A Case of Severe Vertigo: a Cycles & Segments Approach

Amy Rothenberg ND, DHANP This 50 year old woman, Tina, first came to see me after suffering from severe attacks of vertigo which had left her unable to work. She presented as an obese and pale woman, knowledgeable about her own pathology and though somewhat apprehensive about trying something new, eager to report accurately. Her background in the medical profession helped enable her to describe her experience in particular detail. I use a Cycles and Segments approach to all my new patients, which informs both the case-taking and case analysis. I have written up the following case to model how I apply the Cycles and Segments philosophy and practice into daily patient care. Once the concepts of this methodology are understood, the computer repertory program RADAR with its Herscu Module, facilitates the analysis process. I use the program during the interview, which helps to inform my line of questioning. While no repertory program can or should lead the interview, they can help us to hone in on what needs to be cured. In that respect, a clear visual representation of the pattern of illness, which the Herscu Module offers, is useful to me while I am taking the case as well as when I am done and thinking about choosing one remedy to give. I use the Module to help create a Cycle of the patients complaints. The Cycle is generally made up of 5-6 Segments which are defined as groupings of similar symptoms, i.e. symptoms that represent similar ideas. With each symptom a patient shares, I think, what is that symptom an example of? What does it represent? AND, are there OTHER examples of that in their story? I think that, and then ask those questions accordingly. For instance, if I have a patient with chronic throat infections, I would ask myself what is that an example of? Its an example of infection. If it did not come up during the interview and review of systems, I would ask the patient, Are there any other examples of infection that you have had over the years? Perhaps they also have a history of urinary tract infections or struggle with inflamed acne on the face or chest. I would put these symptoms in one segment as they represent the same idea. I would call the Segment: Infection. and would look for rubrics which represent those specific ideas, i.e. Throat, inflammation, chronic; Bladder, inflammation, chronic and Skin, eruptions, inflamed, etc. In this way I insure that I am searching for overall tendencies in the patient. I am less concerned about finding the exact correct rubric, because I trust that I have understood the overarching concepts of the patients pathology. As I choose rubrics which represent the specific Segments and as will be demonstrated in the following case, the remedy that will help, comes through, among a short list of possibilities, in the final repertorization. As to how the Cycle is created from these Segments, and how the Segments are influenced by my understanding of the Cycle, I will discuss and model through the case below. It is an organic process which allows all the case-taking skills honed over years of practice, to be utilized and supports my questioning process in general. Students and preceptors often wonder how there could be only 5-6 Segments in a full case. Often complaints seem separate and unique, but in reality are only further examples of a particular Segment, which I have already defined. With the example above, we might also see a kind of irritability or inflammation of the temperament, so to speak, so that I am free to combine mental, emotional and physical symptoms in the same Segment, as long as they represents the same underlying idea.

More experienced homeopaths might believe that this process would be tedious or unnecessary, but I find it liberating. Instead of feeling inundated by the apparently disparate and often multitudinous symptoms, I now have the ability to streamline information as it comes to me. Some of this data is understood by what the patient says, some by what I can observe visually, and some by what I experience, kinesthetically. I am particularly enthusiastic about this approach because it is easy to teach; my newer students who do not have the benefit of pattern recognition and for whom all of homeopathy can appear overwhelming, consistently arrive at a handful of good remedies choices. From there, they can go to the materia medica for a final decision and also have a few back-up remedies if their first remedy choice does not hit the mark. I believe this approach also rings true to being a holistic way of seeing the patient, of allowing all elements of their case to be represented. Which symptoms should we take? Which are most important? Using the grouping, Segment approach, allows all aspects to be considered without over or under-focusing on one or another problem. With computer analysis, like anything else, its garbage in/garbage out, but by understanding the philosophy of Cycles and Segments, there are less pitfalls and more safeguards to prevent those frustrating elements of repertorizing: too many remedies come through, not enough remedies come through, or worse, a list of possible remedies, but alas, none seems appropriate based on prior experience or the study of materia medica. When we train homeopaths, we spend sufficient time early on, teaching repertory. We begin with the history and basic layout of the Repertory and general concepts of its language; then go section by section with repertory exercises so that all students eventually develop facility with describing, then finding, symptoms. This makes the repertory a much more usable tool and also less intimidating, and gives the homeopath the capacity to be flexible in their use of the repertory, to use it to the fullest advantage. As would be expected, we put extra emphasis on the MIND section. With the case in point, there was a lot of information coming at me very quickly, both verbally from the patient and from what I could observe in her manner and delivery, appearance and speech. What follows is how the patient presented and how I used the Cycles and Segments approach to avoid being inundated, to clarify my thought process, to organize the information and finally, to select an effective remedy. I have placed my impressions and elements of my thought process in italics to both share my inner process and model how I use the Cycle and Segments to help guide my case-taking. **** Tina was a 52 year old woman who presented with the chief complaint of vertigo. The first time she experienced this problem, which had lasted for some months, was three years prior. She had a complete medical workup at that time to rule out stroke. Her EEG, EKG and echocardiogram were normal. The onset of the vertigo coincided with her perimenopausal years. About 4 months ago it began to worsen again, where she felt dizzy and out of touch. She felt it was difficult to get a good breath and as if her throat was closing off. She became anxious. She was given anti-anxiety medication from her primary care physician, which took the edge of the anxiety, but did not address the vertigo.

At the time of our first visit, both seizure and cardiac disorder had been ruled out. The patient felt that the vertigo was related on some axis among her hormonal, neurological and mental areas. Even when she was not totally dizzy, she did not feel right. The patient seemed hyped up, she leaned forward, really wanted to connect, felt totally open. She spoke quickly with ideas flowing rapid fire, as if she did not want to leave out any detail; I felt a tremendous amount of information coming toward me and a kind of urgency on her part. Tina reported that she was treated for depression some 10 years prior. The depression did contain an anxiety component, but she could never tolerate any medications; they all revved her up. I needed to know what the vertigo was like for her, exactly how it felt and what she experienced. This would make up the first Segment of the case. So, I asked her what exactly happened during the vertigo and she related it as follows. She described an overall dizziness with a splitting off, a floating away, a sort of out of body experience. There was a significant headache and then she felt very unbalanced- like she was splitting in two. She also would have a sort of numbness in her scalp and extremities. She would then get into a confused sort of state, felt divided and as if she would black out, though she had never done so. Then I needed to determine if there were any other aspects of the vertigo, if I understood what she experienced completely. I often ask at that point, what is the worst thing about the problem for the patient. She said that when the vertigo was at its worst, she would get a sort of expansive feeling in her head, like her head would burst. And then she offered that she could stay in this sort of state for weeks. I begin creating the Cycle from the very first moments of the interview. The chief complaint is often represented in the first Segment, as above. As illustrated in the repertorization, I separated a few elements of the vertigo into two segments, as there seemed to be two ideas-the floating/numbness aspect and the confusion/being split aspect. I then wanted to know what brought on an episode of the vertigo. What brings on a chief complaint is often represented in the previous Segment of the Cycle. In other words, an etiology or aggravating modality would be placed in a previous Segment to a particular complaint. Wanting to understand what, if anything led Tina to this state, I asked her just that. She recounted two different scenarios in which she was crowded by people or emotion. The emotional interactions had become too much for her. She shared an incident of great emotional trauma and grief which was followed by the initial incidence of the vertigo. Then I wanted to understand what Tina did in order to help herself, i.e. what the main symptom led her to do, which give me to the next Segment. Like anything cyclical, you can begin your understanding anywhere in the case or with any of the main complaints. So I asked her, what did she do to feel better? I tried to understand her story first, the flow of the pathology. If I could do this, I could then always go back and fill in rubrics which represent those ideas. Getting the Cycle staring to form in my mind is a priority; I can get further examples of the pathology, and rubrics which represent those examples, while sitting with the patient or later on. She said she needed to hold her head tight, she needed someone to hold her, to put a hand on her somewhere- it didnt matter where, it helped to ground her. She needed company and to talk with people to help her feel connected.

She would reach our socially and make contact with friends and family. So, so far we have certain situations which bring on the vertigo, a good description of the vertigo itself and a few things that help. I asked her how that would go for her, her connecting with friends and family. She said it would be fine but that then she would over do it, she would become like a social worker, helping in all ways she could. She described a kind or rushing around, trying to do everything for everyone. She also mentioned that she would experience a worsening of digestive symptoms, mostly having to do with belching. She would burp loud and often. Everything would be coming outair, thoughts, words, energy. She would become overly concerned with all the details of her responsibilities and would worry that she was making mistakes. She would feel her throat closing off, a kind of constriction, feeling overwhelmed by all the responsibilities she had taken on. This becoming overwhelmed by the emotional excitement, this rushing-in feeling would lead all over again to a worsening of the vertigo and the confusion. As presented here, it seems cyclical and easy, but this patient, like most others, did not spontaneously relay the story in a chronological sort of way and did not have the self awareness that some might, to see this pattern and how it had been repeating over and over again in her life. It was only after being questioned, by our remaining focused on what happened, what led to each symptom and how these symptoms were worsened and ameliorated, one symptom to the next, that we were able to piece together this repeating scenario. Dependent on the particular case, I often do the repertorizing while sitting with the patient and then show the patient the Cycle and Segments I have drawn up. I ask for feedback; many patients can help me to refine my understanding and come up with a clearer Cycle that better represents what they experience. Sometimes its a matter of changing the order of Segments; sometimes we realize together that an important aspect of the case is absent. I know I have finished taking the case when the Cycle is complete, when I can visualize how this pattern of pathology is sustained. Sometimes I take a full case and do the analysis at a later time, i.e. try to create the Cycle once the patient is gone, but the beauty and promise of this approach is to do the work with the patient, because it helps guide the questions asked and therefore, the case received. I did ask about her history with recreational drugs and she said it had all really bad for her- she would lose all connection she had with reality and take days to recover-it was not fun at all and after some brief teenage experimentation, she refrained. She complained of a dry barky asymptomatic cough since childhood and has a history of many chest colds. Her sleep was shallow, often awaking in the middle of the night. She slept in all positions. Her review of systems and physical generals were otherwise unremarkable. Any information I hear or observation or receive during case-taking, I check out with the patient; I do not take it at face value. In other words, everything I hear, see and experience with the patient is context-dependent and I want to be sure Im not reading too much into anything.

For instance, when this patient spoke about out of body experiences, I asked her specifically what she meant by that, which she described above. When I saw her leaning forward in the chair I needed to find out why she did that. Was she just trying to connect? Did she have a back problem? Did that ease her ability to breath? If youre making assumptions, ask, that way you will be less liable to use inaccurate information. Heres the way I built her Cycle from the information she shared, and from the observations I made. I have copied below from Herscu Module on RADAR, the screen which shows the first Segment, which I called Vertigo and the rubrics used to represent that idea: Vertigo, Floating Mind- Delusions- floating-air, in Head- Numbness, sensation of Mind-Spaced Out feeling Vertigo- Walking-gliding in the air, with sensation of-feet did not touch the ground, as if

I wanted to represent the other elements of the vertigo as well, which were distinct from the above-mentioned ones, so in the next Segment I called Confusion and include these rubrics: Mind- Delusions-enlarged-body is Mind-Delusions enlarged-head is Mind- Confusion of mind- dream, as if in a Mind- Delusions-double-being

I then wanted to represent what the Vertigo and Confusion led Tina to, which comprised the third Segment which I entitled Desires Company and used the following rubrics to describe: Mind-Company-desire for Mind-Company-desire for- friend, of a Mind- Talking-desire to talk to someone Mind- Held- amel. being held Mind-Held- desire to be held

In her rush to connect, she would overdue. Tina would try to do everything for everyone; she would be trying to juggle many details and ultimately would feel like nothing was going right. She would feel overwhelmed and uptight and could feel her throat closing off. The rubrics I chose were: Mind-conscientious about trifles Mind-Delusions-wrong-done wrong, he has Throat- Constriction. I called this Segment Closing Off.

I proceeded to follow this Cycle and saw that from that constricted place, Tinas anxiety would get her into a state where she spoke quickly, had other sorts of discharges as described below: Mind Speech- hasty Mind Speech- loud Stomach- eructations, type of, loud I called this Segment Discharges

As in many cases, when there is a lot of discharge, physically or emotionally, there comes a weakness, the patient is then more susceptible to whatever they are suffering from. In her case I used the rubric: Mind, ailments from emotional excitement, which well described her overall over- sensitivity. From this place she was more susceptible to the vertigo. I called this Segment Susceptibility to Emotion

The Herscu Module allows us to view all six Segments at once and to move rubrics from one Segment to another if the prescribers perceptions or understanding of the patient shifts during case-taking or case analysis. I can do this by highlighting and then dragging the symptom in question to the better Segment. I have found this to be very helpful, as often, during a case my understanding shifts, as further information comes forth. That screen looks as below:

What Ill show next is the mathematical computation of the rubrics used, with the remedy given, highlighted to the left. The rubrics listed to the right are those that the remedy highlighted, is found in.

Nux moschata is a remedy I have used with good success in a number of cases where the imbalance and a dissociative state were present. There were other remedies which also came through this repertorization, that had run through my mind while taking the case. Certainly there was the urgency and loquacity of Lachesis and the openness and desire to connect of Phosphorus. However, the dissociative element which characterized her vertigo and the way she would stay in that state for long periods of time, required a different remedy. Nux moschata was not on my mind as I took the case, until I saw it coming through the repertorization. I was then able to ask confirmatory questions which gave me more confidence prescribing. For instance, she did such have a dry mouth (could go in the Closing off Segment,) and she did have intense and easy sleep during these episodes and even between episodes of vertigo (which could also go in the closing off Segment). Certainly, the chatty sort of spaciness (could be put in the confusion section) helped confirm this remedy. I gave her Nux moschata 200c and had her return to the office one month later. She was all smiles, had not had any major episodes of the vertigo and was feeling very clear. She was not

having out of body experiences either. She was motivated at work and at home and was getting a lot done. She had not had any headaches. Over the course of the following year, we repeated the Nux moschata, once at 200c and once at a 1M, when the vertigo symptoms seemed to be creeping back. I was looking forward to some other set of symptoms or a shifting of her overall health to give her different remedy, perhaps one that had less to do with the neurological and emotional sphereI would perceive that as moving in the right direction. One thing I like about having the Cycles and Segments analysis handy at work is that upon follow-up I can add or delete symptoms and shift around the Cycle or Segments as relevant for the case. Often times, the second prescription, will be culled from a similar list of remedies. In Tinas case, about 14 months after the initial dose of Nux moschata, her case had shifted significantly toward more digestive complaints, a worsening of the belching and a new symptom- constipation. She had also begun to perspire extensively, something new to her. When we look back at the list of remedies which came up ( i.e. remedies that were present in all six Segments delineated, Calcarea carbonica is not there. But if we look at those remedies which appeared in five out of six Segments (see below), there it is. Its not that I would use that same repertorization for the patient at a different time I would re-repertorize with the remaining and new symptoms and characteristics, but it is interesting to note that the remedy underneath, was also coming through the repertorization from the beginning.

Tina has continued to do well on Calcarea carbonica in ascending potencies for the last 18 months and has not had further issue with Vertigo. Homeopathy is an imperfect tool used in the hands of imperfect people, we need all the help we can get! For me, both understanding the Cycles and Segments philosophy and utilizing the Herscu Module on RADAR, have helped me organize and synthesize information gleaned during case-taking. I enjoy having a predictable and repeatable approach I can use with every patient, especially those with many symptoms. If anyone has questions about this approach you can email me at the address below. Amy Rothenberg ND, DHANP ( [email protected]) was the long time editor of The New England Journal of Homeopathy. She teaches for the New England School of Homeopathy & the National Center of Homeopathy, lectures widely and writes on topics in natural medicine. When not busy in the world of natural medicine, she enjoys spending time with her husband, Paul Herscu & her three kids, and doing art. For information on Cycles and Segments or the upcoming 10 Weekend Certificate program at the New England School of Homeopathy see www.nesh.com