Installment 3 of a series on case analysis
© Will Taylor, MD 2001 (bio)
Characterizing Dimensions of the Totality of Symptoms
Part 2: On the Characterizing Dimensions of a Mental/Emotional Symptom
Presented at the March 2001 meeting of the Homeopathic Medical Society of the State of Pennsylvania; and published in the Summer 2001 issue of the journal Simillimum.
The Dimensions of Inner Experience
We can gather some appreciation of the restrictions and distortions of this "moment of choice" by outward observation of the stimuli and situations to which the organism is particularly sensitive or reactive; and of the outward behaviors that it exhibits. For many of our patients - infants, dogs, iguanas - those whose language we do not speak well - these observations may have to be sufficient for our purposes. We may need to rest our case on this two-legged stool, supported further by modalities and concomitants.
However, at least in our human patients outside of infancy, we can obtain more direct descriptions of this inner state. These come out in such repertorial symptoms as:
May I take a rather silly example? It's not that far from some cases I've taken, but is perhaps a bit lighter than some. This guy goes to a psychiatrist, and he says, "Now before we start, I gotta tell you, I've got this thing about dogs. Some people think it's pretty sick." Well, the psychiatrist says, "That's OK, I can work with that. Why don't you just lie down on the couch and we can get started". The guy says, "Oh, no, I'm not allowed on the furniture!!"
Where do we start on a case like this? I actually did have a case once, within a family that raised and bred Shelties, of a 10 year-old homeschooled girl who - at the age of 6-7 - was a dog. She made a bed for herself in one of the crates that the dogs slept in, slept in it for a year, asked for her meals in a bowl on the floor, and barked and snarled when she was angry or upset. She had a lovely, understanding mother, and is today a pretty normal child. (Unless you take her bone away from her). I was asked to see her for recurrent/persistent streptococcal sore throats, recurring since the age of 5.
We might consider this case to illustrate the use of dimensional components of a mental/emotional symptom by analogy, in the manner introduced by Boenninghausen for somatic symptoms. It's obvious that the image of Dog is vital to this case. It's so absolutely central, it needs to be part of the remedy picture. We could look for a specific rubric such as "Delusion, that she is a dog"; and we can in fact find "DELUSIONS - dogs - he is a dog, growls and barks" : Bell, Lyss (both additions from Knerr); but perhaps this is too restrictive for our purposes. A search of the repertory finds 26 rubrics having to do with "dog", some we could eliminate as they describe the form of the stool, etc.
55 remedies are found in these rubrics, of which 25 remedies are notable (listed in 2 or more of these "dog" rubrics, or in high degree in at least one).
We could combine all of these rubrics, and make them a reasonably sized rubric for "Dog as a central image" to be used in the analysis of this case.
We could also bypass our Repertories, and obtain this information straight from the Materia Medica. Fig.2 is a search-result chart for the word "dog" in Encyclopoedia Homeopathica, a computerized Materia Medica database. From this, we could construct a similar rubric of "Dog as a central image" for use in this case.
Now - in the little girl's case - I asked her "What is important to know about dogs?" and she replied - nonverbally - by showing me a Cujo face, lips drawn back, eyes fierce, snapping her incisors. So my second image for the case was "Biting/Bitten".
Another word-search of the repertory gave me 11 rubrics having to do with biting or being bitten (excluding skin eruptions that feel like being bitten by insects, etc.). I combined these, as above, into a single rubric of 22 remedies, using it as a central image, "Biting/Bitten".
The leading remedies at this point - with my 2 "image" rubrics - were Calcarea carbonica, Lyssin, Mercurius, Sulphur, and Hyoscyamus.
I asked her when it was that dogs did .. [and mimicked her Cujo face]. She responded "Like when mom doesn't talk to me nice."
We can use this as a symptom of the Stimulus dimension. So to complement the two Images I had, I took the rubric "AILMENTS FROM - rudeness of others". And gave her Calcarea carbonica.
We often find what appear to us to be deficiencies in our repertories. Where can we go to find "Craves sushi" or "Fears, becoming like own mother"? Yet the absence of specific descriptions of complex mental/emotional symptoms may prove to our advantage, in not allowing us to be misled by the too-simplistic interpretation of a complicated expression that we could better understand when we carefully examine its component parts.
For example, one dream that is so obviously missing from our repertories is "Dreams, that it is the end of the term, and he is not prepared for a class that he has forgotten to attend all semester."
A 42 year/old man related the dream:
"I'm in college, it's the day of final exams, I forgot I had enrolled in a French poetry class; usually it's poetry, sometimes other subjects. I'm sure I'll fail the exam, but I have to take it. On my way across campus, I discover that my pants have fallen off, and I'm completely naked."
When asked to describe the feeling in the dream, he replied only "I'm naked".
Images - Unprepared for an assigned task. Naked.
Feeling - Naked. (see below before you argue that this is not a feeling).
Although the specific remedy is not transparent in this one dream, we can draw some significant conclusions here. There is the perception of a fixed weakness; and the feeling is of being exposed in this fixed weakness. This is a centrally Sycotic dream, and the remedy should be a central or paracentral remedy of the Sycotic miasm. When the entire case was considered, Natrum sulphuricum - the 'signature remedy' of the sycotic miasm - fit the totality.
Incidentally, one might be drawn to suggest that the patient above is emotionally closed, because of what appears to be a rather unrevealing description of his emotions. An understanding of the central mental/emotional state of the sycotic miasm argues against this. The feeling of nakedness (one's self exposed) is a profoundly terrifying emotion in this state. - I think it likely that he believed I knew precisely what he meant by this - and would be as confused by my lack of understanding of it, as I would be if you told me you didn't understand why I said the sky was blue.
Let's look at another very similar dream, this one the frequently recurring dream of a 24 year/old woman (you have to read this one with that, like, contemporary accent?):
"I'm back in college, and I discover that I've got to take a final exam in statistics, or physics, and I haven't gone to any of the classes. So I'm walking to class, and like dreading it the whole way, and pass the student union, and figure I'd better go in and buy a statistics book. So I get one of those Cliff Notes books, but it's about some Dickens novel, and I'm struggling with like trying to figure out what this has to do with statistics, and trying to memorize it, but then I look at the clock and see that I've only got like 5 minutes, and I'm going to need to really hoof it to get to the class in time. I wake up like all sweaty and anxious." When asked her feeling, she replied, "I don't know if I can do it."
Images - Unprepared. Striving, struggling.
Feeling - Fear of failure in the midst of Striving and Struggle.
We can see that this is a very different symptom, even though the dream so much superficially resembles the first dream above. Here again we have the perception of fixed weakness, as revealed in the dream-image of being unprepared. However, the attempted solution to this sense of fixed weakness is very different. Rather than being preoccupied with the fear of being exposed in her weakness, this person is preoccupied by the effort and struggle she needs to exert in order to attempt to be OK. This is not a Sycotic dream, but rather the dream of a miasm intermediate between Sycosis and Syphilis - e.g. either the Tubercular or 'Cancer' (near-syphylitic) miasm. Again the specific simillimum is not transparent in just this dream; but on the totality of the case. I prescribed Nitric acid, a central remedy of the 'Cancer' or near-syphilitic miasm.
The Peripheral Nervous System
One piece still missing from this model involves the peripheral nervous system, with its afferent filtering of perception, and its efferent processing of response affecting the behavior of the organism. The psyche has this "plumbing" to receive the raw material of its perceiving, and to transmit the results of its intent; and its functions may reflect the distorted actions of this peripheral processing.
If one looks through the repertory at all the rubrics that have to do with Sensitivity or Ailments from, a number of remedies stand out. The Loganaceid botanical family leaps out in significance, with Nux vomica mentioned more often than any other remedy for its sensitivity, with Ignatia not far behind. Gelsemium, Spigelia, and Stychninum make a good showing considering their poor overall representation in the repertory. Staphysagria is right up there, as are Zincum and Coffea. The Solanaceids, Belladonna, Stramonium, and Hyoscyamus also make a good showing. Again, accounting for poor overall representation in the repertory, Tarentula hispanica and its crawly friends - esp. Theridion - exhibit a high degree of general sensitivity.
Much of the sensitivity of these remedies is at the level of the peripheral nervous system. Ignatia and Staphysagria are of course highly-tuned mentally/emotionally to be sensitive to moral impressions, but this is not only a central sensitivity to issues that incite their inner state; for the remedies above, there is also an issue of the gain of sensory input. The volume knob on sensory input is turned up; those peripheral processes that normally filter input are not doing their job. The Loganaceids, as one Spigelia patient described vividly to me, feel like "my nerves are on the outside of my body".
We can add this to our growing model:
Stimulus -> [Afferent processing - gain up or down] -> Moment of Choice -> Response
As a concrete example, Ignatia - one of the Loganaceids - is listed in 41 "Ailments from" rubrics and 10 "Sensitive to" rubrics. We need to understand this sensitivity in Ignatia from two perspectives. First, the "moment of choice" is distorted by a disordered sense of idealism, of the way things should be; which means there will be a lot of places where this person collides with the world in unpleasant ways. But as importantly, their nerves are raw on the outside of their body, and stimuli that might normally be filtered out get through loud and clear. Nux vomica's impatience has to do in part with its central "moment of choice" distortion, but also prominently with the fact that it cannot turn off the sensory stimuli constantly impinging on it in that god-damned checkout line.
Tarentula hispanica and Theridion are best understood if this sensitivity to all environmental stimuli is seen as primary, preceding any central interpretation. Of course we can understand this from what we know of the spider venoms - they cause degranulation and release of neurotransmitters in the peripheral nervous system and tremendous resulting peripheral neural disturbance, much as does the Strychnine alkaloid of the Loganaceid plant family.
Similarly, some remedies are well-known for peripheral restlessness and agitation which cannot be entirely understood on the basis of central excitability. Of the group just mentioned, the Spider venoms fall into both the "increased afferent gain" and the "increased efferent gain" groups; while the Loganaceids are not particularly noted for their agitation.
We find in the remedies in this group such symptoms as grimaces, automatic behaviors, tics, chorea-like movements, and other symptoms suggesting disinhibition of motor behavior.
Stimulus -> [Afferent processing] -> Moment of Choice -> [Efferent processing] -> Response
Remedies notable here include Cuprum, Zincum, and the Spider venoms.
Some stuff is just too hard to live with. In the physical realm this may be tough; but in the mental/emotional realm, there is opportunity to modify behavior, to compensate for a mental/emotional state that makes it hard to survive and relate to others.
This complicates our work with mental/emotional symptoms; because many of the symptoms we obtain - particularly in a chronic case - may be symptoms of compensation, rather than primary symptoms of the expression of a disharmony.
We can imagine compensations existing at two important levels. The first, is personal - compensations that the organism adopts to feel more comfortable internally. The second is more social in character - compensations that permit an organism to more easily adapt to and appear acceptable within its social environment. Obviously, the lines between these two blur significantly, as the distinction is largely imposed by our description of them. Ananda Zaren10 has described something akin to these levels of compensation in her writings as "the wall" - adaptations made to keep away the pain of a distorted inner experience - and "the mask" - adaptations made to integrate gracefully into society.
The first of these - the internal, personal compensations - take the form of alternative expressions of the distortions and restrictions of the "moment of choice" for an individual. We find, e.g., Belladonna listed in the rubric "Fearless" (addition, from O. Boericke). The core delusion for Belladonna is of course very much about fear, felt very deeply, and this is the condition of a patient in a Belladonna proving, or one finding themselves in a Belladonna state. This state of fearfulness is incredibly difficult to survive over time; a long-term veteran of a Belladonna state - e.g., a child born into this state - will likely have had to learn how to internally compensate for this unbearable fear, by developing a state in which it is denied; albeit in an equally disharmonious and restricting manner.
The second level of compensation - social compensation - is seen more at the level of outward behavior, without necessary change in the inner experience of the person. An example of this might be the "haughtiness" of Lycopodium - which is a common social compensation for the profound sense of personal deficiency felt in this remedy-state.
The essential thing to understand about compensation is that compensatory behaviors arise from the same disharmony - the same 'delusion' - that they are attempting to compensate for. As such, they cannot "see out of the system", and are constrained by the same disharmony as that for which they are attempting to compensate. More simply put, compensations typically don't work very well, they reveal themselves in their inadequacies, and they fail at critical times.
There is a metaphor I rely on in my understanding of our "moment of choice" and its restrictions/distortions and the role of compensations. Imagine that the room you are sitting in comprises the entire extent of potential human experience. Over in this corner is equanimity, over there is bliss, that corner is sadness, that one is anger, under the door jam is universal cosmic bliss - we can imagine it but can't quite get there. In full health we can walk about the room, sampling each of these experiences when and where it is appropriate. In disease, we are restricted to/from some regions of the room or our experience of some corners is distorted. Now it might seem like a nice thing to be stuck in bliss, but we medicate these people, and it's a problem when this is an inflexible response.
Perhaps we are stuck in the corner with anger, and can't even see the rest of the room. What is wrong here is not anger - anger has its place in the economy of the healthy organism - what is wrong is being restricted to anger, having this as a restriction/distortion/perversion of our "moment of choice".
Now it is very difficult to live in this world when the "moment of choice" is continually "choosing" anger. When you constantly feel like hurling objects at persons who say things you perceive as offensive. Where - without the British Raj in your face, you still feel like Gandhi. So what can you do? You can't just become "normal" - you're really stuck in this corner, the corner of anger, you can't just walk around in the rest of the room. All you can do is restrict yourself further. This is compensation. The mildness (MIND - MILDNESS) of Staphysagria is not about moving out of the corner of anger - it's about sitting down in that very corner. Still restricted; and now restricted even further.
The ground of compensation is the same ground as that of the original restriction/distortion of choice.
Sometimes we can recognize a compensation for its inadequacies. It is perhaps easier to recognize compensation when it fails at critical times.
Rajan Sankaran11 has described the conditions of failure of compensation in his model of the four stages of disharmony:
Original condition -> Compensated state < -> Decompensation -> Breakdown state
In his depiction of the "original condition", the primary disharmony has not yet seen compensation. This is the state of experience in the midst of an acute proving, when compensating behaviors have not yet had time to develop; it represents the unaltered core experience of the disharmony of the person. It often represents the projections that the person puts on the world about him - Pulsatilla's deeply-felt belief that he is abandoned and unloved, Belladonna's overwhelming feeling that he is being chased by creatures with teeth.
The Compensated state is the state in which a chronic patient spends most of their time. The compensations do not cancel the distortions and restrictions of the "moment of choice" - they can only be further restrictive; and arising out of the original disharmony themselves, they appear as mirrors to the primary state of disharmony.
The Compensated state is generally punctuated by periods of decompensation. These could be as simple and brief as isolated dreams or moments of breakdown of compensatory behaviors while driving in traffic; or they may show up as longer and deeper periods of loss of the ability to compensate during adolescence or progressive life stress. They may appear as moments when the patient "lets his hair down" - such as when the normally politically correct sensitive new-age guy has an evening alone and rents a van Damne movie, exhibiting - if only to the flies on the wall - his true nature.
A Breakdown state is less commonly seen, when the compensations - so necessary to the patient's survival of their disharmony -. break down completely and no longer serve their function.