Role of homoeopathic medicine in the treatment of a case of carpal tunnel syndrome with dysthymia: A case report

Clinical features and diagnostic tests of CTS

CTS has symptoms due to compression of median nerve. Clinically, it is diagnosed by Tinel sign, Phalen’s manoeuvre and flick’s sign.^[5] Electrophysiologically (EP) via nerve conduction studies and electrodiagnostically (ED) via ultrasonography of the wrist joint are done which are considered gold standard for diagnosis. However, according to many studies, utility of the ED and EP testing in evaluation of CTS is also a question.^[6,7]

Clinical features and diagnostic criteria of dysthymia

DSM V has laid down criteria for diagnosis of dysthymia.^[8] The point H is further elaborated in Kaplan as dysthymic disorder is typically an ambulatory disorder compatible with relatively stable social functioning. However, the stability is precarious. The dedication of persons with dysthymic disorder to work has been suggested to be overcompensation and a defence against their battle with depressive disorganisation and inertia.

Treatment

Treatment options for CTS include non-surgical and surgical methods.^[9] The prevalence and incidence of CTS increased from 1993 to 2013 with increased rates of surgery.^[10] Hence, it is required to understand the role of homoeopathic medicines in CTS so that we can prevent unnecessary surgeries in patients.

Treatment options for dysthymia include non-pharmacological, pharmacological and a combination of both.^[11] Despite significant psychopharmacological advances in the past six decades, the management of major depression and other mood disorders continues to challenge mental health providers as these drugs have considerable adverse effects. Many patients with mood disorders who are dissatisfied with conventional treatment seek other interventions, in particular complementary and alternative medicine.^[12]

Few studies are available regarding the role of homoeopathic medicine in the treatment of CTS. The homoeopathic medicine Arnica Montana is widely used in cases with inflammation, swelling or bruises. Hughes-Games states that Arnica 6C was effective in post-operative swelling and bruising in CTS surgery.^[13] Another double-blind randomised comparative study demonstrated a significant reduction in pain after 2 weeks of administration of homoeopathic medicine in patients with CTS compared to the placebo group.^[14] A pilot study showed that Bach flower remedies cream was effective in the management of mild-to-moderate CTS, reducing symptom severity and providing pain relief.^[15] A study showed that homoeopathic medicines might be comparable to antidepressants and superior to placebo in depression;^[16] patients with anxiety and depressive disorder who chose to consult general practitioners prescribing homoeopathy reported less use of psychotropic drugs and were marginally more likely to experience clinical improvement.^[17] The database on studies of homoeopathy and placebo in psychiatry is limited; however, studies show some benefit of homoeopathic treatment for patients with self-reported depression.^[18]

A study showed significant correlation of subjective symptoms of CTS with psychological factors, rather than EP severity; prompt treatment of psychological comorbidity is an important in the management of CTS.^[19] We present a case report of a patient with CTS and dysthymia who was treated with homoeopathy using individualisation.

Preliminary data

Mrs. N.B. 50/F, shopkeeper, came for consultation on 3 October 2019.

Chief complaints

Chief complaint is written in the LSMC format^[20] for better clarity [Table 1].

Patient as a person

• Appearance and behaviour: Melasma

• Appetite: Hunger <, craving: Sweets+2, aversion: Sour+2 and milk+3

• Menses: Staining and menopausal for 1 year

• Coldness: Palms and soles (tips of fingers > palms)

• Thermals: Chilly, sun <3 headache. Joint pains in winter, desires open air.

Life space

The patient had cordial relations with family. She refused to speak about her childhood apart from that she had an irritable and excitable temperament. The family’s financial condition was weak as father died when she was young, so she worked to help them.

After marriage, she had daily arguments with husband, as he was censorious, alcoholic and never did what she asked. He did not handle the financial and other responsibilities well, which irritated her. The husband has hit her several times under the influence of alcohol. Her father-in-law (FIL) would protect her. During bouts of anger, she contemplated suicide by hanging from the fan but never attempted it. For 8–10 years, her impulsivity and anger have reduced after attending religious assemblies; she started listening 90% and spoke 10%. At present, the husband is unemployed due to his illness. She did not allow him to work, as he would squander money. She also felt that if he injured himself, it would create consequences for them. She opened a small shop 12 years prior using her savings and with her brother’s support; she manages it by herself. Her younger daughter earns; the elder daughter, who is married, provides some financial help, which patient mostly refuses. The FIL passed away 3 years prior; since then, patient’s husband has developed chronic kidney disease. Due to this, her savings fall short, which creates future anxiety. The care provided by patient has improved her relations with her husband.

The patient was most attached to her middle daughter, and she was the most pampered child. The daughter would get angry on petty issues. She would share her feelings with the patient who would console her saying that Shravan (God’s disciple) has told them not to get angry easily and she would also take her to religious assemblies to resolve her anger issues. Two years prior, the daughter committed suicide without any apparent reason. When the patient came to know this, she was in a state of shock. She felt sad and still feels the grief deep within. The patient continuously thinks about the daughter and weeps when alone. She wonders why her daughter took such a step the patient feels that she raised her daughter with love despite the numerous difficulties; the daughter should have considered the mother’s feelings before taking such a step. Since then, the patient has developed above complaints.

The patient wants things done according to her specifications or else does not like it. She gets angry, which lasts for 5–10 min; she screams in anger then calms down. The patient is quite obstinate.

Examination findings

Mental status examination

Understanding the clinical entity

Understanding of patient

The patient is depressed and desires to be alone due to her grief regarding the death of her middle daughter, which created a state of shock in her. She is constantly dwelling on the grief of the same and weeps when alone; to avoid the thoughts she resorts to religious means and forcefully occupies herself in work. We see that there is predominant suppression of emotions for many years when she considered ending her life. Her relationship with her husband also has not been cordial, whereby she has suppressed her emotions and anger and found solace through religion [Figure 1].

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Figure 1:

Understanding of the patient.

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Repertorial totality

Refer [Figure 2].

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Figure 2:

Repertorial totality of the case.

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Differentiation of remedies

We compared Nat Carb and Sepia. Dr. Hering writes about Nat Carb ‘an inability to think or perform any mental labour even if he tries to exert himself and at the same time in evening restlessness of body unless he exerts himself mentally. Sadness, depression of spirits, an intolerable melancholy and apprehension; she is totally occupied with sad thoughts; aversion to society and mankind; estrangement from individuals and society from her husband and family.’^[21]

Sepia also has a state of indifference and becomes estranged from the family. Dr. Hering states, ‘Heavy flow of ideas, inability for mental activity. Felt all day as if he did not care what happened, no desire to work, every few minutes inclined to cry, without knowing the cause. Great sadness and frequent attacks of weeping which she can scarcely suppress. Discontented with everything. Very nervous and great excitability in company. Aversion to family and one’s occupation. Irritability alternating with indifference. Dread of being alone. Quiet, introspective, rarely speaks a word voluntarily, sits for hours knitting, her answers are intelligent but curt.’^[22]

Differentiation between both the remedies is represented in a diagrammatic manner below [Figure 3].

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Figure 3:

Differentiation between Nat Carb and Sepia compiled from various authors.

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We see that in Sepia, the grief and indifference are associated with a lot of discontentment, excitability, vexation, answering curtly and dreads to be alone. Whereas in Nat Carb, the emotions manifest in the form of being alone, suppressing her emotions and dwelling over it as she is constantly occupied by them hampering her performing capacities. Physically, the sun aggravation, intolerance to hunger and milk aversion, worse by heat which is predominantly marked is also more covered by Nat Carb. Sepia lacks this sensitivity to warmth and sun and has in specific aggravation from boiled milk. Both remedies have an affinity for the circulatory system; however, Sepia has predominantly venous affections whereas Nat Carb has arterial affections as seen in the form of heat, redness and congestions.

Posology understanding

Final selection of remedy and posology

Nat Carb 200C 1P HS weekly.

Summary of the follow-up

There was a significant improvement with Nat Carb 200 1P HS daily in subjective and objective symptoms of dysthymia and CTS. Melasma, paraesthesia and sleep have improved. Her mood has stabilised; there were no weeping spells during festivals or on seeing people of her daughter’s age. She was taking anti-HTN medications irregularly but her BP was maintained in the range of 110–120/80 mmHg. On 15 June 2021, there were weeping spells when alone and BP was 140/90 mm Hg post-death of her husband due to CKD. She took anti-HTN medication for 15 days then stopped on her own. However, post that, the BP was maintained in the range of 140/80–90 mmHg with sadness. Paraesthesia was absent. She was prescribed Pulsatilla 30 BD for 3 days followed by Nat Carb 200 1P HS daily which did not help, she was shifted to Nat Carb 1M 1P HS weekly.

Patient-physician interaction

The physician applied her clinical knowledge and skills to differentiate between cervical spondylosis and CTS through appropriate tests and history. It is not easy to remain an unprejudiced observer while dealing with a life space containing so many painful experiences. It is essential to have equanimity with qualities such as sound senses and fidelity in tracing the portrait of disease as described by Dr. Hahnemann to erect a totality and treat the case. This was not the case with the physician here, who had no faith in her ability to handle the patient’s state and was in a constant state of conflict regarding her duty. The physician handled this by repeatedly poking the reserved patient for the purpose of diagnosis or obtaining symptoms. The physician did not give the patient the right to be with herself in her sorrows. The physician was constantly troubled with the idea that she has diluted patient’s experience and did not take the case in a way that could free the patient from her suffering. These thoughts created restlessness and blocked the physician who could not perceive what was available to her and was finding ways to free herself. The physician finally found a release to her feelings in the form of a poem.