Understanding a Case of Writer’s Cramp – Through the CWP in Geriartic Age Group

This is a geriatric case, male patient aged 65 years, coming with the complaints of difficulty in writing with the right hand; there is pain while writing in the entire arm and shoulder region. We begin with the passive case witnessing process giving him an open space and see what comes up

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Passive case witnessing process

D:        I am not looking for anything specific, I am just trying to understand you, imagine as if there is a mirror in front of you and reflect upon yourself, whatever naturally comes, giving you space to express yourself freely…

P:        my nature: I am a sensitive person, emotional, straight forward, cannot tell lies, don’t like people talking at the back, don’t get angry as much, like to do things, any work has to be done properly, not an angry person. Not a carefree person, always thinking what will happen, going to extreme thinking, what if it turns out to be different.

            Not many friends, introvert, not an extrovert,

D:        Put yourself in the centre and see what comes up

P:        I am a caring father, caring person for people, cannot hurt anyone, I shouldn’t hurt anyone, helping nature where I can, I help people, in some sense I am a little stingy not a spent thrift, like gadgets

            Like to travel, like to drive in the US and Norway, wherever it is possible, but I am tensed person not a carefree person (H/g)

            Was good in studies in schooling, but it puts pressure, parental pressure to score well, always would think what will people think of me, was good in studies, professionally done well. Was good in studies compared to other siblings, but this put bit of a pressure on me in younger days

            Being a very conscious person don’t make friends easily

D:        what else go on, everything looks non-connected to you right now, I am sure everything will make sense in the end

P:        Career I am not of type will argue or fight with someone, I will accept, not the argumentative type, explain coolly, or wait till the person understands on his own, words don’t come easily to me. I have fear in my mind how life would be in terms of security…

The reason I have not made friends is I have changed schools, as father was in the army, this put a pressure on me (H/G) because new school in the form of studies, so that put pressure there

D:        take 2-3 mins so you don’t miss anything that comes to you naturally?

P:        I did technical, mechanical engineering, I have risen to a good level, just regret didn’t do MBA or finance

            Medical issue is problem in writing, this puts a pressure on me as I am working, and doing MBA would have helped me in my career, always have been in services that has certain kind of pressures

            I am person who cannot retaliate, so felt something I should have done so that I should have been my own boss, worked without pressures…

D:        what else, I am purposely creating that environment so that you can reflect upon and see what is coming?

P:        I don’t retaliate, always want people should think about me as a good person, hurts me if people think of me otherwise, I am kind and helpful so they think good of me…that’s it

(here we see that in 2-3 areas he speaks of the feeling of pressure, of being a person who doesn’t hurt anyone, doesn’t retaliate etc… so we now explore other areas to see what comes up and confirm the focus)

Guided Passive CWP: Area Dreams

Q:        what are the dreams which have remained with you in your mind, which are different, not connected…?

P:        I use to get fearful dreams as if you have killed somebody, hit somebody. …

D:        childhood dreams in them what exactly you see?

P:        I had a fear that I had done something wrong, like killing someone and hide the body, I hit and killed and somebody detected it, dreadful, but when I understood it was a dream it was a big relief at that time.

Guided Passive CWP: Geriatric case taking

D:        when you reflect back, what part of your life you want to change?

P:        I did my engineering, wanted to go for masters abroad, managed to get an admission, but father prevailed on me, he said we have land here, we have property here, other families all children are out of India and parent are alone here.

            But then I got into shipping to travel more around the world, got into ONGC again father prevailed on me…life would have been different had I done MS, if I had been allowed to do my MS would have been a different life…

D:        if you relive your life, where the situation is according to you, everything is according to yourself, what will you put in the centre for your life?

P:        if I was my own boss, would have done well, I am a conscientious person so would have done well rather than working under someone, under a constant pressure…

FOCUS OF THE CASE:

Here we see in 2-3 different unconnected areas, in different time zones he talks about this pressure that he feels, in childhood, work, imagination, dreams he talks about this constant pressure that he feels along with the other PQRS symptoms that he speaks about, so we become Active and see what happens further

Active Case Witnessing Process

D:        let us understand this pressure that you are talking about?

P:        I shouldn’t do anything wrong, everything must go well, shouldn’t falter, I am introvert, don’t like people to think negative of me, that type of pressure to perform to expectation of others.

D:        Pressure to perform?

P:        should excel in exams, must come top of class, at work shouldn’t make mistakes, hurts if someone points out, shouldn’t do something which is not correct

D:        more about this pressure to perform, or take wrong decision or I am not competent enough…

P:        decision should be correct; no one should be able to counter or say anything about it…should be competent or perfect or not take a wrong decision

D:        pressure also came up in many areas…

P:        arises from thing that I am not outspoken, shy, don’t speak much, people shouldn’t say anything against me, parents use to say that you should come out with flying colours. In work I should take wrong decisions, looking to a day when I would be free of work pressures. Like I am working as an engineer on the ship, anytime I have to go, in this 40 years, day and night into 365 days, anything will go wrong on the rig, I have got to take the decision, that type of work pressure, I take decision and it shouldn’t go against me, I don’t like it…

(Here we see that as we ask him about pressure, he describes it further and gives us another examples of how and where he experiences pressure, he also connects other PQRS in the passive to it, hence we will now become Active-active)

Active-Active Case Witnessing Process

D:        work pressure, performance pressure, of doing well?

P:        pressure regarding people, to do well take the right decision, people shouldn’t point out that I took the wrong decisions that sort of thing…I carry that home, first that pressure has to go then only I can do something

D:        in the dream you spoke about something wrong will happen?

P:        I have done something wrong and hiding it, that I have killed somebody, somebody is going to find it, and my anxiety starts to builds up

D:        what part of it was most striking?

P:        how did I do it and repenting it, scared about it, how could I have done this. I’ll get exposed, somebody knowing about it, people will find out, people will know about it

D:        pressure in childhood…

P:        I was shy; somebody coming to visit parents it was a big thing for me to go out and meet was not carefree. Would not laugh out loud, would be in limits, within acceptable limits, what will people think of you, should be perceived as good and correct person (HG), not perceived as flamboyant, within limits

D:        physical illness?

P:        difficulty in writing, holding pen hard then have jerks, jerk especially if at a formal dinner, has increased slightly over a period of time, may be it aggravates under stress…

D:        means?

P:        thinking that something wrong will happen, right arm and shoulder especially, my brother has Parkinson’s, but this is not Parkinson’s, very disturbing…

D:        during stress it increases?

P:        becomes stiff, hair fall, facial hair reduced, how will I look, haemorrhoids bleeds once a month, post nasal discharge sinusitis, occasional headache more when cold, humidity or draft of air, floaters in my eyes. H/o Tubercular lymphadenopathy

(So we see when he ask him about the pressure, it is the fear of committing a mistake, that one last mistake and what will people think of him, the same is the reason why he isn’t very carefree or flamboyant…even he mentions his physical complaint increases with this pressure when he experiences it)

Active- active giving the whole to the patient:

D:        trying to understand you, the way you feel, percieve, react in conscious and subconscious area, pressure and expectation of performing is what you experience in yourself…

            Illness is a crystallization of your own personality, everybody feels, thinks, perceives, reacts in a different way. Inappropriate reactions will reduce and gradually when you are in health all this becomes appropriate. Disease is outward manifestation of altered whole, it begins in the centre with the thought, emotion and lastly at the structure on the body. The intensity, frequency goes down after treatment, the same pressure which would make you uncomfortable you will start enjoying it. The whole disturbed pattern first comes from the whole till the periphery…eventually it will be like finding your own design…

Centre of the Case

So we see that the whole centre revolves around the feeling of performing under pressure which is related to work or in school attaining good marks, living upto others expectation, security and not committing a mistake, otherwise people will observe my mistake, wrong decision I should not take, is under constant pressure to perform, should do in limit as a good or correct person

So we see that the centre belongs to the Mineral kingdom 

The pressure of performance, security, work related pressure, pressure is from outside, brings us to Row 4

The feeling of pressure at the top, constant, one small mistake and people will watch, or all the work I have done will come down…is column 9

Hence the remedy is Cobalt.

Materia Medica Pura: Cobalt

• Hahnemann writes: “feeling of guilt, thinks too little of himself, as if he has done something wrong, people will know about it, couldn’t look in the face
• A/f Excitement
• Delusion: criminal, others know it…despite being tall

Dr. Rajan Sankaran in “Structure” writes –

The main feeling of Cobalt is “I can face the opposition and defend myself but I doubt whether my protection is absolute and complete”

“Is it without any chink in the armour”

“Has done everything but if one mistake is made then everything is gone, even though (I am) the best. What if others discover that I have done wrong”

Rubrics (Complete Repertory)

• Delusion, imaginations: criminal that he is a
• Delusion, imaginations: criminal, that he is a; others know it
• Delusion, imaginations: wrong he has done

Follow up criteria:

1. Physical c/o
2. Dreams
3. Ask about dreams of floating
4. Statewise feeling of pressure etc…

Learning from the case: In the above case the questions in guided passive for geriatric cases can  help us open new areas in these patients who are usually self-satisfied due to old age and feel that they have seen everything, and now just want to die…these kind of questions help us bring out the PQRS expressions in such cases –

• When you reflect back, what part of your life you want to change?
• If you relive your life, where the situation is according to you, everything is according to yourself, what will you put in the centre for your life?