Strange, Rare & Peculiar: Homeopathic case analysis & prescribing in serious mental illness

1. Strange, Rare & Peculiar: Homeopathic case analysis & prescribing in serious mental illness Dr. Jennifer bahr, ND

2. Strange, Rare & Peculiar At completion of this lecture participants will: • Have an enhanced understanding of diagnostic criteria for mood and bipolar spectrum disorders, obsessive compulsive disorder, and psychotic disorders • Be able to better identify symptoms that are strange, rare and peculiar for homeopathic prescribing • Understand the process for case analysis for multiple case examples • Understand the keynotes of prominent homeopathic remedies used in the treatment of serious mental illness Lecture Objectives

3. Text No financial disclosures Financial Disclosure

4. Text Review of Dx criteria for several serious mental illnesses Homeopathic prescribing and case analysis approaches Review of cases and some commonly prescribed remedies Review of major risks and assessment What we will be doing today

5. “The physician’s calling, his only calling, is to make sick people healthy - to heal as it is termed” - Samuel Hahnemann Organon of Medicine, Paragraph 1 (1)

6. Organon of Medicine “The hardhearted mindlessness of physicians in many institutions of this kind is astonishing; … they have the inhumanity to torment these most pathetic patients with violent beatings and other agonizing tortures. By this unconscionable and disgraceful behavior they debase themselves far below the level of prison guards, who carry out such punishment on criminals only because it is their duty. These people, on the other hand, humiliated by feelings of their own medical inaptitude, seem to vent their spite at the presumed incurability of mental and emotional diseases by displaying cruelty to the pathetic, innocent sufferers themselves. They are too ignorant to help and too lazy to adopt a therapy that works.” (1) Hahnemann on the doctors who treat Mental Illness

7. Organon of Medicine You must uncover the physical Sx • Paragraph 217: …the physician must carefully investigate the symptom totality, primarily of course to understand exactly the particular character of the principal symptom—the specific mental and emotional state predominating in each case—but also to uncover the physical symptoms, so as to find from among the remedies whose pure effects are known a homoeopathic medicinal disease agent to extinguish the disease totality, a remedy that contains among its symptoms to the greatest possible degree of similarity not only the physical symptoms of the case but also, above all, its mental and emotional state. Hahnemann on treating the mentally ill

8. Organon of Medicine You must ensure these patients have excellent physical and emotional support at home Treat with kindness, don’t reproach • Paragraph 228: In mental and emotional diseases that arise from physical disease and that can be cured only by homoeopathic remedies for the internal miasm (along with carefully regulated living habits), the relatives and the physician must of course also carefully maintain the right psychological attitude toward the patient, surrounding him with emotional support. They must meet raving madness with calm fearlessness and firm, cool determination; agonized lamentation with mute compassion in countenance and bearing; senseless babbling with silence that is not completely indifferent; loathsome, disgusting behavior and speech with complete inattention. They must take measures to prevent damage to property, without reproaching the patient about this, and arrange everything in such a way that corporal punishment and torture are completely eliminated. Hahnemann on treating the mentally ill

9. Organon of Medicine You must treat the patient as if your believe that they are sane. • Paragraph 229: … contradiction, ready agreement, severe reproval, insults, weakness, and timid acquiescence are all entirely inappropriate, all equally harmful to the mind and spirit of such people. But they are embittered, and their disease is aggravated most of all by scorn, deceit, and transparent deceptions. The physician and the attendants must always behave as if they believed such patients to be sane. One should try to remove everything external which bothers their senses or feelings. There is no diversion for their beclouded minds, no healthy amusement, no edification, no way through word or book or any other thing to soothe their souls languishing or raging in the fetters of a diseased body, no way to quicken their spirits but with cure. Not until their physical health is improved do peace and comfort shine once more upon their spirit. Hahnemann on treating the mentally ill

10. Organon of Medicine Always consult with family members or close friends. • Paragraph 220: If one adds to these symptoms the mental and emotional state, accurately observed by the relatives and by the physician himself,a one has constituted a complete disease picture for which a medicine capable of producing exactly similar symptoms, and particularly a similar mental disturbance, can be chosen from among the (antipsoric, etc.) remedies, so that the disease may be cured homoeopathically. This is the way we proceed when the mental disease has lasted for some time. Hahnemann on treating the mentally ill

11. Text Classical/Hahnemanian Homeopathy Posology • Start low (30C) and increase as necessary • Daily dosing is often effective for most of my patients, though not all • Primarily dry dosing All other naturopathic therapies used to support the healing power of homeopathy, or as a temporary “band-aid” when needed A few disclosures on how i practice

12. Text Identification of prescribable Sx • In mental illness, the most “interesting” Sx is more likely to be diagnostic and is less useable for homeopathic prescribing • Ex: MIND - RELIGIOUS AFFECTATIONS - too occupied with religion - not very useable in schizophrenia, more useable in bipolar disorder • Appropriate conventional medication management when necessary Peace of mind for patients • “Finally an explanation for what I have been feeling!” • “I have felt like it was my fault all along and if I just tried harder it would go away.” Importance of accurate diagnosis in severe mental illness

14. Text Be a “medical observer” • Remove yourself and your judgements from the case and situation in front of you Invite, listen, summarize • Let the case come to you • Summarizing will inform you as to the information you don’t have Case taking tips

15. Text Modalities Intensity Radiation Alternating Concomitant Location Else Sensation (Thank you Dr. Stephen Messer!!!) Miracles

16. Major Depressive disorder

17. Major depressive disorder Mood state – may be normal, part of psychopathology, or related to a medical condition • Feelings of sadness, despair, anxiety, emptiness, discouragement, or hopelessness • Having no feelings • Appearing tearful Syndrome • Constellation of symptoms and signs that may include depressed mood Mental disorder: identifies a distinct clinical condition Depression

18. Major depressive disorder 1 or more major depressive episodes with 5 or more of the following Sx for at least 2 weeks • Depressed mood most the day, nearly every day • Loss of interest or pleasure in most or all activities, nearly every day • Insomnia or hypersomnia nearly every day • Significant weight loss or weight gain (eg, 5 percent within a month) or decrease or increase in appetite nearly every day • Psychomotor retardation or agitation nearly every day that is observable by others • Fatigue or low energy, nearly every day • Decreased ability to concentrate, think, or make decisions, nearly every day • Thoughts of worthlessness or excessive or inappropriate guilt, nearly every day • Recurrent thoughts of death or suicidal ideation, or a suicide attempt No Hx of mania or hypomania Cause significant impairments Not due to a substance or medical condition Bereavement does not exclude MDD as a diagnosis DSM-5 criteria

19. Major depressive disorder 39 y/o female Referred to me after seeing another ND following a failed attempted at weaning herself off medication Suicidal - ideation but no plans, action, or intent Needed to resume medication but also work on ND Tx to slowly and safely reduce medication Existing Dx: bipolar disorder NOS Case - KR

20. Major depressive disorder Medication: Lamictal 50mg on presentation - had been at 150mg before titrating completely off AMA, and was slowly titrating back up. Had patient stop here and initiate homeopathic Tx with the understanding that we would increase if remedy was not effective within first 2 weeks. Hx: • Depression starting age 10 or 11 • Lasts weeks to months at a time with little to no relief • Loss of function, no desire to engage in life, frequent suicidal ideation • No discernible Hx of manic or hypomania, but had negative reaction to SSRIs in the past (agitation), so had been Dx’ed bipolar at one point in her life • No mania or hypomania when not on SSRIs or unmedicated Dx: MDD, recurrent Health goals: Feel as well as possible on the lowest dose of medication possible, but willing to take it if that is needed to not feel suicidal Case - KR

21. Major depressive disorder Homeopathic Intake • Weeps constantly throughout visit, requests that her husband stay with her, consolation ameliorates • Very lonely, despite never actually being alone as a mother of 2 young children and in a very happy and supportive marriage • Significant nausea in a warm room only • Participates in Tai Kwon Do - only thing that gives her any relief • Thirstless - has to remind herself to drink unless at Tai Kwon Do • General heaviness - “feels like a lump and can’t move” • Tingling in her brain - described as soldering or brain “zaps” - during withdrawal of Lamictal • Very sensitive to external impressions • Sympathetic - can not watch the news or hear cruel stories CASE - KR

22. Major depressive disorder Weeping while telling is strong, and useable in MDD - I only see weeping while telling in about 25% of cases of MDD, if that Loneliness despite not being alone - not very useable in MDD Best physical Sx currently - nausea in warm room and thirstlessness Homeopathic case analysis

23. Major depressive disorder Pulsatilla • ¤ Continuous crying with great melancholy and fear of losing her reason, or that she might commit suicide. HERING • ¤¤ Weeping : sad, bursting into tears very easily; can hardly tell her symptoms for weeping; at every nursing; at everything, whether joyful or sad; at answering a question; with almost all her sufferings. HERING • WARM ROOM AGGRAVATES - A general as it is found in almost every chapter to aggravate Sx, so may be used broadly • ¤¤ Thirstlessness, with moist or dry tongue. HERING Phosphorus • Humming and tingling in the head, almost all day. ALLEN • The Phosphorus patient is very sensitive to all external impressions; slight odors, noises, touch. KENT Sepia • AMELIORATION: From external heat; from violent exertions; from sitting with legs crossed; from loosening clothes; in open air; and from warmth of bed. LIPPE Homeopathic remedy considerations

24. Major depressive disorder Homeopathic Rx

25. Major depressive disorder Pulsatilla 30C trial dose for 3 days, then QD Much better on first dose, aggravated on taking daily dose Stopped dosing until Sx improved again - found she needed a dose every 5 days Responded positively for 3 months, increased potency to 200C - no rxn, return of suicidal ideation Many Sx still the same, except now she is certain it is a ghost in her house that is upsetting her so much, amplification of her withdrawal Sx (brain “zaps”) • Rx Phos 30C PRN - reacted for 3 months, Phos 200C still reacting 5 months later • Have successfully weaned her off Lamictal in the process Rx and follow up

26. Major depressive disorder Dx: MDD - previously diagnosed and I concurred Medications: Lamictal 200mg QD, Bupropion 450mg QD Hx: • On many medications for the last 20 years, never seemed to work very long and always had to increase then add more meds • No suicidal ideation or attempts • Sx: Low energy, depressed mood, constipation, dry skin, hair falling out Health goals: Came to see me after I successfully treated her daughter for rage and kept her off psychotropic meds, would like to get off meds herself Case - RW

27. Major depressive disorder Indifferent to her husband and child - never really wanted to be a mom in the first place. Shared that she felt that her child knew that she loved her dog more. Wanted to be homeless and live in her car with her dog. Frequent “hot spots” and would scratch until she bled. Brain fog much worse with any slight noise Often feels guilt and dwells on past disagreeable circumstances Case - RW

28. Major depressive disorder Nothing groundbreaking in the analysis - clear presentation of Sepia officials • Eruptive pimples on the dorsum of the foot, severely itching, till they bleed from scratching. HAHNEMANN • ¤¤ Great indifference to one's family, to those they love best. HERING • ¤ Oversensitive to noise, and particularly to music. HERING Rx 200C QD - significant improvement in mood, but energy, constipation, and physical Sx lagging Homeopathic case analysis

29. Major depressive disorder Labs: all WNL (including thyroid) except for vitamin D Had her do BBT and 4 additional readings throughout the day along with pulse for a week - found that she was always low on both Initiate Nature-Throid following Denis Wilson’s protocol (except with combo T4/T3 instead of T3 alone) - titrate up to 1.5 grains - all remaining Sx improve Case - RW

30. Major depressive disorder Is hormone dysregulation dynamic (ie. responsive to homeopathic Tx) or non-dynamic? • Potentially both, depending on the extent of dysfunction and underlying cause The nitty gritty when it comes to patient outcomes - getting thyroid function optimized is vital in mood disorders, regardless of the Tx you use Supportive Therapies with homeopathic Tx

31. bipolar disorder

32. bipolar disorder Mania: A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary) 3 or more of the following: • Inflated self-esteem or grandiosity • Decreased need for sleep • Pressured speech • Flight of ideas (thoughts racing) • Distractibility • Increased goal directed activity • Risky behavior DSM-5 criteria

33. bipolar disorder Hypomania: A distinct period of abnormally and persistently elevated, expansive, or irritable mood and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day nearly every day 3 or more of the following (4 if mood is only irritable): • Inflated self-esteem or grandiosity • Decreased need for sleep • Pressured speech • Flight of ideas (thoughts racing) • Distractibility • Increased goal directed activity • Risky behavior DSM-5 criteria

34. bipolar disorder Bipolar 1 Disorder • At least one manic episode • Depression may or may not be present • Hypomania may or may not be present • Cannot be due to a substance • SSRI induction of mania is an exception Bipolar 2 Disorder • At least one hypomanic but no manic episodes • At least one major depressive episode • Cannot be due to a substance • SSRI induction of hypomania is an exception DSM-5 criteria

35. bipolar disorder 28 y/o female Dx: Bipolar 1 disorder Medication: Latuda 100mg Hx: • 2 hospital stays (14 days and 10 days) for mania • Second hospital stay came within 1 week of discontinuing her medication AMA • Has now been on medications for over 1 year but feels “flat and slow” and has gained over 40 pounds Health goals: to get off medications Case - CP

36. Bipolar disorder Wept while telling of her history • Mania came on rapidly - pressured and tangential speech • Within 1 day was being visited by dead relatives • Visual disturbances - eyes were dilated and “sparkly” and she felt like she was very tall or always standing on a platform Currently, feeling very depressed. She is very afraid that she will never be loved, that she is broken, and will be alone forever. Case - CP

37. bipolar disorder Mania VERY well covered by Stramonium • Eyes fixed, wide open, and sparkling. CLARKE • Eyes staring, swollen, and sparkling; pupils greatly-dilated and immovable (after six hours). ALLEN • Sparkling eyes; he complains of the rays of the sun dazzling him, with loss of appetite.ALLEN • Imagines that he is very large and tall, but surrounding objects small. HAHNEMANN • would fancy some relative standing about her bed who was not present; HOYNE Current state better covered by Pulsatilla • ¤¤ Weeping : sad, bursting into tears very easily; can hardly tell her symptoms for weeping; at every nursing; at everything, whether joyful or sad; at answering a question; with almost all her sufferings. HERING • Forsaken feeling. GUNAVANTE Homeopathic remedy considerations

38. bipolar disorder Pulsatilla 30C QD - responded very positively with improved mood and physical Sx (the main being constipation) Due to rapidity of her decline, used shared decision making to come to the agreement that we would not reduce her medication until we had gone through at least one change in her Rx and verified a response to that change After 4 months, stopped responding, weeping returned along with despair, forsakenness, and constipation Pulsatilla 200C QD - better within 3 days After 1 month follow-up, agreed to reduce Latuda to 80mg. No withdrawal Sx. Gradual withdrawal by 20mg at a time, 1-2 months apart, no change in medication if the remedy had changed. Has now been off her medication completely for just under 2 years, no relapse, and no return of Stramonium mania. Homeopathic rx

39. bipolar disorder Age 11 Dx: Bipolar disorder NOS - diagnosed age 6 Challenges with Dx in children - often do not meet the required timeline, even if there are clear episodes of both mania and depression, irritability/agitation is often present in any mental health diagnosis that emerges in childhood/adolescents Medications: Lamictal 300mg, Lithium carbonate 900mg at time of visit, had been changed almost monthly since initial diagnosis with only partial control of Sx (still having mood shifts every 3 days or so) Case - KG

40. bipolar disorder RAGE!!! • Would destroy everything in her site, kick holes in walls, even her own prized possessions weren’t safe • Eyes would noticeably dilate and face would become bright red, but she would not sweat • Intense fear of the dark - would not even go to the restroom by herself with the door closed Very capricious, and had an aversion to being looked at - sat behind mom’s chair on the floor hiding herself the entire visit Case - KG

41. bipolar disorder Anger/agitation not terribly uncommon in any child with a mental health condition, but the intensity of her Sx and her physical Sx are useable/prescribable Homeopathic case analysis

42. bipolar disorder Tarentula hispanica • Sudden foxlike destructive efforts, requiring utmost vigilance to prevent damage; followed by laughter and apologies. HERING • Paroxysms of insanity; restlessness of legs; threatening words of destruction and death. HERING • Suddenly sprang away from her attendants and swept ornaments from mantelpiece; said she was sorry, but could not help it; very mischievous and destructive, amusing and cheerful; at times pain in left ovary. HERING • Foxy, mischievous and destructive tendency. HERING Belladonna • Brain symptoms predominate; (a) wild delirium; fantastic illusions or rage with destructive mania; (b) constant moaning, starting or jumping in or on going to sleep, even to springing out of bed. CLARKE • ¤¤ Delirium and heat. HERING • ¤¤ Violent delirium; broke into fits of laughter, then gnashed teeth; disposed to bite and strike those around. HERING • ¤ In evening he was seized with such violent delirium that it required three men to confine him; his face was livid; his eyes injected and protruding, pupils strongly dilated; carotid arteries pulsating most violently; a full, hard pulse, with loss of power to swallow. HERING Homeopathic remedy considerations

43. bipolar disorder Stramonium • ¤ Rage; unmanageable; grasping with his hands; laughing; rolling and creeping around in bed; unable to stand on his feet; pupils wide open; insensible; wants to kill people or himself. HERING • With horrible cries he strikes at those around him, and is furious. HERING • Uncontrollable fury, can scarcely be restrained; flies at people; strikes and endeavors to seize them. HERING Chamomilla • Thirst, with febrile heat and redness of the cheeks. ALLEN • Heat of the face, with redness of the cheeks. ALLEN • Anger; being looked at. GUNAVANTE • Cannot bear to be looked at. CLARKE Homeopathic remedy considerations

44. bipolar disorder Homeopathic Rx

45. Bipolar disorder Belladonna 200C QD Has responded well to every potency for 2-3 months Has not needed to change any medication while on Tx Has had significantly improved engagement with teachers, doctors and friends Mood shift frequency significantly reduced from every 3 days to minor shifts when a remedy change is needed Currently on Belladonna CM Homeopathic Rx

46. obsessive compulsive disorder

47. Obsessive compulsive disorder Diagnostic criteria • Presence of obsessions, compulsions, or both • Obsession: Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress • The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (ie, by performing a compulsion) • Compulsion: Repetitive behaviors (eg, hand washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession, or according to rules that must be applied rigidly • The behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive DSM-5 criteria

48. Obsessive compulsive disorder • The obsessions or compulsions are time-consuming or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning • Not due to a substance or medical condition • Symptoms are not better explained by another mental health condition • Hoarding • Body dysmorphic disorder • Trichotillomania • Addictive disorders DSM-5 criteria

49. Obsessive compulsive disorder 42 y/o female Diagnosed age 8 Medications: Zoloft 200mg QD Homeopathic Case: • Obsessions related to germs and that her newborn will get contaminated. Compulsion of washing hands and disinfecting things had reached a point that she was no longer mothering her child. • Very fastidious, but only with things that can be seen - spotless countertops but absolute mess in cabinets/closets • Theorized about everything (a known Sx that I had trained out of her over the course of 2 years prior working with her son, but would still occasionally show up) • Very itchy skin, worse in showers and in bed at night, voluptuous itching. Case - sG

50. Obsessive compulsive disorder Fear of contamination and hand washing alone are not significant for OCD - VERY common presentation Fear of contamination while actually being a pretty messy person - more characteristic Physical Sx in classic OCD are often more important than the nature of the obsession or compulsion itself Homeopathic case analysis