Mood Disorders in TCM, Focus on Depression - Part Two
Part one of this article closed with an exhortation to ‘vigorously uphold the TCM paradigm’ in our dealings with patients who may have acquired the label of ‘depression’ from one of our Western medical colleagues. Before embarking on a discussion of the pathogenesis and treatment strategies for patients with the major presenting symptom of depressed mood, I would like to take a brief look at the paradigm/s of the psyche that are presented to us in the literature both modern and ancient.
The psyche according to TCM classics
The absence of the Western ‘Cartesian dichotomy’ (i.e. ‘the ghost in the machine’ theory) in traditional Chinese medical thought has been amply discussed elsewhere, so I will take this as a given. (Kaptchuk, T, 2000; Maciocia, G, 2005; Sivin, N, 1987). Indeed, one of TCM’s distinguishing features is its emphasis on the interconnectedness of the body and mind, the individual and his environment, the microcosmic and the macrocosmic. Bearing in mind the dualistic/static nature of Western thought and, as a consequence, the language that we use, the conceptual base of TCM finds a rather clumsy expression in its transmission to the West via the English language. This is not to excuse any perceived lack of clarity in my writing style – I simply wish to remind readers to be aware of the underlying unity between ideas that are given separate expression in the following discussion. In the words of Zhu Xi (朱熹) (1130 -1200): ‘Yin and yang are one and the same Qi. The retreat of yang is the birth of yin; it is not that once yang has retreated a separate yin is born … You can look at yin-yang as single or twofold. Seen as twofold it divides into yin and yang; seen as single it is simply a waxing and a waning’ (Zhonghua Shuju 1986)
In modern transmissions of TCM theory the precise nature of the relationships between an individual’s psychic life and the Zang-fu organs are generally described with lists of correspondences between an organ and various emotions and mental faculties. This leads to the assumption that ‘fear comes from the Kidney’; ‘grief arises from the Lung’, etc. However, if we closely examine our classical sources we find that an important differentiation is made between the origins of our emotional responses and the pathological consequences of the same. According to the Ling Shu chapter 8:
‘When the Liver Qi1 is deficient, fear (or a ‘sense of absence’) will occur; when excess, one will become angry. When the Heart Qi2 is deficient, sorrow will occur; when excess, unceasing laughter will occur.’
This is the only reference in the entire Nei Jing to emotions coming from organs. Thus, we may conclude that, as far as the Nei Jing is concerned, only the Liver and Heart are capable of generating emotions. While various emotions can gravitate to different organs and cause damage to them, the Heart and Liver alone are the source of our emotional life – for better or worse.
When an emotional state is prolonged or intense, other organs tend to become involved. In chapter 5 of the Su Wen, the pathological consequences of emotional excesses are discussed:
● Anger injures the Liver
● Joy injures the Heart
● Worry and anxiety injure the Spleen
● Sadness injures the Lung
● Fear injures the Kidney
● Shock injures the Kidney and Heart
In terms of primary (ben 本) and secondary aspects (biao 标), dysfunction of the Heart and/or Liver is primary. The involvement of other organs, when present, is secondary. This has important implications for both diagnosis and treatment, as we shall see in the following discussion.
Heart (xin 心) and the mind (shen 神)
Chapter eight of the Su Wen states:
‘The heart holds the office of monarch, whence the shen ming (神明) originates.’
We can translate shen ming (神明) in various ways. Essentially it refers to the totality a person’s consciousness – when used in the broad sense – and to his ‘mentality’, when used in a narrower context. Thus we can interpret this passage to mean that our mental state and emotions originate from the Heart and that our mental life, as well as our physiology, is controlled by it. As long as the Heart and one’s consciousness are functioning normally, the emotions will remain peaceful, like a well-governed country. But if the Heart and the consciousness are disordered, any emotion can surface; not just joy (or rather excessive joy and over-excitement, e.g. mania), but anger; sadness; pensiveness; fear; and so on, just like a country in a state of political chaos or at war.
This leads us into the ethical dimensions of traditional Chinese healthcare. Normal healthy functioning of the psyche (and hence of the of the body-mind as a whole) depends to a large extent on the voluntary maintenance of an harmonious relationship with Nature. The spirituality of Chinese medicine finds expression in the exercise of self awareness and self control that is directed towards a moral ideal. Although in many ways this is a personal and individual matter, there are several common aspects that may be broadly defined. One is the ongoing study and observation of natural phenomena with a view to deepening and expanding one’s understanding of the laws that underlie their operation. In this way a person becomes able to align his/her behavior more closely with natural laws and processes. This leads to effective and successful functioning in one’s social relations as well as the maintenance of good health. No less important is the ongoing and ever increasing depth of appreciation of the beauty of Nature, in all of its aspects. Yet another important activity involves self-cultivation in the sense of developing talents, skills and abilities to realize one’s potential. This is to be done for the benefit of others – not for self aggrandizement. As stated in the Daoist classic, the Dao De Jing3:
‘The wise man embraces the one and sets an example to all. Not putting on a display, he shines forth; not claiming to be always right, he is able to distinguish right from wrong; not boasting, he receives recognition; not regarding himself as superior, he is qualified to lead.’ (Ch. 22)
Thus, we can see that Chinese medicine takes a pragmatic approach to matters relating to the mind, consciousness and spirit. They are viewed in terms of normal healthy activities of the psyche, contrasted with unhealthy or immoral activities. Although each of the following aspects would require a much more detailed and in depth discussion than that which is within the scope of this article, it is important to remember that the psychological health of an individual depends to a large extent on:
● The maintenance of a moral ideal
● A well developed sense of values
● Harmonious relationships with significant others
● Living in harmony with Nature
In sum, the healthy, normal functioning of the psyche is closely related to a person’s inner direction and integrity, self cultivation, self-control, and capacity for self reflection. In terms of how this impacts on the health of the body, the Ling Shu , chapter 71, states:
‘The Heart is the monarch of the five Zang and six Fu, and houses the jing shen (精神).’
The jing shen (精神) is variously translated as ‘essence-spirit’ or ‘essential spirit’, or simply ‘spirit’. Kaptchuk (2003) explains that this ‘small’ spirit in the Heart acts as an effective interface between the activities that take place within a person’s consciousness and the limitations of the external world of time, space and matter. In a practical sense, the jing shen (精神) in the Heart ensures that our actions are appropriate and timely. It is associated with the virtue of li (礼) ‘propriety’.
According to the Ming Dynasty physician Zhang Jie-bin, a.k.a. Zhang Jing-yue (Zhang Jie-bin 1624), this passage signifies that while different emotions can gravitate to different organs and damage them, all emotions originate in the Heart and ultimately cause some damage to it. Thus, the Heart not only gives rise to anger, but will be injured by anger; it can give rise to sadness and be injured by sadness; so too for fear, pensiveness and the other emotions.
Physiologically, a person’s psyche, which resides in the Heart, may become disturbed by pathogens or weakened by deficiency of the health Qi (i.e. one or more of the Qi, Blood, Body Fluids, or Kidney Essence). In this sense one’s mental state is inextricably connected with the Heart in that it is strongly affected by conditions of excess or deficiency of this Zang organ.
The Liver (gan 肝) & the Hun (魂)
The Ling Shu Ch. 8 states:
‘That which goes hither and thither with the shen (神) is called the hun (魂).’
The hun (魂) is difficult to translate: it is generally rendered as ‘ethereal (or non-corporeal) soul’, to distinguish it from the ‘corporeal soul’ (po 魄) that resides in the Lung. As indicated in the above passage, the hun (神) acts in concert with the shen (神) in bringing the activities of the psyche into the physical world. As discussed by Kaptchuk (2000), we need not concern ourselves over whether or not this entity exists; it provides a viewpoint for assisting patients (and ourselves) in dealing with problems related to uncontrollable anger, low self-esteem, resentment, jealousy, etc.
The virtue associated with the hun (魂) in the Liver is ren (仁) ‘benevolence’ and ‘human kindness’. Perhaps the biggest obstacle to ren (仁) is anger and its associated emotions. It requires a higher vision to be able to see both sides of a situation and to set aside one’s instinct for individual self-preservation in favour of another person or the greater good. This quality of vision goes beyond the immediate moment and demands that one acts from a place outside time and space, i.e. that the hun (魂) operates under the superior guidance of the shen (神).
The emotion of the Liver is often denoted as ‘anger’. This emotion may be either positive or negative – depending on the situation. In a positive sense, this energetic quality of the Liver may be described as the self-assertive, explosive impulse connected with beginnings, or with the defense of boundaries. If this impulse is blocked, it can easily transform into anger, resentment or rage. Thus, a person may have too much anger, or not enough. The inability to manifest anger and defend oneself when appropriate is just as much a sign of imbalance as is the persistent desire to have one’s own way regardless of circumstances. On the one hand there is a lack of kindness to oneself, while on the other there is a lack of kindness to others.
When the hun (魂) is in harmony, it works in conjunction with the shen (神), enabling one to transcend selfishness and manifest benevolence or compassion – both towards self and others. To take a mundane example: the awareness and acknowledgement of ‘human error’ is provided by the Heart- shen (神), while our degree of tolerance to its manifestations is determined by the Liver- hun (魂).
Another important aspect of the hun (魂) in the Liver – one that we tend to loose sight of in this age of comfort and convenience – is the ability to feel and endure pain and suffering. Kaptchuk describes how an awareness of suffering engenders or awakens compassion and is the foundation of a deep appreciation of one’s own humanity as well as that of others. One of the functions of the hun (魂) is to make pain and suffering more bearable by ‘making room’ for it – without the self-defeating attempt to resist it. (Kaptchuk T.J. 2000)
Looking at the way in which a person’s physiology is related to these functions, when the Liver Qi and Blood are in harmony the Liver is able to maintain the smooth and even flow of Qi throughout the body. This manifests in the ‘proverbial’4 relaxed and easy-going disposition – so easily upset by the effects of prolonged stress and emotional strain. In the clinic we can observe that there are two sides to an imbalance in the Liver-hun (魂): low self esteem and timidity on the one hand, and excessive anger and hostility on the other. These, in turn, are closely related to the state of Liver Blood and the Liver Qi.
The clinical management of depressed mood
It follows from the above discussion that while various emotions can ‘gravitate’ to different organs and cause damage to them, only the Heart and Liver are capable of generating emotions. Therefore, emotional disturbances are primarily associated with imbalance or pathological changes in these two organs. In the diagnosis and treatment of depressed mood, we need to focus primarily on the Heart and the Liver, particularly in the early stages and in less severe presentations. However, in prolonged or severe conditions other organs may also become involved – principally the Spleen (Earth, damaged by worry and anxiety and ‘controlled’ by the Liver-Wood) and the Lung (Metal, injured by prolonged sadness and grief).
The pathogenesis of depressed mood centers on a person’s fundamental mismanagement of his or her lifestyle. It follows from the above discussion that if an individual chooses to lead an unbalanced life, physiological and psychological imbalances will eventually follow. The main contributing factors may be categorized as:
● Prolonged or intense emotional strain.
● Lack of emotional self control.
● Imbalance between work and leisure, i.e. too much of the former and not enough of the latter, particularly if work brings little personal satisfaction.
● Excessive mental work, i.e. prolonged and intensive mental work without adequate rest or physical activity.
Any one or a combination of the above may lead to the two primary organ syndromes:
● Liver Qi constraint
● Heart Blood deficiency
These, in turn, lead to various other pathogenetic factors: Liver Qi constraint leads to Spleen Qi deficiency, generalized Qi stagnation with loss of harmony between the internal organs, Blood stasis and Fire (not necessarily in that order!).
Spleen Qi deficiency leads to Blood deficiency, which will further affect the Heart. It also leads to retention of Damp and the development of Phlegm, which may cloud the mind and senses. Qi stagnation may lead to food stagnation as well as the disruption of fluid metabolism, the latter also contributing to the development of Phlegm. Fire from stagnant Liver Qi will agitate the mind as well as deplete the Blood, leading to Blood and possibly also Yin deficiency.
We can see from the above that a vicious cycle is set in train, resulting in Heart and Liver Blood deficiency and Phlegm. In addition, Heat or Fire may develop – from stagnation of the Liver Qi, as well as Yin-Blood deficiency.
These pathodynamics lead to four major syndromes that are generally encountered in patients with depressed mood:
● Liver Qi constraint
● Instability of the Heart Qi
● Heart-Blood and Spleen-Qi deficiency
● Phlegm clouding the mind and senses
It should be noted that patients mostly present with combinations of the above syndromes. However, for simplicity and ease of presentation they will be discussed separately.
Liver Qi constriant
This syndrome is characterized by failure of the Liver to maintain the smooth and even flow of the Qi throughout the body, leading to stagnation of the Qi, particularly in the Liver organ and the Liver channel. In essence this syndrome is the manifestation of disharmony between the Liver Qi and the Liver Blood, in that the Liver Blood fails to temper and moderate the Liver Qi. Thus, Liver function (i.e. the Liver Qi) becomes inhibited leading to what is essentially a deficiency type syndrome. This manifests in a diminution of emotional responses, i.e. depressed mood with loss of a relaxed and easy-going attitude, together with disturbances along the course of the Liver channel (chest, breasts and hypochondrium). In addition there is generally also disruption of the middle Jiao (Stomach and Spleen) functions. The latter may occur through the restriction (ke) relationship between the Wood and Earth or, alternatively, because the Liver fails to regulate and promote the normal Qi movements of the middle Jiao.
Key clinical features
Patient 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
Fatigue, dizziness (postural), loss of appetite
Wiry pulse (usually also thready)
Treatment Principle: Soothe the Liver and resolve Qi stagnation (possibly also tonify the Spleen Qi and Liver Blood)
Formulas: Xiao Yao San (Bupleurum & Danggui Formula)
- Liver Qi constraint excess syndrome (no signs of deficiency, physical discomfort is more pronounced).
- Chai Hu Shu Gan Wan (Bupleurum & Cyperus Combination)
- Mixed excess and deficiency syndrome;
- Chai Hu Shu Gan Tang – Jia Wei (Bupleurum & Cyperus PMS Formula)
- Liver constraint with Fire (insomnia, irritability, headache, thirst, red tip or edges on the tongue, slightly rapid pulse).
- Jia Wei Xiao Yao San (Bupleurum & Peony Formula)
Instability of the Heart Qi
This is also known as the ‘restless Zang-organ disorder’. It is a general deficiency of the Heart, including Heart Qi, Blood and Yin deficiency. It was first described by Zhang Zhong-jing (circa 150 – 219 CE) and recorded in the ‘Synopsis of Prescriptions of the Golden Cabinet’ (jin gui yao lue fang lun), under the heading of gynecological disorders. This syndrome may occur in either sex, and is simply the end result of several of the pathodynamics discussed above. Therefore treatment should include not only tonifying the Heart and calming the mind, but also address the specific underlying pathogenetic factors, such as Fire from stagnant Liver Qi, Spleen Qi deficiency, etc.
Key clinical features
● Uncontrollable, overwhelming emotional changes
● Poor concentration
● Poor sleep
● Possibly also anxiety
● Possibly also disorientation
● Thready pulse
Treatment Principle: Tonify the Heart Qi, nourish the Heart Blood and Yin, calm and stabilize the mind.
Formulas: Gan Mai Da Zao Wan – Jia Wei (Wheat & Jujube Combination) PLUS An Shen Ding Zhi Wan (Zizyphus & Polygala Formula)
Heart Blood and Spleen Deficiency
Because of the close relationship between the Heart and the Spleen in terms of Blood production as well as circulation, deficiency of the one may readily affect the other. Clinically, this is a commonly occurring dual syndrome that may arise due to inadequate care during the recovery phase of an illness, chronic blood loss, excessive worry, anxiety or mental work, dietary irregularities and overstrain. It may readily develop in students due to the added stresses of examinations as well as in athletes due to overtraining.
Key clinical features
● Patient complains that he can’t ‘switch off’ the mind, especially at night
● Cognitive disturbance (poor memory and concentration)
● Pallor, fatigue, poor appetite
● Pale tongue
● Thready-weak pulse
Treatment Principle: Tonify the Qi and strengthen the Spleen, nourish the Heart Blood and calm the mind
Formulas: Gui Pi Wan (Ginseng & Longan Combination) OR Ren Shen Yang Rong Tang (Dangshen, Astragalus & Dang-Gui Qi & Blood Tonic Formula)
Variation: With Phlegm clouding the mind and senses; Yang Shen Ding Zhi Fang (Biota & Polygala Mood-Uplift Formula)
Phlegm clouding the mind and senses
The idea is that the mind and senses are obstructed by Phlegm. This condition may arise as a sequel to Phlegm-Fire mental agitation (as seen in bipolar disorder) when the disorder has ‘run its course’ and left the patient in a deficient condition. Alternatively, it may arise due to Qi stagnation caused by emotional strain or over-stimulation (via Liver constraint). The Qi stagnation causes impediment to the fluid passages, thus generating Phlegm. This process may readily occur in cases with pre-existing Spleen Qi deficiency. The Phlegm is carried upward with the counter flowing Liver Qi to disrupt the mind and senses (i.e. the Heart) in the Upper Jiao. In some cases this syndrome may progress to Phlegm-Fire mental agitation when the stagnant Qi, Phlegm and Damp develop Fire. This syndrome is characterized by both substantial as well as insubstantial Phlegm.
● Apathy, depressed mood, mental confusion, somnolence
● Excessive sputum or mucous
● Gurgling sound in throat (due to sputum or mucus)
● Tongue body is pale and may also be swollen, with a white, greasy coat
● Pulse is slippery
Treatment Principle: Resolve Phlegm to open the mind and senses.
Formulas: Er Chen Wan (Citrus & Pinellia Combination) OR Wen Dan Tang (Bamboo & Hoelen Formula) PLUS An Shen Ding Zhi Wan (Zizyphus & Polygala Formula)
Finally, it is critical that patients with depressed mood are able to sleep soundly through the night, allowing the Qi, Blood and Yin to be adequately regenerated. Therefore, the restoration of a normal sleeping pattern should be a primary goal of treatment. In order to achieve this patients may require more than one of the following formulas.
- An Shen Ding Zhi Wan (Zizyphus & Polygala Formula) – with Heart Qi deficiency
- Jin Gui Suan Zao Ren Tang (Zizyphus Combination) – with Heart-Liver Blood deficiency
- Tian Wang Bu Xin Wan (Ginseng & Zizyphus Formula) – for severe refractory insomnia (Heart-Kidney Yin deficiency)
- Gan Mai Da Zao Wan - Jia Wei (Wheat & Jujube Combination) – Heart Qi, Blood and Yin deficiency
- Wen Dan Tang (Bamboo & Hoelen Formula) – Phlegm-Heat
1. I interpret the use of the word ‘Qi’ in this context to refer to Qi in the broad sense, which includes the Qi, Blood, Body Fluids and nutritive substances.
2. See footnote 1, above.
3. The Lao Zi Dao De Jing (老子道德经).
4. This ‘free and easy-going disposition’ is implied in the meaning of the name of the popular formula that restores the harmony between the Liver Qi and Blood: xiao yao san 逍遥散
Tony Reid has been actively involved in TCM as a practitioner and educator since 1980. He has lectured at the Zhejiang Academy of TCM and the Zhejiang college of TCM (both in Hangzhou, China) on the standardization of English nomenclature in TCM. Tony is now director of Sun Herbal PTY Ltd.
First published in the NZRA Journal of TCM.
Kaptchuk, T. Chinese Medicine: The Web That Has No Weaver. Rider: London, 2000
Maciocia, G, The Foundations of Chinese Medicine: A Comprehensive Text. Churchill Livingstone: London, 2005
Sivin, N. Traditional Medicine in Contemporary China. Center for Chinese Studies, The University of Michigan: Ann Arbor, 1987
Zhang Jie-bin (1624) Jing Yue Quan Shu (景岳全书) (Complete Works of [Zhang] Jing-yue)
Zhonghua Shuju (ed.) Zhu Zi Yu Lei (朱子語類) Classified Sayings of Master Zhu. Beijing. Zhonghua Shuju, 1986