Qiological Community

Case Study: Anxiety, Depression, Pain

Hi all! Sa’am newbie here. Any insights on this case wuld be much appreciated!

27 year old transgender individual (transitioning from male to female; pronouns they/them)

Chief complaint: anxiety and depression

  • Largely related to ongoing pushback from family about sexual orientation
  • History of trauma: childhood attachment trauma, sexual assault, various physical traumas (bike and soccer accidents)
  • Meds: Vyvanse (stimulant for ADHD), Estradiol (estrogen) x 1 year

Secondary complaint: pain along psoas, hip, IT band (left side painful, right side tight) 5/10

Tertiary complaint: tightness and pain in hands, forearms, elbows 4/10 (right hand more painful and slightly larger than left, palms look unusually red). Aggravated by use, particularly motion/vibration of chipping ice.

Appearance and demeanor: facial symmetry/beauty +8; bright eyes +6; polite +5; sloppy hair/clothes +7; shy and soft voice +7 (noticeably nervous when talking with me)

Lifestyle: Personal care worker in group home (reports high stress). Strongly values environmental sustainability - does permaculture landscaping during summer, and practices a “freegan” lifestyle (dumpster dives for food, for “moral reasons”). Sets many food rules for self, but then craves and binges on high fat/sugar foods. Was living with 5 roommates but recently moved out with partner. Smokes a lot of weed to manage anxiety and pain (goes to addictions counselling).

Body Morphology/Flesh: strong build, good muscle tone

Skin: normal moistness but very sweaty hands/feet during needling

Body Temp: warm body +5; cool extremities +2

GI: tightness in left hypochondriac region +6, alternating constipation/diarrhea, suspected hiatal hernia (bike accident a couple year ago – handlebars dug into stomach/ribcage area)

Respiratory: unremarkable

Sleep: poor, difficulty falling asleep +8. Irregular sleep schedule due to 2 night shifts a week. Usual bed time is 1-8am.

Emotions: Anxiety started in teenage years – had to “walk on eggshells” around family of “narcissists and sociopaths”. Manifests as sense of urgency, rapid thoughts, forgets to breathe, tightness in hip and gut, wanting things to be good/right. Tends to keep everything to self. Depression manifests as a sense of being frozen, wanting to withdraw and stay in bed all day (but taking Vyvanse helps get them out of bed).

Urination: forgot to ask

Pulse: wiry left, soggy right

Tongue: pinkish red body, multiple deep cracks in centre, thin yellow coat

Excess Presentations:

HT: none

BL: history of sexual assault may have diminished love for others? sense of feeling “frozen” when depressed?

GB: insomnia +8, pain along GB channel +6

PC: lack of self-assertiveness/weak boundaries +5, pain along GB channel +6

SJ: bright eyes+6, polite +5, social anxiety +6, anger directed at self +7, tight left hypochondrium +5, left-sided pain +5

LU: none

ST: lacks resources (multiple payment cards declined, no car) +8, acid reflux in childhood (gone now) +1, suspected hiatal hernia +2

LI: none

SP: none

SI: diminished self-love +7

KI: lots of pain +8, good symmetry/beauty +8

Grossest things in the room: lack of calm rootedness, lots of pain

Treatments: Only one so far. +PC on right side to address anxiety, insomnia and left-sided pain along GB channel

  • Response: patient was sensitive to needles and became very anxious during needling (hands and feet dripping with sweat, faster breathing, increased heartrate). Aside from the increased anxiety, I didn’t observe other adverse effects so I left the needles in. They took a long time to settle, and just started to get comfortable about 20-25 minutes into needle retention so I retained for 40 minutes (too long?). After needles were removed, patient reported feeling more relaxed, had a rosier complexion and appeared more at ease when interacting with me. However, pain was unchanged at the time. I checked in with them a few days after the treatment and they said they were “less tense/in pain, able to fall asleep 05.-1h earlier than before, and had good sleep 3/5 past nights”.

Other treatment ideas:

  • +LR on right to provide shielding and address left-sided pain
  • +SI on left to address pain in general
  • +KI on left to cultivate self-love

Questions:

  • Any thoughts on whether to prioritize +LR or +SI (or something else) for the next treatment? The patient seems fairly SJ excess but perhaps I need to start by reducing pain and stagnation?
  • I am wondering which side to needle when working with transgender patients. I think Toby mentioned in the on-demand course to examine where they are along the spectrum of masculine to feminine? At the moment I perceive my patient to be more on the masculine side so I am thinking to needle the left side in general.
  • Any thoughts on compelling findings for opposite channels, such as diminished self-love (SI excess) but also lots of pain (KI excess), or insomnia (GB excess) prsenting with lack of assertion/boundaries (PC excess)? Potential for a “toggle” situation?
  • I am debating whether to use thinner needles on this patient next time. They are quite needle-sensitive so I want to avoid triggering more anxiety, but I’m hearing that thicker gauge needles tend to get better results. Currently I am using 0.30-0.35 mm.

Thank you so much for reading through this case! I have found it a useful exercise to lay out and categorize all the information gathered.

Brenda

Hi Brenda,

Thanks for such a well presented case study.
A few more pieces of information would fill out the picture. Thenar and heel presentations. Tension/heat/cold on the midline of the middle abdomen. Presence of varicosities, interesting moles/birth marks.

Does this mean dense flesh?

Any channels besides GB? Where exactly does the patient experience the psoas pain?

Stomach excess sign. Lung+ has potential here.

I understand the impulse to try to make the patient more comfortable. I struggled with this issue when I first started practicing Saam but now use thicker needles with everyone except kids under 10. You risk losing clarity if you use thinner needles, especially judging settling. Their response to P+ on the table wasn’t great and a little confusing to me. Even if P+ isn’t the perfect match it is usually settling on the table. Are they a reliable reporter?

The order of importance when choosing sides is location of symptoms, Lung/Liver, and then gender. You won’t have to make a choice based on gender until the pain goes away.

Keep in mind that insomnia can be treated with any channel, not just P+.

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Hi Kristin,

Thank you for your input! Really appreciate your guidance on this forum.

The midline of the middle abdomen felt soft and warm, and I did not find any varicosities, moles or birthmarks. I will examine the thenar and heel at the next visit.

I would say the patient has more of a fit, athletic build. It doesn’t really strike me as dense.

Aside from the hip region, the other area of pain and tightness is in the elbows, forearms and hands. Next time, I will examine which channels of the hands/arms are most affected. The psoas pain presents around GB 26 and 27.

I see what you are saying with losing clarity - thin needles will probably end up giving patients a weak, half-hearted “shove”, which may just muddy things up. I think there may be other ways to help our patients feel more comfortable, such as talking them through the treatment and asking them to take a breath with needle insertion.

They are a new patient so I’m not sure how reliable the reporting is at this point.

Fit and athletic can mean different things to different people. If their flesh is dense, I would be more cautious about Liver+.

I asked because shy polite folks can bright-side their reporting in an attempt to please you.

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