If you cannot move your muscles then you cannot harm her. Making her come after you with similar intentions is making you doubly under control - in fact putting you on a self-protective instead of destructive mode."

"That reminds me," the patient added, "Another part of the dream which I had forgotten to tell you.  Before she can get on top of me and start tickling me sometimes I make an escape.  But she pursues me. Sometimes I fly. Sometimes I can fly so high that she cannot reach me. Often the chase goes into my running out of the house.  But the outside looks so ominous. The trees are barren. It is lonely and cold and though I have managed to leave her far behind I still fear running in to her. 

"And let me tell you it is not a projection of my own evil nature and her preventing me from acting out my evil intentions but a reflection of her evil nature too. For she has a split personality and I do fear her. Especially if my going to her is to get something from her. You know she was a wonderful artist. Her paintings are incredibly beautiful. She would have been world famous if she had devoted her life to it. In fact as a young girl she had got a scholarship to go to a prestigious Arts School but her parents overruled it and instead encouraged her to just become a housewife. And then when she finished raising her children I came along and ruined it for her one more time. She could never get that great adulation from public that she deserved. And the anger over it is what is reflected in her evil appearance."

"Where does the tickling fit in?"

First the girl could not come up with any associations but then after going through some intermediate links recalled that when she was a very little girl a sister's boyfriend - who was a "jerk" - would tickle her till she could not breath. "I would go into asthmatic attack and almost pass out and they would treat it as funny,  and my mother who knew how much distress I was in would make no move to stop that son-of-a-bitch from torturing me in the guise of just kidding."

"So that is another grudge you have against your mother. And before you leave the house and part ways with her mother you want to subject her to what she failed to protect you from, but because of your guilt and fear you are reversing the situation and repeating that childhood trauma with mother replacing the boyfriend. But why is her face pale, her hair jet-black and she looks like a zombie?"

"That is taken from a TV show which my mother and I watch together and which has a character that looks as if she was death warmed over. But that character is not a zombie so I don't know why I make my mother appear as a zombie?"

"Zombies are our projected death wishes [that uses paranoid process of imputing the ones we want to harm as the ones trying to harm us]. It is you who wants to attack your mother - hesitatingly, in a zombie like fashion, for the impulse to protect her is putting brakes upon the impulse to harm giving the movements the staccato character. However the dream under the influence of filial piety reverses it and projects your motor movements on your mother. You inability to move is being imputed to her."

"But I thought you said I could not move and scream because I was in Sleep Paralysis!"

"You were in sleep paralysis but the dream will use any physical event to fulfill its psychological motives. Your sleep paralysis was used to find expression for your guilt over wanting to attack your mother. Your sleep apnea was used to give expression to the memory of that abusive tickling and to show in visual language your ambivalence towards your mother. Using the mechanism which is present in Capras Sydrome - where the person sees a close family member or someone close as not the real person but an impostor with evil intentions. You see your mother as an impostor and an evil one."

"Where is the biting of the jaw coming from?"

This was very difficult to explain to the patient  for the only association to it that the patient could come up with was that zombies do it.

So we had to resort to psychoanalytic theory and my knowledge of her complexes from previous sessions. Now the girl had never separated from the parents, partly to control her worries that if she was not there with them some harm will befall on them, but there was another motive. Being highly competitive she was saddled with intense penis envy and much of her inexplicable and pathological behaviors arose from the wish to possess one so she could stand up to the men who had done wrong to her. She had been raped at the age of 14 by a boy who she had trusted and the pain of the trauma and unfairness of the world towards women had worsened because the mother had blamed her and instead of taking steps to punish that boy. She knew the family of the boy and not to spoil relations with them had hushed it.  If only she could obtain the organ that put women in the role of the second sex she would not have to rely upon other men to redress wrongs done to her and she could stand up for herself. She could never leave the house until she obtained from her mother - if necessary by force - what she was seeking.

The mother's feeling at the biting could not be analyzed but in all likelihood it was affirmation to her that her basic love bond with her mother despite the ambivalence was strong enough that she will be happy at her daughter getting what she desires so much even if it means losing part of herself.

Panic Attacks as imitation of death

A woman in her forties who has suffered from relentless panic attacks and chronic anxiety from the age of 19 gave the following reason as to why she came down with the illness.
She was a newly married young girl who had moved with her husband to a small town in Upper Michigan near an Air Force base. She already was mother of two children, an year old boy and a 2 month old perfectly healthy girl.
Her arrival at the town was immediately followed by her newborn getting sick. The baby stopped tolerating whatever was fed to her. Numerous brands of formula were tried, but she just threw up all of them. And one day, when she was barely 3 months old, she took turn for the worse. The mother begged her sister-in-law to drive her baby to the doctor for she did not have a car but the latter found some excuse to not do so. Two days later the little girl, just 3 months old, died.
Just before death, a 911 call was made, and the policeman who had accompanied the paramedics to her house, told her, that his son too had died a similar death, and it was all the fault of the Air Force base who were discharging their chemical wastes into the water system.
The death caused a devastating depression in the mother, which only abated, and partially, when she started investigating the cause of the death, spurred by that policeman's remark, and found that 8 other similar deaths had occurred in that small town. All eight were children, all below the age of one, and all had died of arsenic poisoning. The more she explored this matter the less depressed she felt, but at a price. It seems as if another affect had to emerge in place of depression to extricate herself from the latter - a rage at the Air Force base for allowing the arsenic to seep in to the drinking water. She became convinced that the planes that were flying above her - the air force base was just a mile away from the apartment complex - were dumping chemicals in the Huron Lake - which was right next to the complex - and that was seeping in to the well water. Her investigation also led her to ask the local health authorities as to why she and her husband had not gotten sick from that contaminated water and was told because they were older and could tolerate small amounts of arsenic that was present in the well water. The same explanation was given to her as to why her year-old had not gotten sick, for his water needs were mainly being met by the same food and drinks that the adults were eating -  obtained from the local supermarket which got all its supplies from outside the town.
She approached the Air Force personnel but they refused to take the responsibility for the deaths, claiming that the arsenic in the well water had nothing to to do with them but was naturally present in that region. This did not satisfy the patient, and the rage she felt towards them continued to deepen, finally culminating in panic attacks. The panic was a defensive maneuver to prevent the rage turning into actual destructive behavior towards the Air Force people. The panic attacks which soon spilled from discrete episodes into chronic anxiety and were accompanied by the emergence of agoraphobia. The rationale of agoraphobia was to prevent her from coming anywhere near the Air Force base where losing control completely she could have attacked those people. Within months the agoraphobia worsened and was no longer limited to avoiding the Air Force base but extended to every thing that was of any distance from the house, the radius of which kept on shrinking. At this point she had a big fight with her sister-in-law who had reneged from her promise to take the child to the doctor and who lived in the same apartment complex. She stopped talking with this sister-in-law on whose invitation they had moved to that town and then their apartment itself came under prohibition and she had to leave town.
She came back to Metro Detroit where she had grown up. But this physical distancing herself from the site of the trauma did not resolve the problem. Her husband, the only living representative of that painful period now became the reminder of the Air Force base, and the object of the phobia. She blamed him for moving them to that infernal town at the invitation of his sister, it was he who had failed to take heed when she pointed that the water looked cloudy and which he had dismissed as a joke by quipping that the water must be full of vitamins and hence cloudy and good for your health rather than bad, and any contact with him provoked the same panic reaction. This left her with no choice but to divorce him. His becoming an alcoholic, perhaps to deal with his own sorrow at the little girl's death, also played a significant role in her opting for the divorce.
Twenty-five years later, when she came to me, she still suffered from panic attacks, which were characterized now primarily by the feeling that she is about to die. Analysis showed that behind this feeling of dying, which provoked the 'flight response' and gave rise to the phenomenology of panic attacks - sinking spell, breathlessness, rapid heart rate, sweating, all physiological responses that one would experience if one was physically running - lay fantasies of going and murdering the Air Force base people and then getting killed as a punishment. And as the illness progressed this aim went beyond its original purpose - the hatred of the Air Force base changed into hatred of the world in general and even her husband.  And when she could not move away any further from people physically her mind started running away from people in imagination, which was reflected in her racing thoughts and pressure of speech.
But the rage which was fed by the loss of her daughter and which was permanent and incapable of getting undone in reality, still pressed for discharge and still wanted some live person to be punished. After leaving that town her husband had served the role of the whipping boy. But once she divorced him and he was no longer available, the rage was forced to find complete strangers as representative of the Air Force Base. But since one cannot attack every person one runs in to unless one goes outright psychotic, she had to express this hatred by becoming eccentric and goofy-headed in dealing with people. This goofiness which made people think of her as mentally imbalanced and someone to be avoided was now her expression of revenge.
But the rage was still not quelled. Even after the isolation was more or less complete, the rage persisted. And finally with no live person left to kill she made part of herself as that object, the representative of the Air Force Base. And it was this part of herself that she felt as dying when she would have panic attacks.
It is interesting that her nightmares repeated this process in sleep. They were PTSD like in their structure. The dreams would start as typically wish fulfilling. They would first show her daughter alive. The patient would then be filled with happiness. The daughter would not just be alive but would be shown blossoming through different stages of life, from 3 months onward to a young school girl, to a teenager, to a fully grown young woman. She would be surprised at knowing that she had not really not died but had survived the arsenic poisoning and that they had moved back to Detroit where she had grown up. But even the dream would not maintain the facade for too long, the underlying rage would rear its ugly head and reality would break through. And soon all the villains, including her ex-husband, would take the central stage of the dream. And finally she would wake up in a panic fearful of her own death.
I would not be surprised if a similar imitation of death underlies the sleep apnea - an imitation of one's death to satisfy murderous impulses towards others. Even "the sinking feeling" that patients describe that precedes full blown panic attack may be a premonition of death. For we know that in dreams death and rebirth are often depicted by the same symbol: drowning.       

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.