The "Ask Dr. Jiang" column is designed to explore corners of Chinese medicine that may not be easily understood by American practitioners or are underrepresented in American clinical health literature.
The TCM Diagnosis and Treatment of Bipolar Disorder, Part Two
In my last article, I showed "Qi Healer" how to understand the development of bipolar disorder ("manic-depression") according to TCM. Now we need to explain its treatment. The strategy here is pretty straightforward: You should treat the phase of the disease that is manifesting at the time of treatment. If the patient is in the manic phase, treat mania; if the patient is in the depressive phase, treat depression. Let's take a look at the differential breakdown of mania and depression.
Diagnosis and Treatment of Manic Phase
Chinese medicine differentiates mania into four distinct patterns: Heart-Liver fire; phlegm fire harassing the Heart; yang ming bowel heat; and blood amassment (xu xue).
1. Heart-Liver Fire
In the case of Heart-Liver fire, the mania comes mixed with insomnia, anger or excess joy. Discriminating signs include headache; red eyes; ringing ears; dizziness; a bitter taste in the mouth; sores in the mouth (a telltale sign of Heart fire); rib-side pain; and a wiry, strong, slippery and rapid pulse. The treatment principle is to drain Heart-Liver fire and calm the spirit.
There are three primary formulas that are used to treat this pattern. If Liver fire symptoms such as anger, headache and rib-side pain are more prominent, choose long dan xie gan tang. If Heart fire symptoms such as excess joy (excitability) and mouth sores predominate, then prescribe zhu sha an shen wan. Given the concern over mercury toxicity in the modern world, I recommend you substitute dai zhi shi or ci shi for zhu sha in this last formula.
If the overall symptoms are particularly severe, or if there are signs of phlegm fire, use sheng tie luo yin. This formula has the strongest sedative effects of the three. The heaviness of the iron helps to settle the spirit and drain the fire downward. It also contains ingredients such as bei mu, dan nan xing and chen pi, which transform phlegm. Zhu sha is also an ingredient, and in this case I think you can simply remove it without affecting the formula very much.
In the above formulas, you can add da huang, which will greatly improve each formula's ability to immediately calm the patient. This is done only during the first one or two doses; once the patient has settled down, the da huang is no longer necessary.
2. Phlegm Fire Harassing the Heart
In the case of phlegm fire harassing the Heart, the differential diagnosis can be a little tricky. Although this is a distinct pattern, sometimes it looks exactly like Heart-Liver fire. The mania symptoms, for example, are very similar: insomnia; restlessness; and an inability to answer questions. Likewise, the pulse of phlegm fire does not distinguish it very well: It is typically rapid, strong and slippery. Sometimes the pulse is wiry, as well - just like Heart-Liver fire.
My advice here is to pay special attention to the tongue. The "textbook" tongue appearance for phlegm fire is a red body with a thick, yellow, greasy coat. Even here, however, you have to be careful. Sometimes phlegm fire damages fluids, causing the coat to become dry instead of greasy.
The treatment principle is to clear heat, transform phlegm and calm the spirit. The typical formula for phlegm fire harassing the Heart is sheng tie luo yin. Since this formula is also an option for treating Heart-Liver fire, we can see the two patterns overlap in both appearance and treatment. Once again, you should remove the zhu sha. You can also add da huang to the first dose to enhance the sedative effects.
3. Yang Ming Bowel Heat
When it comes to yang ming bowel heat, you need to think of this pattern as more than a febrile disease. While invading warm disease evils can certainly cause a kind of mania when they reach the yang ming bowel, this pattern can also be caused by eating when one is angry, which drives fire into the bowels.
Symptoms of the yang ming bowel pattern include mania with pain and distention in the abdomen. The patient, however, may not be fully in touch with the pain he or she is experiencing, so this may not be included as a complaint. It is best to palpate the abdomen to see if pressure elicits discomfort. The tongue has a deep, dry yellow coat, and the pulse is fast, strong and deep.
The treatment principle for yang ming bowel heat is to drain fire downward by purging. The main formula is da cheng qi tang. Note that this formula already contains da huang.
4. Blood Amassment
The final cause of mania is blood amassment (xu xue), a pattern described in the Shang Han Lun. In this case, blood stasis accumulates in the lower burner and transforms into heat, which disturbs the spirit. In addition to mania, the patient will experience strong, cramping lower abdominal pain. This should not be confused with the abdominal pain of yang ming bowel heat, which is felt over the entire abdomen. The patient is restless and thirsty, but the heat signs are not as obvious. The tongue might be purple, with blue or purple spots on the edges. The pulse is strong and rapid. Even though this is a blood stasis pattern, don't expect the pulse to be choppy; excess heat tends to smooth this quality out of a pulse.
The treatment principle here is to move blood stasis and drain heat downward. The formula is tao he cheng qi tang. If the mania is particularly severe, you can use di dang tang. Note that both of these formulas contain da huang.
The ubiquitous presence of da huang in the above formulas reflects the ancient understanding of mania arising from fire in the stomach channel, as described in chapter 10 of the Ling Shu. Da huang calms the spirit by purging the bowels, which strongly drains the fire from the Stomach channel, thereby removing the disturbance from the spirit.
Differential Diagnosis and Treatment of Depressive Phase
The depressive phase of bipolar disorder falls into four main patterns: Liver qi stagnation; qi stagnating with phlegm (qi yu tan zu), Heart-Gallbladder qi deficiency; and Heart Spleen disharmony.
1. Liver Qi Stagnation
I think every acupuncturist is familiar with this pattern. Look for depression; irritability; insomnia; low appetite; rib-side pain; wiry pulse; and so on. If the depression is caused by emotions such as anger or sorrow, they are likely to be repressed and not easily seen in the patient's affect or behavior.
There are three different formulas that can be used. If the pattern is one of pure stagnation with no underlying deficiency, then use chai hu shu gan san. If the Spleen and Stomach are involved, with nausea or poor appetite, or if there are signs of qi deficiency, use xiao chai hu tang. If there is Liver-Spleen disharmony with blood deficiency, use xiao yao wan.
2. Qi Stagnating with Phlegm (qi yu tan zu)
Look for depression with irritability; insomnia; low appetite; fullness and distention in the stomach and flanks; and digestive disorders. The tongue coat is thick and greasy, and the pulse is slippery and/or wiry. The patient may also complain of "plum stone sensation" in the throat (mei he qi), or there might be some phlegm expectorated from the lungs.
The treatment principle is to transform phlegm and regulate the movement of qi. For this pattern, use ban xiao hou po tang. If the phlegm transforms into phlegm heat, use wen dan tang.
3. Heart Gall Bladder Qi Deficiency
The Nei Jing referred to this pattern as "Gallbladder qi deficiency," but nowadays we look at it as primarily a Heart pattern. The depression in this case is characterized primarily by fear and paranoia. There are often no physical symptoms at all. Think of this pattern when you see a depressive patient who is seemingly asymptomatic, whose pulse and tongue signs fall within normal limits, and who does not seem to fit with other Chinese medical patterns.
The treatment principle is to tonify the qi and calm the spirit, and the formula is ding zhi wan. If the qi deficiency is mixed with yin deficiency, you can use tian wang bu xin dan.
4. Heart Spleen Disharmony
In this pattern, the symptoms simultaneously reflect Heart blood and Spleen qi deficiencies. The depression is mixed with fatigue; insomnia; palpitations; pale complexion; and possibly menstrual irregularity. The pulse is thin and the tongue is pale.
The treatment principle is to tonify qi and blood and calm the spirit. The formula is gui pi tang.
I hope this helps you with your healing work, Qi Healer. Although little is written about bipolar disorder in the TCM literature, the above protocols show that each phase of the illness is treatable with Chinese medicine.
Edited with the assistance of John Pirog, MSOM.
Click here for previous articles by Yong Ping Jiang, DOM, PhD.