Three dreams of an agoraphobic

A woman who suffers from advanced obsessive compulsive disorder, numerous touch phobias, and barely leaves home because she has to dress and undress repeatedly, and do other cleaning rituals, before she can step out, brought in the following three dreams. She prefaced it by saying that when she was young her dreams were pleasant, but as years pass by they have become increasingly frightening, and now they wake her up almost nightly.

1. I have to go to work at the store at 3.  My mother who also works there is pressing upon me to go or at least to tell them that I will be late, but I cannot find my key, or the phone and anyway I am still in my pajamas.

2. I am being chased by bad people. I am running through streets. 

3. My brother comes to my house with his girlfriend, and destroys everything inside.


For the first dream the patient stated that she did work at that store but 30 years ago, when she was 18, for 3 or 4 years and then had come down with her illness and had stopped working altogether.  Her mother had worked there too at that time. What was different in the dream was that the store now was at a different location.  The store where they had actually worked no longer exists.

So the patient who during waking hours is virtually a cripple from her agoraphobia, was attempting recovery at night and seeing herself as cured and working again. Alas only in dreams. For the illness   was at the heels of the cure, and her neurotic fear of leaving the house was finding excuses to not be at work by still being in pajamas, not finding the car key, not finding the phone etc, despite the support she was receiving from her mother to overcome her phobia and show up at work.

From psychoanalytic theory I knew that agoraphobics avoid going in to public places afraid that while not in right mind they may do something [sexually] inappropriate. And I wondered if this expectation will be fulfilled by further associations.

And to my pleasant surprise this was confirmed when the patient had following to say about the second dream on being asked why those bad people were chasing her.


"They wanted to have sex with me. I had landed up I don't know how [the typical dread of agoraphobic that in a state of amnesia, or by some other inadvertence, they may land up in a sexually dangerous situation] in a bar or club or something like that. Those bad people were there. Along with some shady women. They were all like hanging together. And looked as if they were expecting me to join in whatever lewd thing was about to start. I think they belonged to a motorbike club or something like that for they ruled the town and nobody could challenge them. They could do whatever they wanted to. When I took off,  they came after me, trying to find me. I ran in to the trailer home of a middle aged woman. But instead of giving shelter, she said,  why don't you submit yourself to them. It will be so much easier. It will save you all this trouble of running away. All of us in this town do whatever they ask. They are so powerful. In fact I am going to that orgy myself. I have been there many a times."

So being chased and subjected to violence in the manifest content of the dream, which one would simply look upon as running away from ordinary aggression, also had an underlying layer: running away from sexual temptation. The patient agreed to the construction that the middle aged woman was  her mother. And just like in the first dream she had come in to the second dream to help her  overcome her agoraphobia. Here she was trying to help her get over her illness by telling her not to disown her unacceptable sexual impulses and run away from them but to give in to and thus be able to face the world again.

I wondered in my mind how the third dream would fit in with the other two. Was the coming of her  brother into her house was continuation of the bad people chasing her right in to the house to enforce sex upon her? And was his destroying the house another representation of sadomasochistic sex - the house representing herself? But I could not tell any of this to the patient to avoid influencing her associations. Instead I asked her as to what thoughts occur to her in connection with her brother.

To my astonishment the patient said, "My brother is no different that those bad people. Given a chance he would destroy my peace of mind as those bad guys. You know when I was in my twenties, he one day came to my house and forced sex upon me."

"Did he rape you?"

"No, it was not quite rape, for I did not protest. I was so stunned I just went through the motions. You know I grew up in a very chaotic household. There was no order, discipline, or sense of right or wrong in it. My parents did drugs and let us run wild. Anything we did was OK with them. So when my brother came upon me like that I could neither say yes nor no. But when he tried to do it more than a few times I told him to get out of my house and never come back again. In the beginning I felt  sorry for him, because he looked on verge of nervous breakdown, and I thought he will go over the edge if I did not let him have his way with me. But I quickly realized that allowing him to do such a crazy thing as to have sex with his own sister could not be good for him, however disturbed he was. So I put a stop to it."

"Did you stop working at the store after your brother enforced sex upon you. Was that the beginning of your agoraphobia?"

"No. I had phobias and fears even as a child. Even when I was a teenager it would take me forever to leave the house, so afraid I was of the world."

A revenge dream showing dreamer as a superhero

A patient who comes once every two months, and who rather not come because of his shyness and because he feels he is letting me down if he does not bring up something significant to the table, has discovered that a good way to fill up the 45-minute session is to narrate a dream or two, for he knows how it immediately perks up my attention, declared triumphantly that he has five dreams for me to analyze. But as he began, he apologetically confessed, he can now recall only three, and then proceeded to tell me the following four laconic dreams:

1. I am in a house and suddenly on top of me the glass shatters. It is strange that though there is extensive breaking of glass they don't hurt me at all.

2. Somebody is terminally ill.  I feel real sad for him.

3. A teacher with whom my brother and I went to Europe on a college sponsored group trip and who died not too long after we returned due to breast cancer was alive again. She looked young and had resumed teaching classes.

4. My mom is laying on hilltop on a grassy nice area. And she was young. 

To the first dream patient expressed his puzzlement as to why suddenly the glass will break over his head and why it caused no injury to him. But at my suggestion - based upon psychoanalytic theory and my knowing the patient for over two decades - that shattering of glass could have symbolized loss of virginity and gave the example as to how in Jewish weddings smashing of glass is a standard ritual and most likely an allusion to the rupturing of the hymen and consummation of marriage, the patient said that what I say could be correct for in real life he has never been able to look at any woman as a sexual partner but in dreams he often does so.

After some other things that the session drifted into he returned to the dream and talked about another association that had popped up in his head regarding breaking of glass. His passion for reading Marvel Comics and how in them superheroes like Superman, Incredible Hulk, Batman, Captain America crash through glass walls while in pursuit of supervillains and nothing ever happens to them. The crashed glass never ever even scratches them.


So the patient who in waking life is the very model of meekness, utterly respectful of women, who finds sexual as a violation of a woman's dignity, in his dream had turned into a superhero - the ultimate phallic symbol - boldly going through the glass wall - deflowering a virgin without a thought- and coming out of it unscathed.

In the second dream as to the person who was terminally ill, patient could think only of Professor J, who is director of the theater program at the college where he works, and whose health is rapidly deteriorating because of liver cancer. He had run in to the professor on the day before the dream and feeling sorry had asked if he could do anything for him. The professor had told him, "Pray for me." The meeting had aroused associations in the patient's mind connected with the theater but through the bridge of cancer primarily about a co-worker, M, who gets parts in the plays staged by Professor J. Now this lady had beaten lung cancer. In fact, given that she is in her late seventies and had smoked all her life, it is remarkable that she had survived the cancer. And the patient expressed his admiration for her in that she can still act on stage and recently had done an excellent job of playing a funny alcoholic.

As to why the association to M came in connection with J, besides both having cancer and both connected to the theater, the patient recalled that couple of weeks ago, M had met him and his brother at the church and had joked that she would love to fix them up with suitable matches but alas they were past the age when people date and get married. This putdown, which was at least on surface done to provoke humor, had provoked impulses of revenge, which at that particular time could not emerge in consciousness but which perhaps ran on some such line:"if the bitch had only died of lung cancer how much better the world would have been".  But true to his nature, which due to his religious upbringing forbids him to see or think any evil, what had emerged in his consciousness was seeing her playing the drunkard on stage which the patient did not fail to tell me with a laughter, was incredibly funny.  

The third and the fourth dreams were continuation of this vision of seeing M as a funny lady, alive and well and not dead due to her lung cancer. But there was a slight modification. Instead of M being brought back from dead, it was the person who the patient and his brother had gone to Europe with, and who also had cancer, and had died because of it, who was being being made alive again. The logic of course was that it would have been so much more fair if M the bitch had died of cancer instead of the professor. Whom he not only brought back from dead but also gave her additional presents of being young and back to teaching at the college.  This granting of reprieve from death had also been extended to his mother, who had died a few years ago.

 The mother had been brought into the equation because underneath his great filial piety and love for her, there was an equally strong resentment for her making such strong bonds with her sons that they could not dare venture away from her and find mates for themselves. In fact all their lives they had lived in the same house where they had been born and raised. They were now in their late fifties and even though their mother had died they could not leave the house as if it would have been betrayel of their mother.  In fact his inability to develop courage to have sex with [strange] women owed to this excessive loyalty to his mother and which part of his mind greatly hated. So the dream was showing his mother young and enjoying herself on the grass on top of a hill instead of showing her dead and six feet under.

The motive for the first dream became clear as well. Unlike what K had claimed that he was no longer fit for being fixed up with a girl, he was not past his sell-by-date but a young and vigorous superhero, invincible, devouring a virgin with impunity.

Role of unconscious Oedipal guilt in shaping the structure of two dreams

A patient brought to two dreams which he had dreamt on consecutive nights and had typewritten for the session:

Dream on Saturday, Nov. 22nd

I was driving a car with my friend Al. We were driving down 6 Mile road in a big Cadillac which is strange as I always buy Ford vehicles. We stopped at my house and I noticed All had a large cup of coffee. He tripped and splattered the entire cup of coffee on the big picture window at our house as well as two other smaller windows. I remember there were a total of 3 windows he hit with coffee. In true life I haven't talked to him in a while because of a disagreement we had over the way he was treating his sister. She has multiple sclerosis and he and his wife were her caregivers. He lost patience with her and became rejectful. As a result she was taken away from his care and moved to a nursing home where things are much better. However, since that time last year I haven't talked to him.

Dream on Sunday, Nov. 23rd

In the other dream I was sleeping on my bed when I found myself flying up into the sky where there was stormy weather. As I got near the clouds I spun around really fast like a spinning top and in front of me when I stopped there was a former girlfriend I met in Germany while in the Army name Julie. She said to me, "I've been thinking about you Sargent Hall, we should go back to Austria." (This is where we actually went in 1971 to visit her grandmother.) Then she handed me a rectangular box with 3 metal balls in it. One of them had a black dot in the middle. She then said "which one do you want?"

Patient who came to the session on Monday morning handed me the paper on which the dreams were printed out and wanted to know which of the two dreams should he associate to first. I of course told him that is entirely up to him. In all these matters it is the dreamer/patient who takes the lead.

He picked up the first dream and started talking about Al. How Al was a close friend of his. And then elaborated upon his disgust at this friend for the inhumane way he treated his sister and mother, even his wife, and how it shocked him to the point that it ended the friendship. The details of Al's ill treatment of his family members did not lead us too far in to solving the mystery of the dream, so I took up another element of the dream, choosing that particular one because the patient had shown visible pride over it when I had made him verbally repeat the dream in addition to reading what he had written, and which had risen my hopes that associations to that element may be more copious. "Why are you driving Cadillac instead of Ford?"

The patient worked for Ford as the head of its security operations for many years and thus feels great protective loyalty towards the company.

"That is strange. For I would never drive anything but Ford. And the funny part is that it is a vintage open convertible Cadillac."

Riding in an open vintage Cadillac on a busy thoroughfare had to do with satisfaction of the component sexual instinct of exhibitionism. Now the patient shows no trace of flamboyance in his manifest behavior. In his daily life he is a thoroughly modest man. Whatever desire to "show off" exists in him, it is limited to getting appreciation for volunteering in a nursing home and taking care of old folks, and yes he has a passion for rescuing stray animals from alleys. But there it was emerging in his dreams, his cruising down the street in a convertible Cadillac, which shows that the drive to exhibit oneself is a most powerful instinct of humans, and even those who have in their waking lives matured into great modesty can still show it quite openly in their sleep and dreams when their guards are down.

But for our present purposes all I was interested in this exhibitionism of his was to find out as to how it fitted in with the rest of the dream.

The patient did add that on Saturday, the day before the dream, he had gone with his son to Home Depot and had helped him load and carry brand new appliances to his rental house in an open truck. So the day residue of "showing off" the new appliances in an open truck had been exploited by the dream-work to show off himself, and Al, in an open vintage Cadillac.

Also behind the figure of Al was showing off of his son. Al was a composite of his son and Al. At daytime it was him and his son who were riding in an open truck. In the dream it became him and Al in a convertible Cadillac. The Al of the dream was the straw-man behind which his son was hidden. As we will see a few paragraph down Al was also serving as a straw-man for the patient. And the reason why his son was being shown off was because he has a tumor in his brain. The tumor is benign and the size of a small coin but the patient worries about its potential to grow in the future. He has no clear idea as to how serious is his son's overall neurological condition. So along with his own exhibitionism there was the wish to exhibit his son's tumor in the open Cadillac for the world to notice and thus find a cure for it. 

A Cadillac instead of Ford was chosen as an act of defiance towards his father, who he feared would disapprove of his exhibitionism, and because of other ancient Oedipal grudges which resided in his unconscious - Ford Motor Company symbolized to him paternalistic authority.This dream element of disobeying his father was originating from a completely different complex and making inroad into the main dream.

The above deduction however was not made from patient's associations but from my knowledge of him from years of therapy. Patient neither agreed nor disagreed with the above constructions.

Since dreams are always narcissistic and concern themselves exclusively with the wishes of the dreamer, we had to assume that behind Al's figure and his spilling of coffee on the three windows, was dreamer himself and his mental complexes surrounding his own impulses to transgress.  The dream was projecting upon Al his own tendencies to do misdeeds. "It is Al who is guilty of ill treating his sister, mother and wife not me. He is blameworthy not me." This line of reasoning which the dream was showing pictorially - with his own figure completely hidden behind Al's - was there to protect the patient's belief in himself as a good man who does no wrong. When this "construction" was conveyed to the patient, he not only agreed with it but brought some more associations that threw light upon other elements of the dream.

Al's spilling of coffee on the three window panes was connected to his being mean not just to his sister, but to his mother, and his wife, as well. The sister who had multiple sclerosis would be incontinent at times and he would force her to sleep on the floor as a punishment. He punished his mother, who has Alzheimer's, quite severely for having diarrhea on the floor. The brown of the coffee was taken from the brown color of the feces.

But behind these accusations of Al being mean towards his mother, wife and sister, symbolized by the three windows, there appeared to be self-accusations (guilty conscience) about his being mean - or more correctly thoughts of being mean  - towards his own father, sister and mother. The big window was his father who he wanted to insult to give vent to his grudges towards him. He also carried unconscious guilt about having not done enough for his sister, who had died in her early forties due to alcoholism, and towards his mother, who had suffered greatly because of the divorce that took place when patient was 10, and about which he felt somehow responsible. His son's tumor bothered him and his sense of guilt had latched upon it, and he felt he was somehow responsible for that too.

After giving above associations the patient drifted into talking about one of his daughters who is causing him even greater mental pain than his son's illness because of her recent divorce. His son's tumor is quiescent while her daughter's life is in total turmoil. She shows up with her children at their house all the time. The children are reacting to the divorce with great degree of confusion, especially one of the boys who seems to have lost direction in his life, getting into accidents, and who reminds him of how he had felt - confused and directionless - when his parents had gotten divorced.

His daughter whose financial status plummeted with her divorce, and is living hand to mouth, had borrowed  the patient's I-Phone, when her own phone had gone dead, and while in an argument with her ex-husband, the father of her four children, had flung it down the stairs to the basement, sending it flying through the air with such vehemence that its glass surface was smashed to pieces.

Since patient's daughter's hurling of the phone through the air happened on the day before the second dream, we wondered if his own flying up into the sky towards stormy weather and then getting spun around like a top in the dream was not his identification with his I-Phone which was being ruthlessly thrown down the staircase. Patient laughed at it and said that sounds about right. For he often views his children's trials and tribulations as bad weather in which he is involuntary thrown in to, and which he often wishes he could just escape.

Further associations revealed that the escape which he was wishing for was being fulfilled through going all the way back - spinning back through time - when he was Sargent in the Army and stationed in Germany and redo his life from that time onwards. At that time he had dated a German girl named Julie, whom he was about to marry. But just before taking the final step he had come home for Christmas, and had run in to his future wife, which had changed everything, for she appeared to him the more right person to spend the rest of his life with. However, few years later Julie married another American man, came to the States, located him, and though she lives in an another State, every now and then calls him, keeping the friendship alive and always still addresses him as Sargent Hall; that particular way of addressing him being the reminder of a time when things were so idyllic between them.

While a devoted family man, who would never think of abandoning his family, he, in his dreams,  often redoes his life with Julie. But only in dreams now. And only when the troubles of his children and grandchildren become too overwhelming for him to handle, provoking the wish for freedom from all his current ties and obligations. And it was only when the daughter smashed his phone did he feel justified in dreaming about how life would have been so different if he had married the other woman.

"Why is she asking you to go back to Austria?"

"Because that's where her grandmother lived. We took a train from Germany to Austria to visit her and that was the most romantic train journey anyone can imagine, with the countryside so beautiful - Austria and the surrounding region is breathtaking - and her grandmother was so nice and gracious. No wonder I want to repeat that experience in my dreams."

The time ran out to analyze as to where the three metal balls in the rectangular box were taken from, but the patient did associate that the one with the black dot perhaps signified his son, the black dot being his tumor, and that Julie was tempting him to choose between her and his family.



 

Psychological underpinnings of Racing Thoughts in a woman with Bipolar Disorder

When a patient reports racing thoughts the psychiatrist immediately thinks of Bipolar Disorder, especially of mania, and generally writes a prescription for Lithium, Depakote or Lamictal, the traditional mood stabilizers, or recently, being a captive audience of the pharmaceutical industry, brand name antipsychotics like Seroquel, Abilify and Latuda.

However, racing thoughts are a reaction to anxiety and have only an indirect relationship with mania. Anxiety itself is the organism's preparation for running away from danger. And when a person cannot run with his feet he runs with his thoughts. It is the perception of this frantic mental running that he reports as racing thoughts, or more colorfully with phrases like "my mind is running million miles a minute" or "my mind is all over the place" - by which he means he is putting out fire at every front from where the lurking danger may strike him.

Recently I could analyze to some extent the mental processes underlying racing thoughts in a Bipolar patient who was rapidly losing her euthymic state. The analysis threw some light on the underpinnings of racing thoughts.

The patient, who is in her late forties, cut her clonazepam dosage - a benzodiazepine - to half. This self-attempt to wean herself off the psychotropics triggered a partial relapse, the first manifestation of which was racing thoughts. She at once raised back her clonazepam but by then the cat was out of the bag.  Her morbid thoughts were no longer amenable to the benzodiazepines and demanded a running of their full course before going in to quiescence. 

When I inquired of the patient if her racing thoughts were the beginning of her mania she said,"No. They are the beginning of my depression. In mania I have this tremendous energy and I can actually control my anxiety by doing something like obsessively cleaning the house, washing walls, doing jigsaw puzzles etc. But the racing thoughts are not quite the mania itself.  In fact in all my three states I have a slight different reaction to anxiety. When I am in my normal state I still do the same obsessive activities as when I am in mania, but it is not accompanied by the agitation and nervousness that characterizes my mania. It is in depression that I have true racing thoughts and frank anxiety. I have no energy to do the obsessive rituals that control my anxiety. You know the purpose of my obsessions is to do something constructive that will ward off the impending doom. I can do that easily when I am euthymic, with some difficulty when I am manic, but I am completely paralyzed and cannot do my motor rituals when I am depressed. It is then that the racing thoughts start. As if recurrent thoughts replace the motor rituals. They are an attempt to run away from the disaster that is about to happen. When I am depressed I have no energy left to physically deal with the wolf on the door. I can only run and run and that too only in my thoughts."

Her statement about the racing thoughts made me wonder if we should not treat them more as a symptom of depression than mania, or, rather, as a symptom of both the phases of Bipolar Disorder.

"Can you tell me the content of your racing thoughts? That may give a clue as to their purpose."

But what she brought up as the substrate of her racing thoughts could hardly be seen as something that would cause anxiety. They were about a Stuart family and their son John. He was her first  boyfriend. As to why she was thinking about them was hard to tell. The scenes that she was playing in her mind were exact replaying of things that had happened to her in their company. Some of it  boring routine stuff, some of it tender, romantic and intimate moments with John. But she was repeating these memories obsessively through the night, especially in the morning hours, when she would wake up around 3 or 4, in great anxiety, her mind racing out of control."

"Why of all people you chose the Stuarts to think about obsessively?"

"You know when I left my home I was a minor. I had to live with strangers. Stuarts were one such family. They were nice to me. In fact they were the only ones who did things for me without any expectation of reciprocation. And then John and I became lovers. That was my first love. It was such a relief after the icky feelings I had developed towards sex because of the sexual abuse that I was subjected to by my father, which, as you know, is the reason I ran away from home at the age of 15."

"But why would you think about the Stuarts 30 years later? They are not in your life anymore.  John got married, divorced and now lives on the West Coast. There is no trace of the rest of the Stuarts, at least here in Michigan. You are not going to run in to them. You met John a few years ago and he aroused no passion in you. You were completely indifferent to him romantically. You have no expectation or desire to get back with him. Why would your mind race on and on about the Stuarts? And if the memories of the Stuarts is pleasant why do they leave you so exhausted in the morning?"

Patient then confessed that behind the thoughts of Stuarts, and her love-making with John, there were also thoughts about her father, that were simultaneously running in the background, though so faint, they were barely perceptible.  And yes they were connected with the sexual abuse. So the racing thoughts of her sexual relationship with John, and her pleasant memories of the Stuart family, were running in the foreground to cover up and replace the memories of the sexual abuse that was flooding the unconscious. She was running away from the memories of the sexual abuse, just like she had actually run away from the real abuse when she was 15.

"But why would you want to run away from the memories of the sexual abuse?"

"Wouldn't you?" the patient was incredulous. And then she realized I was not condoning it but wanted to know as to what were the underlying psychological processes that had made the abuse so distasteful to her, and if it was distasteful why it kept coming back to her mind every night.

 She went on,"A father is not suppose to do things like that to his daughter. Even then I knew it was wrong. I felt sorry for him, because our mother had left when we were very young, and he had to look after four children, and he was lonely and short with us, but that is no excuse for him to have done what he did to me."

So the pleasant memories of Stuarts were obsessively appearing in her mind to block out the unpleasant memories of the sexual abuse. So the racing thoughts do not emerge out of the blue when a person becomes depressed or manic, but have their own raison d'etre, and there is some psychological advantage to be derived from them. The depression and mania and the obsessions are a defense against the trauma. In this patient they were the preferred mode of dealing with adversities.

And the racing thoughts are better looked upon not so much as illness but as an attempt to prevent worsening of the psychopathology. In this case of her slipping into outright depression.

But why were the memories of the sexual abuse causing her to run away from them? Even if they were unpleasant  - or rather one part of it was unpleasant because it was something that should not happen between father and daughter -  there had to be some missing link that would account for why she had to run away from these memories. And if running away, and its mental counterpart racing thoughts, are due to fear/anxiety, what it is that she is fearing when she thinks of the sexual abuse?

Here the clue was provided by a series of dreams that had been analyzed over the years.

Whenever she would get into depression she would have anxiety dreams. It would be instructive to examine a couple of them.

She dreamt that she was destroying the top floor of her house with a bulldozer. There was awful din made by the bulldozer. After destroying it she just walked away. The dream was sparked by the garbage truck that was going back and forth next to her house. But it was reminiscent of her father telling her to keep awfully quiet during the furtive sexual activity lest her grandmother who lived in the lower flat would get woken up. They lived on the top floor and in the dream she was destroying it to erase the memory of the sexual abuse, and destroying her father at the same time as a revenge for doing what he did to her.

Another dream was of cutting grass. There were black snakes in the grass which were getting chopped off. This was again revenge fantasy of castrating the father for using his penis to violate her.

So the emergence of memories of sexual abuse were there to take revenge upon the perpetrator. And it was connected with intense fear that her father would retaliate if she attempted to kill or castrate him. And that is what she was running away from.

When she would wake up from these dreams she would be very shaky and spend all morning and early part of the afternoon till about 2 pm doing obsessive activities to control the fear. These obsessive activities were symbolic acts of repentance for wishing evil for the father. They were undoing of all the aggressive thoughts and actions she had dreamt in the night for being subjected to all the sexual things her father did to her. When all the penance had been done, which was by mid afternoon, she was free of obsessions, anxiety and racing thoughts.

There was an interesting diurnal variation to her racing thoughts. They would start when she would wake up at 3 or 4 in the morning, reach their peak by 7 or 8 am, and quit by the afternoon. She would feel somewhat OK for a few hours and then would go to bed by 7 or 8 pm. Analysis showed that once she started feeling good the thoughts of abuse, hidden behind which was wish for sexual satisfaction, would start emerging. But since these thoughts were intimately connected with shame, feelings of being take advantage of and of being wrong in eyes of others (morally reprehensible), they would provoke more unpleasure than pleasure and they would be accompanied by thoughts of revenge. And it is to escape this unpleasure that the patient would take to bed and sleep. However, they would continue on in sleep become too powerful by midnight and unable to be handled by dreaming of pleasant things like her relationship with Stuart family by 3 or 4 am. It was then that she would wake up with racing thoughts.

I cannot resist taking a swipe at all those drug company touts who come as experts and give CME and drug company sponsored lectures to us private practitioners, flaunting their professorships and other ivory tower badges of honor. Their psychiatry is limited to giving drugs and whenever I have asked them what they do in terms of psychotherapy they, one and all, as if they all get handed out a pamphlet in their annual neuropsychopharmacology conference how to deal if they ever get cornered with this question, reply with, " Well, I recommend my patients to take a walk. So you see I am not averse to mental factors having a role in mental illnesses."  With this declaration they seem to believe that they have discharged all their obligation to study and teach psychology's role in causing and sustaining mental illnesses. And well one cannot fault them either for there is some truth in that walking away from one's problems does give temporary relief. Running away from true understanding of the patient through zonking them with drugs or telling them to take a walk is the alpha and omega of their practice.

A dream of a self divided against itself

A 24-year-old man who complained of an inability to focus, problems at work because of his tendency to daydream, and chronic moderate depression, was put on Zoloft (Sertraline) 25 mg. He discontinued it after 3 days on the grounds that it clouded his mind. Instead, on his next visit, he requested Adderall (dextroamphetamine) for his attention problems.

Adderall immediately improved his work performance and mood, but he began having, as he put it, very strange dreams. They were violent in nature and intensely vivid.

The way he narrated all this gave the impression that the unconscious conflicts that were responsible for his depression and for dividing his attention were now emerging in violent dreams and as a direct consequence of Adderall-induced redistribution of his mental energies (cathexis). Perhaps Adderall's dopamine enhancing properties were boosting the pleasure (feeling of reward) in whatever tasks he was doing during the day and because of that his attention was focused upon it undivided; instead of getting diverted into daydreams through which his intrapsychic conflicts were indirectly presenting themselves to his consciousness. But this reconfiguration of mental forces due to Adderall was getting reversed at night, when with effects of Adderall gone his unconscious conflicts, gaining cathexis (charge) from lying fallow all through the day, were emerging with greater vigor, forming vivid and violent dreams.

When asked to give an example of his "strange, violent and vivid dreams" he narrated the following which he added he had dreamt two or three times since he was put on Adderall. 

Three guys are doing a hold up at a McDonald's. Two of them approach the counter while the third one waits at the door. Then the guy at the door shoots one of the two at the counter.  The head splatters,  blood and gore fly all over the place. The scene is still so vivid in my mind. In fact the whole dream was incredibly vivid. Strangely I did not panic or feel any other negative emotions despite the vividness of the violence.

"Who were the three guys?"

"They were thin and tall with shaved heads like myself, that is all I can say about them."

"Well you do not have shaved head, though your hair are pretty short."

"Those three guys had hair like mine - shaved or short whatever you prefer. I shave my head whenever my hair grows to any measurable length. Those three guys had hair like myself and they looked thin and tall like myself."

I looked at his physical dimensions and had to agree he was thin and tall.

"Were those three people yourself?"

"I never thought of it like that. But they were remarkably like each other, so what you are saying makes some sense. But I was there too, watching them, so I couldn't be them."

"You could be watching yourself in the dream.

"Anything else about the three guys, any other association, or detail in the dream itself,  that comes to your mind about them?"

"Two of them are wearing thin rimmed glasses. The third one is not."

"Why two of them are wearing glasses? You don't wear glasses. Why do the glasses come into the dream?"

"That is interesting. I know someone who wore glasses like that in my elementary school. We were very close. I haven't seen him in 10 years. Strange that he suddenly popped up in my dream. But yes those are his glasses and he shaved his head too."

"He shaved his head in elementary school?!"


"No, in middle school."

"Did you shave your head then too?"

"No, not then. He did, but not me. I started shaving my head after my grandmother came down with cancer and lost her hair to chemotherapy. I don't know why I did it. But when she died I shaved my head. And ever since I have keep my hair short."

Based upon the background knowledge I had of him I made the following conjecture,"You shaved your head because you felt guilty about your grandmother's plight. You blamed yourself for it and tried to subject yourself to the same misfortune that had struck her. It was making of amends in the way unconscious thought processes do. It is a form of mourning for losing an "ambivalently" loved person. You feel somehow you are responsible for their suffering and death and subject yourself to same torture that they experienced in the process of dying. You identify with people who are suffering and take on their problems as your own as if to compensate for what you assume you have caused them. Of course you had no choice over developing cancer, and certainly you would not have gone that far, but cutting your hair off was something you could sacrifice without too much trouble.*"

The patient did not quite follow my explanation but added, " I shave my head because it saves me 15 dollars each time I do not go to the barber. Punishing myself for my grandmother's cancer I don't know if that is true or not. But I did feel quite bummed out about it as if I should have done something to prevent it from happening."

"Since you have a tendency to do yourself what you do to others, is it possible that in that holdup there was intent to shoot someone, but before you did that your conscience - as one of the guys - shot yourself as the other guy?"

"Whoa that is deep. But there was no intention to shoot anybody during the holdup."

"There is gun in the dream and somebody is shot violently, so the intent to brutally kill someone was there in the latent dream-thoughts all along. All we have to explain is as to why instead of shooting the person who you were robbing - by making him show resistance, which would have provided the motive for killing him - you make one of the partners in crime shoot another which on face makes no sense. But it would make sense if we assume that you had ambivalence about shooting the person who you went to rob and kill and who in your unconscious is equated with McDonald's

"And if the three guys are different aspect of yourself then one one part of yourself, your conscience, the moral part, is shooting the other part, the murderous part.

"And as to who this person is who you want to rob and shoot we may be able to decipher if we figure out as to why the holdup was at McDonald's rather than a bank or convenience store. Any association to McDonald's?"


"My mother would not let us eat at McDonald's. We were not allowed to eat fast food as kids. So for a while when I could do it without anybody telling me what I could or could not eat I was eating at the McDonald's all the time. Actually for good three years that was my favorite food joint, at times I may have eaten breakfast, lunch and dinner there on the same day.

"So McDonald's is somehow connected with your mother.  You ate at McDonald's all the time to make up for the love your mother did not give enough of?"

"No, I never felt that way. Nor did my brother, who is four years younger than me, but my father may have felt that way."

"Why your father?"

"She cheated on him. He forgave her. But was depressed about it all the time. Finally she left him for the same guy that she had been cheating on him for 10 years, and for a while my father was very depressed; and tried to kill himself."

"So are your going to the McDonald's to shoot your mother, or her boyfriend, perhaps both to avenge your father?"

[I did not tell this to the patient but thoughts arose in my mind that the situation was identical to what Hamlet had faced when his mother had affair with his father's brother which resulted in his father's death, and he was faced with the dilemma of killing his mother and her mother's lover, but his conscience did not permit it since he was guilty of the same impulse that his mother's lover harbored, and he ended up killing a whole slew of people and finally himself instead of straightaway putting his mother and her lover to death. In my patient's case too instead of straightaway taking revenge upon his mother and her lover, who had made his father suicidal, he had in the dream chosen to kill himself and his childhood friend. In Hamlet too, Hamlet's two childhood friends meet the same fate as himself - death.]  

"The three guys went to the McDonald's to rob not to kill anybody. But who knows. You are the doctor you know better than me what goes on in my head."

"Now if McDonald's symbolizes your mother then it makes sense to rob her. During our first phase of sexuality, which reaches its peak around 4 to 5 years of age, there are sexual impulses towards the mother which is often felt as an impulse to rob her and which is tantamount to taking away from the  father something that  belongs to him**. So under the layer of going to McDonald's and shooting someone who symbolized your mother and her lover, there is another, and more ancient layer, of robbing your father of his wife for the satisfaction of your own love impulses. Which makes your guilt doubly strong, and leads to your shooting yourself for having such evil thoughts."

This piece of analysis did not quite make sense to the patient and in reality was conveyed to him quite partially, not in quite the same words, and was actually fully formulated while writing it now. But he did hint at its possible correctness by stating, "I never thought that my robbing of McDonald could be symbolic of my robbing my mother. But all my life I have felt as if she stole something from me." This feeling of having been robbed by her was projection of his own unconscious impulses to rob her***.

I asked the patient,"When did your mother leave your father?"

"When I was 19."

"When did you start eating at McDonald's morning, noon and night?"

"When I was 19."

So these revenge fantasies were there in his unconscious draining his energies and causing depression and robbing his focus and causing his attention deficit for five years but only when he was put on Adderall did they gain enough cathexis to get a foothold in his consciousness and that too in dream and not waking consciousness using the crutches of weirdness (dream distortion) and disguise (dream displacement). It was no doubt the intensity of his violent wishes that had kept them buried for so long, and only when he entered treatment and received the chemical boost from the amphetamine, that he could allow them to emerge in his sleep, when the muscular paralysis made sure that they could not be acted out.

The two details of the dream which were not analyzed but constructed by me needs a few comments. The two guys were wearing thin rimmed glasses and one was not. And it was one of the glass- wearing guys who shot the one who had no glasses. The one who was shot was himself and the one who was wearing glasses was his friend symbolizing his conscience. The friend was imported in to the dream to make a distinction between that part of himself which was connected to his conscience from the part which harbored revengeful impulses.

His comment that he did not panic and felt no emotions was triumph of the wish fulfillment. Such a violent and gruesome action could be enacted without feeling fear and other negative emotions because they were being enacted in the dream-pictures against his own self. Perhaps the glasses with their function of seeing more clearly symbolized the conscience.

Footnotes:

* One recalls here how Hindus shave their hair as an expression of mourning when one's parent dies. Since hair serves as an excellent symbol of penis one wonders if the cutting of hair in mourning symbolizes the following train of thought: since my phallic sexual impulses generated the wish for sex with my mother and death of my father, as well as sexual wishes for my father and death of my mother (negative Oedipal Complex), and now that the wish has come true, I must symbolically castrate myself by shaving off my hair.
In olden days Brahmins keep their head permanently shaved as if to symbolize that due to their unusually strong sexual drive, which consequently emerged with the most violent force during the oedipal phase, they have to live their entire life under the weight of the oedipal guilt. Only through the aid of a very strong oedipal guilt could they control the strength of their genital impulse, preventing it from regressively flowing into neuroses and perversions.
It is interesting as to how the Brahmins leave a small strand of hair at the back of the head like a thin ponytail - their choti - reminiscent of how the Mohawk Indians shaved their heads but for a thin strip of hair. Perhaps this hair ritual gives expression to the following train of thoughts: Under the pressure of Oedipal guilt  I have self castrated myself in most spheres of my life. Only a narrow band of direct sexual expression is left for me, rest of it restricted to aim-inhibited modes of discharge.  It may not be too far fetched to conjecture that the prohibition of cutting hair in Jews - a practice which Muslims and Sikhs plagiarized for their religions  - may be expression of this psychological complex but in reverse.

 
** Much of bank robbery, forgery, con games, cheating in money transactions,  and other forms of sociopathy in human affairs, originate from this impulse  - from the oedipal phase - to rob the mother and father too - because whether the mother belongs to oneself or the father is in dispute in child's mind.

*** In women the obsession to rob the mother for having robbed something from oneself lies at the heart of shop-lifting.

A Unified Theory of Physical and Mental Illnesses

All chronic illnesses - mental no less than physical - at the deepest level are an inflammatory response to an external object that has made an unwelcome entry inside the organism - broken through its protective shield - and disturbed its homeostasis. Entry of objects from one body system to another, like the intestinal bacterial flora entering into the peritoneum or blood stream, are reacted to as if they are an external object.

The inflammation is the organism's method of creating a wall around and extruding the unwelcome object out of the system and restore the earlier state. If the object cannot be expelled, excreted or exhaled then the organism works towards nullifying its harmful effects through embedding it and eventually making it a part of the organism, finding some 'secondary use' for it.

The process is assumed to happen just with physical objects that have traumatically entered into the organism, but the phenomena is equally applicable to the mind. Unpleasant experiences are treated as something foreign that should not be made part of the self (ego), and provoke mental (ego) defenses that try not to think about them any further, sometimes sealing them out of consciousness permanently by subjecting them to repression. They remain embedded in the unconscious memory banks, continuously subject to modification till they can be made part of one's self and 'secondary use' can be found for them.

These ego defenses are like the inflammatory response of the mind.  Ego originates from the mental representation of body surface - eyes and ears being the most specialized parts of this body surface - and other body sensations including those that give report of one's muscular activities (kinesthetic sensations), and just like skin, and other body organs, heighten their activities to expel an unwanted foreign object at the physical level, ego mechanisms gear up their activities to nullify the harmful effects of mentally painful experiences. The id impulses - sexual and aggressive drives - that originate from inside the organism, if they cross a certain threshold and cannot be safely discharged without provoking a retaliation from the outside world, are treated as if they are arising from the outside and ego defenses are mobilized against them as if they are not part of oneself. An extreme example would be how a paranoid schizophrenic may enucleate his eyes to reject the scopophillic id impulses, treating the eyes not as part of one's body but as an alien evil force that is inimical to one's self.  

Most interestingly an unpleasant psychosocial experience not only activates mental defenses, it simultaneously provokes the same somatic reactions that happens when some physical trauma  occurs. This latter phenomena has far reaching consequences. It is as if the body has a tendency to sympathetically respond to any inflammatory activity anywhere and it does not matter whether the provocative agent is mental or physical. As if the organism anticipates that one traumatic event is likely to be followed by some more, and all defensive processes must be put on alert if there is stressful assault on any part of it.

The above idea which has been with me for a long time, and bits and pieces of which have appeared in my previous posts, found its impetus to be written in greater detail while listening to a patient of mine who commented that her throat was inflamed which means that her Crohn's (autoimmune inflammatory bowel disease) will follow suit in a few days. She claimed that any inflammatory reaction anywhere in her body becomes generalized and her intestines, because of previous vulnerabilities, show this sympathetic inflammatory response the most.

Inflammation is mobilization of body's counter-attack mechanisms to deal with anything unwanted from the outside. But when these counterattack mechanisms go beyond their call of duty and start overdoing their job then we get chronic diseases. The body's reaction to an external object should be commensurate to the strength of the trauma. If, however, the organism is genetically oversensitive and/or has been subjected to too many traumas in the past, the hatred/rejection of the outer world becomes so strong that response to any assault, no matter how minor, becomes pathologically disproportionate. Every unpleasant encounter with the outside gets under one's skin so to speak. All chronic diseases are kind of Post Traumatic Stress Disorder if one may be allowed to express the above idea in psychiatric parlance. In psychoanalytic terminology they are "Traumatic Neurosis": abreaction of stress through exaggerated (displaced) mental and somatic processes.

Now our body comes into contact with the external world via limited portals. Skin of course is  phylogenetically the oldest organ, evolved to form a barrier between the subject and the object -  between the self and the universe. Modifications of the skin occurred to create various portals to more efficiently imbibe aspects of the world essential to one's existence while keeping the unwanted objects at bay. The gastrointestinal tract evolved from the protoplasmic wall inlets that increased the cell (skin) surface to more effectively incorporate food and water and excrete the superfluous; the respiratory tract developed to provide infinitely greater oxygen and carbon dioxide exchange area in the lungs along with a long passageway to trap subtle pollutants in the nostril hair and block food particles at the larynx; the circulatory system became specialized for taking the nutrients and oxygen from GI and respiratory tracts to distant organs of the body and to bring excretions back to the same tracts and also to the renal-urinary system; the optic, nasal and oral passages for taking in visual, olfactory and gustatory impressions respectively; and finally the brain which is the most marvelous extension of the skin, and where impressions impinging upon the five senses are converted to complex perceptions - which are further refined into concepts (brain's 'shorthand') - to more quickly react to danger and to more expediently search for food and sexual objects.

Now with mental trauma if its effect cannot be countered by pure psychological means (ego defenses) the reaction spills into physical sphere - modeled after hysteria in which psychological conflicts and excitations are expressed through bodily innervations - and different body organs react as if they are dealing with an intrusion of an unwanted foreign physical object in their system.

A full appreciation of this phenomena forces us to correctly realize as to how most chronic diseases, even those that appear to be solidly somatic, are psychosomatic in nature, and are initiated and maintained by psychological traumas. Chronic somatic diseases are not so much a reaction to some physical insult as a result of psychological stresses that generate compulsions to rid the memory of the offensive person in displacement. In respiratory tract one finds that the spasms of bronchial muscles and asthmatic attack are motivated to symbolically choke the psychological irritant in the bronchial passage. In an analogous manner, in the upper GI tract, we pour excessive acid to burn the source of our stress and then regurgitate, after 'eating alive' the hated person, through the reverse peristalsis of Gastro-Esophageal Reflux Disease. The psychology of binging and purging may show itself to have its roots in the desire to ingest the ambivalently loved object (person) and then throwing him up as a hated (foreign) object. In lower GI tract we try to eliminate him through various forms of colitis; as if we want to 'bury him in excreta'. In urinary tract the desire to flush out the person who is 'pissing us off' is reflected in various forms of irritable bladder syndrome and interstitial cystitis. In eyes and surrounding paranasal sinuses inordinate amounts of mucosal secretions (post-nasal drip) occur as if to 'drown in tears' the person who is causing us the pain. In the circulatory system we gear up to deal with the hostile outside world by increasing our blood pressure, by mobilizing inappropriate amounts of sugar inside the cell to make it more readily available for instant energy in case we have to indulge in fight or flight, by gearing up various other components of metabolic syndrome like increasing the rate of oxidation and mobilizing various forms of immune mechanisms, the excessive activity of which leads to autoimmune disorders. In the skin lopsided production of dermal tissue, as if to 'make oneself thick skinned' against the sling and arrows of life, causes psoriasis, neurodermatitis and other skin blemishes. It may be mentioned that the suppurative skin reactions in which the unwanted intruder is embedded in a pocket of pus to be eventually spilled out, gives us in a most transparent fashion the raison d'etre of inflammatory reaction. Finally in the brain, the most important extension of skin, where perceptions correspond to the touch sensations of the skin and muscle (motor activities) of the body correspond to thought processes of all kinds, exaggerated perceptions (hysterical disturbances) and excessive thinking (obsessive disorders) occur when a person is subjected to a traumatically intruding outside world. 

If I may be allowed to do so I may expand a little upon an interesting observation I have made upon  GI tract's role in dealing with psychological irritants. Perhaps people's love for eating hot and spicy food and drinking harsh spirits - the latter's intoxicating/anesthetic effect act as an additional motive of course  - may be a way to use the abrasive food as a symbol of the caustic world outside over which they can triumph by voluntarily swallowing its roughness. It is as if they are convincing themselves that no I am not subject to this hostile world against my wishes but it is I who is subjecting myself to this corrosiveness and enjoying it too. [It is not too different than how a woman who was sexually abused as a child repeatedly gets in to relationships with men who will repeat the sexual experience but over whom she has greater control now that she is an adult.]  The human obsession with eating some food and not others, in Obsessional Neurosis and Autism reaching ridiculous proportions, is a way to reject the painful aspects of the outside world by symbolizing it in some foods. Thrill seekers and those who court other forms of troubles, their psychology is similar to those who eat highly seasoned food. They expose themselves to dangerous situations or lure worthless people into intimacy, those who are sure to harm them, so they can triumph over these unpleasant objects and purge them out of their system.

Finally in this context one may mention that pregnancy, which during my student days was an object of  mirthful debate whether it should be looked upon as a physiological process or a disease - for it shows all the pathphysiological processes of an illness - can be conceptualized as an inflammatory response to a foreign irritant too.  The man's spermatazoa is treated as an outside object, its impact is lessened by walling it off from rest of the organism with uterine muscles which are also used to extrude the final product, the baby, out of the system. Excessive cautionary fear of the woman towards the larger world may lead to infertility in her. Such an attitude is often present in highly narcissistic women who finds sex and its consequences at variance with their life trajectories.  Such narcissism, where pregnancy and babies are looked upon as having no place in one's conception of ideal life, may pervade a culture to such an extent that the people belonging to it may slowly non-breed themselves in to extinction.

Body pain being utilized by dreamwork to find sexual wish fulfilment.

A widow in her fifties who suffers from multiple physical and psychiatric problems -  her diagnosis flits between Schizophrenia, Schizoaffective Disorder and Major Depression with Psychosis-  brought in the following - as she put it - "crazy dream":

I was in my trailer when some friends came and said lets go to a bar. We go there and I drink a lot.  There is a tall man there who has brown hair.  He buys me drinks and then takes advantage of me.  I come out of the bar staggering, and in great pain, and start walking towards my house to get away from the place, when one of the girls, who had come with me, tells me that you cannot let him get away like that. She calls 911 and the ambulance takes me to the hospital, where they interrogate me with some weird questions. At that point I wake up. 

"Did he actually take advantage of you or were you a willing partner?"

"You are asking me the same questions which the interrogators were asking me at the ER."

"Like what?"

"Like they did not quite believe me that it was a rape, and wanted to know if I secretly liked it, and did I trap him in to it."

"You live in a group home, you do not have a partner, so your need for sex may have been finding outlet in the dream."

"Well, you are right. I did want him to have sex with me. But he was taking advantage of me too. I will not tell you the details, but he was very rough with me causing me great pain."

Living alone it made sense for her to dream of having sex. But why did the dreamwork made it so painful?

"Do you enjoy rough sex. Sex which causes you pain?"

"No. I don't. I was so angry with him for what he was doing to me. In fact I tried kicking him on his nuts to make him go away.  But strangely, my legs would not move, and I could not push him away." [In the next session she claimed that she did kick him on his testicles and hurt him bad. This change in dream recall further confirms the high degree of ambivalence she had about having or not having the painful sex.]

"That shows ambivalence. You wanted to kick him away and yet there was the counter impulse to not do so, and for him to continue to do what he was doing. Why this ambivalence towards him?"

"Because he was hurting me."

"Who was this man? Was he your husband?"

"My husband died an year ago and had gotten divorced an year prior to that."

"He may still become alive in your dreams. Especially since you did not go out with any other man after he passed away."

"This man was not my husband."

"What makes you so sure?"

"Because my husband was very gentle. He never would would have done to me what he (the dream man) was doing. He was hurting me so much."

"Then who was this man? Any other associations that occurs to you about him, besides the brown hair? Anybody else besides your husband he could be representing?"

"He reminds me of nobody. "

"Anybody you know who has brown hair?"

"My husband."

"Any other thing about this man that you can recall?"

"He had green eyes and was 6' 3" tall."

"What was the color of your husband's eyes and how tall was he?"

"My husband had green eyes and he was 6' 3" tall."

"And he was not representing your husband!!??"

"My husband would have never caused me so much pain."

"Any associations to the pain."

"Well. I am having terrible pain down there. In fact when I finish my session with you, Linda (the group home manager) is taking me to the ER to get me examined.  The pain woke me up.  I should have come to the ER in the ambulance last night instead of dreaming about doing so."

The meaning of the dream was clear now. The dream was sparked by pain in the pelvic region. Instead of getting woken up by it she had conjured up the dream where pain was being shown as not due to disease but from sexual intercourse with her husband. The wish for him to be alive and having sex with her had found a common cause with finding relief for the pain.

However the pain was not getting fully masked by the pleasure from the discharge of the sexual drive through the fantasy. This was changing the character of the fantasy from pure pleasurable love making with her husband to rough sex with a stranger who was taking advantage of her. By doing so she could take some action against the man who was causing the pain and thus get rid of the cause of the pain, which she did it by attempting to kick the rapist on his testicles. When these actions did not cease the pain - for the pain though shown in the dream as due to being raped was in reality real and due to a genuine medical problem - the dream conjured up the motive to go to the hospital in her friend insisting that she call 9/11 and she saw herself going to the ER in an ambulance.

Since it was a dream hospital the pain was not being taken care of and instead of the gynecologist coming and helping her the interrogators were doubting whether she was really raped or she had asked for it.

Behind the pelvic pain (belly aching) and its cure through sex whether there was a fantasy of having another child with her husband could not be explored, for the session came to an end.