Transcript Mood Disorders In Traditonal

ANTA NATIONAL
SEMINAR
MOOD DISORDERS IN TRADITONAL
CHINESE MEDICINE
MOOD DISORDERS IN TCM
- and the over diagnosis of
depression in modern medicine
CASE STUDY
A.P. male, 46 with depressed mood and anxiety. G.P. prescribed Temazepam
(benzodiazepine), which was recently changed to Zoloft (SSRI)
SIGNS AND SYMPTOMS
A.
Feelings of sadness and emptiness with loss of motivation  worrying
about family life (wife and 2 young children) and work (stock broker) 
anxiety and mental over-activity  difficulty falling asleep with restless
sleep and frequent waking during the night.
B.
Talked coherently and with animation, appeared alert and emotionally
responsive. Slightly red complexion.
C.
Fatigue, poor appetite, some weight loss (but happy about it), loose
stools, sour regurgitation (related to certain foods), headaches (daily),
chest feels tight, gets palpitations when feeling anxious, feels hot and
sweaty in the head and chest when stressed.
Pulse: Wiry, thready and slightly rapid
Tongue: Pale, slightly swollen, red tip
THE TCM PARADIGM
Wood=Liver-Gallbladder
Fire = Heat-Small Intestine
Earth = Spleen-Stomach
Metal = Lung-Large Intestine
Water = Kidney-Bladder
THE TCM PARADIGM
 Physical basis of the psyche: The Liver houses the
ethereal soul (hun); the Heart is the seat of the mind or
consciousness (shen)  normal and pathological
emotional responses.
 Nei Jing: ‘When the Liver Qi is deficient, fear (or a
‘sense of absence’) will occur; when excess, one will
become angry. When the Heart Qi is deficient, sorrow
will occur; when excess, unceasing laughter will occur.’
 While various emotions can ‘gravitate’ to different
organs and cause damage to them, only the Heart
and Liver are capable of generating emotions.
 Emotional disturbances are primarily associated with
imbalance or pathological changes in these two organs.
THE HEART AND THE SHEN神
 Close relationship between the psyche and the Heart
zang-organ: it is adversely affected by conditions of
excess or deficiency of this organ.
THE HEART AND SHEN 神
 The Chinese concepts relating to mind, consciousness
and spirit are pragmatic – viewed in terms of normal
healthy activities of the psyche, contrasted with
unhealthy or immoral activities.
 The importance of a moral ideal, relationships with
significant others and harmony with nature. Spirit
(shen) in the broad and narrow sense.
 The Heart-shen ensures the appropriate
manifestation of a person’s mental-emotional
activities in the physical world of time and space.
Virtue of ‘propriety’.
 Also governs a person’s inner direction and integrity,
self cultivation, self-control, self reflection.
THE LIVER AND THE HUN 魂
 Nei Jing: ‘That which goes hither and thither with the
shen is called the hun – ethereal (or ‘non-corporeal’)
soul’
THE LIVER AND THE HUN 魂
 The virtue ren: human kindness, compassion or
benevolence is linked with the hun – both towards
others and oneself.
 Also closely related to the ability to feel and endure
pain and suffering.
 The Liver fosters a relaxed and easy-going disposition.
 Liver ensures the smooth and even movement of the Qi
throughout the body: adversely affected by repressed
emotional responses
 Two sides to an imbalance in the Liver-hun: low self
esteem and timidity or excessive anger and hostility.
APPROACHES TO TREATMENT
 Only the Heart and Liver are capable of generating
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emotions.
In mild cases or early stages, simply treat the Liver
and/or the Heart.
In prolonged or intense cases other organs tend to
become involved.
Anger (Wood)  Liver
Joy (Fire)  Heart
Worry and anxiety (Earth)  Spleen
Sadness (Metal)  Lung
Fear (Water)  Kidney
Shock  Kidney and Heart
WESTERN PARADIGMS
HEGEMONY OF THE DSM-IV
DIAGNOSTIC & STATISTICAL MANUAL OF MENTAL DISORDERS (1994, -TR 2000)
 Descriptive; not based on etiology ( useful for physicians with various
‘theoretical orientations’)
 5 Axis diagnostic system
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Axis I = Psychiatric diagnosis (-es)
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Axis II = Developmental diagnoses and diagnoses first made in infancy
and childhood (incl. personality disorders and mental retardation) –
maladaptive personality features and defense mechanisms
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Axis III = Physical diseases
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Axis IV = Psychological stress factors affecting the patient (past and
present)
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Axis V = Global functioning of the patient (GAF scale to rate
psychological, social and occupational functioning)
WESTERN PARADIGMS
LIMITATIONS OF DSM-IV
 Emphasis on reliability over validity
 Statistical not etiological basis: people sharing the same diagnosis
may not have the same etiology or require the same treatment.
 Includes many disorders that are not psychological, e.g.
impotence, premature ejaculation, jet lag, caffeine addiction, and
bruxism.
 Influence of multinational pharmaceutical companies (MPC’s) 
vested interest in ‘widening the net’ (“Every psychiatric expert involved in
writing the standard diagnostic criteria for disorders such as depression and
schizophrenia has had financial ties to drug companies that sell medications for
those illnesses.”)
 Diagnosis and prescription of SSRI’s is often made by
inadequately trained GP’s, who may have been overly influenced
by the representatives of MPC’s
NEURASTHENIA

Phasing out of ‘neurasthenia’ & replacement with
‘depression’ or ‘anxiety disorder’  Rx with SSRI’s
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Neurasthenia – at least 3 symptoms from:
1.
Weakness (mental or physical fatigue/decreased efficiency)
Dysphoria (irritable, worrisome, inability to relax)
Excitement – easily mentally excitable (accompanied by
unpleasant feelings)
Nervous muscular pain (e.g. tension headache, myalgia)
Sleep disturbances
2.
3.
4.
5.
At least 3 months duration; lowering of work, study or social
functioning; mental distress  seeks treatment
‘LIMITATIONS’ OF SSRI’S
Prozac, Paxil, Zoloft, Celexa, Lexapro, Luvox, Effexor, Sarafem
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Only effective in 50% of cases
Increased risk of suicide (almost 4 x higher than for other Rx)
Increased risk of violent behavior
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Short term: Nausea, diarrhea, headache, and agitation (first 2-3 weeks)
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Long term:
Insomnia (15-20%) - “people who sleep poorly are more likely to
relapse and suicide risk is higher”
Weight gain (18-50%)
Sexual dysfunction: decreased libido and delayed or absent orgasm
– also the "yawning-excitement syndrome." Patients experience sexual
arousal when they yawn, often progressing to orgasm.
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Metabolized by cytochrome P450 microsomal enzymes
YU ZHEG (郁 证)
 Confusion in both Chinese and English over the meaning and
usage of this term.
 In TCM, historically yu (郁) was originally used in reference to
‘stagnation’ or ‘obstruction’ of the Qi, Blood, Body Fluids, etc.
 More recently, yu (郁) refers to stagnation due to emotional factors
affecting the Liver (i.e. ‘Liver constraint’); Yu Zheng (郁证) refers to
emotional disorders as a category of Internal Medicine (nei ke).
 In modern Chinese medical psychiatry Yi Yu Zheng (抑郁证) is
used to refer to the Western disease ‘depression’.
 Influence of Multinationals  over-prescribing of SSRI’s (and over-
diagnosis of ‘depression’).
 Often modern translators translate yu (郁) as ‘depression’ or
‘depressed’ – regardless of context.
TCM APPROACH TO TREATMENT
Differential diagnosis based on major presenting symptom
DEPRESSED MOOD
DSM IV
a)
Minor depression (anxious and anergic types)
b)
Major depression (psychomotor disturbances or complaints
about sleep, appetite, and libido)
1.
ANXIETY
DSM IV
a)
Generalized anxiety
b)
Phobias
c)
Stress disorders, e.g. post traumatic stress (n.b. ‘stress’ in the
broad and narrow senses)
d)
OCD
e)
Panic disorders
2.
MINOR DEPRESSION (DYSTHYMIA)
 Duration of at least 2 years in adults and 1 year in adolescents
and children.
 Depressed mood for most of the day, occurring more days than
not, and accompanied by at least 2 of the following symptoms:
1.
2.
3.
4.
5.
6.
7.
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration
Difficulty making decisions
Feelings of hopelessness.
 Manic episodes must not have occurred, and major depressive
episodes must not have occurred in the first 2 years of the illness
(1 year in children).
MAJOR DEPRESSION
A. At least 5 of the following, during the same 2-week period, representing a change
from previous functioning; must include either (a) or (b):
a) Depressed mood
b) Diminished interest or pleasure
c) Significant weight loss or gain
d) Insomnia or hypersomnia
e) Psychomotor agitation or retardation
f) Fatigue or loss of energy
g) Feelings of worthlessness
h) Diminished ability to think or concentrate; indecisiveness
i) Recurrent thoughts of death, suicidal ideation, suicide attempt, or specific plan for
suicide
B. Symptoms do not meet criteria for a mixed episode (ie, meets criteria for both manic
and depressive episode).
C. Symptoms cause clinically significant distress or impairment of functioning.
D. Symptoms are not due to the direct physiologic effects of a substance or a general
medical condition.
E. Symptoms are not better accounted for by bereavement, i.e, the symptoms persist
for longer than 2 months or are characterized by marked functional impairment,
morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms,
or psychomotor retardation.
DEPRESSED MOOD
TCM PATHOGENESIS
a) Emotional strain  Liver  Liver Qi constraint 
1.
2.
3.
4.
Qi stagnation  Food stagnation, stagnation of fluids
Fire  Blood and Yin deficiency
a) Spleen Qi deficiency  Damp  Phlegm.
b) Spl. Qi def.  Blood deficiency  Heart Blood
deficiency
Liver Blood deficiency  Heart Blood deficiency
b) Prolonged Blood def.  Yin def.  Kidney def.
Prolonged Qi def.  Yang def.  Kidney def.
DEPRESSED MOOD
TCM DIFFERENTIAL DIAGNOSIS
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Liver Qi constraint
Instability of the Heart Qi
Heart-Blood and Spleen-Qi deficiency
Heart-Kidney Yin deficiency
Heart-Kidney Yang deficiency
Complicating factors:
 Phlegm (or Phlegm-Damp)  mental ‘clouding’
 Food stagnation  poor appetite and digestion
 Fire  agitation
LIVER QI CONSTRIANT
Key Features
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Feels ‘stressed’, ‘wound-up’, ‘frustrated’, ‘irritable’
Discomfort in the hypochondrium and/or chest (needs
to make an effort to take a deep breath)
Menstruation disorders (irregular cycle, PMT)
Aggravation of physical symptoms by emotional strain
Wiry pulse
HEART DEFICIENCY
Key Features
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Cognitive changes – memory, concentration
Sleep disturbance
Self control – overwhelmed by emotions
Low self esteem
Palpitations
Thready (possibly also weak) pulse
SPLEEN DEFICIENCY
Key Features
 Worrisome, anxious, bored, lack of mental clarity
 Fatigue, muscular weakness
 Poor appetite and digestion (bloated after meals)
 Aggravation of symptoms by over-exertion
 Pale tongue, possibly with excessive coating
 Weak, soft pulse
KIDNEY DEFICIENCY
Key Features
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Severe fatigue, discouragement, lack of drive
Irrational fears, exaggerated fear of death
Low back pain
Loss of libido
Long term, chronic condition
Deep and weak pulse (Kidney Yang deficiency) or
thready and rapid pulse (Kidney Yin deficiency)
CLINICAL SYNDROMES
 Liver Qi constraint
 Instability of the Heart Qi
 Heart-Blood and Spleen-Qi deficiency
 Heart-Kidney Yin deficiency
 Heart-Kidney Yang deficiency
Complicating factors:
 Phlegm (or Phlegm-Damp)
 Food stagnation
 Fire
LIVER QI CONSTRAINT
a)
EXCESS TYPE
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Absence of fatigue
Marked physical discomfort or pain (chest,
hypochondria, stomach, dysmenorrhea)
Wiry pulse with normal strength (or full)
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Formula:
BP006 Chai Hu Shu Gan Wan (Bupleurum & Cyperus
Comb.)
OR
CM104 PMS Formula
Chai Hu Shu Gan Tang (Jia Wei)
LIVER QI CONSTRAINT
B) DEFICIENCY TYPE
 Fatigue, dizziness (postural), loss of appetite
 Wiry and weak pulse
Formula:
B031 Xiao Yao San (Bupleurum & Danggui Formula)
OR
BP013 Jia Wei Xiao Yao San (Bupleurum & Peony F.)
(with Heat: insomnia, headache, thirst, irritability, dry
stool, tongue with red edges, wiry-rapid pulse)
INSTABILITY OF THE HEART QI
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‘Restless Zang-organ disorder’
Uncontrollable, overwhelming emotional changes
Restlessness
Possibly disorientation
Thready pulse, possibly also wiry
Formulas:
BP054 Gan Mai Da Zao Wan (jia wei)
Wheat & Jujube Combination
+
BP001 An Shen Ding Zhi Wan
Zizyphus & Polygala Formula
HEART-BLOOD AND SPLEEN-QI
DEFICIENCY
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Can’t switch off mind, especially at night
Insomnia
Cognitive disturbance (memory, concentration)
Palpitations
Pallor, fatigue, poor appetite
Pale tongue
Thready-weak pulse
Formula:
BP012 Gui Pi Wan (Ginseng & Longan Combination)
OR
CM146 Qi & Blood Tonic Formula
HEART-KIDNEY YIN DEFICIENCY
‘Loss of co-ordination between Heart & Kidney’
‘Agitated depression/agitated major depression’
Anxiety, psychomotor agitation
Chronic or long-term condition
Severe sleep disturbance
‘Heat’ signs (hot hands and feet, hot at night, night sweats, dry
mouth, dry stools or constipation)
 Red tongue with little coating
 Thready-rapid pulse
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Formula:
BP025 Tian Wang Bu Xin Wan (Ginseng & Zizyphus Formula)
±
BP001 An Shen Ding Zhi Wan (Zizyphus & Polygala F.)
HEART-KIDNEY YANG DEFICIENCY
 Chronic, long term condition
 Severe fatigue
 Psychomotor retardation
 Cold hands and feet
 Low back pain
 Pale tongue (possibly also swollen)
 Deep and weak pulse
Formulas:
CM 132 Mood-Uplift Formula
+
BP011 Fu Gui Ba Wei Wan (Rehmannia Eight F.)
COMPLICATING FACTORS
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Insomnia (deficiency syndromes)
BP001 An Shen Ding Zhi Wan (Zizyphus & Polygala F.)
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Phlegm- Heat  Insomnia
BP050 Wen Dan Tang (Bamboo & Hoelen Formula)
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Indigestion (Food stagnation)  Insomnia
CM102 Digest-Aid Formula
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Liver Qi constraint with Fire
BP013 Jia Wei Xiao Yao San (Bupleurum & Peony F.)