CASE STUDY |
(The client's name has been changed to honor the family's request for confidentiality. All other details of the case are factual.)
Margaret
Pullman
A 28 Year-Old
Woman Experiencing Difficulties with Her Mental Functions
Margaret, a charming twenty-eight year-old woman with a good job as a dental hygienist, heard of HANDLE on the David Essel show. She and her partner John came to a free community information presentation of "Getting Beyond the Labels." From what she learned about he HANDLE approach, Margaret was so enthusiastic and eager to get the help HANDLE offered that John decided to give her the gift of a HANDLE evaluation for her birthday.
Margaret came in with complaints of fuzzy thinking, being "spacey", feeling "tongue-tied", experiencing confusion about directions, and having difficulty remembering names of things, sequences, dates. In short, Margaret perceived that "something’s haywire" in her neurological functioning. She reported being terrible at math, and that reading is tiring. Therefore she reads only sporadically and tends to read "easy" books, though she would prefer to read books of greater substance. Of major concern to her was the fact that fully two weeks out of every month these symptoms were exacerbated because of PMS, accompanied by a feeling of having no energy. When asked about aspirations, Margaret stated that she would like to be able to visualize things, and to be more creative.
Margaret reports sensitivities to many sensory stimuli. In the area of smell, she is bothered by perfume, smoke, and diesel fumes in particular. She is aware of issues related to how clothing feels on her; and she remembers constantly removing her clothes and shoes as a child. And still today she prefers little clothing and no shoes, her socks must be straight or they drive her crazy, and she dislikes feeling dryness on her skin. Auditorily, high pitches bother her, especially in her left ear, where she also reports tinnitis. Light sensitivity sometimes causes the letters on a page to look like they’re moving around.
As an infant she did not suck her thumb or use a pacifier. As an adult she dislikes chewy things such as meat or tough seafood. Margaret also suffers from tempero-mandibular joint dysfunction (TMJ). Margaret reports falling out of bed when young, and today likes sleeping in a "nest" of pillows. She thrashes about in her sleep. It is extremely hard for her to get to sleep – everything has to be "just right" in her surroundings, and still her sleep can be very erratic. She recalls having ear infections as a child, and continues to have car-sickness and dizziness from carousels and other turning rides. Reading was difficult in her youth; Margaret was diagnosed with dyslexia – she confused "saw’ with "was", had poor spelling, especially of names and places, and other classic symptoms of dyslexia. She also had a speech impediment, which has cleared up.
Margaret made it through high school, but was terrified at the thought of college. She held a number of different jobs, working in retail sales, in a drug store, and as a telephone operator before finding a niche that was right for her, that of a dental hygienist.
Margaret has very strong compensation skills, and for all outward appearances seems highly confident and capable. During the assessment, Margaret demonstrated few problems that could be seen as a blatant area of weakness,. However, she repeatedly stated that that particular day was about the best possible day of the month for her, as far as the PMS goes, and that normally some of the tasks involved would have been more difficult.
One deficit that was clearly significant was in the area of audition – auditory sequencing and auditory/linguistic integration. When asked to repeat a series of nonsense syllables, the longer ones eluded her. On the next task Margaret correctly repeated an entire sentence thirteen words in length; however, in answer to the question "Who was that sentence about?", she could not recall the names correctly.
Another irregularity appeared on the tasks involving binocular vision. It was hard for her to sustain convergence when looking at beads on a string, and when she put on glasses with one lens red and the other blue, white paper in front of her appeared red and blue, indicating rivalry between her eyes. Also of note, Margaret has mixed dominance in that she is left handed, but right eyed and right footed.
Margaret’s reported history gave evidence of multiple sensory hypersensitivities, including smell, sound, light, and touch. In the area of smell and touch, bothersome sensations must necessarily either distract one’s attention or be suppressed. Suppression of these distracting elements requires energy and effort that could otherwise be focused on higher cognitive functions. In the area of light and sound, bothersome sensations are distorting and disorganizing to the visual and auditory systems.
The reported history of car-sickness, dizziness on turning rides, difficulty getting to sleep, and many ear infections indicates a very weak vestibular system. Poor proprioception, evidenced by falling out of bed when young and needing a nest of pillows around her as clues to where she is in space, is both an effect of and an impact on a weak vestibular system.
Dealing efficiently with mixed eye/hand dominance requires excellent integration of the right and left hemispheres of the brain. This integration is also necessary for multiple tracking of mental tasks, such as looking and listening at the same time. Margaret’s right cerebral hemisphere, in charge of visualizing things, is not in good communication with her left hemisphere, where the names of things are stored; she cannot recall names of people, places, dates, details, etc., and she has deficits in theability to visualize. This includes comprehension in reading – she prefers watching television (where the pictures are provided for you). This lack of recall was demonstrated during the evaluation by the fact that even though Margaret repeated a long sentence word for word, she could not correctly name the subjects of the sentence. Margaret is an individual who is highly motivated and anxious to succeed, and when she knows that a certain thing is required of her (as she knew the sentence was to be repeated) is able to over-focus on that particular task to the exclusion of others. Thus she paid attention to the sound and sequence of the words in the sentence (left hemisphere tasks) but neglected the visualizing and comprehending aspects of who was doing what (right hemisphere tasks). Her interhemispheric communication was not strong enough to do both automatically.
Another reason for Margaret’s difficulty in reading, and her diagnosis of dyslexia as a youth, is her lack of binocular vision, evidenced by an inability to sustain convergence on a focal point. When the two eyes have difficulty focusing on the same thing at the same time, the brain tends to let them work alone, choosing to register the image of one or the other at a time, and very often alternating between them at a certain interval of time so as not to be favoring one over the other. This was apparent in Margaret’s case by the fact that when looking at a white piece of paper wearing red/blue glasses, she saw red and blue instead of off-white. Her eyes are working separately, and they are vying for the position of which eye leads and which supports. Thus, reading along a line of print, the left eye suddenly takes over from the right, and things appear to be in different places than they were -- "saw" becomes "was" and other reversals occur. This is also one reason for poor spelling, which she listed as a complaint. Spelling is a visual recall skill. Is it any wonder that someone has difficulty spelling if she has not seen the sequence of letters in a word in constant relationship to one another and if she has difficulty relying on visualization and visual sequential memory?
Margaret also complained of being terrible at math. An innate understanding of numbers arises originally from the ability to visually manipulate objects in space, and also from a good sense of body in space, concept of midline, and mature lateralization. Since all of these were weak in Margaret when she was young, and continued to appear as neurodevelopmental deficits into adulthood, it is not surprising that math confounded her. Even as an adult she still complained of confusion about right and left (directionality).
An underlying theme of the HANDLE approach is that when an organism is stressed, the weakest system or systems will fail first. This is what was happening with Margaret and her PMS, resulting in the "foggy thinking" series of symptoms she reported having for two weeks out of every month. The stress was hormonal, and the weak systems, vestibular, visual, and interhemispheric, got even weaker.
Margaret was given a set of exercises designed to
- strengthen the vestibular system
- enhance and utilize the sense of proprioception
- improve her binocular vision
- encourage and require the right and left hemispheres to communicate and work together.
Her program was carefully constructed so no activity that was chosen to enhance a specific area of function would rely on natural strength in another area that was also weak.
Several additional compensatory recommendations were made for immediate relief of stress (particularly for visual stress). Margaret also received additional suggestions for nutritional supplementation to enhance the strengthening of new neuronal pathways, and general recommendations of complementary therapies that would stimulate the brain without stressing it, thereby strengthening its functions.
Margaret reported to us five days after her first exercise check that she already felt more control over her hands, especially when writing or typing. She said "It feels like some wires have been connected from my brain to my fingers." She was excited to see this change only eleven days into the program.
One month later she came in for her second exercise check session. She reported that her confusion about right and left directionality is gone, that words come more easily, and that her recall is better. The most exciting news, however, is that the PMS has really been relieved. Whereas she used to have two weeks every month that were low energy, confused and frustrating, now she has only two days of low energy at work, and does not feel "foggy" at all. Some of the exercises were discontinued at that time and some others were adjusted and fine tuned.
Margaret and her partner John are thrilled with the results they have seen from the HANDLE program, and she has offered to do some volunteer work for HANDLE as a way to show her gratitude.
