MENTAL—EMOTIONAL SYMPTOMS

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Chapter 44

imageMENTAL—EMOTIONAL SYMPTOMS

WHY WE ASK

The area of questioning surrounding the emotions experienced by the patient is one of the most important, if not the most important one. Emotional causes of disease play a very prominent role in the aetiology and clinical manifestations of most of our patients. Therefore we should always ask patients about their emotional life. However, some patients may regard an enquiry about their emotional life as an intrusion and we should be sensitive about this.

The emotional state of the patient reflects of course the state of their Mind and Spirit and the findings from interrogation need to be carefully integrated with those gleaned from observation, particularly observation of the lustre (shen) of the eyes. In addition, the state of the patient’s Mind and Spirit is an important prognostic factor.

WHEN WE ASK

Enquiry about a patient’s emotional life must be closely integrated with observation (especially of the eyes, complexion and tongue), with palpation (of the pulse) and with hearing (voice).

If the emotional condition is not the presenting problem, I generally ask about a patient’s emotional life towards the end of the consultation to try to find the cause of the disease. In many cases, the emotional state of the patient is the main presenting problem; for example, patients may come to us because they are depressed or anxious. In other cases, the emotional state of the patient is the underlying cause of physical symptoms; for example, a patient may complain of tiredness and digestive symptoms when frustration and resentment may be the cause of the condition.

Unless the patient comes specifically seeking help for an emotional state such as depression, irritability or anxiety, I generally ask about the patient’s emotions when the pattern emerging from the interrogation, together with observation of the eyes and tongue and palpation of the pulse, strongly points to an emotional cause of disease. For example, if the Lung pulse is somewhat full and the patient looks sad, I may try and find out whether sadness or grief has been experienced that has not been expressed (the fullness of the Lung pulse would indicate this).

If the Heart pulse is Overflowing and there is a Heart crack on the tongue, I may enquire whether the patient has suffered from a shock. If the Lung pulse is particularly Weak and without wave and the eyes lack lustre, I may explore whether events in the patient’s life have caused sadness or grief. If the pulse is Wiry on all positions I ask the patient whether some life situation is causing frustration, anger or resentment. If the Heart pulse is Choppy, the complexion dull, the eyes lustreless and the voice weak and weepy, I will try and determine whether the patient is sad.

There are two main reasons why I ask a patient to confirm what I suspect from observation, palpation and hearing. First, it engages patients more with the treatment and, by making them aware of a possible emotional cause of their symptoms, it may further their healing process. Secondly, even if the eyes lack lustre, there is a deep Heart crack on the tongue and the pulse is Sad, this may be caused by a severe physical illness such as cancer, or a treatment such as chemotherapy (which may weaken even the strongest of Spirits).

It is important to be sensitive when asking about the emotional state of the patient (if this is not the presenting problem) and often it is observation that gives us a clue about the emotional state, in which case I would ask the patient about it. For example, a patient may come in complaining of tiredness and premenstrual breast distension: if the eyes of the patient lack lustre, I would suspect emotional stress to be the cause of the problem and I would circumspectly ask the patient about it.

It is important to mention, however, that in most cases of treating emotional symptoms, or symptoms which are caused by emotional problems, observation should take precedence over what a patient verbally reports. It is most often when we see beyond what a patient is telling us that we find the true cause of a disease.

DEPRESSION

Symptoms and Signs, Chapter 79

Depression is a very common symptom in Western patients, even though some patients may not admit to being depressed and others may not even recognize that they are depressed.

Definition of depression

‘Depression’ is a modern Western term which indicates a change in mood ranging from a very mild feeling of despondency to the most abject depression and despair. In mild depression the change in mood varies and is not permanent, whereas in severe depression the change in mood is fixed and persists over a period of months or years. Severe depression is also accompanied by characteristic changes in behaviour, attitude, thinking efficiency and physiological functioning. Of course, it is normal to experience a temporary feeling of depression following adverse life events such as bereavement. In distinguishing a normal reaction from pathological depression a quantitative judgement has to be made. If the precipitant seems inadequate, or the depression appears too severe or too long lasting, the condition may be regarded as abnormal. In addition, the severity and incapacity in depressive illness differ qualitatively as well as quantitatively from depressed feelings that are part of normal experiences.

Depression is twice as common in women as in men and its onset increases towards middle age. The main symptoms of depression are depressed mood, loss of interest, self-esteem or motivation, fatigue, anxiety, insomnia and loss of appetite. In very severe cases, the patient never comes out of an extremely depressed mood, is unable to experience any pleasure at any time, is in utter despair and may be suicidal. A major depressive syndrome has the following characteristics:

In addition to the above manifestations, a major depressive syndrome is also defined by the absence of the following: an organic factor, a normal reaction to bereavement, delusions or hallucinations in the absence of mood symptoms, schizophrenia, delusional disorder, psychotic disorder.1

Diagnosis of depression

Asking patients about feelings of depression should always be part of our questions about the patient’s emotional state and it should be carried out with sensitivity and tact. In fact, some patients will not want to admit to being depressed, some will admit to being depressed but do not necessarily want to talk about it, and others may not even realize that they are in a state of depression. These patients will often complain only of physical symptoms such as extreme tiredness, lack of motivation and feeling cold, preferring not to face up to the fact that they may be depressed. In China this is more the norm than the exception as Chinese patients will seldom complain of feeling ‘depressed’ and somatization of their feelings of depression into bodily symptoms is often seen.

Signs of depression In patients who are not aware of being depressed, Chinese diagnosis often enables us to recognize the true condition of the patient’s mental–emotional state. In fact there are certain signs that point to mental depression as the root cause of the patient’s problems and these are:

The complexion of a severely depressed person will lack lustre and will tend to be greyish or greenish; the eyes will also lack sparkle (shen); the tongue has a Red tip and may have a deep Heart crack; and the voice will be low and lacking vitality.

The pulse in a depressed person varies according to whether the condition is primarily Full or Empty. In Full conditions, the pulse feels very Wiry or Wiry and Slippery, whereas in Empty conditions (especially when sadness and grief prevail) the pulse is Weak or Choppy, often Short and nearly always lacks a ‘wave’ (Sad pulse). Interestingly, very often the pulse of a depressed person may point to the true cause of the problem being repressed anger; in fact, in some cases, a depressed patient may display many signs pointing to an Empty condition (low voice, dull complexion, slow movements) while the pulse is very Wiry. This usually indicates that the patient’s depression is due to repressed anger. Vice versa, a pulse that is Choppy, Short or Sad indicates that sadness or grief is the prevalent emotion at the root of the depression.

Depression in Chinese medicine

In Chinese medicine, mental depression was called Yin Yu, which means ‘gloominess’ or ‘depression’ or, Yu Zheng, which means ‘depression pattern’. Yu has the double meaning of ‘depression’ and ‘stagnation’, which implies that, according to this theory, mental depression is always caused by a stagnation.

In fact, the ‘Simple Questions’ in Chapter 71 mentions the Five Stagnations of Wood, Fire, Earth, Metal and Water.2 The ‘Essential Method of Dan Xi’ (Dan Xi Xin Fa, 1347) describes six stagnations of Qi, Blood, Dampness, Phlegm, Heat and Food. It says: ‘When Qi and Blood are harmonized, no disease arises. If they stagnate diseases arise. Many diseases are due to stagnation… stagnation makes things accumulate so that they cannot flow freely, they would like to rise but cannot, they would like to descend but cannot, they would like to transform but cannot … thus the 6 Stagnations come into being.’3

The ‘Complete Book of Jing Yue’ (Jing Yue Quan Shu, 1624) gives stagnation an emotional interpretation and talks about Six Stagnations of anger, pensiveness, worry, sadness, shock and fear. This confirms that all emotions can lead to stagnation of Qi. It says: ‘In the 6 Stagnations, stagnation is the cause of the disease. In emotional stagnation, the disease [i.e. the emotion] is the cause of the stagnation.’4

Patterns in depression

Chinese books normally ascribe mental depression to Liver-Qi stagnation in its various manifestations including Liver-Qi stagnation turning into Heat and Liver-Qi stagnation with Phlegm. In the later stages of mental depression, Empty patterns appear. Thus, although in Chinese medicine stagnation and depression are almost synonymous, Empty patterns may also cause depression.

In severe depression, the Liver is always involved owing to its housing the Ethereal Soul (Hun). The Ethereal Soul is responsible for our life’s dreams, plans, ideas, projects, relationship with other people, etc. The Ethereal Soul was often described as ‘the coming and going of the Mind (Shen)’: this means that the Ethereal Soul assists the Mind in giving it the capacity to have dreams, plans, ideas, projects, etc. In this sense, the Ethereal Soul gives the Mind ‘movement’, outward projection and ability to form relationships with other people, hence its ‘coming and going’ described above. On the other hand, the Mind guides and controls the Ethereal Soul and, most of all, integrates the activity of the Ethereal Soul within the overall psychic life of the person.

Thus, if the ‘movement’ of the Ethereal Soul is lacking (either through its lack of activity or through overcontrol of the Mind), the person is depressed; if the ‘movement’ of the Ethereal Soul is excessive (either through its overactivity or through lack of control by the Mind), the person may display manic behaviour (bearing in mind that the latter may vary in intensity and seriousness from full-blown bipolar disease to much less severe manifestations that are relatively common also in mentally healthy individuals).

When a person is severely depressed, the Ethereal Soul is not ‘coming and going’ enough, and therefore the person lacks dreams, has lost faith in the future, does not know which direction to take in life and has a feeling of loss, isolation and separation. From this point of view, many Liver (and other organs) patterns, and not just Liver-Qi stagnation, may cause depression. When the Ethereal Soul ‘comes and goes’ too much, the person may develop manic behaviour; in this case, the person has lots of dreams, projects and ideas but nothing comes to fruition because of the chaotic state of the Ethereal Soul and the lack of control of this by the Mind.

Figure 44.1 illustrates the two states of the Ethereal Soul: when it ‘comes and goes’ too much; and when it does not ‘come and go’ enough.

Essential to the proper movement of the Ethereal Soul is its restraint by the Mind. The Mind (Shen of the Heart) needs to restrain the Ethereal Soul (but not too much) and integrate the material coming from it into the totality of the psyche. If the Mind controls and restrains the Ethereal Soul too much, depression ensues; if the Mind fails to control and restrain the Ethereal Soul, manic behaviours may result (Fig 44.2).

The lack of ‘movement’ of the Ethereal Soul and hence depression may be due to pathogenic factors inhibiting the Ethereal Soul (e.g. Liver-Qi stagnation), or to a deficiency of the Liver, Spleen or Kidneys not stimulating the Ethereal Soul. The excessive movement of the Ethereal Soul and hence manic behaviour may be due to pathogenic factors overstimulating the Ethereal Soul (e.g. Fire or Phlegm-Fire), or to the lack of anchoring of this Soul from a deficiency of Liver-Blood or Liver-Yin, or both. Note that Liver-Blood deficiency may lead to lack of movement of the Ethereal Soul when it is combined with Liver-Qi deficiency (itself associated with deficiency of Gall-Bladder Qi); otherwise, deficient Liver-Blood fails to house the Ethereal Soul and this leads to excessive movement.

Box 44.1 summarizes patterns relating to ‘movement’ of the Ethereal Soul.

BOX 44.1   ‘MOVEMENT’ OF THE ETHEREAL SOUL

Figure 44.3 illustrates the Liver patterns leading to excessive and to deficient movement of the Ethereal Soul.

When diagnosing the prevailing patterns in depressed patients, it is important to differentiate between Full and Empty conditions; as the mood of depressed patients is the same in both cases, the main differentiating signs are the pulse and the tongue. In Full conditions causing depression, the pulse is usually Wiry or Slippery and Wiry, while in Empty conditions it is Choppy, Short or Sad. As depression is often accompanied by anxiety, this is obviously more pronounced in Full than in Empty conditions.

The main Full patterns accompanying depression are:

The main Empty patterns accompanying depression are:

For a detailed description of these patterns, see Part 5, Chapter 79.

Box 44.2 summarizes the clinical manifestations of these patterns.

BOX 44.2   DEPRESSION

• Liver-Qi stagnation: depression, moodiness, irritability

• Stagnant Liver-Qi turning into Heat: depression, irritability, Red tongue

• Liver-Qi stagnation with Qi-Phlegm: depression, moodiness, feeling of a lump in the throat

• Phlegm-Fire harassing the Mind: depression, anxiety, agitation, expectoration of phlegm, Swollen tongue

• Heart-Blood stasis: depression, agitation, Purple tongue

• Gall-Bladder Heat: depression, irritability, bitter taste, hypochondrial fullness

• Diaphragm Heat: depression, anxiety, feeling of stuffiness in the chest following an invasion of Wind-Heat

• Spleen- and Heart-Blood deficiency: depression, insomnia, palpitations, tiredness

• Heart-Yang deficiency: depression, palpitations, cold hands

• Liver-Blood deficiency: depression, lack of sense of direction, sadness

• Kidney- and Heart-Yin deficiency with Heart Empty-Heat: depression, anxiety, night sweating, palpitations, Red tongue without coating

• Kidney-Yang deficiency: depression, lack of motivation, lack of will-power, feeling cold, frequent urination

FEAR/ANXIETY

Symptoms and Signs, Chapter 79

A chronic feeling of anxiety (occurring on its own without depression) is very common in Western patients. A feeling of anxiety includes emotional states akin to the emotions of fear and worry (two of the seven emotions) in Chinese medicine. It may be accompanied or caused by deficiency (usually of Blood or Yin), by Excess (usually Heat) or by a combination of Deficiency and Excess (usually Yin deficiency with Empty-Heat).

The main patterns in anxiety are listed in Box 44.3.

BOX 44.3   PATTERNS IN ANXIETY

When there is a deficiency of Blood or Yin, the Mind and Ethereal Soul lose their ‘residence’ in the Heart-Blood and Liver-Blood respectively and the person becomes anxious and sleeps badly. Conversely, pathogenic factors such as Qi stagnation, Blood stasis, Heat or Phlegm-Heat may ‘agitate’ the Mind and Ethereal Soul and lead to anxiety and insomnia. In some cases, of course, the Mind and Ethereal Soul are restless both from a deficiency (e.g. Yin deficiency) and a pathogenic factor (e.g. Empty-Heat). Figure 44.2 illustrates graphically the two causes of anxiety, that is, a Deficiency leading to the Mind’s not being ‘anchored’ (Fig 44.2, bottom) or a pathogenic factor ‘agitating’ the Mind (Fig 44.2, top).

As a general rule, the degree of anxiety or fear depends on whether it is caused by an Empty or a Full condition: in Empty conditions it is mild whereas in Full conditions it is severe.

It is usually easy to see whether patients are anxious: they look restless, their voice may be quivering, they may fidget, talk a lot (in the case of a Full condition) or be very quiet (in the case of an Empty condition), and may be very anxious about receiving acupuncture. In a few cases, however, a state of anxiety may not be apparent in patients who make a brave attempt to hide their true state. In fact, those who are in a constant state of fear may initially appear to be calm and grounded. In these cases, the tongue, pulse and eyes may reveal the patient’s state of anxiety or fear. The tongue may have a Red tip, often with a deep Heart crack, the pulse may be Wiry (in case of a Full condition) or Floating-Empty (in case of an Empty condition) and Rapid, and the eyes may look ‘unstable’ and lack control (see Part 1, Chapter 6).

Case history 44.1 illustrates a pattern underlying panic attacks.

Case history 44.1

A 39-year-old woman had been suffering from panic attacks for the past 6 years. During the attacks her throat would become tense, she felt as if she were unable to swallow, she became slightly breathless, had palpitations and felt hot. They occurred every day and became worse after eating lunch. It was interesting to note that when the patient was describing the attacks she repeatedly mentioned the word ‘throat’.

The patient also mentioned that she suffered from night sweats. Her periods were unproblematic but she did become aggressive premenstrually.

The tongue body was Swollen, slightly peeled on the root and very slightly Red on the sides and tip. Her pulse was very Weak in the left Rear position and Overflowing in the left Front position.

Diagnosis:

The panic attacks are caused by rebellious Qi in the Penetrating Vessel. The clinical manifestations displayed by this patient are fairly typical of the Penetrating Vessel’s pathology of Qi rebelling upwards along its pathway. The Penetrating Vessel flows up through the abdomen and chest, along the line of the Kidney channel and flowing through the Heart on its way up to the throat and face. It therefore influences the Heart and chest area and, in this case, is causing the symptoms of palpitations and breathlessness. The symptoms associated with the syndrome of Qi rebelling upwards in the Penetrating Vessel were called Li Ji, which literally means ‘internal urgency’, and it indicates a state of anxiety and panic, as in this case.

The tension in the throat and difficulty in swallowing are caused by the Qi of the Penetrating Vessel rebelling upwards. The feeling of heat is caused by the Qi of the Penetrating Vessel rushing up to the face: this is reflected in the Overflowing quality of the pulse on the left Front position and the Weak quality on the left Rear position. This pulse reflects clearly the deficiency of the Penetrating Vessel in the Lower Burner and the subsequent rushing upwards of the rebellious Qi to the face. It should be remembered that the pulse positions reflect not only the organs but also the areas of the body and their respective channels; in this case there is Emptiness below (the lower abdomen) and Fullness above (throat and face) making the pulse Weak in the third position and Overflowing in the first.

However, in this case, the pulse is reflecting also a pathology of the relevant organs. The Weak pulse on the left Rear position indicates a Kidney deficiency, predominantly of Kidney-Yin, as evidenced by the peeling of the root of the tongue and the night sweating. The Overflowing quality on the left Front position indicates Heart-Heat, which is evidenced also by the Red tip of the tongue.

The swelling of the tongue indicates the presence of Phlegm but the patient has no symptoms of this at present; such cases highlight the preventative value of tongue diagnosis and I would therefore resolve Phlegm even in the absence of symptoms.

The fact that, when describing her symptoms, the patient repeatedly and emphatically said the word ‘throat’ may indicate that the origin of her condition is an emotional one and that she had felt unable to express herself, leading to a feeling of restriction in the throat area.

For a detailed description of the patterns accompanying anxiety and fear, see Part 5, Chapter 79.

Box 44.4 summarizes the main patterns and their clinical manifestations.

BOX 44.4   FEAR/ANXIETY

IRRITABILITY/ANGER

Symptoms and Signs, Chapter 79

Irritability is a common emotional complaint. It includes feeling irritable frequently, flying off the handle easily, feeling frustrated, and similar emotional states. Of the traditional seven emotions, irritability is akin to ‘anger’ but it encompasses a broader range of emotional states and is generally not so intense. A propensity to anger is generally due to Liver patterns, whereas irritability may be caused by many different patterns affecting most organs.

In particular, the patterns that may cause irritability include:

Therefore, irritability may be due to Full or Empty causes; in general, the irritability from Empty causes is mild and somewhat vague, whereas that due to Full causes is more intense. The interrogation, therefore, should first of all try to establish the Full or Empty character of the irritability. In Empty conditions, the patient may say ‘I get easily annoyed’, or ‘Things that did not use to get to me, now do’, etc. In Full conditions, the patient may say something like ‘I feel always irritable’, ‘I feel so on edge that I take it out on my children’, etc.

Box 44.5 links examples of patterns that may cause irritability and examples of patients’ expressions.

BOX 44.5   EXAMPLES OF PATIENTS’ EXPRESSIONS IN PATTERNS CAUSING IRRITABILITY

• Liver-Qi stagnation: ‘I feel extremely irritable before my periods and take it out on my family.’

• Lung-Qi stagnation: ‘I feel this lump in the throat, I am on edge and feel like bursting into tears.’

• Liver-Blood stasis: ‘I seethe with resentment.’

• Heart-Blood stasis: ‘My mind is constantly judging and I feel resentful.’

• Liver-Yang rising: ‘I fly off the handle easily.’

• Liver-Fire: ‘I explode into a rage.’

• Heart-Fire: ‘I feel irritable, impatient and angry.’

• Lung-Heat: ‘I feel frustrated, weepy and irritable.’

• Stomach-Heat: ‘I feel often angry and obsessive.’

• Liver-Blood deficiency: ‘I feel lost, overwhelmed and on edge and I can’t cope.’

• Kidney-Yin deficiency: ‘I feel helpless, unmotivated and on edge in the evening.’

• Heart-Blood deficiency: ‘I feel sad and on edge, and I can’t cope.’

• Kidney-Yin deficiency with Empty-Heat: ‘I feel hot and bothered.’

• Heart-Yin deficiency with Empty-Heat: ‘I feel sad and hot and bothered.’

• Damp-Heat: ‘I feel heavy, yucky and irritable.’

WORRY/OVERTHINKING

Many patients complain of a propensity to worry and overthinking and, even if it is not the presenting condition, many people profess to it when asked. The emotion of worry is related to the Spleen, and overthinking is more akin to the Lungs. Worry describes a condition when the patient is prone to imagining the worst possible outcome in a certain situation, for example a mother who imagines that her son has been in an accident when he is late home. Overthinking describes a state where the patient is unable to empty the mind of repetitive thoughts, which may be of a relatively trivial nature. Molehills may become mountains in these patients’ minds when an apparently insignificant issue develops into a cause of great concern.

A propensity to worry and overthinking is most commonly caused by, and may in turn cause, an Empty condition. A deficiency of Spleen-Qi or Spleen-Blood, or both, is the most commonly seen pattern leading to worry and overthinking. However, deficiency of Heart-Qi, Lung-Qi, Heart-Yin, or of Heart- or Liver-Blood, or both, may also lead to excessive worrying.

There are also cases where overthinking is caused by a mixed or Full condition, namely stagnation of Lung-Qi or Yin deficiency and Empty-Heat. Worry from a Full condition (such as Lung-Qi stagnation) is usually more intense and consuming than that from an Empty condition, which a patient may describe as more ‘lurking in the background’.

Box 44.6 summarizes patterns underlying worry and overthinking.

BOX 44.6   WORRY/OVERTHINKING

• Heart- and Spleen-Qi deficiency: worry, slightly obsessive thinking, slight depression, overthinking, Pale tongue, Empty pulse

• Lung-Qi deficiency: worry, depression, Pale tongue, Empty pulse

• Heart-Blood deficiency: worry, depression, Pale and Thin tongue, Choppy or Fine pulse

• Liver-Blood deficiency: worry which increases after the period in women, Pale tongue, Choppy or Fine pulse

• Heart-Yin deficiency: worry, insomnia, dream-disturbed sleep, poor memory, anxiety, propensity to be startled, mental restlessness, uneasiness, ‘feeling hot and bothered’, Floating-Empty pulse, especially on the left Front position

• Lung-Qi stagnation: worry, mild irritability, depression, a feeling of a lump in the throat, tongue slightly Red on the sides in the chest areas, pulse very slightly Tight on the right Front position

• Heart-Yin deficiency with Empty-Heat: worry, especially in the evening, anxiety, propensity to be startled, mental restlessness, uneasiness, ‘feeling hot and bothered’, Red tongue, redder on the tip, no coating, Floating-Empty and Rapid pulse

SADNESS/GRIEF

‘Sadness’, which pertains to the Lungs, must be distinguished from a ‘lack of joy’, which pertains to the Heart. Sadness is an emotional state that weakens the Lungs and usually manifests with Lung-related symptoms such as a pale complexion, a weepy and weak voice. Lack of joy, on the other hand, is not an actual emotional state but a certain lack of vitality deriving from Heart deficiency; this manifests not with a sad demeanour, but with a flatness and lack of ‘fire’.

A patient may report a feeling of sadness, or may be unaware of it. A Full or Empty quality on the Lung pulse is usually the most reliable indication of whether sadness is involved in a presenting condition. I find that a Full Lung pulse often indicates sadness which has been held on to for a long time by the patient, who may be totally unaware of its presence. When the Lung pulse is Weak or Empty, I find the patient more likely to report feeling sad.

Sadness depletes Lung- and Heart-Qi; however, with time, the deficiency of Qi in the chest may also give rise to some stagnation of Qi in the chest. This stagnation is associated with the Lungs and Heart and not the Liver. It manifests with a slight feeling of tightness of the chest, experiencing the sadness in the chest, sighing and slight palpitations.

The most likely Empty patterns giving rise to sadness are a deficiency of Lung-Qi and Heart-Qi, Liver-Blood or Heart-Blood. When sadness is due to an Empty condition it is often accompanied by frequent crying. Sadness from Liver-Blood deficiency is more common in women and becomes worse after the period or after childbirth. Sadness with a feeling of lump in the throat may be due to Lung-Qi stagnation.

Grief is akin to sadness and usually derives from loss, separation or bereavement. Like sadness, it depletes Lung- and Heart-Qi but, with time, it may also give rise to some stagnation of Qi in the chest causing similar symptoms to the ones mentioned above for sadness.

Case history 44.2 illustrates a pattern of grief underlying chest pain.

Case history 44.2

A 57-year-old woman presented with the main complaint of pain in the chest. As she was speaking, I observed that her eyes were quite lustreless and lacking in shen. This always points to an emotional origin of the problem. I asked her how long she had had the chest pain and she replied that it had started after her husband’s death a few years before.

Her tongue was Swollen with a red tip and her pulse was slightly Slippery but very slightly Tight on the Lung position.

Diagnosis:

This is a very good example of the effect of grief. The grief from her husband’s death had caused initially a deficiency of the Heart and Lungs; with time, this had caused some stagnation of Qi in these two organs. The stagnation of Heart-Qi manifested with a red tip of the tongue while the stagnation of Qi in both Heart and Lungs caused the chest pain. As this condition was long-standing, the depletion and simultaneous stagnation of Lung-Qi had disrupted the movement and transformation of Qi and fluids, giving rise to some Phlegm in the chest which contributed to the chest pain. The Phlegm was indicated by the swelling of the tongue and the Slippery pulse.

This patient had an interesting emotional reaction to the treatment which is worth reporting. I used a simple treatment needling PE-6 Neiguan on one side, LU-7 Lieque on the other, Ren-12 Zhongwan and ST-40 Fenglong. A few days after the treatment she went to the graveyard to visit her husband’s grave for the first time since his death and she cried. She had obviously repressed her grief for many years and this had caused the stagnation of Qi of the Heart and Lungs in the chest. Another emotional reaction a few days after the treatment was that for the first time she experienced anger at work. This is also interesting as, just as there is a controlling relationship between Wood and Metal, there is one between their allied emotions (i.e. anger and sadness/grief). Obviously the release of Qi stagnation in Metal had stopped excessive control of Metal over Wood and led to an explosion of anger. Moreover, each emotion can counteract another across the reverse Controlling (Ke) cycle of the Five Elements; that is, anger (Wood) counteracts sadness (Metal), joy (Fire) counteracts fear (Water), pensiveness (Earth) counteracts anger (Wood), etc.

Box 44.7 summarizes the patterns underlying sadness and grief.

BOX 44.7   SADNESS/GRIEF

EXCESS JOY

Of course, few patients will report feeling excessively joyful! A normal state of joy is obviously not a cause of disease. Several emotional states are included under the term of ‘excess joy’. First, it includes the sudden state of extreme elation deriving from joyful news. This makes Qi rise and it expands the Heart. Secondly, excess joy can be interpreted as a life characterized by excessive excitement and stimulation. This also causes Qi to rise and may lead to Heart-Fire. Thirdly, excess joy is seen in certain mental conditions such as hypomania or manic behaviour.

The negative effect of excess joy can be easily observed in young children. Every mother knows that a period of extreme playfulness, hyperactivity and laughing is frequently followed by tears.

A Full pattern of the Heart is most likely to cause excess joy. Phlegm-Fire harassing the Heart may cause the most severe cases of excess joy; that seen in mental diseases such as bipolar disorder is a typical example of this. However, Phlegm-Fire does not necessarily always cause severe symptoms. It may be seen relatively frequently in milder forms when it causes excessive and inappropriate laughter, bouts of excess joy and hyperactivity. Heart-Fire may also cause a permanently elated mood.

Phlegm-Fire harassing the Heart does not always manifest with severe mental symptoms.

Empty-Heat of the Heart may also lead to excess joy and a feeling of being driven and not being able to stop.

Box 44.8 summarizes the patterns underlying excess joy.

BOX 44.8   EXCESS JOY

MENTAL RESTLESSNESS

‘Mental restlessness’ is a translation of the term Fan Zao, which literally means ‘vexation and restlessness’. It also includes restless legs. The term Fan Zao encompasses two different symptoms: Fan (vexation) is due to Full-Heat and pertains to the Lungs, whereas Zao (restlessness) is due to Empty-Heat and pertains to the Kidneys. Fan is Yang whereas Zao is Yin.

A patient is unlikely to use the term ‘mental restlessness’ but may describe having ‘difficulty in concentration’, ‘not being able to focus on one thing for any length of time’ or ‘not being able to sit still and do nothing’.

Yin deficiency with Empty-Heat may cause a vague feeling of mental restlessness which worsens in the evening. Phlegm-Heat in the Stomach or Heart, or both, or Heart-Fire, will cause a more intense feeling which may be accompanied by mental confusion. Mental restlessness may also be caused by Lung-Heat, in which cause it will be accompanied by worry and other Lung symptoms such as breathlessness or cough.

Box 44.9 summarizes the patterns underlying mental restlessness.

BOX 44.9   MENTAL RESTLESSNESS

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