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Case Study

OCN: Plight of the Hapless Bird
Dr Praful Barvalia
Dr Yamini Bhagat
'Calc-sil / Carc

The rising sun sparkled across the ripples of the large river. Simultaneously the vacuum filled by the melodious songs of the birds, rustling of leaves and humming of the initiation of human activities. Birds leave their nest and fly. A few even go up and up to explore new horizons. There is one bird that just makes rounds around the nest. He holds his breath and forces himself to go beyond the point but alas! His feathers ruffle, he stalls and falls.

This bird is not Jonathan Living Stone seagull! This is the portrait of Obsessive-Compulsive Neurosis. He is gifted with a desire to fly, but psychic disability prevents any flight. His wings are clipped by a rigid conscience and morbid anxiety.

In Freud's view, all neuroses originate in childhood from conflicts between parents and child. Along with loving parental care, the child is at the same time, subject to parental discipline. Though the conflicts and consequences become repressed, they may nonetheless disturb patient's development. This failure to cope sows the seeds now and gets integrated in adaptational psychodynamics.

The origin of OCN is believed to rest in the early struggles of the growing child between his drives for omnipotent self-assertion and the necessity to conform to parental demand, in order to earn their love. The early period of toilet training initiates the conflict, compounded later by the obsessive-compulsive mother, who insistently demands compliance and threatens both loss of love and punishment for failure to behave. The growing child experiences repeated arousal of rage but must repress them in order to retain his relationship with the parent. Very early in life he learns to regard his underlying thoughts of hostile reprisal to be taboo, and therefore subject to punishment and requiring penance.

This attitude has impact on the development of a rigid conscience, sense of right and wrong and consequent development of guilt.

Insistent obsessive thoughts are defensive in purpose. The persistent idea is not to be taken at face value, but it is a substitute for another idea and thereby serves an anxiety preventing function. Hidden feeling of guilt is the common source.

Let us examine the following case.

Name: Mr BRM, 66 - Retired commercial inspector at Central Railways

Father: expired 4½ years back
Brother: 59, 56, 53, 49, 45
Son - 26 years, Engineer.

Mother: 83 years.
Sister: 62 years.
Consultation date: 22/12/98.

Chief Complaints:

  1. Obsessive thoughts & compulsive acts. Intense since 15 years.
    "Aversion to touch previous clothes, bed sheets etc after a bath."
    "Collecting unnecessary things (plastic-papers)"
    "Accumulation of clothes and dresses (using seldom to prevent wear and tear)."
    Dread of taking bath, drowsy in day and sleepless at night.
  2. Depression - Anticipatory fears ++ < Cloudy Weather
    - Imaginary Fear < Cold Weather (T<20°C); Grief - Sorrow
    - Boredom - no purpose of the life < Lack of Sun
    - Dullness < Lack of Sleep
    Guilt, terror of conscience
  3. Insomnia - persistent.
  4. Disorientation - No sense of direction-East/West, North/South. Gets lost in maze of streets.
  5. Skin h/o Eczema - nape of neck, forearms "dry itch, thick scaly skin" discoloration - still hyper-pigmented. At the age of 21 years.
    Rx: Psorinum, Sulphur, Petroleum, Graphites, Merc-sol, Nux-vom & Allopathic medications & ointments. Mental disturbances got aggravated after treatment of skin ailment.
  6. Recurrent URTI and Sinusitis - difficult expectoration - Allopathic medications.
  7. H/o - Frozen shoulder 7 years back, since tonsillectomy at 17 years of age.
  8. Constant twitching of facial muscles. muscles and blinking of eyes.
  9. Generals: craving for sweets2 Aversion meat2.
    Perspiration - h/o- offensive -rank , fishy odour. Deafness < draft of air
    Thirst App-good.
    Since last 15 years : Skin & respiratory complaints reduced.
    Offensiveness of perspiration disappeared. Mental disturbances worse.
  10. Dreams: Big snakes, Death of mother - twice when 7 years old.
  11. Thermal State: Sun à easy exhaustion & perspiration; Cloudy weather < depression Fan - slow in Summer; Covering - 2 bed sheets upto neck in winter.
    Bath: Aversion3; cannot tolerate cold bath, feels chilly. Takes hot water bath.

Life Space:
Mr MRB is a 66 yrs old man. Bespectacled, short, stout person, round faced with gray hair. Marked nasolabial folds with thick lips and cheeks. Continuous involuntary blinking of eyes and twitching of facial muscles especially cheeks, more marked when answering some qs. Patient comes from an orthodox Muslim community. He is eldest of 5 brothers and 1 sister, sister next to him. Studied till Inter Arts and retired as Inspector in Central Railway. Father, a lawyer, died 4½ years ago at the age of 91. Mild by nature, but a workaholic, always in a hurry. Patient admired him for his fast life style. Patient's mother is 84 yrs and stays with him.

Patient described her as an "over dominating and very strict regarding etiquette, discipline, manners and tidiness". She is schizophrenic, at times having manic spells- shouting and taking the whole house on her head. Patient's father being mild, he used to avoid her by being involved in work and staying out. Mother often threatened suicide by jumping from balcony.

Belonging to an orthodox Muslim background, she would make the patient go inside the house whenever any female visitors came. She also instilled an impression in the patient that men are bad. All this resulted in the patient becoming a timid, introvert person always dependent on his mother. In school he used to be shy, mix less with other classmates, as he had a fear of other people.

He had a strong, suppressed (due to fear of strict mother, inhibited family and religion) sexual drive since 15, which was never fulfilled, nor indulged.

His sister being of fairer complexion and the only girl in family, was given more affection-giving rise to a neglected feeling in the patient's mind, but held no grudges. Academically he was a good student, very particular about his studies. He passed his 10th standard with 67% marks. Patient had high dreams: to become a VIP (Scientist) or do something great in life; the aim remains even now. He joined Diploma Course in Mechanical Engineering at VJTI, but could not cope up with the excessive load of studies. After trying for 1 year he switched over to Arts, but did only till Inter Arts. Then joined Western Railways on a clerical post but later shifted to Central Railways. He worked there for almost 35 years and retired as a Railway Inspector earning a pension of Rs 3000/ Being an introvert, he avoided all parties and social functions. Constant anxiety and nervousness with respect to completion of work on time or in all smaller incidences. He had 2 relationships:

  1. at 26 with a nurse which lasted for 1½ years: patient broke off due to fear of mother and society.
  2. with a neighborhood girl, which continued for a short period & broke off because patient once saw her blowing her nose. He found this very dirty and developed repulsion towards her. There was no sexual experience with either of them.

Patient is very particular about cleanliness; he doesn't like to touch even previous clothes or bed sheets after having a bath.

Patient married at the age of 39. Patient described his wife as a "hot-tempered, dominating lady, repulsive, loner, non-sympathetic and non-adjusting; doesn't care about me, somewhat frigid and living in her maternal house. She never dressed or carried herself well. She was physically thin and repulsive." Patient's relations with wife were never good, there were constant conflicts. After 21 years of living together, she shifted to her mother's place in Jabalpur because her son had taken admission in a computer engineering college. Patient visits her regularly for 10 days every month.

Patient's son is 26 years old and an IT Professional, working at Nasik. Patient is proud of him, describes him as of a "noble and of good character". He is very attached to him and worries about how he will adapt to the new environment after having been the centre of attraction for mother and .brought up in a over-protective home.

Patient's relation with his brothers is quite superficial; they are busy in their own work. 2 brothers are abroad and rest in India. One is a schizophrenic and other, a depressive.

He has a "love-hate relationship" with his mother; wants to leave her and go away because of her domination but again has a large sense of responsibility (other children have deserted her). In fact he always wanted her in the childhood.

Patient has voracious appetite for reading; having read various philosophical books like Plato, Sufi literature, also likes reading books of physics, maths, mysticism and Homoeopathy. He picks up a lot of things from the textbooks of Materia Medica & Philosophy & makes correlations which leads to a lot of anticipatory. He constantly think about the future, frustration and guilt with respect to actions taken in past. This leads to depression.

Theorising++ patient's whole history consists of various examples where he keeps on corelating all his symptoms to one thing or other.

Patient described himself as a "religious, God fearing, philosopher, theoriser, simple, ignorant". "Fear of sin (even minor) dreads me". Along with this, a dominating mother led him to become fearful of other men and women; coward and fastidious as a person. Thus the arose the "terror of conscience."

Lately to avoid depressive thoughts he tries to get in to conversation with others and mix with other people, sit in busy market etc.
Patient's ambition of being a VIP (Scientist) could not be realized which led to frustration and depression, "thus from introvert (drowned into a world of fantasy and imagination and inferiority complex) I became half-extrovert and talkative (counter reaction)". Thus boosting up his inferiority complex.

He is extremely sensitive and gets terribly upset on slightest remark. Gets lost in smallest details. This creates problems with colleagues. And finally result in lot of anxiety & apprehensions. Actually, in the initial 15 years, he not all that bothered about work, thereafter started becoming particular in his accounts, documenting and supervision (obsession setting in).

He also has guilt about neglecting his son when he was a child because of his work. Now as he stays away, does not correspond well nor is very close to him, patient feels depressed.

Here we clearly see a child, because of mother's dominating over-bearing personality coupled with her psychological problems (schizophrenia and hysterical behaviour) turning into a timid, meek, submissive individual with low self-esteem. He sets high ambitions but is unable to realize them because of drowning in a world of imaginations (escape mechanism). Also his sexuality, which he finds immoral because of his rigid conscience, serves as a hindrance bringing a conflict between basic instincts and a terror of conscience. Thus comes suppression and "Fear of sin". This terror of conscience makes him reject his basic instinct, by rejecting his girlfriend. Blowing her nose is hatred towards one's own "dirtiness". It appears as mania for cleanliness to us:

To allay his anxieties regarding this existing conflict he gets into a chain of compulsive acts - collecting plastics-papers, clothes, not wearing them to prevent wear and tear etc.

Being a timid individual unable to stand for himself, he tends to be dependent on mother. But he exchanges dependence for a sense of responsibility and does not "desert" his mother like his other siblings.

·         Sensitive to reprimand.

·         Timidity and Dependence

·         Conscientious at trifles, terror of conscience

·         Rigid

·         Fastidious

·         Theorizing - Active imagination

·         Strong sex desire http://www.njhonline.com/images/rtarrow.gif suppression

·         Craving sweets

·         Chilly patient

·         H/o offensive perspiration fishy odour

A timid individual with dependence and mildness coupled with a rigid conscience. Active imagination, various fixed ideas, theorising.

Sensitive to mother's domination, shouting to wife's behaviour, aggrieved of his son neglecting him, not corresponding through letters.
On these grounds Calcarea-silicata was considered.
Case also demonstrates the phenomenon of syndrome shift & suppression. Patient suffered from skin & respiratory allergies in past. They were suppressed with allopathic medications. Evidence of suppression lies in disappearance of generals like offensive sweat and deeper deterioration of the psychic illness.

The case was opened with Thuja 200: strong sycotic traits- a strong history of suppression, theorizing, fixity and obsession.
Calcarea-silicata 30 was given daily bedtime & later 200 infrequently.
Posology -his low susceptibility, withered dull look & h/o suppression lead to 30 potency.

There was gradual improvement in his sleep, enthusiasm, lethargy and depression. His anxiety for his son and his future decreased to half. By end of two months, his face looked refreshed; the twitching of facial muscles substantially reduced.

At general level the craving for sweet had decreased considerably.
After 6 months of treatment patient was more relaxed generally and his compulsive acts showed marked reduction.
He is now on infrequent doses of Calcarea-silicata 200.

Case 2
Master VS, 4 yrs old, south Indian Brahmin, consulted on 4/6/1993
Father - 36 years Mother - 34 years. Both the parents work in same bank.

Chief Complaints :

  1. Discomfort/strain while passing urine. Some pain. No phimosis, since 3 months.
  2. White patches: face, legs, since 1 year.
  3. Preoccupation with cleanliness.

Patient As A Person: 
Perspiration: Profuse face.
Sleep: Talking during sleep
Thermal state: wants full fan. Tends to uncover. Hot patient.
Bath. Warm, cold in summer.

Life Space:
He comes from a rigid south Indian Brahmin family. Mother married late due to non-matching of horoscopes. Father is mild & quite reserved. Mother is sensitive, vexed and anxious. She suffers from Atopic Dermatitis. She finds the rules set by her in-laws extremely rigid and has faced lot of restrictions. Even frequency of her visits to her parents place was decided by them. PGF works as "Pandit". He is quite strict, dominating and a disciplinarian. No one can argue with him.

He finds his mother quite strict. In fact, her vexed state often leads to unnecessary demands on the patient. Patient is more close to his father though harbours no ill feelings towards any family members. He is sociable, mixes well.

He is extremely scared of darkness and being alone. He switches off TV if some 'horrible scene' comes: some wild animal eating small creature etc. Reconciles fast after any fight and mixes back. Forgets that incident.

He is quite particular about switching off fan, light etc. If some one forgets he asks: "Why haven't you done that?". He wants his plates to be cleaned well. He will clean his hands thoroughly before meals; if soap happens to fall down; he asks another one and also cleans the fallen soap. He washes his slippers alternate days.

He is quite particular about his bed sheets, belongings, toys etc. He does not like to stay at anybody's place. He would like to be back home by night. He will not use others' toilet. He mixes well with strangers, guests.

He is quite helpful to others. He has sharp memory and has "excellent grasp"
Milestones: Normal
P/H- prolonged whooping cough.

Case Analysis:
Child demonstrates morbid obsession with cleanliness and order. This is pathologically fastidious attitude since this hardly serves any positive purpose. He comes from the rigid South Indian Brahmin set up and has imbibed ritualism of the rigid GF.

He finds his mother quite strict. In fact her vexed state often leads to unnecessary aggression & demands towards patient. This correlated with native intelligence; helpful nature and P/H prolonged whooping cough http://www.njhonline.com/images/rtarrow.gif Carcinosin gets confirmed. Carcinosin 1M 1dose brought about total relief within 2 weeks and never required another dose. His obsession also reduced. In fact mother was available for treatment, which allowed handling of child. 2 years later he came down with jaundice c/o Anorexia and abdominal discomfort since 3 days. Since no characteristics were there, Carcinosin 1M was repeated which brought about total relief within 2 days.

He has been excellent in his studies & extra curricular activities.

When we examine OCN, conflict between conscience & desire occupies central position. Khalil Jibran's words beautifully define the conflict & also throw light on resolution. We shall conclude with his observation:

"Your soul is oftentimes a battlefield,
Upon which your reason and Judgement wage war
Against your passion and your appetite.
Would that I could be the peacemaker in your soul,
That I might turn the discord and the rivalry
Of your elements into oneness and melody.
But how shall I, unless you yourselves
Be also the peacemakers,
Nay, the lovers of all your elements?"