Liz Kerr, RMT Dip RAc
December 2013
OVERVIEW
40-year-old woman presents with depression, emotional stress and dream-disturbed sleep. She presents with a secondary complaint of chronic ringing in her ears. 2 months ago her daughter committed suicide, and she is emotionally distraught from the incident. The clinic provides a safe place for her to express her sadness, and renders her with coping mechanisms otherwise unavailable to her.
Subjective
40-year-old woman presents with stress, unstable emotions and dream-disturbed sleep. Originally, patient complaints were of bilateral knee pain and chronic ringing in the ears, but she has not been to the the clinic in over a month. When asked about her previous symptoms, the patient becomes visibly upset and begins to tear up. She explains that her quality of sleep is poor, and she wakes many times during the night. The patient's 14-year-old daughter committed suicide a month prior, and she has not been able to sleep through the night since. The patient reports having dream-disturbed sleep, including nightmares, about the incident. She also reports constant ruminating thoughts about her daughter without any relief. She is distracted from work and has a hard time getting daily tasks at home completed. She has a lack of appetite, is not cooking, and is not eating full servings. She complains of being weak from the emotional pain in her heart and suffers palpitations. She suffers from blurry vision and headaches, which are worse after a crying episode. She also discloses that she has a son and husband at home who are also suffering, and another daughter in Kathmandu.
The patient is unaware that acupuncture and herbs will benefit her stress, depression and dream-disturbed sleep. The patient would like to work on this, and would also like to continue addressing the ringing in her ears. She reports that the ringing in her ears began 1 year ago, and describes it as high-pitched, coming and going throughout the day. The patient reports that she has had diminished hearing since birth. She agrees to a treatment plan of coming to the clinic regularly, but only when her neighbour also comes.
Objective
The patient is visibly upset. She conceals herself under a scarf, which covers her head and lower face. She is not able to look the practitioner in the eyes while explaining how she feels, and tears up when talking about her stress levels and sleep. The patient quickly wipes tears from her face and eyes, and looks frustrated as she does. She has a lack of lustre in her eyes and a dull complexion. Occasionally, there is a scent of alcohol on her breath in the mornings. She is distracted by the ringing in her ears, and needs to have questions repeated. Her voice is muffled, and she speaks with a slight speech impediment (confirmed by my interpreter due to the language barrier).
Her pulse is deep and choppy on the left, and slippery on the right. Examination of the patient’s ears shows a bright red irritation along the lower border of the tympanic membrane in the right ear. In the left ear, there is visible scarring on an opaque white coloured tympanic membrane.
Assessment
DX: Post-Traumatic Stress Disorder (PTSD) with a secondary complaint of a right-sided chronic outer ear infection.
In order to differentiate PTSD from Acute Stress Disorder, it is important to consider that PTSD is identified by recurrent, intrusive recollections of an overwhelming traumatic event. Symptoms of PTSD include avoidance of stimuli associated with the traumatic event, nightmares and flashbacks. Depression, other anxiety disorders and substance abuse are common among patients with PTSD. Symptoms last for over a month. With Acute Stress Disorder, people have been through a traumatic event, have recurring recollections of the trauma and avoid stimuli that remind them of the trauma. Unlike PTSD, Acute Stress Disorder symptoms begin within 4 weeks of the initial incident, last a minimum of 2 days, but do not surpass 4 weeks. As this case spans a timeline of almost 10 weeks following the traumatic event, PTSD is the more probable diagnosis.
TCM DX: Liver qi stagnation with phlegm fire harassing the Heart
Liver qi stagnation as seen in the symptoms of depression, irritability, poor appetite, ringing in the ears and a choppy left pulse. Prolonged Liver stagnation leads to phlegm fire harassing the Heart. This is identified in the symptoms of mental restlessness, insomnia, dreamdisturbed sleep, palpitations, lethargy and a slippery right pulse.
Secondary Complaint TCM DX: Outer ear infection - damp-heat in the Sanjiao channel
Treatment plan
Acupuncture: Treat with acupuncture 3 times per week for 10 treatments before reassessing.
Focus on calming the mind and promoting sleep (soothing Liver qi and dispersing Heart phlegm). Resolve outer ear infection by clearing heat in the Sanjiao channel with acupuncture and the use of antibiotic ear drops.
Typical points include: Anmian, Yintang, LV3, LI4, HT7, KD7
To assist with clearing the ear infection: SJ17, SI3
Allopathic: Administer Ciprofloxacin antibiotic ear drops, 2 drops TID for 10 days to the right ear to resolve the infection.
Herbal: Internally use formulas to harmonize and soothe the Liver qi: Chai Hu Shu Gan Wan, 8 pills TID for 3 weeks
Counsel the patient about the purpose of the clinic, reaffirming that it is a place of healing and non-judgement. Assure her that the clinic is a safe place for her to reveal her emotions in order to heal, and convey the importance of healing. Ensure that the patient is provided with a secure environment for her to properly grieve.
Prognosis
Primary: Using regular acupuncture and herbal treatment, 75% improvement in sleep is expected within 10 treatments. A 50% decrease in stress levels is also expected. This being said, grief is a process that differs from individual-to-individual, and it is not certain how much time this will take. The acupuncture, herbs, environment of the clinic and the support of the community will aid in this healing process.
Secondary: Using antibiotic ear drops and acupuncture, a complete recovery from the ear infection is expected. Ringing in the ears is also expected to dissipate, although the scarring in the left ear, and the speech impediment, indicate that full recovery of hearing is unlikely.
Outcome
The patient continued to have good and bad emotional days. 3 out of 7 days were good. On the good days, she was cheery, talkative and animated in her story-telling of daily events. She spoke with her hands and her expressions were large and without constraint. She came to the clinic on her own, without the support of her neighbour. Her eyes were bright, and she was able to smile while she spoke. On the bad days, she reported crying spells followed by blurry vision and headaches. These, however, were not everyday, as they were before. When asked if the clinic was helping her cope with the stress that she feels, her face brightened, she smiled and said yes, while looking the practitioner in the eye. She was still having a difficult time sleeping through the night due to the difficulty with falling back asleep after dreams. However, she reported that the dreams were not always disturbing anymore, and that sometimes they were good memories of her late daughter. She stated that she misses her daughter, and this was in part the reason why she was unable to fall back asleep. She still felt that, at times, she gets stuck in her thoughts, and is unable to escape them. She was now able to express her sadness through conversation with the practitioner. Her appetite was fully recovered, and she was cooking regularly for herself and her family. She stated that she felt stronger, and able to get through the day. The weakness that she felt before was becoming less and less with each treatment.
After 6 treatments, the patient reported less ringing in the ears. She had an easier time hearing conversations and was less frustrated when trying to listen while in settings where several conversations were occurring simultaneously. The ear infection had cleared and the patient communicated that her hearing had not been further compromised.
Conclusion/Discussion
This case demonstrates that the use of acupuncture and herbs effectively provides support to the healing process of psychological conditions such as PTSD. The environment of the community style clinic also plays a role in benefiting the patient, by providing a place of healing where there are no other options.
The limitations of this case include the lack of objective evidence, as this is more of a psychological case, and measures are often subjective in nature. Background information about the mental state of the patient, as well as if alcoholic behaviours were present before the incident, would be interesting to note. Unfortunately, this information is not available. Despite these limitations, this case demonstrates the effectiveness of acupuncture and herbs in terms of benefitting psychological health, as the patient shows continuing improvement.
It is concluded that further treatment with acupuncture and herbs will be beneficial to this patient. It is both the physical treatment, as well as the environment in which it is administered, that will continue to heal the depression symptoms and the patient's spirit. It is important to have this space available as a safe place for emotions and grieving, as well as a place to break free from everyday routines. Having alternative options available in order to avoid substance abuse is valuable in a rural setting.
Upon further research and speaking with the Acupuncture Relief Project interpreting staff about suicide and village culture, it is found that, just as in the western world, it is a sensitive subject. There is apparently much gossip and talk of the patient and the event amongst people in the community. This gossip is behind the backs of the family involved, and is often about the increased alcohol consumption of the patient. Culturally, the village takes pity on the family. Suicide is not socially accepted, and is viewed as a failure on the parent's account, especially when it involves a young person. Suicide creates an air of bad luck surrounding the community. It is said that the spirit of the deceased is stuck in-between heaven and earth and is in a space of unrest. Spirits are taken very seriously in Nepal, as it is believed that they can harm people. Without knowing the conditions of the home environment, it is hard to speculate if the patient will experience a full recovery. Is there support at home? Do the husband and son respect the grieving process and allow it to occur? This makes the support of the clinic in the community that much more important. The clinic provides not only physical care with acupuncture and herbs, but also a safe place for emotions to be expressed without judgement.
Continued treatment
Educate the patient about possible coping strategies, such as taking 10 diaphragmatic breaths when the world seems too much, or when she is having trouble stopping the thoughts in her head. As treatment continues, work towards teaching the patient about meditation techniques, and how space for the spirit can be created anywhere.