Application of Traditional Chinese Medicine in the Diagnosis and Treatment of Depression
THE TREATMENT OF PATTERNS OF DISHARMONY INVOLVED IN DEPRESSION
The absence of understanding of the disease mechanisms that precipitate the patterns and of the rationale for point selection will provide, at best, a mechanical cook-book approach to treatment that will fail to address the complexity of depression as experienced by most people.
Based on the proposed framework, depressive episodes are generally characterized by the combination of various patterns. To deter-mine the disease mechanisms relevant to the different pattern combinations, one needs to evaluate to what extent the following four features are present in each person:
- Qi stagnation, stemming from the liver’s inability to perform its function of coursing and discharge
- Shen disturbance, arising from the heart’s inability to perform its function of housing the spirit (shen) due to either vacuity or repletion
- Yin features including (a) qi and yang vacuity (yang) and/or (b) repletion of dampness and phlegm (yin)
- Yang features including (a) yin and blood vacuity (yin) and/or (b) repletion of heat or fire (yang).
In addition, one needs to identify which specific viscera and bowels are involved. Generally, a person experiencing depression does not fit only one pattern, and similarly does not present with an imbalance in only one viscus or bowel. It is common clinically to encounter a complex combination of patterns which includes elements of these four features. The particular complex pattern combination will determine the treatment principles and the individually tailored treatment plan. For example, a person might present with: (1) stagnant liver qi, trans-forming into heat (depressive heat), and (2) heart blood vacuity, and (3) spleen qi vacuity. The pattern then will be: liver depression transforms heat, heart—spleen dual vacuity. The treatment principles will be: course the liver and rectify the qi, clear heat and resolve depression, fortify the spleen and nourish the heart, boost the qi and supplement the blood.
Traditionally, the disease mechanisms are evaluated first, then the patterns and combination of patterns are determined, then the treat-ment principles are outlined, and finally a treatment plan is designed. Some of the patterns emerging from the four features mentioned above, and some pattern combinations, are particularly relevant in depression, while others are not. To facilitate pattern differentiation and to clarify the disease mechanisms underlying depression, the pat-terns that become the building blocks for more complex patterns will first be reviewed. Within the description of each pattern, the natural progression of depression patterns will be described, and then common pattern combinations may be listed under ‘special consider-ations’ for that pattern. Then the 12 most commonly encountered basic and combined patterns that precipitate depression will be listed.
At the end of this post there is a summary that presents this information in condensed form for easy reference.
The main basic patterns involved in major depression are:
1. Qi stagnation
- Liver depression qi stagnation
- Liver depression transforms heat
- Qi stagnation affecting the heart and lung
- Blood stasis and stagnation
2. Shen disturbance: vacuity
- Heart blood vacuity
- Heart qi vacuity
- Heart yin vacuity
- Heart fire flaming upward (heart yin vacuity with vacuity heat)
3. Shen disturbance: repletion
- Qi stagnation affecting the heart and lung
- Depressive heat affecting the heart or lung
- Exuberant heart fire
- Phlegm confounding the heart (orifices)
- Phlegm (heat) fire harassing the heart
4. Qi/yang vacuity
- Spleen/lung qi vacuity
- Spleen yang vacuity
- Kidney qi vacuity
- Kidney yang vacuity
5. Dampness and phlegm
- Spleen vacuity, dampness accumulation
- Phlegm confounding the heart (orifices)
- Heart vacuity, gall bladder timidity
- Phlegm dampness obstruction and stagnation
- Phlegm fire harassing the heart
6. Blood/yin vacuity
- Heart blood vacuity
- Liver blood vacuity
- Liver yin vacuity
- Kidney yin vacuity
- Lung yin vacuity
7. Yang repletion and vacuity heat
- Liver depression transforms heat
- Hyperactivity of liver yang
- Liver fire flaming upward
- Yin vacuity, fire effulgence (vacuity heat)
- Spleen vacuity giving rise to fire (yin fire)
Much of the material concerning the specific patterns derives from two comprehensive sources: Finney & Flaws (1996) and Maciocia (1994). Information concerning symptoms specific to depression has been adapted from clinical observation and integrated with the material from these sources to produce the protocol outlined below.
Liver depression qi stagnation
Disease causes, disease mechanisms: Emotional stress, anger, and frus-tration cause the liver to lose its ability to regulate coursing and discharge; there is emotional depression and lack of smooth flow of the qi mecha-nism.The qi becomes stagnant along the pathway of the liver channel, which traverses the lower abdomen and stomach, and spreads across the chest and sides of the ribs. One may see abdominal and chest oppression, pain along the ribs; if the liver attacks the stomach, the stomach loses its harmony and downbearing; there may be epigastric oppression, belching and burping, possibly nausea and vomiting; if it affects the spleen, there is loss of appetite, abdominal distension, and diarrhea.
Main symptoms: Chest, lateral, costal, breast and abdominal distension and oppression, sighing, dysmenorrhea, irregular menstruation, premenstrual tension, a feeling of a lump in the throat; nausea, vomiting, hiccups, burping, belching, if the liver is invading the stomach.
Symptoms associated with depression: Irritability, mental depression, moodiness, feeling wound-up, alternation of moods, snapping easily, and an intense feeling of frustration.
Tongue: Normal or slightly dark, thin coating.
Treatment principles: Course the liver, rectify the qi, and resolve depression. Main acupuncture points: Lv 3, L I 4.
Additional points: Lv 14, UB 18.
n For chest and breast distension and pain: Ren 17 or Sp 21
n For lower abdominal distension or pain: Ren 6, Ren 4, St 28, St 29
n For hypochondriac distension and pain: Lv 14
n For epigastric fullness and distension: Ren 12.
Special considerations: Only in very acute and uncomplicated depressive episodes may liver depression qi stagnation cause depression all by itself. Liver depression qi stagnation usually combines with, and aggravates, pre-existing tendencies towards imbalances in other viscera and bowels. The specific mechanisms triggered by a failure in the functions of coursing and discharge determine the individual’s symptoms of depression, the nature and duration of the depressive episode, and the prognosis and outcome of the treatment. However, most major depressive episodes seem to involve liver depression qi stagnation as a significant component. In dysthymia as well as recurrent, chronic, and recalcitrant depression, liver depression qi stagnation seems to precipitate phlegm obstruction and blood stasis, and/or occurs on a background of long-standing constitutional insufficiency.
Liver depression transforms heat
Disease causes, disease mechanisms: Extreme or long-term stagnation of liver qi will eventually transform into heat. Because heat is yang in nature, it tends to counterflow or move upwards, negatively affecting the function of organs (stomach, heart, and lungs) and tissues (head, mouth, nose, ears, and eyes) located above the liver. In addition to symptoms of qi stagnation, there will be symptoms of heat. This heat can force the blood to move recklessly, outside its pathways. Because the spirit resides in the heart, upwardly counterflowing depressive heat may disturb the heart spirit, causing it to become restless. (See below under Depressive heat affecting the heart or lung.)
Main symptoms: Insomnia, excessive dreams, chest oppression, agitation, red eyes, red facial complexion, acne, heart palpitations; breast distension but more prominent pain, hypersensitive nipples; bitter taste in the mouth, thirst; early or excessive menstruation, dysfunctional uterine bleeding.
Symptoms associated with depression: Irascibility, easy anger, impetu-osity, mental restlessness, aggression, violent outbursts of anger.
Pulse: Wiry and rapid.
Tongue: Darl< and red and/or swollen edges, with a thin yellow coat. Treatment principles: Course the liver and rectify the qi, clear heat, and resolve depression.
Main acupuncture points: UB 18, UB 15, Lv 2 and Lv 3, LI 4, LI I 1, P 7, Ht 5. Additional acupuncture points: Add points to settle the heart and calm the spirit, and/or points to open the chest and stimulate the descending of lung qi.
Special considerations: When enduring or severe liver depression trans-forms into heat or fire, this heat is known as depressive heat. In addition to anger and frustration, any of the seven emotions may transform into fire, if extreme. Depressive heat may be aggravated by heat accumulating in the stomach due to eating hot, spicy, and greasy fatty foods or drinking alcohol. lf, in addition to liver depression qi stagnation, there is dampness and phlegm due to spleen vacuity, the stomach may further lose its ability to digest the food, and food may accumulate. It is not uncommon to find symptoms of food stagnation such as bad breath, nausea, indigestion, thick, slimy tongue fur, and a slippery pulse complicating other patterns. As we age, depression transforms into heat more readily; heat and fire tend to evaporate and consume blood and yin, and aggravate the natural predisposition to yin vacuity that is part of the process of aging.
Qi stagnation affecting the heart and lung
Disease causes, disease mechanisms: When sadness and grief remain for a long time they deplete the qi and lead to qi stagnation in the chest, which is ruled by both the heart and the lungs.Worry knots the qi and can also give rise to this pattern.
Main symptoms: A feeling of oppression and tightness in the chest, palpi-tations, sighing, slight breathlessness, a feeling of a lump in the throat with difficulty swallowing, pale complexion.
Symptoms associated with depression: Sadness, a tendency to weep, accompanied by anxiety, easily affected negatively by the problems of other people.
Pulse: Weak, with no wave, specially in the cun position both sides. It may also be slightly wiry, although at the same time it is vacuous and weak. Tongue: It can be slightly red in the chest area (sides of its central section). Treatment principles: Rectify and move the qi, stimulate the descending of heart and lung qi, and calm the spirit.
Main acupuncture points: Lu 7, Ht 7, P 6, Ren 17, Ren I 5.
Additional points: St 40, LI 4, SI 5, GB I 8.
Special considerations: This pattern is characterized by underlying lung qi vacuity, and possibly by heart blood vacuity in combination with liver depression.The qi stagnates primarily in the chest area, affecting the lung’s function of governing qi (breathing and production of true qi) and to some extent the heart’s function of governing blood (movement of blood), which are complementary to each other.There may be slight dampness or phlegm accumulation due to both lung and spleen qi vacuity. The difference between this pattern and depressive heat affecting the heart and/or lungs is that, in this case, the vacuity is more prominent and there is very slight or no depressive heat.
Blood stasis and stagnation
Disease causes, disease mechanisms: Enduring or severe liver depres-sion may lead to an inability of the qi to move the blood; the blood becomes static because the qi is stagnant, so there is a combination of signs and symp-toms of liver depression qi stagnation and symptoms of blood stasis.
Main symptoms: Abdominal distension, stabbing, fixed pain, formation of masses or swellings, dark purple, clotted bleeding (specially vaginal); dark complexion, rough, dry, and lusterless skin, with red speckles or purple macules, spider veins, prominent green-blue veins in the abdomen; in addi-tion to signs and symptoms of qi stagnation.
Symptoms associated with depression: Vexation, agitation, thoughts of suicide, severe insomnia; chronic, recalcitrant, or severe depression. Pulse: Fine, choppy.
Tongue: Dark, purple, with stasis speckles. Purple, distended veins under the tongue.
Treatment principles: Quicken the blood and transform stasis.
Main acupuncture points: UB 17, SP 10, SP 6, SP 8, Per 3.
Additional acupuncture points: Points used to course the liver and rectify the qi.
Special considerations: Blood stasis may result from long-standing liver depression not moving the blood, but it can also result from traumatic injury, from blood vacuity not able to nourish the vessels and keep them open, from qi vacuity not able to push the blood, or from cold congealing the blood. Because static blood hinders the creation of new or fresh blood, blood stasis may precipitate blood vacuity, and blood vacuity may precipitate blood stasis. If blood stasis is referred to the liver specifically, this means that the stasis is particularly manifest along the path traversed by the liver channel: the pelvic region, abdomen, chest, throat, and head. In depression, blood stasis either results from enduring liver depression qi stagnation or is a further complication of an underlying pattern. Blood stasis may complicate many cases of depression, especially in women who may often experience blood stasis as a factor in either the uterus, the breasts, or both.
Shen disturbance: vacuity
Heart blood and heart qi vacuity share several features in common. Before listing the features unique to each, the common features will be discussed. General symptoms for shen disturbance caused by either heart blood or heart qi vacuity: Insomnia, heart palpitations, mild anxiety, poor memory, mild dizziness, easily startled.
General treatment principle for heart blood or heart qi vacuity patterns: Nourish the heart and calm the spirit (boost the qi and sup-plement the blood).
Main acupuncture points for heart blood and heart qi vacuity patterns: UB 15, UB 44, Ren 14, Ren 15, Ht 7, P 6.
Heart blood vacuity
Disease causes, disease mechanisms: As a result of constitutional insufficiency, enduring disease, aging, blood loss, or prolonged sadness and grief, there may be insufficient blood to nourish the heart.
Main symptoms: Fright palpitations, restlessness, suspiciousness, insomnia with an inability to fall asleep, excessive dreams, mild anxiety, mild dizziness, propensity to be startled, dull pale complexion, poor memory, lassitude of the spirit.
Symptoms associated with depression: Depression with fatigue, confu-sion, lack of concentration.
Pulse: Fine, possibly choppy.
Tongue: Pale and thin, with a thin white coat.
Treatment principles: Nourish the heart and calm the spirit, supplement the blood.
Main acupuncture points: In addition to general points above, Ren 4, St 36, Sp 6, Sp 4.
Additional acupuncture points: UB I 7, Sp 10, P 7.
Special considerations: Because the spleen is the source of engender-ment and transformation of both qi and blood, heart blood vacuity is com-monly encountered in clinical practice in conjunction with spleen qi vacuity. This pattern is known as heart—spleen dual vacuity (refer to the section below on Spleen qi vacuity).
Shen disturbance: vacuity
Heart qi vacuity
Disease causes, disease mechanisms: Constitutional insufficiency, over taxation, too much thinking and worrying, sadness, grief and regret, endur-ing diseases, aging, blood loss.
Main symptoms: Shortness of breath and heart palpitations aggravated by exertion, insomnia, mild anxiety, poor memory, mild dizziness.
Symptoms associated with depression: Lack of motivation, fatigue and exhaustion, poor sleep.
Pulse: Fine, weak, regularly interrupted pulse.
Tongue: Pale with a thin white coating.
Treatment principles: Supplement the heart, nourish the blood, and calm the spirit.
Main acupuncture points: In addition to the main points above, Ren 4, St 36, Sp 6, Sp 4.
Additional acupuncture points: UB 20, UB 21, Du 20.
Special considerations: Heart qi vacuity is rarely seen by itself in actual clinical practice. Two subpatterns of heart qi vacuity in the Chinese Medicine literature are heart qi not securing (the spirit), characterized by confusion, impaired memory, easy fright, spontaneous perspiration on movement. The second subpattern is heart qi inability to lie down, when the heart qi is insufficient, the spirit will not be quiet, and it is difficult to lie down at night to sleep; the person is easily aroused from sleep, there are heart palpitations, a lack of strength, lassitude of spirit, aversion to cold, and a slow, forceless pulse.
Heart yin vacuity
Disease causes, disease mechanisms: Fear and worry combined with overwork for many years, aging, and congenital insufficiency may all lead to yin vacuity. In addition, enduring depressive heat may consume and evapor-ate blood and yin.
Main symptoms: Heart palpitations, insomnia (inability to stay asleep or wal<ing up frequently), propensity to be startled, poor memory and con-centration, anxiety, malar flush, night sweating, heat in the five centers, vex-ation and agitation, fidgetiness, uneasiness, restlessness, and a worsening of symptoms in the evening.
Symptoms associated with depression: Dispirited, depressed, and tired, yet anxious and restless at the same time; lack of willpower and drive. Pulse: Rapid and thin, or floating and vacuous.
Tongue: Red tongue, redder tip, without coating.
Treatment principles: Enrich yin, settle the heart, and calm the spirit. Main acupuncture points: UB 15, UB 44, Ren 14, Ren 15, Ht 7, P 6. Additional acupuncture points: P 7, Kd 6, Kd 3, Kd I 0, Sp 6.
Shen disturbance: vacuity
Heart fire flaming upward (heart yin vacuity with vacuity heat)
Disease causes, disease mechanisms: If depressive heat counterflows and accumulates in the heart, it may eventually consume and damage yin and blood, in which case yin will be unable to control heart yang which then becomes effulgent and hyperactive.
Main symptoms: Heart vexation, chaotic spirit, insomnia, excessive dreams, fright palpitations, racing heart, dryness of the mouth and throat, and flushing. In general, heart yin vacuity symptoms are more pronounced, anxiety and restlessness will be extreme, and the sleep will be more severely disturbed.
Symptoms associated with depression: Mentally, the person may become aggressive and very impatient.
Pulse: Floating or surging, in addition to being rapid and thready.
Tongue: Red, mirror with more pronounced redness of the tip.
Treatrnent principles: Enrich yin, clear heat, and drain fire; settle the heart and calm the spirit.
Main acupuncture points: Same as for yin vacuity above; in addition use Ht 6.
Special considerations: Heart fire flaming upward can be either a vacuity or repletion pattern, characterized by upper body signs (reddening of the tip of the tongue, vexation, cracking of the tongue, and erosion of the oral and glossal mucosa, rapid pulse). Here we are referring to heart fire due to heart yin vacuity, which is in turn due to kidney yin vacuity (heart—kidney not com-municating); it is therefore necessary to supplement the kidney in order to enrich yin.As a repletion pattern, heart fire flaming upward is due to hyper-active heart fire, which in turn is due to liver fire (see below underYang reple-tion patterns); in that case there is headache, red eyes, agitation, and irascibility in addition to the symptoms above. Heart fire may also spread to the small intestine, where it manifests as painful, dribbling, reddish urination.
Shen disturbance: repletion
Qi stagnation affecting the heart and lung
This is a repletion pattern that stems from a progression of liver qi stagna-tion, and is therefore discussed under Qi stagnation above.
Depressive heat affecting the heart or lung
This is also a repletion pattern that develops from qi stagnation transforming into heat; the disease causes, disease mechanisms, treatment principles, and points are discussed above under Liver depression transforms heat. Depressive liver heat due to emotional stress and frustration may travel upwards and accumulate in the heart and lungs. If it accumulates in the heart, it causes vex-ation, agitation, anxiety, insomnia, and restlessness. If it accumulates in the lungs, it causes weepiness and sadness.
Exuberant heart fire
Disease causes, disease mechanisms: Fire in the heart develops from below. It is either due to enduring emotional stress and frustration, which cause the ministerial fire to stir up and counterflow, or it is due to overeating sweet, greasy, spicy food and drinking alcohol, which cause spleen damage that leads to yin fire counterflow.
Main symptoms: Heart vexation, agitation, insomnia with excessive and disturbing dreams, racing heart, restlessness that is projected outward or is accompanied by compulsive behavior; ulcers in the mouth and on the tongue; frequent, urgent, yellow urination, dry stools, red face, red, painful, swollen, skin sores.
Symptoms associated with depression: Recurrent suicidal ideation, possibly with suicidal attempts; aggression, violent outbursts; if severe, manic agitation and delirious speech.
Pulse: Rapid, wiry, and possibly slippery or surging pulse.
Tongue: Red with a yellow coat.
Treatment principles: Clear the heart, drain fire and lead it downward, and settle the spirit.
Main acupuncture points: Ht 8, Ht 5, P 7, Ren I 5, GB I 5, Sp 6.
Additional acupuncture points: Du 14, LI 4, LI I I, P 8, Ht 3.
Phlegm confounding the heart (orifices)
Phlegm (heat) fire harassing the heart.
Qi and yang vacuity tends to occur as a continuum, because yang is generated by the movement of qi.Yang vacuity usually implies that, in addition to signs and symptoms of qi vacuity, there is also the presence of cold.
Spleen qi (and lung qi) vacuity
Disease causes, disease mechanisms: Overwork and prolonged stress; poor diet, overeating raw and chilled foods, or undereating; overthinking and too much worry over a long period of time; chronic illness, lack of exercise.
Main symptoms: Fatigue, weakness, lethargy, loose stools, poor appetite, pale face, faint voice.
If lung qi vacuity is also present: Shortness of breath, spontaneous sweating, cough, all aggravated upon exertion.
Symptoms associated with depression: Depression with fatigue, slow thinking and speaking, slow movements, poor memory and concentration, decreased motivation, diminished interest or pleasure, excessive desire to sleep, apathy, excessive guilt, obsessive thinking or phobias, lassitude of spirit.
Pulse: Relaxed, or soggy annd weak.
Tongue: Pale, swollen, with thin white coating.
Treatment principles: Boost the qi, fortify the spleen (and the lungs). Main acupuncture points: UB 20, UB 21, UB 49, Ren 4, Ren 6, Ren 12, St 36, Sp 3.
For lung qi vacuity: Add Lu I , Lu 9, Lu 7, UB 13, UB 42.
Special considerations: Too much work, or even too much exercise, may consume the qi and blood, whereas too little exercise causes the qi to become stagnant. A diet of too many raw, cold, chilled foods may exhaust the digestive fire of the spleen; too many sweets, dairy products, and fried foods may also damage the spleen.As explained above, liver depression may also give rise to or exacerbate spleen vacuity.The spleen is usually the first viscus to become diseased after the liver has become depressed. If the spleen becomes vacuous and weak, it will not engender and transform the qi and blood properly, leading to vacuity of both heart blood and spleen qi (heart—spleen dual vacuity). If heart blood is too vacuous to nourish and quiet the spirit, the spirit may become hyperactive and restless, or it may be unable to engage the world and respond to the environment.
Spleen yang vacuity
Disease causes, disease mechanisms: Enduring spleen qi vacuity or severe damage due to enduring disease; aging, or overeating raw, chilled foods.
Main symptoms: In addition to spleen qi vacuity symptoms above; edema, cold body with chilled extremities, abdominal distension and fatigue after eating, dull abdominal pain that likes warmth and pressure.
Symptoms associated with depression: More pronounced symptoms than in spleen qi vacuity.
Pulse: Sunken, forceless, or even slow.
Tongue: Swollen and pale, with teeth marks on the borders; a thin, white, slightly slimy coat.
Treatment principles: Supplement the qi and warm the spleen.
Main acupuncture points: Same as for spleen qi vacuity above. Moxa is applicable.
Kidney qi vacuity
Disease causes, disease mechanisms: Constitutional insufficiency, aging, or chronic disease; enduring spleen qi vacuity.
Main symptoms: Low back and knee soreness and weakness, premature graying or loss of hair, impotence or frigidity, uterine prolapse with weak-ness in the low back, frequent urination, night urination, tinnitus, dizziness, diminished auditory acuity.
Symptoms associated with depression: Mental and physical exhaustion, no willpower or initiative; hopelessness about getting better or starting or changing anything. Everything is too much effort.
Treatment principles: Nourish the kidney and supplement the qi. Pulse: Deep and weak.
Tongue: Pale red tongue.
Main acupuncture points: UB 23, UB 52, Du 4, Ren 6, Kd 3, Kd 7.
Qi/yang vacuity Kidney yang vacuity
Disease causes, disease mechanisms: Constitutional insufficiency. aging, or chronic disease; overwork, excessive sexual activity, or drug use.
Main symptoms: In addition to the symptoms for kidney qi vacuity above: a cold feeling in the lower part of the body, lower abdominal tension, inhib-ited or excessive urination, early morning diarrhea.
Symptoms associated with depression: In addition to the symptoms for kidney qi vacuity above, the person will be extremely exhausted and will lack spirits.
Treatment principles: Nourish the kidney and warm yang.
Pulse: Deep and fine in the first (chi/foot) position.
Tongue: Pale, fat, with a thin, moist coating.
Main acupuncture points: UB 23, UB 52, Du 4, Ren 6, Kd 3, Kd 7. Moxa is applicable.
Special considerations: Kidney vacuity is rarely seen alone in clinical prac-tice; rather, it commonly combines with spleen qi vacuity to create the pattern spleen—kidney dual vacuity.Yang causes transformation and change; it activates and moves, and grants us the capacity to react and respond. Constitutional insufficiency, enduring disease, aging, and overwork can all lead to yang becoming vacuous. Kidney is the root of both yin and yang, providing the foundation of our life and the source of both yin and yang for all the other organs.Yang vacuity can therefore lead to vacuity of the yang of the spleen; conversely, long-standing spleen qi vacuity will lead to a deple-tion of kidney yang. Yang is like the fire under a kettle, if the fire is insufficient, the water in the kettle will tend to stagnate, creating a state of sogginess, congestion, inactivity, and a feeling of being frozen. Depression characterized by spleen—kidney dual vacuity will manifest as exhaustion, lack of will power and initiative, as well as hopelessness. Prolonged fear, shock, and guilt may all injure the kidney and cause this condition; but yang vacuity due to other causes can also result in fear and guilt.
Yin repletion: dampness and phlegm Spleen vacuity, dampness accumulating
Disease causes, disease mechanisms: Due to constitutional insufficiency, chronic disease, faulty diet, overwork and too much stress, too much think-ing and worry, the spleen qi may be insufficient to transport and transform liquids. It is also possible for external dampness to invade the body, causing damage to the spleen.
Main symptoms: Edema, dizziness, headache, fatigue, chest and epigastric fullness, and oppression, nausea, vomiting, diarrhea with white mucus: frequent but scanty urination; a slimy, sweet taste in the mouth.
Symptoms associated with depression: In addition to spleen qi vacuity symptoms above, mental confusion will be more severe and obsessive thinking will be more pronounced.
Pulse: A soggy, fine, and wiry pulse or a slippery, relaxed pulse.
Tongue: A swollen, pale tongue, with teeth marks on its edges and a thin, slimy, white coat.
Treatment principles: Fortify the spleen and transform dampness.
Main acupuncture points: In addition to points used to fortify the spleen above, add Sp 5, Sp 9, Ren 9.
Yin repletion: dampness and phlegm
Phlegm confounding the (orifices of the) heart
Disease causes, disease mechanisms: This pattern in mostly due to spleen vacuity and dampness engendering phlegm plus liver depression qi stagnation resulting in upward counterflow; the counterflow drafts the phlegm upwards causing mental confusion and disorientation.When such phlegm causes blockage of the flow of qi and blood to the heart, the spirit becomes much more upset. The spleen vacuity is due to a faulty diet, excessive worrying, overwork, and overthinking; the liver depression is due to anger and frustration. In addition, there may or may not be heart blood vacuity, further complicating the inability of the heart to house the spirit.
Main symptoms: Dizziness, excessive white phlegm, a feeling of oppression in the chest; no desire to eat, the sound of phlegm in the throat.
Symptoms associated with depression: Mental confusion, poor memory, withdrawal. lf severe, loss of insight and total mental confusion, obsessive thinking and rumination.
Pulse: Slippery and wiry, possibly bound.
Tongue: A thick, white, slimy tongue coating.
Treatment principles: Eliminate phlegm and open the orifices of the heart.
Main acupuncture points: St 40, P 5, P 6, P 7, LI 7, LI 4, St 25, Du 20, St 8. Additional acupuncture points: Add points that fortify the spleen, boost the qi, transform dampness, and rectify the qi.
Special considerations: This pattern occurs in several different diseases such as withdrawal disease and epilepsy. Traditionally, when this pattern refers to depression, it is characterized by severe mental confusion and dis-orientation, gradual appearance of abnormal behavior and dementia; this picture is more lil<ely to be seen in patients presenting with depression with psychotic features. It is quite common, however, to encounter a milder form of this pattern in major depressive episodes.The treatment principles and treatment strategies outlined above are extremely helpful in treating major depressive episodes characterized by the presence of dampness and phlegm affecting the spirit (shen).
Yin repletion: dampness and phlegm Heart vacuity, gall bladder timidity
Disease causes, disease mechanisms: Spleen vacuity causes, simultane-ously, dampness and phlegm on the one hand, and blood vacuity on the other. Because the spleen qi is weak, the blood is not produced sufficiently to nourish the heart spirit, which becomes restless; the heart and lung qi are also vacuous as a result of the spleen qi being weak.At the same time, there is liver depression qi stagnation and possibly counterflow.
Symptoms associated with depression: Difficulty making decisions, lack of courage and sense of direction in life, easily startled, susceptibility to fright and fear.
Pulse: Vacuous and weak, it may be slippery in the second (guan/bar) position. Tongue: Swollen and pale, moist coating.
Treatment principles: Warm the gall bladder, nourish the heart, and quiet the spirit.
Principal acupuncture points: GB 40, Ht 7.
Phlegm dampness obstruction and stagnation
Disease causes, disease mechanisms: The causes for this pattern are the same as those for phlegm obstructing the spirit. lf in addition following the path of the liver channel, the qi becomes bound in the chest, it affects the heart and lung and causes a feeling of oppression in the chest; if the qi accumulates and counterflows, it may cause a feeling of something being stuck in the throat. In this case, phlegm and qi loin and obstruce.
Main symptoms: A feeling of oppression in the chest or the feeling of something stuck in the throat that can be neither spat out nor swallowed down; the person may simply experience a feeling of constant postnasal drip. Excessive phlegm that is white in color and easily expectorated, nausea, possibly vomiting, fatigue, excessive desire to sleep, possibly vertigo and palpitations.
Symptoms associated with depression: Mental confusion, tendency to ruminate and obsessive thinking, irritability and frustration.
Pulse: Wiry and slippery.
Tongue: White, slimy tongue coat.
Treatment principles: Transform phlegm, disinhibit the qi, and resolve depression.
Main acupuncture points: St 40, P 5, P 6, P 7, LI 17, LI 4.
Additional acupuncture points: Ren 17, Sp 21, St 12, GB 17, GB 18.
Yin repletion: dampness and phlegm Phlegm fire harassing the heart
Disease causes, disease mechanisms: Basically the same as for phlegm obstructing the spirit (above), except for the addition of heat or fire arising from liver depression, qi stagnation.
Main symptoms: Emotional tension, heart vexation, agitation, red face and eyes, incessant talking, insomnia, bitter taste in the mouth, excessive or profuse yellow phlegm, chest oppression, constipation, aversion to food, burping, belching, acid regurgitation, possible nausea, vertigo, dizziness.
Symptoms associated with depression: Phlegm fire both mists and agi-tates the spirit. The phlegm aspect causes mental confusion, profound apathy and fatigue, poor memory; the fire aspect causes agitation, insomnia, anxiety, and in severe cases manic behavior.
Pulse: Wiry, large, rapid, slippery, possibly urgent.
Tongue: Crimson red with a thick slimy, yellow coat.
Treatment principles: Transform phlegm, clear heat, harmonize the stomach, and quiet the spirit.
Main acupuncture points: St 40, GB 15, L I, Lv 2, Ht 5, Ht 8, GB 18.
Special considerations: This mechanism is a further progression of the two mechanisms above. In this case, however, depression has endured long enough or is severe enough for liver depression to turn into depressive heat or fire.Thus there is phlegm blocking the orifices of the heart at the same time as there is fire disturbing the heart spirit. In this case, the person may alternate between periods of depression and confusion due to phlegm, and periods of abnormal elation or agitation, due to fire.This pattern, which when severe may correspond to manic depression, is very helpful in under-standing the disease mechanisms that precipitate depression. It is actually extremely common to find depressive heat concomitant with dampness and phlegm accumulation. The degree of liver depression, heat or fire, and dampness or phlegm varies widely; generally, people presenting with this pattern either alternate or experience simultaneously symptoms of damp-ness and phlegm, such as profound apathy and lethargy, and symptoms of heat and fire, such as anxiety and agitation. Phlegm dampness obstruction and stagnation, phlegm obstructing the orifices of the heart, and phlegm fire harassing the heart lie along a continuum of a series of patterns; these pat-terns derive from dampness accumulation due to spleen vacuity, in combi-nation with liver depression qi stagnation. Manic depression is a severe manifestation of this pattern, but unipolar depression accompanied by anxiety, agitation, and aggression may also be a result of this mechanism.
Additional comment on the dampness and phlegm patterns
The five depression patterns above are aggravated by faulty diet and emo-tional stress. Any food or drink that either damages the spleen or gives rise to more phlegm and dampness will make this disease mechanism worse. Similarly, any emotional stress or frustration mal<ing the person’s liver more depressed and the qi more stagnant will exacerbate this disease mechanism.
Yin and blood vacuity are considered a continuum because blood is part of yin, with the exception that blood vacuity patterns do not in themselves give rise to heat.Therefore, one important differentiation between these two pat-terns is the presence or absence of heat.Yin vacuity and its effects on depres-sion depend on whether yin vacuity has given rise to vacuity heat. lf there is yin vacuity only, without vacuity heat, the spirit becomes weakened and the person feels depressed, tired, and dispirited; there is mental confusion and the memory and concentration are poor.When, in addition, there is vacuity heat as a result of yin vacuity, the spirit is not only weakened but is also unsettled; the person additionally experiences anxiety and mental restlessness.
Heart blood vacuity
Liver biood vacuity
Disease causes, disease mechanisms: Congenital insufficiency, chronic disease, aging, excessive blood loss, prolonged anger.
Main symptoms: Mild dizziness, numbness of the limbs, early insomnia (inabil-ity to fall asleep), blurred vision, floaters in the eyes, scanty menstruation or amenorrhea, brittle nails, muscle spasms or cramps, dull pale complexion.
Symptoms associated with depression: Depression with fatigue, lack of sense of direction, in life and ‘vision’, confusion about own aims, fear of making decisions.
Pulse: Thin, may be choppy.
Tongue: Pale and thin, with thin white coating.
Treatment principles: Nourish the liver and supplement the blood. Main acupuncture points: UB 17, UB 18, UB 20, UB 47, Lv 8.
Liver yin vacuity
Disease causes, disease mechanisms: Congenital insufficiency, overwork, excessive blood loss, aging, excessive sexual activity or anger, frustration and resentment over a long period of time can give rise to this pattern.
Main symptoms: Poor memory, dizziness; dry eyes, skin, and hair; blurred vision or night blindness, insomnia with restless, interrupted sleep, heat in the five centers, tidal fever, flushed cheeks in the afternoon, tremors or con-tractions of the sinews and muscles, numbness of the limbs, fragile nails, lateral costal pain; early, scanty, or painful menstruation.
Symptoms associated with depression: Deep depression with a lack of purpose in life, confusion about objectives and aims, restlessness.A sensation of floating before falling asleep.
Pulse: Floating and empty, or fast and wiry.
Tongue: Red tongue with no coat, or pale with red sides and tip.
Treatment principles: Nourish the liver, enrich yin, settle the hun, and quiet the spirit.
Main acupuncture points: UB 18, UB 47, Lv 8, Sp 6, Kd 3, Ren 4.
Additional points: Du 24, GB 13.
Kidney yin vacuity
Disease causes, disease mechanisms: Constitutional insufficiency, age, chronic disease, overwork and prolonged emotional stress, excessive sexual activity, sequela of a febrile disease, excessive blood loss. Prolonged fear or guilt and sudden shock.
Main symptoms: Low back soreness and weakness, loss of hair, tinnitus or deafness, dizziness, low-grade afternoon fever, malar flushing, early mensiru-ation, uterine bleeding, amenorrhea. Insomnia with difficulty staying asleep.
Symptoms associated with depression: Depression with exhaustion, lack of willpower, feeling aimless; rigid mental attitude, restlessness, fidgety, despair.
Pulse: Deep, fine, and rapid.
Tongue: Red tongue, with a thin, yellow, scanty, dry or absent coating. Treatment principles: Supplement the kidney and enrich yin.
Main acupuncture points: UB 23, UB 52, Kd 3, Kd 6, Kd 14, Sp 6, Ren 4. Additional points: Kd 9, Kd 22, Kd 27.
Lung yin vacuity
Disease causes, disease mechanisms: Same as for kidney yin vacuity. Kidney yin vacuity and lung yin vacuity may give raise to each other or appear simultaneously. Lung yin vacuity may also be precipitated by sadness and grief.
Main symptoms: Same as for kidney yin vacuity, with the addition of dry cough with scanty phlegm, chronic low-grade sore throat, dry skin, with skin rashes.
Symptoms associated with depression: In addition to symptoms of kidney yin vacuity above, melancholy, sadness, and a tendency to hang on to the past nostalgically.
Pulse: Fine and floating.
Tongue: Red tongue with scanty coating.
Treatment principles: Supplement the lung (and kidney), enrich yin. Main acupuncture points: In addition to points for kidney yin vacuity, add UB 13, UB 42, Lu 9, Lu 5, Lu 7 (with Kd 6).
Yang repletion and vacuity heat
Liver depression transforms heat
As seen above, this pattern develops from liver depression qi stagnation, and is therefore described in full under that section.
Hyperactivity of liver yang
Disease causes, disease mechanisms: Kidney yin vacuity due to constitu-tional insufficiency, aging, long-term or severe disease, too much work, exces-sive sexual activity or sexual desire may give rise to hyperactivity of liver yang or ascendant fire. Anything that speeds up the body or pushes the body to prolonged excessive activity may lead to yin vacuity and yang hyperactivity, such as caffeinated drinks, recreational drugs, and too much exercise.Any of these can waste yin and stir yang hyperactively. Enduring stress may cause prolonged liver depression to transform into heat; this heat may eventually consume blood and body fluids, and damage yin. Depleted yin becomes unable to control yang, and yang counterflows upward, with symptoms of heat and repletion above and of cold and vacuity below.
Main symptoms: Headache, dizziness, vertigo, tinnitus, low back ache. Symptoms associated with depression: Pronounced irritability, palpita-tions, insomnia, and anxiety.
Pulse: Wiry and rapid.
Treatment principles: Pacify the liver and subdue rebellious yang; clear heat, quicken the blood, supplement and boost the liver and kidney.
Main acupuncture points: GB 20, Lv 2, Lv 3, LI I I ,Yintang.
Additional acupuncture points: Sp 6,TH 5, GB 43, Kd 3.
Special considerations: In depression, this pattern rarely occurs on its own. Generally, one encounters anxiety, agitation, and severe insomnia as manifestations of yin vacuity, fire effulgence, concomitant with spleen qi, kidney yang vacuity (spleen—kidney dual vacuity); the latter gives rise to dampness and phlegm, which precipitates some of the apathy, lethargy, and anhedonia characteristic of depression.
Yang repletion and vacuity heat
Liver fire flaming upward
Disease causes: Emotional stress, frustration, and anger may cause endur-ing liver depression, which transforms into heat. lf this heat becomes exac-erbated it can turn into fire and flare upward, affecting the Iiver and its associated channels and network vessels. Overeating hot, greasy, and fatty foods, and alcohol, can give rise to dampness, which precipitates downward to the liver channel and causes damp heat in the lower burner; the heat may also draft the dampness upwards in the form of phlegm, obstructing the heart and agitating the spirit.
Main symptoms: Red face and eyes, bitter taste in the mouth, dry mouth, headache, dizziness, tinnitus and deafness, scorching pain on the ribs.
Symptoms associated with depression: Very angry, prone to outbursts of anger, impatience, restlessness, irritability; insomnia with violent dreams, vex-ation, and agitation. lf the anger is harbored inside for many years, this may lead to depression, which looks like sadness and grief, but is in fact anger.
Pulse: Rapid and forceful, or rapid, slippery, and wiry.
Tongue: Red with a slimy yellow coat.
Treatment principles: Clear the liver and drain fire, quiet the spirit, and settle the hun.
Main acupuncture points: Lv 2, IN 3, UB 18, Sp 6, Du 18, Du 24, GB 13, GB 15.
Additional acupuncture points: Ht 5, Ht 8.
Yang repletion and vacuity heat
Yin vacuity, fire effulgence (vacuity heat)
Disease causes, disease mechanisms: ff, as a result of constitutional insufficiency, aging, enduring disease, overtaxation or excessive sexual activity, yin becomes insufficient, it may be unable to control yang, and therefore fire counterflows upward. In this case, the fire stems from yin vacuity and is severe.
Main symptoms: Night sweats, tidal fever, heat in the five centers, increased sexual libido, heart palpitations, malar flush, dizziness, tinnitus, fre-quent urination, with scant, yellow urine; red lips, dry throat; vertigo and dizziness; possibly seminal emission in men and irregular periods in women.
Symptoms associated with depression: Fearfulness, anxiety, restless-ness, insomnia, heart vexation, easy anger, symptoms worst in the evening, fidgetiness, hypersensitivity.
Pulse: Fine, rapid, and possibly floating, specially in the first (inch/cun) position.
Tongue: A red tongue with scanty yellow coating.
Treatment principles: Enrich yin, clear heat or drain fire, settle the heart, and calm the spirit.
Main acupuncture points: UB 23, Kd 3, Kd I 0, Sp 6.
Additional acupuncture points: Ht 6, SI 3.
Special considerations: The patterns hyperactivity of liver yang, yin vacuity—fire effulgence, vacuity heat or fire, and yin vacuity—heat effusion (not mentioned here) are all variations of a basic disease mechanism in which there is insufficiency of yin, and repletion of heat or fire due to or exacerbated by this insufficiency.Yin vacuity originates from the kidney and may affect the other viscera and bowels; the heat or fire may arise from the liver, the heart, or the stomach and consume yin; alternatively, it may arise from the yin insufficiency itself, and flare upwards or exacerbate an under-lying accumulation of heat.
Yang repletion and vacuity heat Spleen vacuity giving rise to fire (yin fire)
Disease causes, disease mechanisms: Overthinking and worry, over-working, faulty diet and poor eating habits damage the spleen; if the spieen fails to control transportation and transformation it gives rise to dampness which percolates downward and damages the liver and kidneys. Dampness accumulation often transforms into damp heat. Dampness damages the kidney yang and the heat of damp heat tends to float upward; yang loses its root in its lower source (kidneys) and also tends to surge upwards
Main symptoms: Fatigue, lassitude of the spirit, weak extremities, lower back ache, low sexual desire, incontinence of urine, cold extremities, possibly unusual vaginal discharge or genital itching, turbid urination.
Symptoms associated with depression: Sorrow, inexplicable weeping and crying, agitation, anxiety, and insomnia.
Pulse: Large. slippery, floating, and rootless, especially in the first (cun/inch) position.
Tongue: Swollen. tooth-marked, dark hue, thicker yellow coat in the back, red tip.
Treatment principles: Supplement the spleen, transform dampness, rectify the qi, and clear heat.
Main acupuncture points: Ren 4, Ren 6, Ren I 5, UB 20. UB 23, Sp 9. Sp 6. Ht S.
Additional acupuncture points: Depend on the specific presenting signs and symptoms.
Special considerations: This pattern is a result of the complex mecha-nisms known as yin fire.Yin fire is different from vacuity heat (effulgent fire due to yin vacuity).Yin fire is a condition where yin cold and dampness are generated by a damaged spleen. Due to overthinking and worry. over-working, or faulty diet and eating habits, the spleen fails to controi trans-portation and transforrnation.The turbid portion of foods and liquids is not separated from the clear, and this becomes damp turbidity.This damp tur-bidity, which is yin, percolates downward, damaging the liver and kidneys. Because the host qi of the body is yang, yang turbidity often transforms into damp heat; dampness damages kidney yang, and both the heat of damp heat and the yang of the kidney tend to float and surge upwards. Usually there are syrnptoms of cold (and possibly also damp heat) in the lower body, as well as symptoms of heat in the upper part of the body, with other symp-toms manifesting as weakness of the spleen. ln the case of depression, this fire can either disturb the lungs giving rise to sorrow, inexplicable weeping, and crying. or it can disturb the heart giving rise to agitation, inappropriate laughter, and insomnia. This heat can also affect the stomach, precipitating insomnia and in severe cases manic symptoms.
The 12 Main Basic Patterns and Pattern Combinations
Basic patterns and pattern combinations
I. Liver depression qi stagnation
- Liver depression transforms heat (including depressive heat affecting the heart and lung)
- Liver qi stagnation affecting the heart and lung
- Liver stagnation and stasis
- Heart—spleen dual vacuity (heart blood—spleen qi vacuity)
- Spleen—kidney dual vacuity (spleen qi—kidney yang vacuity)
- Phlegm confounding the orifices of the heart
- Heart vacuity, gall bladder timidity
- Phlegm dampness obstruction and stagnation
I O. Phlegm fire harassing the heart I I. Yin vacuity, fire effulgence
12. Spleen vacuity giving rise to fire
STRATEGIES AND TECHNIQUES
Points, Point Combinations, and Their Use in Major Depression
Patterns of disharmony rarely, if ever, happen on their own. Clinically, a combination of two or more patterns forms a complex web of inter-actions and interrelations. In depression, the combination of patterns incorporates elements of the four features on which this framework is based: (1) qi stagnation, (2) shen disturbance (vacuity or repletion), (3) vacuity of qi/yang and/or repletion of dampness/phlegm, (4) vacuity of yin/blood and/or repletion of heat/fire.
To arrive at a set of treatment principles and develop a treatment strategy, the patterns of disharmony involved, as well as their interac-tions and interrelations, must be identified. This is where the skill of the practitioner comes into play: to weave all the pertinent informa-tion into a complete symptom picture and, with this information, develop a treatment approach.
The assessment questionnaire developed for the study (see Appendix A) outlines the main symptoms for each pattern; because it is not a linear process, some overlap and some omissions are inevitable. The qualified practitioner takes this information to create a pattern of disharmony, and then uses this pattern as a guideline to develop a treatment protocol. The rationale for arriving at a particular treatment strategy needs to be outlined clearly. This is essential so that the practitioner can evaluate treatment progress; if the treatment fails, it will help the practitioner to determine why it may not be yielding the expected results. It is also important for allowing other practitioners to follow the rationale and assess the suitability of the diagnosis and treatment.
For example, assume a client presents with depression character-ized by depressed mood with both irritability and lethargy. Additionally she experiences breast distension, premenstrual exacer-bation of emotional lability, edema and fatigue after eating, insomnia with an inability to fall asleep, and an increased desire to sleep during the day; her pulse is wiry but also soggy in the second position on the right, and her tongue is swollen, pale, with darker sides and a red tip.
The first step involves differentiation of signs and symptoms:
n depressed mood with both irritability and lethargy: liver depression qi stagnation, spleen qi vacuity
n breast distension, premenstrual emotional lability: liver depression qi stagnation
n edema and fatigue after eating: dampness accumulation due to spleen vacuity
n insomnia with an inability to fall asleep: heart blood vacuity
n increased desire to sleep: qi vacuity, dampness accumulation
n wiry pulse: liver depression qi stagnation
n soggy pulse in the second right position: spleen qi vacuity
n puffy pale tongue: spleen qi vacuity, blood vacuity
n darker sides of tongue: liver depression qi stagnation
n red tip of tongue: shen disturbance due to heat agitating the heart.
Second, identify the pattern(s) of disharmony. This combination of signs and symptoms points to liver depression qi stagnation, heart—spleen dual vacuity, dampness accumulation due to spleen vacuity.
Third, establish the treatment principles. Course the liver, rectify the qi, and boost the qi, strengthen the spleen, nourish the heart (and blood), and calm the spirit.
Finally, select the points:
n to course the liver, rectify the qi: LV 3 and LI 4
n to boost the qi and strengthen the spleen: Ren 4, St 36, UB 20, SP 6
n to nourish the heart and calm the spirit: UB 15, Ht 7, P 6.
A first treatment, then, might include the following points: Lv 3 bilateral, LI 4 on the right, P 6 on the left, HT 7 on the left, Ren 4, ST 36 bilateral, Sp 6 bilateral.
The decision to needle the points contralaterally’ instead of bilater-ally is made on the basis of the clinical findings (signs and symptoms, tongue, pulse). The treatments and the sequence of treatments throughout the sessions are selected on the basis of severity and number of symptoms for each category (i.e. qi stagnation, shen disturbance, qi vacuity), as well as on the basis of an understanding of the disease mechanisms that precipitate specific patterns. Points are selected for their specific actions and their most effective combinations.
GUIDELINES FOR TREATMENT DESIGN
The points listed under each pattern above are given only as guidelines to address the treatment principles. To design successful treatments, one must choose from the lists of points and create effective point combinations, which address the specific pattern interactions for each client. The point functions and indications are based on The Practice of Chinese Medicine (Maciocia 1994).
Within the parameters of a research study, and in order to facilitate reliability and replica bility, clear guidelines must be established in the selection of points. Furthermore, needling techniques must be stan-dardized and consistent (neutral stimulation being the most easily replicable technique in a research setting). Without the additional benefit of specific needling techniques, effective point combinations are even more essential. The guidelines for point selection and needling techniques must allow the practitioner sufficient flexibility to provide an individually tailored treatment, while keeping in line with the stated framework.
In our research protocol, neutral stimulation and standard angle insertion (Xinnong 1987) were selected; needles were retained for 20 minutes, unless otherwise specified. Assessing acupuncturists (who design the treatment plans) were asked to adhere to the list of points and not to add points or combinations not included in the manual.
Because of the nature of the study design, which involved separat-ing the assessment from the treatment, the assessing acupuncturists
‘The term contralaterally, when used in this text, implies a point used unilaterally in relation-ship to another point needled on the opposite side as well as the opposite extremity, e.g. a point on the left foot needled in conjunction with a point on the right arm.
were asked to design a series of treatments to be used over time (8 weeks). These series needed to address effectively the complete set of treatment principles for treating the pattern combination and disease mechanisms appropriate for each person. For this reason, guidelines for point combinations, as well as guidelines for designing treatment progressively over time, have been outlined.
To design the most effective treatments there are four factors that must be taken into consideration in the selection and combination of points, which are described more fully in Maciocia (1994):
- The dynamics of the flow of qi in the channels (according to their position and dynamics within the channel system)
- The energetic action of the point (their particular action, function, nature, or quality)
- The combination of points from different channels (to address the complex pattern combination and disease mechanisms)
- The area of the body affected by the point. The Dynamics of the Flow of Qi in the Channels
It is important always to balance local and distal, upper and lower, left and right. Later on, the use of specific guidelines in combining points following our protocol will be described in detail.
Local and Distal
Local points (L) include the head and trunk. Distal points (D) include the arms below the elbows, and the legs below the knees.
Upper and Lower
Upper points (U) include the arms, and lower points (L) include the legs; the combination of upper and lower points allows the balance of yin—yang channels, greater units (taiyin, shaoyang, jueyin), etc.
Left and Right
This is an extremely important tool that allows us to create dynamic treatment strategies. Maciocia (1994) says that needling points contralaterally is ‘like applying a force to the tangents of two opposite poles of a circle, making it spin’. Seem (1985) describes it as setting in motion the flow of qi in the channels in an infinite (.0) pattern. Points can be combined and needled contralaterally.
- When intended to move qi and blood: Lv 3 (R)-LI 4 or P6 (L); or Sp 4 (R)-P 6 (L)
- To balance arm and leg channels of the same polarity (spleen and lung, heart and kidney, liver and pericardium, etc.): KD 3 (L)-Ht 7, Ht 5 (R); or LV 3 (R)-P 6, P 5, P 4 (L)
- To balance exteriorly—interiorly related channels (lung—large intestine, spleen—stomach, kidney—bladder): TB 6 (R)—P 6 (L); or TB 3 (L)—P 7 (R); or HT 7 (L)—SI 5 (R)
- To balance extraordinary vessels (du mo, ren mo, chung mo, yin wei mo, etc.): Sp 4 (L)—P 6 (R); or GB 41 (R)—TH 5 (L)
- To balance divergent channels (although divergent channels are not used in this protocol)
- To balance connecting channels (i.e. using connecting and source points): LI 4 (L)—Lu 7 (R); or P 6 (R)—TH 4 (L); or ST 40 (L)—SP 3 (R)
- To balance unrelated yin and yang channels, to achieve effective point combinations: St 40 (R)—P 5 (L); or GB 40 (L)—Ht 7 (R)
It is important to note that this is a sample list of how points may be combined; some of the point combinations listed above have not been used as part of our protocol. For a more complete list of effective point combinations, refer to the following section.
Strengthens willpower and drive, settles po, and releases emotions.
Strengthens willpower and drive, calms the spirit, and relieves anxiety, depression, mental restlessness, and insomnia.
Strengthens the spirit.
Treats slight anxiety, insomnia, and depression.
Stimulates intelligence, and clears the mind.
Calms the mind, settles the hun.
To treat anxiety, mental restlessness due to liver disharmonies.
Calms the spirit, settles the po.
Releases emotions constraining the po in the chest and causing a feeling of oppression or tightness in the chest.
Can be a very calming point, especially in conditions due to vacuity.
Calms the spirit, relieves anxiety, insomnia, and mental restlessness.
Strengthens the willpower and calms the spirit. Roots the spirit in the kidney,`grounding’ it. Used to treat anxiety and mental restlessness in kidney vacuity.
Calms the spirit, settles the hun; gathers essence to the head.
Relieves severe anxiety and mental restlessness due to liver disharmony. Reduces jealousy and suspicion. Improves mental clarity due to injury of the hun by sadness.
As described above, enhances its calming effect.
Calms the spirit in severe anxiety due to heart disharmony.
Calms the spirit, settles the hun.
Reduces emotional fluctuations and obsessive thinking.
Calms and clears the spirit.
Stimulates memory and concentration.
Settles the hun and po, and stops obsessive thoughts.
Physically stimulates the dispersing and descending of lung qi and opens the nose.
Strengthens the willpower and the spirit. Bolsters the capacity to make decisions.
Calms and nourishes the spirit.
Specially indicated in heart blood and heart yin vacuity.
Points and point combinations useful in the treatment of depression (contd)
Ht 6 YINXI
Ht 8 SHAOFU
Ht 9 SHAOCHONG
Calms the spirit. Repletion patterns with vacuity heat.
Calms the spirit. Reduces severe mental restlessness, anxiets and insomnia from repletion patterns such as heart fire, phlegm fire.
Same as Ht 8 above.
Resolves heart phlegm.
Specially indicated for emotional problems from the breaking of relationships.
Has an inward movement.
Calms the spirit, lifts mood, relaxes the chest. Rectifies the qi. Specially indicated for emotional problems associated with qi stagnation.
Settles the hun and calms the spirit when they are affected by anger, resentment, or frustration.
Releases constrained emotions in the chest, with a feeling of oppression or tightness. Has an outward movement, moves the qi, resolves stagnation, and ‘opens’ the spirit.
Opens yin wei mo, nourishes blood, relaxes the chest, calms the spirit, and settles the hun.
Strengthens its qi rectification action in emotional problems from repressed anger.
Lifts the mood, clears the spirit, relieves depression.
Lifts the mood, clears the spirit, opens the heart orifices, and relieves depression.
Point Combinations from Different Channels
The following section summarizes the actions of point combinations, involving points from different channels. They emphasize functions of the viscera and bowels involved in depression.
n To harmonize heart and kidney, nourish the heart (enrich yin), and calm the spirit: Ht 7—KD 3
— In addition, to clear vacuity heat (and stop night sweating): Ht 6—KD 7
—To enrich yin further and clear vacuity heat: Ht 5—KD 6
—In addition to relieve oppression in the chest (very calming point combination): Ht 7—KD 9
—To clear heat further from the heart (depressive, replete, or vacuity heat): Ht 5—KD 9
n To harmonize Jueyin (Lv/Per), regulate qi, open the chest, resolve depression, release suppressed emotions, and settle the hun: Lv 3—P 6
—In addition, to calm the spirit and/or eliminate phlegm and open orifices of the heart: Lv 3—P 7
—To regulate the descending of Lu/Ht qi, clear depressive heat affecting the Ht/Lu, settle the heart, and calm the spirit: Lv 3—P 4
n To course the liver, rectify the qi, resolve depression, calm the spirit, settle the ethereal soul, and regulate the ascendance and descendance of qi: Lv 3—LI 4 (Note: Avoid this combination during pregnancy.)
n To regulate the middle burner, subdue counterflow qi, resolve phlegm, calm the spirit: P 6—St 40
—In addition, to open the orifices of the heart add: GB 18
—In addition, to clear heat and drain fire from the heart add: Ht 5, Ht 8
—In addition, to clear heat: P 5—St 40
n To regulate the middle burner and subdue counterflow qi, con-comitant with spleen—stomach vacuity: P 6—St 36
n To strengthen memory and concentration due to spleen—heart dual vacuity: Ht 5—Sp 3
n To nourish the heart, calm the spirit, and open the orifices of the heart. To assist decision-making by discriminating between choices: Ht 7—SI 5
n To course the live; rectify the qi, settle the ethereal soul, when dis-tension combines physically with emotional moodiness and depres-sion: Lv 3—GB 342
n To fortify the spleen, boost the qi, and nourish the blood: St 36— Sp 6 (Note: Needle both points bilaterally.)
n To course the liver, rectify the qi, and resolve depression, when it causes chest oppression and sighing: P 6—TH 6
n To course the live; rectify the qi, open the orifices of the heart, calm the spirit, and lift the mood, when the patient presents with mental confusion and depression due to long-standing emotional problems and suppressed emotions: P 6—TH 3
n For the same indications as the previous combination, with a more calming effect: P 7—TH 3
n To course the liver, rectify the qi, calm the spirit, resolve counterflow qi headaches, neck tension due to emotional problems: P 6—TH 4
n To nourish the heart, calm the spirit, and strengthen the gall bladder’s capacity to make decisions: GB 40—Ht 7.
According to the Areas of the Body Affected by the Points
When selecting distal points, it is important to consider the area affected by the point, in addition to considering the action of the points or the dynamics of the flow of qi in the channels (Maciocia 1994). The general principle is that the further the point is along the channel, the further its influence is exerted; this is true only for the points on the arms and the legs, which affect the upper extremity of the channels. For a detailed overview of the areas affected by the principal channel points, see Maciocia (1994).
SPECIAL CONSIDERATIONS WHEN TREATING DEPRESSION DURING PREGNANCY
It is traditionally stated in Chinese Medicine that acupuncture should be performed conservatively during pregnancy in order to minimize the possibility of inducing miscarriage or precipitating premature labor. If performed judiciously, knowledgeably, and with care, however, it can be extremely beneficial as a remedial treatment for a number of problems that may arise during pregnancy, including depression. Caution must be employed to avoid any points forbidden during pregnancy, unless they clearly readdress a complication of pregnancy (Flaws 1983). The application of this framework in research protocols during depression in pregnancy should avoid the following points:
With needle LI 4, Sp 1, Sp 6, GB 21, UB 60, UB 67, Ren 3, 4, 5, and 6 With moxa LI 4, Sp 2, Ren 3, 4, 5, and 6
In addition, the following points are advised against: St 36, St 45, UB 23, UB 32, Kd 4, GB 44, Lv 1 (moxa).
These points either directly or indirectly create a lot of movement in the pelvic cavity, and some affect the uterus specifically; they can potentially create an unnecessary stirring of the fetus, which could lead to miscarriage or premature labor. Many of these points are in fact used to promote labor.
GUIDELINES FOR TREATMENT DELIVERY
In our research protocol, we adhered to the following guidelines in the delivery of treatment:
- Only use points outlined in the manual and preferably use points in combinations that include more than just one function.
- Address two or more treatment principles simultaneously with fewer needles, by needling two sets of points contralaterally; for example, liver depression, qi stagnation affecting the heart and lung, kidney vacuity, heart yin vacuity with vacuity heart: Lv 3 (R)—P 6 (L) or LI 4 (L); or KD 3 (L)—Ht 6 (R).
- Use a balanced combination of local and distal points. Needle local points bilaterally when appropriate. In the example above, add Sp 21 bilaterally or Ren 17 or Ren 15.
- Always needle bilaterally points that are intended to supplement and nourish. In the example above, one could add Sp 6 bilater-ally, UB 23 bilaterally, or needle KD 3 bilaterally instead.3
- Add at least one point to lift the mood further, resolve depression, calm the spirit and/or open the orifices of the heart, as appropri-ate. In the example above, one could add Du 19.
- If more than one treatment is being given per week, for example at the beginning when more frequent treatments are indicated, it is helpful to maintain the same strategy throughout the week and have the option to alternate or choose between two points that have a similar and complementary function. Only choose or alter-nate between two points that have similar indications when in combination to the whole treatment. For example:
Sp 21 choose/alternate Ren 17; Ren 4 choose/alternate Ren 6 or UB
20, UB 23; and P 6 choose/alternate LI 4.
Do not choose or alternate between two points meant to be used in combination with each other, such as LV 3—P 6.
31n pregnant women, abdominal points will be avoided as outlined in the guidelines for treatment during pregnancy. Remember that pregnant women will likely be treated lying on their side, in which case one could do a set of back shu points and a front mu point.
7. Design treatment plans to address over time (the entire duration of the treatment; i.e. 8 weeks,) all the treatment principles out-lined in the pattern differentiation (based on the presenting signs and symptoms, constitution of the patient, rate of severity, previ-ous history of depression, etc.).
8. During the first 4 weeks of treatment emphasize coursing the liver, rectifying the qi, transforming dampness and phlegm, clearing heat, calming the spirit, etc., and secondarily treat the underlying vacuity. After that, focus on fortifying the spleen, boosting the qi, nourishing the heart, supplementing the kidneys, etc., while continuing to address the other disease mechanisms.
9. In menstruating women, emphasize coursing, rectifying, trans-forming, and clearing in the 2 weeks preceding the menstrual cycle. Focus on boosting, supplementing, nourishing, and fortify-ing in the week after the period. During menstruation it is best to continue with the premenstrual strategy, except towards the end of the period.
- Use mu points and other points on the ventral aspect of the body for the first 2 weeks and then use shu points. Use the points on the outer line of the UB channel, after having addressed the main patterns, on both the ventral and dorsal aspects of the body (around week 4, treatment 7).
- Use a total of seven acupuncture points and three auricular points.
- Select the seven acupuncture points from a set of five main points that together address the appropriate combination of the four main features: (1) liver depression qi stagnation, (2) shen disturbance due to vacuity or repletion, (3) vacuity of qi—yang/blood—yin, and/or (4) repletion of dampness—phlegm or hyperactivity of yang.
b. Select at least one of the two remaining points to regulate the du channel or directly affect mental functions (i.e. Du 24 or GB 18), and the other point to address the pattern differentiation further.
- Select three auricular points from the list provided, based on the Auriculotherapy Manual (Oleson 1992), to further address damage by the emotions.
d. The treatment course consists of 12 acupuncture treatments given over an 8-week period, biweekly for the first 4 weeks and weekly during the next 4 weeks.
e. Although in our original study no maintenance or follow-up phase was built in, it is strongly advised to follow the acute treatment phase with maintenance treatments. Maintenance may involve two acupuncture treatments per month for 3 months, then one treatment per month for the following 3 months, with a seasonal tune-up treatment every time the season changes.
ASSESSMENT: SPECIAL CONSIDERATIONS REGARDING THE USE OF THE FOUR EVALUATIONS IN ASSESSING DEPRESSION
As mentioned in a previous post, the theoretical framework presented in this category focuses primarily on the use of three of the five filters — (1) eight principles, (2) viscera and bowels, (3) qi, blood, and body fluids, — with additional consideration of the five phases in the assessment interview, and a broad inclusion of channel interactions in the design of treatment protocols. The integration of all five levels is ideal; this manual represents our own particular effort towards developing a multidimensional approach to the treatment of depression based on the principles of Chinese Medicine.
In the protocol presented here, after conducting an assessment with the four evaluations, the presenting signs and symptoms are differen-tiated on the basis of the four features as detailed below. It is also necessary to assess the specific viscera and bowels involved.
Liver Depression Qi Stagnation
The level of liver depression qi stagnation is evaluated, as are the level of heat transformation and the degree to which the stagnation may be affecting either the heart or the lung. Points are then chosen to course the liver and rectify the qi, clear heat, calm the shen, and assist in descending lung qi accordingly. In menstruating women, mood and symptom changes related to the menstrual cycle are considered impor-tant factors because of the liver’s effect on the movement of blood. Premenstrually, emphasis is placed on coursing the liver, rectifying the qi, and clearing heat, as appropriate (i.e. treating the repletion caused or aggravated by stagnation). Postmenstrually, emphasis is placed on supplementing vacuity. This is based on the understanding that reple-tion symptoms typically manifest before menstruation and vacuity symptoms manifest after menstruation. As explained in the section on the menstrual cycle, yang begins to grow during the third week of the cycle, and qi and blood are both at their maximum in the week pre-ceding menstruation. The blood becomes relatively empty as part of the process of menstruation, being most vacuous at the conclusion of the period (Flaws 1992). Again, we determine to what extent the stag-nation has transformed into heat (repletion of yang), whether it has given rise to blood stasis, or whether it has caused dampness and phlegm to accumulate. We believe that this information can poten-tially help to predict outcome and relapse, based on the hypothesis that the greater degree of blood stasis and phlegm accumulation, the lower the rate of remission and the higher the incidence of relapse, given acupuncture treatment alone.
The nature and degree of shen disturbance is examined to determine whether it is due to vacuity (heart blood, heart qi, or heart yin vacuity with or without vacuity heat) or to repletion (qi stagnation, or depres-sive heat affecting the heart, or phlegm confounding the orifices of the heart, with or without heat or fire). Points are then chosen to nourish the heart, calm the shen, and/or clear heart, drain fire, transform phlegm, and open the orifices, as needed.
Vacuity and Repletion
The way in which liver depression qi stagnation and shen disturbance combine with, exacerbate, or precipitate tendencies towards vacuity of qi—yang and/or blood—yin is analyzed. Additionally, the extent to which dampness and phlegm accumulate (repletion of yin), and the extent to which yang becomes replete (hyperactive liver yang, liver fire, or vacuity heart), is also evaluated. Points are then chosen to supplement vacuity of qi—yang and/or yin—blood, and/or to transform dampness and phlegm, clear heat, drain fire, etc., in order to regulate yin and yang based on the presenting signs and symptoms.
Viscera and Bowels
The involvement and role of each viscus and bowel and the functional interactions among them are analyzed. On one hand, special attention is paid to how the mechanisms of depression affect each one of their functions. On the other hand, the extent to which their dysfunction precipitates this particular depression episode is also determined.
Channels and Network Vessels
The 12 regular channels plus du mai, ren mai, and chong mai are the only channels used in our protocol. To regulate the flow of qi, stimu-late brain function, and clear the heart’s orifices, the use of points along the du channel is emphasized. To help refine point selection, the use of palpation of both the channels and the abdominal area is encouraged. Additionally, the concept of the six great units as consti-tutional predispositions (based on Yves Requena’s eight diatheses (Requena 1986) has been used as a diagnostic tool; the six great units have also been used as guidelines for effective point combinations.
The Five Phases
The precipitating factors, the nature of the depressive episode, and the constitutional predisposition of the patient are analyzed by using the five phases as a framework. Primarily, Denmei’s (1990) concept of constitutional types as predisposing factors, Beinfield & Korngold’s (1991) five phases as types, and the classic five phases correspondences (Maciocia 1989) have been used.
In our protocol, the last two theories have been used exclusively to refine our understanding of the constitutional tendencies of each individual. These theories are used in order to design more effectively a treatment strategy that would address both circumstantial manifestations and
trait tendencies. We believe that by using the five phases and the six units extensively as reframing tools, in both assessment and patient education, we gain the ability to capture the complexity of interaction between trait and circumstantial tendencies, between the branch and the root.
It would be well beyond the scope of this manual to present in detail any of those two theories. The interested reader is invited to consult the sources cited in the References for an indepth overview of the use of the six units and the five phases in diagnosis.
Implementation of the Assessment Framework
After using conventional Western assessment techniques to diagnose major depression and to exclude other relevant conditions, we perform a differential diagnosis on all participants entering treatment. The differential diagnosis is accomplished by using the traditional method of the four evaluations (Kaptchuk 1983, Maciocia 1989). The basic procedure is as follows.
First, a questionnaire is administered (see Appendix A). In the first section, we ask about the precipitating factors, previous history of depression, and the person’s unique experience of being depressed. We aim at getting a clear sense of the person’s constitutional tendencies, the psychosocial nature of their depression, and how their lifestyle has influenced their health. It is in this section that we make the most use of the six great units, the five phases, and the eight principles, to under-stand constitutional tendencies. In the second section of the question-naire, we focus on differentiating the symptom criteria for major depressive episode (DSM-IV) on the basis of our theoretical framework; special attention is paid to how the symptom criteria correspond to liver depression, qi stagnation, shen disturbance, and vacuity or repletion of yin and yang. During the interview, the assessors probe the questions in detail, to differentiate disease mechanisms and pattern combinations clearly. For women, we take an indepth gynecological history, including menstrual cycles, pregnancies, etc. We conclude by inquiring about the emotional nature of the patient’s complaints and the current specific manifestations of the depression.
Pulses are taken in the traditional fashion, as detailed in The Secret of Chinese Pulse Diagnosis (Flaws 1995). The main pulse definitions employed can be found in Appendix B. Additional information on pulse diagnosis is taken from Kaptchuk (1983) and Maciocia (1989).
Although not officially part of our research protocol, clinically we have found it helpful to perform abdominal palpation following the traditional Japanese system. We base our findings on Denmai’s (1990) Introduction to Meridian Therapy (1990), Matsumoto & Birch’s (1988) Hara Diagnosis: Reflections on the Sea, and Seem’s (1990) Acupuncture Imaging. We also encourage palpation of the channel pathways and zones when making the final selection of points.
Assessment of the tongue is based on Tongue Diagnosis in Chinese Medicine (Maciocia 1987). We follow traditional observation of the patient’s demeanor and features (face color, eye expression, shen, etc.).
We determine the pattern(s), treatment principles, and treatment strategy by emphasizing differentiation of signs and symptoms, and pulse and tongue evaluation, as traditionally performed in the eight principles model. We begin with the premise that liver depression qi stagnation and an inability of the heart to store the shen properly underlie the disharmony in most cases. We determine to what extent this is true and explore whether the stagnation is affecting other viscera, and whether the shen disturbance is due to vacuity or reple-tion disease mechanisms. Additionally, based on the information gathered, we assess to what extent the pattern is characterized by yang features (psychomotor agitation, dream-disturbed sleep, and irritability) and develops along the yin vacuity—yang repletion con-tinuum. Similarly, we determine the extent to which the pattern is characterized by yin features (psychomotor retardation, fatigue, hypersomnia) and develops along a vacuity of qi—yang/repletion of yin continuum. The involvement of each viscus and bowel is analyzed as well.
The following is a summary of the approach:
1. The acupuncturist performs a Chinese Medicine assessment using the intake form (provided in Appendix A) as a guide to gather information about the signs and symptoms, inquiring verbally about problem areas.
2. Tongue and pulse evaluation helps determine the disease mechanisms and pattern(s) involved. (Abdominal palpation and assessment of the channels assist in focusing the diagnosis.)
3. The acupuncturist arrives at a set of treatment principles to address the pattern or combination of patterns, by focusing on four features:
- liver depression qi stagnation
- shen disturbance due to either vacuity or repletion disease mechanisms, or both
- vacuity of qi—yang and/or (repletion) accumulation of dampness/ phlegm
- vacuity of yin—blood and/or (repletion) hyperactivity of heat/fire.
4. Points are selected as detailed in the section Strategies and techniques.