Author: Mahesh Gandhi
An Understanding of the Lithium Series with the Sensation Approach
Dr. Mahesh Gandhi, M.D. (Psychiatry), Senior Consultant and Faculty, the other song
Dr. Sneha Vyas, Resident Doctor, the other song
Dr. Devang Shah, Resident Doctor, the other song
Abstract: This article is a compilation of successful psychiatric cases treated over years, with an added insight from a background of post graduation in psychiatry. The cases demonstrate a simple yet effective approach to difficult cases, with an in-depth logical analysis in order to trace a pattern, even through a random conversation with the patient using the Sensation Approach.
Keywords: Anxiety disorder, Panic attacks, Schizophrenia, trauma, catastrophe, suffocation, separation
(The key to short-forms: D – doctor, P – patient, HG –patient’s hand gesture, Italics demonstrate the case-taking method and techniques which were used so as to elicit the case to the best. The cases are edited for brevity.)
This is a case of a 45-year-old man, who had come with the complaint of long standing panic disorder that he had been suffering for the last 20 years and was on medication for the same. 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 and started experiencing a lot of palpitations and chest pain, due to which he started dreading 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 leprosy ward during his internship. Even while going through a simple procedure like 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 an 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 too, 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 patient using Ayurvedic medicines, which he thought was extremely safe. Once, when treating an obese person, with blood pressure of 140/100 mm Hg, he panicked, thinking that the patient would get a heart attack and he imagined all possible worst scenarios and was very restless, calling up the patient every few minutes, to check out on his health.
Since this was most intensely coming up in the case, I decided to probe this deeper and try and reach the level of sensation.
D: What is the worst that can 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 criminals. I will be sexually harassed and what if I get AIDS? These thoughts produce palpitations, dryness of mouth, chest pain and light-headedness.
The patient said that he is very mild, friendly, peace-loving, and does not like to work hard and likes all 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 that he makes an issue out of a small thing and he panics over petty things. E.g. 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 HIV infection.
(Observation: 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.
P: Also, any journey where the movement is restricted is discomforting for me. This gives rise to a dilemma whether I should go ahead or no. Should I stay or go? This is like an attempt to escape, his jerkiness is in a way wanting 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 and after investigations the pathologist asked him to come after 3 days, at which he panicked. The feeling that he has to wait for 3 days causes extreme anxiety. The problem for him is not about the report being bad, but having to wait for 3 days which is an excruciating period for him. This anxiety kills him. It produces a tightness in chest, heaviness, palpitations, etc. He further explains 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 after 2 days, then his anxiety starts and he becomes very anxious as he starts obsessing about it.
At this juncture in the case we go back to the incidence of being in jail and see what comes up.
P: A lot of homosexuals and associative infections abound in jail. 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 kind of jumps or jerks, Observation: patient taking deep breaths)
The stress is of the uncertainty of what is going to happen. All the time, I am 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.
The experience of entanglement, he describes in 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 routine train journey at a short notice is a strain. Uncertainty is such that it is beyond his control, and where things just keep dragging 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 as the Sensation or the Vital Sensation according to the Sensation Approach.
We see that main aspect about this patient is the uncertainty and extreme anxiety about future. There is also anxiety about health that he will contract some infection, that he will suffer from AIDS (Acquired Immune Deficiency Syndrome). By nature, he is not hard working and 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 represent the main sensation of Nitrogen.2
Nitrogen belongs to Lithium line (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 Lithium line is that of separation from the mother. Going from left to right, the Lithium line 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, he writes, that patient needing this remedy cannot take suspense which is his unique feature. Moreover, this uncertainty is uncontrollable. This ‘not in control’ is peculiar to right side of Lithium series.
So, on the one hand we see peculiar features of Calcarea like fear of infectious diseases, cowardice and on the other hand we have the experience of uncertainty, restricted, entangled, beyond control which correspond to the Nitrogen belonging to the right side of Row 2 of the periodic table. So, Calcarea nitricum was the remedy similar to his case. Hence, he received Calcarea nitricum 200 (to avoid chances of aggravation).
In his follow up after 6 months, he reported that he is much better and peaceful. Anxiety levels have significantly diminished. Earlier the smallest of situations would trigger off absolute panic, now he is markedly relaxed. His family and friends noted a positive shift in him. He still visits the clinic for some problem of a bloated abdomen which it settles with a dose of his constitutional medicine.
Taking the session further, Dr. Gandhi then showed a case of a 19-year-old girl suffering from epilepsy and panic disorder and was 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 was more 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 watching out of a running train. She felt giddy and the giddiness is experienced as land or the floor shaking like a mild earthquake.
At the very sight of a crowd, she goes into a dream-like state where she could not see beyond a certain frame. The mother recounts that she first had an epileptic convulsion when she was around 16 years of age, and the second episode recurred within 6 months of the first. During the second episode, her eyes turned to the left and so did her neck and she was unconscious for 15 minutes. After this episode, her mother advised her not to go out alone and she was apprehensive of doing so ever since.
She was extremely scared of travelling due to her convulsions, as she feared that something would happen to her and there would be no on to care for her. The patient then spontaneously said that she was scared of crowds and fainted when amidst a crowd. She felt that people observe her, the thought of which makes her afraid and 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 mentioned about exams, for which she prepares thoroughly but still feels she cannot write the examination. She tells that she cannot attend classes as she feels giddy due to the bright computer screen which precipitates a dream-like state where eyes cannot see beyond a certain frame. Her mother boosts her confidence, motivates her and provides her moral support. Nobody can understand her the way she does, not even her father or brother. She is an extreme hypochondriac, fearing that the disease would break into her body. She panics on trifling issues, e.g - She once had a headache and she 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 as people look at her with a feeling that something is wrong or different about her like she is mentally retarded and slow on uptake. She perceives herself as being an odd one out, who is completely dependent on someone, i.e. her mother.
She dreams of travelling to various places, but cannot go alone, always needs mother to accompany her. She also dreams of ghosts. On seeing blood, she feels faint and is very scared on witnessing any accidents, horror movies, funerals or even 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 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 done away with all her confidence. All this is the language of 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 and needs her mother around to hold on to. We see her panicking at small matters. 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 line.
The next feature of the case was confusion; she is confused what career to choose. Confusion is an important theme of remedies belonging to Column 3 of the periodic table (e.g. 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 has 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, the ground is not stable, confusion and inability to see beyond certain frame from Row 2 of Mineral Kingdom is Boron.5
She was given Boron metallicum 200, to which she responded quite positively, her fear of going out having 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 are non-existent and she is no longer on any modern medicine. Her parents feels that she is 100% better.
Amongst one of the cases, was a case of a man who feels constantly cramped, nervous and tensed. He is very anxious when doing something for the first time and cannot relax. After this, he feels nauseated and his palms and soles become sweaty, thus plunging him into 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 self worth 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 gesture of body 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 and this feels like being able to breathe freely. The experience of cramped, (he goes into fetal position) is like being stuck in a dark place being pressed 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 can hit or break a wall that time. His anger is aggravated when people don’t 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. When he is with people, he feels safe, as there is someone to care for. 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.
The core theme of this case is cramps, tense as if stuck in dark place and being pressed from all sides, choked, with no way out. The opposite of this is like breathing freely, peace, bliss and no wall in front. The choking or pressure from all sides triggers panic and anger which amplifies when things are beyond control. He has a very low self worth and feels that he is incapable to doing things. Moreover, being alone is also scary and being together or with people makes him feel safe, protected from external world of daily life. 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 which is what he received.
He was given Nitrogen 200 once a week. After 4 months, his panic episodes were significantly better. The feeling of explosion that he experienced earlier has considerably abated.
Dr. Gandhi then narrated another case of a 39-year-old lady who came to his clinic and the first sentence she uttered was ‘I don’t know where to start.’ Everything seemed catastrophic for her. She worried about everything; about relationships, finance, studies and almost everything under the sun. She found it very difficult to trust people. Physically, she was diagnosed with cholecystitis and has recurrent migraines. Migraines are better in dark and with the pain she needs open air and 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 was very erratic about her routine and is clueless about what her plans were, even in next 30 minutes. She was unable to choose or distinguish between things. She felt dizzy and sick on looking at moving objects.
When asked about catastrophe, which was how she began her case, she related to this word with an example that if her boyfriend wanted to be alone, she thought that he does 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 studies. Everything felt like the end of world to her. End of the world means loss, as if she is a burden on someone and feels worthless. She cannot separate from someone who she 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 mother’s hug and she feels very safe when hugged. 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 the support from outside. I once saw a toy which was like a closed system of living creatures, it didn’t need support from outside, and I want to be like that.”
This spontaneous association with 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 glass, closed and it has some creatures in it which are not dependent on the outside for support, e.g. food. 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 to her grandparents’ home as she did not obey her. The patient felt very hurt and humiliated and to her it was like being thrown out of the house. She felt that she did not want come to her home and if she had 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 perfect all the time, so that she would be never sent away again. She could not exist without her mother’s help all her childhood and always desired that her mother should respect her the way she was.
Further describing the toy, she said that it was like a glass bubble, like an aquarium which is closed. (Here, she makes a hand gesture of a circle). It is a safe place for a baby, (starts weeping at this point) 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 delivered.
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 all things 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 one side she is totally dependent where 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 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, no respect are themes of Muriaticum (Chlorine element)7. Remedy she received was Lithium muriaticum 200, which was shifted to 1M later.
After 6 months of treatment, her panic attacks were much better. Her cholecystitis was completely cured. Her migraines have disappeared. Her dependence is much better, but she needs someone to support her. She was able to take a decision to separate from her partner. This shows that the need for dependence is markedly better.
Another case was of a 27-year-old female patient who presented with complaints of panic attacks and she says that all her problems began after marriage. She found it very difficult to get married and was married just last month to a boy whom she was in a relationship for last 3 years, and considered him as a part her family. She felt strangulated in marriage. 2 years ago, on a visit to Prague with her boyfriend, where 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 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 freaked 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 marriage 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 blooming. Within the marriage, she felt that she was not connected, not alive. She felt no freedom, feeling 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 case on him. He left the house and the patient had to shoulder the responsibility of her mother and her sister. They told people that father worked abroad and sent them money. She had to play role of elderly member of the family. She detested this as she wanted to be in control of her life. The patient resented her family as 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 and life seemed frozen, with difficulty to inhale. ‘I want someone to pull me out of here’, is her expression.
Her hobbies include performing, acting, writing as all these give her a feeling of being ‘me’, a feeling which makes her feel free like a bird, almost like she can 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. This hints towards the right side of the row 2. This is seen where she wants to divorce her husband with whom she was in a relationship for more than 3 years. We we see that the energy of the case is more towards separation from the boyfriend who is like a family to her. But the way she demonstrates 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 clinging and separation both together. So, she received Oxygen 200.
Panic attacks much better. She has normal physical relationship with her husband now. She is a 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 relationship with her mother and sister has also improved. Words like locked up, suffocation, caught are no longer a part of her vocabulary.
Summary of Lithium line :
In Mineral kingdom the main issue is about structure and capability. Mineral kingdom represents the journey of a human being from birth to death. Each row is a symbolic representation of various life stages a human being undergoes in the course of his life. Row 1 represents existence, row two - birth processes, row three - identity, row four –security, row five - creativity and row six - responsibilities. Each individual in the Mineral kingdom is fixated or stuck at a particular level of development.
Lithium line is very important to understand especially in psychiatric illnesses. This row is the cornucopia of efficacious medicines for the practicing psychiatrists.
Lithium line is compared to the process of child birth and separation of the baby from mother’s womb. All the patients needing remedies from this row 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 row 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 whether to stay in or to go out. The world that he knows starts shaking so he panics and tries to hold on. In Carbon, the child has decided to come out and is a stage where the head is lodged. The question at this stage for it 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. Flourine is symbolic of separation where the umbilical cord is cut; it wants to be separate which can be seen through the rubric ‘delusion marriage must dissolve’.9
1 – Michael Hourigan and David Kent Warkentin, ReferenceWorks Pro, 188.8.131.52, 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.