This issue of the Three Treasures News is part of a cycle dedicated to the "four ages of humankind", the first having been dedicated to the treatment of children and the second to that of adolescents. In this issue we focus on adult age, i.e. from about 21 to 55.

While the aetiology of children and adolescent is fairly limited to a few specific causes of disease (especially for children), in adults, all causes of disease normally contemplated by Chinese medicine play a role in the aetiology of disease. These causes of disease include diet, emotional stress, excessive physical work, mental overwork, excessive sexual activity, climate, trauma, etc. For this reason, in this newsletter I shall concentrate on the pathology and treatment of mental-emotional problems since stress is such a major factor in the adult patients we see.

ADULT AGE AND EMOTIONAL STRESS

EMOTIONS AS A CAUSE OF DISEASE

Traditionally, 7 emotions were considered as causes of disease but I use an expanded list as follows:

Anger (and frustration and resentment) affecting the Liver
Joy affecting the Heart
Worry affecting the Lungs and Spleen
Pensiveness affecting the Spleen
Sadness (and grief) affecting the Lungs
Fear affecting the Kidneys
Shock affecting the Kidneys and Heart
Guilt affecting the Kidneys and Heart.

The effect of each emotion on a relevant organ (as indicated above) should not be interpreted too restrictively as a particular emotion may affect more than one organ. Moreover, because the Heart houses the Mind (Shen) that recognizes the emotions, all emotions affect the Heart, in addition to affecting the relevant organ (hence a red tip of the tongue is very common).

The first effect of emotional stress on the body is to affect the proper circulation and direction of Qi. Each emotion is said to have a particular effect on the circulation of Qi. The "Simple Questions" in chapter 39 says: "Anger makes Qi rise, joy slows down Qi, sadness dissolves Qi, fear makes Qi descend...shock scatters Qi...pensiveness knots Qi...". Dr Chen Yan in "A Treatise on the Three Categories of Causes of Diseases" (1174) says: "Joy scatters, anger arouses, worry makes Qi unsmooth, pensiveness knots, sadness makes Qi tight, fear sinks, shock moves".

Let us now discuss the effects of each emotion individually.

Anger
The term "anger" should be interpreted very broadly to include resentment, repressed anger, feeling aggrieved, frustration, irritation, rage, indignation, animosity, or bitterness.

Any of these emotional states can affect the Liver, if they persist for a long time, causing stagnation of Liver-Qi or Blood, rising of Liver-Yang or blazing of Liver-Fire. The effect of anger on the Liver depends, on the one hand, on the person's reaction to the emotional stimulus and, on the other hand, on other concurrent factors. If the anger is bottled up it will cause stagnation of Liver-Qi, whereas if it is expressed it will cause Liver-Yang rising or Liver-Fire blazing. In a woman stagnation of Liver-Qi may easily lead to stasis of Liver-Blood. If the person also suffers from some Kidney-Yin deficiency (perhaps from excessive sexual activity), then he or she will develop Liver-Yang rising. If, on the other hand, the person has a tendency to Heat (perhaps from excessive consumption of hot foods), then he or she will tend to develop Liver-Fire blazing.

Anger (intended in the broad sense outlined above) makes Qi rise and many of the symptoms and signs will manifest in the head and neck, such as headaches, tinnitus, dizziness, red blotches on the front part of the neck, a red face, thirst, a Red tongue with red sides and a bitter taste.

Joy
A normal state of joy is not in itself a cause of disease; on the contrary, it is a beneficial mental state which favours a smooth functioning of the internal organs and their mental faculties.

What is meant by "joy" as a cause of disease is obviously not a state of healthy contentment but one of excessive excitement and craving which can injure the Heart. This happens to people who live in a state of continuous mental stimulation (however pleasurable) or excessive excitement: in other words, a life of "hard playing".

Inordinate craving is an aspect of the emotion "joy" and it stirs up the Minister Fire which over-stimulates the Mind.

Worry
Worry is one of the most common emotional causes of disease in our society. Worry knots Qi, which means that it causes stagnation of Qi, and it affects both Lungs and Spleen: the Lungs because when one is worried breathing is shallow, and the Spleen because this organ is responsible for thinking and ideas.

If worry affects the Lungs it will cause an uncomfortable feeling of the chest, slight breathlessness, tensing of the shoulders, sometimes a dry cough and a pale complexion. The Lung pulse position may feel slightly Tight or Wiry, indicating the knotting action of worry on Qi.

If worry affects the Spleen it may cause poor appetite, a slight epigastric discomfort, some abdominal pain and distension, tiredness and a pale complexion. The Spleen pulse position will feel slightly Tight but Weak. If worry affects the Stomach as well (which happens if one worries at meal times), the right Middle pulse may be Weak-Floating.

Pensiveness
Pensiveness is very similar to worry in its character and effect. It consists in brooding, constantly thinking about certain events or people (even though not worrying), nostalgic hankering after the past and generally thinking intensely about life rather than living it. In extreme cases, pensiveness leads to obsessive thoughts. In a different sense, pensiveness also includes excessive mental work in the process of one's work or study.

Pensiveness affects the Spleen and, like worry, it knots Qi. It will therefore cause similar symptoms as outlined above.

Sadness and grief
Sadness and grief affect the Lungs and Heart. The Lungs govern Qi and sadness and grief deplete Qi. This is often manifested on the pulse as a Weak quality on both left and right Front positions (Heart and Lungs). In particular, the pulse on both Front positions is Short and has no wave, i.e. it does not flow smoothly towards the thumb. Other manifestations deriving from sadness and grief include a weak voice, tiredness, pale complexion, slight breathlessness, weeping and a feeling of oppression in the chest.

Although sadness and grief deplete Qi and therefore lead to deficiency of Qi, they may also, after a long time, lead to stagnation of Qi, because the deficient Lung- and Heart-Qi fail to circulate properly in the chest.

Fear
Fear includes both a chronic state of fear and anxiety and a sudden fright. Fear depletes Kidney-Qi and it makes Qi descend. Examples of Qi descending are nocturnal enuresis in children and incontinence of urine or diarrhoea in adults, following a sudden fright. Situations of chronic anxiety and fear will have different effects on Qi depending on the state of the Heart. If the Heart is strong, it will cause Qi to descend, but if the Heart is weak, it will cause Qi to rise in the form of Empty-Heat. This is more common in old people and in women as fear and anxiety weaken Kidney-Yin and give rise to Empty-Heat of the Heart with such symptoms as palpitations, insomnia, night-sweating, a dry mouth, a malar flush and a Rapid pulse.

Shock
Mental shock scatters Qi and affects Heart and Kidneys. It causes a sudden depletion of Heart-Qi, makes the Heart smaller and may lead to palpitations, breathlessness and insomnia. It is often reflected in the pulse with a so-called "moving" quality, i.e. a pulse that is short, slippery, shaped like a bean, rapid and gives the impression of vibrating as it pulsates.

Guilt
Guilt is an extremely common emotion and cause of disease in the West. A feeling of guilt may derive from the transgression of social or religious taboos or from having done something wrong which is later regretted. People who are prone to blame themselves for everything that goes wrong may also suffer an unjustified and subjective sense of guilt.

Guilt affects the Heart and Kidneys and it causes Qi to stagnate. It may cause stagnation of Qi in the chest, epigastrium, or abdomen, and its clinical manifestations include an uncomfortable feeling in the chest, epigastric or abdominal pain and distension and a Fine pulse. The tongue will have a red tip and the pulse will be vibrating as it pulsates. The eyes will look unstable and often flap shut while talking.

When guilt results from repressed anger, the pulse will be Wiry.

PATHOLOGICAL STATES OF THE MIND

I translate the Shen that resides in the Heart as "Mind" while I translate the totality of the five zhi, i.e. the Ethereal Soul (Hun), Corporeal Soul (Po), Intellect (Yi), Will-Power (Zhi) and the Mind (Shen) itself as "Spirit".

Anxiety and insomnia may derive from a Deficiency pattern when the Mind and Ethereal Soul are not rooted in the Heart and Liver, or from an Excess pattern when pathogenic factors agitate the Mind and Spirit. In the first case, one needs to calm the Mind and Spirit by tonifying and nourishing; in the latter case, one needs to calm the Mind and Spirit by eliminating pathogenic factors. Some of the remedies fall under the first category and some under the second.

Remedies that calm the Mind and Spirit by nourishing are Calm the Spirit and Root the Spirit. Remedies that calm the Mind and Spirit by eliminating pathogenic factors are Clear the Soul, Open the Heart, Release Constraint and Drain Fire.

REMEDIES

The remedies discussed are:

Calm the Spirit
This remedy, a variation of Gui Pi Tang Tonifying the Spleen Decoction, is a major formula to calm the Mind and Spirit. It is only for mental-emotional conditions deriving from Deficiency patterns and, specifically, deficiency of Qi and Blood of the Spleen and Heart.

The main indications for this remedy are insomnia and anxiety. The insomnia would be characterized by inability to fall asleep and the anxiety would be relatively mild, different than, for example, the anxiety caused by Heat or Empty Heat. This person would have a dull-pale complexion, a Pale tongue and a Weak or Choppy pulse. The eyes may lack shine or shen, indicating disturbance of the Mind.

This formula calms the Mind and Spirit by nourishing the Heart and Spleen.

A central Heart crack is a strong indication for the use of this remedy.

Root the Spirit
Root the Spirit is a variation of the formula Yin Mei Tang Attracting Sleep Decoction which nourishes Liver-Blood and Liver-Yin to promote sleep. Root the Spirit promotes sleep and treats insomnia and anxiety by nourishing Liver-Blood and Liver-Yin in order to "anchor" the Ethereal Soul (Hun) in the Liver at night. Thus, this remedy is specific for anxiety and insomnia that are due to Liver-Blood and/or Liver-Yin deficiency and therefore to the excessive "wandering of the Hun" at night. In this case, the sleep is noticeably disturbed by dreams which are due to the "wandering" of the Hun at night.

Clear the Soul
Clear the Soul is a variation of Wen Dan Tang Warming the Gall-Bladder Decoction which, on a physical level, resolves Phlegm-Heat from the Lungs and can be used effectively for this condition affecting the Lungs after an invasion of exterior Wind. On a mental-emotional level, this formula calms the Mind and the Corporeal Soul when the person is afflicted by worry or grief. The main patterns addressed by this formula are Qi stagnating in the chest together with Phlegm-Heat obstructing the chest and the Mind. Thus, this formula calms the Mind not by nourishing but by expelling pathogenic factors and therefore settling the Mind and Spirit.

Heat agitates the Mind while Phlegm obstruct the Mind: therefore a person suffering from this pattern will experience anxiety, insomnia, mental restlessness and depression. On a physical level, the symptoms are experienced in the chest, causing a slight breathlessness and a tightness of the chest. The typical tongue indicating the use of this remedy is Red, Swollen, with a sticky coating and a Heart crack.

Open the Heart
Open the Heart is a variation of the formula Ban Xia Hou Po Tang Pinellia-Magnolia Decoction which was described in the Shang Han Lun. This formula is for the plum-pit syndrome, i.e. a feeling of obstruction of the throat with a sensation of being unable to swallow clearly related to emotional problems: the obstruction feeling fluctuates according to the emotional state. This pattern is nowadays always related to the Liver but, in fact, the original formula was for stagnation of Qi of the Lungs and Stomach with impairment of the descending of Qi of these two organs.

Open the Heart was therefore formulated for anxiety and depression deriving from stagnation of Qi of the Lungs and Stomach, itself caused by worry, grief and sadness. Qi stagnates in the chest and throat and causes a feeling of obstruction in the throat, a feeling of tightness of the chest and sighing.

Open the Heart calms the Mind and the Corporeal Soul not by nourishing but by expelling pathogenic factors and therefore by settling the Mind and Spirit.

Release Constraint
Release Constraint is a variation of Yue Ju Wan Ligusticum-Gardenia Pill. This formula is the most important remedy for mental depression deriving from Qi stagnation. It actually treats also stasis of Blood and stagnation of Food, Heat, Dampness and Phlegm (the "six stagnations") but it is primarily for Qi stagnation.

Release Constraint is the main remedy to use for mental depression deriving from Liver-Qi stagnation: this is usually due to repressed anger, resentment or frustration and this type of person will have a very Wiry pulse in every position. Indeed, a Wiry pulse is an essential condition for the use of this remedy. Often, a patient suffering from this condition may appear subdued, speak with a low voice, walk slowly and be pale, all signs indicating a Deficiency; once we take the pulse, however, its wiriness clearly indicates Liver-Qi stagnation as the cause of the condition. In addition, the tongue would have red sides, indicating severe Liver-Qi stagnation.

Drain Fire
Drain Fire is a variation of the prescription Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction which drains Liver-Fire. Fire agitates the Mind, Ethereal Soul and Spirit and causes anxiety, mental restlessness and insomnia. Drain Fire therefore calms the Mind and settles the Ethereal Soul by draining Liver- and Heart-Fire. The essential sign for the use of this remedy is a tongue that is Red, redder on the sides and with a dry-yellow coating.

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