December 30, 1990|By John R. Lion

IN A WORLD gone largely mad, I deal with the smallest insanities of mind. Patients reveal the microscopic things that bother them, yet are cognizant that worldly issues prevail in vast juxtaposition. This realization in itself produces pain. Thus a man tells me that his daughter served him last at the Thanksgiving day family dinner. He writhes in the chair with the recollection.

''There's a war beginning in the Middle East,'' he laments, ''and here I am upset about not getting a piece of turkey.''

I acknowledge his sense of relativity. The mind has the capacity to see the vast universe or a single atom. It can see both while dismaying over each.

''My daughter hates me,'' he declares as we come down to basics, for it's not turkey we're talking. Hate and love are the recurring issue, an epic polarity never resolved, barely understood. Men and women love and hate one another, repudiate each other's presence, are inextricably dependent. We have come to understand the composition of most matters and can label chromosomes, but love remains an occult force, like gravity. The silent weight is always there.

''I shouldn't be so obsessed with all this,'' a patient tells himself and me. ''I ought to be happy. I have good health and a good job and money in the bank and a loving wife and -- '' The ''ands'' are the problem for this man who was denied a promotion. Love is grafted onto success, and success is etched onto a brass plate affixed onto some door on the 14th floor of power. Compared with the deficits that clang within him, his health and money and family are not enough. The whole galaxy would not be enough.

''It's Christmas time and poor people are starving, and the homicide rate is sky high in the city, and here I am talking about a silly promotion.''

''It clearly bothers you,'' I tell him.

''It haunts me. It shouldn't haunt me. There are more important things in life.''

''It won't help to compare your plight to the S&L crisis,'' I warn. ''That just distracts you from grieving.'' We are in the early stages of therapy and the remark is cryptic to him. I am referring to a large mourning for a love never fully received. Highly successful folks may be driven by machines that run so very close to empty. Praise and money are the rare and costly fuels.

''I bet Saddam Hussein doesn't care what people think about him,'' a patient declares. ''Why do I care so much?''

I have read an article about Mr. Hussein's so-called malignant narcissism written by a State Department psychiatrist who analyzed his speeches. Quite possibly Mr. Hussein does not fret very much at night, but the issue is irrelevant. My patient does, and his frets are painful and real. It does no good to contrast one's ruminations with the larger plights of man, the famines and plagues, the national debt. Each small agony counts, disturbs sleep, saps the organism's strength. A patient is snubbed at a cocktail party, another receives poor service at a restaurant, a third misses a train and fumes at the taxi driver who took the slow route. Each one correctly views the trauma as small and large, silly and serious, frivolous and desperate.

''How is it possible that I can worry over the fate of Israel and still get upset when my son doesn't call me on Sunday?'' a patient asks.

It is possible. The Berlin Wall tumbles, the head of the Soviet Union wins the Nobel Peace Prize, perhaps Saddam Hussein takes Prozac. Anything is possible.

''Little things upset me more that big things,'' someone comments to me. He is talking about his luxury car being dirty and in the next breath bemoans the fate of the schizophrenics in the state hospitals. ''I have so much,'' he says, ''and yet it feels like so little.'' He is aware of a huge paradox. The chronically ill he refers to appear hopeless, yet his despair is suicidal in the face of massive plenty. He yearns for meaning, yet invokes tragedy to bring it about, as if bad luck would bring about contentment by default. Small hangnails and gaping wounds hurt equally in the measureless psyche. There is no logic to it, only the realization that we can cry over spilled milk or lost love, the tears will taste the same.

Dr. Lion practices psychiatry in Baltimore.

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