Clinical Cases

Evaluation of Progression of Mental Cases

mental dysfunction

Dr. Ilyas Akhundzada shares a case of chronic fatigue in a woman of 42. The case is meant to illustrate that mental symptoms which occur after a remedy do not necessarily indicate a wrongly chosen remedy.


It is not infrequent to see psychologically disturbed patients in our daily practice. One must admit the challenge of treating such cases. Unfortunately, many homeopaths are still under some wrong assumptions concerning management of symptoms related to mind and soul (emotional level).  One of such assumptions  probably originated from misinterpretation of Kent`s words, according to which we must see amelioration first on the mental-emotional plane provided the treatment is correct.

That may seem even more persuasive as the mind sphere is a very deep layer of the human being and its disturbance must shift towards more periphery during correct course of action according to Hering’s laws.

Therefore some homeopaths can naively consider any perceivable disturbance in the patient`s disposition as a sign of a wrong prescription. As for instance, if the deeply depressed patient starts to be bothered by a bunch of fears after receiving the remedy, should this be interpreted as a failure of prescription?

Beginning from that point we can confuse and finally lose many of our cases being driven by false assumption that only pleasant changes may take place in a recovering mind.

It is surprising but even in Organon we have a paragraph where the great master Hahnemann clearly points to us (Aphorism 210, footnote 192): “How often, for instance, do we not meet with a mild, soft disposition in patients who have for years been afflicted with the most painful diseases, so that the physician feels constrained to esteem and compassionate the sufferer! But if he subdue the disease and restore the patient to health – as is frequently done in homoeopathic practice – he is often astonished and horrified at the frightful alteration in his disposition. He often witnesses the occurrence of ingratitude, cruelty, refined malice and propensities most disgraceful and degrading to humanity, which were precisely the qualities possessed by the patient before he grew ill.”

From here it is clear that mind symptoms must have a kind of evolution to their present condition as do their bodily fellows, according to Hering’s laws. Thus, if we were more diligent in investigating our cases, surely we would be able to reveal all intermediate states of mind finally finished by its present pathological state.

One of the most convenient schemes concerning depth of psychological pathology has been accomplished by contemporary homeopath Prof. George Vithoulkas. It can be thought as a hierarchic order of most probable development of pathology in mind and emotional spheres. Therefore it also can be used as a tool for evaluation of the patient’s progress during treatment.

(Table 1)

Developmental hierarchy of mental emotional pathology (according to G.Vithoulkas)

Depth of pathology Emotional level Mental level









Dissatisfaction Absentmindedness
Irritability Forgetfulness
Anxiety Lack of concentration
Phobias Dullness
Anguish Lethargy
Sadness Delusions
Apathy Paranoia
Suicidal depression Destructive delirium
Total confusion of mind

Below I would like to describe a case of depression progressed quite well according to Vithoulkas’ scheme. I use the concept of “underlying” by Vithoulkas, according to which, each symptom gets a rank from 1 to 4 on the basis of the following rules: 1) revealed by asking, unclear, non-intense, 2) revealed by asking, yet clear and moderately intense, 3) spontaneous, rather clear and intense 4) spontaneous, clear and very intense. I also use categorization on levels of health proposed by Vithoulkas (in his book “Levels of Health”, 2010, first edition, pp. 39-56).


The patient is female, born in 1979, of height 167 cm and weight 62 kg. She is married and has 2 small children.

Main complaint and modalities, present illness history:

Her main complaint is a constant, chronic feeling of fatigue and exhaustion (3). She must carry about her mentally deficient mother and two children and she doesn’t have any support from relatives. She feels mentally exhausted (2). Often she feels irritated and prefers to stay alone (3), this condition is aggravated (agg.) by the loss of sleep (3).

Personal history (past illnesses, medications, vaccinations): 

She had all childhood vaccinations; at age 15 she got mumps. She notes that in childhood she often was motion sick and almost always had nausea with vomiting in the car.

From time to time she had intensive leucorrhoea which was treated allopathically. Since her youth she had to work hard and about 4 years ago she started feeling exhaustion. She is prone to have sore throat, for which she uses antibiotics sometimes. Her last cold with high fever was 2-3 years ago (she doesn’t sure).


Temperature regulation (feels warm or cold) – how weather affects complaints (e.g. wet, dry, stormy weather):

Cloudy weather agg (1).

Perspiration (e.g. inability to perspire, profuse perspiration, which parts):

No particularities.

Thirst and characteristics (e.g. for sips, for large quantities, desire for warm drinks, cold drinks): No particularities.

Appetite (e.g. increased, decreased, changeable, specific time): She usually likes to eat at night, when she is free from daily routines.

Foods modalities:

Desires: greens (1).

Aversions: milk (1).

Sleep: (position of sleep, cold feet at night or uncovers feet, salivation during sleep, grinding of teeth during sleep, repeated dreams etc.):

She goes to bed after 1.00 a.m. or even later, as night feels like her only free time from daily routine and care about children.

She prefers to sleep on her abdomen. She usually sleeps for 3-3.5 hours and then wakes. It is difficult to fall asleep thereafter. Her sleep is often disturbed as she must care about her small child and her ill mother. She doesn’t feel refreshed in the morning.

Time modalities: Better toward 9-10 p.m.

Mental & emotional symptoms: Often she feels “on edge”, being unable to continue her daily life. Because of her fatigue she has to postpone many of her plans, which in turn makes her more depressed (2). She fears getting mad (1), old (1), to be encumbrance for her own children in future (1).Often she worries about health of her children and whether she is a good mother (1-2).

She feels sorry because she lost her warm feelings toward her mentally ill mother. She tries not to react to everything, otherwise she feels like she will “go to pieces”. Her emotions toward husband and other relatives are dull (3).

Marked mental symptoms (e.g. too timid, reserved, excessive loquacity, haughty): There is some loquacity; she speaks quickly and a lot (2).

Mood (sadness, anxiety, discontented): Generally irritable, depressed (3)

Memory-concentration: (e.g. weakness of memory, forgetful for words): She feels that her memory is generally weak since last 3-4 years (1).

Physical symptoms:

Head (headaches, perspiration, eruptions):

Face, nose, ear: She experience seasonal cold, without any particularities.

Respiratory system: Since 2 months, after the last cold she has some irritation in the pit of throat which makes her to cough (2).

Cardiovascular system: No symptoms

Gastrointestinal system (pain, eructation, distention and modalities): No symptoms

Urinary system (e.g. urination offensive, feeble stream, forked stream): After her 2nd birth, sometimes she feels she loses urine during strong cough or laughing (1).

Genital system (e.g. menses in women, painful, copious, intermittent, clotted):

Menses are regular and since age of 13 years. She becomes very irritable before them (2-3) and desires sweets (1-2).

Sexual desire: Almost absent after birth of her children (3).

Back-extremities, joints (e.g. pains and modalities, sensations): No symptoms

Skin: She feels that her skin has become older during last 2-3 months (1).

Nails (e.g. hard, brittle, ingrown toenails): No symptoms

Other: No symptoms

Latest high fever: 2 or 3 years ago.

Family history: Her father has died from stroke. Her brother is an alcoholic. Her mother has been diagnosed with dementia.

Comments about level of health: The picture more or less seems to be clear and acute diseases were here until last 2-3 years. We can think that the patient initially was somewhere in the group B but her health level was dropped to group C because of suppressive treatment and difficult external circumstances.

It is also notable that both brother and mother of the patient have mental ailments, which can be a sign of general genetic predisposition to mental sphere disorders in the patient herself.

First prescription:

There is a quite strong disturbance primarily on the emotional level. As her main complaint, namely the exhaustion, had no clear cut modalities it was not itself used in repertorization. According to the repertorization (Figure 1) Sepia was chosen and given in 200 C potency at 07.03.2018.

The case also may remind of Cocculus, if we take into account motion sickness and origin of present state from loss of sleep. However, Cocculus has a  special kind of dullness related to peripheral nerves, whereas the patient has dullness on the emotional level.

Follow-up 1, 11.04.2018 (1 month after taking the remedy)

She is quite loquacious and the main theme she is concerned with is the health of her children. Immediately after taking the remedy her cough stopped but after 10 days she got a cold, without high fever.

Everything resolved in 5 days but now she again started to cough. Emotionally sometimes she felt better, but generally everything is the same and she is again irritable. She was particularly very irritable before menses this time.

Her sleep again is very disturbed because she carries about her children and mother. She feels physically exhausted; it seems to her that her motions are slow. Her libido is a bit higher than before, but generally she prefers to sleep rather that to have sex.

Notes: There is no amelioration on the emotional level; there’s only slight change in small local symptoms in the form of previous aggravation, partial cure and then relapse. This might be related to weakness of the vital force in group C patients, which are incapable to show clear reaction. As there were some local changes it was decided to wait for one additional month.

Follow-up 2, 08.05.2018

This time the patient states that she was better for the first 3 weeks after Sepia and now again is very irritable on approach of menses. She is also very irritated by mess at home. Now she also reacts to the noise (3-4). She feels dizziness when traveling by car or looking at her mobile phone when travelling.

Her fear of losing her mind is less, however now she’s concerned that she is not a good mother to her children and has fear of mistreating them (2). The food seems to her more salty than before.

Notes: The patient now reports that she had amelioration from the previous remedy. This might be merely because she has not realized average amelioration and expected something stronger and at once. So one can deduce that Sepia has some effect, although without clear initial aggravation; that is still a good reaction for patients in group C. Now we have return of two symptoms (sensitiveness to noise and dizziness during traveling) both of which are very characteristic of Cocculus.

It seems that Sepia cleared up the picture of the next remedy. The patient received 2 doses of Cocculus on 8.05.2018 and 16.06.2018, as there was dental work with complete relapse of symptoms in between. It is also noticeable, that by some relief of depression her anxieties and concerns have somewhat increased, which are in agreement with the scheme proposed by Vithoulkas.

Follow-up 3, 04.08.2018

She states that there are no changes. She feels a little bit better if she has time to sleep. She is extremely irritable a few days before menses; she wants to shout loudly to somebody.

Her libido is again absent. She has developed constipation last 2 weeks; it is difficult to expel the stool. She likes order in her house. As for daily routine she must plan everything, otherwise she feels stressed. She often thinks about past times when she was empathic and communicative. She is no longer sensitive to noises and she doesn’t have dizziness traveling in the car.

Notes: As the symptoms according to what Cocculus was prescribed for have resolved but there was not general amelioration in mental-emotional sphere or initial aggravation, it might be considered that the remedy was partial or even suppressive. Moreover, the patient has dropped to a previous state. So she was given Sepia 200 C 5.08.2018, as it was the last properly working remedy.

Follow-up 4, 22.12.2018

As she was better and then had relapse due to dental work she repeated the Sepia 200 C at 19.11.2018. After taking the last remedy she felt some pressure of uterus on her bladder for 1 week. She feels very tired in mornings.

She is very concerned that her life is not planned and she even has not got strength or clearness of mind to do it. She is calmer with her children now. However, she is often upset by her mother; she’s angry with her but then feels remorse. She is weeping when talking about her mother.

Notes: She reports that after the Sepia she feels generally and emotionally better for 2-3 weeks. Then she is again overwhelmed with home problems. On the other hand, we see some new symptoms (feeling of pressure of womb, weeping when telling her story) that are confirmative (or proving) of Sepia. There are also a lot of disturbances of cure because of dental work. So, as the remedy has some calming effect on her emotional level, I decided to wait.

Follow-up 5, 1.06.2019

She feels emotionally very bad. She is fed-up by routines of life and wants “just to leave everything and quit out to be alone” (3-4). She is angry that relatives don’t help her.

On the other hand, she is very fastidious and demanding and doesn’t agree with the performance of the nurse and home assistant. She is clearly loquacious (3). She feels guilt (3) because she’s angry with her mother and cannot be a good mother (as she considers) to her children. She has general amelioration toward 9.00 p.m. Her routine prayer doesn’t ameliorate her as before. (She is a Muslim and prays 5 times a day.)

Notes: This time the trio of guilt together with critics and loquacity are very prominent. There is also amelioration at evening. Repertorization by Vithoulkas Expert System with use of aforementioned symptoms has suggested Aurum metallicum (Figure 2).

The later was confirmed by asking whether the patient had thoughts of suicide. The answer was amazingly confirmative: “I wanted to throw myself from a window, to finish finally all of my sufferings”. The patient was given one dose of Aurum metallicum 1000 C.

Follow-up 6, 21.09.2019

At the beginning of treatment, she had tremendous emotional tension and had to be reassured by phone several times. She also had some sensation of swelling in ankles at night, for 9-10 days.

Now she notes great amelioration in quality of sleep. There is no more irritability from noise and desire to shout at the children. Her relations with her husband are much warmer and her libido is much better.

She is calmer toward her mother now. She doesn’t feel exhausted and her energy is much better than before. Currently she is very concerned that every good thing in her life may be ruined in the future.

Notes: Now we can see definite amelioration of the main problem after initial aggravation. This comes together with increase of general energy level and clear positive dynamical changes in the emotional sphere; there is no more dullness and apathy toward close people, irritability is much less and she started having some fears and concerns.

Follow-up 6, 11.11.2019

Sometimes her irritability returns but it is milder and resolves quickly. Now she is more contented with herself. There are no more fears about misfortune in the future. However, she has become quite critical toward others and often makes bitter remarks about people around her. Her energy is good and so is her libido.

Notes and Conclusion

At this point we just observe the process of amelioration and don’t interfere by any means. Now, as long as treatment is proceeding the fears of the patient are substituted with dissatisfaction. We cannot be certain at this point whether this is the usual state of a person’s mind or it is going to change. However, here again we have a good example according to which not every dissatisfaction, anger or similar disagreeable appearance on the mental level is an indicator of mistakes in treatment. Each case is unique and must be worked on painstakingly to achieve substantial results. The hierarchic scheme of mental-emotional disorders by G.Vithoulkas is particularly useful in evaluation of treatment results in patients with correspondent symptomotology.

About the author

Ilyas Akhundzada

Dr. Ilyas Akhundzada (MD, PhD) has been practicing Homeopathy since 2005. He graduated from medical university of Baku, Azerbaijan in 2001 and completed his residency training of plastic, reconstructive and aesthetic surgery at Ege Medical Faculty Hospital, Izmir, Turkey in 2009. He became a fellow of European Board of Plastic Reconstructive and Aesthetic Surgery in 2011 (Fellow of EBOPRAS). Since 2015 he has been studying the E-learning program by Prof. George Vithoulkas. After completing the E-learning program by passing the exam in June 2017 he has become coordinator of the E-learning Program of the International Academy of Classical Homeopathy in Azerbaijan.

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