The Emotions In Traditional Chinese Medicine – Part 1 The Five Elements

Abstract

The paradigm of the Five Elements provides a practical framework for understanding the emotions in health and disease. The relationships that are described within this paradigm allow effective therapeutic interventions in patients with emotion based problems, utilizing various physical and psychological modalities. The basic concepts of this paradigm are discussed along with the general principles of its clinical application, so as to provide a context for further discussion on herbal formulas and treatment protocols.

Introduction

Traditional Chinese medicine (TCM) has long recognized the importance of psychological factors, particularly the emotions, in health and disease. In the Nei Jing, the major TCM source text from the 1^st Century BCE, the question is posed:

‘Why is it that after using the various treatment modalities … the patient does not recover?’ The reply follows: ‘To completely heal a person, acupuncture, herbs and these other modalities are only one aspect of the treatment. You must also come into synchrony with the patient in many other ways… When patients lack the confidence to conquer illness, they allow their spirits to scatter and wither away. They let their emotions take control of their lives. They spend their days drowned in desires and worries, exhausting their Essence (jing) and Qi and Spirit (shen). Of course, then, even with all these other modalities, the disease will not be cured.’ (Ni, 1995, pp. 53-4)

The above statement may appear to correlate closely with Plato’s famous words from Charmides: ‘And therefore if the head and body are to be well, you must begin by curing the soul; that is the first thing’[1]. (Stevenson, 2009) However, the underlying logic of TCM is quite different from that of western science and the Greco-Roman tradition. In general, TCM is not analytical, and while both deductive and inductive reasoning are used to a limited extent, a synchronistic world view predominates. In other words, TCM is based upon meaningful connections between things that are not explained by causality. Thus, when approaching TCM, it should always be borne in mind that synchronistic logic plays a very important role, without necessarily diminishing the usefulness of analysis and linear cause and effect thinking when appropriate. Another essential feature of TCM is the use of several different theoretical paradigms, each of which may furnish useful clinical outcomes when applied in the right way, and in an appropriate situation. These considerations are exemplified in the theory of the Five Elements and the way in which the various relationships between individual Elements may be applied in clinical practice.

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[1] This statement follows on from a criticism of the ancient Greek physicians who were unable to cure many diseases. ‘As you ought not to attempt to cure the eyes without the head, or the head without the body, so neither ought you to attempt to cure the body without the soul.’

The emotions according to the Five Elements

The following analysis of human emotional responses is primarily based on the theory of the Five Elements (wu xing). The Chinese term signifies five different types of activity within a repeating cycle. In addition, the Five Elements may be also be understood in a static way and be applied to structures, locations and directions. (For more detailed discussion, see: Maciocia, 2014; Maciocia, 2005; McDonald & Penner, 1994; Kaptchuk, 2000) The dynamic application of this theory is, in general, more important in medicine. Emotions in themselves are dynamic, in that they rise and fall, change from one to the other (sometimes quite rapidly) and motivate our behavior to a very large extent. Thus, in TCM, emotional states may readily be understood and acted upon using the paradigm of the Five Elements.

Juxtaposed against the gamut of our emotions is the uniquely human ability to reason within the context of a set of principles or a moral code. This reasoning faculty is latent in children and needs to be developed, refined and strengthened during adulthood. As such, our ability to reason is the complementary opposite of our emotional life (in terms of Yin-Yang), the careful application of which is a manifestation of emotional intelligence (Goleman, 1994). At this point, let us review and reconsider the Five Elements theory from this perspective.

The Five Elements: the divisions of cyclic change

The Five Elements theory, which is based on Yin and Yang, is a more elaborate paradigm wherein phenomena are grouped into five categories. In this way, correlative relationships are established for items within a category (e.g. for the Liver and Gallbladder within the Wood element), while various types of relationships are described for similar items within different categories (e.g. the ‘generation’ and ‘control’ sequences, as discussed below).

In terms of Yin-Yang, a further differentiation gives: Yang within Yin (emerging or young Yang); Yang within Yang (mature or full Yang); Yin within Yang (emerging or young Yin); Yin within Yin (full or mature Yin). In addition to these four stages we have the point of balance, or the ground upon which they manifest. Thus, we have the Five Elements wherein Qi (universal life-energy) undergoes five stages of transformation – Wood (young Yang), Fire (mature Yang), Earth (point of balance), Metal (young Yin), and Water (mature Yin), and these denote five different types of activity that occur within a repetitive cycle. As summarized in the Nei Jing:

‘The universal yin and yang transform into the five earthly transformative energies, also known as the five Elements that consist of wood, fire, earth metal and water.’ (Ni, 1995, p.8)

Every observable phenomenon is seen as an expression of these transformations. A clear example is the cycle of growth and activity that occurs during the seasons of the year (specifically related to food crops). Spring is the time of germination and new growth. This is the emerging Yang and is related to Wood. Summer is the period of active growth and is the mature Yang, related to Fire. In autumn the harvest occurs and this is the emerging Yin, related to the Metal. Finally, winter is the time for storage and dormancy, which is the mature Yin, related to Water. In addition, there is a period of ripening and maturing of the crops, which occurs in late summer. In this period the activities of growth and decline are momentarily balanced. This period is the fifth season and belongs to Earth.

A more static example is seen in a description of the four cardinal directions: North, South, East and West – a simple division into four. In the northern hemisphere, the South is the related to the path of the sun, a hotter climate,  and the source of hot winds (Fire); the East is the direction from which the sun rises (Wood); West is where the sun sets (Metal) and North is the location of the colder regions, from which arise the cold winds (Water). However, a system of co-ordinates must have a reference point. Thus, the initial fourfold division receives a fifth when we include the center or reference point (Earth).

Another helpful way to understand the dynamic nature of the Five Elements is to analyze the progress from ‘potentiality’ to ‘actuality’, where a specific result is derived from a sequence of activities.

1. The initial plans and decisions are made, the necessary performers and materials are gathered together in an organized way.
2. The specific activities are carried out.
3. The final result is achieved.

Wood is the state of potential activity in which all the components are prepared, organized and made ready to provide the preconditions for the stage of actual activity. Fire represents the stage of actual activity directed towards the end result. Immediately preceding the completed action, when the processes involved in the active stage (Fire) are about to produce the result, the potential for producing this specific result is at its greatest and, in fact, the result is now inevitable. This is Metal, when the momentum of the activity needs to be restrained, controlled and guided towards the finishing point. The specific result is Water. Thus, we have:

• Wood – potential activity
• Fire – actual activity
• Metal – potential result, restraint of activity
• Water – actual result

Let us take the act of driving a car to a specific destination as an example:

• Wood – making the decision to go to this destination, determining the route to follow, gathering together the driver, car, road-map etc., making sure that there is adequate fuel, oil, water, etc., and then inserting the key into the ignition, i.e. preparing to move.
• Fire – starting the engine and driving safely to the destination, i.e. moving.
• Metal – the destination comes into view, the brakes are applied and the car slows down, i.e. preparing to stop
• Water – The destination is safely reached, i.e. stopping and arriving.

Thus, we have our basic system of four stages; all on one plane, as it were – goal directed physical activity and tangible results. From the Yin-Yang perspective, we can infer that there should also exist a complementary factor that gave birth to these various activities. This complementary factor is the background of the many possibilities, against which this whole process occurs, and out of which one particular pathway is chosen. This is also the realm in which the tendency to activity and the tendency towards latency are in a state of balance, with neither predominating. This is Earth. In addition, after the end result of this sequence has been reached, there is also a return to Earth, which represents the period in which there exists the undefined potential for further activities, from which a single pathway is chosen and a new sequence of events arises to create another result.

This background of possible activities is an undifferentiated state (i.e. Yin), from which arises the differentiated state of one specific sequence of events leading to a particular result (i.e. Yang). In the example given above, the stage pertaining to Earth exists in the period before the decision has been made to go to this particular destination, where there are very many other possible destinations. Earth is also reached again on arrival at the destination, in the period of time before the next sequence of activities, when there are any number of possibilities for further action. Thus, Earth represents the period between completed activity and potential activity, where Yin and Yang are momentarily in balance. (Porkert, 1974, Ch.1)

Medical application of the Five Elements

In TCM all of the structures and functions of the human body and psyche are classified according to this system. The items that are listed within each element correspond with one another, i.e. they have a very close relationship, which is not necessarily of a causal nature. Moreover, all of the physiological, structural, psychological and pathological aspects within each element are ‘represented’ by (or line up behind) the specific ‘zang’ organ (solid viscus) belonging to that element and are considered as attributes of that particular organ. Thus, when a person is prone to crying, although we can see that the tears flow from her eyes, from the broader perspective of the Five Elements, the crying ‘comes from’ the Liver and may denote a disorder of that organ. The following chart summarizes the medical correlations within the Five Elements.

ELEMENT	WOOD	FIRE	EARTH	METAL	WATER
DYNAMIC	Potential activity	Actual activity	Undifferentiated world of possibility	Potential result	Completion of activity
YIN-YANG	Young Yang	Mature Yang	Balance	Young Yin	Mature Yin
DEVELOPMENT	Germination	Growth	Ripening	Harvest	Storage, Seed
SEASON	Spring	Summer	Late summer, Monsoon	Autumn	Winter
CLIMATE / PATHOGEN	Wind	Heat	Damp	Dryness	Cold
ZANG ORGAN	Liver	Heart	Spleen	Lung	Kidney
FU ORGAN	Gallbladder	Small Intestine	Stomach	Large Intestine	Urinary Bladder
EMOTIONAL QUALITY	Self-assertion, Righteous indignationo	Joy, Enthusiasm	Intellectual focus, Ability to concentrate	Instincts, Drive towards survival	Will, Drive
PATHOLOGICAL EMOTION	Anger	Over-excitement	Obession, Worry	Sadness, Grief	Fear, Timidity
HUMAN QUALITY	Planning, Decisino making	Clarity of conscious-ness	Ideas, Understanding working memory	Taking in, holding on & Letting go	Long term memory, Concentration
TISSUE	Tendons and Nails	Blood and Blood vessels	Muscle, Fat	Skin and Body hair	Bones and Marrow
SENSE ORGAN	Eyes, Vision	Tongue, Speech	Mouth, Taste	Nose, Smell, Touch	Ears, Hearing
FLUID	Tears	Sweat	Watery saliva	Nasal mucus	Mucoid saliva
SOUND (OR TONE OF VOICE)	Shouting	Laughing	Singing	Crying	Groaning
COLOUR	Green	Red	Yellow	White	Blue, Black
INJURED BY EXCESSIVE	Walking	Staring	Sitting	Lying	Standing
FLAVOUR	Sour	Bitter	Sweet	Pungent (Spicy)	Salty
WESTERN MEDICAL CORRESPONDENCES	Hepatobiliary system, Emotion and Stress-related disorders	Cardiovas-cular system, Brain and Psyche	Digestive system including pancreas	Respiratory system	HPA axis, HPG axis, Urogenital system, Congenital disorders

Table 1: Five Element Correspondences

An important application of Five Elements is in the classification of the internal organs, which are regarded primarily as functional systems within the body and secondarily as physical structures. The major bodily organs are divided into Yin-Yang pairs and each pair is allocated to one of the Five Elements. The Yin component of each pair is referred to as the zang organ (viscus, or solid organ), and the complementary Yang organ is referred to as a fu organ (bowel, or hollow organ). The zang organs, as listed above, are regarded as the major representatives of each of the Elements in the body. The other items that pertain to the body, listed under each Element, are generally thought of as the attributes of each specific zang organ. Thus, each of the bodily organs has a vastly different significance in TCM compared to Western biomedicine. This is one of the reasons why the name of the Element (e.g. Wood) and the name of the corresponding zang (e.g. the Liver) may often be used together, e.g. Liver-Wood, or Kidney-Water, in order to emphasize the broader concept behind the organ name.

 

Important Relationships

The main relationships amongst the Elements that are used in TCM, are those of generation (or promotion) and control (or restriction). These are represented by two different orderly sequences from one Element to another, which explain the relationships of nourishment/promotion and restraint that underlie both normal (i.e. physiological) and abnormal (i.e. pathological) activities.

One can observe in Nature that there are processes that involve cyclical change, in which a series of changes occurs only to return to the starting point and repeat. The seasons are a graphic example of this. Physiological processes, pathological processes and their resolution, as well as the life cycle itself, all progress in such a cyclical manner. In order to apply the Five Elements to cyclical phenomena, the Elements are placed in a specific order, which describes a causal or temporal sequence (i.e. one phenomenon arising out of, or as a direct result of a prior phenomenon), as follows:

Wood → Fire → Earth → Metal → Water → Wood → Fire …. (and so on)

This is generally expressed in the following diagram:

                                    Wood

            Water                                      Fire

                        Metal              Earth

          Diagram 1: The generation sequence.

This sequence progresses in a clockwise direction and represents the natural progression of birth, growth and development. One Element arises out of, or develops from, the previous one. However, there also needs to be a system of controls and checks in place to ensure an orderly progression within the cycle. It is not sufficient that an impulse for growth, development or increase be given and passed on. There must also be a mechanism that limits and directs this impulse in an appropriate way. The sequence of control or restriction is as follows:

Wood → Earth → Water → Fire → Metal → Wood  → Earth …. (and so on)

 This is generally expressed using the same circular diagram as the generation sequence in Diagram 1, above. However, the arrows indicating the relationships are arranged as follows (clockwise, going to the Element after the adjacent one):

                                                 Fire

                        Wood                                      Earth

                                    Water              Metal

                        Diagram 2: The control sequence

In health, the relationships described by the control sequence serve to maintain an harmonious state. However, when pathology is present, this sequence helps to explain the pathophysiological consequences of various types of imbalance.

In the broadest sense, pathological states may be viewed as excess or deficiency. Excess refers to over-activity of an organ or the presence of pathogenic material that disrupts normal function. Deficiency refers to functional under-activity or lack of essential bodily materials, which are not present in sufficient quantity to maintain normal physiological activities. According to the control sequence, an excess in one organ (e.g. Liver-Wood) will lead to the organ over-controlling the organ that it normally controls (in this example Spleen-Earth), leading to a pathological deficiency condition in this organ (i.e. Spleen deficiency). On the other hand, when an organ is in a deficiency condition (e.g. the Lung-Metal), the organ this is normally under its control (in this example the Liver-Wood) will tend to develop an excess condition (e.g. Liver excess). Moreover, a deficiency condition within an organ (e.g. Lung-Metal) may allow the controlling organ (in this example, the Heart-Fire) to develop an excess condition.

We need to remember that the control sequence only points to possibilities that may develop in a patient. It is quite possible for a patient to have only a single imbalance, without any of the repercussions that are predicted by the control sequence. This paradigm simply alerts a practitioner to the potential for development of a pathological change that has been detected. This is summarized in the following table.

ORGAN-ELEMENT	CONSEQUENCES OF EXCESS CONDITION	CONSEQUENCES OF DEFICIENCY CONDITION
Liver-Wood	Spleen-Earth deficiency	Spleen-Earth excess; Lung-Metal excess
Heart-Fire	Lung-Metal deficiency	Lung-Metal excess; Kidney-Water excess
Spleen-Earth	Kidney-Water deficiency	Kideny-Water excess; Liver-Wood excess
Lung-Metal	Liver-Wood deficiency	Liver-Wood excess; Heart-Fire excess
Kidney-Water	Heart-Fire deficiency	Heart-Fire excess; Spleen-Earth excess

Table 2: The Control Cycle – Pathological conditions

Representation of the psyche according to the Five Elements

As can be seen from Table 1, above, our normal healthy psychological faculties are categorised into the Five Element paradigm, together with normal human emotional responses. One purpose in viewing human psychic life in this way, is that a practitioner may assess not only the pathological extremes, but also the deficiencies. If we take self-esteem as an example, a certain level may be regarded as healthy and a positive personal attribute; too much and the person becomes ego-centric and possibly even psychopathic; whereas if a person has too little self-esteem, this may lead to a chronic state of anxiety, frustration or sadness. In this example the psychological states are readily observable, and are within our common experience.  Now, by applying the Five Elements paradigm, we can see that low self-esteem correlates with a deficiency state of the Liver, which can be treated by nourishing the Liver Blood.

On the other hand, in excess states, we may need to look for the underlying or associated deficiency, by following the control cycle relationships, in addition to addressing the excess condition of the main organ directly. A patient with an excess condition of the Liver (generally Liver Heat or Liver Fire, manifesting in extreme anger), may also have a deficiency condition in Earth (Spleen). The deficiency may be psychological (lack of a rational perspective, lack of intellectual focus, etc..) and/or physical, i.e. Spleen Qi deficiency, with symptoms of digestive system disorder. A basic principle here is that we must always be grounded by the actual condition of the patient, while allowing the theory to guide us in terms of where to look and what types of questions to ask, ensuring that no important clinical data are overlooked.

Below is a summary chart of emotional states according to the Five Elements. The first row denotes the range of normal healthy responses; the second outlines the extremes of emotion that may become pathogenic; while the third lists the emotional responses that may be generated when the positive ones are lacking. These lists should be understood in the sense that we are translating human feeling states from one culture to another, in which there are considerable differences in the context within which these emotions are experienced. This consideration also applies for each individual person under consideration, including the personal biases of each practitioner juxtaposed against the personal biases of each patient. As Maciocia repeatedly cautions, we should not take this information, nor any conclusions derived from it, too rigidly; rather we should take a broad and flexible approach, utilising it as appropriate. (Maciocia, 2009, pp. 124, 125, 138, 144,145, 147)

ELEMENT	WOOD	FIRE	EARTH	METAL	WATER
Normal healthy emotional responses	Anger (in the sense of righteous indignation, self-assertion, sticking up for your rights)	Happiness, Joy in living	Intellectual focus, Ability to concentrate	Sadness (in response to some sort of loss)	Fear (i.e. Being cautious)
Pathogenic (extreme) emotions	Rage, Easily angered	Over-excitement, Mania	Being overly intellectual (denial of emotions), Obession, Worry	Grief (especially prolonged grief), Gloomy disposition	Being overly fearful, Anxiety
Pathogenic (deficiency) emotions	Low self-esteem, Feeing unworthy, Anxiety	Lack of Joy, Depressed mood	Lack of rationality, Carelessness, Thoughlessness impulsiveness	Shallow emotional responses, Uncaring disposition	Recklessness, Lack of a sense of danger

Table 3: Emotional responses and the Five Elements

Maintaining balance

As mentioned above, the complementary opposite to our emotional life consists of the more subtle aspects of the psyche: our conscious awareness, our ability to reason, and also what may be referred to as strength of character or moral fiber. In TCM the ongoing development of these faculties, and the commitment to this development, is the cornerstone of mental health and the path to fulfilment of our human potential. On the one hand, these faculties enable one to maintain emotional balance and harmony, while on the other they enable one to grow as a person and make a significant contribution to the welfare of others and to society. These are also classified according to the Five Elements, as in Table 3. 

FIRE	Clarity of consciousness, sense of appropriateness (especially conduct)
WOOD	Planning, decision making, orderliness self-esteem, benevolence, kindness
EARTH	Intellect; ability to ponder and predict outcomes, ability to endow things with significance, working memory
METAL	Vitality, boldness, ability to hold on and let go
WATER	Will power; ability to follow one’s own path in life, long term memory

Table 4: Psychological faculties

By taking these faculties into account, a practitioner may assess which particular aspects have been neglected and the under-development of which may be contributing to the patient’s present state of emotional imbalance.

The place of reason and ethics

In line with the above comments on the role of our human psychological faculties in maintaining mental health and harmony, the traditional literature affirms that the health of the Spirit in the Heart (i.e. our overall mental health) depends upon the following:

• Moral ideals – having clearly defined values
• Harmonious relationships with significant others
• Cultivation of harmony with nature and peace of mind
• Integrity
• Self-cultivation: developing talents, skills and abilities to realize one’s potential (for the benefit of others – not for self-aggrandizement)
• Self-control (to support the above values)
• Self-reflection (to gain greater self-knowledge, in order to improve one’s relationships, standard of work etc.)

(Dharmananda, undated; Kaptchuk, 2000, pp. 58-66, 157-159; Ni, 1995, pp.1-2; Wu, 1993, pp.40-41; Sivin, 1987, pp. 49-50, 96-99)

A TCM practitioner will strive to incorporate these practices and ideals into his/her own life. In this way, the practitioner can model these virtues for the benefit of patients in the clinic and use them as a point of reference to assist in the restoration of mental and emotional balance. As these are perennial values, the same can apply within our own culture. 

Practical applications

Now that we have seen how the emotions and mental faculties may be classified according to the Five Elements paradigm, let us examine how this aspect of TCM theory is put into practice. One very important underlying assumption is that body and mind are not seen as separate and mutually exclusive; there is no ‘ghost within the machine’ – the machine is part of the ghost and the ghost is part of the machine.

To give a concrete example, in TCM the Liver is inextricably bound up with feelings of anger, self-esteem, the ability to plan and make decisions, etc. In practice, this means that in a patient with issues related to anger, self-esteem, etc., an important part of the TCM diagnosis and treatment involves assessing the state of the Liver and providing physical based therapies for the imbalances detected. On the other hand, when presented with a patient who manifests the physical signs of a Liver imbalance, the TCM clinician will also explore the possible psychological manifestations, and include some form of counselling, if deemed appropriate, along with the physical based therapies.

The other, perhaps more novel practical application is in the use of the relationships between the Elements as discussed above, in particular the control sequence. This relationship may be applied in two ways: diagnostically and therapeutically. In terms of collecting and assessing clinical data, the control relationship may provide important clues as to the physical and psychological repercussions of an initial disorder. To continue with the Liver as an example:

‘In cases of rage, the Liver is in excess and invades the Spleen.’ (Ni, 1995, p.79)

This illustrates how the controlling sequence may be applied when a pathogenic emotion has the effect of inducing over-activity (‘excess’) in an organ. According to the control sequence of the Five Elements, this condition of excess in the Liver may lead to under-activity of the Spleen-Earth (equivalent to being ‘invaded’). In any one patient, this may manifest on a physical level, psychological level or both. Thus, in clinic a patient may present with the symptoms of Spleen Qi deficiency (fatigue, poor appetite, loose stools, etc.) and this will alert the astute practitioner to a possible excess condition in Wood (i.e. the Liver); conversely, in a patient presenting with signs of Liver excess (e.g. Liver Fire) manifesting with extreme irritability and frequent uncontrollable angry outbursts, the practitioner will remember to pay attention to the condition of the Spleen, on both a physical and psychological level. 

The other relevant application of the control sequence to emotion based disorders is in the use of a therapeutically induced emotional response to counteract an emotional disorder. On a mundane level, this is something that we all tend to do as part of any caring or close relationship. As a therapeutic method, it often requires a certain degree of theatrical skill on the part of the practitioner, and may not always produce the intended results. This is discussed in more detail below.

An important message of caution is appropriate here. The five Element relationships may readily be intellectualised to create an image of universal orderliness and consistency. However, we need to be very careful when applying this paradigm, to avoid forcing the facts to fit in with our pre-conceived notions. In real-life clinical situations, the Five Elements theory does have its limits. Some of the relationships described above are clinically useful, while others are not and may even be misleading. The more important applications of this approach are discussed below. 

The emotions in TCM

Pathogenic emotions are generally grouped into seven broad categories, each of which includes several related emotional states. The ‘seven emotions’ (qi qing) are:

• Anger (includes: resentment, frustration, irritability, and rage)
• Joy (includes: excitement, nervousness)
• Worry (includes some types of anxiety)
• Pensiveness (includes: preoccupation and obsessive thinking)
• Sadness (includes: grief, regret, sorrow, despondency)
• Fear (includes anxiety, phobias, apprehensiveness)
• Fright (includes: being startled, being shocked, being alarmed ….by something)

Based upon observations of their effects on the body, each of the primary emotions is classified according to the Five Elements. When unduly prolonged or intense an emotion can directly affect the corresponding zang organ to create pathological conditions. 

• Anger (Wood) → the Liver
• Joy (Fire) → the Heart
• Worry and pensiveness (Earth) → the Spleen
• Sadness (Metal) → the Lung
• Fear (Water) → the Kidney
• Fright (Wood and Fire) → Gallbladder and Heart (scatters the Qi → indecisive, confused, lacking courage)[1]

Later authors included the Heart and Liver, together with the other organs specified, as additional targets for injury in all of the different types of emotional extremes that are listed above. (Maciocia, 2009, p.119) The reason for his is that the Heart controls all conscious mental activities and is the ultimate controller of all the zang and fu organs. Therefore, any pathogenic emotion will adversely affect the Heart and the Spirit (i.e. the state of consciousness) together with the organ to which it corresponds. Moreover, it is the Spirit in the Heart (i.e. the psychological faculties discussed above) that is responsible for maintaining control and balancing the emotional state. Thus, in the Nei Jing, Ch.5, there is the statement:

‘Overindulgence in the five emotions – happiness, anger, sadness, worry/fear and fright – can create imbalances.’ (Ni, 1995, p.19)

The implication here is that a disorder or imbalance of the Heart / Spirit leads one to overindulge in one or more of the emotional states. In addition, the Liver is the centre of ego-based emotional responses in that it is concerned with personal boundaries and sense of self-worth. The Nei Jing refers to the Heart and Liver as the primary sources of human emotional responses: 

‘When the Liver (Qi) is deficient, fear (or a ‘sense of absence[1]’) will occur; when excess, one will become angry. When the Heart (Qi)[2] is deficient, sorrow will occur; when excess, unceasing laughter will occur.’ (Chen & Cheng, 1963, p.86)

This is the only reference in the entire Nei Jing to emotions ‘coming from’ organs, as opposed to injuring them. Thus, we may conclude from these statements that while various emotions can gravitate to different organs and cause damage to them, the Heart and Liver alone are the source of our emotional life – the good and the bad.

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[1] This is the rendering used by Ted Kaptchuk in the 2000 edition of Chinese Medicine – the Web that has no Weaver, p.82.  His exposition on the psychological aspects of TCM, although brief, is, in my opinion, excellent.

[2] I have deliberately placed ‘Qi’ inside brackets as this passage makes more sense if we take the Chinese character ‘Qi’ to refer to Qi in the broad sense, in which case its use is purely rhetorical and can be omitted in an English translation.

Anger

Included in the concept of pathogenic anger are: resentment, repressed anger, irritability, frustration, rage, indignation, animosity and bitterness. These emotions tend to cause the Liver Qi to become stagnant as well as to counterflow upwards. In addition the stagnant Liver Qi may develop into Fire. Symptoms are often seen in the head and neck, with tension in the neck and shoulder muscles, headache, flushed face, dizziness, tinnitus, thirst, bitter taste in the mouth, red tongue and red blotches on the front of the neck. The stagnant Liver Qi may affect the Spleen and Stomach, causing sluggishness of movement with accumulation of incompletely digested materials and poor elimination of wastes, which may give rise to the production of Damp and Phlegm. The Phlegm may subsequently be carried upwards (by the Qi counterflow and/or Fire) affecting the throat (e.g. resulting in globus hystericus) or the head (with headaches, mental dullness, confusion or clouding of consciousness).

In the short term, pathogenic anger tends to create an excess condition in the Liver, while long term anger, resentment etc. may lead to a deficiency condition. 

Joy

While happiness is an ideal and positive state, at the extreme (i.e. over-excitement and the desire for excessive stimulation) it becomes pathogenic. Pathological ‘joy’ disperses the Heart Qi leading to a loss of mental focus and vigilance. It eventually leads to deficiency of the Heart Qi as well as deficiency of the Gallbladder Qi. Over time the Heart Yin may also become depleted. This may give rise to palpitations, insomnia with dream disturbed sleep, being easily startled or frightened, and over-excitability.

Worry and Pensiveness

Excessive worrying injures the Spleen Qi. Other related pathogenic states of mind include: habitual pensiveness, too much thinking or mental work (e.g. cramming for an exam). These factors may cause Spleen Qi deficiency with loss of appetite, epigastric distention after eating, fatigue and loose stools. This condition may lead to Blood deficiency, which will affect the Heart, giving rise to palpitations, insomnia, mental dullness, forgetfulness and depressed mood. Spleen deficiency may also give rise to internal retention of Damp and Phlegm with a sensation of heaviness in the head and body, nausea or vomiting, etc.

Sadness

This category of pathogenic emotion includes sorrow, grief, despondency and gloom, which have the effect of initially depleting and eventually stagnating the Lung Qi, i.e. creating a deficiency condition in the short term, and an excess condition in the longer term). This also affects the Heart, leading to Qi deficiency and/or Qi stagnation in both the Lung and Heart, with shortness of breath, fatigue, spontaneous sweating, palpitations, insomnia and depressed mood. When prolonged sadness or grief affects the Lung, the resultant stagnation may lead to the development of Phlegm, which may also affect the Heart, causing clouding of consciousness or confusion. In women Lung Qi deficiency can lead to Blood deficiency and amenorrhea.

Fear

Fear causes the Qi to descend, as in the involuntary opening of the bowels, urinary incontinence and weakening of the knees, which occur at times of intense fear. The other aspect of this change is that the Kidney Qi (i.e. Water) does not ascend to balance the Heart Qi (i.e. Fire), and this leads to unrestrained Heart Fire. Over time, this imbalance causes depletion of the Kidney Qi and the Kidney Yin with loss of harmony between the Kidney and the Heart. Common symptoms include insomnia, anxiety, night sweats, dizziness, tinnitus, low back pain, palpitations, irritability, facial flushing, etc.

Fright and Shock

A sudden fright or mental shock causes depletion of the Heart and Gallbladder Qi, which may adversely impact on decision making, judgements, courage and initiative, and the ability to take decisive action, especially if a person is repeatedly subject to such stimuli. In order to cope with the effects of fright or shock, the body draws on the reserves of the Kidney. Thus, the harmonious interaction between the Heart and Kidney may also become disrupted (as discussed above under ‘fear’), in addition to effect on the Gallbladder, giving rise to anxiety, indecisiveness, palpitations, insomnia with dream disturbed sleep, night sweats, dry mouth, tinnitus, etc.

Injury to the internal organs

In general, extremes of emotion may cause functional derangement of the internal organs, which in turn may lead to further disturbances in emotional responses and mood in a vicious cycle. On the other hand, any type of primary physical disorder of the internal organs may adversely affect mood and emotional responses. Thus, extremes of emotion can not only be the cause but may also be the result of a physical condition.

A passage from Nei Jing, Ch.19, illustrates how emotional imbalance may affect organ systems outside the one that is directly affected: 

‘Worry, fear, grief, over-excitability and rage, because they do not follow the creative cycle, may result in a more severe disorder. Extremes of excitability injure the Heart. When the Heart is deficient, the Kidney energy overcontrols. In cases of rage, the Liver is in excess and invades the Spleen. Grief causes the Lung to overcontrol the Liver. Fear weakens the Kidney and causes the Spleen to overcontrol the Kidney. In excessive sadness, the Lung Qi becomes deficient and, allowing the Heart to dominate. These illnesses, induced by emotional extremes, that do not follow the typical creative (i.e. generation) cycle, but rather follow the control pattern.’ (Ni, 1995, p.79)[1]While these secondary effects may not always become manifest in an individual patient, the cascading effect of an emotional extreme is something that the alert practitioner should always bear in mind. This is summarized in the following table. 

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[1] Note that worry and pensiveness are not discussed in this passage from the Nei Jing. However, we may infer that when worrying leads to Spleen deficiency, an excess condition of the Liver may arise.

EXTREME EMOTION (ELEMENT)	PRIMARY INJURY	SECONDARY EFFECTS
Excitement, happiness (Fire)	Heart (Deficiency)	Kidney (Excess)
Rage, Anger (Wood)	Liver (Excess)	Spleen (Deficiency)
Grief (Metal)	Lung (Excess)	Liver (Deficiency)
Fear (Water)	Kidney (Deficiency)	Spleen (Excess)
Sadness (Metal)	Lung (Deficiency)	Heart (Excess)

Table 5: Effects of emotional extremes, according to the control cycle.

Using emotions as therapy

According to a passage in the Nei Jing, Ch.5, emotion based disorders may be treated by invoking another emotion to control or balance the extreme emotional state of the patient. (Ni, 1995, pp.20-21) As mentioned above, by taking a more theatrical approach a practitioner may attempt to induce an emotional state in a patient, by utilizing the control cycle of the Five Elements to balance emotional extremes or stuck emotions. As noted by one TCM author: ‘Medicinal herbs alone cannot cure a disorder caused by an extreme emotion. Another emotion should be engaged to reduce the extreme emotions that is causing the disorder in order to strike a balance…. A healing emotion is an invisible herbal remedy.’ (Lu, 2005, p.18) This method may be applied in cases when it is apparent that a patient’s own emotional reactions have caused (and are maintaining) the presenting disorder. According to this sequence, we have the following:

• Control anger with sadness
• Control excessive joy or over-excitement with fear
• Control worry or excessive pensiveness with anger (or indignation)
• Control sadness or grief with joy
• Control fear with thoughtfulness

Eminent TCM practitioners have recorded case histories where they have gone to great lengths, using costumes and disguises to induce a healing emotion and help a patient overcome a condition brought on by an emotional extreme. (Chiang, 2014, pp.37-55; Fruehauf, 2009) In more recent times, the work of Dr Patch Adams is a good example of this approach. (Adams & Mylander,1993) On a more mundane level, we have all experienced the effectiveness of a well-timed joke or humorous comment to help a patient lighten up and stop taking himself and his condition too seriously. Sometimes this is all it takes to establish the rapport that is necessary for the patient to allow healing to take place, by restoring a very broad sense of confidence – not only in the skills of the practitioner and the efficacy of the medicines but also confidence in himself and confidence in the essentially benevolent nature of life itself.

The above discussion has been presented to help maintain focus on the whole person and not just the physical aspects of a patient’s presenting disorder. The influence of Maoism has tended to reduce emotional responses to mere physiological reactions to environmental stimuli (Sivin, 1987, p.287), to be corrected using acupuncture and herbal formulas. This paper favors a twofold path of influence that includes the physical affecting the mental as well as mental affecting the physical. In this way, the place of empathy, ethics, self-discipline and self-cultivation in the healing encounter between practitioner and patient should be regarded as essential; for they are neither more nor less important than the physical treatment modalities that are being employed.

In the next part of this discussion, we will focus on the actions of select Chinese herbal formulas and their applications in disorders due to emotional imbalance.

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