AIMS/OBJECTIVES OF CASE
- To understand the clinical picture of a case of seizure disorder
- Evaluation of the ‘mental state’ of a patient with the help of ‘life space table’ (An ICR tool).
- Understanding the importance of studying ‘mental state’ in formulation of totality and selection of simillimum.
INTRODUCTION OF SUPERVISORS
This case was done as per ICR methodology under consultation of Dr Kumar Dhawale (MD Psychiatry) and supervision of Dr Manoj Patel MD (HOM), HOD of department of Psychiatry and Dr Sunita Nikumbh MD (HOM), Reader of department of Psychiatry at Department of Neuropsychiatry, Dr ML Dhawale Memorial Homoeopathic Institute, Palghar, India.
PRELIMINARIES
Name: N.S. Age: 35yrs Sex: Male Education: 8th std Occupation: Unemployed Marital Status: Single Religion/Caste: Muslim/Shiya Diet: Mixed Father Age: 72 years Mother Age: 57 years Siblings Age: Brothers 36 years, 30 years, Sisters- 27years
CHIEF COMPLAINTS
| No. | Location | Sensation and Pathology | Modalities A.F.,<,> | Accompaniments |
| 1 | CNS- Brain
Since 10-15years O-Sudden D-15-20 minutes P- Progressive F- Initiallly-2-3 times/day Since 2014- Once/month
|
Convulsions:-
Pre ictal phase- -Movement of B/L hands2 Ictal phase (4-5 minutes )- -Unconsciousness -Up rolling and redness of eyes2 -Frothing from mouth2 -Deviation of mouth2 -Tongue bite2 -Vomiting of indigestible things2 -Involuntary passage of stool/urine2 -Stiffness2 of whole body -Twitching/Jerking2 of whole body -Profuse Perspiration2 Post ictal phase (10-15 minutes )- -Sleepiness2 -Weakness2 |
H/o head injury
<Anger when2 <Sleep after2 <Full moon2 >Tab Levera 750mg BD >Tab Cloba 10
|
PHYSICAL CHARACTERISTICS
| Appearance- Fair complexion, well groomed, maintaining eye contact, obese, nose-broad, straight, right eye squint | Perspiration- Moderate2 specially on face2 |
| Appetite- Hunger- causes irritability | Aversion: sweets2
Craving: Pungent3, Chicken2, Salt2, Tea2, Warm food2 |
| Reactions-physical factors: Sun aggravation | Thermal: Hot |
PATIENT’S/MOTHER’S OBSTETRIC HISTORY: FTND, LBW, H/O delayed cry for 5-10 minutes, Neonatal Asphyxia
DEVELOPMENTAL LANDMARKS/PROBLEM: N
PAST HISTORY: Family history- Mother HTN/OA, Brother- DM
LIFE SPACE:
Patient was born and brought up at M. His father is a businessman and his mother is a housewife. Patient is 2nd child of his parents. Patient has 3 siblings, 1 elder brother, 1 younger sister and 1 younger brother.
is fHis father is very domineering by nature. Patient had fear of his father in childhood. Mother is calm and quiet by nature. Mother does not reply to anyone and she remains quiet if her husband scolds her.
Most of the time the mother suppressed her anger when anyone scolded her. Patient easily gets angry at trifles. Even during case taking patient scolded his mother 2 -3 times because when she was narrating the complaint of the patient, he thought that she was criticizing him. Patient went to school up to 8th standard and left school after that because he was not interested in study.
He was not able to read and write until 8th standard. Still patient’s recalling capacity is poor. Patient took education in Urdu medium. As patient was very weak in study, his parents paid more attention to him, and tried to fulfill all his demands.
Since childhood patient is very obstinate and demanding. Now patient demands money from his mother and brother. If they do not give it to him, he becomes irritable, abusive and throws things. Many times, he stole money from the pocket of his brother and the cash counter of the shop.
He wants money to eat outside food and to drink tea. Patient has addiction of tea. He takes tea 5-6 times per day. Patient cannot tolerate contradiction. One year ago patient’s sister asked him to do some work, but he refused and broke a mobile phone in anger. He said,”I am older than you, you don’t have any right to ask me to do any work”.
Patient is very egoistic. Three years ago the patient’s father asked him to bring milk. Patient refused to obey his command and replied back to his father. So, his father got angry and scolded him. Patient also became angry but did not express anger towards his father. He expressed his anger towards his mother and siblings.
Patient is indecisive by nature. Patient is very unskilled in purchasing, selling and marketing because of poor mathematics. Fifteen to twenty days ago patient’s mother asked him to bring fish from market but he paid extra money to the shopkeeper because of poor math skill. Patient is fastidious by nature and does not allow anyone to wash his clothes. He is never satisfied with the clothes washed by family members.
PHYSICAL EXAMINATION:
| General examination- | P0/I0 /O0/CY0/ C0, T-Afeb/ P 80/m/R16/m/BP-120/80 mmhg |
| Systemic examination- | CNS- conscious oriented, sensation and motor function normal, reflexes normal, muscle strength normal |
INVESTIGATIONS DONE: MRI 23/12/14 Gliotic changes noted in the b/l parietal region predominantly on right side with paucity of white matter is likely the sequel of ischemic insult in perinatal period.
DIAGNOSIS: Remote symptomatic generalized epilepsy with tonic clonic seizures
LIFE SPACE TABLE:
| No | Event / Key word | Onset | Duration | Life-Space | Characteristics Expression | PPT Factors | Attributes | Interpretation |
| 1. | IPR with father | Since childhood | Dominating father | -Fear of father | -Sensitive to reprimand+ | |||
| 2. | IPR with mother | Since childhood | -Mother calm and quiet
-When mo speaks about his complaint to anyone |
-Anger2
-Scolding to mother -Feeling as if back bitching for him |
<Trifles2 | -Irritable2
-?Image conscious |
||
| 3. | Obstinate and demanding child | Since childhood | -He likes outside food and drinking tea. | -Demanding for money2
-If not given- than gets angry2, abusive2, throwing things2, stealing money2 |
<Contradiction2 |
-Irritable2
-Demanding2 -Obstinate2 |
||
| 4. | Egoistic person | -Relatives ask to do house hold work | -Refuses for work2
-Anger2 -Breaks mobile2 -Saying he is elder so he will not do any work (to younger person)2 -Anger suppressed+ (Towards father) |
<Contradiction
<Fear2 |
-Egoistic2
-Irritable2 |
|||
| 5. | Fastidious person | -He does not allow anyone to wash his clothes, because he is never satisfied with the clothes washed by family members.
– If anyone spoils things in front of him |
-Angry2, shouts2 and cleans that thing. | -Fastidious2
-Irritable2 |
MENTAL STATE
Emotional state
–Anger-Irritable, <Contradiction2, <Trifles on2, Abusive2, Violent2, Shouting2, Anger suppressed+
-Love-Attachment, Self2, Money2, Egoistic
-Fear- Sensitive to reprimand2
Intellectual state: Memory weak2, Thinking sluggish2 and Indecisisve2, Orientation poor, Confidence poor, Judgement poor, MWD weak
Reaction: A.F., <,>: state effects:- <Contradiction (Anger, Obstinacy), <Trifles2 (Anger), <Fear+ (Sensitive to reprimand2)
Action/ Behavior:- Aggressive2, Fastidious2, Demanding2, Obstinate2
TOTALITY:
| Mental characteristics | Classification of symptoms | Physical characteristics | Classification of symptoms |
| Anger <contradiction2 | Emotional aggravating modality | Perspiration on face2 | Physical general |
| Anger <trifles on2 | Emotional aggravating modality | Intolerance of hunger2 | Physical general |
| Anger-violent2 | Emotional | Sun < | Physical general |
| Anger-abusive2 | Emotional | Aversion sweets2 | Physical general |
| Anger-shouting2 | Emotional | Craving pungent3 | Physical general |
| Sensitive to reprimand2 | Emotional | Craving chicken2 | Physical general |
| Weak memory | Intellectual | Craving salt2 | Physical general |
| Sluggish thinking2 | Intellectual | Craving tea2 | Physical general |
| Indecisive2 | Intellectual | Craving warm food2 | Physical general |
| Fastidious2 | Behavioral | Thermal hot | Physical general |
| Obstinate2 | Behavioral | Convulsion anger after2 | Physical general |
| Demanding2 | Behavioral | Convulsion full moon2 | Physical general |
| Convulsion sleep after2 | Physical general |
CONTRIBUTION TO THE TOTALITY:
In this case, anger from contradiction and from trifles is the emotional aggravating modality. Violent, abusive, shouting in anger, sensitive to reprimands are emotional expressions of the mental state. Weak memory, sluggish thinking and indecisiveness are intellectual expressions of his mental state. Fastidious, obstinacy and demanding are behavioral expressions of his mental state.
MATERIA MEDICA DIFFERENTIATION: Natrum Muriaticum vs Staphisagria
The patient is irritable, egoistic, unintelligent, has weak memory, is indecisive, obstinate, demanding and fastidious. Natrum Mur and Staphisagria are the remedies that come closest. Along with this, considering physical characteristics and convulsion from anger and full moon, Natrum Mur as the closest remedy.
FINAL REMEDY CHOICE: Natrum Mur 200 1PHS weekly.
IMPORTANCE OF MENTAL STATE IN SELECTION OF CORRESPONDING REMEDY:
Here mental states of the patient helped us to formulate the totality and finer differentiation of the closest remedies. Similar expressions were observed in both remedies but the characteristic expressions at the emotional level like violent anger from contradiction and trifles, mentally weak, fastidiousness, obstinacy helped to differentiate them.
FOLLOW UP CRITERIAS
| SR NO | CRITERIAS | SR NO | CRITERIAS |
| 1 | Irritability | 5 | Convulsion intensity |
| 2 | Anger-violent | 6 | Convulsion duration/frequency |
| 3 | Appetite | 7 | Any new co |
| 4 | Thirst | 8 | Use of anti epileptic medicines |
| DATE | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | RX |
| JAN 2016 | SQ | SQ | N | N | 0 | 0 | 0 | SQ | RII |
| FEB
2016 |
SQ | SQ | N | N | 0 | 0 | 0 | SQ | RII
NATRUM MUR 200 1PHS/WEEK CUPRUM MET 200 STOCK (SOS) |
| MARCH 2016 | SQ | SQ | N | N | >++ | 3 epi
(2 in 1st fortnight on alternate day 1 in last week after 15 days of last episodes) |
0 | SQ | NATRUM MUR 2OO 1PHS/WEEK
RII
|
| APRIL 2016 | >20% | >20% | N | N | 0 | 0 | 0 | SQ | CT ALL |
| MAY 2016 | >20% | >20% | N | N | >++ | Once/2 week | 0 | SQ | CT ALL |
| JUNE /16 | GAP | ||||||||
| JULY/16 | >25% | >25% | N | N | 0 | 0 | 0 | SQ | CT ALL |
| AUG/16 | >25% | >25% | N | N | 0 | 0 | 0 | SQ | CT ALL |
| SEPT/16 | >30% | >30% | N | N | 0 | 0 | 0 | SQ | CT ALL |
| OCT/16 | >30% | >30% | N | N | 0 | 0 | 0 | SQ | CT ALL |
| NOV/16 | <+ | <+ | N | N | <++ | In first week-2-3 episodes for one day
In 3rd week 1 episode appeared |
0 | SQ | 1ST week- Cuprum met 200/1 dose
RII In 3nd week/ 4th week Tub. 1m Natrum mur 200 3phs RII |
| DEC/16 | >++ | >++ | N | N | 0 | 0 | 0 | SQ | NATMUR 200 3PHS
RII |
| JAN/17 | >++ | >++ | N | N | >+ | 1 epi | 0 | Sq | TUB 1M PHS
NAT MUR 200 3PHS RII |
| FEB/17 | >50% | >50% | N | N | >+ | 1epi | Cold/
coryza |
SQ | GELSE200/QDS/4
DAYS/ACUTE NAT MUR 200 3PHS RII |
| MAR/17 | >50% | >50% | N | N | 0 | 0 | Skin eruption/cold | SQ | PULS 200 QDS/4DAYS/ACUTE
NAT MUR 200 3PHS RII |
| APR/17 | >50% | >50% | N | N | 0 | 0 | 0 | SQ | CT ALL |
| MAY/17 | SQ | SQ | N | N | 0 | 0 | 0 | SQ | CT ALL |
| JUN/17 | SQ | SQ | N | N | 0 | 0 | 0 | SQ | CT ALL |
| JULY/17 | >50% | >50% | N | N | 0 | 0 | Injury on leg | SQ | ARNICA 200/QDS
NAT MUR 200 4PHS? RII |
| AUG/17 | – | – | N | N | >++ | 1 EPI | 0 | SQ | CTALL |
| SEPT/17 | SQ | SQ | N | N | 0 | 0 | 0 | SQ | CT ALL |
| OCT/17 | SQ | SQ | N | N | 0 | 0 | 0 | SQ | CT ALL |
| NOV/17 | GAP | ||||||||
| DEC/17 | SQ | SQ | N | N | 0 | O | 0 | SQ | CT ALL |
| JAN/18 | SQ | SQ | N | N | > | 1 EPI | 0 | SQ | CT ALL |
| FEB/18 | NO ANY CO | CT ALL | |||||||
| MAR/18 | NO ANY CO | CT ALL | |||||||
| APR/18 | NO ANY CO | CT ALL | |||||||
| MAY/18 | NO ANY CO | CT ALL | |||||||
| JUNE/18 | >+60% | >60% | N | N | > | 1EPI | 0 | SQ | TUB 1M 1PHS
CT ALL |
| JULY/18 | NO ANY CO | ||||||||
| AUG/18 | >60% | >60% | N | N | >++ | 1 EPI | 0 | SQ | TUB 1M 1PHS
CT ALL |
Tuberculinum was used as an intercurrent based on over-all features of the tubercular miasm: disease activity, mental state, generals and birth history.
Natrum Mur was the most similar remedy yet it did not evoke the desired result. This led to the introduction of an antimiasmatic remedy.
Cuprum Met was used as a phasic when needed based on the symptoms of convulsion.
Gelsemium & Pulsatilla were prescribed for acute conditions of cold and skin eruptions.
FOLLOW UP SUMMARY: After prescribing, Natrum Mur 200 1phs the intensity, frequency and duration of convulsions reduced up to 70-80%. One AED i.e. Tab Cloba stopped. Irritability reduced up to 60-70%. Initially patient was at home and now he has started to go shopping with his brother. No any new complaint appeared since last 3 years showing improvement in susceptibility.
CONCLUSION: Natrum Mur is the indicated remedy that was prescribed upon different expressions of his mental state along with physical generals and it showed effective results on every aspect from mentals, physicals and particulars.
