The paranoid dynamic and mindfulness

Paranoia consists of individuals projecting on to other objects their unconscious desires or motives. There is a certain amount of a paranoia existent in every individual and there are a good number of people who have more of this trait than other people. According to the DSM-IV-TR, between 0.5% and 2.5% of the general population of the United States may have PPD, while 2%–10% of outpatients receiving psychiatric care may be affected. A significant percentage of institutionalized psychiatric patients, between 10% and 30%, might have symptoms that qualify for PPD.

Paranoia is sometimes used to cope with intra-psychic conflicts. When used like that it is called a defence in classical pshychoanalytical literature. For example lets consider a person who does not like a certain sweater and wants to destroy it while it is hanging on display in the shop. For the sake of appropriateness he will inhibit that impulse and by inhibition will give rise to an intrapsychic conflict. This conflict will become more and more strong as the impulses to destroy this sweater increase because of the opposite tendency which is in harmony with not doing anything inappropriate while looking at sweaters in the shop. Now let us consider the shop manager who to help out this person looking at sweaters in the shop comes over and starts hovering around. This person who has been thinking of destroying the sweater will project on to the manager. Now he will feel persecuted by the manager and feel that the manager is expecting him to destroy the sweater and that is why he is hovering around him. This will lead to paranoia on the part of the person who is browsing the sweater line up in the sweater shop.
If people use this defence exclusively it results in a certain type of a personality called the paranoid personality disorder. People described as having a Paranoid personality employ other defences also but we are foucsing on the paranoid dynamic.

In clinical situations it is proscribed that dealings with these individuals should be follow certain rules.

-It is important to hide as little as possible from these individuals. This transparency should include note taking; details of administrative tasks concerning the individual; correspondence; and medications.

-Individuals with paranoid tendencies often don't have a well-developed sense of humor; those who must interact with people with PPD probably should not make jokes in their presence. Attempts at humor may seem like ridicule to people who feel so easily threatened.

-Asking about an individual's past can undermine the treatment of PPD people. Concentrating on the specific issues that are troubling the patient with PPD is usually the wisest course.

-The paranoid thought should not be challenged too directly.

The basic proscription is because of the following dynamic. The paranoid dynamic vascillates in between two extremes. The model of the two extremes is useful for a number of dynamics and the etiology of defences (from Level I to Level IV), Gustafson has called these extremes the near-far dilemma. On one hand is the threat to be engulfed in the closeness which is too uncomfortable and on the other hand is the distance which threatens total isolation and loss of touch from reality.

So with a health care provider there is a dance which the paranoid person engages in. If the clinician is not quick on his/her toes they can soon find themselves out of rhythm with the interview. The above general rules serve well but it is to be kept in mind that rules are made for people and not vice versa.

"The unfettered mind" which is taught in everyday mindfulness is needed in many things including dealing with this trait/defense/jinn described above.

The Secret

A lot of commotion has been occurring in the new age thought circles about the secret. This is how I understand it. I made this opinion after religiously following Dilbert for several years.

Entropy is going on. That means that all the universe is full of particles that are evolving towards a state which can be understood by the following example. If X be the state of a particle and X+1 is the state produced in it by any one of the million factors impacting that state then the future state of the particle is going to be more chaotic than X or X+1. Every new calculation made by the system for the future will grow more chaotic as the aberrant X will deviate more and more from its original position.

As mentioned in the Heisenberg principle the mere state of awareness/observation/entanglement changes the system being observed. So if a particular observation effects a system to grow more chaotic in the future then it is possible that the future state of affairs can be changed by a thought or a level of entanglement with the system.

I am sure the results that a person desires also have to be translatable in the language of life. Unfortunately life does not understand winning the lottery so no matter how much one can think or entangle or contemplate on winning the lottery it is not very liable to happen. The language of life will probably also not understand the language of money. But what it does understand is that if one wishes for happiness or if one wishes to find an answer about a question or if one wishes for fulfillment or enlightenment the whole universe conspires to bring that around. Usually materials or objects will be used to bring around the end result and the possibilities are endless how a particular wish is granted. The time of the fulfillment are also something that life chooses.

Heisenberg Uncertainty Principle

The more precisely the POSITION is determined,
the less precisely the MOMENTUM is known.

While this is a specific statement concerning two characteristics of a particle, there are many interpretations also which apply this principle to the observer and the observed. It can also be called the observer effect. It is used to describe changes that the act of observing will make on the phenomenon being observed. In psychology it refers to the behavior of anyone being observed changing by the act of the observation.

Position and momentum are two characteristics of a particle that are being used to study it. If we consider the particle to be an analogy of life, then the two characteristics that we can use to study life are through the mind or through the heart (thoughts or feelings).

Neurobiologically both heart and mind are denizens of the brain and their interactions with each other are complex. At a certain level just like a particle can be described as pure momentum or pure mass (the dual theory of light) thus any perception of the mind can be accomplished using entirely reason or entirely feelings. That is a polarized level and in the interest of talking about averages we will consider the middle ground in the dyads of thought-feeling and momentum-mass. In the middle ground of the thought-feeling dyad, one cannot exist without the other. To separate the two probes of sensing is not possible. Primarily "thought" can be used to observe an object based on its height, length and depth but without the "feeling" the object being sensed will remain in a vacuum. The information about an apple will only be complete once I know that it is red and that it promises the same feeling as I had when I ate a similar one.A balance between thought and feeling needs to be struck for me to decide on the observation about that apple.

Human beings cannot be aware of the true state of affairs if they utilize feeling or reason alone. To be aware of the nearest estimate one has to use a blend of thought and feeling. Just like to determine the nature of particle ony postion or only momentum cannot be used. Both have to be used in conjunction and knowing at the same time what the possibility of error is.

We were talking about an apple which happens to be an object of mass. Hence to perceive it fully to ourselves in the two poles of thought and feeling, we might need to perceive it closer to the pole of thought. Similarly if we were attempting to perceive an aesthetic concept or art, it might be useful to perceive it closer to the pole of feeling. The truce that we negotiate in between the extent of thought and extent of feeling is intuition. Just like mathematical formulae can give the probability and extent of error in oberving particles, our souls or whatever the organ of intuition is called, determines the adequacy of our under or over reliance on thought and feeling.

So the question arises whether it is a good idea to observe life and reach a useful conclusion about it with reason or feeling. Is it good to think about life or is it good to believe in it without question. The great instrument of orientation is the thing by which we come up with an answer to this.

"Human beings are feeling animals", some say. Agreed that the primitive brain (amygdala, thatlamus, hypothalamus and pituitary) is entirely feeling. However the telencephalon or the executive brain is also well developed and both parts can override each other depending on the situation. If feeling is the only thing that is used to perceive life and make decisions about it, then we run the risk of turning into suicide bombers. If reason is the only thing that is used to perceive life and make decisions about it, then we run the risk of becoming an equally abhorrent creed of scientists.

A Dream Triptych about Gustafson

I have had the luck and the fortune to learn from Dr Gustafson. The following dream triptych I believe describes a journey which is defined by the first dream and ends with the last dream.

ACT I:


As a part of residency training in our program we were required to have one hour per week of general psychiatry supervision and one hour per week of psychotherapy supervision. In the third year I had requested Dr Gustafson as a supervisor. The following dream marked that time.















Dream notes:
The dream is set in Silent Hill universe. It was in the film adaptation of silent hill. It was primarily focused on the siren which signaled the transition into the alternate universe. Dr Gustason had started recently writing his book The Great Instrument of Orientation.

Dream:
Throughout the dream, I was exploring a very strange house. I had the feeling constantly that we had to get out before the universe changed into the dark one. With me was Dr Gustafson and there was the siren which scared me and gave a desperate longing and spurred a frantic struggle to get out of the house. My guide was Dr Gustafson and together through various rooms we made our way. We had pistols and we killed several monsters in the process of trying to fight our way out.

Interpretation:
Dealing with psychiatric patients is a tricky business.

ACT II:






Dream notes:
This dream was set in the painting of the last supper. Instead of JC I had a condensed figure in it. By this time I was roughly half way through the supervision with Dr Gustafson. I had already seen him transform his everyday life encounters into words and pen them down. The rigorous discipline which came to him like breathing (inspiration and expiration). I had by this time asked myself the big question of why life was going in and out of silent hill psychosis.
Also of note all pulmonologic diseases are divided into those dealing with inspiration(restrictive) and those deal with expiration(obstructive)
(Thanks to Darkdiscordia)



Dream:
The main figure was that of Jesus who was not Jesus but a condensed figure that I had created by combining a Pulmonology attending that I once met and Dr Gustafson. The Pulmonology attending I described next day to Dr Gustafson as "a show off who was very capable but liked showing off to his students". I was asking the savior about a Pulmonologic illness that I was suffering from and the condensed figure of the savior looked at me and said to me, "the problem with you is not in the expiration but in the inspiration."

Interpretation:
Inspiration can be difficult when the organism is threatened with expiration at every instance.


ACT III:



Dream notes:
The third and the last of the Triptych, I had the night that I received news that Dr Gustafson had published his book. All through the dream instead of seeing that book, I was thinking about Eckhart Tolle and A New Earth.

Dream:
I was going around a table of people who were studiously writing about something. Each had their own book and I was going around trying to make out the book that each person had with them. Suddenly I stopped because I saw a new book by Eckhart Tolle. I knew he had not written a new book after A New Earth. Not wanting to interrupt the person who was working with this new book, I took great pains to glance at the cover about this new book.

Interpretation:
Dr Gustafson writes about the dream "The dream could be taken several different ways, of course: one is that the new author is yourself, which seems to be exciting in finding your own center; another that you are getting pulled into someone else's center."

VACTERL association

V- Vertebral anomalies
A- Anal Atresia
C- Cardiovascular anomalies
T- Tracheoesophageal fistula
E-Esophagial Atresia
R- Renal anomalies or Radial anomalies
L- Limb anomalies

This is an association not a syndrome because of a lack of one single pathogenic gene. PubMed as of 9/15/08 does not give any psychological sequelae to this association. That is odd, given the neuroectodermal involvement as evidenced by the vertebral anomalies.
One paper found that IQ did not tend to be different from any other children hence the need to address individual anomalies early on is essential. Like any other chronic disease the earlier any barriers to development are removed the more "normal" the development.
Here is a network for family and children with VACTERL .
I have seen one child with this syndrome with anger issues. I did not have the opportunity to engage in a psychiatric interview though so I cannot delineate the etiology of the anger.

More research needed. :)

All the rivers of psychodynamic therapy combine

I hold to the belief of all therapy having one common theme to it. There is one expectation from therapy and that is too work. And sometimes not to work but do the least bit of damage. To explain all the intricate manifestation of human behavior, all theories come fairly close to each other. Yes they differ also on some key elements but then again if a therapist cannot practice being all inclusive, he or she runs the danger of trying to see everything in the world as all squares or as all circles.
The discussion of Beck about modes of cognition which exist in our minds and how they become activated through cognitive reactivity brings back some memories of archetypes that Jung talks about.
My psychotherapy supervisor, who i just started with believes in thinking in psycho dynamic terms but making plans keeping in mind behavioral or interpersonal principles. I found his approach as somewhat unique. He believes that initially the problem needs to clarified. One should be clear whether one is dealing with problem of libidinal drives, problem of function of the ego (like reality testing, impulse control etc), problem with how the person perceives the world around it or how the person recognizes itself. By this he is combining all the schools of psycho dynamics and giving each of them a place to help formulate each case.
The four schools broadly being drive theory, self psychology, object relations and ego psychology.

I think every good therapist tries to unite all these things in the mind and clinical practice. It is informative trying to see what every one's picture of unity looks like.

My previous psychotherapy supervisor who is a man held in awe by many including myself, was a minimalist. He was the king of brevity. Actually still is. He saw all therapy and condensed it into the very basic rudimentary dynamic. On those basic framework of dynamics he would plan the clinical dance to take some very interesting forms.

Pakistan and ADHD

I was trying to research ADHD in Pakistan today and came across this article from J Pak Med Assoc. 2003 Sep;53(9):441-3

Qureshi A, Thaver D.Aga Khan University Hospital, Karachi.

Ok so ADHD exists in Pakistan. Now what is the treatment for it. Primarily would be the use of analeptics. If one class of analeptics is not effective the medication can be switched to the other class and ~90% children respond. One class being the Methylphenidate products like Ritalin and the long acting methylphenidate products and methylated compounds of methylphenidate. The other class is the amphetamine salts like dextroamphetamine and the mixture of the two enantiomers of the dextroamphetamine (Adderall, Vyvanse, Dexedrine). In Pakistan only the MPH compounds are available.

I found Ritalin at an online pharmacy. 10 mg tablets. The price is Rs 4.7 for 10mg. It is certainly not steep. A 40kg child would be taking roughly 1mg/kg/dose as the high end would end up spending ~Rs 18. If this dose is taken two to three times a day the cost increases up to 18x3=54. If this is not given on days off from school, the child will take it ~20 days. So Rs 1080 for an entire month.

Now the question is what is the other option besides Ritalin. Nothing. I have not been able to find Amphetamine salts. Second line medications like Alpha 2 agonists (Guanfacine and Clonidine) which are also used as blood pressure medications are also not available.

Bupropion is available. This also a second to third line agent. 75 mg tablet costs Rs 10. It is usually needed in doses of 150mg-300mg and everyday medication will make it a cost of anywhere from Rs 600-Rs 1200 per month.

Atomoxetine is not available. That would also be a second to third line agent. Especially useful in children who cannot withstand analeptics.

Then there is the tricyclics, which are available but that would be third line agents and not the best medications for a hyperactive child. Side effect profile unfavorable.