I am trying not to think about something..
Abstract: This case illustrates the importance of conducting the clinical interview in a way that elicits the patient’s trust and empathy. We homoeopaths must train ourselves extensively in methods that put patients at ease and facilitate communication, including non-threatening ways of seeking information as well as appropriate listening skills.
Keywords: Obsessive Compulsive Disorder, Anxiety, Thoughts, Nitric Acid
Jayant was referred to our clinic for evaluation and possible treatment of severe distress and anxiety centering on his marriage. He arrived neatly dressed in his work clothes (he was a mechanic). He reported that he was 24 yrs old and this was the first time he had ever seen a Homoeopath who is dealing as a psychologist as well. He wasn’t sure that he really needed (or wanted) to be there, but he felt he was beginning to “come apart” a little bit due to his marital difficulties. He figured that it certainly wouldn’t hurt to come once to see whether we could help. What follows is a transcript of parts of this first interview.
Doctor: What sorts of problems have been troubling you during the past month?
Jayant: I’m beginning to have a lot of marital problems. I was married about 9 months ago, but I’ve been really tense around the house and we are having a lot of arguments.
Doctor: Is this something recent?
Jayant: Well, it wasn’t too bad at first, but it’s been worse lately. I’ve also been really uptight in my job, and I have not been getting my work done.
Note that we always begin by asking the patient to describe for us, in a relatively open-ended way, the major difficulties that brought him or her to the clinic in the first place. When dealing with adults, or children old enough (or verbal enough) to tell us their story, this strategy tends to break the ice. It also allows us to relate details of the patient’s life revealed later in the interview to the central problems as seen through the patient’s eyes.
After Jayant described this major problem in some detail, I then asked him about his marriage, his job, and other current life circumstances. Jayant reported that he had worked steadily in an auto body repair shop for the past 4 years and that, 9 months previously, he had married a 20 year-old woman. After getting a better picture of his current situation, we returned to his feeling of distress and anxiety.
Doctor: When you feel uptight at work, is it the same kind of feeling you have at home?
Jayant: Pretty much; I just can’t seem to concentrate, and lots of times I lose track of what my wife is saying to me, which makes her mad and then we’ll have a big fight.
Doctor: Are you thinking about something when you lose your concentration, such as your work, or may be other things?
Jayant: Oh, I don’t know; I guess I just worry a lot.
Doctor: What do you find yourself worrying about most of the time?
Jayant: Well, I worry about getting fired and then not being able to support my family. A lot of the time I feel like I am going to catch something – you know, get sick and not be able to work. Basically I guess I am afraid of getting sick and then failing at my job and in my marriage, and having my parents and her parents both telling me what an ass I was for getting married in the first place.
During the first 15 minutes or so of the interview, Jayant seemed to be quite tense and anxious and would often look down at the floor while he talked, glancing up only occasionally to make eye-contact. Sometimes his right leg would twitch a bit. Although it was not easy to see at first because he was looking down, Jayant was also closing his eyes very tightly for a period of 2 to 3 seconds. It was during these periods when his eyes were closed that his right leg would twitch.
The interview proceeded for the next half hour, exploring marital and job issues. It became increasingly clear that Jayant was feeling inadequate and anxious about handling situations in his life. By this time he was talking freely and looking up a little more at me, but he was continuing to close his eyes and twitch his right leg slightly.
Doctor: Are you aware that once in a while you are closing your eyes while you are telling me this?
Jayant: I’m not aware all the time, but I know I do it.
Doctor: Do you know how long you are been doing that?
Jayant: Oh, I don’t know, may be a year or two.
Doctor: Are you thinking about anything when you close your eyes?
Jayant: Well, actually I’m trying not to think about something.
Doctor: What do you mean?
Jayant: Well, I have these really frightening and stupid thoughts, and …. It’s hard to even talk about it.
Doctor: The thoughts are frightening?
Jayant: Yes, I keep thinking I am going to take a fit, and I am just trying to get that out of my mind.
Doctor: Could you tell me more about this fit?
Jayant: Well, you know, it’s those terrible things where people fall down and they froth at mouth, and their tongues come out, and they shake all over. You know seizures. I think they call it epilepsy.
Doctor: And you are trying to get these thoughts out of your mind?
Jayant: Oh, I do everything possible to get those thoughts out of my mind as quickly as I can.
Doctor: I have noticed you moving your leg when you close your eyes. Is that part of it?
Jayant: Yes, I have noticed if I really jerk my leg and pray real hard for a little while the thought will go away.
What’s wrong with Jayant? The first interview reveals an insecure young man experiencing substantial stress as he questions whether he is capable of handling marriage and a job. He reports that he loves his wife very much and wants the marriage to work and he is attempting to be as conscientious as possible on his job, a job from which he derives a lot of satisfaction and enjoyment. Also, for some reason, he is having troubling thoughts about seizures.
So where do we go from here? How do we determine whether Jayant has a psychological disorder or if he is simply one of many young men suffering the normal stresses and strains of a new marriage who, perhaps, could benefit from some marital counseling?
Observing Jayant’s persistent motor behaviour in the form of a twitch led to the discovery of a connection (functional relationship) with some troublesome thoughts regarding seizures. Beyond this his appearance was appropriate, and the flow and content of his speech was reasonable; his intelligence was well within normal limits and he was oriented times three. He did display an anxious mood; however, his affect was appropriate to what he was saying. These observations suggested that we direct the remainder of the clinical interview and additional assessment and diagnostic activities to identify the possible existence of a disorder characterized by intrusive, unwanted thoughts and the attempt to resist them – in other words, obsessive compulsive disorder.
Patients usually have a good idea of their major concerns in a general sense (“I’m depressed”; “I’m phobic”); occasionally, the problem reported by the patient may not, after assessment, be the major issue in the eyes of a Homoeopath. The case of Jayant illustrates this point well: He complained of distress relating to marital problems, but the principal difficulties lay elsewhere. Jayant wasn’t attempting to hide anything from me, he just didn’t think his intrusive thoughts were the major problem; additionally talking about them was very difficult for him because they were quite frightening.
It is not uncommon for someone with Obsessive Compulsive Disorder to experience severe generalized anxiety, recurrent panic attacks, debilitating avoidance, and major depression, all occurring simultaneously in conjunction with obsessive-compulsive symptoms. In other anxiety disorders the danger is usually in an external object or situation, or atleast in the memory of one. In OCD the dangerous event is a thought, image or impulse that the patient attempts to avoid as completely as someone with a snake phobia avoids snakes. Obsessions are intrusive and mostly nonsensical thoughts, images, or urges that the individual tries to resist or eliminate. Compulsions are the thoughts or actions used to suppress the obsessions and provide relief. Compulsions can be either behavioural (handwashing, checking) or mental (thinking about certain words in a specific order, counting, praying, and so on). Jayant had both obsessions and compulsions.
I took the following rubrics from Synthesis Repertory for repertorising Jayant’s case.
And the result that came after repertorisation was:
Final Selection of Medicine:
Based upon the above repertorisation I selected Nitric Acid 1M – 1dose followed by placebo for one month.
Why Nitric Acid?
According to Sankaran:
“The theme of Nitricum acidum is a constant feeling of threat. This threat is perceived in several spheres: health, work, relationships, and so on. Like other acids there is also the theme of a lot of effort, a lot of activity, followed by exhaustion. In Nitricum acidum this effort is directed at fighting off the constant threat or danger that they perceive. The effort takes the form of a hard, obstinate struggle carried on with an unforgiving, violent, malicious attitude and an internalized cold anger. It is a desperate, almost superhuman struggle for survival. They are tremendously suspicious, mistrustful, see danger everywhere and are ever ready to strike back.”
* “Another feature of Nitric acid patients is that they do not easily make contact with others. They talk as if there is always a barrier between them and others. Even when there is anxiety and the doctor confirms that nothing is wrong, they remain absolutely certain of their own idea. It is as if this barrier prevents any real communication. Nitric acid patients stay within their own world of suspicion. Because of this, these people make very poor conversationalists; they seem incapable of seeing the point of the other person.” [Vithoulkas]
Moreover, Jayant is a very CHILLY patient and he is having marked aversion to Cheese. This personal history also favoured Nitric Acid.
As Jayant winds down his present course of medicine for around 6 months, I ponder the relationship and the process of change. Jayant is undoubtedly more fulfilled in his work and life than before. He has seized his own rung. Whatever frustrations now ensue, they are, at the very least, a consequence of choosing his own life rather than what we may call “soul murder.” This is genuine freedom, freedom that encompasses destiny.
The thoughts of fit do occur once in a while but they don’t disturb Jayant any more. He is now least bothered about these thoughts and there is no need to jerk his leg.
In relationship, Jayant continues to struggle with feelings of uneasiness, inconsistency but here, too, however there are signs of real growth as the patient is far less defensive and more open to others than was formerly the case. Jayant’s purview is now at least broader. He sees further into life as he embraces the joys and burdens of freedom. He is no longer a wheel horse.