A Needy Patient, Lots of Meds

[Dale Moss]

Dear List:

I need some help re-establishing my perspective on a difficult patient with
a difficult case. She came to me
two years ago with a lengthy list of medical problems (you know you’re in
trouble when the patient checks
almost every box on your intake form!). The initial intake took 5 hours; I
just shut up and let her talk
because it was obvious she needed to do so.

PC: memory problems from head trauma from a fall at work (she was in the
process of seeking
disability). Other problems: knees needed surgery (joint replacement),
fluid retention (idiopathic edema),
psoriatic arthritis, fibromyalgia, recurrent UTIs, [spell out], sudden
urinary incontinence, etc. Lots of
hospitalizations & operations, including tonsillectomy, urethrotomy,
C-sections, arthroscopy, replacement
of both knee joints, and the removal of a pilonidal cyst, bony growths, and
a mole. Allergies to numerous
foods, medications (or contrary reactions to meds). If she eats spicy or
hot foods, she develops a rash on
her buttocks that burns and bleeds. She was given a single huge dose of
penicillin for a nasty gonorrhea,
and developed an allergy to penicillin as a result. Obese, affable,
somewhat distractable; would go off topic
suddenly (not in the faster-than-the-eye-can-see way of Lach., but more sort
of a drifting off, as if she could
not maintain the thread of a conversation).

She claims she was never heavy until age 40, when she was given inimical
diuretics that poisoned
her and screwed up her metabolism. Her problems with idiopathic edema,
however, started much earlier,
when her father abducted her and forced her to have an abortion. Hx of
assaults, sexual and physical,
starting at age 8 and continuing through her two marriages (she’s been
divorced for years). A distant mom,
strained relations with siblings.

Over the years, she’s had a number of remedies, such as Thuja,
Staphysagria, Sepia, Med., Coloc., and
Nat-m., all of which helped enormously with one problem or another, yet I
don’t feel I’m getting to the heart
of her case & for numerous reasons I’m starting to feel resentful and
“used.” She has attempted to turn me
from her homeopath into her friend, a transformation I have deliberately
resisted. There is much about her
that is likable, but I feel wary around her and see myself withdrawing
increasingly from contact with her. A
lot of the work I’ve done has been for free because she’s strapped, but I
don’t think that’s at the root of my
reaction: I’d probably still feel used even if she were paying top dollar.

Karen Cohen, in a presentation to the IFH, wrote that “The more patients
believe that their
physical sxs and diagnosis ... are the major problems or root cause, the
more they are likely to be estranged
from the true cause or true disturbance within the organism.” I keep
reminding myself of that with this Px,
who is very needy and who focuses minutely and obsessively on her physical
problems. At first she wanted
to get off her many meds, but now she’s balking; I think they and her many
physical problems are tools she
uses to keep people around & catering to her needs.

I feel that she’s on far too many meds (probably over a dozen at this
point) and that it’s impossible
to treat her properly until she starts shedding some. She counters that she
doesn’t want to give up her
methotrexate (immuno-suppressant) for a natural alternative like CMO because
1) it will be painful to go
off the methotrexate; 2) the CMO is too expensive, and she can get
methotrexate thru her insurance for only
$2. Sounds to me like a patient who talks the holistic talk but doesn’t
really want to walk the walk. I’m no
longer comfortable applying homeopathic bandaids here, especially since no
matter how much I try to educate, she continues to see each problem as a
discrete entity that needs attention NOW!

She wants attention (but naturally doesn’t see that in herself), and she
can be demanding. E.g., she
got upset recently because I saw another patient before her upon returning
from a trip; she also got upset
when I was delayed in dropping off a remedy at her house & accused me of
delivering an “unspoken
message.” (I was delayed because a visit to another patient took longer
than expected; I was not playing
passive-aggressive games.)

So my question is, how would others treat this patient? Give her Palladium
and be done with it
[MIND, delusion she is neglected], or try to see a complex case through to
the end?

Let me add that the last remedy she received, Nat-m., she felt made an
immediate difference.
Yeah, she probably should be on repeated doses of a remedy because there’s
so much continued
suppression going on. But it seems to me poor, even unethical, homeopathy
to keep repeating a remedy that
has some good effect but doesn’t feel like the simillimum. It doesn't even
feel like palliation; it feels like placation. But what do you do if the
constitutional picture is obscured by all those meds?

With a sigh,
Cinnabar

[Rosemary Hyde]

Nat-m is not only capitalized but is also underlined in one of the
"hypochondriasis" rubrics (it's capitalized in the other one too.) The fact
that she felt a shift when she took it might be interpreted to mean that the
primary complaint is, as it appears to be, hypochondriasis. It would be
interesting to follow that line of thinking with a course of Nat-m in LM
potency, and see what does shift. Maybe the picture will become a bit
clearer. Another thought is that her use of her symptoms to get emotional
support (exaggerating symptoms) makes one think seriously of Puls, which is
capitalized and alone in the rubric "Hysteria - changing symptoms" as well
as in all the hypochondriacal rubrics, in "dependent of others" (weird
syntax, but that's what it says...) which has 3 remedies, and in "fear of
being neglected" (3 remedies). I think you're right that this is what needs
to be treated, not the individual symptoms. Your feeling of "being used"
would make me look carefully at Puls. Your symptom in this case may well
point the way to the remedy.

This type of case is really devilishly difficult to treat. When I've wended
my way through symptoms with patients like this one,the hypochondriasis has
remained, even if there remained virtually no physical symptoms. Most of my
patients are people who've been treated medically for years and are on a
bunch of meds. I find that whatever is bothering them can constitute a
workable case, and can, using LMs,lead back through what determined the
perceived need for meds, so gradually they know they don't need the meds any
more, and give them up.But needy patients with huge masses of symptoms and
treatments are very tricky to treat, because the overriding complaint is the
hypochondriasis, which, of course, they aren't aware of and don't discuss,
and it remains if not treated.

Good luck!! Rosemary

[Dave Hartley]

Hullo Cinnabar,

I would treat what seems to be the top-most issue(s) which you seem to
have identified:

demanding; wants attention; is using multiple health-challenges as
devices to obtain attention & manipulate others; is a lifelong Victim
(capital V)

I would likely choose a multimiasmic polychrest if I did not feel I
could hit a perfect hole-in-one... this would likely be given in LM;
and would be intended to help this person become willing to TAKE
RESPONSIBILITY for her health, her life, her side of various
relationships (including the therapeutic relationship), etc..

I would also verbally specify (after getting quite clear myself)
boundaries around
1. client/practitioner therapeutic relationship
1a. I would likely decline trying to see this person & change Rx over
each new so-called emergency, but set a course & steer it..
2. find a way to enlist the client's cooperation for a "long haul" with
a SINGLE Rx (perhaps you will decide to change, but it WILL NOT be at
the client's whim)
3. maybe helpful to dissuade client from expecting immediate
(miraculous) gratification; she's apparently spent half a lifetime
operating under an increasing load of disabilities; if she wishes to
address them homeopathically it WILL take time, & she WILL NOT be
competent or able at any level to direct "cure."
4. decide what amount of time/energy/contact you are willing to provide
for cheap$ or free; spell it out; stick to it.

than pall.

warm regards,

Dave Hartley www.holistiq.com
San Francisco, CA (415)626-6390 cell(415)424-5644
www.localcomputermart.com/dave

[Shannon Nelson]

Oh, OUCH!!!!
(Has she had puls?)
One thing that struck me was the methotrexate. The only thing I know about
this drug is what I have in school notes, to the effect that it is one of a
small handful that can leave the patient's VF so depleted that remedies
don't work any more. (I'm nearly certain I'm remembering this right.)

One possibility that leaps to my mind is to tell her that you *can't* treat
her effectively thru all the drugs, and unless she is willing to work with
you (and her doctor) to get off them, you feel you are wasting your time and
hers. Ask what she is willing to do to get off the drugs so that you can
prescribe more accurately?

Shannon
on 6/1/03 10:22 AM, DMH at igan@gis.net wrote:

[Wendy Howard]

> But what do you do if

Hi Cinnabar

Suggest you send her off to spend an evening researching Methotrexate and
its side effects on the net. I wish I'd kept the site reference (and a quick
search on Google hasn't turned it up again) of a French (I think) site which
catalogues all the recorded deaths due to this drug. I found it when doing
some research of my own after it killed my mother.

Regards
Wendy

[Rochelle]

Dear Cinnabar,
It appears to me that you are feeling resentful of this patient and quite rightly so. Why should she use you and not heed your advice? There are patients that come for a chat because no one else will listen to them. If she drains you after a consultation think of the 3 remedies that do this Carc. Plutonium and Granite. In fact the latter may be worth a look.
The first thing I would do in the situation , which is easy for me to say as I don't have to do it, is to start to charge her. Explain that owing to your circumstances (no explanations necessary) it has become necessary to charge every patient that you see. In fact the ploy I have used , re phone prescriptions , is to say that my homeopathic Society has a code that it expects everyone to adhere to out of fairness to others and therefore it will not be possible to give free consultations anymore. Now the outcome will either be that she will continue seeing you, she will have more respect for what you suggest since she is paying and you won't feel so compromised because at least you are being paid for your efforts even if she takes no notice OR she doesn't see you anymore where upon you can breathe a big sigh of relief!!

I hope that some of what I have said may be of use. If not just ignore it and know that I meant well!!!
regards
Rochelle.
www.rochellemarsden.co.uk

[Non-text portions of this message have been removed]

[EarthLink User]

Methotrexate is a very strong Chemo drug and as Wendy says is capable of
killing cancer cells and the patient right along with the cells. Have you
considered referring this lady to another homeopath? That's what I have done
after lots of education and no reponse on the pts part.
Good Luck
Sue

----------

caused.

[Joy Lucas]

Dear Cinnabar, just thought I would add a few thoughts to the interesting
comments from others, but from a remedy point of view.

Of course this begs the question as to whether one remedy is capable of
dealing with a case of this nature but it can happen and it does happen,
even though it appears to be at a stage where you feel you might want to
walk away from the case and the client clearly doesn't want to or cannot
meet you half way by volunteering some approach to dealing with all the
allopathic medications.

So what I did was glean, stripped it a bit bare. I know it might seem brutal
but I well imagine what 5 hours of case taking must look like )

So,

Loquacity but with a tendency to lose the thread of the conversation
Hypochondriacal
Oedema
Eczema
History of abuse
History of head trauma = memory defects
She is distant from her own children
She feels she has been poisoned in the past (inimical diuretics)
She has 'lured' you (hypnotised?), seems charming and affable but also
threatening in some way
I would have to begin with the snakes - forever persecuted they too, in turn
abandon their young. Nearly all the snakes are loquacious and have this
tendency to lose the thread - oedema and eczema are also common to them all
(the poisons cause swellings and the snakes skins peel) - Crot Casc is
perhaps the most hypochondriacal?? but this too is a tendency amongst the
snakes, it is very much bound up with suspicion and not trusting any
medication so they take them all. Finally most snakes are capable of
creating this kind of relationship between Homeopath and client - they lure
and then become dependent, draining and even threatening (all the snakes are
very jealous to the point they may strike out and kill). This jealousy also
makes them real attention seekers but beware the poison. Unfortunately this
person really has been poisoned when you consider the medications she is
taking.

I would gather together all you can on the snakes and have a good read if
you feel inclined.

Good luck, I hope this helps.

Best wishes, Joy
on 6/1/03 4:22 PM, DMH at igan@gis.net wrote:

[Dale Moss]

Thank you, Dave, for your thoughtful comments. I have tried repeatedly to establish just those boundaries you suggest. The client is unwilling to adhere. Sometimes her poor memory is the excuse, although that is not so poor as she'd like to make out. Yes, there is a decided element of hypochondria here, notwithstanding that she does have some very real problems.

BTW, I wasn't serious about Palladium -- it was a joke born out of frustration. Will definitely keep the Lac-m. in mind, however. Thanks again!

Peace,
Cinnabar

[Barbara *]

Dear Cinnabar, as you say the P.C. is memory problems from a head injury, I
would start with Carc. (Treat what the px wants treated). Although there
is this:

MIND; HYPOCHONDRIASIS (142) : abies-n., acon., agn., alf., aloe, alum.,
am-c., ambr., anac., anag., anan., ant-t., arg., arg-n., arn., ars.,
arum-m., asaf., Aur., aur-m., aur-s., aven., aza., bamb-a., bcg, bell.,
Benz-ac., bism., both-l., bran., brom., bry., Cact., Calc., cann-s., canth.,
caps., carc., card-m., caust., cham., chel., chin., chion., cimic., coca,
cocc., coff., colch., Con., croc., cupr., cur., cycl., der., dig., esp-g.,
euphr., ferr., ferr-p., fried., gels., gran., Graph., grat., hell., helon.,
hep., hydr-ac., hyos., Ign., iod., ip., kali-br., kali-c., kali-chl.,
kali-hp., kali-p., kreos., Lach., land., lath., lil-t., lob., lyc., lycps.,
lyss., m-arct., mag-c., Mag-m., malar., merc., merc-d., mez., mill., mosch.,
murx., nat-c., Nat-m., nep., nit-ac., nux-m., Nux-v., ol-an., op., petr.,
ph-ac., phos., plat., plb., podo., puls., rhus-t., sabad., sabin., sac-alb.,
sel., seneg., sep., sil., sin-n., spong., stann., staph., stram., sul-ac.,
sulph., sumb., tab., tarent., ter., thuj., v-a-b., Valer., verat., vib-t.,
viol-o., Zinc., zinc-o., zinc-val., zing., ziz.
T; Toxicity; ADDICTIVE, personality (6) : carc., lach., med., nux-v., op.,
thuj.
T; Toxicity; DRUGS, general,; addictions (3) : aven., nux-v., tab.
T; Toxicity; DRUGS, general,; abuse (22) : aloe, ars., Aven., bapt., camph.,
carb-ac., carb-v., coff., hep., hydr., ip., kali-i., lob., mag-s., nat-m.,
nit-ac., Nux-v., paeon., puls., sulph., teucr., thuj.

Personally, I would not be thinking of a overall prx here (except for a
nosode like Carc. - low), I would be looking to detox (although one can do
that with Avena, or Puls/Sulph) - initially - (I find either 3x-qd or 6x-tds
for a 14/21 days works a treat). I had a case where I thought I would have
to treat each layer as it arose after the detox, and found that the
Puls/Sulph a.m. & p.m. did it all ! After all, SH used Sulph to open a case
all the time, so perhaps it is underrated!

As you are feeling disrespected and "used", I expect that is how she feels
too - so it might be useful to take that 'feeling' and use it in deciding
your prx ? (She also sounds as tho' she might be a Borderline Personality
Disorder case going towards Munchhausens, but as funds are tight, I guess
the therapy option is out of the question ? My guess is she is going to
need the support once you do 'unwind' her pathology). Anyway, just another
viewpoint.

Hope you get a handle on it from the List 'reflections'.

All the best,
Barbara
From: "DMH"
Subject: A Needy Patient, Lots of Meds

Dear List:

I need some help re-establishing my perspective on a difficult patient
with
a difficult case. She came to me
two years ago with a lengthy list of medical problems (you know you’re
in
trouble when the patient checks
almost every box on your intake form!). The initial intake took 5
hours; I
just shut up and let her talk
because it was obvious she needed to do so.

PC: memory problems from head trauma from a fall at work (she was in
the
process of seeking
disability). Other problems: knees needed surgery (joint replacement),
fluid retention (idiopathic edema),
psoriatic arthritis, fibromyalgia, recurrent UTIs, [spell out], sudden
urinary incontinence, etc. Lots of
hospitalizations & operations, including tonsillectomy, urethrotomy,
C-sections, arthroscopy, replacement
of both knee joints, and the removal of a pilonidal cyst, bony growths,
and
a mole. Allergies to numerous
foods, medications (or contrary reactions to meds). If she eats spicy
or
hot foods, she develops a rash on
her buttocks that burns and bleeds. She was given a single huge dose of
penicillin for a nasty gonorrhea,
and developed an allergy to penicillin as a result. Obese, affable,
somewhat distractable; would go off topic
suddenly (not in the faster-than-the-eye-can-see way of Lach., but more
sort
of a drifting off, as if she could
not maintain the thread of a conversation).

She claims she was never heavy until age 40, when she was given
inimical
diuretics that poisoned
her and screwed up her metabolism. Her problems with idiopathic edema,
however, started much earlier,
when her father abducted her and forced her to have an abortion. Hx of
assaults, sexual and physical,
starting at age 8 and continuing through her two marriages (she’s been
divorced for years). A distant mom,
strained relations with siblings.

Over the years, she’s had a number of remedies, such as Thuja,
Staphysagria, Sepia, Med., Coloc., and
Nat-m., all of which helped enormously with one problem or another, yet
I
don’t feel I’m getting to the heart
of her case & for numerous reasons I’m starting to feel resentful and
“used.” She has attempted to turn me
from her homeopath into her friend, a transformation I have deliberately
resisted. There is much about her
that is likable, but I feel wary around her and see myself withdrawing
increasingly from contact with her. A
lot of the work I’ve done has been for free because she’s strapped, but
I
don’t think that’s at the root of my
reaction: I’d probably still feel used even if she were paying top
dollar.

Karen Cohen, in a presentation to the IFH, wrote that “The more
patients
believe that their
physical sxs and diagnosis ... are the major problems or root cause, the
more they are likely to be estranged
from the true cause or true disturbance within the organism.” I keep
reminding myself of that with this Px,
who is very needy and who focuses minutely and obsessively on her
physical
problems. At first she wanted
to get off her many meds, but now she’s balking; I think they and her
many
physical problems are tools she
uses to keep people around & catering to her needs.

I feel that she’s on far too many meds (probably over a dozen at this
point) and that it’s impossible
to treat her properly until she starts shedding some. She counters that
she
doesn’t want to give up her
methotrexate (immuno-suppressant) for a natural alternative like CMO
because
1) it will be painful to go
off the methotrexate; 2) the CMO is too expensive, and she can get
methotrexate thru her insurance for only
$2. Sounds to me like a patient who talks the holistic talk but doesn’t
really want to walk the walk. I’m no
longer comfortable applying homeopathic bandaids here, especially since
no
matter how much I try to educate, she continues to see each problem as a
discrete entity that needs attention NOW!

She wants attention (but naturally doesn’t see that in herself), and
she
can be demanding. E.g., she
got upset recently because I saw another patient before her upon
returning
from a trip; she also got upset
when I was delayed in dropping off a remedy at her house & accused me of
delivering an “unspoken
message.” (I was delayed because a visit to another patient took longer
than expected; I was not playing
passive-aggressive games.)

So my question is, how would others treat this patient? Give her
Palladium
and be done with it
[MIND, delusion she is neglected], or try to see a complex case through
to
the end?

Let me add that the last remedy she received, Nat-m., she felt made an
immediate difference.
Yeah, she probably should be on repeated doses of a remedy because
there’s
so much continued
suppression going on. But it seems to me poor, even unethical,
homeopathy
to keep repeating a remedy that
has some good effect but doesn’t feel like the simillimum. It doesn't
even
feel like palliation; it feels like placation. But what do you do if
the
constitutional picture is obscured by all those meds?

With a sigh,
Cinnabar

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