I get absorbed, losing my boundaries; a case of Natrium muriaticum

Ms. N. A., a 23 year old woman, came to me in May 2011 with the following complaints:

Hair falling in 3 to 4 patches on her scalp (alopecia). Skin eruptions over her arms, aggravated with sun exposure, accompanied by itching. She says: “I am always confused; I intend to say something and end up saying something else. I cannot remember numbers, and I have problems with spelling.”

Falak Shaikh (FS): Of all these complaints, what bothers you the most?
Patient (P): “Hair fall bothers me the most. Apart from this, when I meet a new person I cannot speak confidently, I get nervous. Even in exams I get confused.”
FS: Which of these bothers you the most?
P: “Hair fall is affecting me the most.”
FS: Describe how it bothers you? (The maximum energy lies in the chief complaint, and this often helps to take us to the core disturbance.)
P: “It makes me tense. For a girl, hair is important. What if I go bald? How would I look? Girls’ hair should be maintained. People would say “Oh! She is bald.” I keep it covered to prevent people asking me about it. It does not feel good, so I avoid going out.”
FS: How does it affect you if someone says something and you have to hide?
P: “I only share things with close ones; I would share everything with them. If others would get to know, they would make fun of me.”
FS: Describe “they would make fun of me.”
P: “They would make a joke about me; it would feel like an insult. They would pull my leg and make fun of me. On a one hand, friends behave like we are good friends, but then they start bitching behind my back. It is better to be alone. Whenever there is a problem, we first share it with our friends, specifically the things that we cannot share with our parents. If I share something with my friend, and later, she shares that with someone else, then it’s like there is no support. Normally friends support each others; they give advice and we find solutions for the problems together.”
FS: If friends do not support you, or speak badly about you, how does that make you feel?
P: “I am left alone. If friends behave that way, then, I have to get use of being alone. I do have friends, but they behave that way, so I don’t stay in the group; I get disturbed, so I go and sit alone. I had problems with my roommates, so I shifted my room and stayed alone. I got a turtle (pet) and he was my friend.”
FS: Describe more about support and the feeling of being left alone
P: “If you have friends, you have emotional support. You share with them and they are there for you. But if your friends tell others about you, then you won’t share your feelings with them; you keep them for yourself. I used to have friends but then with my experiences, I felt like friends do not exist, they are all selfish. A few are good but with time, they also go away.
“As a child, in 5th - 6th class, I had a best friend, and then she became someone else’s best friend. It happened many times.
“I get attached easily, and if I’ve good friends, then I feel sad when they leave. I would be friends with people older than me. I had older friends, they cared for me, but they left the college, so the relations broke and the bonding wasn’t there as before.
“They are friends for a certain time, and then with time, they would just go away. My roommates also went away like that!!!  I cannot adjust readily to others, So, I went and stayed alone, and my turtle was my only friend and then he died, too (crying).
“I don’t like being alone.  Whenever I have a 100% attachment in a relationship (gesture: bringing two hands together) that person goes away. When I am close to someone, I don’t need anyone else. I don’t even like to go home from the hostel. A friend becomes more important than anything else.
“If I am in a relationship with someone, we share everything with each other; but then if she has to go away, then that relation also breaks (HG: hands moves apart). I don’t like anyone going away from me. If she is older than me, she cares for me as a younger sister in the hostel, which I like, and if she is younger than me, I care for her as I want to be cared for. I can’t share with people of my age. This keeps on happening: someone comes, we become friends, and then she goes away. So, I decided to be alone (weeping).”
FS: What is the feeling when that friend goes away, or the bonding, attachment is not there as before, when the relationship breaks?
(Now, we understand what affects her, it is about loss of relationship, breaking of bond or attachment; what she gets from a relationship is the care and the sharing.)
P: “I am left alone; since I am so close just to one person, I don’t have other friends. If I am attached to one person, I won’t even talk with others.”
FS: Describe the feeling of being left alone.
P: “I am alone, no friends, no one is around. I cannot share with everyone. I must have some fault in me, that’s why this happens to me! Something is lacking in my friendship! I do so much for my friends, I would do as they say, give away my things for them.”
FS: What do you experience in that loneliness?
P: “I am nothing; I cannot do anything if I am alone. I need one person, at least. I feel helpless. If a person is alone, anyone can use them. A person becomes like a puppet. I get attached to people very fast (HG: fingers interlocked). At least, one person should be there, she should not go away.”
FS: Describe the feeling of helplessness.
P: “If we are alone, we cannot say anything. Without a close friend, it is like being handicapped.  If I am alone, I get confused, messed up. If there is a friend, everything gets handled; half of it goes away just by sharing. Everyone has two supports - family and friends; if one does not share with the family, he shares with friends; without friends, it would be like a building getting tilted. (HG: tilting the body). Everything has support, it is like a pillar of a building; if a building has support, it will not fall.
“You should have one friend. If you have one friend then there is a support: ‘you would not fall because I am here.’ (HG: hand supporting the back).”
FS: Describe support?
P: “Even a tree needs support, without roots it will fall. I cannot be alone, there has to be someone who can understand.  If I have one friend, I will do everything for her, so that she does not go away. I would not look at her weak points. If there is an earthquake the building will fall.  If I have a problem, and if I don’t have friends, I would collapse mentally. Friends will support or help. Without friends, it’s like something is lacking, some part in me is lacking. Without friends I cannot handle my problems.”
FS: “I cannot handle problems, it gets messed up”, describe this feeling.
(This would help us to know in which area she needs support.)
P: “In taking any decision, or if there is any problem, then a friend can advise: “Do this or that”; at least I can share. If a person is in touch with me, there is a support. I cannot share my problems with someone who doesn’t keep in touch or who only calls once in a year. I am afraid that my friends will go away. I get attached very fast.
“Whenever I am alone, I love listening to sad songs.
“If I stay confused in coping with things, how would I learn to practice medicine? (She is a medical student). I feel confused, everything is mixed up. I am blocked, so I feel I won’t be able to say anything. I am in confusion.
“My mom says that I start copying every friend I’m with, and that is true.
“If my friend has some favorite thing, then it would be my favorite too. I still don’t know my favorite color, or my favorite hero.  I am confused if someone asks me what my favorite color is.  If a friend comes into my life, her favorite color would become my favorite color. I would not think “what is my choice?” Then, later on, when she goes away,  I realize that I took on her choice as my own choice.  As friends change, so do I.”
(Here, she beautifully describes that she does not have a choice and she would take on the choice of the person whom she is closely attached to.)
“I would get mixed with them. It’s like being a puppet.”
(The same delusion she had mentioned earlier in the case.)
“It dances as you make it dance. I follow their advice, absorb that. If they say to dress up in a particular fashion, I do that without thinking how I want to be. I get influenced by them (close friends). I do not use my brain. I get moved like a toy; it moves as you want it to move (HG).”
FS: Describe this - moved like a toy?
P: “She does not make me move, it’s like I am ready to be moved, like a robot is told ‘do this, do that.’  I would do things as she desires, like a toy or a robot.”
FS: Describe the fear that your close friend would go away.
P: “I will be left alone, I will not have any support. What would I do without this person? I would fall, this person was my support. I get completely absorbed in that person. I give myself away, I take in everything about them, I take in their thoughts. It is like when you mix salt in water, it gets dissolved completely. It’s like when you mix color in water, it get mixed: whatever is hers, is mine, I would take it. I will not keep boundaries: this is me and that is her. After the person is gone, I would realize I took on everything that was hers. I had an identity; I had my thinking, why did I have to do this? I don’t know who I am.
“I would get absorbed in that person, and then there is no boundary. Someone would feel these two people are the same. I would be like them, one cannot differentiate.
“I cannot even stand alone. I want someone as a support. I want one person. I cannot do anything alone.
“Even when I sit on chair, I have the same feeling in my back. I want support so that no one can shake me. I want something my back can fit into. It is like there is a curve and you fit something into that curve (HG). I want to get attached, so that it cannot be separated. Once I get fixed attached to it, I am stable, complete. Then, I do not want anyone, I would be like her, and we areone.”
(While describing the above, the hand gestures had increased and she was trying to explain her experience, I asked her to draw what she experiences.)
It cannot be just like this (HG) …..(Drawing: half part) when  the other part comes then it would be stable. (drawing : other part).
FS: Tell me about any dreams you remember that had a deep impact on you.
P: “I had a dream where everyone in my family died and I was left alone. I wondered, what will I do, how will I handle things alone. I will have to manage everything on my own. I was afraid. With a family there is a bond, there is a support. I am nothing without them. There should be at least one person who can help me, support me, help me to take decisions, or I get confused.”
FS: Describe more “I am nothing without them and their support.”
P: “If I am there alone, no one knows me. If my father is not there, I don’t have an identity; I am his daughter, if he is not there, who am I? No one would know me. I am nothing without him. I cannot handle things on my own. I need someone, I cannot be alone.”
Then, I asked her about food cravings, to which she responded that she has an excessive craving for salt: she always puts extra salt in her food. She even carries salt in her pocket!!!

UNDERSTANDING OF THE CASE:
The center of the case is about bonds and attachment, which ultimately lead to having no self-identity, and the need to have one special bond with either friends or family. In that bond, she looks for care and support, but then there is disappointment by the person she is dependent on for care and support. She would completely dissolve herself in the person she is in close relationship with. She would do whatever her friend chooses or decides for her. It is like “I don’t know what I want, I don’t know who I am, so whatever you say is acceptable to me.” She would take on the identity of the one she has a close relationship with. And then she is let down, or is disappointed by the person she is dependent on for her identity and becomes completely indifferent towards them. Her food craving confirms the choice of remedy for her.

RUBRICS SELECTED:
DELUSIONS - identity - errors of personal identity
CONFUSION  identity, as to his  own, as if it were not his
FEAR   alone, of being
Ailments from disappointments
Forsaken feeling
INDIFFERENCE, apathy  everything, to
Memory, weakness of memory, read for what he has
Desire salt
Hair falling spots in
Skin, eruptions sun from

Allen’s encyclopedia:
Lack of independence
When alone, she becomes uneasy about herself, and must weep
Offended by a joke
Indifferent or sad mood

Prescription: Natrum muriaticum 200C, one dose
The potentcy 200 was selected as the level of experience of the patient was feelings/emotions

Follow-up: 
September 2011: she developed an acute fever, body ache, headache, and a lot of weakness. She described a situation in which she has some argument with friends from her group, and she described her feeling as: “It’s like that bond is broken. It’s like two parts now. I am alone now, I have to do everything on my own.”
She said that she had been doing fine but, since this incident, her hair fall has increased and her backache has returned.
Prescription: Natrum Muriaticum 200C, 1 dose.
Here, I repeated the dose in the same potency as her state had again surfaced and her level of experience was emotion.

August 2011: “I feel more energetic. Now things do not affect me. I don’t have the backache I used to have. I don’t have a headache. Hair fall has reduced. Now, I can understand things with more clarity. I can study well.”

November 2011: alopecia patches have disappeared, only one small patch is there, but still general hair fall is present. Skin eruptions due to sun exposure.
Prescription: Natrum Muriaticum 1M, 1 dose
Here, I decided on 1M because earlier when I gave her 200C, she responded well for a certain time period and now again the hair fall has started; so I moved to the next higher potency.

Janvier 2012: all alopecia patches have gone. No skin eruptions. Feeling much better and more confident than before.  

November 2012: in between follow-up, I repeated 3 doses of Nat Mur 1M for episodes of acute complaints. “I don’t have hair fall now; all the patches are gone. In the past, I used to get exhausted and weak, which is not there now. My energy levels are good. Before, I had problems in remembering numbers, not anymore. I used to like sad songs and I used to brood but now, I like all kinds of songs. I used to consider my friends to be everything, become dependent on them, and if they went away I used to get upset. Now, I don’t feel so dependent anymore. I can make my own decision and I don’t get stuck in relationships.

Photos:
Marionette; Asian Art Museum; Flickr