CHAPTER 19

BIPOLAR DISORDER
(MANIC-DEPRESSION)
(DULLNESS and MANIA,
DIAN KUANG)

AL
BIPOLAR DISORDER IN WESTERN MEDICINE 498 Qi deficiency with Phlegm 519

N
Symptoms of bipolar disorder 498 Phlegm obstructing the Heart orifices 520

O R
FI
Diagnosis of bipolar disorder 500 Kuang 521
Course of bipolar disorder 501
- N IE Phlegm-Fire harassing upwards 521

T
T V
Treatment of bipolar disorder 501 Fire in Bright Yang 524
N SE
History 502 Gall Bladder- and Liver-Fire 524
Fire injuring Yin with Phlegm 525
TE L

BIPOLAR DISORDER IN CHINESE MEDICINE 503

N E

Qi stagnation, Blood stasis, Phlegm 526

Historical development of Dian Kuang in Chinese Yin deficiency with Empty Heat 527
O F

medicine 503
C O

Correspondences and differences between bipolar disorder MODERN CHINESE LITERATURE 528
E TY

and Dian Kuang 504

CLINICAL TRIALS 532
Pathology of Dian Kuang 506
PL R

ETIOLOGY OF DIAN KUANG 508

M PE

Emotional stress 508

SA O

Diet 508
PR

Constitution 508

PATHOLOGY AND TREATMENT PRINCIPLES OF DIAN

KUANG 509
Pathology of Dian Kuang 509
DIAN
Treatment principles for Dian Kuang 511
How to adapt the patterns and treatment of Dian Kuang • Qi stagnation and Phlegm
to the treatment of bipolar disorder 513 • Heart and Spleen deficiency with Phlegm
• Qi deficiency with Phlegm
ACUPUNCTURE TREATMENT 514 • Knotted Heat in the Heart channel
Points that open the Mind’s orifices 514 • Phlegm obstructing the Heart orifices
Sun Si Miao’s 13 ghost points 515
The Pericardium channel in Manic-Depression 515
KUANG
• Phlegm-Fire harassing upwards
IDENTIFICATION OF PATTERNS AND • Fire in Bright Yang
TREATMENT 516 • Gall Bladder- and Liver-Fire
Dian 516 • Fire injuring Yin with Phlegm
Qi stagnation and Phlegm 516 • Qi stagnation, Blood stasis, Phlegm
Heart and Spleen deficiency with Phlegm 518 • Yin deficiency with Empty Heat
498 The Psyche in Chinese Medicine

• little sleep needed

BIPOLAR DISORDER • rapid, excitable and intrusive speech
(MANIC-DEPRESSION) • fast thinking, moving quickly from topic to topic
• unrealistic beliefs in one’s abilities and powers
Bipolar disorder, also called manic-depression, is a
• grandiosity
serious mental illness. The discussion of this dis­
• chaotic patterns of personal and professional
ease will be conducted according to the following
relationships
topics.
• impulsive involvement in questionable
• Bipolar disorder in Western medicine endeavors
• Bipolar disorder in Chinese Medicine • reckless driving, excessive risk-taking
• Etiology of Dian Kuang • certainty of conviction about the correctness and
• Pathology and treatment principles of Dian Kuang importance of their ideas
• Acupuncture treatment • poor judgment
• Identification of patterns and treatment • spending sprees
• Modern Chinese literature • a lasting period of behavior that is different from
• Clinical trials usual
• intense and impulsive romantic or sexual liaisons

AL
BIPOLAR DISORDER IN • increased sexual drive

N
WESTERN MEDICINE • abuse of drugs, particularly cocaine, alcohol and

O R
FI
sleeping medications

- N IE
Bipolar disorder, also known as manic-depressive • provocative, intrusive or aggressive behavior

T
T V
illness, is a serious medical illness that causes • denial that anything is wrong
N SE
shifts in a person’s mood, energy and ability to • in its extreme forms, violent agitation, bizarre
behavior, delusional thinking, visual and auditory
TE L

function.
N E

More than 2 million American adults, or about 1% hallucinations.

O F

of the population age 18 and older in any given year, A manic episode is diagnosed if elevated mood
C O

have bipolar disorder.1 Bipolar disorder typically devel- occurs with three or more of the other symptoms most
ops in late adolescence or early adulthood.
E TY

of the day, nearly every day, for 1 week or longer. If the

mood is irritable, four additional symptoms must be
PL R

Symptoms of bipolar disorder present.

M PE

Bipolar disorder causes dramatic mood swings – from

SA O

overly “high” and/or irritable to sad and hopeless, and

SUMMARY
PR

then back again, often with periods of normal mood in

between. Severe changes in energy and behavior go
Symptoms of mania
along with these changes in mood. The periods of highs
• Elevated and expansive mood (also paranoid or
and lows are called episodes of mania and depression,
irritable)
respectively. Previously called manic-depression, this
• Increased energy, activity, and restlessness
disease is now called bipolar disorder.
• Excessively “high” euphoric mood
Signs and symptoms of mania (or a manic episode)
• Extreme irritability
include:
• Racing thoughts and talking very fast, jumping
• elevated and expansive mood (also paranoid or from one idea to another
irritable) • Distractibility, inability to concentrate
• increased energy, activity and restlessness • Extreme impatience
• excessively “high” euphoric mood • Little sleep needed
• extreme irritability • Rapid, excitable and intrusive speech
• racing thoughts and talking very fast, jumping • Fast thinking, moving quickly from topic to
from one idea to another topic
• distractibility, inability to concentrate • Unrealistic beliefs in one’s abilities and powers
• extreme impatience
 Bipolar Disorder (Manic-Depression) 499

• Grandiosity SUMMARY
• Chaotic patterns of personal and professional
relationships Symptoms of depressive phase of
• Impulsive involvement in questionable endeavors bipolar disorder
• Reckless driving, excessive risk-taking • Apathy, lethargy
• Certainty of conviction about the correctness and • Lasting sad, anxious or empty mood
importance of their ideas • Slowed physical movement
• Poor judgment • Feelings of hopelessness or pessimism
• Spending sprees • Feelings of guilt, worthlessness or helplessness
• A lasting period of behavior that is different from • Loss of interest or pleasure in activities once
usual enjoyed, including sex
• Intense and impulsive romantic or sexual liaisons • Decreased energy, a feeling of fatigue or of being
• Increased sexual drive “slowed down”
• Abuse of drugs, particularly cocaine, alcohol and • Difficulty concentrating, remembering, making
sleeping medications decisions
• Provocative, intrusive or aggressive behavior • Restlessness or irritability

AL
• Denial that anything is wrong • Sleeping too much or insomnia
• In its extreme forms, violent agitation, bizarre • Change in appetite and/or unintended weight

N
loss or gain

O R
behavior, delusional thinking, visual and auditory

FI
- N IE
hallucinations • Chronic pain or other persistent bodily symptoms

T
that are not caused by physical illness or injury
T V
• Thoughts of death or suicide, or suicide attempts
N SE
TE L

Signs and symptoms of depression (or a depressive

N E

episode) include:
O F

• apathy, lethargy
C O

experiences it and may even be associated with

• lasting sad, anxious or empty mood good functioning and enhanced productivity. Thus,
E TY

• slowed physical movement even when family and friends learn to recognize
• feelings of hopelessness or pessimism
PL R

the mood swings as possible bipolar disorder, the

• feelings of guilt, worthlessness or helplessness
M PE

person may deny that anything is wrong. Without

• loss of interest or pleasure in activities once proper treatment, however, hypomania can become
SA O

enjoyed, including sex severe mania in some people or can switch into
PR

• decreased energy, a feeling of fatigue or of being depression.

“slowed down” Occasionally, severe episodes of mania or depression
• difficulty concentrating, remembering, making include symptoms of psychosis (or psychotic symp-
decisions toms). Common psychotic symptoms are hallucina-
• restlessness or irritability tions (auditory or visual) and delusions.
• sleeping too much or insomnia Psychotic symptoms in bipolar disorder tend to
• change in appetite and/or unintended weight loss reflect the extreme mood state at the time. For example,
or gain delusions of grandiosity, such as believing one is Jesus
• chronic pain or other persistent bodily Christ or has special powers or wealth, may occur
symptoms that are not caused by physical illness or during mania; delusions of guilt or worthlessness, such
injury as believing that one is ruined and penniless or has
• thoughts of death or suicide, or suicide attempts. committed some terrible crime, may appear during
A depressive episode is diagnosed if five or more of depression. People with bipolar disorder who have
these symptoms last most of the day, nearly every day, these symptoms are sometimes incorrectly diagnosed
for a period of 2 weeks or longer. as having schizophrenia.
A mild to moderate level of mania is called hypo­ Redfield Jamison lists six criteria for the diagnosis of
mania. Hypomania may feel good to the person who a manic episode, as follows.
500 The Psyche in Chinese Medicine

A. A distinct period of abnormally and persistently Cyclothymia is a milder form of manic-depression,

elevated, expansive or irritable mood. with swings between depression and hypomania.
B. At least three of the following symptoms: Cyclothymic temperament can be manifested in differ-
– Inflated self-esteem or grandiosity ent ways, i.e. as predominantly depressive, manic,
– Decreased need for sleep hypomanic or irritable. There are swings between
– More talkative than usual cheerfulness and unhappiness. Not all individuals who
– Flight of ideas, thoughts racing have cyclothymia go on to develop the full manic-
– Distractibility depressive syndrome, but many do. One out of three
– Increase in goal-directed activity (social, work, persons with cyclothymia goes on to develop full-blown
school, sexual), psychomotor agitation manic-depression.
– Excessive involvement in pleasurable activities Redfield Jamison lists five criteria for the diagnosis of
(buying spree, sexual indiscretions, foolish busi- cyclothymia, as follows.3
ness investments). A. Numerous hypomanic episodes for 2 years and
C. Mood disturbance (severe). numerous periods of depressed mood that did not
D. No delusions or hallucinations. meet the criteria for a major depressive episode.
E. Not superimposed on schizophrenia, delusional B. Never without hypomanic or depressive
disorder, psychotic disorder. symptoms for 2 years for more than 2 months at

AL
F. No organic factor. a time.

N
(A) plus (B) plus (C) constitutes a manic syndrome, C. No major depressive episode or manic episode.

O R
FI
while (A) plus (B) constitutes hypomania.2 D. Not superimposed on psychotic disorder.

- N IE
It may be helpful to think of the various mood states E. No organic factor.

T
T V
in bipolar disorder as a spectrum or continuous range.
N SE
In the depressive phase, at one end is severe depression, Diagnosis of bipolar disorder
TE L

below which is moderate depression and then mild low

N E

mood, which is termed “dysthymia” when it is chronic. A diagnosis of bipolar disorder is made on the basis of
symptoms, course of illness and, when available, family
O F

In the manic phase, there is normal or balanced mood,

C O

above which comes hypomania (mild to moderate history. The diagnostic criteria for bipolar disorder are
mania) and then severe mania (Fig. 19.1). described in the Diagnostic and Statistical Manual for
E TY

In some people, however, symptoms of mania and Mental Disorders, 4th edition (DSM-IV).4
PL R

depression may occur together in what is called a Descriptions offered by people with bipolar disorder
M PE

mixed bipolar state. Symptoms of a mixed state often give valuable insights into the various mood states
include agitation, trouble sleeping, significant change associated with the illness.
SA O

in appetite, psychosis and suicidal thinking. A person

PR

may have a very sad, hopeless mood while at the same Depression
time feeling extremely energized. “I doubt completely my ability to do anything well. It seems
as though my mind has slowed down and burned out to the
point of being virtually useless … [I am] haunt[ed] … with
Severe mania
the total, the desperate hopelessness of it all … Others say,
‘It’s only temporary, it will pass, you will get over it,’ but
MANIC PHASE Hypomania of course they haven’t any idea of how I feel, although they
are certain they do. If I can’t feel, move, think or care, then
Normal mood what on earth is the point?”

Mild low mood (dysthymia)

Hypomania
“At first when I’m high, it’s tremendous … ideas are fast …
DEPRESSIVE PHASE Moderate depression like shooting stars you follow until brighter ones appear …
All shyness disappears, the right words and gestures are
Severe depression suddenly there … uninteresting people, things become
Figure 19.1 Range of mental disturbance between severe intensely interesting. Sensuality is pervasive, the desire to
mania and severe depression. seduce and be seduced is irresistible. Your marrow is infused
 Bipolar Disorder (Manic-Depression) 501

with unbelievable feelings of ease, power, well-being, bipolar disorder tends to worsen. Over time a person
omnipotence, euphoria … you can do anything … but, some­ may suffer more frequent (more rapid-cycling) and
where this changes.” more severe manic and depressive episodes than those
experienced when the illness first appeared. In most
Mania cases, however, proper treatment can help reduce the
“The fast ideas become too fast and there are far too many frequency and severity of episodes and can help people
… overwhelming confusion replaces clarity … you stop with bipolar disorder maintain good quality of life.
keeping up with it – memory goes. Infectious humour
ceases to amuse. Your friends become frightened … every­ Treatment of bipolar disorder
thing is now against the grain … you are irritable, angry,
frightened, uncontrollable, and trapped.”5 Most people with bipolar disorder – even those with the
The following is a description of a manic attack by most severe forms – can achieve substantial stabiliza-
Redfield Jamison: “At first, everything seemed so easy. I tion of their mood swings and related symptoms with
raced about like a crazed weasel, bubbling with plans and proper treatment. Because bipolar disorder is a recur-
enthusiasm, immersed in sports, staying up all night, night rent illness, long-term preventative treatment is
after night, out with friends, reading everything that wasn’t strongly recommended and almost always indicated. A
nailed down, filling manuscript books with poems, and frag­ strategy that combines medication and psychosocial

AL
ments of plays, and making expansive, completely unreal­ treatment is optimal for managing the disorder over
time.

N
istic plans for my future.”6

O R
FI
The following is a description of a depressive phase:

- N IE
“Then the bottom became to fall out of my life and mind. Medication

T
T V
My thinking, far from being clearer than a crystal, was
N SE
Medications known as “mood stabilizers” are usually
tortuous. I would read the same passage over and over again
prescribed to help control bipolar disorder. Several dif-
only to realize that I had no memory at all for what I had
TE L

ferent types of mood stabilizer are available. In general,

N E

just read. Each book or poem I picked up was the same way.
people with bipolar disorder continue treatment with
Incomprehensible, nothing made sense.”7
O F

mood stabilizers for extended periods of time (years).

C O

Other medications are added when necessary, typically

E TY

Course of bipolar disorder for shorter periods, to treat episodes of mania or

depression that break through despite the mood
PL R

Episodes of mania and depression typically recur across

stabilizer. Medications for bipolar disorder include the
M PE

the life span. Between episodes, most people with

following.
bipolar disorder are free of symptoms, but as many as
SA O

one-third of people have some residual symptoms. A • Lithium, the first mood-stabilizing medication
PR

small percentage of people experience chronic unre- approved by the US Food and Drug Administration
mitting symptoms despite treatment. (FDA) for treatment of mania, is often very effective
The classic form of the illness, which involves recur- in controlling mania and preventing the recurrence
rent episodes of mania and depression, is called bipolar of both manic and depressive episodes.
I disorder. Some people, however, never develop severe • Anticonvulsant medications, such as valproate
mania but instead experience milder episodes of hypo- (Depakote) or carbamazepine (Tegretol), also can
mania that alternate with depression; this form of the have mood-stabilizing effects and may be especially
illness is called bipolar II disorder. When four or more useful for difficult-to-treat bipolar episodes.
episodes of illness occur within a 12-month period, a • Newer anticonvulsant medications, including
person is said to have rapid-cycling bipolar disorder. lamotrigine (Lamictal), gabapentin (Neurontin)
Some people experience multiple episodes within a and topiramate (Topamax), are being studied to
single week, or even within a single day. Rapid cycling determine how well they work in stabilizing mood
tends to develop later in the course of illness and is cycles.
more common among women than among men. Generally, children and adolescents with bipolar dis-
People with bipolar disorder can lead healthy and order are treated with lithium, but valproate and car-
productive lives when the illness is effectively treated. bamazepine also are used. There is some evidence that
Without treatment, however, the natural course of valproate may lead to adverse hormone changes in
502 The Psyche in Chinese Medicine

teenage girls and polycystic ovary syndrome in women • Family therapy uses strategies to reduce the level of
who began taking the medication before age 20.8 distress within the family that may either
Therefore, young female patients taking valproate contribute to or result from the ill person’s
should be monitored carefully by a physician. symptoms.
Research has shown that people with bipolar disor- • Interpersonal and social rhythm therapy helps people
der are at risk of switching into mania or hypomania, with bipolar disorder both to improve interpersonal
or of developing rapid cycling, during treatment relationships and to regularize their daily routines.
with antidepressant medication. Therefore, “mood- Regular daily routines and sleep schedules may
stabilizing” medications generally are required, alone help protect against manic episodes.
or in combination with antidepressants, to protect
people with bipolar disorder from this switch. Lithium
and valproate are the most commonly used mood-
History
stabilizing drugs today. Aretaeus of Cappadocia (2nd century ad) was probably
Atypical antipsychotic medications, including clo- the first doctor who correlated melancholia with
zapine (Clozaril), olanzapine (Zyprexa), risperidone mania: “Melancholia is without any doubt the beginning
(Risperdal), quetiapine (Seroquel) and ziprasidone and even part of the disorder called mania.”9
(Geodon), are being studied as possible treatments for Alexander of Tralles (ad 57) said: “Mania is nothing

AL
bipolar disorder. else but melancholia in a more intense form.”10

N
Jason Pratensis (16th century) said: “Most physicians

O R
FI
associate mania and melancholia as one disorder.”11 He
Psychosocial treatments
- N IE
distinguished mania and melancholia by degree and

T
T V
manifestation only.
N SE
As an addition to medication, psychosocial treatments Dr Thomas Willis (17th century) said:12
– including certain forms of psychotherapy – are
TE L

helpful in providing support, education and

N E

In the melancholic … the spirits were sombre and dim;

guidance to people with bipolar disorder and their they cast their shadows over the images of things and
O F

families. Studies have shown that psychosocial

C O

formed a kind of dark tide; in the manic, on the contrary,

interventions can lead to increased mood stability, the spirits seethed in a perpetual ferment; they were
E TY

fewer hospitalizations and improved functioning in carried by an irregular movement, constantly repeated; a
several areas.
PL R

movement that eroded and consumed, and even without

A licensed psychologist, social worker or counselor
M PE

fever, sent out its heat. Between mania and melancholia,

typically provides these therapies and often works the affinity is evident; not the affinity of symptoms linked
SA O

together with the psychiatrist to monitor a patient’s in experience, but the affinity – more powerful and so
PR

progress. The number, frequency and type of sessions much more evident in the landscapes of the imagination –
should be based on the treatment needs of each that unites in the same fire, both smoke and flame.
person. Psychosocial interventions commonly used
for bipolar disorder are cognitive behavioral Richard Mead (1751) said:13
therapy, psychoeducation, family therapy and a
newer technique, interpersonal and social rhythm Two kinds of Madness … the one is attended with
therapy. audaciousness and fury, the other with sadness and fear;
• Cognitive behavioral therapy helps people with and that they call mania, this melancholy. But these
bipolar disorder to learn to change inappropriate or generally differ in degree only. For melancholy very
negative thought patterns and behaviors associated frequently changes, sooner or later, into maniacal
with the illness. madness, and, when the fury is abated, the sadness
• Psychoeducation involves teaching people with generally returns heavier than before.
bipolar disorder about the illness and its treatment,
and how to recognize signs of relapse so that early Jean Pierre Falret and Jules Baillarger (mid 19th
intervention can be sought before a full-blown century) formally posited that mania and depression
illness episode occurs. Psychoeducation may also could represent different manifestations of a single
be helpful for family members. illness.14
 Bipolar Disorder (Manic-Depression) 503

Chapter 59 of the Classic of Difficulties distinguishes

BIPOLAR DISORDER IN Dian from Kuang:19
CHINESE MEDICINE
Kuang has a sudden onset, the person does not like to lie
Bipolar disorder follows closely the symptoms of the
down or eat, has an inflated opinion of himself or herself,
ancient Chinese disease of Dian Kuang, which may be
thinks he is wise and from a noble family, is arrogant,
translated as “dullness and raving” or “dullness and
laughs and sings inappropriately, is restless and cannot
mania”.
stop. In Dian, the person is unhappy, lies down and stares
The Chinese characters for Dian Kuang are .
straight ahead.
The character Dian is composed of the following
parts:
The Classic of Difficulties says in Chapter 20: “Excess
• Zhen indicates the Daoist ideal of “gentleman” of Yin causes Dian, Excess of Yang causes Kuang.”20
• Ye is the top of the head through which the soul The Essential Prescriptions of the Golden Chest (ad
of the “gentleman” goes out 220) says:21
• Bing is the character for “disease”. The “disease”
character tells us it is a pathological state, i.e. soul Excessive crying makes the Ethereal Soul and Corporeal
leaving through the top of the head. Soul restless, Blood and Qi are depleted, when these are

AL
The character Kuang indicates the rambling of a depleted the Heart is affected, Heart-Qi becomes deficient,

N
mad dog. the patient becomes fearful, the eyes close and want to

O R
FI
Dian indicates a depressive state, indifference, being sleep, there are excessive dreams which disperse the

- N IE
withdrawn, worry, unresponsiveness, incoherent Spirit, and the Ethereal Soul and Corporeal Soul are

T
T V
speech, quiet, inappropriate laughter and taciturnity; agitated. If there is Yin deficiency, Depression [Dian]
N SE
Kuang indicates agitation, shouting, scolding and develops; if Yang deficiency, Mania [Kuang] develops.
hitting people, irritability, aggressive behavior,
TE L
N E

offensive speech, inappropriate laughter, singing, Sun Si Miao describes Dian Kuang in his Thousand
climbing high places, wild behavior, smashing objects, Golden Ducats Prescriptions (ad 652):22
O F
C O

unusual physical strength, and refusing sleep and

food. In Dullness and Mania [Dian Kuang], the patient may be
E TY

silent and emit no sound, speak incessantly, sing and cry,

PL R

Historical development of Dian chant or laugh, sleep sitting in ditches, eat his or her own
M PE

feces, discard clothes to be naked, sleep-walk, be angry

Kuang in Chinese medicine and shout; these are symptoms of Dullness and Mania
SA O

The earliest mention of the term Kuang (mania) is in a [Dian Kuang]. It must be treated with acupuncture and
PR

non-medical text. The Rites of Zhou (1100 bc) says: herbs.

“Some people behave strangely in a manic [Kuang] way:
this disease is called Mania [Kuang].”15 A text from the Yuan dynasty attributes the develop-
The conditions of Dian and Kuang appear as early as ment of Kuang to excess Fire and the disconnection
in the Yellow Emperor’s Classic of Internal Medicine. between Heart and Kidneys: “The Kidney Water controls
Chapter 74 of the Simple Questions says: “The syndrome the Will-Power [Zhi] and is in opposition with Fire; when
of irritable raving [Kuang] is due to Fire.”16 Chapter 46 of Heart-Fire is exuberant, Kidney Water is depleted with the
the Simple Questions says: “Irritable raving is due to loss of Will-Power and the development of Mania
[Excess] Yang … and is treated with the formula Sheng Tie [Kuang].”23 It also says: “When Heart has Heat, the
Luo Yin.”17 patient laughs and has Dian; when the Liver has Heat, the
The Spiritual Axis says in Chapter 22:18 patient is angry and there is Kuang.”24
The Essential Methods of Dan Xi (Dan Xi Xin Fa, 1347)
When Dian first appears, there is lack of joy, heavy and says: “Dian pertains to Yin and Kuang to Yang … all cases
painful head, red eyes, eyes looking up. When Kuang first are due to Phlegm stagnating in the space between the
appears, there is little sleep, no hunger, glorification of the Heart and the chest.”25 Zhu Dan Xi was the first doctor
self as if one were the most knowledgeable person, who correlated the pathogenesis of Dian Kuang with
shouting at people, no rest in day or night. Phlegm. In another passage, he clearly correlates the
504 The Psyche in Chinese Medicine

development of Manic-Depression to stagnation, not exactly correspond to mania. For example, some of
Phlegm and Fire: “The Fire of the five spirits [i.e. Mind, the manifestations of Kuang would fall under the cate-
Ethereal Soul, Corporeal Soul, Intellect and Will- gory of generalized anxiety disorder.
Power] is due to the arousal of the seven emotions and In particular, the symptoms of Dian do not necessar-
stagnation gives rise to Phlegm.”26 ily correspond exactly to the depressive phase of bipolar
The Correct Transmission of Medicine (Yi Xue Zheng disorder. Moreover, the symptoms of Dian do not cor-
Chuan) of the Ming dynasty confirms the association of respond to what we call “depression” in Western psy-
Mania (Kuang) with Phlegm and Fire, and says:27 chiatry. Modern Chinese books equate the symptoms
of Dian with depression but I find this unhelpful. I
Mania [Kuang] is a Full condition due to Phlegm and maintain that, first, the pathology of depression is quite
Fire; Dullness [Dian] is due to Heart deficiency. To treat different from that of the depressive phase of bipolar
Mania, use the moving downward method; to treat disorder, and second, the symptoms of Dian are not
Dullness calm the Mind and nourish Blood; in both cases necessarily or always those of the depressive phase of
eliminate Phlegm-Fire. Manic-Depression. Indeed, especially Dian may corre-
spond to some cases of schizophrenia.
The last statement is interesting, as it confirms
that Phlegm is central to the pathology of Manic-

AL
Depression and is present in both the manic and the

N
depressive phases. CLINICAL NOTE

O R
FI
In the ancient literature, the differentiation Please note that Dian Kuang does not necessarily

- N IE
between Dian Kuang and epilepsy is often not clear.

T
correspond exactly to bipolar disorder. Indeed,
T V
Wang Ken Dang of the Ming dynasty was the first to especially Dian may correspond to some cases of
N SE
make a clear differentiation between Dian Kuang and schizophrenia.
epilepsy.
TE L
N E

The Complete Book of Jing Yue (Jing Yue Quan Shu,

1624) says: “In Kuang the patient is always active and
O F
C O

angry; in Dian, the patient is quiet and withdrawn as if he Moreover, when discussing bipolar disorder, some
or she were unconscious.”28 In treatment, Zhang Jing modern books simply merge the patterns of Depression
E TY

Yue advocates first of all draining Fire as the principal (Yu Zheng) with those of Kuang to offer a differentiation
PL R

method of treatment; secondarily, one must resolve and treatment for this disease.31 I personally think this
M PE

Phlegm and move Qi.29 is unhelpful.

Wang Qing Ren in his Corrections of Errors of Medical It is worth noting that epilepsy (called Dian Xian in
SA O

Circles (Yi Lin Gai Cuo) attributes the pathology of Dian which “dian” is the same as in Dian Kuang) was wrongly
PR

Kuang to Blood stasis:30 classified with mental illnesses in ancient Chinese med-
icine. One particular modern Chinese doctor actually
In Dian Kuang the patient cries, laughs, shouts, curses, maintains that the word Dian in Chapter 22 of the
sings. This is due to Qi and Blood stagnation in the Brain Spiritual Axis refers to epilepsy and not to Dian
and to stagnation in the Internal Organs. Kuang.32
Indeed, the description of the symptoms of Dian from
Correspondences and differences Chapter 22 of the Spiritual Axis (entitled Dian Kuang)
between bipolar disorder and sounds a lot more like epilepsy than those of the mental
illness Dian:33
Dian Kuang
Although the symptoms of Dian Kuang closely resemble In the initial stages of Dian, the patient is unhappy, there
those of bipolar disorder, we must always exercise is heaviness and pain of the head, with the eyes looking up
caution when making direct connections between … in later stages, the patient has twitching of the mouth,
Western and Chinese medicine. As we shall see when crying out, panting and palpitations … then the body is
we discuss the patterns of Dian and of Kuang, Dian does stiff and arched in the wrong direction, and there is pain
not exactly correspond to depression and Kuang does in the spine.
 Bipolar Disorder (Manic-Depression) 505

Further on, the chapter seems to confirm that it is and the executive functions that allow us to plan
talking about tremors as it distinguishes three types of and organize.
Dian, i.e. Bone Dian, Sinews Dian and Blood-Vessel The term “negative symptoms” refers to reductions
Dian. Dr Zhang then says that, by contrast, the term in normal emotional and behavioral states, which
Kuang in Chapter 22 of the Spiritual Axis includes both include:
mental illnesses of Dian and Kuang.
• flat affect (immobile facial expression, monotonous
voice)
• lack of pleasure in everyday life
CLINICAL NOTE • diminished ability to initiate and sustain planned
One modern Chinese doctor maintains that the activity
word Dian in Chapter 22 of the Spiritual Axis refers • speaking infrequently, even when forced to
to epilepsy and not to Dian Kuang. interact.
As can be seen, the above “negative symptoms” of
schizophrenia resemble those of Dian. Figure 19.2
To complicate matters further, the disease category summarizes the relationships between Dian Kuang and
of Dian Kuang may even correspond in some cases to Western psychiatric disorders.

AL
schizophrenia in Western medicine. In fact, in a modern Therefore, although we must be careful in making
Chinese clinical trial, of the 30 patients suffering from direct connections between Western and Chinese

N
O R
Dian Kuang that were treated, 16 had a diagnosis of medical disease entities, the formulae used for the

FI
- N IE
schizophrenia.34 The modern book Chinese Internal treatment of Dian Kuang can be adapted to the treat-

T
T V
Medicine confirms this possibility as, under the chapter ment of bipolar disorder.
N SE
of Dian, it reports the treatment of four cases of
schizophrenia.35
TE L

People with schizophrenia may hear “voices” or

N E

believe that others are reading their minds, controlling

O F

their thoughts or plotting to harm them. These experi-

C O

ences are terrifying and can cause fearfulness, with- CHINESE MEDICINE WESTERN MEDICINE
E TY

drawal or extreme agitation. People with schizophrenia

may not make sense when they talk, may sit for hours
PL R

DEPRESSIVE PHASE OF
without moving or talking much, or can seem perfectly
M PE

BIPOLAR DISORDER
fine until they talk about what they are really thinking.
SA O

As can be seen, some of the manifestations may resem-

PR

ble those of Dian, e.g. fearfulness, withdrawal, sitting DIAN SCHIZOPHRENIA

for hours without talking or moving.
The symptoms of schizophrenia fall into three broad
categories. EPILEPSY

• Positive symptoms are unusual thoughts or

perceptions that include hallucinations, delusions
MANIC PHASE OF
and thought disorder. BIPOLAR DISORDER
• Negative symptoms represent a loss or a decrease
in the ability to initiate plans, speak, express
emotion or find pleasure in everyday life. These KUANG PSYCHOSIS
symptoms are harder to recognize as part of the
disorder and can be mistaken for laziness or
depression. Again, these may resemble those of SCHIZOPHRENIA
Dian.
• Cognitive symptoms (or cognitive deficits) are Figure 19.2 Relationships between Dian Kuang and Western
problems with attention, certain types of memory psychiatric disorders.
506 The Psyche in Chinese Medicine

Zheng, see Chapter 16). In Depression (Yu Zheng), there

SUMMARY are many patterns without Phlegm. Moreover, the
depressive and the manic phases of bipolar disorder,
Correspondences and differences between
although so different from each other in their manifes-
bipolar disorder and Dian Kuang
tations, are really two sides of the same coin. I therefore
In conclusion, I would summarize the main points
disagree with modern Chinese books which, when
regarding the correspondence between Dian Kuang
describing the symptoms of Depression (Yu Zheng), list
and psychiatric diseases as follows.
many of the symptoms of the depressive phase (Dian)
1. Dian Kuang does not necessarily correspond
of Dian Kuang.
exactly to bipolar disorder.
2. Dian is not depression as we intend it in Western
psychiatry.
3. Dian could correspond to schizophrenia. CLINICAL NOTE
4. Epilepsy was often confused with Dian of Dian Phlegm is central to the pathology of bipolar
Kuang in the past. disorder (and of Dian Kuang) in both its manic and
5. Dian Kuang itself may correspond to depressive phases.
schizophrenia.

AL
N
As there is Phlegm, bipolar disorder is, by definition,

O R
Pathology of Dian Kuang

FI
a case of Mind Obstructed, while Depression (Yu Zheng)

- N IE
is seldom so.
Disharmony of Yin and Yang

T
T V
N SE
In Dian Kuang there is always a disharmony of Yin and
Yang. Chapter 3 of the Simple Questions says: “When CLINICAL NOTE
TE L
N E

Yin does not vanquish Yang, the pulse is Overflowing and The “depression” of the depressive phase of bipolar
there is Kuang.”36 Chapter 23 of the Simple Questions
O F

disorder is different from that of “Depression”: in

C O

says: “When pathogenic factors enter Yang, there is Kuang; bipolar disorder, the Mind is Obstructed by
when they enter Yin, Painful Obstruction syndrome.”37 definition; in Depression, it is only seldom so.
E TY

Chapter 20 of the Classic of Difficulties says: “In Excess

PL R

of Yang there is Kuang; in Excess of Yin, Dian.”38 The

M PE

Discussion of the Origin of Symptoms in Diseases (Zhu

Bing Yuan Hou Lun) (ad 610) says: “When Qi merges Fire harassing upwards
SA O

with Yang, there is Kuang.”39

PR

Thus, as a broad generalization, we can say that in The constraint of Qi-induced emotional stress usually
Mania there is an Excess of Yang such as Fire; in this leads to Heat and Fire. In Manic-Depression, there is
condition, there is an Excess of Yang also in the sense nearly always Fire which, together with Phlegm,
that Yang is rising to the top of the body. accounts for the rash behavior during the manic phase.
In Dullness, there is broadly speaking an Excess of As we have seen above, all the old texts attribute Kuang
Yin in the form of Phlegm and Qi stagnation. Of course, to Fire and Excess of Yang. Fire combines with Phlegm
that is not to say that there is no Phlegm in Mania as and it harasses upwards to agitate the Mind while the
there certainly is, but it is usually combined with Phlegm obstructs it.
Fire. The Fire harassing upwards derives primarily from
the Liver and Heart.
Phlegm
Qi stagnation and Blood stasis
Central to the pathology of Dian Kuang is Phlegm and
both the depressive and the manic phases are due to The Qi stagnation caused by emotional stress in time
obstruction of the Mind by Phlegm. This is a major dif- leads to Blood stasis; this is a feature of chronic cases
ference between the depressive phase of bipolar disor- of Manic-Depression and one that complicates the con-
der (or Dian Kuang) – Dullness – and “Depression” (Yu ditions of Phlegm and Fire.
 Bipolar Disorder (Manic-Depression) 507

Disharmony of the “coming and going” of the Ethereal Soul is excessive, either by itself (on the
of the Ethereal Soul (Hun) left side) or because the Mind does not control it enough
(on the right side).
It is also my opinion that, in bipolar disorder (and in If the movement of the Ethereal Soul is excessive,
Dian Kuang), the primary aspect is the manic phase, contents breaking through from the Ethereal Soul
and the depressive phase is merely a reaction to it.40 cannot be integrated by the Mind. The Mind should
This means that, contrary to what happens in Depres- integrate the Ethereal Soul so that images, symbols and
sion (Yu Zheng), in bipolar disorder (and in Dian Kuang) dreams coming from it can be assimilated. When the
the essential pathology is the excessive “coming and “coming and going” of the Ethereal Soul is excessive,
going” of the Ethereal Soul, even in its depressive phase there is a steady and excessive stream of ideas, inspira-
(see below). tion and plans flooding the Mind; in serious cases, this
As described in Chapters 3 and 16, the Ethereal Soul can lead to mania.
gives the Mind inspiration, creativity, ideas, plans, life
dreams and aspirations; this psychic energy is the Degrees of “mania”
result of the “coming and going of the Ethereal Soul”
and it is the psychic manifestation of the free flow of The important thing to realize is that mania and manic
Liver-Qi (and, in particular, of the physiological ascend- behavior can occur in many degrees of severity, i.e. the

AL
ing of Liver-Qi). border between “mental illness” and “normality” is not

N
On the other hand, the Mind needs to control the a clear-cut separation. There is, however, a broad area

O R
FI
Ethereal Soul somewhat and to integrate the psychic of behaviors that, while not normal, do not constitute

- N IE
material deriving from it. It is in the nature of the Ethe- “mental illness”. In other words, in its milder forms,

T
T V
real Soul to “come and go”, i.e. it is always searching, “mania” and “manic behavior” are relatively common;
N SE
it has ideas, inspiration, aims, etc. The Mind needs to these are states of “mania” that are even below that
integrate the material deriving from the Ethereal Soul represented by hypomania. Whenever the “coming
TE L

and going” of the Ethereal Soul is excessive, there is the

N E

into the general psyche: the Ethereal Soul is the source

of many ideas simultaneously; the Mind can only deal possibility of “manic” behavior.
O F

Thus, in mania, there is always an excessive move-

C O

with one at a time. Therefore “control” and “integra-

tion” are the key words describing the function of the ment of the Ethereal Soul.
E TY

Mind in relation to the Ethereal Soul (see Fig. 3.15).

PL R

When the “coming and going” of the Ethereal Soul

M PE

is deficient, there is a lack of inspiration, creativity,

CLINICAL NOTE
ideas, plans, life dreams and aspirations; this is an
SA O

Mania and manic behavior can occur in many

important feature of mental depression. In severe
degrees of severity, i.e. the border between
PR

depression, there is a disconnection between the Mind “mental illness” and “normality” is not a clear-cut
(Shen of the Heart) and Ethereal Soul (Hun); the Ethe- separation between the two. There is, however, a
real Soul lacks its normal “movement” and the person broad area of behaviors that, while not normal, do
lacks creativity, ideas, imagination and, most of all, not constitute “mental illness”. In other words, in
plans, projects, life aims and inspiration so that depres- its milder forms, “mania” and “manic behavior”
sion results. are relatively common. Whenever the “coming and
When the movement of the Ethereal Soul is excessive going” of the Ethereal Soul is excessive, there is the
by itself, or because the Mind is weak and fails to possibility of “manic” behavior.
restrain and control it, this may be too restless and its
“movement” excessive; this will only bring confusion
and chaos to the Mind, making the person scattered, My own criteria for diagnosing mild “mania” (i.e. in
unsettled and slightly manic. This can be observed in normal people who are not mentally ill and below the
some people who are always full of ideas, dreams and level of hypomania) are as follows.
projects, none of which ever comes to fruition because • Mental restlessness, agitation
of the chaotic state of the Mind, which is therefore • Hyperactivity
unable to restrain the Ethereal Soul. Figure 3.15 illus- • Working and being active at night
trates the two situations when the “coming and going” • Spending a lot
508 The Psyche in Chinese Medicine

• Having many projects simultaneously, none of ETIOLOGY OF DIAN KUANG

which comes to fruition
• Mental confusion Emotional stress
• Obsessive thoughts
• Laughing a lot Emotional stress is the main etiological factor of bipolar
• Talking a lot disorder. Anger, worry, excess joy and guilt may all be
• Propensity to take risks the initial cause of this disease. The initial Qi stagna-
• Often artistic tion resulting from emotional stress generates Heat,
which harasses the Mind. The stagnation of Qi in the
Triple Burner leads to the impairment of the transfor-
SUMMARY mation of fluids and therefore to Phlegm. This is also
aggravated by the condensing action of Heat on
Symptoms of mild “mania” in
fluids.
normal individuals
Anger, shock and fear injure Liver and Kidneys;
• Mental restlessness, agitation
these become deficient and lose the nourishment of
• Hyperactivity
Water, which causes Dian. Excess joy and anger injure
• Working and being active at night
Heart-Yin; this leads to Heart-Fire and Kuang. Pensive-
• Spending a lot

AL
ness and worry injure Heart and Spleen, the Heart
• Having many projects simultaneously, none of
loses its nourishment, the Spleen cannot transform;

N
which comes to fruition

O R
this leads to Dian.

FI
• Mental confusion

- N IE
Worry and pensiveness injure Heart and Spleen; the
• Obsessive thoughts

T
T V
latter cannot transform and transport, and this gives
• Laughing a lot
N SE
rise to Phlegm.
• Talking a lot
The Complete Book of Jing Yue (Jing Yue Quan Shu)
TE L

• Propensity to take risks

says: “Kuang is due to Fire deriving from worry, pensive­
N E

• Often artistic
ness and anger.”43
O F

Zhang Jing Yue says:44

C O

It is interesting to note that people suffering from

Kuang is due to Fire deriving from worry and anger; the
E TY

bipolar disorder are often artistic. Or to put it differ-

ently, among famous artists there is a disproportionate Qi of Liver and Gall-Bladder rebels upwards, Wood and
PL R

incidence of bipolar disorder.41 This is due to the fact Fire combine, the condition is Full, pathogenic factors
M PE

that the artistic inspiration derives from the Ethereal invade the Heart so that the Mind and Ethereal Soul
Soul; therefore, the same psychic energy of the Ethe- become restless.
SA O

real Soul that makes someone artistic, in pathological

PR

Interestingly, Dr Zhang Fa Rong includes shock as

conditions, may also make them mentally ill. an emotional cause of disease for Dian Kuang. He says
During manic episodes, the bipolar patient is bris- that a big shock injures the Kidneys.45
tling with ideas, he or she is inspired, feelings intensify,
sensations are keener and he or she often writes Diet
poetry.42
As Phlegm plays a central role in the pathology of
bipolar disorder, irregular diet is an important contrib-
SUMMARY uting factor to its etiology. Excessive consumption of
dairy foods, fried food, fatty foods, carbohydrates and
Pathology of Dian Kuang sugar leads to the formation of Phlegm.
To summarize, the main elements of the pathology
Phlegm may also be formed when the person eats in
of Manic-Depression are:
an irregular and chaotic way, i.e. eating late at night,
• disharmony of Yin and Yang
eating in a hurry, eating while working, etc.
• Phlegm
• Fire harassing upwards Constitution
• Qi stagnation and Blood stasis
• disharmony of the Ethereal Soul. A constitutional tendency to mental-emotional prob-
lems plays a role in the development of bipolar disor-
 Bipolar Disorder (Manic-Depression) 509

der. Both children and adolescents can develop bipolar

disorder. It is more likely to affect the children of parents
PATHOLOGY AND TREATMENT
who have the illness.46
PRINCIPLES OF DIAN KUANG
Interestingly, as far back as the time when the Yellow
Emperor’s Classic of Internal Medicine was written Pathology of Dian Kuang
(approximately 100 bc), Chinese doctors knew that The pathology of bipolar disorder is complex, especially
heredity plays a role in the development of Manic- in chronic conditions. In the beginning stages there is
Depression. The Simple Questions says in Chapter 47:47 Qi stagnation, Fire and Phlegm, while in later stages,
The disease of Dian arises in the mother’s womb during there is also a deficiency (of Qi, Blood or Yin). The
gestation and it is due to the mother’s suffering a big manic stage is characterized by more Fullness while
shock so that Qi rises and cannot descend to the residence the depressive stage is characterized by a mixture of
of Essence [Jing]; this leads to the development of Dian in Full and Empty conditions. Four words could summa-
the fetus. rize the pathology of bipolar disorder: Qi (stagnation),
Fire, Phlegm and Stasis (of Blood).
Because bipolar disorder tends to run in families,
researchers have been searching for specific genes
passed down through generations that may increase a CLINICAL NOTE

AL
person’s chance of developing the illness. But genes are Four words could summarize the pathology of
bipolar disorder:

N
not the whole story. Studies of identical twins, who

O R
• Qi (stagnation)

FI
share all the same genes, indicate that both genes and

- N IE
• Fire
other factors play a role in bipolar disorder. If bipolar

T
• Phlegm
T V
disorder were caused entirely by genes, then the identi-
• Stasis (of Blood).
N SE
cal twin of someone with the illness would always
develop the illness, and research has shown that this is
TE L
N E

not the case. But if one twin has bipolar disorder, the Central to the pathology of bipolar disorder (and Dian
other twin is more likely to develop the illness than is Kuang) is Phlegm. Bipolar disorder is a serious mental
O F
C O

another sibling.48 illness characterized by loss of insight; in Chinese

From the point of view of Chinese medicine, a tongue terms, this is due to obstruction of the Mind’s orifices.
E TY

with a deep Heart crack indicates the tendency to The Mind’s orifices can be obstructed by Phlegm or by
PL R

mental-emotional problems (see Fig. 11.6). severe Blood stasis. In bipolar disorder (and Dian
M PE

Figure 19.3 summarizes the etiology of Dian Kuang. Kuang), the Mind’s orifices are obstructed principally
by Phlegm, although, in later stages, Blood stasis may
SA O

also contribute to the obstruction. Obstruction of the

PR

SUMMARY Mind by Phlegm accounts for both the manic and the
depressive phases of bipolar disorder.
Etiology of Dian Kuang
Please note that Phlegm does not derive only from a
• Emotional stress
Spleen deficiency: Qi stagnation may give rise to
• Diet
Phlegm by obstructing the free flow of Qi in the Three
• Constitution
Burners; Fire can also give rise to Phlegm by condens-
ing the body fluids; Blood stasis (which itself derives
EMOTIONAL
from Qi stagnation) aggravates Phlegm.
STRESS In bipolar disorder, there is usually also Fire, which
agitates the Mind and Ethereal Soul and “stokes up”
the manic behavior of the person. In chronic cases, Fire
IRREGULAR DIET DIAN KUANG injures Yin and the resulting Empty Heat further agi-
tates the Mind.
Furthermore, the Qi stagnation that is usually
CONSTITUTION present in the beginning stages of bipolar disorder may
also give rise to Blood stasis; this further clouds the
Figure 19.3 Etiology of Dian Kuang. Mind’s orifices.
510 The Psyche in Chinese Medicine

In Dian, there is often Phlegm with Qi stagnation and ration, etc. in a chaotic way that leads to mania. This
a deficiency of the Heart and Spleen; in Kuang, there is has already been discussed above.
often Phlegm-Fire agitating and obstructing the Mind The Mind needs to control and integrate the psychic
and eventually leading to Yin deficiency. In chronic material deriving from the Ethereal Soul; the Mind can
cases, the Qi stagnation and the Phlegm may also give deal with only one thing at a time. Flooding of the Mind
rise to Blood stasis. by the psychic material deriving from the Ethereal Soul
The Medical Records of the Guide to Clinical Practice results in total immersion of the Mind within the
(Lin Zheng Zhi Nan Yi An) summarizes the etiology and Ethereal Soul and therefore mental illness as in bipolar
pathology of Dian Kuang as follows:49 disorder; this situation is illustrated in Figure 3.21.
The pathology of the depressive phase is character-
Mania [Kuang] is due to a big shock and big anger; the ized by a mixture of Full and Empty conditions. In the
disease is in the Liver, Gall-Bladder and Stomach beginning stages, there is Qi stagnation and Phlegm
channels, the three Yang rise, Fire burns and Phlegm which obstructs the Mind’s orifices. In chronic cases,
surges, the orifices of the Heart are obstructed. Dullness there is a deficiency of the Heart and Spleen.
[Dian] is due to worry, the disease is in the Spleen, Heart The main organs involved in the pathology of bipolar
and Pericardium channels; the three Yin cannot diffuse, disorder are therefore the Heart, Liver, Lungs and
Qi stagnates and Phlegm is formed so that the Mind is Spleen. The pathology affecting these organs is sum-

AL
confused. marized in Figure 19.4.

N
O R
FI
In conclusion, the pathology of the manic phase of

- N IE
bipolar disorder is characterized by Qi stagnation in its

T
T V
beginning stages; Qi stagnation in the Three Burners
N SE
leads to the formation of Phlegm that clouds the Mind’s
orifices. On the other hand, Qi stagnation also leads to HE
TE L
N E

Fire, which harasses the Mind and causes mania. In

chronic cases, Qi stagnation also leads to Blood stasis,
O F
C O

which obstructs the Mind’s orifices further. In chronic

conditions, Fire injures Yin and leads to Yin deficiency. Blood Blood
E TY

deficiency Fire
The main organs involved are Heart, Liver and stasis
PL R

Spleen.
M PE
SA O

CLINICAL NOTE
PR

SP PHLEGM LU
Pathology of manic phase
The pathology of the manic phase of bipolar
disorder is characterized by:
• Qi stagnation
• Phlegm that clouds the Mind’s orifices Blood
• Fire which harasses the Mind and causes mania Fire
stasis
• Blood stasis which obstructs the Mind’s orifices
further
• Yin deficiency.
The main organs involved are Heart, Liver and Qi
Spleen. stagnation

Another essential characteristic of the pathology of

bipolar disorder in its manic phase is the excessive LIV
“coming and going” of the Ethereal Soul, resulting in
the flooding of the Mind by ideas, projects, plans, inspi- Figure 19.4 Pathology of Dian Kuang.
 Bipolar Disorder (Manic-Depression) 511

• Resolve Phlegm: in case of Phlegm, add Tian

SUMMARY Zhu Huang Concretio Silicea Bambusae and
Dan Nan Xing Rhizoma Arisaematis preparatum.
Pathology of Dian Kuang
The pathology of Manic-Depression (Dian Kuang) Doctors Shen Quan Yu, Wu Yu Hua and Shen Li
can be summarized as follows. Ling advocate the following treatment principles. They
• Phlegm say that the condition causing Dullness (Dian) is Yin
• Fire and Empty in character, and that the main pathogenic
• Qi stagnation factors are Phlegm and Qi stagnation. The treatment
• Blood stasis principle is therefore to resolve Phlegm, move Qi, elimi-
• Deficiency (of Qi, Blood or Yin) nate stagnation, settle the Heart, calm the Mind, tonify
Qi and nourish Blood.
The condition leading to Mania (Kuang) is Yang and
Full in character; the main pathogenic factors are Fire,
Treatment principles for Dian Kuang Phlegm and Blood stasis. The treatment principle is
therefore to drain Fire, resolve Phlegm, invigorate
In view of the pathology of bipolar disorder, the main Blood and eliminate stasis; in later stages nourish Yin
treatment principles are as follows. and clear Empty Heat.

AL
• Move Qi The treatment principle of Dullness in the acute

N
• Resolve Phlegm stage must address the Manifestation, resolve Phlegm

O R
FI
and open the Mind’s orifices. In between attacks, one

- N IE
• Nourish Heart and Spleen
must tonify the Heart and the Spleen, resolve Phlegm,

T
• Drain Fire
T V
• Nourish Blood move Qi and eliminate stagnation (treating the Root).
N SE

• Nourish Yin if necessary The treatment principle of Mania in the acute stage
TE L

• Invigorate Blood must address the Manifestation by resolving Phlegm

N E

• Calm the Mind and opening the Mind’s orifices. In between attacks,
O F

• Open the Mind’s orifices one must regulate Yin and Yang, nourish Yin and
C O

clear Empty Heat (treating the Root). See Table 19.1.

The veteran Beijing doctor Zhang Li Sheng treated
E TY

The above doctors recommend the following treat-

hundreds of cases of Dian Kuang. He recommends the ment methods and applicable herbs.
PL R

following treatment principles.50

• Move Qi: Xiang Fu Rhizoma Cyperi, Mu Xiang Radix
M PE

• Nourish the Heart and calm the Mind: Yuan Zhi Aucklandiae, Yu Jin Radix Curcumae.
Radix Polygalae, Bai Zi Ren Semen Platycladi, Suan • Resolve Phlegm and open the Mind’s orifices: Dan Nan
SA O

Zao Ren Semen Ziziphi spinosae, Fu Ling Poria, Hu Xing Rhizoma Arisaematis preparatum, Ban Xia
PR

Po Succinum. Rhizoma Pinelliae preparatum, Fu Ling Poria, Shi

• Clear the Heart and open the Mind’s orifices: Shi Chang Pu Rhizoma Acori tatarinowii, Yu Jin Radix
Chang Pu Rhizoma Acori tatarinowii, Yu Jin Radix Curcumae.
Curcumae, Gou Teng Ramulus cum Uncis Uncariae, • Nourish the Heart and calm the Mind: Dang Gui
Lian Zi Xin Plumula Nelumbinis nuciferae. Radix Angelicae sinensis, Bai Zi Ren Semen Platycladi,
• Move Liver-Qi: Xiang Fu Rhizoma Cyperi, Hou Po Yuan Zhi Radix Polygalae, Suan Zao Ren Semen
Cortex Magnoliae officinalis. Ziziphi spinosae, Wu Wei Zi Fructus Schisandrae.

Table 19.1 Treatment principles for Dian and Kuang

ACUTE STAGE (TREAT MANIFESTATION) IN BETWEEN ATTACKS (TREAT ROOT)

Depression (Dian) Resolve Phlegm, open the Mind’s orifices Tonify Heart and Spleen, resolve Phlegm, move Qi

Mania (Kuang) Resolve Phlegm, open the Mind’s orifices Regulate Yin and Yang, nourish Yin or Blood, clear
Empty Heat
512 The Psyche in Chinese Medicine

• Strongly resolve Phlegm: Sheng Tie Luo Frusta Ferri, For Kuang, he advocates resolving Phlegm, draining
Dai Zhe Shi Hematitum, Zhe Bei Mu Bulbus Fire, sinking Heart-Qi, clearing the Liver. If Fire has
Fritillariae thunbergii, Da Huang Radix et Rhizoma injured Yin, nourish Yin, clear Empty Heat and calm
Rhei, Dan Nan Xing Rhizoma Arisaematis the Mind.
preparatum. Interestingly, Dr Zhang says that until the Yuan
• Drain Fire and resolve Phlegm: Da Huang Radix dynasty, Dian Kuang was often confused with Dian Xian
et Rhizoma Rhei, Long Dan Cao Radix (epilepsy) and epilepsy was wrongly classified as a
Gentianae, Huang Lian Rhizoma Coptidis, mental illness. Wang Ken Dang of the Ming dynasty
Shi Gao Gypsum fibrosum, Zhi Mu Radix was the first to distinguish Dian Kuang from Dian Xian
Anemarrhaenae. (epilepsy).
• Resolve Phlegm with the attacking method: Meng Shi The famous gynecologist of the Qing dynasty, Fu
Lapis Chloriti seu Micae, Ban Xia Rhizoma Pinelliae Qing Zhu, wrote a chapter on Dian Kuang in both men
(unprepared), Da Huang Radix et Rhizoma Rhei, and women. He went against the prevailing view that
Huang Qin Radix Scutellariae. mania is always due to Fire and is Yang in nature. He
• Draining Fire: Shi Gao Gypsum fibrosum, Zhi Mu maintained that there are also Cold types of mania due
Radix Anemarrhaenae, Huang Lian Rhizoma Coptidis, to Spleen-Qi deficiency and Cold Phlegm obstructing
Da Huang Radix et Rhizoma Rhei, Huang Qin Radix the Mind’s orifices.52 He therefore advocates treating

AL
Scutellariae. the Root (Ben) as well as the Manifestation (Biao). This

N
• Nourish Yin and clear Empty Heat: Sheng Di Huang means that, in the treatment of Kuang due to Cold

O R
FI
Radix Rehmanniae, Mai Men Dong Radix Phlegm, it is important not only to resolve Phlegm but

- N IE
Ophiopogonis, Xuan Shen Radix Scrophulariae, also to tonify and warm the Spleen, especially with

T
T V
Huang Lian Rhizoma Coptidis, Mu Tong Caulis high doses (over 30 g) of Ren Shen Radix Ginseng and
N SE
Akebiae trifoliatae, Gan Cao Radix Glycyrrhizae Bai Zhu Rhizoma Atractylodis macrocephalae.
uralensis. Table 19.2 compares and contrasts Depression (Dian)
TE L
N E

• Drain Liver-Fire: Long Dan Cao Radix Gentianae, Lu with Mania (Kuang).
Hui Aloe, Shan Zhi Zi Fructus Gardeniae.
O F
C O

• Invigorate Blood: Dang Gui Radix Angelicae sinensis,

Chi Shao Radix Paeoniae rubra, Tao Ren Semen Table 19.2 Differentiation between Dian
E TY

and Kuang
Persicae, Hong Hua Flos Carthami tinctorii, Yu Jin
PL R

Radix Curcumae.
DIAN KUANG
M PE

• Vomiting: Gua Di Cucumis melo, Li Lu Radix et

Rhizoma Veratri. Pathology Qi stagnation and Phlegm-Fire
SA O

Phlegm harassing the Heart

PR

Dr Zhang Fa Rong discusses the treatment principles

of Manic-Depression in his book Chinese Internal Mood Unhappy, dull Agitation, mania,
symptoms thinking anger, anxiety
Medicine.51 He advocates the following treatment
principles. Speech Silent, incoherent Incessant talking,
symptoms speech, stumbling incoherent speech,
• Regulate Yin-Yang speech shouting abuse,
cursing
• Calm the Mind
• Settle the Will-Power (ding Zhi) Movement Singing, crying, Mania, anger,
• Resolve Phlegm symptoms likes to be alone, ascends to high
sadness, erratic places and sings,
• Open the Mind’s orifices behavior casts off clothes,
• Invigorate Blood hitting people,
taking risks
He further distinguishes Dian from Kuang in identify-
ing the treatment principle. For Dian, he advocates Special points Stillness and A lot of movement
depression and frequent
moving Qi, resolving Phlegm, opening the Mind’s changes
orifices, rectifying Qi; in case of Heart and Spleen
deficiency, tonify Heart and Spleen, nourish the Heart Yin-Yang Yin Yang
character
and calm the Mind.
 Bipolar Disorder (Manic-Depression) 513

DIAN KUANG
SUMMARY
Heart and Spleen
Treatment principles for Dian Kuang deficiency with Phlegm
Phlegm-Fire
The main treatment principles are as follows.
• Move Qi
• Resolve Phlegm Qi deficiency Fire injuring
with Phlegm Yin with Phlegm
• Nourish Heart and Spleen
• Drain Fire
• Nourish Blood Fire injuring
• Nourish Yin if necessary Yin with Phlegm
Qi deficiency
• Invigorate Blood with Phlegm
• Calm the Mind Qi stagnation, Blood
• Open the Mind’s orifices stasis and Phlegm

Figure 19.5 Possible combinations of patterns of Dian and

Kuang in bipolar disorder.
How to adapt the patterns and

AL
treatment of Dian Kuang to the I believe that, in the treatment of bipolar disorder, we
treatment of bipolar disorder need to put the emphasis on the manic rather than the

N
O R
depressive side of the disease. This is because the

FI
- N IE
In the ensuing discussion, I follow the Chinese books’ depressive side is usually a reaction to a manic phase

T
discussion of Dian and Kuang separately as two single
T V
and it is really the other side of the coin of the same
N SE
disease entities. However, one of the characteristics of disease.
bipolar disorder is precisely the alternation, in the same In bipolar disorder there is always Phlegm, and in
TE L

patient, of phases of abnormally elated and abnormally the manic phase there is bound to be some Fire, usually
N E

depressed mood. in the Liver and/or Heart. In chronic conditions, Fire

O F

Therefore, patterns of both Dian and Kuang may may injure Yin and the clinical picture would become
C O

appear in the same patient, and not necessarily in the more complex.
E TY

depressive and the manic phase, respectively. In other Of course, for there to be Phlegm, there must also be
words, if, for example, a patient displays the pattern of a deficiency (and/or a stagnation) of Qi; there is usually
PL R

Heart and Spleen deficiency during the depressive a deficiency of the Spleen and/or Lungs giving rise to
M PE

phase, this pattern is not going to disappear during the Phlegm. This deficiency needs to be addressed and we
SA O

manic phase, although it may be overshadowed by a should not concentrate solely on the treatment of
PR

Full pattern such as Phlegm-Fire. More often than not, Phlegm and Fire.
each patient will have a combination of patterns and it It is extremely important to note that on no account
is not at all unusual to have a pattern from Dian (e.g. should we advise a patient to discontinue taking
Spleen and Heart deficiency) and one from Kuang (e.g. lithium or other medication prescribed by a psychia-
Phlegm-Fire harassing upwards). trist. Any change in the dosage of lithium must be
Figure 19.5 gives three examples of combinations of agreed by and discussed with the patient’s psychiatrist.
patterns from Dian and Kuang in bipolar disorder. Given the possibility of suicide in the depressive phase,
Please note that these are only examples and other this is extremely important.
combinations are possible. The combinations illus-
trated in Figure 19.5 are: CLINICAL NOTE
• Heart and Spleen deficiency with Phlegm (Dian) It is extremely important to note that on no
plus Phlegm-Fire (Kuang) account should we advise a patient to discontinue
• Qi deficiency with Phlegm (Dian) plus Fire injuring taking lithium or other medication prescribed by a
psychiatrist. Any change in the dosage of lithium
Yin with Phlegm (Kuang)
must be agreed by and discussed with the patient’s
• Qi deficiency with Phlegm (Dian) plus Fire injuring psychiatrist. Given the possibility of suicide in the
Yin with Phlegm (Kuang) plus Qi stagnation, Blood depressive phase, this is extremely important.
stasis and Phlegm (Kuang).
514 The Psyche in Chinese Medicine

Explanation of the Acupuncture Points reports Sun Si

SUMMARY Miao as saying that ST-25 is the abode of the
Corporeal Soul and Ethereal Soul; this would
How to adapt the patterns and treatment
explain the mental effect of this point that is
of Dian Kuang to the treatment of
actually not reported by modern books.53
bipolar disorder
• ST-40 Fenglong: Dian Kuang, inappropriate
• Patterns of both Dian and Kuang may appear in
laughter, inappropriate elation, desire to ascend to
the same patient and not necessarily in the
high places and sing, undress and run around,
depressive and the manic phase, respectively.
mental restlessness and “seeing ghosts”.
• For example, if a patient displays the pattern of
• ST-42 Chongyang: Dian Kuang, desire to ascend to
Heart and Spleen deficiency during the depressive
high places and sing, discarding clothes and
phase, this pattern is not going to disappear
running around.
during the manic phase, although it may be
• ST-45 Lidui: excessive dreaming, fright, insomnia,
overshadowed by a Full pattern such as
dizziness, Dian Kuang, desire to ascend to high
Phlegm-Fire.
places, sing, discard clothes and run around.
• Each patient will have a combination of patterns
• S.I.-16 Tianchuang: manic behavior, Dian Kuang
and it is not at all unusual to have a pattern from
and “talking with ghosts”.

AL
Dian (e.g. Spleen and Heart deficiency) and one
• BL-10 Tianzhu: manic behavior, incessant talking
from Kuang (e.g. Phlegm-Fire harassing upwards).

N
and “seeing ghosts”.
• In the treatment of bipolar disorder, put the

O R
FI
• P-5 Jianshi: palpitations, agitation, feeling of

- N IE
emphasis on the manic rather than the depressive
oppression of the chest, manic behavior, fright,

T
side of the disease.
T V
mental restlessness, poor memory and “seeing
N SE
• In bipolar disorder there is always Phlegm, and in
ghosts”.
the manic phase there is bound to be some Fire,
• G.B.-13 Benshen: manic behavior and fright.
TE L

usually in the Liver and/or Heart. In chronic

N E

• G.B.-17 Zhengying: obsessive thoughts, pensiveness

conditions, Fire may injure Yin and the clinical
and manic behavior.
O F

picture would become more complex.

C O

• G.B.-18 Chengling: obsessive thoughts and

• There is also a deficiency (and/or a stagnation) of
pensiveness, dementia.54
E TY

Qi; there is usually a deficiency of the Spleen and/

• Du-16 Fengfu: manic behavior, desire to commit
or Lungs giving rise to Phlegm.
PL R

suicide, sadness and fear.

• It is extremely important to note that on no
M PE

• Du-19 Houding: manic behavior, anxiety, mental

account should we advise a patient to discontinue
restlessness and insomnia.
taking lithium or other medication prescribed by a
SA O

• Du-20 Baihui: disorientation, sadness and crying

PR

psychiatrist.
with desire to die, mania.
• Du-26 Renzhong: Dian Kuang.
ACUPUNCTURE TREATMENT • All the Well (Jing) points.
The modern text Chinese Acupuncture Therapy lists
Points that open the Mind’s orifices the following points for Dian and Kuang.55
In order to treat bipolar disorder, it is important to use
points that open the Mind’s orifices. These include the Dian (two groups of points)
following. • BL-15 Xinshu, BL-18 Ganshu, BL-20 Pishu, ST-40
• LU-3 Tianfu: somnolence, insomnia, sadness, Fenglong, HE-7 Shenmen, LIV-3 Taichong.
weeping, forgetfulness and “talking to ghosts”. • BL-15 Xinshu, Ren-14 Juque, P-6 Neiguan, HE-7
• L.I.-5 Yangxi: manic behavior, propensity to Shenmen, SP-6 Sanyinjiao.
inappropriate laughter, “seeing ghosts” and fright.
• L.I.-7 Wenliu: inappropriate laughter, manic Kuang (two groups of points)
behavior and “seeing ghosts”. • Du-26 Renzhong, Du-16 Fengfu, L.I.-1 Shangyang,
• ST-25 Tianshu: mental restlessness, anxiety, P-7 Daling, L.I.-11 Quchi, ST-40 Fenglong, SP-1
schizophrenia and mania. The Qing dynasty’s An Yinbai.
 Bipolar Disorder (Manic-Depression) 515

• Du-26 Renzhong, Du-23 Shangxing, Yintang, ST-6 Jiache Guichang “Ghost Bed”
HE-7 Shenmen, P-6 Neiguan, P-7 Daling, BL-62 Ren-24 Chengjiang Guishi “Ghost Market”
Shenmai. P-8 Laogong Guiku “Ghost Cave”
The modern text A Study of Acupuncture lists the fol- Du-23 Shangxing Guitang “Ghost Hall”
lowing points for Dian and Kuang.56 Ren-1 Huiyin Guicang “Ghost Hiding”
Yumen Guicang “Ghost Hiding”
Dian L.I.-11 Quchi Guichen “Ghost Minister”
• HE-7 Shenmen, P-7 Daling, LIV-3 Taichong, ST-40 Haiquan Guifeng “Ghost Seal”
Fenglong, SP-6 Sanyinjiao, Du-20 Baihui.

Kuang Sun Si Miao’s instructions

• Du-26 Renzhong, P-8 Laogong, HE-8 Shaofu,
LIV-2 Xiangjian, ST-40 Fenglong. Ren-1 is used in men with moxa cones and Yumen (in
the anterior fold of the vagina) is used in women with
The modern book A Collection of Chinese Acupuncture a moxa stick. Haiquan is a point in the veins under the
Prescriptions recommends the following treatment tongue.
principles and points for Dian and Kuang.57 The points were used for insanity from invasion of

AL
evil spirits. Use points bilaterally but start on the left for

N
Dian men and the right for women, and withdraw in reverse

O R
FI
• Treatment principle: Eliminate stagnation, resolve order.

- N IE
Phlegm, open the Mind’s orifices, regulate Qi.

T
T V
• Points: Du-15 Yamen, HE-4 Lingdao, Du-14 Modern use
N SE
Dazhui, Du-26 Renzhong, HE-7 Shenmen, P-6
Neiguan, BL-15 Xinshu, ST-36 Zusanli. Anxiety, uncontrolled weeping, fear, fright, disorienta-
TE L
N E

tion, delirium, seizures, depression, hysteria and mania.

Kuang
O F
C O

• Treatment principle: Move Liver-Qi, resolve Phlegm,

drain Fire, calm the Mind, place emphasis on the The Pericardium channel in
E TY

Governing Vessel’s points. Manic-Depression

PL R

• Points: Du-16 Fengfu, Du-14 Dazhui, HE-4

In the acupuncture treatment of Manic-Depression, it
M PE

Lingdao, Du-12 Shenzhu, Du-20 Baihui, Du-26

is important to place the emphasis on the Pericardium
Renzhong, Yintang.
SA O

channel, perhaps even more than on the Heart channel.

PR

This is because the Pericardium points have a stronger

action in opening the Mind’s orifices than the Heart
Sun Si Miao’s 13 ghost points points.
Su Si Miao listed 13 points for the treatment of Dian The Medical Records of the Guide to Clinical Practice
Kuang. In the following list, the first name is the most (Lin Zheng Zhi Nan Yi An) summarizes the etiology and
common one and the one next to it is the alternative pathology of Dian as follows:58
name. As can be seen, all the alternative names contain
the word gui, i.e. “ghost”. This is due to the fact that Depression [Dian] is due to worry, the disease is in the
some kind of mental illnesses were considered to be due Spleen, Heart and Pericardium channels; the three Yin
to the invasion of “ghosts”. cannot diffuse, Qi stagnates and Phlegm is formed so that
the Mind is confused.

Du-26 Renzhong Guigong “Ghost Palace” According to this statement, therefore, the use of the
LU-11 Shaoshang Guixin “Ghost Message” Pericardium channel is particularly important in the
SP-1 Yinbai Guiyan “Ghost Eye” treatment of Dian.
P-7 Daling Guixin “Ghost Heart” The modern doctor Dr Liang Jian Bo stresses the
BL-62 Shenmai Guilu “Ghost Road” importance of using the Pericardium channel in the
Du-16 Fengfu Guizhen “Ghost Pillow” treatment of both Dian and Kuang. Dr Liang thinks
516 The Psyche in Chinese Medicine

that, in Kuang, the Liver, Heart, Stomach and Pericar- remembering to eat, emotional dullness, alternation of
dium are affected, with Fire in the Liver, Heart and anger and laughing without reason.
Stomach. Fire also invades the Pericardium and this Tongue: Swollen, sticky coating.
causes the Ethereal Soul to become restless.59 Pulse: Wiry and Slippery.
Dr Liang says that in some cases of Dian, although
the main manifestations are depression and withdrawn Treatment principle
mood, some patients may display some restlessness;
this indicates Heat in the Heart, Spleen and Pericar- Move Qi, eliminate stagnation, resolve Phlegm, open
dium and that there is some Fullness within the the Mind’s orifices.
Deficiency.
The main points from the Pericardium channel to Acupuncture
open the Mind’s orifices are P-7 Daling, P-8 Laogong Points
and P-5 Jianshi: P-7 is selected in case of severe Mania
to calm the Mind and settle the Ethereal Soul; P-8 is P-6 Neiguan, LIV-3 Taichong, T.B.-6 Zhigou, P-5
selected if there is Fire; P-5 resolves Phlegm from the Jianshi, ST-40 Fenglong, Ren-12 Zhongwan, Ren-9
Mind. Shuifen, SP-6 Sanyinjiao, Du-20 Baihui. All with
reducing or even method.

AL
SUMMARY
Explanation

N
O R
FI
The Pericardium channel in

- N IE
Manic-Depression • P-6, LIV-3 and T.B.-6 move Qi and relieve

T
depression.
T V
• In the acupuncture treatment of Manic-
N SE
Depression, it is important to place the emphasis
• P-5 resolves Phlegm from the Heart and the Mind
on the Pericardium channel to open the Mind’s
and opens the Mind’s orifices.
TE L

• ST-40, Ren-12, Ren-9 and SP-6 resolve Phlegm.

N E

orifices.
• The Medical Records of the Guide to Clinical
• Du-20 lifts mood and opens the Mind’s orifices.
O F
C O

Practice (Lin Zheng Zhi Nan Yi An) states:

“Depression [Dian] is due to worry, the disease is Herbal therapy
E TY

in the Spleen, Heart and Pericardium channels.” Prescription

PL R

• The modern doctor Dr Liang Jian Bo stresses the

M PE

importance of using the Pericardium channel in SHUN QI DAO TAN TANG Variation
the treatment of both Dian and Kuang. Rectifying Qi and Eliminating Phlegm Decoction
SA O

• The main points from the Pericardium channel to Variation

PR

open the Mind’s orifices are P-7 Daling, P-8

Laogong and P-5 Jianshi: Explanation
– P-7 is selected in case of severe Mania to calm
the Mind and settle the Ethereal Soul
This formula promotes the descending of Qi in the
– P-8 is selected if there is Fire
Triple Burner in order to resolve Phlegm. It has been
– P-5 resolves Phlegm from the Mind.
modified with the addition of Huang Lian Rhizoma
Coptidis, Huang Qin Radix Scutellariae, Yuan Zhi Radix
Polygalae, Shi Chang Pu Rhizoma Acori tatarinowii
and Chen Xiang Lignum Aquilariae resinatum.
IDENTIFICATION OF PATTERNS
AND TREATMENT Prescription
DIAN WEN DAN TANG Variation
Warming the Gall-Bladder Decoction Variation
Qi stagnation and Phlegm
Clinical manifestations Explanation
Depression, apathy, dull thinking, incoherent speech, This formula resolves Phlegm-Heat from the Lungs
muttering to oneself, inappropriate laughter, not and Heart and calms the Mind. It is used if Phlegm is
 Bipolar Disorder (Manic-Depression) 517

combined with Heat and the patient is anxious and several banned substances from the formula Su He
worried, in addition to being depressed. It is especially Xiang Wan.
indicated if there is a feeling of oppression of the These two formulae together have the strongest
chest. effect in opening the Mind’s orifices.
Table 19.3 compares and contrasts the formulae for
Prescription the pattern of Qi stagnation and Phlegm of Dian.

SI QI TANG Variation
Four Seasons Decoction for the Seven Emotions
Variation
SUMMARY
Qi stagnation and Phlegm
Explanation
Points
This formula moves Lung- and Heart-Qi in the chest P-6 Neiguan, LIV-3 Taichong, T.B.-6 Zhigou, P-5
and relieves worry and anxiety. This formula is used if Jianshi, ST-40 Fenglong, Ren-12 Zhongwan, Ren-9
the symptoms of obstruction of the Mind by Phlegm are Shuifen, SP-6 Sanyinjiao, Du-20 Baihui. All with
pronounced (mental dullness, incoherent speech, reducing or even method.

AL
staring gaze without blinking, very Swollen tongue
Herbal therapy
with very sticky coating).

N
Prescription

O R
It has been modified with the addition of herbs to

FI
- N IE
resolve Phlegm and open the Mind’s orifices such as SHUN QI DAO TAN TANG Variation

T
T V
Yuan Zhi Radix Polygalae, Dan Nan Xing Rhizoma Ari­ Rectifying Qi and Eliminating Phlegm Decoction
N SE
saematis preparatum, Yu Jin Radix Curcumae and Shi Variation
Chang Pu Rhizoma Acori tatarinowii.
Prescription
TE L
N E

WEN DAN TANG Variation

Prescription
O F

Warming the Gall-Bladder Decoction Variation

C O

SU HE XIANG WAN plus SI QI TANG Variation Prescription

E TY

Styrax Pill plus Four Seasons Decoction for the Seven

SI QI TANG Variation
Emotions Variation
PL R

Four Seasons Decoction for the Seven Emotions

M PE

Variation
Explanation
SA O

Prescription
PR

This formula is used if Phlegm is very pronounced and SU HE XIANG WAN plus SI QI TANG Variation
the symptoms of obstruction of the Mind are very Styrax Pill plus Four Seasons Decoction for the
severe. This formula has a very strong effect in opening Seven Emotions Variation
the Mind’s orifices. Please note that I have removed

Table 19.3 Differentiation of formulae for the pattern of Qi stagnation and Phlegm of Dian

ACTION TONGUE

Shun Qi Dao Tan Tang Restore the descending of Qi, resolve Phlegm Swollen, sticky coating

Wen Dan Tang Resolve Phlegm, clear Heat Swollen, sticky-yellow coating

Si Qi Tang Restore the descending of Heart- and Lung- Swollen, very sticky coating
Qi, resolve Phlegm

Su He Xiang Wan plus Si Qi Tang Resolve Phlegm, open the Mind’s orifices Very Swollen, very sticky coating
518 The Psyche in Chinese Medicine

Heart and Spleen deficiency with the addition of herbs to resolve Phlegm and open
with Phlegm the Mind’s orifices such as Yuan Zhi Radix Polygalae,
Ban Xia Rhizoma Pinelliae preparatum and Shi Chang
Clinical manifestations Pu Rhizoma Acori tatarinowii. Either (I) or (II) may
be used; however, if Yang deficiency is pronounced,
Depression, excessive dreaming, insomnia, mental
use (I).
confusion, easily startled, bewilderment, sadness,
crying, shutting windows, muttering to oneself, visual
or auditory hallucinations, palpitations, dull-pale com- Prescription
plexion, slow movement, dislike to speak, loose stools, GAN MAI DA ZAO TANG
tiredness, weak limbs, poor appetite. Glycyrrhiza-Triticum-Jujuba Decoction
Tongue: Pale, Swollen with a sticky coating.
Pulse: Soggy.
Explanation
Treatment principle This formula is used if there is sadness, crying a lot,
disorientation, bewilderment.
Strengthen the Spleen, nourish Heart, benefit Qi, calm

AL
the Mind, resolve Phlegm, open the Mind’s orifices.
Prescription

N
Acupuncture

O R
JI SHENG SHEN QI TANG Variation

FI
- N IE
Kidney-Qi Decoction from “Formulae to Aid the Living”
Points

T
T V Variation
N SE
HE-7 Shenmen, HE-5 Tongli, P-5 Jianshi, ST-36
Zusanli, Ren-12 Zhongwan, BL-20 Pishu, Du-24 Explanation
TE L

Shenting, Du-20 Baihui, ST-40 Fenglong, Ren-9

N E

Shuifen, SP-6 Sanyinjiao. HE-7, HE-5, ST-36, Ren-12 This formula is used if there a Spleen deficiency and a
O F

and BL-20 with reinforcing method; all others with constitutional deficiency of the Kidneys with Phlegm
C O

even method. (mental dullness, incoherent speech, tiredness,

E TY

weakness).
Table 19.4 compares and contrasts the three
PL R

Explanation
formulae for Heart and Spleen deficiency with Phlegm
M PE

• HE-7 and HE-5 tonify the Heart. of Dian.

SA O

• P-5 opens the Mind’s orifices and resolves Phlegm

PR

from the Mind.

• ST-36, Ren-12 and BL-20 (with reinforcing
Table 19.4 Differentiation of formulae for the
method) tonify the Spleen.
pattern of Heart and Spleen deficiency with Phlegm
• Du-24 and Du-20 lift mood and open the Mind’s
orifices. ACTION SYMPTOMS TONGUE
• ST-40, Ren-9 and SP-6 resolve Phlegm.
Yang Xin Nourish Heart- Insomnia Pale, dry,
Tang and Thin
Herbal therapy Spleen-Blood
Prescription Gan Mai Tonify the Sadness, crying, Pale
Da Zao Spleen, nourish disorientation
YANG XIN TANG (I) or (II) Tang Heart-Blood
Nourishing the Heart Decoction
Ji Sheng Tonify the Mental dullness, Pale,
Shen Qi Spleen and lack of Swollen,
Explanation Tang Kidneys, Will-Power wet
strengthen
This formula nourishes Heart-Blood and Spleen-Blood. Will-Power,
resolve Phlegm
In order to treat bipolar disorder, it should be modified
 Bipolar Disorder (Manic-Depression) 519

Shuifen, SP-6 Sanyinjiao, ST-40 Fenglong, P-5 Jianshi,

SUMMARY P-6 Neiguan, Du-20 Baihui, Du-26 Renzhong. LU-9,
BL-13, Ren-12, BL-20, BL-21 and ST-36 with reinforc-
Heart and Spleen deficiency with Phlegm
ing method; all others with even method.
Points
HE-7 Shenmen, HE-5 Tongli, P-5 Jianshi, ST-36 Explanation
Zusanli, Ren-12 Zhongwan, BL-20 Pishu, Du-24
• LU-9 and BL-13 tonify Lung-Qi.
Shenting, Du-20 Baihui, ST-40 Fenglong, Ren-9
• Ren-12, BL-20, BL-21 and ST-36 tonify Stomach-
Shuifen, SP-6 Sanyinjiao. HE-7, HE-5, ST-36, Ren-12
and Spleen-Qi.
and BL-20 with reinforcing method; all others with
• Ren-9, SP-6 and ST-40 resolve Phlegm.
even method.
• P-5 and P-6 open the Mind’s orifices.
Herbal therapy • Du-20 and Du-26 open the Mind’s orifices and
Prescription clear the Brain.
YANG XIN TANG (I) or (II)
Nourishing the Heart Decoction Herbal therapy
Prescription

AL
Prescription
GAN MAI DA ZAO TANG DI TAN TANG

N
O R
Washing Away Phlegm Decoction

FI
Glycyrrhiza-Triticum-Jujuba Decoction
Prescription
- N IE
T
T V
Explanation
N SE
JI SHENG SHEN QI TANG Variation
Kidney-Qi Decoction from “Formulae to Aid the This formula resolves Phlegm and tonifies Qi. It should
TE L

Living” Variation be modified with the addition of Yuan Zhi Radix Polyga-
N E

lae to open the Mind’s orifices.

O F
C O

Prescription
E TY

Qi deficiency with Phlegm SHI WEI WEN DAN TANG Variation

Clinical manifestations
PL R

Ten-Ingredient Warming the Gall-Bladder Decoction

M PE

Variation
Chronic condition, emotional dullness, reluctance to
SA O

move or speak, staring eyes, inappropriate laughter,

Explanation
PR

muttering to oneself, incoherent thinking, visual and

auditory hallucinations, self reproach, feeling of guilt, The variation of this formula resolves Phlegm, tonifies
mental dullness, loose stools, pale complexion, tired- Qi and opens the Mind’s orifices.
ness, shortness of breath, no appetite.
Tongue: Pale.
Pulse: Soggy. SUMMARY
Treatment principle Qi deficiency with Phlegm
Points
Tonify Lung-, Stomach- and Spleen-Qi, resolve Phlegm,
open the Mind’s orifices. LU-9 Taiyuan, BL-13 Feishu, Ren-12 Zhongwan,
BL-20 Pishu, BL-21 Weishu, ST-36 Zusanli, Ren-9
Shuifen, SP-6 Sanyinjiao, ST-40 Fenglong, P-5
Acupuncture
Jianshi, P-6 Neiguan, Du-20 Baihui, Du-26
Points Renzhong. LU-9, BL-13, Ren-12, BL-20, BL-21 and
ST-36 with reinforcing method; all others with even
LU-9 Taiyuan, BL-13 Feishu, Ren-12 Zhongwan, method.
BL-20 Pishu, BL-21 Weishu, ST-36 Zusanli, Ren-9
520 The Psyche in Chinese Medicine

Explanation
Herbal therapy
Prescription This formula drains Heart-Fire and calms the Mind.
DI TAN TANG
Washing Away Phlegm Decoction Modifications
Prescription • If there is agitation, add Dan Dou Chi Semen Sojae
SHI WEI WEN DAN TANG Variation preparatum and Shan Zhi Zi Fructus Gardeniae.
Ten-Ingredient Warming the Gall-Bladder Decoction • If there is a feeling of heat in eyes and nose, add
Variation Long Dan Cao Radix Gentianae, Shi Jue Ming Concha
Haliotidis and Huang Qin Radix Scutellariae.
• If there is epistaxis, add Da Ji Radix Euphorbiae seu
Knoxiae, Xiao Ji Herba Cirisii, Mu Dan Pi Cortex
Moutan and Zi Cao Herba Lithospermi.
Knotted Heat in the Heart channel • If the patient is suffering from insomnia, add Suan
Clinical manifestations Zao Ren Semen Ziziphi spinosae, Ye Jiao Teng Caulis
Polygoni multiflori and Zhen Zhu Mu Concha

AL
Depression with sudden onset, flustered feeling in the Margaritiferae usta.
heart region, laughing without reason, insomnia,

N
feeling of heat in the nose and eyes, thirst, mouth

O R
FI
- N IE
ulcers.

T
Tongue: Red, redder tip, yellow coating.
T V
Pulse: Overflowing-Rapid. SUMMARY
N SE

Knotted Heat in the Heart channel

TE L

Treatment principle
N E

Points
O F

Drain Heart-Fire, open the Mind’s orifices, calm the

C O

HE-8 Shaofu, HE-7 Shenmen, Du-24 Shenting,

Mind.
Ren-15 Jiuwei, BL-44 Shentang, P-8 Laogong, P-5
E TY

Jianshi. All with reducing or even method.

Acupuncture
PL R

Herbal therapy
M PE

Points
Prescription
SA O

HE-8 Shaofu, HE-7 Shenmen, Du-24 Shenting, Ren-15 DAO CHI SAN Variation
PR

Jiuwei, BL-44 Shentang, P-8 Laogong, P-5 Jianshi. All Eliminating Redness Powder Variation
with reducing or even method.

Explanation
• HE-8 drains Heart-Fire. Phlegm obstructing the Heart orifices
• HE-7, Du-24, Ren-15 and BL-44 clear Heart-Heat
and calm the Mind. Clinical manifestations
• P-8 drains Heart-Fire and opens the Mind’s
Depression, mental dullness, backwardness, emotional
orifices.
dullness, muttering to oneself, incoherent speech,
• P-5 Jianshi resolves Phlegm from the Mind.
staring eyes, absence of blinking.
Tongue: Swollen with sticky coating.
Herbal therapy Pulse: Slippery.
Prescription
Treatment principle
DAO CHI SAN Variation
Eliminating Redness Powder Variation Resolve Phlegm, open the Mind’s orifices.
 Bipolar Disorder (Manic-Depression) 521

Acupuncture Tongue: Red, thick-sticky-yellow coating, Stomach–

Heart crack with rough-sticky-dry yellow coating
Points inside it.
P-5 Jianshi, Du-20 Baihui, Du-24 Shenting, ST-40 Pulse: Rapid-Wiry-Overflowing-Slippery.
Fenglong, SP-6 Sanyinjiao, Ren-9 Shuifen. All with
reducing or even method. Treatment principle

Explanation Calm the Heart, resolve Phlegm, drain Liver-Fire, drain

Heart-Fire, open the Mind’s orifices.
• P-5, Du-20 and Du-24 open the Mind’s orifices.
• ST-40, SP-6 and Ren-9 resolve Phlegm.
Acupuncture
Herbal therapy Points
Prescription P-7 Daling, P-5 Jianshi, LIV-2 Xingjian, HE-8 Shaofu,
DI TAN TANG P-8 Laogong, Du-19 Houding, G.B.-17 Zhengying,
Washing Away Phlegm Decoction G.B.-18 Chengling, ST-40 Fenglong, Ren-12

AL
Zhongwan, Ren-9 Shuifen, SP-6 Sanyinjiao. All with
Explanation reducing or even method.

N
O R
FI
This formula resolves Phlegm and opens the Mind’s
- N IE
Explanation

T
orifices.
T V
N SE
• P-7 and P-5 open the Mind’s orifices.
• LIV-2 and HE-8 drain Liver- and Heart-Fire,
SUMMARY
TE L

respectively.
N E

• P-8 drains Heart-Fire and opens the Mind’s orifices.

Phlegm obstructing the Heart orifices
O F

• Du-19, G.B.-17 and G.B.-18 calm the Mind and

C O

Points open the Mind’s orifices.

E TY

P-5 Jianshi, Du-20 Baihui, Du-24 Shenting, ST-40 • ST-40, Ren-12, Ren-9 and SP-6 resolve Phlegm.
Fenglong, SP-6 Sanyinjiao, Ren-9 Shuifen. All with
PL R

reducing or even method.

M PE

Herbal therapy
Herbal therapy Prescription
SA O

Prescription
PR

SHENG TIE LUO YIN

DI TAN TANG
Frusta Ferri Decoction
Washing Away Phlegm Decoction

Explanation
KUANG This formula resolves Phlegm, calms the Mind and
opens the Mind’s orifices. The original formula con-
Phlegm-Fire harassing upwards tains Zhu Sha Cinnabaris which should be eliminated
due to its toxicity.
Clinical manifestations
The formula obviously contains iron, which is actu-
Manic behavior with sudden onset, emotional upsets, ally its emperor herb; the use of minerals in herbal for-
shouting, scolding or hitting people, exceptional physi- mulae is not allowed in European Union countries.
cal strength, not eating or sleeping, agitation, an angry
look in the eyes, shouting abuse, desire to climb to high Prescription
places, irritability, inability to rest, breaking things,
rash/impulsive behavior, rash movements, constipa- WEN DAN TANG
tion, headache, insomnia, red face and eyes, anger. Warming the Gall-Bladder Decoction
522 The Psyche in Chinese Medicine

Explanation Explanation
This formula resolves Phlegm-Heat from the Heart and These two formulae are used if the symptoms of
Lungs, calms the Mind and opens the Mind’s orifices. obstruction of the Mind are pronounced (mental con-
The formula should be modified with the addition of fusion, incoherent speech, loss of insight).
herbs to resolve Phlegm and open the Mind’s orifices, Please note that the use of Zhu Sha is not allowed
such as Shi Chang Pu Rhizoma Acori tatarinowii and and it should therefore be omitted from the formula.
Yuan Zhi Radix Polygalae.
Prescription
Prescription
MENG SHI GUN TAN WAN
DANG GUI LONG HUI WAN Chloritum Chasing-away Phlegm Pill
Angelica-Gentiana-Aloe Pill
Explanation
Explanation This formula strongly resolves Phlegm by moving
downwards. It is used if there is constipation or dry

AL
This formula drains Liver-Fire and calms the Mind. It
stools.
contains She Xiang which should be removed from the

N
O R
formula.

FI
Prescription
- N IE
The formula should be modified with the addition of

T
herbs to resolve Phlegm and open the Mind’s orifices,
T V
XIE XIN TANG Variation
N SE
such as Ban Xia Rhizoma Pinelliae preparatum, Shi
Draining the Heart Decoction Variation
Chang Pu Rhizoma Acori tatarinowii and Yuan Zhi
TE L

Radix Polygalae.
N E

Explanation
O F

This formula is used if there are pronounced manifesta-

C O

Prescription
tions of Heart-Fire.
E TY

WEN DAN TANG plus ZHU SHA AN SHEN WAN Table 19.5 compares and contrasts the formulae for
Warming the Gall-Bladder Decoction plus Cinnabar the pattern of Phlegm-Fire harassing upwards in
PL R

Calming the Mind Pill

M PE

Kuang.
SA O
PR

Table 19.5 Differentiation of formulae for the pattern of Phlegm-Fire harassing upwards in Kuang

ACTION SYMPTOM TONGUE

Sheng Tie Luo Yin Resolve Phlegm, sink the Mind, Mental confusion, Swollen, sticky coating
open the Mind’s orifices irritability

Wen Dan Tang Resolve Phlegm, clear Heat, Anxiety Red, Swollen, sticky-yellow coating
restore the descending of
Lung-Qi

Dang Gui Long Hui Wan Drain Liver-Fire, calm the Mind, Constipation, dry Red, redder sides
move downwards stools

Wen Dan Tang plus Zhu Resolve Phlegm, clear Heat, Mental confusion Red tip, Swollen, sticky coating
Sha An Shen Wan open the Mind’s orifices

Meng Shi Gun Tan Wan Resolve Phlegm, sink the Ming, Mental confusion, Swollen
move downwards constipation, dry stools

Xie Xin Tang Drain Heart-Fire, calm the Mind Insomnia Red, redder tip
 Bipolar Disorder (Manic-Depression) 523

to leave Italy after the beginning of the persecu-

SUMMARY tion of the Jews during the Fascist years. So they
sailed to Egypt when my patient was 3 years old.
Phlegm-Fire harassing upwards
He lived in many different countries and was one
Points of the very few people to take part in all three
P-7 Daling, P-5 Jianshi, LIV-2 Xingjian, HE-8 Shaofu, Israeli–Arab wars. He was a tank commander and
P-8 Laogong, Du-19 Houding, G.B.-17 Zhengying, a decorated war hero. I was struck by the way he
G.B.-18 Chengling, ST-40 Fenglong, Ren-12 talked about his war experiences as if they had
Zhongwan, Ren-9 Shuifen, SP-6 Sanyinjiao. All with been exciting school-boy adventures.
reducing or even method. He had a colorful sexual history, with a string
of infidelities to the chagrin of his long-suffering
Herbal therapy wife. When he spoke, he almost shouted and was
Prescription difficult to stop.
SHENG TIE LUO YIN He had been diagnosed with bipolar disorder
Frusta Ferri Decoction after a period of intense, ceaseless activity and
insomnia. His periods of high energy were always
Prescription
followed by periods of black depression; however,

AL
WEN DAN TANG these did not last long and he had longer periods
Warming the Gall-Bladder Decoction

N
of mania than of depression.

O R
FI
Prescription I asked him about his general health and this

- N IE was quite good; he had few physical symptoms.

T
DANG GUI LONG HUI WAN
T V
However, the ones that were significant from the
N SE
Angelica-Gentiana-Aloe Pill
point of view of Chinese medicine were a feeling
Prescription of oppression in the chest, palpitations and
TE L
N E

WEN DAN TANG plus ZHU SHA AN SHEN WAN sputum in the throat.
His tongue was quite typical: it was Red, Swollen,
O F

Warming the Gall-Bladder Decoction plus Cinnabar

C O

Calming the Mind Pill with a deep Heart crack and a sticky-yellow
coating; his pulse was Slippery-Wiry-Rapid.
E TY

Prescription
PL R

MENG SHI GUN TAN WAN Diagnosis The few symptoms of feeling of oppres-
M PE

Chloritum Chasing-away Phlegm Pill sion in the chest, palpitations and sputum in the
throat, together with the tongue and pulse, point
Prescription
SA O

unmistakably to Phlegm-Fire in the Heart as the cause

PR

XIE XIN TANG Variation of his manic-depression. His excessive weight also
Draining the Heart Decoction Variation confirms Phlegm.

Treatment I treated him primarily with acupuncture

Case history and selected points from the following.
A 52-year-old man had been suffering from • HE-7 Shenmen and P-5 Jianshi to calm the Mind
manic-depression for at least 20 years. His wife and open the Mind’s orifices.
confirmed that it would be difficult to pinpoint • Du-19 Houding and Ren-15 to calm the Mind
when the disease started as it was difficult to and open the Mind’s orifices.
distinguish pathological traits from his normally • Ren-12 Zhongwan, ST-40 Fenglong, Ren-9
boisterous behavior. Shuifen, SP-6 Sanyinjiao and KI-7 Fuliu to resolve
He was short and overweight, talked in a loud Phlegm.
voice and his speech was frequently interspersed • HE-8 Shaofu to clear Heart-Heat.
by bursts of laughter. His complexion was reddish. I treated him weekly for a long time (at least 2
He talked a lot and frequently went off on a years) and then started spacing out the treatments.
tangent, telling a story about his colorful and He improved dramatically, reporting a reduction in his
interesting life. His family was Italian but they had manic phases, feeling much calmer and sleeping
524 The Psyche in Chinese Medicine

better. Significantly, he also stopped his womanizing. Explanation

Apart from a progressive improvement in his symp-
toms, he always felt an immediate benefit during This formula drains Stomach-Fire by moving down-
each treatment. wards, resolves Phlegm and opens the Mind’s orifices.
This patient continues to be well at the time of
writing (15 years later) and I treat him only four or
five times a year. SUMMARY
Fire in Bright Yang
Points
Fire in Bright Yang ST-44 Neiting, L.I.-11 Quchi, ST-40 Fenglong, P-8
Clinical manifestations Laogong, HE-8 Shaofu, ST-25 Tianshu, SP-15
Daheng, P-5 Jianshi. All with reducing or even
Manic behavior, raving walking, shouting, abusing method.
people, climbing to high places, singing, discarding
Herbal therapy
clothes, unusual physical strength, foul breath, red
Prescription

AL
face, constipation.
Tongue: Red with dark-yellow or black, dry DA CHENG QI TANG Variation

N
coating. Great Conducting Qi Decoction Variation

O R
FI
- N IE
Pulse: Deep and Wiry.

T
T V
Treatment principle Gall Bladder- and Liver-Fire
N SE

Clinical manifestations
TE L

Drain Stomach-Fire by moving downwards, calm the

N E

Mind, open the Mind’s orifices, resolve Phlegm.

Manic behavior, irritability, propensity to outbursts
O F

of anger, red face and eyes, bitter taste, laughing inap-

C O

Acupuncture propriately, shouting, hypochondrial and chest pain,

E TY

Points palpitations.
Tongue: Red with dark-yellow coating.
PL R

ST-44 Neiting, L.I.-11 Quchi, ST-40 Fenglong, P-8

M PE

Pulse: Rapid-Wiry-Slipper.
Laogong, HE-8 Shaofu, ST-25 Tianshu, SP-15 Daheng,
SA O

P-5 Jianshi. All with reducing or even method. Treatment principle

PR

Explanation Drain Liver-Fire, resolve Phlegm, calm the Mind.

• ST-44 and L.I.-11 drain Stomach-Fire. Acupuncture

• ST-40 helps to drain Stomach-Fire.
• P-8 and HE-8 drain Heart-Fire and calm the Mind. Points
• ST-25 stabilizes the Ethereal Soul and Corporeal
LIV-2 Xingjian, G.B.-44 Zuqiaoyin, L.I.-11 Quchi,
Soul.
ST-40 Fenglong, SP-6 Sanyinjiao, Ren-9 Shuifen,
• SP-15 moves downwards and promotes the bowel
HE-7 Shenmen, P-5 Jianshi. All with reducing or
movement.
even method.
• P-5 Jianshi resolves Phlegm from the Mind.

Explanation
Herbal therapy
Prescription • LIV-2 and G.B.-44 drain Liver- and Gall
Bladder-Fire.
DA CHENG QI TANG Variation • L.I.-11 clears Heat and cools Blood in general.
Great Conducting Qi Decoction Variation • ST-40, SP-6 and Ren-9 resolve Phlegm.
 Bipolar Disorder (Manic-Depression) 525

• HE-7 calms the Mind. Ren-12 Zhongwan, Ren-9 Shuifen, Du-24 Shenting,
• P-5 Jianshi resolves Phlegm from the Mind. Du-19 Houding, P-5 Jianshi. KI-3, Ren-4 and SP-6
with reinforcing method; all the others with even
Herbal therapy method.

Prescription
Explanation
LONG DAN XIE GAN TANG Variation • HE-7, HE-6 and P-7 calm the Mind and open the
Gentiana Draining the Liver Decoction Variation Mind’s orifices.
• KI-3, Ren-4 and SP-6 nourish Yin.
Explanation • ST-40, Ren-12 and Ren-9 resolve Phlegm.
• Du-24 and Du-19 calm the Mind and open the
This variation of Long Dan Xie Gan Tang drains Liver- Mind’s orifices.
Fire, resolves Phlegm and calms the Mind. • P-5 resolves Phlegm from the Mind.

SUMMARY Herbal therapy

Prescription

AL
Gall Bladder- and Liver-Fire
ER YIN JIAN

N
Points

O R
Two Yin Decoction

FI
LIV-2 Xingjian, G.B.-44, L.I.-11 Quchi, ST-40

- N IE
T
Fenglong, SP-6 Sanyinjiao, Ren-9 Shuifen, HE-7
T V
Shenmen, P-5 Jianshi. All with reducing or even
Explanation
N SE
method. This formula nourishes Yin and calms the Mind. In
TE L

order to treat bipolar disorder, it should be modified

Herbal therapy
N E

with the addition of some herbs to resolve Phlegm and

Prescription
O F

open the Mind’s orifices, such as Ban Xia Rhizoma

C O

LONG DAN XIE GAN TANG Variation Pinelliae preparatum, Yuan Zhi Radix Polygalae and Shi
E TY

Gentiana Draining the Liver Decoction Variation Chang Pu Rhizoma Acori tatarinowii.
Please note that the original formula contains Mu
PL R

Tong which should be eliminated due to its potential

M PE

Fire injuring Yin with Phlegm toxicity.

SA O

Clinical manifestations
Prescription
PR

Chronic Kuang, talking a lot, easily startled, mental ER YIN JIAN Variation
restlessness, thin body (loss of weight), red face, malar Two Yin Decoction Variation
flush, feeling of heat in the evening.
Tongue: Red, Swollen, without coating.
Explanation
Pulse: Fine-Rapid.
This formula nourishes Yin, settles the Ethereal Soul
Treatment principle and calms the Mind.

Nourish Yin, clear Empty-Heat, calm the Mind, resolve

Phlegm, open the Mind’s orifices. SUMMARY
Acupuncture Fire injuring Yin with Phlegm

Points Points
HE-7 Shenmen, HE-6 Yinxi, P-7 Daling, KI-3 Taixi,
HE-7 Shenmen, HE-6 Yinxi, P-7 Daling, KI-3 Taixi, Ren-4 Guanyuan, SP-6 Sanyinjiao, ST-40 Fenglong,
Ren-4 Guanyuan, SP-6 Sanyinjiao, ST-40 Fenglong,
526 The Psyche in Chinese Medicine

Treatment I treated her with a variation of Er Yin

Ren-12 Zhongwan, Ren-9 Shuifen, Du-24 Shenting, Jian as follows.
Du-19 Houding, P-5 Jianshi. KI-3, Ren-4 and SP-6 • Ban Xia Rhizoma Pinelliae preparatum 6 g
with reinforcing method; all the others with even • Zhu Ru Caulis Bambusae in Taeniam 6 g
method. • Yuan Zhi Radix Polygalae 6 g
Herbal therapy • Shi Chang Pu Rhizoma Acori tatarinowii 6 g
Prescription • Sheng Di Huang Radix Rehmanniae 10 g
• Mai Men Dong Radix Ophiopogonis 9 g
ER YIN JIAN
• Suan Zao Ren Semen Ziziphi spinosae 15 g
Two Yin Decoction
• Huang Lian Rhizoma Coptidis 3 g
Prescription • Mu Dan Pi Cortex Moutan 6 g
ER YIN JIAN Variation • Fu Ling Poria 9 g
Two Yin Decoction Variation • Deng Xin Cao Medulla Junci 6 g
• Gan Cao Radix Glycyrrhizae uralensis 3 g
I treated her with variations of this formula as well
as with acupuncture, selecting points from the
following.

AL
• HE-7 Shenmen and P-5 Jianshi to calm the Mind
Case history

N
and open the Mind’s orifices.

O R
FI
A 45-year-old woman had been suffering from • G.B.-13 Benshen and G.B.-18 Chengling to open

- N IE
bipolar disorder for 10 years. Her disease seemed the Mind’s orifices.

T
T V
to have started after the birth of her third child. • Du-19 Houding and Ren-15 to calm the Mind.
N SE
Her symptoms during the manic phases were • LIV-2 Xiangian and HE-8 Shaofu to drain Liver-
severe and included grossly increased energy and Heart-Fire.
TE L
N E

and activity, mental restlessness, excessively • Ren-12 Zhongwan, Ren-9 Shuifen, ST-40
“high” euphoric mood, talking a lot and very Fenglong and SP-6 Sanyinjiao to resolve Phlegm.
O F
C O

fast, staying up all night, spending sprees and • Ren-4 Guanyuan, KI-3 Taixi and SP-6 Sanyinjiao
delusional thinking. Her condition was quite to nourish Yin.
E TY

severe as it was bordering on psychosis. For The combination of herbal medicine and acupunc-
PL R

example, she once spent a very long time telling ture greatly helped to stabilize her moods and work
M PE

me how the KGB had been shadowing her years out the proper dosage of lithium. Due to the severity
before. of her condition, she will have to be on lithium con-
SA O

She was on medication (lithium) but she had tinuously and she is still being treated with herbal
PR

not been consistent taking it and her disease was medicine only.
therefore out of control. She was thin, had a
gaunt, haunted look and her complexion was red
on the cheekbones.
Her tongue was Red, redder on the sides, Qi stagnation, Blood stasis, Phlegm
Swollen, with a sticky but rootless yellow coating;
Clinical manifestations
her pulse was Fine and Rapid.
Chronic Kuang, talking a lot, easily startled, mental
Diagnosis As she displays clear symptoms of obstruc- restlessness, abdominal pain, dark complexion, insom-
tion of the Mind, she must have Phlegm and this is nia, agitation at night.
confirmed by the swelling of her tongue and the Tongue: Reddish-Purple, Swollen.
stickiness of the coating. The thinness of her body, Pulse: Wiry-Slippery.
the red cheekbones, the rootless coating and the
pulse indicate Yin deficiency. This is therefore a case Treatment principle
of Fire having injured the Yin fluids, with Phlegm-Fire
obstructing the Heart. Fire was also affecting the Liver Move Qi, invigorate Blood, eliminate stasis, resolve
as indicated by the redder sides of the tongue. Phlegm, calm the Mind, open the Mind’s orifices.
 Bipolar Disorder (Manic-Depression) 527

Acupuncture
SUMMARY
Points
Qi stagnation, Blood stasis, Phlegm
P-6 Neiguan, HE-7 Shenmen, LIV-3 Taichong, SP-10
Xuehai, BL-17 Geshu, ST-40 Fenglong, Ren-12 Points
Zhongwan, Ren-9 Shuifen, Du-24 Shenting, Du-19 P-6 Neiguan, HE-7 Shenmen, LIV-3 Taichong, SP-10
Houding, G.B.-17 Zhengying, G.B.-18 Chengling, P-5 Xuehai, BL-17 Geshu, ST-40 Fenglong, Ren-12
Jianshi. All with reducing or even method. Zhongwan, Ren-9 Shuifen, Du-24 Shenting, Du-19
Houding, G.B.-17 Zhengying, G.B.-18 Chengling,
Explanation P-5 Jianshi. All with reducing or even method.
Herbal therapy
• P-6 and HE-7 calm the Mind and invigorate
Blood. Prescription
• LIV-3, SP-10 and BL-17 invigorate Blood and DIAN KUANG MENG XING TANG
eliminate stasis. Manic-Depression Regaining Consciousness after a
• ST-40, Ren-12 and Ren-9 resolve Phlegm. Dream Decoction
• Du-24 and Du-19 calm the Mind and open the

AL
Prescription
Mind’s orifices.
DING KUANG ZHU YU TANG

N
• G.B.-17 and G.B.-18 open the Mind’s orifices.

O R
FI
• P-5 resolves Phlegm from the Mind. Calming Mania and Eliminating Stasis Decoction

- N IE
T
T V
N SE
Herbal therapy
Yin deficiency with Empty Heat
TE L

Prescription
N E

Clinical manifestations
O F

DIAN KUANG MENG XING TANG

Chronic manic behavior, listlessness, incessant talking,
C O

Manic-Depression Regaining Consciousness after a

easily startled, mental restlessness, insomnia.
E TY

Dream Decoction
Tongue: Red without coating.
Pulse: Fine-Rapid.
PL R

Explanation
M PE

This formula moves Qi, invigorates Blood, resolves Treatment principle

SA O

Phlegm and opens the Mind’s orifices. It is suitable if

PR

Nourish Yin, clear Empty Heat, calm the Mind.

there is Blood stasis.
Please note that the original formula contains Mu
Tong which should be eliminated due to its potential Acupuncture
toxicity. Points

Prescription KI-3 Taixi, LIV-8 Ququan, SP-6 Sanyinjiao, Ren-4

Guanyuan, HE-7 Shenmen, Ren-15 Jiuwei, HE-6
DING KUANG ZHU YU TANG Yinxi, P-7 Daling, ST-40 Fenglong, Ren-9 Shuifen, P-5
Calming Mania and Eliminating Stasis Decoction Jianshi. KI-3, LIV-8, SP-6 and Ren-4 with reinforcing
method; all others with even method.
Explanation
Explanation
This formula invigorates Blood, calms the Mind and
opens the Mind’s orifices. It should be modified with the • KI-3, LIV-8, SP-6 and Ren-4 nourish Liver- and
addition of herbs to open the Mind’s orifices such as Kidney-Yin.
Yuan Zhi Radix Polygalae and Ban Xia Rhizoma Pinelliae • HE-7, Ren-15, HE-6 and P-7 calm the Mind and
preparatum. clear Empty Heat.
528 The Psyche in Chinese Medicine

• ST-40 Fenglong and Ren-9 resolve Phlegm. • Shi Chang Pu Rhizoma Acori tatarinowii
• P-5 resolves Phlegm from the Mind. • Suan Zao Ren Semen Ziziphi spinosae
• Long Gu Mastodi Ossis fossilia
Herbal therapy • Mu Li Concha Ostreae
• Zhen Zhu Mu Concha Margaritiferae usta
Prescription • Mai Men Dong Radix Ophiopogonis
ER YIN JIAN Variation The authors report that 13 patients (43%) were
Two Yin Decoction Variation cured; 5 (17%) improved; 8 (27%) somewhat improved;
no results, 4 patients (13%).

Chen Jin Guang 1992 Complete

SUMMARY
Textbook of Chinese Patterns in
Yin deficiency with Empty Heat Contemporary Chinese Medicine
Points (Xian Dai Zhong Yi Lin Zheng Quan Shu
KI-3 Taixi, LIV-8 Ququan, SP-6 Sanyinjiao, Ren-4 ). Beijing Publishing House,
Guanyuan, HE-7 Shenmen, Ren-15 Jiuwei, HE-6 Beijing, p. 109.

AL
Yinxi, P-7 Daling, ST-40 Fenglong, Ren-9 Shuifen,
Dr Wang Ning Ni treated 310 patients with Mania

N
P-5 Jianshi. KI-3, LIV-8, SP-6 and Ren-4 with

O R
(Kuang) with Meng Xia Cheng Qi Tang Chlorite-Pinellia

FI
reinforcing method; all others with even method.

- N IE
Conducting Qi Decoction.

T
Herbal therapy The patients ranged in age from 15 to 59. There
T V
N SE
Prescription were 216 men and 94 women. The results were as
follows.
ER YIN JIAN Variation
TE L

• Cured: 165
N E

Two Yin Decoction Variation

• Improved: 129
O F

• No results: 16
C O

The formula used was as follows.

E TY

MODERN CHINESE LITERATURE • Meng Shi Lapis Chloriti seu Micae 20 g

PL R

• Huang Qin Radix Scutellariae 20 g

M PE

Journal of Chinese Medicine (Zhong Yi Za • Ban Xia Rhizoma Pinelliae preparatum 10 g

• Zhi Shi Fructus Aurantii immaturus 10 g
SA O

Zhi ), Vol. 25, No. 11, 1984, p. 31.

• Shi Chang Pu Rhizoma Acori tatarinowii 10 g
PR

Chen Chao, “Clinical observations on the • Lian Qiao Fructus Forsythiae 10 g

use of a variation of Wen Dan Tang to • Yu Jin Radix Curcumae 15 g
treat 30 cases of Dian Kuang” • Hou Po Cortex Magnoliae officinalis 12 g
• Da Huang Radix et Rhizoma Rhei 10 g
Thirty patients suffering from Dian Kuang were treated,
• Mang Xiao Natrii Sulfas 10 g
8 men and 22 women ranging in age from 14 to 49;
16 patients had a diagnosis of schizophrenia. Of the Modifications
total, 26 patients fell under the category of Dian and 4
under that of Kuang. • Heart-Fire: Huang Lian Rhizoma Coptidis, Zhu Ye
The formula used was a variation of Wen Dan Tang Folium Phyllostachys nigrae.
Warming the Gall-Bladder Decoction as follows. • Liver-Fire: Long Dan Cao Radix Gentianae, Xia Ku
• Zhu Ru Caulis Bambusae in Taeniam Cao Spica Prunellae.
• Chen Pi Pericarpium Citri reticulatae • Stomach-Heat: Shi Gao Gypsum fibrosum, Zhi Mu
• Ban Xia Rhizoma Pinelliae preparatum Radix Anemarrhaenae.
• Fu Ling Poria Dr Ma Ming Lei treated 75 patients suffering from
• Zhi Ke Fructus Aurantii Manic-Depression. The formula used was a variation
• Yuan Zhi Radix Polygalae of Di Tan Tang Washing Away Phlegm Decoction:
 Bipolar Disorder (Manic-Depression) 529

• Long Chi Fossilia Dentis Mastodi 30 g Front in a straight line, it indicates the presence of
• Shi Gao Gypsum fibrosum 15 g Phlegm.
• Dan Nan Xing Rhizoma Arisaematis preparatum For Dian, Dr Liang recommends regulating
10 g Heart-Qi, eliminating stagnation, calming the Mind
• Shi Chang Pu Rhizoma Acori tatarinowii 10 g and resolving Phlegm. He uses the following variation
• Zhi Shi Fructus Aurantii immaturus 10 g of the formula Dao Tan Tang Conducting Phlegm
• Fu Ling Poria 10 g Decoction.
• Chen Pi Pericarpium Citri reticulatae 10 g • Ban Xia Rhizoma Pinelliae preparatum
• Ban Xia Rhizoma Pinelliae preparatum 10 g • Chen Pi Pericarpium Citri reticulatae
• Gan Cao Radix Glycyrrhizae uralensis 10 g • Fu Ling Poria
• Dang Shen Radix Codonopsis 10 g • Gan Cao Radix Glycyrrhizae uralensis
• Zhu Ru Caulis Bambusae in Taeniam 6 g • Dan Nan Xing Rhizoma Arisaematis preparatum
• Wu Gong Scolopendra 2 pieces • Zhi Shi Fructus Aurantii immaturus
• Sheng Jiang Rhizoma Zingiberis recens 3 slices • Mu Xiang Radix Aucklandiae
• Da Zao Fructus Jujubae 7 dates. • Shi Chang Pu Rhizoma Acori tatarinowii
• Fu Zi Radix Aconiti lateralis preparata
Liang Jian Bo, “To treat Dian, settle

AL
• Sheng Jiang Rhizoma Zingiberis recens
the Heart, eliminate Stagnation, calm • Da Zao Fructus Jujubae

N
the Mind and resolve Phlegm; to

O R
If in Dian there is a complicated condition of

FI
treat Kuang, clear the Stomach, drain
- N IE
Heart-Qi stagnation, Phlegm in the Interior and

T
Fire and resolve Phlegm” In: Shi Yu
T V Liver-Fire with Phlegm, Dr Liang recommends using
N SE
Guang 1992 Dang Dai Ming Yi Lin Zheng Jing Hua the above formula Dao Tan Tang Conducting Phlegm
Decoction plus:
[Essential Clinical Experience of
TE L
N E

Famous Contemporary Doctors – Manic-Depression • Huang Lian Rhizoma Coptidis

• Huang Qin Radix Scutellariae
O F

and Epilepsy]. Ancient Chinese Medicine Texts

C O

• Yuan Zhi Radix Polygalae

Publishing House, Beijing, pp. 14–18.
• Zhu Sha Cinnabaris (we are not allowed to use
E TY

Dr Liang says that in Dian there is a deficiency of the this)

PL R

Heart, Liver and Spleen so that the Mind is harassed • Chen Xiang Lignum Aquilariae resinatum.
M PE

and Liver-Qi is chaotic. Dr Liang says that in some cases of Dian, although
He thinks Kuang is due to sadness, anger, indigna- the main manifestations are depression and withdrawn
SA O

tion and vexation, which cause the Liver to develop mood, some patients may display some restlessness;
PR

Fire; this invades the Stomach and harasses the Heart, this indicates Heat in the Heart, Spleen and Pericar-
the Heart orifices are obfuscated and Heart-Qi rebels dium and that there is some Fullness within the
upwards. In Kuang, the Liver, Heart, Stomach and Peri- Deficiency.
cardium are affected, with Fire in the Liver, Heart and In these cases, Dr Liang uses first Di Tan Tang
Stomach. Fire also invades the Pericardium and this Washing Away Phlegm Decoction, then Niu Huang Qing
causes the Ethereal Soul to become restless. As a broad Xin Wan Calculus Bovis Clearing the Heart Pill.
generalization, Dr Liang says that in Dian there is a Afterwards, he nourishes the Heart with Gui Pi Tang
deficiency of the Yin Organs, while in Kuang, an Excess Tonifying the Spleen Decoction with the addition of:
of the Yang Organs.
Interestingly, Dr Liang describes the pulse qualities • Long Gu Mastodi Ossis fossilia
associated with Dian and Kuang. He says that in the • Mu Li Concha Ostreae
former the pulse is Deep and Fire, while in the latter it • Shi Chang Pu Rhizoma Acori tatarinowii
is Overflowing and Full. He says that in Kuang the pulse • Wu Wei Zi Fructus Schisandrae.
feels Floating, Big, Slippery, Rapid and Long; in Dian Alternatively, one can use Shen Zhong Dan Pillow
the pulse feels Empty, soft, Soggy and Weak. Pill.
Dr Liang then makes the interesting observation that In chronic Dian, there is Heart and deficiency which
if in Dian the pulse feels Floating from the Rear to the deprives the Mind of its residence. There is therefore
530 The Psyche in Chinese Medicine

Heart deficiency, the Mind is scattered and the Original • Long Chi Fossilia Dentis Mastodi
Qi is weakened. In such cases, Dr Liang uses Gui Shen • Yuan Zhi Radix Polygalae
Dan Tonifying the Spirit Pill. • Suan Zao Ren Semen Ziziphi spinosae
• Suan Zao Ren Semen Ziziphi spinosae 9 g • Shan Yao Rhizoma Dioscoreae
• Fu Ling Poria 9 g • Ren Shen Radix Ginseng
• Ren Shen Radix Ginseng 9 g • Sheng Di Huang Radix Rehmanniae
• Zhu Sha Cinnabaris 9 g (we are not allowed to use • Fu Ling Poria
this) • Shi Chang Pu Rhizoma Acori tatarinowii
• Dang Gui Radix Angelicae sinensis 6 g • Wu Wei Zi Fructus Schisandrae
• Mai Men Dong Radix Ophiopogonis
As for Kuang, Dr Liang thinks this is often due to Fire
• Gan Cao Radix Glycyrrhizae uralensis
in the Stomach deriving from emotional stress such as
anger, sadness and indignation. These cause the devel- Dr Liang uses this formula to regulate the Ethereal
opment of Fire in the Liver and Pericardium. For treat- Soul when this is injured by sadness. When the Corpo-
ment, Dr Liang advocates draining Stomach-Fire and real Soul is injured by excessive joy, Dr Liang uses Qing
resolving Phlegm with the formula Er Yang Jian Two Shen Tang Clearing the Spirit Decoction, as follows.
Yang Decoction. • Huang Lian Rhizoma Coptidis

AL
• Huang Lian Rhizoma Coptidis • Fu Ling Poria
• Meng Shi Lapis Chloriti seu Micae • Bai Zi Ren Semen Platycladi

N
• Yuan Zhi Radix Polygalae

O R
• Da Huang Radix et Rhizoma Rhei

FI
- N IE
• Long Dan Cao Radix Gentianae • Shi Chang Pu Rhizoma Acori tatarinowii

T
• Gan Cao Radix Glycyrrhizae uralensis
T V
• Shan Zhi Zi Fructus Gardeniae
• Suan Zao Ren Semen Ziziphi spinosae
N SE
• Qing Dai Indigo naturalis
• Mang Xiao Natrii Sulfas • Zhu Li Succus Bambusae
TE L

• Dan Nan Xing Rhizoma Arisaematis preparatum If there is Lung deficiency, add Bei Sha Shen Radix
N E

• Di Long Pheretima Glehniae; if Stomach deficiency, Ren Shen Radix

O F

• Shi Chang Pu Rhizoma Acori tatarinowii Ginseng; if Liver deficiency, Ling Yang Jiao Cornu Saigae
C O

• Yuan Zhi Radix Polygalae tataricae.

E TY

• Shi Jue Ming Concha Haliotidis

Wang Ji Ru, “The disease [Dian
PL R

Dr Liang says that he has been using this formula for

M PE

bipolar disorder (manic phase) for many years with Kuang] is due to Phlegm, Fire and
good results. Stagnation; treat it by resolving
SA O

As for chronic Kuang, Dr Liang says that, in addition

Phlegm and clearing Heat” In: Shi Yu
PR

to Fire and Phlegm (Full conditions), there is also

a deficiency of Heart-Blood or of Yin which, in turn, Guang 1992 Dang Dai Ming Yi Lin Zheng Jing Hua
leads to Empty Heat. In severe cases of chronic Kuang [Essential Clinical Experience of Famous
he also advocates using the vomiting treatment Contemporary Doctors – Manic-Depression and
method. Epilepsy]. Ancient Chinese Medicine Texts Publishing
If there is Fire in the Upper Burner, Dr Liang uses House, Beijing, pp. 20–22.
Sheng Tie Luo Yin Frusta Ferri Decoction; if there is Fire
in Bright Yang, he uses Dang Gui Cheng Qi Tang Angel­ Dr Wang treats Mania (Kuang) with two main formu-
ica Conducting Qi Decoction (Dang Gui Radix Angelicae lae which resolve Phlegm and drain Fire. The first is
sinensis, Da Huang Radix et Rhizoma Rhei, Mang Huo Tan Ding Kuang Tang Breaking Phlegm and Stop­
Xiao Natrii Sulfas and Gan Cao Radix Glycyrrhizae ping Mania Decoction, as follows.
uralensis). • Long Chi Fossilia Dentis Mastodi 30 g
If there is Fire in the Middle Burner, Dr Liang uses • Mu Li Concha Ostreae 30 g
Liang Ge San Cooling the Diaphragm Powder. If there is • Shi Jue Ming Concha Haliotidis 30 g
Heart-Yin deficiency, he uses Long Chi Qing Hun San • Zhen Zhu Mu Concha Margaritiferae usta 30 g
Fossilia Dentis Mastodi Clearing the Ethereal Soul Powder, • Long Dan Cao Radix Gentianae 10 g
as follows. • Tian Zhu Huang Concretio Silicea Bambusae 10 g
 Bipolar Disorder (Manic-Depression) 531

• Shi Chang Pu Rhizoma Acori tatarinowii 10 g Tang Regulating the Stomach Conducting Qi Decoction
• Yu Jin Radix Curcumae 10 g with the addition of the following herbs:
• Xuan Fu Hua Flos Inulae 10 g • Long Dan Cao Radix Gentianae
• Dai Zhe Shi Hematitum 10 g • Shan Zhi Zi Fructus Gardeniae
• Meng Shi Lapis Chloriti seu Micae 30 g • Zhe Bei Mu Bulbus Fritillariae thunbergii
• Chen Xiang Lignum Aquilariae resinatum 3 g • Tian Hua Fen Radix Trichosanthis
• Huang Qin Radix Scutellariae 10 g • Gua Lou Fructus Trichosanthis
• Da Huang Radix et Rhizoma Rhei 6 g • Huang Lian Rhizoma Coptidis.
The emphasis of this formula is very much on sinking For Depression from deficiency of the Heart and
Qi to calm the Mind. The other formula that Dr Wang Spleen, Dr Ban uses a variation of Gui Pi Tang Tonifying
uses for Kuang is Jia Wei Wen Dan Tang Augmented the Spleen Decoction, with the addition of the following
Warming the Gall-Bladder Decoction: herbs:
• Ban Xia Rhizoma Pinelliae preparatum 10 g • Zhe Bei Mu Bulbus Fritillariae thunbergii
• Chen Pi Pericarpium Citri reticulatae 10 g • Hai Fu Shi Pumice
• Fu Shen Sclerotium Poriae pararadicis 12 g • Tian Zhu Huang Concretio Silicea Bambusae.
• Yuan Zhi Radix Polygalae 10 g
If the pulse is Fine and the tongue lacks a coating,

AL
• Zhu Ru Caulis Bambusae in Taeniam 12 g
indicating deficiency of Heart-Yin, Dr Ban uses a varia-
• Zhi Shi Fructus Aurantii immaturus 10 g

N
tion of Gan Mai Da Zao Tang Glycyrrhiza-Triticum-
• Shi Chang Pu Rhizoma Acori tatarinowii 10 g

O R
FI
Jujuba Decoction together with Bai He Di Huang Tang

- N IE
• Yu Jin Radix Curcumae 10 g
Lilium-Rehmannia Decoction, with the addition of the

T
• Tian Zhu Huang Concretio Silicea Bambusae 10 g
T V
following herbs:
• Meng Shi Lapis Chloriti seu Micae 30 g
N SE

• Long Chi Fossilia Dentis Mastodi 15 g • He Shou Wu Radix Polygoni multiflori preparata
• He Huan Pi Cortex Albiziae
TE L

• Mu Li Concha Ostreae 15 g
N E

• Long Dan Cao Radix Gentianae 10 g • Gou Qi Zi Fructus Lycii chinensis

O F

• Zhu Sha Cinnabaris 1.5 g (we are not allowed to • Ye Jiao Teng Caulis Polygoni multiflori
C O

use this). • Mu Li Concha Ostreae

• Long Gu Mastodi Ossis fossilia.
E TY
PL R

Ban Xiu Wen, “To treat Dian Kuang Ma Rui Ting, “An outline of patterns
M PE

distinguish Emptiness from Fullness; and treatment of Manic-Depression

SA O

in Full conditions, drain Liver and (Dian Kuang)” In: Shi Yu Guang 1992 Dang
PR

Stomach, in Empty conditions, tonify Dai Ming Yi Lin Zheng Jing Hua [Essential Clinical
Heart and Spleen” In: Shi Yu Guang 1992 Experience of Famous Contemporary Doctors –
Dang Dai Ming Yi Lin Zheng Jing Hua [Essential Manic-Depression and Epilepsy]. Ancient Chinese
Clinical Experience of Famous Contemporary Doctors Medicine Texts Publishing House, Beijing, pp. 20–22.
– Manic-Depression and Epilepsy]. Ancient Chinese Dr Ma Rui Ting has an interesting view of Manic-
Medicine Texts Publishing House, Beijing, pp. 20–22. Depression for two reasons – saying first that, within
This text provides useful guidelines for differentiating Depression, there may be aspects of Mania and vice
Full from Empty conditions in Manic-Depression. Dr versa; second, Dr Ma treats the Lungs as well, which
Ban says that when the disease starts with Depression other doctors do not stress.
and then progresses into Mania, it is likely to be of a For Mania, Dr Ma moves Liver-Qi, restores the
Full nature with Fire in the Liver and Stomach; when descending of Lung-Qi, subdues rebellious Qi and
it starts with Mania and progresses into Depression, it resolves Phlegm. Dr Ma uses the following
is likely to be of an Empty nature with deficiency of the prescription.
Heart and Spleen. • Fu Ling Poria 9 g
In treatment for Mania from Fire in the Liver and • Gan Cao Radix Glycyrrhizae uralensis 6 g
Stomach Dr Ban uses a variation of Tiao Wei Cheng Qi • Huang Qin Radix Scutellariae 9 g
532 The Psyche in Chinese Medicine

• Bai Shao Radix Paeoniae alba 12 g Zhang ZJ, Kang WH, Tan QR, Li Q, Gao CG, Zhang
• Mu Dan Pi Cortex Moutan 9 g FG et al.
• Chen Pi Pericarpium Citri reticulatae 12 g
• Gua Lou Fructus Trichosanthis 12 g Objective
• Ban Xia Rhizoma Pinelliae preparatum 9 g
• Yu Jin Radix Curcumae 9 g Chinese herbal medicines possess the therapeutic
• Tian Men Dong Radix Asparagi 9 g potential for mood disorders. This double-blind, ran-
• Shu Qi Lacca 3 g domized, placebo-controlled study was designed to
• Zhu Sha Cinnabaris 3 g (we are not allowed to use evaluate the efficacy and side-effects of the herbal med-
this) icine called Free and Easy Wanderer Plus (FEWP) as an
In case of Depression symptoms, Dr Ma adds Long Gu adjunct to carbamazepine (CBZ) in patients with
Mastodi Ossis fossilia and Mu Li Concha Ostreae. bipolar disorders.
To treat Depression, Dr Ma strengthens the Spleen,
harmonizes the Stomach, clears the Lungs and restores Method
the descending of Qi, subdues rebellious Qi, calms the
Mind and resolves Phlegm. Dr Ma uses the following A total of 124 bipolar depressed and 111 manic patients
empirical prescription. were randomized to treatment with CBZ alone, CBZ

AL
plus FEWP, or equivalent placebo for 12 weeks. CBZ
• Fu Ling Poria 9 g

N
was initiated at 300 mg/day and FEWP was given at a
• Gan Cao Radix Glycyrrhizae uralensis 6 g

O R
FI
fixed dose of 36 g/day. Efficacy measures included the

- N IE
• Bai Shao Radix Paeoniae alba 9 g
Hamilton Rating Scale for Depression, Montgomery-

T
• Mu Dan Pi Cortex Moutan 9 g
T V
Asberg Depression Rating Scale, Young Mania Rating
• He Shou Wu Radix Polygoni multiflori preparata
N SE
Scale, Bech-Rafaelsen Mania Scale, and Clinical Global
9g
Impression-Severity (CGI-S).
TE L

• Chen Pi Pericarpium Citri reticulatae 9 g

N E

• Xing Ren Semen Armeniacae 9 g

O F

• Ban Xia Rhizoma Pinelliae preparatum 9 g Results

C O

• Yu Jin Radix Curcumae 9 g

CBZ monotherapy produced significantly greater
E TY

• Long Gu Mastodi Ossis fossilia 12 g

improvement on manic measures at week 2 through
• Mu Li Concha Ostreae 15 g
PL R

endpoint and CGI-S of depression at endpoint com-

• Sheng Jiang Rhizoma Zingiberis recens 6 g
M PE

pared to placebo. CBZ monotherapy also yielded signifi-

• Cao Guo Fructus Tsaoko 5 g
cantly higher clinical response rates than placebo on
• Shi Chang Pu Rhizoma Acori tatarinowii 12 g
SA O

bipolar depression (63.8% vs. 34.8%, P = 0.044) and

• Zhu Sha Cinnabaris 1.5 g (we are not allowed to
PR

mania (87.8% vs. 57.1%, P = 0.012). Compared to CBZ

use this)
monotherapy, adjunctive FEWP with CBZ resulted in
In case of symptoms of Mania, Dr Ma adds Shu Qi significantly better outcomes on the three measures of
Lacca. depression at week 4 and week 8, and significantly
greater clinical response rate in depressed subjects
(84.8% vs. 63.8%, P = 0.032), but failed to produce
CLINICAL TRIALS significantly greater improvement on manic measures
and the response rate in manic subjects. There was a
Herbal medicine lesser incidence of dizziness and fatigue in the combi-
Adjunctive herbal medicine with nation therapy compared to CBZ monotherapy.
carbamazepine for bipolar disorders: a
double-blind, randomized, placebo- Conclusion
controlled study
These results suggest that adjunctive FEWP has addi-
Journal of Psychiatric Research 2007 April–June, tive beneficial effects in bipolar patients, particularly
Vol. 41, Issue 3–4, pp. 360–369. for those in the depressive phase.
 Bipolar Disorder (Manic-Depression) 533

The beneficial effects of the herbal Method

medicine Free and Easy Wanderer Plus
(FEWP) for mood disorders: double-blind, A total of 87 unipolar and 62 bipolar depressed patients
placebo-controlled studies were randomly assigned to treatment with 36 g/day
FEWP (n = 86) or placebo (n = 63) for 12 weeks under
Journal of Psychiatric Research 2007 November, Vol. double-blind conditions. Efficacy was measured using
41, Issue 10, pp. 828–836. the Hamilton Rating Scale for Depression (HAMD),
Zhang ZJ, Kang WH, Li Q, Tan QR Montgomery-Asberg Depression Rating Scale (MADRS)
and Clinical Global Impression-Severity (CGI-S).
Objective
Results
To ascertain the effect of the herbal medicine Free and
Easy Wanderer Plus (FEWP) as adjunctive therapy Both unipolar and bipolar patients assigned to FEWP
with carbamazepine (CBZ) in the treatment of bipolar displayed significantly greater improvement on the
disorders. three efficacy indices and significantly higher clinical
response rate (74%) than those treated with placebo
Background (42%, p < 0.001) at endpoint.

AL
A study published in the Journal of Psychiatric Research
Conclusion

N
in 2005 conducted by Zhang ZJ, Kang WH, Tan QR, Li

O R
FI
Q, Gao CG, Zhang FG et al. showed the beneficial effects
- N IE
These results suggest that adjunctive FEWP improves

T
of the herbal medicine Free and Easy Wanderer Plus tolerability of CBZ in the long term, which may be asso-
T V
(FEWP) as adjunctive therapy with carbamazepine
N SE
ciated with the suppression of blood CBZ concentra-
(CBZ) in the 12-week treatment of bipolar disorders. tions via herb–drug interactions. FEWP monotherapy
TE L

Here, follow-up data obtained from a continuation of may also be an effective alternative treatment for
N E

the 2005 study are presented. depression.

O F
C O

Method
END NOTES
E TY

Treatment and clinical evaluation of bipolar patients

PL R

1. Regier DA, Narrow WE, Rae DS et al 1993 The de facto mental and
(n = 188) who had randomly received 12-week CBZ addictive disorders service system. Epidemiologic Catchment Area
M PE

plus placebo (n = 92) or CBZ plus FEWP (n = 96) were prospective 1-year prevalence rates of disorders and services.
extended to 26 weeks under double-blind conditions. Archives of General Psychiatry 50(2): 85–94.
SA O

2. Redfield Jamison K 1993 Touched with Fire – Manic-depressive

Patients in the adjunctive FEWP group showed a
PR

Illness and the Artistic Temperament. Free Press, New York,

significantly lower overall discontinuation rate (31%) pp. 262–263.
3. Ibid., p. 263.
at endpoint compared to the placebo group (51%, 4. American Psychiatric Association 1994 Diagnostic and Statistical
p = 0.009). Of the patients in the adjunctive FEWP Manual for Mental Disorders, 4th edn (DSM-IV). American
group, 15% discontinued treatment due to intolerable Psychiatric Press, Washington, DC.
5. National Institute of Mental Health website: [Link].
side-effects, markedly lower than those in the placebo [Accessed 2008].
group (28%, p = 0.019). No difference in discontinua- 6. Redfield Jamison K 1995 An Unquiet Mind. Picador, London,
p. 36.
tion for lack of efficacy and exacerbation was observed 7. Ibid., p. 37.
in the two groups. 8. Vainionpaa LK, Rattya J, Knip M et al. 1999 Valproate-induced
hyperandrogenism during pubertal maturation in girls with
epilepsy. Annals of Neurology 45(4): 444–450.
Results 9. Touched with Fire – Manic-depressive Illness and the Artistic
Temperament, p. 34.
Patients receiving adjunctive FEWP had significantly 10. Ibid., p. 34.
11. Ibid., p. 34.
fewer adverse side-effects and lower serum levels of 12. Ibid., p. 35.
CBZ than those on placebo. A separate study was 13. Ibid., p. 35.
14. Ibid., p. 35.
further conducted to evaluate the effectiveness of 15. Shen Quan Yu, Wu Yu Hua, Shen Li Ling 1989 Dian Kuang Xian
FEWP as monotherapy in depressed patients. Zheng Zhi [The Treatment of Manic-Depression and
 534 The Psyche in Chinese Medicine

Epilepsy]. Ancient Chinese Medicine Texts Publishing House, 38. Qin Yue Ren 2004 Nan Jing Jiao Shi [Classic of Difficulties].
Beijing, p. 1. Scientific and Technical Documents Publishing House, Beijing,
16. 1979 Huang Di Nei Jing Su Wen [The Yellow p. 13. First published [Link] 100.
Emperor’s Classic of Internal Medicine – Simple Questions]. People’s 39. Zhang Bo Yu 1986 Chinese Internal Medicine, p. 125.
Health Publishing House, Beijing, p. 539. First published c.100 bc. 40. An Unquiet Mind, pp. 92–93 and p. 120.
17. Ibid., pp. 257–258. 41. Touched with Fire – Manic-depressive Illness and the Artistic
18. 1981 Ling Shu Jing [Spiritual Axis]. People’s Health Temperament.
Publishing House, Beijing, p. 57. First published c.100 bc. 42. Trimble MR 2007 The Soul in the Brain. Johns Hopkins University
19. Nanjing College of Traditional Chinese Medicine 1979 Nan Jing Jiao Press, Baltimore, p. 105.
Shi [A Revised Explanation of the Classic of Difficulties]. 43. Cited in The Treatment of Manic-Depression and Epilepsy, p. 6.
People’s Health Publishing House, Beijing, p. 132. First published 44. Ibid., p. 6.
c. AD 100. 45. Zhang Fa Rong 1989 Zhong Yi Nei Ke Xue [Chinese
20. Ibid., p. 52. Internal Medicine]. Sichuan Science Publishing House, Chengdu,
21. He Ren 2005 Jin Gui Yao Lue [Essential Prescriptions of the p. 103.
Golden Chest]. People’s Health Publishing House, Beijing, p. 42. 46. National Institute of Mental Health website: [Link].
The Essential Prescriptions of the Golden Chest was written by Zhang [Accessed 2008].
Zhong Jing and first published [Link] 220. 47. Tian Dai Hua 2005 The Yellow Emperor’s Classic of Internal
22. Cited in The Treatment of Manic-Depression and Epilepsy, p. 3. Medicine – Simple Questions, p. 94.
23. Ibid., p. 3. 48. The NIMH Genetics Workgroup 1998 Genetics and mental
24. Ibid., p. 3. disorders. National Institute of Mental Health, Rockville, MD. NIH
25. Cited in Zhang Bo Yu 1986 Zhong Yi Nei Ke Xue Publication No. 98: 4268.
[Chinese Internal Medicine]. Shanghai Science Publishing House, 49. Cited in The Treatment of Manic-Depression and Epilepsy, p. 6.
Shanghai, p. 125. 50. Liu Xiu Zhen 1994 [The experience of Dr Zhang Li Sheng in the

AL
26. Cited in The Treatment of Manic-Depression and Epilepsy, p. 4. treatment of Dian Kuang and epilepsy]. Journal of Chinese Medicine
27. Ibid., p. 4. 35(2): 77.
28. Zhang Jing Yue 1986 Jing Yue Quan Shu [Complete Book 51. Zhang Fa Rong 1989 Chinese Internal Medicine, pp. 103–105.

N
of Jing Yue]. Shanghai Scientific Publishing House, Shanghai, p. 52. Yang Tai De et al. 2001 [Fu Shan’s views on Dian Kuang]. Journal

O R
FI
574. First published 1634. of Chinese Medicine 42(9): 571.

- N IE
29. Cited in The Treatment of Manic-Depression and Epilepsy, p. 4. 53. Shan Chang Hua 1990 Jing Xue Jie [An Explanation of the

T
30. Ibid., p. 5. Acupuncture Points]. People’s Health Publishing House, Beijing,
T V
31. Huang Tai Tang 2001 Nei Ke Yi Nan Bing Zhong Yi Zhi Liao Xue p. 88. An Explanation of the Acupuncture Points was written by Yue
N SE
[The Treatment of Difficult Diseases in Han Zhen and first published in 1654.
Chinese Internal Medicine]. Chinese Herbal Medicine Science 54. Dr Zhang Ming Jiu, personal communication, Nanjing 1982.
TE L

Publishing House, Beijing, pp. 761–774. 55. Chen You Bang 1990 Zhong Guo Zhen Jiu Zhi Liao Xue
N E

32. Zhang Gang 1986 [Differentiating terminology and reality of Dian [Chinese Acupuncture Therapy]. China Science
Kuang in the Yellow Emperor’s Classic of Internal Medicine]. Journal Publishing House, Shanghai, p. 501.
O F

of Chinese Medicine (Zhong Yi Za Zhi ) 27(5): 56. 56. Yang Jia San 1989 Zhen Jiu Xue [A Study of Acupuncture].
C O

33. Spiritual Axis, p. 57. Beijing Science Publishing House, Beijing, p. 632.
34. Chen Chao 1984 [Clinical observations on the use of a variation of 57. Wang Li Cao 1997 Zhong Guo Zhen Jiu Chu Fang Da Cheng
E TY

Wen Dan Tang to treat 30 Cases of Dian Kuang]. Journal of Chinese [A Collection of Chinese Acupuncture
Medicine 25(11): 31. Prescriptions]. Shanxi Science Publishing House, Taiyuan, p. 446.
PL R

35. Wang Yong Yan 2004 Zhong Yi Nei Ke Xue [Chinese 58. Cited in The Treatment of Manic-Depression and Epilepsy, p. 6.
Internal Medicine]. People’s Health Publishing House, Beijing, 59. Liang Jian Bo 1992 To treat Dian, settle the Heart, eliminate
M PE

p. 354. Stagnation, calm the Mind and resolve Phlegm; to treat Kuang, clear
36. Tian Dai Hua 2005 Huang Di Nei Jing Su Wen The the Stomach, drain Fire and resolve Phlegm. In: Shi Yu Guang
SA O

Yellow Emperor’s Classic of Internal Medicine – Simple Questions]. 1992 Dang Dai Ming Yi Lin Zheng Jing Hua
PR

People’s Health Publishing House, Beijing, p. 6. First published [Essential Clinical Experience of Famous Contemporary Doctors –
c.100 bc. Manic-Depression and Epilepsy]. Ancient Chinese Medicine Texts
37. Ibid., p. 49. Publishing House, Beijing, pp. 14–18.

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