November 2014

Understanding the Lithium series: five psychiatric cases

by Mahesh Gandhi

 Abbreviations: MG: Mahesh Gandhi; P: patient; HG: Hand Gesture. Cases are edited for brevity.

 Case 1.

This is a case of a 45-year-old man, who had come with the complaint of long standing panic disorder from which he had been suffering for the last twenty years, and for which he was on medication. He said that he first experienced panic when he was preparing for his MBBS final exams, for which he studied 14-16 hours a day at a stretch. He started experiencing a lot of palpitations and chest pain, which made him dread that there was something wrong with his heart.

The patient recollected situations when he was extremely distressed and anxious of being infected when he was posted in the leprosy ward during his internship. Even while going through a simple procedure like a pleural tap on a patient suffering from tuberculosis, he had lot of trembling and was very anxious, fearing that he may have punctured the patient’s lung. He was afraid to give even a vitamin injection, fearing that the patient may land up with anaphylactic shock. His fears of the supposed dangers associated with the field made him take up pathology as his stream for post graduation later because, in his perception, it meant less stress and anxiety.

However, after selecting pathology as his mainstream, he could not overcome his panic. He regularly sent reports to other laboratories for a second opinion, so as to allay his anxiety, despite having to spend money from his own pocket. He was under the impression that he would slowly muster enough courage to start his own practice after a year’s time, which never happened, as he soon joined his father’s practice, which involved treating obese patients using Ayurvedic medicines, which he thought was extremely safe. Once, when treating an obese person with a blood pressure of 140/100 mm Hg, he panicked, thinking that the patient would get a heart attack; he imagined all possible worst scenarios and was very restless, calling up the patient every few minutes to check on his health.  

Since this was most intensely coming up in the case, I decided to probe this deeper to try to reach the level of sensation.

MG: What is the worst thing that could have happened?

P: “There can be a police case and these legal proceedings linger for years. How will I live in this uncertainty for so many years? There are many grades of their (police) treatment and I will be in jail with all the criminals. I will be sexually harassed – what if I get AIDS?  These thoughts produce palpitations, a dry mouth, chest pain and light-headedness.”

The patient said that he is very mild, friendly and peace-loving. He does not like to work hard and he enjoys all the comforts of life. He loves flying kites. He is cowardly by nature but he dreams of beating up all the bad guys and all his friends are happy with him. His wife tells him that he makes an issue out of small things and he panics over petty things. For instance, once he misplaced his cell phone and he assumed that criminals would use his phone for killing someone and then he would be implicated for murder and would be put in jail. He was always anxious that he may be sexually abused in jail and might contract an HIV infection (he jumps up from the chair and takes deep breaths).

Here, you see that when he is talking about palpitations, he jumps up from his chair. We see a lot of anticipation which causes palpitations, cramps, etc.

signP: “Any journey where the movement is restricted is discomforting for me. This gives rise to a dilemma of whether I should go ahead or not. Should I stay or go?” His jerkiness is like an attempt to escape. “Should I stay or go? So whenever I have these symptoms, I feel I want to escape. I then ask for reassurance. I get cheesed off in such circumstances.”  

He gives one more incidence of his anxiety where his daughter was unwell; after investigations, the pathologist asked him to come after three days, at which he panicked. The feeling that he has to wait for three days causes extreme anxiety. The problem for him is not about the report being bad, but having to wait for three days, which is an excruciating period for him. This anxiety kills him. It produces tightness in his chest, heaviness, palpitations, etc. He further explains that it is similar to someone asking him to board a bus or a train right away: then there is no problem, but if someone asks him to do the same thing after two days, then his anxiety starts and he becomes very anxious as he obsesses about it.

At this point in the case, we go back to the incidence of being in jail and see what comes up.

P: “There are a lot of dangers in jail:  I could get attacked by a homosexual and get an infectious disease. Legal processes like that take a long time. They are very slow but I want a quick solution. This would be the main stress for me (HG: hand jumps or jerks. Patient is taking deep breaths).

“The stress is the uncertainty of what is going to happen. I am always afraid that something is going to happen; the whole legal process is beyond me. The court proceedings will entangle me and drive me out of my mind.”

In describing the experience of entanglement, he talks in detail about the legal matters, which keep dragging on for days, where they keep calling a person day after day indefinitely. The entire slowness of the procedure will cause sleepless nights and render him completely restless.

The main problem for the patient, the essence of his individuality, is the uncertainty that is a source of extreme stress for him. The uncertainty, whether it is an anaphylactic shock, pathology, herbal medicines or even a routine train journey at a short notice is a strain for him. Uncertainty is such that it is beyond his control, and where things just keep dragging on indefinitely. Restriction of movements, taking deep breaths, jumping from the chair and jerking of the hands when experiencing or even thinking about these situations are all features peculiar to him. This is something that runs through and through his case. It is seen at the level of mind, and even at the level of body. This innermost experience that runs through a patient and which is seen in different areas of life is called the Sensation or the Vital Sensation. 

We see that the main aspect of this patient is the uncertainty and extreme anxiety about future. There is also anxiety about health: that he will contract some infection, perhaps suffer from AIDS (Acquired Immune Deficiency Syndrome). By nature, he is not hard working; he is a coward who fantasizes hitting people and tries to show off his strength. This fear of future and fear of health, especially of contracting an infectious disease, is very peculiar to Calcarea. (Ref - Despair in consequence of the impaired condition of the health, or hypochondriacal humor, with fear of being ill or unfortunate, of experiencing sad accidents, of losing the reason, of being infected by contagious diseases.)1

There is one more aspect to the case: being contracted, restricted, and entangled. This aspect represents the main sensation of Nitrogen.2

Nitrogen belongs to the Lithium series (Row 2 of the Mineral Kingdom). The main experience of the Mineral Remedies is that of structure, where the core issue is of one’s structure and one’s need to fulfill all the functions required to maintain that structure. This creates either a lack or loss of abilities, which are required to fulfill a particular function. The issues are ‘Am I capable or not?’ This is very well represented in the seven rows of the periodic table, where each row represents a stage of development of human life. The prime issues of the seven rows of the periodic table are:

Row 1: Existence

Row 2: Separation

Row 3: Identity

Row 4: Security and task

Row 5: Creativity and performance

Row 6: Responsibility

Row 7: Disintegration3

As seen above, the main theme of the Lithium series is that of separation from the mother. Going from left to right, the Lithium series has Lithium, Beryllium, Boron, Carbon, Nitrogen, Oxygen and Fluorine. The remedies in this line represent different phases of an individual after conception through the journey from the mother’s womb to the outside world and separation from the mother. Hydrogen (Row 1 of the Mineral Kingdom) is the stage where the child is about to be conceived, where the sperm and the ovum unite. Thereafter, remedies in Row 2 represent stages in mature people, who still have their innermost experience of being dependent, within the womb, or separating from the mother figure. Every remedy in this line has its individual stage in development. Nitrogen, belonging to the right side of Row 2, has an experience of being restricted and constricted in the passage from womb to the outside world. This experience corresponds to the patient’s experience.

Here, the main issue of the case is uncertainty. When you read Argentum nitricum from ‘Soul of Remedies’ by Rajan Sankaran, you see that patients needing this remedy cannot bear suspense, which is his unique feature. Moreover, this uncertainty is uncontrollable. This ‘not in control’ is peculiar to the right side of the Lithium row.

So, on the one hand, we see peculiar features of Calcarea like fear of infectious diseases and cowardice, and on the other hand, we have the experience of uncertainty, restricted, entangled, beyond control, which correspond to Nitrogen, belonging to the right side of Row 2 of the periodic table. So, Calcarea nitricum was the remedy similar to his case.

Prescription: Calcarea nitricum 200C, to avoid chances of aggravation.

Follow-up: after six months, he reported that he is much better and more peaceful. Anxiety levels have significantly diminished. Earlier, the smallest of situations would trigger off absolute panic, now he is markedly more relaxed. His family and friends noted a positive shift in him. He still visits the clinic for a bloated abdomen, which settles with a dose of his constitutional medicine.

 Case 2

This is the case of a 19-year-old girl suffering from epilepsy and panic disorder, who is on anti-epileptic medicines and tranquilizers. The mother, who had accompanied the patient, narrated that the patient was very afraid to go out of the house alone owing to her fainting spells. She was comparatively more relaxed and comfortable at home.  She experienced an occasional aura in her head and felt faint before the epileptic episode, which happened most when she was viewing television or when she saw bright light from the computer screen. Her epilepsy is also aggravated when she is looking at moving fans or looking out of a moving train. She feels giddy, which she described as though the floor or the land under her was moving in a mild earthquake.  

At the very sight of a crowd, she goes into a dream-like state, where she cannot see beyond a certain frame. The mother recounts that the girl first had an epileptic convulsion when she was around 16 years of age, and the second episode recurred within six months of the first. During the second episode, her eyes turned to the left and so did her neck: she was unconscious for fifteen minutes. After this episode, her mother advised her not to go out alone, and she has been apprehensive of doing so ever since.

She is extremely scared of travelling due to her convulsions, as she fears that something would happen to her and there would be no one to care for her. The patient then spontaneously said that she was scared of crowds, which can make her faint. She felt that people observe her, the thought of which makes her afraid. She goes into a dream-like state where her eyes are open but she cannot see beyond a certain frame. So, she avoids crowds, as the experience is very suffocating for her.

She then talked about exams, for which she prepares thoroughly but still feels she cannot answer the questions. She says that she cannot attend classes as she feels giddy due to the bright computer screen which precipitates a dream-like state, where her eyes cannot see beyond a certain frame. Her mother boosts her confidence, motivates her, and provides her moral support. Nobody can understand her way of reacting, not even her father or brother. She is an extreme hypochondriac, fearing that disease would break into her body. She panics on trifling issues: for example, she once had a headache and panicked, thinking that she was suffering from leptospirosis and would die.

At the moment, she is thoroughly confused about which field she would choose for her career. She thinks that she is abnormal, thinking that people look at her with a feeling that something is wrong or different about her, as though she is mentally retarded and slow to comprehend things. She perceives herself as being an odd one out, who is completely dependent on someone, her mother, for example.

She dreams of travelling to various places, but cannot go alone and always needs her mother to accompany her. She also dreams of ghosts. On seeing blood, she feels faint and is very scared of witnessing any accidents or funerals, watching horror movies, or even seeing a shroud. She is very scared of cockroaches, lizards, and dogs, as they can bite her.

We see that the central theme in her case was clinging, needing her mother, needing moral support. According to her, only her mother can truly understand her. Also, there is a feeling that something is wrong with her, that she is not OK, that she is mentally retarded. Her illness has completely undermined all her confidence. All this is the language of the Mineral kingdom, where she feels she is not independent and has to depend completely on her mother.

Defining her individuality further is the experience that she will fall when she is out alone; she needs her mother around to hold onto. We see her panicking at small matters and she panics when she is alone. The main story is the need to hold on in acute situations. This is the essence of her case. This panic is experienced like an earthquake, as if the ground is not stable. This kind of panic when alone is an important feature of the Lithium series.

The next feature of the case was confusion; she is confused about what career to choose. Confusion is an important theme of remedies belonging to stage 3 of the periodic table (Alumina, Scandium, Yttrium – where they are confused and highly doubtful). Another key feature is a constant repetition of “not being able to see beyond a frame.” This is symbolic of being encased in the womb and having to come out suddenly, where you cannot see beyond, so you hold on to what is familiar. The remedy that has this feature of holding on in panic, as if there is earthquake and the ground is not stable, and confusion and inability to see beyond a certain frame corresponds to Row 2 of Mineral Kingdom, stage 3: Boron.5

Prescription: Boron metallicum 200C

Follow-up: she responded quite positively to the remedy. Her fear of going completely disappeared. She feels that she is no longer abnormal. Epileptic episodes and the dream-like state of being unable to see beyond a certain frame ceased, and she is no longer on any conventional medicine. Her parents feel that she is 100% better.

Case 3

The case of a man who feels constantly cramped, nervous, and tense. He is very anxious when doing something for the first time, he cannot relax. After this, he feels nauseated and his palms and soles become sweaty, thus plunging him into a panic. Everything feels blocked from inside. Every situation produces a cramp or a tension, whether it is his job, travelling or even having to coming for this interview. By nature, he is very impatient. He has a very low selfworth and feels he is incapable of doing anything. He is very anxious of doing anything, as he feels that things may go wrong. He gets attached to people easily and this feels safe.

The cramp comes before the panic (he indicates that by a body gesture being cramped up). There is a wall in front of him. The opposite of the cramped up feeling is bliss, peace, as if there is no wall in front of him; this feels like being able to breathe freely. The experience of being cramped, (he goes into fetal position) is like being stuck in a dark place, being pressed on from all sides, feeling choked with no way out. This causes discomfort in the stomach. He screams and shouts in anger, and panics so much that he says that he could hit or break down a wall. His anger is aggravated when people do not listen and things go beyond his control, which intensifies the panic attack. He feels safe when he is with people, when there is someone to care for him. This gives him a feeling of being in a circle where things are under control, which makes him feel protected from the external routine world.

This dependence on people and the inability to do things are characteristic of the Mineral kingdom. The experience of being stuck, pressed, choked, cramped along with panic are suggestive of Row 2 and the remedy which has this experience as its central issue or essence is Nitrogen6.

Prescription: Nitrogen 200C once a week.

Follow-up: after four months, his panic episodes were significantly better. The feeling of explosion that he experienced earlier has considerably abated.  

Case 4

The case of a 39-year-old lady, whose first sentence at the clinic was “I don’t know where to start.” Everything seemed catastrophic for her. She worried about everything: about relationships, finance and studies; almost everything under the sun. She found it very difficult to trust people. Physically, she was diagnosed with cholecystitis. She also has recurrent migraines, which are better in the dark. With the pain, she needs open air and she wraps up in warm clothes. She cannot sleep with closed windows. Her nature is very reactive: she has sudden bursts of anger, after which she calms down quickly. She complains of leucorrhoea with a foul odor.

The patient is very erratic about her routine and is clueless about what her plans are, even in the next thirty minutes. She is unable to choose or distinguish between things. She feels dizzy and sick on looking at moving objects.

When asked about catastrophe, which was how she began her case, she gave the example that if her boyfriend wanted to be alone, she thought that he did not love her; a thought which was like the end of the world for her. In childhood, if the teacher did not like her work, she would be so devastated that she would want to give up her studies. Everything feels like the end of world to her, meaning “loss”, as if she is a burden on someone and feels worthless. She cannot separate from someone who is close to her. She wants a lot of attention from people around her; attention for her is warmth. Warmth is to be hugged, like the warmth of a mother’s hug: she feels very safe when hugged.  Here, she experiences safety from the external world, where one has to prove oneself.

Suddenly, out of the blue, the patient said “I always feel that I have to change myself to deserve things. I try to be perfect – there is someone inside who demands perfection. I want to be independent, to stand on my own feet and not depend on support from outside. I once saw a toy which was like a closed system of living creatures; it didn’t need support from the outside, and I want to be like that.” 

bubbleThis spontaneous association with a toy is called free association. The toy was the most surprising feature that surfaced, so we investigate it and see where it leads us.

This toy is like a closed glass, and it has some creatures in it, which are not dependent on the outside for support, food, for example. The experience here is of independence. To be in the glass is to be away from the risk of humiliation or being away from the situation where you may be thrown out of the house. She recollected a childhood incident when her mother sent her to her grandparents’ home as she did not obey her. The patient felt very hurt and humiliated; to her it was like being thrown out of the house. She felt that she did not want to go back home and if she had her things in a bag, she would be off to a forest and never come back again. Then again, she felt that it would be very dark and scary away from home in the forest. So, she tried to be perfect all the time so that she would be never sent away again. During her whole childhood, she could not exist without her mother’s help and she always desired that her mother should accept her the way she was.

Further describing the toy, she said that it was like a glass bubble, like a closed aquarium (HG: of a circle). “It is a safe place for a baby, (starts weeping) it is like a hug. You experience protection, care, tenderness, and attention there. It is like an unborn baby; it is like something that the baby has before delivery but is missing after it is born.”

Here, she connected to a story which she had read in magazine, which featured a baby who was  not safe, having being thrown out onto a street in China like a piece of garbage. She felt that the baby would be feeling vulnerable, unprotected, with everything being lethal around it. The patient related that she too had a ‘thrown out’ feeling, when she discovered that her husband was involved in an extramarital affair.

There are two important aspects in the case: one is of the womb and the other is of trust, humiliation, and respect. On the one hand, she is totally dependent, she feels like she is in a glass bubble which is safe, tender, loving, caring, and protecting. On the other hand, is the feeling of being disappointed by her partner or mother throwing her out of this safe protective womb, which is humiliating and disrespectful. This total dependency, as if being in a womb, is Lithium and the disappointment, mistrust, humiliation and lack of respect are themes of Muriaticum (Chlorine element)7.

Prescription: Lithium muriaticum 200C, which was shifted to 1M later.

Follow-up: after six months of treatment, her panic attacks were much better. Her cholecystitis was completely cured and her migraines have disappeared. Her feelings of dependence have improved, but she still needs someone to support her. She was able to make the decision to separate from her partner, which shows that the need for dependence is markedly better.

Case 5

A 27-year-old female patient with complaints of panic attacks. She says that all her problems began after her marriage. She found it very difficult to get married and was married just last month to a boy with whom she was in a relationship for the last three years; she considered him as part of her family. She felt strangled in marriage. Two years ago, on a visit to Prague with her boyfriend, when she was separated from him for an hour, she was in panic and became hysterical. She felt that her boyfriend was childish and not talented.

After the marriage, when they had gone to visit her father in New York, she woke up one night, feeling stuck in this marriage, with no way out.  She woke up her husband and in the middle of the night asked him to divorce her. While verbalizing this with vehemence, she pulls her husband physically closer, holding on to him quite tight. She was not attracted towards him and she often panicked over why she was still in this marriage. It felt like she was tied up, strangled, like a bird in a cage. She found it difficult even to wear her wedding ring. Marriage to her meant losing power. There is a strong desire to burst out free, exploding, to do big things. According to her, this marriage prevents her from blossoming; she feels that she is not connected, not alive. She felt no freedom: feelings of narrowing and constriction gradually locking her in completely.

The patient then went on to narrate a childhood incidence where her father molested her friend and she filed a complaint against him. He left the house and the patient had to shoulder the responsibility of her mother and her sister. They told people that her father worked abroad and sent them money. She had to play the role of the oldest member of the family. She detested this as she wanted to be in control of her life. The patient resented her family since they robbed her of her childhood. To her, her life seemed like it was stuck, as if there was a hole in her stomach; her lungs felt narrowed with difficulty to inhale, and life seemed frozen. “I want someone to pull me out of here,” was her expression.

Her hobbies include performing, acting, and writing, as all these give her a feeling of being ‘me’, a feeling which makes her feel free like a bird, almost as though she could fly. The opposite of this free feeling, she said, is being locked up, stuck, and caught. The caught up feeling is like being “locked up in an egg shell made out of elastic. It is very small, closing around me. I sit folded inside with not enough room to stand up (she makes a gesture of fetal position). Everything is stuck, no air, as if I am in a coffin.”

The main experience of the patient was suffocation, no air, locked up, caught up and stuck as if in an egg shell, in a fetal position. This is a typical expression of patients needing Row 2 remedies. However, this womb-like structure is not comfortable, cozy and warm for her, which directs us towards the right side of Row 2. This is seen in her wanting to divorce her husband with whom she has been in a relationship for more than three years.  We see that the energy of the case is more towards separation from the boyfriend, who is like family to her. The way she behaves while asking to divorce is interesting: she uses the word divorce but she pulls her husband towards her and holds on tight. So, we see there is clinging and separation, which is the main thing. Lithium has only clinging, Fluorine has separation but Oxygen has both clinging and separation.8

Prescription: Oxygen 200C

Follow-up: panic attacks are much better. She has a normal physical relationship with her husband now. She is now mother to a lovely son. The suffocation has lessened significantly. She has developed a positive orientation to the demands of the world. She now feels like a woman. Her relationships with her mother and sister have also improved. Words like “locked up, suffocation, caught” are no longer a part of her vocabulary.  

Summary of the Lithium series:

In the Mineral kingdom, the main issue is about structure and capability. The Mineral kingdom represents the journey of a human being from birth to death. Each row is a symbolic representation of various life stages that a human being undergoes in the course of his life. Each individual in the Mineral kingdom is fixated or stuck at a particular level of development.

The Lithium series is very important to understand, especially in psychiatric illnesses; it is the cornucopia of efficient remedies for practicing psychiatrists.

The Lithium series is compared to the process of child birth and separation of the baby from mother’s womb. All patients needing remedies from this series need to have protection from outside world. The world seems very frightening and scary for them. Independent existence is very dreadful. In my experience, all the remedies in this series have a fear of falling. They have a very weak ego and are very fragile.

Lithium: is like a fetus which is completely dependent on the womb, with the umbilical cord still attached. Beryllium: is like 9 month old fetus that has enjoyed everything in the womb, does not want to come out and is happy inside.

Boron: is a stage at the beginning of the process of delivery, where the labour contractions start. The child is confused about whether to stay in or to go out. The world that he knows starts shaking, so he panics and tries to hold on.

Carbon: the child has decided to come out: this is the stage where the head is lodged. The question at this stage is “Do I have enough vitality to go out and face the world?”

Nitrogen: feels restricted and constricted in the birth canal and wants to come out as quickly as possible. Oxygen: represents coming out of the birth canal and taking the first independent breath.

Fluor: is symbolic of separation, when the umbilical cord is cut; wants to be separate, which can be seen through the rubric ‘delusion marriage must dissolve’.9

Cases written and edited by Sneha Vyas and Devang Shah

References:

1 – Michael Hourigan and David Kent Warkentin, ReferenceWorks Pro, 4.2.1.1, Clarke’s Dictionary, Mind

2 – Rajan Sankaran, Structure, Volume 1, Row 2, Nitrogen

3 – Rajan Sankaran, Structure, Volume 1

4 – Rajan Sankaran, Structure, Volume 1, Row 2

5 - Rajan Sankaran, Structure, Volume 1, Row 2, Boron

6 - Rajan Sankaran, Structure, Volume 1, Row 2, Nitrogen

7 – Rajan Sankaran, Structure, Volume 1, Columns, Column 17 and Row 3, Chlorine

8 - Rajan Sankaran, Structure, Volume 1, Row 2, Oxygen

9 – For further references, Structure, Volume 1, Row 2

Photos: Shutterstock
Green two-way sign;iQoncept
Single soap bubble; PanicAttack

Categories: Cases
Keywords: anxiety disorder, panic attacks, schizophrenia, trauma, catastrophy, convulsions, confusion, hysteria, Lithium series, suffocation, separation
Remedies: Boron metallicum, Calcarea nitricum, Lithium muriaticum, Nitrogen, Oxygen

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