A 30 year old male patient came to us with anal fissure and c/o constipation and pain. He is currently taking laxatives daily. His stools are very hard and there is extreme pain in the anus which makes it difficult to sit and walk. The pain is as if it’s a sharp edge of a cut glass, like a needle poking. There is extreme burning, as if lemon or salt is sprinkled on the anus which is cut and sore. The pain lasts for 4-5 hours after passing stools. The discomfort lasts an entire day. There is bleeding sometimes. He says “In the pain I feel I will break into two parts and collapse”
He was suffering from tuberculosis of the spine two years back. Although, he recovered from the tuberculosis, he still complains of back pain which started after his surgery. The pain is dull and aching in nature.
The patient says “I was in extreme discomfort during the tuberculosis episode and after that I got the anal fissures. I am unable to lead a normal life since a long time and need to get better”. The patient was in a lot of agony and desperately wanted to feel better.
Case History – As narrated by patient –
“All my complaints started when I changed my work; there is no pick up and drop service in this job like in earlier job. My wife and I were working in same company before marriage. There was lot of stress before marriage and even now after marriage also. We had many issues before marriage, it was quite difficult to convince our families as they were against our marriage.”
“My mother is living separate from us due to fights between her and my wife. This really stresses me.” My wife is very caring. She takes good care of me. But she is not in favor of my mother. When we have to go to mother’s house for festivals she doesn’t want to come. My mother also doesn’t like her. I have to tackle and balance both these women of my life. I make it a point to go and see my mother. I feel very responsible for her. I constantly think about her. Today I am staying alone but she is the one who fed me and she has taken care of me. It is my responsibility to take care of her now. But I can’t. I worry what is she going to do? How much she has done for me. She is a very loving woman. Situation is stopping me from being together with her. How can I help her? She wants to spend time with me, I am her son. She means lot to me. I respect and appreciate her. She stood up and brought me up. She is an inspiration. She tried to manage my education fees, she ran errands for the house, and she did all that alone after my father died.”
“With wife also I want to enjoy. I am in sickness post my marriage. I want to go to couple of places, honeymoon places with her but I have fear for my disease because of it I can’t go anywhere. I am supposed to do something for her. I am responsible for her health and wealth. But I am not able to do. But she understands me. I feel sad for her that I do not do anything for her.”
“Both these women have a different place in my life. I want them to get along with each other. I wanted to keep balance. Currently they are at least in talking terms. Once in a week, they talk to each other. I could have done much better, but I am still hopeful that things will get better”.
Respect is very important in any relationship. For examples I have come to you and you are a doctor. I will give you the respect you deserve.
So far the patient has been talking about his relationships, family and his incapability to maintain these relationships (striking a balance). He was just talking about his relationship and family.
D- Describe a person without respect?
P- Person without respect: not understanding, as per my standard, they don’t respect each other, my wife and my mother. I did try in many ways. Didn’t work out. I tried my level best. So that they atleast talk to each other. I can’t push them artificially. For me Family matters a lot. As a child, we were staying together.
D- What is family? Feeling of being together?
P- Taking care of each other. Going out together with family e.g. for movies. Supporting each other. They support when I am not well, going for any interview, I am the youngest son in my family. My sister and brother have always supported me. They are familiar, they always guide me. They will encourage and provide any help I need. Without this support it is little difficult. You will have to struggle.
If you’re alone with no siblings then you have try to help yourself best. Although my brother and I do not talk much, we have different understanding. He will be there when I need him. I know he will never cheat me. With friends you have to be careful, to ensure they do not cheat you.
The meaning of relationships and family means support for the patient. He looks to them for guidance and support.
D- What if someone cheats you?
P -I notice the person, I see the person, his behavior. How that person is talking? I don’t easily make friends. If he cheats me I will get angry. I won’t talk to him. I will completely disconnect. I will not even look at him. If someone hurts me I can’t hold things back. Someone insulting me, talking in high tone, acting smart.
When I am in group I go away if they talk or make fun of me. It depends how my mood is. I will get angry. I will try to pull their leg, my blood pressure goes high. There has to be limit. Can’t listen to crap from anyone.
I will behave in same manner with him also. But it hurts me to do that. I will wait for an opportunity. That’s my karma which I will complete it. But to give him back it is important so that the opposite person realizes his mistake.
Overall I am a very chilled guy. I am good person. I will not to hurt anyone. I will always help.
This question was asked to see if there are any animal themes in the patient. He is sensitive to being cheated or bullied. He will ignore, disconnect- but if it becomes unbearable he will get back to the person. More than the animal theme, the sensitivity of the patient was more prominent.
D- Tell me something about your work?
So far only one aspect of his life has been the focus, so it is essential to see how his work life is. He did mention the stress at work. Often what work a patient does, how he does it, why he does it is a window to the case.
P – I am responsible for workforce management. I make offshore staffing plan. I am more creative, I am creative with excel sheets. I was a report analyst, then became a team leader and now I am a manager. I got different promotions. I provided floor management support at different sites.
I am good at problem resolving, with persistent and different ideas. I have been awarded as the best performer.
D- What does performance mean to you?
P- Performance means incentives, how to grow accounts. Finally it is your rating that will matter. I am a hard worker. I constantly strive to exceed my performance.
The patient talks about creativity and performance and about a specialized skill set and logical analysis. This gives us further hints and narrows down our search.
D- How was your Childhood?
P- I had lot of fun. I used to fear heights and darkness. Infact I still have some fear about it.
D- Any hobbies?
P- I play pool- mainly virtual, watching horror movies.
D-What is pool? What do you enjoy about it?
P- You have to hit the ball with precision. You need to take support. You have to be good with your calculations, how it’s going to be. It involves lot of planning, concentration, logical calculation and patience.
The patient talks about support, planning, precision (mastering a skill) again. The remedy we select must cover these aspects, as they are coming in different spheres of the patient’s life.
P-There is a lot of stress about what I have to eat and what not. What is good for my health? This complaint is lowering down my confidence. I do not have sexual relationship with wife as the pain is driving me crazy. So there is no physical pleasure also.